Jason Frischer

1500 timestamped statements across 14 collections — auto-found in recorded discussions, each timestamp jumps to the exact moment.

Abdominal Wall Defects · guest expert Colorectal / ARM & Hirschsprung · guest expert Congenital Lung Lesions (CPAM) · guest expert Etiologies (Gastroschisis/NEC/Atresia/Volvulus) · guest expert Intestinal Rehab · guest expert Motility / Pseudo-obstruction · guest expert

Featured diaries

▶ Ep 87 · 8:25
I have two answers for you, Mark. I think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me.
quote · Anorectal Malformation
▶ Ep 88 · 8:25
I have two answers for you, Mark. I think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me.
quote · Anorectal Malformation
▶ Ep 243 · 8:25
I have two answers for you, Mark. I think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me.
quote · Colorectal / ARM & Hirschsprung
▶ Ep 243 · 8:25
I have two answers for you, Mark. I think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me.
quote · Colorectal / ARM & Hirschsprung
▶ Ep 22 · 7:20
I think it was probably what we were expecting, I think, for a couple of reasons. One, due to the heterogeneity of this disease, you know, especially with gastroschisis, a lot of the patients that were able to undergo, you know, especially a primary repair, they probably had more favorable bowel. And then those patients, you know, theoretically would have less hospital stay and theoretically feed faster and things like that.
quote · Abdominal Wall Defects
▶ Ep 31 · 7:20
I think it was probably what we were expecting, I think, for a couple of reasons. One, due to the heterogeneity of this disease, you know, especially with gastroschisis, a lot of the patients that were able to undergo, you know, especially a primary repair, they probably had more favorable bowel. And then those patients, you know, theoretically would have less hospital stay and theoretically feed faster and things like that.
quote · Etiologies (Gastroschisis/NEC/Atresia/Volvulus)

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Abdominal Wall Defects 36 entries

Gastroschisis and sutureless abdominal wall closure

▶ Ep 22 · 7:20
opinion Many patients who underwent sutureless repair were done in more recent cohorts and tended towards less interventions. ↗
▶ Ep 22 · 7:20
opinion Due to the heterogeneity of gastroschisis, patients able to undergo primary repair probably had more favorable bowel and theoretically would have less hospital stay and feed faster. ↗
▶ Ep 22 · 7:20
quote I think it was probably what we were expecting, I think, for a couple of reasons. One, due to the heterogeneity of this disease, you know, especially with gastroschisis, a lot of the patients that were able to undergo, you know, especially a primary repair, they probably had more favorable bowel. And then those patients, you know, theoretically would have less hospital stay and theoretically feed faster and things like that. ↗
▶ Ep 22 · 8:05
quote Moreover, too, if you think about just the way that we close a sutured repair, you mobilize flaps from the skin and flaps from the fascia. So there's always, you know, redness around the incision, bruising around the incision. And so, you know, even that tissue manipulation is going to put you at higher risk for a potential infection or calling it erythema infection. ↗
▶ Ep 22 · 8:05
opinion The finding of increased antibiotics needed after sutured repair was expected due to tissue manipulation. ↗
▶ Ep 22 · 8:05
clinical In sutured repair, mobilizing flaps from the skin and fascia causes redness and bruising around the incision, which puts patients at higher risk for potential infection. ↗
▶ Ep 22 · 8:50
clinical The next phase of the study is examining the same patients over several years of follow-up to assess growth and umbilical hernia repair rates. ↗
▶ Ep 22 · 8:50
clinical The consortium is working on operationalizing protocolization of gastroschisis closure across member institutions for a more prospective study with long-term follow-up. ↗
▶ Ep 22 · 8:50
host_summary Initial small studies showed that some sutureless patients had a high umbilical hernia repair rate, or at least a high umbilical hernia rate. ↗

Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee

▶ Ep 29 · 3:10
clinical Jason Fraser's institution starts feeding immediately after dressing placement as long as the baby is not sick, not having horrible output, and not vomiting. ↗
▶ Ep 29 · 3:10
quote we start feeding essentially you have to put the dressing on uh as long as the baby's not sick not having horrible output not puking or anything like that ↗
▶ Ep 29 · 3:54
quote we don't innovate our babies at all so we put the dressing plastic dressing on and as long as the kid's not you know has voluminous output we'll try to start start feedings on it ↗
▶ Ep 29 · 3:54
clinical Fraser's institution does not intubate gastroschisis babies for reduction. ↗
▶ Ep 29 · 5:13
clinical Awake reduction can be successful if performed slowly, with stomach emptying, colon decompression, oral sucrose, and gradual abdominal wall stretching. ↗
▶ Ep 29 · 5:13
quote if you try to just keep pushing and pushing pushing the baby kind of can squirm and stuff but if you go slow if you empty out the stomach if you kind of squish out the colon a little bit and you go slow you give the baby some sweeties the nurses are there to kind of relax the baby you have a couple people that that are there doing it you go slow you slowly kind of push things in you stretch out the belly a little bit ↗
▶ Ep 29 · 6:19
clinical Cincinnati Children's feeding protocol is based on patient tolerance and data from resource-limited settings where TPN is unavailable and feeding is mandatory. ↗
▶ Ep 29 · 6:19
quote it's really just based upon patient tolerance and it's kind of based upon some of the data that's out there from the rest of the world where they don't have tpn and so they just you have to feed the kid if the kid does okay then they keep going ↗
▶ Ep 29 · 10:30
opinion The reduction in surgical site infections with protocol feeding was likely due to decreased care variability rather than the feeding protocol itself. ↗
▶ Ep 29 · 10:30
quote a lot of the inconclusivity from the the study showed that you know most likely due to the fact that there was lots of different feeding protocols that were used uh across our member institutions ↗
▶ Ep 29 · 10:30
epidemiological The multi-institutional study showed inconclusive results due to significant variation in feeding protocols across institutions. ↗
▶ Ep 29 · 10:50
quote the ssi thing was probably just because patients that were fed via protocol were cared for via protocol and so that they actually had less variability and less uh less changes uh in the way that these these patients are not you know look for ↗
▶ Ep 29 · 11:20
quote our length of stay for gastroschisis and cincinnati was astronomically higher than like any other nick micu in the cooperative network that we worked with so we sat down we're like what is going on here so our average length of stay was 49 days ↗
▶ Ep 29 · 11:20
epidemiological Cincinnati Children's average gastroschisis length of stay was 49 days before protocol implementation, which was astronomically higher than comparable NICUs in their cooperative network. ↗
▶ Ep 29 · 12:10
quote we instituted this uh a feeding protocol we spent a lot of time trying to get people to follow it and and making some adjustments and over two years we dropped the length of stay by 10 days and the mix of patients is not different ↗
▶ Ep 29 · 12:10
epidemiological After implementing a feeding protocol, Cincinnati Children's reduced gastroschisis length of stay by 10 days over two years. ↗
▶ Ep 29 · 12:10
epidemiological Cincinnati Children's has seen a decrease in time from first feed to full feeds but has not yet reduced the time from admission to first feed (except in 2020). ↗
▶ Ep 29 · 14:20
clinical Cincinnati Children's gastroschisis protocol includes prenatal care coordination with obstetricians and neonatologists, with surgery continuing to follow patients throughout hospitalization. ↗
▶ Ep 29 · 15:17
host_summary Some institutions ignore bilious emesis or bilious NG residuals completely during gastroschisis feeding advancement. ↗
▶ Ep 29 · 16:00
quote the most important thing that kind of keeps showing up is the fact that we really need to define what your own institution has for tolerance and to kind of stay on the protocol and then really just look at the infant condition as you continue to go is the most important thing ↗
▶ Ep 29 · 16:00
opinion The most important aspects of gastroschisis feeding are defining institutional tolerance criteria, adhering to protocol, and continuously evaluating the infant's condition. ↗
▶ Ep 29 · 16:40
quote yes you can have a protocol yes you know you need to follow it but the most really you really need to continually evaluate the patient as they continue to go to make sure that you know yes your protocol is working but also to the patient does okay throughout ↗
▶ Ep 29 · 16:40
clinical For significant feeding intolerance, Cincinnati Children's protocol calls for stopping feeds for six hours, though this is not clearly evidence-based. ↗
▶ Ep 29 · 17:22
clinical One recent Cincinnati Children's gastroschisis patient who was primarily reduced on day of life zero was discharged at approximately two weeks and remained well at two-week follow-up, though this is an outlier on the faster end. ↗
▶ Ep 29 · 17:22
epidemiological Cincinnati Children's current average gastroschisis length of stay is 30 to 34 days. ↗
▶ Ep 29 · 18:14
epidemiological Cincinnati Children's has not seen any aspirations with their early aggressive feeding approach, though they acknowledge they are still early in implementation and continue to monitor data. ↗
▶ Ep 29 · 18:56
clinical At Cincinnati Children's, approximately two-thirds of gastroschisis cases cannot be reduced immediately and are placed in a silo for gradual reduction followed by sutureless closure, with feeds started after closure. ↗
Anorectal Malformation 230 entries

Bowel Management Updates & Innovations with Live Q&A: April 2018

▶ Ep 2 · 0:15
clinical The Colorectal Center patient population includes anorectal malformations (imperforate anus), Hirschsprung's disease, spina bifida, sacrococcygeal teratomas, trauma patients, and refractory constipation. ↗
▶ Ep 2 · 2:32
clinical Appendicostomy (Malone/MAC/ACE procedure) involves bringing the appendix to the belly button with a valve mechanism to prevent reflux, allowing patients to independently administer flushes through the colon over 10–15 minutes, then sit on toilet for approximately 45 minutes to empty. ↗
▶ Ep 2 · 3:42
clinical Sacral nerve stimulator is not FDA approved for children under 18, but is performed off-label; it acts like a heart pacemaker, stimulating the third sacral nerve to improve bowel and urinary continence outcomes. ↗
▶ Ep 2 · 4:41
clinical Sacral nerve stimulator is a two-stage procedure (test phase and permanent phase) and has been performed at Cincinnati Children's for almost 3 years. ↗
▶ Ep 2 · 4:53
clinical Solesta is an injection of hyaluronic acid polymer that fills space in the anal canal, used in patients with patulous (more open) anuses to help gain control. ↗
▶ Ep 2 · 7:27
clinical Patients with deformed sacrums have lower likelihood of success with bowel management using medication alone (not on enema program). ↗
▶ Ep 2 · 7:50
clinical Malone procedure requires prior success with enemas because it only changes the route of administration; surgical procedure should not be performed on patients unsuccessful with enema program. ↗
▶ Ep 2 · 8:17
clinical Malone procedure is typically performed starting at age 5 years and older, most commonly between ages 5 and 10–12 years. ↗
▶ Ep 2 · 8:53
clinical Vomiting after enema can be caused by high-volume enema with irritant causing colon distention and discomfort. ↗
▶ Ep 2 · 10:59
guideline Sacral nerve stimulator indication per manufacturer requires 50% improvement on symptoms; patient must have tried non-surgical bowel management first. ↗
▶ Ep 2 · 11:17
clinical Sacral nerve stimulator requires normal sacrum; it is the least invasive option compared to Malone or Solesta when bowel management is working or needs improvement. ↗
▶ Ep 2 · 11:49
clinical Using hybrid OR with 3D imaging, sacral nerve stimulator can be placed in patients with very abnormal sacrums by identifying anatomy in real-time. ↗
▶ Ep 2 · 13:45
clinical For failed redo Hirschsprung's pull-through, redo surgery can almost always create a channel for stool evacuation via rectum/anus, even after 1–3 prior redos; very few patients end up with ileostomy if goal is rectal evacuation. ↗
▶ Ep 2 · 17:18
clinical The large intestine (colon) primarily absorbs water; in adults it can absorb up to 1 liter of water per day. When colon is removed, stool becomes softer/looser because less water is absorbed. ↗
▶ Ep 2 · 17:46
clinical Bowel management sometimes requires using Imodium to constipate/harden stool, then using enema to empty it—thickening stool first, then mechanically emptying. ↗
▶ Ep 2 · 19:12
opinion There is no perfect surgery for constipation; if there were, all surgeons would recommend and perform it. ↗
▶ Ep 2 · 19:12
quote There is no perfect surgery for constipation. If we had it, we would all recommend it and do it. ↗
▶ Ep 2 · 19:20
clinical Transanal colon/rectum resection is minimally invasive but carries risk of post-surgical incontinence in some patients. ↗
▶ Ep 2 · 19:56
clinical Colon resection for constipation may lessen treatment burden (e.g., reduce laxative dose from 10 to 5 squares of Ex-Lax) but this outcome is not guaranteed. ↗
▶ Ep 2 · 20:22
clinical Before colon resection, offer sacral nerve stimulator and perform manometry (colonic and anorectal) to identify non-functioning colon segments or outlet problems (sphincter dysfunction). ↗
▶ Ep 2 · 20:55
clinical Anorectal manometry can reveal paradoxical sphincter function where child squeezes when trying to relax and vice versa; Botox works in younger children, physical therapy and biofeedback in older children for this. ↗
▶ Ep 2 · 22:31
clinical Colon resection is a big surgery requiring bowel anastomosis with associated risks; once colon is resected, it cannot be replaced. All other treatments (sacral nerve, enemas, laxatives) are reversible. ↗
▶ Ep 2 · 25:25
opinion Senna laxative is like insulin for a diabetic—a necessary medication to help move bowels in severe constipation; dose may change over time but patients are not 'addicted' to it. ↗
▶ Ep 2 · 25:29
quote I sort of say it's like insulin for a diabetic. A diabetic needs insulin to lower their blood blood glucose levels. A patient who has severe constipation needs a laxative stimulant to help move their bowels. ↗
▶ Ep 2 · 26:48
clinical Stimulant laxatives (Senna, Dulcolax) make the colon squeeze/push stool forward and reduce water absorption time, resulting in softer stool—two mechanisms that benefit the patient population. ↗
▶ Ep 2 · 27:17
clinical Only two stimulant laxatives are available in the United States: Senna (Ex-Lax chocolate squares, tablet, liquid forms) and Dulcolax. ↗
▶ Ep 2 · 27:35
clinical MiraLax is not a stimulant laxative; it prevents colon from absorbing water, keeping water in colon and making stool softer. ↗
▶ Ep 2 · 27:51
clinical MiraLax is avoided in patients without full continence mechanisms because very loose stool is hard to control when nerves and muscle are partially impaired. ↗
▶ Ep 2 · 28:15
clinical In spinal cord patients (tethered cord, spina bifida), stool is often so formed that MiraLax-type agent is needed to soften stool along with motility agents. ↗
▶ Ep 2 · 30:09
clinical Bowel rest with colostomy is typically used in patients with anorectal malformation or Hirschsprung's pull-through complications (narrowing, stenosis, tightness) causing dilated colon/rectum upstream. ↗
▶ Ep 2 · 30:47
clinical If colostomy is not working due to constipation, consider ileostomy to totally exclude colon and divert stool before it reaches colon. ↗
▶ Ep 2 · 35:30
clinical Michael Helmrath at Cincinnati Children's is growing colons in the lab from single cells, able to lengthen colon in mice and expanding to larger primates. ↗
▶ Ep 2 · 35:48
clinical Anal sphincter tissue regeneration has been attempted by many researchers (using muscles from other areas, other sphincters from esophagus/stomach) but none have been proven to work; no successful procedure is currently offered. ↗
▶ Ep 2 · 37:00
clinical Cincinnati Children's has nearly 3 years of experience with sacral nerve stimulators in children; it works in refractory constipation and combined urinary/stool issues, but pediatric patient heterogeneity makes outcome prediction difficult. ↗
▶ Ep 2 · 37:05
clinical Sacral nerve stimulator was initially designed for urinary incontinence in postpartum women; during testing it was found to also help fecal constipation and incontinence, leading to later FDA approval for fecal symptoms. ↗
▶ Ep 2 · 37:30
clinical Sacral nerve stimulator in adults is used in patients with normal anatomy/development, but in pediatrics it is used in patients with prior pelvic operations, malformations, or disease processes, making study difficult because every patient is different. ↗
▶ Ep 2 · 38:58
clinical Sacral nerve stimulator has a temporary trial stage (1–2 weeks); if it doesn't work, the device is removed without implanting permanent battery. ↗
▶ Ep 2 · 40:34
clinical Constipation or fecal impaction puts pressure on urinary tract, causing urinary infections, improper emptying, urgency, and other symptoms; treating stool issues is often first step before urologic investigation. ↗
▶ Ep 2 · 41:58
guideline All anorectal malformation patients should be followed by urology long-term; more complex malformations have more associated urinary tract malformations, but even minor malformations require periodic follow-up to ensure kidney function and proper urinary tract emptying. ↗
▶ Ep 2 · 42:43
clinical Urinary tract problems in anorectal malformation patients can cause diminished health with late-appearing signs/symptoms; regular urology checkups (exam, renal ultrasound, possibly further testing) are important even without visible problems. ↗
▶ Ep 2 · 43:37
clinical Cincinnati Children's has weekly meeting with colorectal, urology, and gynecology teams reviewing all patients to ensure comprehensive (not just focused) evaluation. ↗
▶ Ep 2 · 44:12
clinical Long-term MiraLax literature is scant; many patients do fine on it. A class action lawsuit against MiraLax occurred 1–2 years ago but has not been heard about recently. ↗
▶ Ep 2 · 45:00
clinical A couple of studies suggested MiraLax may have less-than-ideal neurodevelopmental outcomes, but these have not been reproduced; it is something to be thoughtful about when prescribing. ↗
▶ Ep 2 · 46:05
clinical Fleet phosphate enema causes the most irritation with long-term use, making colon look like a 'lead pipe' (very stiff, lacking mobility and pliability); it is used intermittently as rescue enema, not for long-term maintenance. ↗
▶ Ep 2 · 47:14
clinical Solesta is not FDA approved for children; it is used in patients with patulous (open) anus as a filler to close the anal canal and help with fecal incontinence. ↗
▶ Ep 2 · 48:13
clinical Solesta can be used in any age patient; Cincinnati has used it in patients 3–4 years old and older, with mixed results but little side effect (small infection risk). ↗
▶ Ep 2 · 48:31
clinical Solesta or sacral nerve stimulator may help patients transition from enemas to laxatives when prior attempts have failed, depending on individual anal canal anatomy and situation. ↗
▶ Ep 2 · 49:17
clinical Sacral nerve stimulator results in spina bifida patients are mixed; some respond positively, others do not. Literature and research exist on this. ↗
▶ Ep 2 · 49:36
clinical Sacral nerve stimulator in spina bifida requires adequate sacrum anatomy and presence of third sacral foramina (opening where third sacral nerve exits sacrum to innervate pelvis). ↗
▶ Ep 2 · 51:56
clinical Botox is a muscle relaxant that relaxes the anal sphincter; it is used in Hirschsprung's disease patients with high anal resting pressures. ↗
▶ Ep 2 · 52:19
clinical Solesta is hyaluronic acid polymer, a gel filling agent that closes a wide-open (patulous) anal canal; it acts very differently from Botox. ↗
▶ Ep 2 · 55:06
clinical Hirschsprung's patients can potty train around the same age as other children; some will have harder time with continence depending on post-surgical anal canal anatomy and development. ↗
▶ Ep 2 · 55:30
clinical Hirschsprung's evaluation requires contrast enema to assess surgical anatomy of anal canal and entire colon, plus repeat biopsy because initial frozen section may show adequate nerve cells but later those cells may be less abundant (transition zone). ↗
▶ Ep 2 · 56:58
clinical Anorectal malformation is abnormal development of where colon/rectum ends up (where it 'lands' in development); there is a wide spectrum in males and females. ↗
▶ Ep 2 · 57:13
clinical In anorectal malformation, rectum can land outside anal canal/sphincter complex on skin just above that area, outside vagina in girls, anywhere along urinary tract in boys (with fistula causing stool to come out urinary tract), or connected to bladder in more complex cases. ↗
▶ Ep 2 · 57:53
clinical Anorectal malformation diagnosis requires good physical exam and sometimes imaging. ↗

The Colorectal Quiz Episode 1: ARM - Low Bulbar Fistula

▶ Ep 34 · 4:11
quote I always worry about a missed presacral mass. ↗
▶ Ep 34 · 5:08
clinical Cross-table lateral X-ray should be obtained at approximately 24 hours of life to assess the air column position relative to the perineal skin, with the baby positioned prone to allow air to rise to the buttocks. ↗
▶ Ep 34 · 6:28
clinical The cross-table lateral film should include a marker at the expected anal location to allow measurement of the distance between the air column and the perineal skin. ↗
▶ Ep 34 · 7:47
clinical Well-formed buttocks, visible sphincter mechanism location, and well-developed sacrum together predict good prognosis for continence. ↗
▶ Ep 34 · 8:25
quote Well, I have two answers for you, Mark. I think if I was sitting in a hotel room, being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. ↗
▶ Ep 34 · 9:58
quote It goes without saying and, and one of our, I think one of our big teaching points is you should never try to go in blind. ↗
▶ Ep 34 · 9:58
clinical The surgeon should never attempt posterior sagittal approach blind; imaging must confirm that the first structure encountered will be the air pocket of the distal rectum. ↗
▶ Ep 34 · 11:37
quote We both agree that probably in real life, we would have done a primary posterior sagittal approach on this patient, and we would have found the rectum, and we could have made that rectum reach the perineum and done our anoplasty. How do we handle this? Because I didn't know that there was a fistula there. This is troublesome. ↗
▶ Ep 34 · 12:34
quote You can see this fistula is very close to the rectum. And if you're going to dissect that free, and along the urethra, um, it's important to make sure that you know that those two structures are not very far apart, and getting that into that proper plane is very important. ↗
▶ Ep 34 · 12:55
clinical A bulbar fistula is located at the elbow of the urethra, using anatomic nomenclature based on the urethral location. ↗
▶ Ep 34 · 13:00
quote The reason why Doctor Levitt or Mark is saying that. It's a bulbar fistula, it's at the elbow. You can see it's at the elbow of the urethra. And tell us that the uh the nomenclature we like to use is an anatomic pure anatomic nomenclature saying that it's a bulbar fistula. ↗

Colorectal Quiz Episode 2: When to redo a PSARP

▶ Ep 35 · 0:00
opinion For anorectoplasty, if you don't get it perfect, you might not have the best outcomes, which separates it from other surgical procedures. ↗
▶ Ep 35 · 0:40
host_summary A lot of surgeons agree that oftentimes your first shot might be your only shot to give this patient a good outcome and the right anatomy. ↗
▶ Ep 35 · 1:20
quote How many patients, Jason, have you seen on laxatives that comes with an anus in the wrong place? How many patients have you seen having had a cecostomy with perfect anatomy? That's the real frustrating one. Right? A lot. ↗
▶ Ep 35 · 5:50
quote I can tell you, the family doesn't really care how technically elegant is your analplasty. What they care about is whether that analplasty that you make is going to work. And is the child going to be clean and in normal underwear and just like all the other kids? ↗
▶ Ep 35 · 5:50
opinion The family doesn't really care how technically elegant is your analplasty. What they care about is whether that analplasty that you make is going to work and is the child going to be clean and in normal underwear. ↗
▶ Ep 35 · 6:25
clinical The higher the malformation, the worse the prognosis. ↗
▶ Ep 35 · 6:35
clinical A sacrum ratio of 0.7 or greater usually means normal or close to normal sphincters and good muscle tone, indicating that spine innervation of that area is probably good. ↗
▶ Ep 35 · 6:40
clinical Patients can come with associated spinal anomaly, most commonly tethered cord, but the worst is a myelomeningocele, and those patients have much more trouble with continence. ↗
▶ Ep 35 · 7:44
clinical It's amazingly common to have a mislocated anus, either because the surgeon misses where the center is during laparoscopic pull-through or opens the PSARP incision first. ↗
▶ Ep 35 · 8:05
quote A key pitfall is not do that. Mark the sphincters first, then open the PSARP because then you don't get confused at the end when you're trying to place the anoplasty in the correct location. ↗
▶ Ep 35 · 8:05
clinical A key pitfall is opening the PSARP incision first; instead, mark the sphincters first, then open the PSARP so you don't get confused when placing the anoplasty in the correct location. ↗
▶ Ep 35 · 10:19
clinical In higher malformations such as a bladder neck fistula in a boy, the sphincter complex isn't always where you think it's going to be and is sometimes more anterior than anticipated. ↗
▶ Ep 35 · 15:19
opinion An alternative approach for borderline cases is to let the child take their car out for a ride first and see how it works—if it drives well, stay with that anatomy; if not, then consider the redo. ↗

Colorectal Quiz Episode 13: Newborn ARM Part 2

▶ Ep 38 · 4:45
clinical Perineal groove with mucosal lining will keratinize and look like normal perineal body over time ↗
▶ Ep 38 · 4:45
quote My conversation with the family often involves that this will keratinize and look like a normal peroneal body over time. ↗
▶ Ep 38 · 5:00
clinical Surgical intervention for perineal groove is indicated only if secreting mucus, causing irritation, or developing ulcers ↗
▶ Ep 38 · 9:35
clinical Vestibular fistula is very common in females and needs formal repair with hole transposed to center of sphincter ↗
▶ Ep 38 · 10:22
clinical For vestibular fistula diagnosed in newborn period, options are primary repair if baby is well, or allow stooling through fistula for couple months then elective repair without stoma ↗
▶ Ep 38 · 10:22
clinical Purpose of diversion in ARM repair is to avoid perineal body dehiscence ↗
▶ Ep 38 · 10:22
clinical Patients diagnosed with vestibular fistula at 6-12 months who have dilated rectosigmoid need diversion as first step, then repair ↗
▶ Ep 38 · 14:11
clinical To evaluate for vestibular fistula, pull labia towards examiner with both hands to visualize vaginal opening and urethra ↗

The Colorectal Quiz Episode 23: Hirschsprung Disease - The Soiling Patient...

▶ Ep 41 · 2:44
quote Can I scare you for a moment? Can we talk scientifically for one minute? I know this is crazy. ↗
▶ Ep 41 · 3:08
clinical The dentate (or pectinate) line is the transition from squamous epithelium to columnar epithelium, located about 2/3 of the way up the anal canal. ↗
▶ Ep 41 · 3:25
clinical Blood supply changes occur at the dentate line (splanchnic versus systemic), and there is also innervation in that area. ↗
▶ Ep 41 · 3:54
clinical The nerves located at the dentate line region tell you gas, liquid, solid; how hard, how long, and how tight to squeeze. ↗
▶ Ep 41 · 3:54
quote I talk about that dentate line in the area where the nerves are located that tell you gas, liquid, solid. How hard do I need to squeeze, how long do I have to squeeze for, how tight do I have to squeeze? ↗
▶ Ep 41 · 4:15
clinical Preserving the dentate line region is key because injury to that region affects a patient's ability to be continent. ↗
▶ Ep 41 · 6:11
clinical In children with anorectal malformation, Hirschsprung disease, spinal conditions, or combinations thereof, the ability to sense stool in the rectum or neorectum region is critical to success; the right consistency and bulk of stool is very important. ↗
▶ Ep 41 · 6:45
clinical If clinicians make stool too soft or too loose with medications, they put a child on the edge of having control or not and throw them over that edge, preventing success. ↗
▶ Ep 41 · 6:59
quote And if we make it too soft or too loose, we're putting a child or a person who is on the teeter of having control or not, and you throw them over that edge, and, and you just won't be successful. ↗
▶ Ep 41 · 11:16
clinical A Hirschsprung patient with missing dentate line and intact muscle should be able to achieve continence, similar to an anorectal malformation anastomosis (rectum or colon mucosa to skin). ↗
▶ Ep 41 · 11:16
quote I mean, it makes sense that they should if the muscle is intact, right, because this is no different than an anorectal malformation, anastomosis. That's right. But it's, it's, it's rectum or colon mucosa to skin. ↗
▶ Ep 41 · 12:08
clinical Patients with no dentate line and patulous sphincters who are soiling develop severe skin irritation from sitting in pull-ups or diapers. ↗
▶ Ep 41 · 12:08
quote That is a patient with no dentate line and pattula sphincters, and you clearly see with the skin changes around that, that this patient has really struggled and has been soiling and, and, and sitting in, in pull-ups or a diaper, really causing severe skin irritation. ↗
▶ Ep 41 · 18:17
quote This, this is, these are the harder patients to take care of, and the trick that I use is you have to constipate them. And then if they're able to empty with continence on their own, then great. If they're not, then you have to mechanically help them empty. ↗
▶ Ep 41 · 18:17
clinical For hypermotile patients (stooling 7-8 times a day), the approach is to constipate them first, then figure out how to empty them in a time-controlled fashion. ↗
▶ Ep 41 · 18:35
quote But it, it's, it's like, it sounds counterintuitive, but at least the way I treat these patients, I constipate them, and then I empty them. ↗
▶ Ep 41 · 18:35
clinical Whether hypermotile patients can empty on their own versus needing mechanical emptying to maintain social continence depends on their sphincter function. ↗
▶ Ep 41 · 18:58
quote But that's how I sort of explain it to the families. It sounds weird, but we're gonna constipate you, and then we have to figure out how to empty you in a time-controlled fashion. ↗
▶ Ep 41 · 22:42
clinical Some Hirschsprung patients who have a good operation have super strong sphincters that just need a little relaxation to allow passage of stool until they learn proper sphincter coordination for evacuation. ↗
▶ Ep 41 · 23:10
clinical Botox helps train sphincters in Hirschsprung patients; anorectal manometry can provide objective data showing resting pressures are usually on the higher end of normal, and some patients need extra relaxation to allow them to go. ↗
▶ Ep 41 · 23:31
clinical Nutrition in Hirschsprung patients is very important; some patients are very sensitive to certain foods, particularly lactose. ↗
▶ Ep 41 · 23:50
clinical Paying attention to diet (whether breastfed infants or older children) is important because lactose is particularly problematic in some Hirschsprung patients. ↗
▶ Ep 41 · 24:26
quote None. We have to get it right the first time. ↗
▶ Ep 41 · 24:29
opinion Every Hirschsprung patient should be able to do well; they might need help and might need mechanical evacuations or Botox, but all should be able to get on the right track. ↗
▶ Ep 41 · 24:29
quote And if you don't get it right, you gotta use these techniques and this algorithm to figure out what's wrong, cause we could get every patient doing well. They might need help, and they might need mechanical evacuations, Botox, etc. but we could, we all should be able to get these patients on the right track. ↗

Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula

▶ Ep 41 · 15:22
clinical When neurologic anomalies are found in anorectal malformation patients, gynecological anomalies are more likely, especially on the same side. ↗
▶ Ep 41 · 15:22
quote when you do find neurologic anomalies. That leads to more likely gynecological anomalies as well, especially on the same side. ↗

Colorectal Quiz Episode 29: Female ARM-Post Op Management

▶ Ep 42 · 7:17
clinical Dr. Fisher's protocol for perineal body primary repair (no stoma) is 5-7 days NPO on D10 via midline catheter (not PICC line) until the repair is confirmed healed. ↗
▶ Ep 42 · 8:03
quote Just because it's published doesn't mean it works. ↗
▶ Ep 42 · 13:51
quote My only concern is what's the continence rate of your patients? ↗
▶ Ep 42 · 14:20
host_summary In the dilation trial, 4 patients required redo operations for stricture: 2 in the dilation arm (who didn't actually dilate) and 2 in the non-dilation arm. Additional patients required Heineke-Mikulicz procedures (3 in one group, 47 total procedures mentioned). ↗
▶ Ep 42 · 15:01
quote I guess my question is somewhere around 20% required a redo either local or total operation. Most just like local, but what did a functional out in the end of the game, all the parents want is their kid pooping in the potty. And we don't know that answer. ↗
▶ Ep 42 · 15:24
quote That's a very valid point. So what you're saying, wait, wait, Mark agreed with me. ↗
▶ Ep 42 · 19:00
quote And when I was working with Mark here, I know, especially in the older patients that we were doing redos on, used to teach me to make the anoplasty maybe a little larger. ↗

Colorectal Quiz Episode 38: Transitional Care in Colorectal Surgery

▶ Ep 49 · 3:59
clinical MRI with specific protocols and endorectal ultrasound can help determine whether the anoplasty is within the muscle complex. ↗
▶ Ep 49 · 14:05
opinion The transition model includes joint clinic visits and collaborative operating, which is key to successful handoff. ↗
▶ Ep 49 · 14:54
opinion Freestanding children's hospitals face greater challenges than integrated hospitals because they are completely separate entities both physically and financially. ↗
▶ Ep 49 · 15:14
clinical In Cincinnati, ARM patients still come to the colorectal center at the children's hospital whether they are 12 or 40 years old, partnering with an adult colorectal surgeon; collaborative operating occurs at the University of Cincinnati with adult colorectal surgeons, adult neurologists for urology, and pediatric urologists who have privileges at the university. ↗
▶ Ep 49 · 18:58
opinion Adult hospitals are much more adept and skilled at managing perioperative complications like pulmonary embolism or myocardial infarction; such events in a children's hospital lead to many meetings and potential for poor outcomes. ↗
▶ Ep 49 · 19:33
clinical Physicians and surgeons are making progress on transition, but the greater struggle is providing intensive bowel management training for 35-year-old patients; pediatric centers are adept at bowel management for patients of any age, but currently adult patients requiring intensive outpatient bowel management are still being seen at children's hospitals. ↗
▶ Ep 49 · 24:21
quote This is the future. ↗

Colorectal Quiz: Episode 47

▶ Ep 77 · 6:29
clinical There are many ways to tell if the anus is in the proper position, such as electrical stimulation and rectal ultrasound or MRI. ↗
▶ Ep 77 · 6:29
guideline Anorectal manometry is not part of the standard initial workup for anorectal malformation patients; it is saved for circumstances that are difficult to figure out. ↗
▶ Ep 77 · 6:29
quote We don't typically do anorectal manometry in our anorectal malformation patients as part of the standard initial workup. I never say never and I never say always, but it's not part of our standard evaluation. ↗
▶ Ep 77 · 9:40
quote This is one of those things I always wonder, cause we all have a few patients that have this anatomy like chicken or the egg. Like what came first? ↗
▶ Ep 77 · 16:49
quote I think this patient is going to be a bowel management candidate. And I doubt they will ever achieve successful bowel control anyway, given the quality of their pelvis, the amount of quadruple regression that they have. ↗
▶ Ep 77 · 16:49
clinical A sacral ratio of 0.45 indicates the sacrum is not great and the perineal musculature is probably not great. ↗
▶ Ep 77 · 16:49
clinical A patient with sacral ratio 0.45 is likely to be a bowel management candidate and will probably never achieve successful bowel control given the quality of their pelvis and amount of caudal regression. ↗
▶ Ep 77 · 17:18
host_summary Dr. Levitt has had some patients with good success with continence where the sigmoid is able to feel some distension after resection and sigmoid pull-through, but it is not the expectation. ↗

Colorectal Quiz: Episode 43

▶ Ep 79 · 5:37
epidemiological About 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff, but about 40% of the time you cannot make it work. ↗
▶ Ep 79 · 7:37
clinical The longer the appendix, the less likely it will leak based on Poiseuille's law (flow through a tube based on radius to fourth power and length). ↗
▶ Ep 79 · 8:35
quote So we plicate them all. And I haven't had a leakage in a long, long time, several years. So I think it's a very effective strategy. ↗
▶ Ep 79 · 8:35
clinical Dr. Frischer and Levitt did 10 Malones in a row without plicating and five leaked, so they decided to plicate them all and have not had a leakage in several years. ↗
▶ Ep 79 · 9:03
clinical If appendix is 7 centimeters or greater it can be split, requiring minimum 2 centimeters for the Malone and 5 centimeters minimum for the Mitrofanoff. ↗
▶ Ep 79 · 9:03
clinical If appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel. ↗
▶ Ep 79 · 9:03
clinical If appendix is 5 to 7 centimeters, that is not enough to share and should go for the Mitrofanoff because long term the Mitrofanovs do much better, requiring a neo-Malone. ↗
▶ Ep 79 · 16:13
clinical Using a 10 French tube (not 8), leaving it in for a month, and cathing twice a day can minimize stenosis rate. ↗
▶ Ep 79 · 16:54
clinical Leaving indwelling tubes in Malones increases the amount of prolapse, likely due to pressure on the appendiceal base pushing up mucosa. ↗
▶ Ep 79 · 17:45
clinical Urologists almost never get stenosis of Mitrofanovs because they catheterize every four hours; applying this to Malones by cathing twice daily has reduced stenosis rate. ↗
▶ Ep 79 · 20:00
clinical For lost Malone access, blow up a balloon on a Foley catheter to occlude the umbilicus and inject dye under pressure to find any micro hole tract. ↗

Colorectal Quiz: Episode 43

▶ Ep 78 · 5:37
epidemiological About 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff; about 40% of the time you cannot make it work. ↗
▶ Ep 78 · 7:37
clinical Flow of fluid through a tube is based on Poiseuille's law: radius to the fourth power and length. A longer appendix or narrower appendix affects flow probability. ↗
▶ Ep 78 · 8:35
clinical The longer the appendix, the less likely it will leak and you should not need to plicate. ↗
▶ Ep 78 · 8:35
clinical Plicating all malones is a very effective strategy; no leakage has occurred in several years using this approach. ↗
▶ Ep 78 · 8:35
epidemiological In a study of 10 malones done in a row without plicating, five leaked, leading to the decision to plicate all malones. ↗
▶ Ep 78 · 9:03
clinical If appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel. ↗
▶ Ep 78 · 9:03
clinical If appendix is five to seven centimeters, that is not enough to share and should go for the Mitrofanoff because long term the Mitrofanovs do much better, requiring a neo-Malone. ↗
▶ Ep 78 · 9:03
clinical If appendix is seven centimeters or greater it can be split, requiring minimum two centimeters for Malone and five centimeters minimum for Mitrofanoff. ↗
▶ Ep 78 · 10:00
clinical For patients with appendix 4-7 centimeters, 90% of appendix can be given to urologist with extension of appendiceal stump into cecum using non-cutting endo-TA stapler or hand-sewn non-absorbable braided suture. ↗
▶ Ep 78 · 12:08
clinical Pay attention to ileocecal valve location when creating Malone and plication to avoid obstruction at the ileocecal valve. ↗
▶ Ep 78 · 16:13
clinical Using a 10 French tube instead of 8, leaving it in for a month, and cathing twice a day has reduced the incidence of stenosis. ↗
▶ Ep 78 · 16:54
clinical Leaving tubes in prevents stenosis but increases the chance of leakage because the valve is no longer as pertinent with a stent across it. ↗
▶ Ep 78 · 16:54
clinical Prolonged stenting increases prolapse rate due to pressure on the appendiceal base pushing up mucosa. ↗
▶ Ep 78 · 17:45
clinical Urologists almost never get stenosis of Mitrofanoff because they cath every four hours; cathing the Malone twice a day has reduced stenosis rate. ↗
▶ Ep 78 · 18:20
clinical For recurrent leakage after two wraps, consider whether appendix length is a problem and whether channel needs lengthening. ↗
▶ Ep 78 · 20:00
clinical Blowing up a balloon on Foley catheter to occlude umbilicus and injecting dye creates pressurized system that will find any micro-hole tract still present. ↗

Colorectal Quiz: Episode 40

▶ Ep 79 · 11:35
clinical Options for vaginal reconstruction when native vagina cannot reach include: dilating the existing introitus, opening the area and laying in a buccal graft, or waiting for tissue engineering options expected within 20 years or less. ↗
▶ Ep 79 · 12:14
quote I think it's going to be, there are people right now taking a few vaginal cells and growing them and hopeful, just like you said, Mark, we're going to have some great tissue engineering that will assist us and make this a easier and better procedure for our patients. ↗
▶ Ep 79 · 13:09
opinion If a neovagina bridge is functioning well without problems, there may be no reason to remove it later. ↗
▶ Ep 79 · 15:57
quote Fred Reichman used to say, you are judged by what you are willing to stop for. And as surgeons, you have to be willing to say, hold on, I'm not exactly sure what I'm dealing with here. I'm going to stop. I'm going to get more information. I'm going to go get some help. I'm not going to plow through. ↗
▶ Ep 79 · 15:57
host_summary Fred Reichman used to say 'you are judged by what you are willing to stop for'—surgeons must be willing to stop when uncertain, get more information or help, rather than plowing through. ↗

Colorectal Quiz: Episode 40

▶ Ep 80 · 5:32
quote Wait, is this Meyer-Rotakansky-Kuster-Hauser syndrome? ↗
▶ Ep 80 · 11:35
opinion The introitus in this case is potentially dilatable in the future to create a functional vagina. ↗
▶ Ep 80 · 12:14
opinion Tissue engineering options for vaginal reconstruction are expected to be available within 20 years or perhaps even shorter, with researchers currently growing vaginal cells. ↗
▶ Ep 80 · 12:14
quote There are people right now taking a few vaginal cells and growing them. ↗
▶ Ep 80 · 13:09
quote I think you need it when there's a problem. If there's no problem, why go in and remove tissue, whether it be bowel or whatever you have as your graft? ↗
▶ Ep 80 · 13:09
opinion If a neovagina functions well and causes no problems, there is no reason to remove it later even if it is bowel or another graft material. ↗
▶ Ep 80 · 14:50
quote I applaud you, Chris, and your partners for going in thinking you're going to do this big reconstruction, encounter something that you weren't expecting and doing the safe thing. ↗
▶ Ep 80 · 15:57
opinion Fred Reichman used to say that surgeons are judged by what they are willing to stop for. ↗
▶ Ep 80 · 15:57
quote Fred Reichman used to say, you are judged by what you are willing to stop for. ↗
▶ Ep 80 · 15:57
guideline If a surgeon is uncertain about vascular anatomy during an operation, they should stop, gather more information, and reconfront the situation rather than proceeding blindly. ↗
▶ Ep 80 · 15:57
quote As surgeons, you have to be willing to say, hold on, I'm not exactly sure what I'm dealing with here. I'm going to stop. I'm going to get more information. I'm going to go get some help. I'm not going to plow through. ↗

Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies

▶ Ep 81 · 4:36
quote Do you automatically get an echo on every one of your anorectal malformation babies? ↗
▶ Ep 81 · 7:24
clinical In a cardiac patient with an external opening from ARM, the typical approach is to dilate as long as they're evacuating okay. ↗
▶ Ep 81 · 7:24
opinion For perineal fistula or vestibular fistula in a female, one can consider just dilating with good evacuation and letting the cardiac situation play itself out. ↗
▶ Ep 81 · 7:48
quote My concern would be if you're going to have a significant cardiac lesion that's going to likely require early surgery, you have a blue baby. You're having a lesion that a patient isn't oxygenating well. And then I worry about the healing of that repair ↗
▶ Ep 81 · 7:48
clinical In a blue baby with significant cardiac lesion requiring early surgery where patient isn't oxygenating well, there is concern about healing of an ARM repair. ↗
▶ Ep 81 · 11:08
quote Dissecting in with a mosquito, making sure you're in, not touching any vessel before you insufflate, and also clear the line of air ↗
▶ Ep 81 · 11:08
clinical For umbilical access in laparoscopy, dissect in with a mosquito, ensure you're in the peritoneum without touching any vessel before insufflation, and clear the line of air. ↗
▶ Ep 81 · 13:56
clinical The white beads along the raphe should be scraped off during repair, as they can persist into teenage years and young adulthood if left alone. ↗
▶ Ep 81 · 13:56
quote I've seen teenagers and young adults with those beads that never went away. So, yeah, you've got to scrape that off ↗
▶ Ep 81 · 14:23
clinical For a 50-50 perineal fistula (half within muscle complex, half anterior), leave the anterior wall as it's the danger zone, mobilize posteriorly to fill the anal sphincter, creating an 80-20 reconstruction. ↗

Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies

▶ Ep 82 · 4:36
quote Do you automatically get an echo on every one of your anorectal malformation babies? ↗
▶ Ep 82 · 7:24
clinical In a cardiac patient with an external ARM opening, the typical approach is to dilate as long as they're evacuating okay, allowing the cardiac situation to play itself out. ↗
▶ Ep 82 · 7:48
clinical The concern with early ARM repair in a blue baby with significant cardiac lesion requiring early surgery is the healing of that repair when the patient isn't oxygenating well. ↗
▶ Ep 82 · 7:48
quote My concern would be if you're going to have a significant cardiac lesion that's going to likely require early surgery, you have a blue baby. You're having a lesion that a patient isn't oxygenating well. And then I worry about the healing of that repair. ↗
▶ Ep 82 · 11:21
host_summary Dr. Levitt's technique for distal irrigation involves having someone look laparoscopically while he passes the tube into the distal segment and does the irrigation under direct visualization. ↗
▶ Ep 82 · 11:21
quote It is important to irrigate as much as you can ↗

Colorectal Quiz Episode 29: Female ARM

▶ Ep 83 · 7:17
clinical Dr. Frisher uses a midline catheter (not PICC line) with D10 until the repair is confirmed healed, typically five to seven days NPO. ↗
▶ Ep 83 · 15:02
clinical Approximately 20% of patients in the dilation study required a redo operation, either local or total, with most being local procedures. ↗

Colorectal Quiz Episode 29: Female ARM

▶ Ep 84 · 7:17
clinical Frischer uses midline catheter (not PICC line) with D10 for 5-7 days NPO after primary perineal body repair. ↗
▶ Ep 84 · 14:04
quote My only concern is what's the continence rate of your patients? You have a percent of looking at, right? You're somewhere in the order of 15 to 20, 22% got redo operations, mostly local. ↗
▶ Ep 84 · 15:02
host_summary Approximately 20% of patients in the dilation RCT required redo operations (either local or total), with most requiring only local revision. ↗
▶ Ep 84 · 15:23
clinical Long-term continence outcomes are unknown for patients who developed strictures and underwent revision in the non-dilation group. ↗
▶ Ep 84 · 16:30
clinical Full continence can be restored with redo surgery for stricture, based on available data for longer strictures requiring full redo. ↗

Colorectal Quiz: Episode 2

▶ Ep 85 · 1:46
quote That's the real frustrating one. ↗
▶ Ep 85 · 10:19
clinical In higher malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated ↗
▶ Ep 85 · 15:20
opinion Alternative approach for borderline anatomy: let the child try their current anatomy first; if it works well, stay with it; if not, consider redo ↗

Colorectal Quiz: Episode 2

▶ Ep 86 · 10:19
quote Patients like patients who have a higher malformation, such as a bladder neck, sometimes those sphincter complexes are sort of more anterior than you think that you're anticipating it might be. ↗
▶ Ep 86 · 10:19
clinical In higher malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated. ↗
▶ Ep 86 · 15:20
opinion An alternative approach for borderline anatomy is to be more conservative and let the child take their car out for a ride first to see how it works before considering redo. ↗

The Colorectal Quiz: Episode 1

▶ Ep 87 · 4:15
epidemiological Pre-sacral masses are rare in typical imperforate anus but occur in almost half of anal stenosis or rectal atresia cases, requiring MRI ↗
▶ Ep 87 · 4:15
quote if it's an anal stenosis or a rectal atresia defect, then you need to be very worried about finding a pre-sacral mass. And almost half the time, you'll find one. And those patients will end up getting an MRI. ↗
▶ Ep 87 · 5:05
guideline Cross-table lateral x-ray should be obtained at approximately 24 hours of life to assess gas column height and guide surgical planning ↗
▶ Ep 87 · 5:05
quote We typically get at about the 24-hour mark, give or take a few hours, a cross table lateral to see what does the gas column look like in this patient? Is there a low gas column that looks like it's almost touching the skin or is it pretty high up? And that might dictate what your next steps might be. ↗
▶ Ep 87 · 7:36
clinical Well-formed buttocks, good muscle, true sphincter mechanism area, and well-developed sacrum together indicate likely good prognosis ↗
▶ Ep 87 · 8:25
opinion With air column 8.8mm from skin, primary posterior sagittal anorectoplasty is a reasonable option based on imaging ↗
▶ Ep 87 · 8:25
quote I have two answers for you, Mark. I think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me. ↗
▶ Ep 87 · 9:57
quote you should never try to go in blind, right? We're going in with knowing that if we make a posterior sagittal incision right now, the first thing we're going to hit is that air pocket, which is the distal rectum. ↗
▶ Ep 87 · 9:57
guideline Should never try to go in blind—must know what structure will be encountered before making posterior sagittal incision ↗
▶ Ep 87 · 12:34
quote The reason why Dr. Levitt or Mark is saying that it's a bulbar fistula is it's at the elbow. You can see it's at the elbow of the urethra. And tell us that the nomenclature we like to use is an anatomic, pure anatomic nomenclature saying that it's a bulbar fistula. ↗
▶ Ep 87 · 12:34
quote you can see this fistula is very close to the rectum. And if you're going to dissect that free and along the urethra, it's important to make sure that you know that those two structures are not very far apart. And getting that into that proper plane is very important. ↗
▶ Ep 87 · 12:34
clinical Fistula can be very close to rectum, making proper plane dissection along urethra important ↗
▶ Ep 87 · 12:34
clinical Bulbar fistula nomenclature refers to anatomic location at the elbow of the urethra ↗

The Colorectal Quiz: Episode 1

▶ Ep 88 · 4:15
epidemiological Pre-sacral mass is rare in typical imperforate anus but occurs in almost half of anal stenosis or rectal atresia cases ↗
▶ Ep 88 · 4:15
clinical Patients with anal stenosis or rectal atresia and pre-sacral mass will need MRI evaluation ↗
▶ Ep 88 · 5:05
clinical Cross-table lateral x-ray is typically obtained at about 24 hours of life, give or take a few hours, to visualize the gas column position ↗
▶ Ep 88 · 5:05
quote We typically get at about the 24-hour mark, give or take a few hours, a cross table lateral to see what does the gas column look like in this patient? Is there a low gas column that looks like it's almost touching the skin or is it pretty high up? And that might dictate what your next steps might be. ↗
▶ Ep 88 · 7:36
clinical Well-formed buttocks, good muscle mass, and identifiable sphincter mechanism location on physical exam contribute to favorable prognosis in anorectal malformation ↗
▶ Ep 88 · 8:25
quote I have two answers for you, Mark. I think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me. ↗
▶ Ep 88 · 9:57
quote It goes without saying, and one of our, I think one of our big teaching points is you should never try to go in blind, right? We're going in with knowing that if we make a posterior sagittal incision right now, the first thing we're going to hit is that air pocket, which is the distal rectum. ↗
▶ Ep 88 · 12:34
clinical A bulbar fistula is named for its location at the elbow of the urethra, using pure anatomic nomenclature ↗
Cloaca 36 entries

Colorectal Quiz Episode 17: Cloaca Part 1

▶ Ep 12 · 11:30
quote This is huge. This is why, this is real time, and we all know a book chapter takes five years to, three to five years to get published. ↗

Colorectal Quiz Episode 18: Cloaca Part 2

▶ Ep 13 · 4:50
clinical During cystoscopy it is important to look for cervices to understand Müllerian development (one vagina vs. two, presence of uterus) and to identify ureteral orifices, which in complex malformations may attach anomalously low to the bladder or bladder neck. ↗

Colorectal Quiz: Episode 47

▶ Ep 20 · 6:29
clinical There are many ways to tell if the anus is in the proper position, such as electrical stimulation and rectal ultrasound or MRI. ↗
▶ Ep 20 · 6:29
guideline Anorectal manometry is not part of the standard initial workup for anorectal malformation patients; it is saved for circumstances that are difficult to figure out. ↗
▶ Ep 20 · 6:29
quote We don't typically do anorectal manometry in our anorectal malformation patients as part of the standard initial workup. I never say never and I never say always, but it's not part of our standard evaluation. ↗
▶ Ep 20 · 9:40
quote This is one of those things I always wonder, cause we all have a few patients that have this anatomy like chicken or the egg. Like what came first? ↗
▶ Ep 20 · 16:49
clinical A sacral ratio of 0.45 indicates the sacrum is not great and the perineal musculature is probably not great. ↗
▶ Ep 20 · 16:49
clinical A patient with sacral ratio 0.45 is likely to be a bowel management candidate and will probably never achieve successful bowel control given the quality of their pelvis and amount of caudal regression. ↗
▶ Ep 20 · 16:49
quote I think this patient is going to be a bowel management candidate. And I doubt they will ever achieve successful bowel control anyway, given the quality of their pelvis, the amount of quadruple regression that they have. ↗
▶ Ep 20 · 17:18
host_summary Dr. Levitt has had some patients with good success with continence where the sigmoid is able to feel some distension after resection and sigmoid pull-through, but it is not the expectation. ↗

Colorectal Quiz: Episode 40

▶ Ep 21 · 11:35
clinical Options for vaginal reconstruction when native vagina cannot reach include: dilating the existing introitus, opening the area and laying in a buccal graft, or waiting for tissue engineering options expected within 20 years or less. ↗
▶ Ep 21 · 12:14
quote I think it's going to be, there are people right now taking a few vaginal cells and growing them and hopeful, just like you said, Mark, we're going to have some great tissue engineering that will assist us and make this a easier and better procedure for our patients. ↗
▶ Ep 21 · 13:09
opinion If a neovagina bridge is functioning well without problems, there may be no reason to remove it later. ↗
▶ Ep 21 · 15:57
host_summary Fred Reichman used to say 'you are judged by what you are willing to stop for'—surgeons must be willing to stop when uncertain, get more information or help, rather than plowing through. ↗
▶ Ep 21 · 15:57
quote Fred Reichman used to say, you are judged by what you are willing to stop for. And as surgeons, you have to be willing to say, hold on, I'm not exactly sure what I'm dealing with here. I'm going to stop. I'm going to get more information. I'm going to go get some help. I'm not going to plow through. ↗

Colorectal Quiz: Episode 40

▶ Ep 22 · 5:32
quote Wait, is this Meyer-Rotakansky-Kuster-Hauser syndrome? ↗
▶ Ep 22 · 11:35
opinion The introitus in this case is potentially dilatable in the future to create a functional vagina. ↗
▶ Ep 22 · 12:14
opinion Tissue engineering options for vaginal reconstruction are expected to be available within 20 years or perhaps even shorter, with researchers currently growing vaginal cells. ↗
▶ Ep 22 · 12:14
quote There are people right now taking a few vaginal cells and growing them. ↗
▶ Ep 22 · 13:09
quote I think you need it when there's a problem. If there's no problem, why go in and remove tissue, whether it be bowel or whatever you have as your graft? ↗
▶ Ep 22 · 13:09
opinion If a neovagina functions well and causes no problems, there is no reason to remove it later even if it is bowel or another graft material. ↗
▶ Ep 22 · 14:50
quote I applaud you, Chris, and your partners for going in thinking you're going to do this big reconstruction, encounter something that you weren't expecting and doing the safe thing. ↗
▶ Ep 22 · 15:57
quote Fred Reichman used to say, you are judged by what you are willing to stop for. ↗
▶ Ep 22 · 15:57
quote As surgeons, you have to be willing to say, hold on, I'm not exactly sure what I'm dealing with here. I'm going to stop. I'm going to get more information. I'm going to go get some help. I'm not going to plow through. ↗
▶ Ep 22 · 15:57
opinion Fred Reichman used to say that surgeons are judged by what they are willing to stop for. ↗
▶ Ep 22 · 15:57
guideline If a surgeon is uncertain about vascular anatomy during an operation, they should stop, gather more information, and reconfront the situation rather than proceeding blindly. ↗

Colorectal Quiz Episode 18: Cloaca Part 2

▶ Ep 23 · 1:45
quote Yeah, so we usually do it at about five to six months. ↗
▶ Ep 23 · 1:45
clinical Definitive diagnostic workup for cloaca is usually performed at about 5-6 months of age ↗
▶ Ep 23 · 4:34
clinical During cystoscopy it is important to look for cervices to determine if there is one or two vaginas and assess Müllerian development ↗
▶ Ep 23 · 4:50
quote I think it's also important to look for cervices and see if you have one vagina, two vaginas. Do you have a cervix, which will sort of be the front door? Is there a uterus behind there? ↗
▶ Ep 23 · 5:00
clinical Surgeons should look for ureteral orifices during cystoscopy because in complex malformations there can be anomalous ureteral attachments to the bladder or bladder neck that come in very low and could be treacherous ↗
▶ Ep 23 · 7:41
opinion Endoscopy performed by general pediatric surgeons has value in determining whether a cloaca is straightforward or complex, helping surgeons decide whether to refer to a specialized center ↗
▶ Ep 23 · 8:30
clinical As recently as 10-15 years ago, there was much more redoing of cloacas required because surgeons attempted repairs without adequate evaluation and realized the cases were more complicated than imagined ↗
▶ Ep 23 · 8:30
quote I can tell you, as recently as 10 or 15 years ago, there was a lot more redoing of cloacas that was required because I think surgeons attempted a repair and then realized that it was much more complicated than they had imagined. ↗
▶ Ep 23 · 9:00
opinion Lower confluence cloacas are elegant operations if the surgeon knows how to perform them, while higher confluence cases with vaginal replacements and ectopic ureters should be done at specialized centers ↗
▶ Ep 23 · 19:00
quote The definition is of urethral length because I think some people may consider that from the single orifice all the way to the bladder neck and I don't think that's what you're alluding to. ↗
Colorectal / ARM & Hirschsprung 889 entries

Bowel Management Updates & Innovations with Live Q&A: April 2018

▶ Ep 2 · 0:15
clinical The Colorectal Center patient population includes anorectal malformations (imperforate anus), Hirschsprung's disease, spina bifida, sacrococcygeal teratomas, trauma patients, and refractory constipation. ↗
▶ Ep 2 · 0:15
clinical The Colorectal Center patient population includes anorectal malformations (imperforate anus), Hirschsprung's disease, spina bifida, sacrococcygeal teratomas, trauma patients, and refractory constipation. ↗
▶ Ep 2 · 2:32
clinical Appendicostomy (Malone/MAC/ACE procedure) involves bringing the appendix to the belly button with a valve mechanism to prevent reflux, allowing patients to independently administer flushes through the colon over 10–15 minutes, then sit on toilet for approximately 45 minutes to empty. ↗
▶ Ep 2 · 2:32
clinical Appendicostomy (Malone/MAC/ACE procedure) involves bringing the appendix to the belly button with a valve mechanism to prevent reflux, allowing patients to independently administer flushes through the colon over 10–15 minutes, then sit on toilet for approximately 45 minutes to empty. ↗
▶ Ep 2 · 3:42
clinical Sacral nerve stimulator is not FDA approved for children under 18, but is performed off-label; it acts like a heart pacemaker, stimulating the third sacral nerve to improve bowel and urinary continence outcomes. ↗
▶ Ep 2 · 3:42
clinical Sacral nerve stimulator is not FDA approved for children under 18, but is performed off-label; it acts like a heart pacemaker, stimulating the third sacral nerve to improve bowel and urinary continence outcomes. ↗
▶ Ep 2 · 4:41
clinical Sacral nerve stimulator is a two-stage procedure (test phase and permanent phase) and has been performed at Cincinnati Children's for almost 3 years. ↗
▶ Ep 2 · 4:41
clinical Sacral nerve stimulator is a two-stage procedure (test phase and permanent phase) and has been performed at Cincinnati Children's for almost 3 years. ↗
▶ Ep 2 · 4:53
clinical Solesta is an injection of hyaluronic acid polymer that fills space in the anal canal, used in patients with patulous (more open) anuses to help gain control. ↗
▶ Ep 2 · 4:53
clinical Solesta is an injection of hyaluronic acid polymer that fills space in the anal canal, used in patients with patulous (more open) anuses to help gain control. ↗
▶ Ep 2 · 7:27
clinical Patients with deformed sacrums have lower likelihood of success with bowel management using medication alone (not on enema program). ↗
▶ Ep 2 · 7:27
clinical Patients with deformed sacrums have lower likelihood of success with bowel management using medication alone (not on enema program). ↗
▶ Ep 2 · 7:50
clinical Malone procedure requires prior success with enemas because it only changes the route of administration; surgical procedure should not be performed on patients unsuccessful with enema program. ↗
▶ Ep 2 · 7:50
clinical Malone procedure requires prior success with enemas because it only changes the route of administration; surgical procedure should not be performed on patients unsuccessful with enema program. ↗
▶ Ep 2 · 8:17
clinical Malone procedure is typically performed starting at age 5 years and older, most commonly between ages 5 and 10–12 years. ↗
▶ Ep 2 · 8:17
clinical Malone procedure is typically performed starting at age 5 years and older, most commonly between ages 5 and 10–12 years. ↗
▶ Ep 2 · 8:53
clinical Vomiting after enema can be caused by high-volume enema with irritant causing colon distention and discomfort. ↗
▶ Ep 2 · 8:53
clinical Vomiting after enema can be caused by high-volume enema with irritant causing colon distention and discomfort. ↗
▶ Ep 2 · 10:59
guideline Sacral nerve stimulator indication per manufacturer requires 50% improvement on symptoms; patient must have tried non-surgical bowel management first. ↗
▶ Ep 2 · 10:59
guideline Sacral nerve stimulator indication per manufacturer requires 50% improvement on symptoms; patient must have tried non-surgical bowel management first. ↗
▶ Ep 2 · 11:17
clinical Sacral nerve stimulator requires normal sacrum; it is the least invasive option compared to Malone or Solesta when bowel management is working or needs improvement. ↗
▶ Ep 2 · 11:17
clinical Sacral nerve stimulator requires normal sacrum; it is the least invasive option compared to Malone or Solesta when bowel management is working or needs improvement. ↗
▶ Ep 2 · 11:49
clinical Using hybrid OR with 3D imaging, sacral nerve stimulator can be placed in patients with very abnormal sacrums by identifying anatomy in real-time. ↗
▶ Ep 2 · 11:49
clinical Using hybrid OR with 3D imaging, sacral nerve stimulator can be placed in patients with very abnormal sacrums by identifying anatomy in real-time. ↗
▶ Ep 2 · 13:45
clinical For failed redo Hirschsprung's pull-through, redo surgery can almost always create a channel for stool evacuation via rectum/anus, even after 1–3 prior redos; very few patients end up with ileostomy if goal is rectal evacuation. ↗
▶ Ep 2 · 13:45
clinical For failed redo Hirschsprung's pull-through, redo surgery can almost always create a channel for stool evacuation via rectum/anus, even after 1–3 prior redos; very few patients end up with ileostomy if goal is rectal evacuation. ↗
▶ Ep 2 · 17:18
clinical The large intestine (colon) primarily absorbs water; in adults it can absorb up to 1 liter of water per day. When colon is removed, stool becomes softer/looser because less water is absorbed. ↗
▶ Ep 2 · 17:18
clinical The large intestine (colon) primarily absorbs water; in adults it can absorb up to 1 liter of water per day. When colon is removed, stool becomes softer/looser because less water is absorbed. ↗
▶ Ep 2 · 17:46
clinical Bowel management sometimes requires using Imodium to constipate/harden stool, then using enema to empty it—thickening stool first, then mechanically emptying. ↗
▶ Ep 2 · 17:46
clinical Bowel management sometimes requires using Imodium to constipate/harden stool, then using enema to empty it—thickening stool first, then mechanically emptying. ↗
▶ Ep 2 · 19:12
opinion There is no perfect surgery for constipation; if there were, all surgeons would recommend and perform it. ↗
▶ Ep 2 · 19:12
opinion There is no perfect surgery for constipation; if there were, all surgeons would recommend and perform it. ↗
▶ Ep 2 · 19:12
quote There is no perfect surgery for constipation. If we had it, we would all recommend it and do it. ↗
▶ Ep 2 · 19:12
quote There is no perfect surgery for constipation. If we had it, we would all recommend it and do it. ↗
▶ Ep 2 · 19:20
clinical Transanal colon/rectum resection is minimally invasive but carries risk of post-surgical incontinence in some patients. ↗
▶ Ep 2 · 19:20
clinical Transanal colon/rectum resection is minimally invasive but carries risk of post-surgical incontinence in some patients. ↗
▶ Ep 2 · 19:56
clinical Colon resection for constipation may lessen treatment burden (e.g., reduce laxative dose from 10 to 5 squares of Ex-Lax) but this outcome is not guaranteed. ↗
▶ Ep 2 · 19:56
clinical Colon resection for constipation may lessen treatment burden (e.g., reduce laxative dose from 10 to 5 squares of Ex-Lax) but this outcome is not guaranteed. ↗
▶ Ep 2 · 20:22
clinical Before colon resection, offer sacral nerve stimulator and perform manometry (colonic and anorectal) to identify non-functioning colon segments or outlet problems (sphincter dysfunction). ↗
▶ Ep 2 · 20:22
clinical Before colon resection, offer sacral nerve stimulator and perform manometry (colonic and anorectal) to identify non-functioning colon segments or outlet problems (sphincter dysfunction). ↗
▶ Ep 2 · 20:55
clinical Anorectal manometry can reveal paradoxical sphincter function where child squeezes when trying to relax and vice versa; Botox works in younger children, physical therapy and biofeedback in older children for this. ↗
▶ Ep 2 · 20:55
clinical Anorectal manometry can reveal paradoxical sphincter function where child squeezes when trying to relax and vice versa; Botox works in younger children, physical therapy and biofeedback in older children for this. ↗
▶ Ep 2 · 22:31
clinical Colon resection is a big surgery requiring bowel anastomosis with associated risks; once colon is resected, it cannot be replaced. All other treatments (sacral nerve, enemas, laxatives) are reversible. ↗
▶ Ep 2 · 22:31
clinical Colon resection is a big surgery requiring bowel anastomosis with associated risks; once colon is resected, it cannot be replaced. All other treatments (sacral nerve, enemas, laxatives) are reversible. ↗
▶ Ep 2 · 25:25
opinion Senna laxative is like insulin for a diabetic—a necessary medication to help move bowels in severe constipation; dose may change over time but patients are not 'addicted' to it. ↗
▶ Ep 2 · 25:25
opinion Senna laxative is like insulin for a diabetic—a necessary medication to help move bowels in severe constipation; dose may change over time but patients are not 'addicted' to it. ↗
▶ Ep 2 · 25:29
quote I sort of say it's like insulin for a diabetic. A diabetic needs insulin to lower their blood blood glucose levels. A patient who has severe constipation needs a laxative stimulant to help move their bowels. ↗
▶ Ep 2 · 25:29
quote I sort of say it's like insulin for a diabetic. A diabetic needs insulin to lower their blood blood glucose levels. A patient who has severe constipation needs a laxative stimulant to help move their bowels. ↗
▶ Ep 2 · 26:48
clinical Stimulant laxatives (Senna, Dulcolax) make the colon squeeze/push stool forward and reduce water absorption time, resulting in softer stool—two mechanisms that benefit the patient population. ↗
▶ Ep 2 · 26:48
clinical Stimulant laxatives (Senna, Dulcolax) make the colon squeeze/push stool forward and reduce water absorption time, resulting in softer stool—two mechanisms that benefit the patient population. ↗
▶ Ep 2 · 27:17
clinical Only two stimulant laxatives are available in the United States: Senna (Ex-Lax chocolate squares, tablet, liquid forms) and Dulcolax. ↗
▶ Ep 2 · 27:17
clinical Only two stimulant laxatives are available in the United States: Senna (Ex-Lax chocolate squares, tablet, liquid forms) and Dulcolax. ↗
▶ Ep 2 · 27:35
clinical MiraLax is not a stimulant laxative; it prevents colon from absorbing water, keeping water in colon and making stool softer. ↗
▶ Ep 2 · 27:35
clinical MiraLax is not a stimulant laxative; it prevents colon from absorbing water, keeping water in colon and making stool softer. ↗
▶ Ep 2 · 27:51
clinical MiraLax is avoided in patients without full continence mechanisms because very loose stool is hard to control when nerves and muscle are partially impaired. ↗
▶ Ep 2 · 27:51
clinical MiraLax is avoided in patients without full continence mechanisms because very loose stool is hard to control when nerves and muscle are partially impaired. ↗
▶ Ep 2 · 28:15
clinical In spinal cord patients (tethered cord, spina bifida), stool is often so formed that MiraLax-type agent is needed to soften stool along with motility agents. ↗
▶ Ep 2 · 28:15
clinical In spinal cord patients (tethered cord, spina bifida), stool is often so formed that MiraLax-type agent is needed to soften stool along with motility agents. ↗
▶ Ep 2 · 30:09
clinical Bowel rest with colostomy is typically used in patients with anorectal malformation or Hirschsprung's pull-through complications (narrowing, stenosis, tightness) causing dilated colon/rectum upstream. ↗
▶ Ep 2 · 30:09
clinical Bowel rest with colostomy is typically used in patients with anorectal malformation or Hirschsprung's pull-through complications (narrowing, stenosis, tightness) causing dilated colon/rectum upstream. ↗
▶ Ep 2 · 30:47
clinical If colostomy is not working due to constipation, consider ileostomy to totally exclude colon and divert stool before it reaches colon. ↗
▶ Ep 2 · 30:47
clinical If colostomy is not working due to constipation, consider ileostomy to totally exclude colon and divert stool before it reaches colon. ↗
▶ Ep 2 · 35:30
clinical Michael Helmrath at Cincinnati Children's is growing colons in the lab from single cells, able to lengthen colon in mice and expanding to larger primates. ↗
▶ Ep 2 · 35:30
clinical Michael Helmrath at Cincinnati Children's is growing colons in the lab from single cells, able to lengthen colon in mice and expanding to larger primates. ↗
▶ Ep 2 · 35:48
clinical Anal sphincter tissue regeneration has been attempted by many researchers (using muscles from other areas, other sphincters from esophagus/stomach) but none have been proven to work; no successful procedure is currently offered. ↗
▶ Ep 2 · 35:48
clinical Anal sphincter tissue regeneration has been attempted by many researchers (using muscles from other areas, other sphincters from esophagus/stomach) but none have been proven to work; no successful procedure is currently offered. ↗
▶ Ep 2 · 37:00
clinical Cincinnati Children's has nearly 3 years of experience with sacral nerve stimulators in children; it works in refractory constipation and combined urinary/stool issues, but pediatric patient heterogeneity makes outcome prediction difficult. ↗
▶ Ep 2 · 37:00
clinical Cincinnati Children's has nearly 3 years of experience with sacral nerve stimulators in children; it works in refractory constipation and combined urinary/stool issues, but pediatric patient heterogeneity makes outcome prediction difficult. ↗
▶ Ep 2 · 37:05
clinical Sacral nerve stimulator was initially designed for urinary incontinence in postpartum women; during testing it was found to also help fecal constipation and incontinence, leading to later FDA approval for fecal symptoms. ↗
▶ Ep 2 · 37:05
clinical Sacral nerve stimulator was initially designed for urinary incontinence in postpartum women; during testing it was found to also help fecal constipation and incontinence, leading to later FDA approval for fecal symptoms. ↗
▶ Ep 2 · 37:30
clinical Sacral nerve stimulator in adults is used in patients with normal anatomy/development, but in pediatrics it is used in patients with prior pelvic operations, malformations, or disease processes, making study difficult because every patient is different. ↗
▶ Ep 2 · 37:30
clinical Sacral nerve stimulator in adults is used in patients with normal anatomy/development, but in pediatrics it is used in patients with prior pelvic operations, malformations, or disease processes, making study difficult because every patient is different. ↗
▶ Ep 2 · 38:58
clinical Sacral nerve stimulator has a temporary trial stage (1–2 weeks); if it doesn't work, the device is removed without implanting permanent battery. ↗
▶ Ep 2 · 38:58
clinical Sacral nerve stimulator has a temporary trial stage (1–2 weeks); if it doesn't work, the device is removed without implanting permanent battery. ↗
▶ Ep 2 · 40:34
clinical Constipation or fecal impaction puts pressure on urinary tract, causing urinary infections, improper emptying, urgency, and other symptoms; treating stool issues is often first step before urologic investigation. ↗
▶ Ep 2 · 40:34
clinical Constipation or fecal impaction puts pressure on urinary tract, causing urinary infections, improper emptying, urgency, and other symptoms; treating stool issues is often first step before urologic investigation. ↗
▶ Ep 2 · 41:58
guideline All anorectal malformation patients should be followed by urology long-term; more complex malformations have more associated urinary tract malformations, but even minor malformations require periodic follow-up to ensure kidney function and proper urinary tract emptying. ↗
▶ Ep 2 · 41:58
guideline All anorectal malformation patients should be followed by urology long-term; more complex malformations have more associated urinary tract malformations, but even minor malformations require periodic follow-up to ensure kidney function and proper urinary tract emptying. ↗
▶ Ep 2 · 42:43
clinical Urinary tract problems in anorectal malformation patients can cause diminished health with late-appearing signs/symptoms; regular urology checkups (exam, renal ultrasound, possibly further testing) are important even without visible problems. ↗
▶ Ep 2 · 42:43
clinical Urinary tract problems in anorectal malformation patients can cause diminished health with late-appearing signs/symptoms; regular urology checkups (exam, renal ultrasound, possibly further testing) are important even without visible problems. ↗
▶ Ep 2 · 43:37
clinical Cincinnati Children's has weekly meeting with colorectal, urology, and gynecology teams reviewing all patients to ensure comprehensive (not just focused) evaluation. ↗
▶ Ep 2 · 43:37
clinical Cincinnati Children's has weekly meeting with colorectal, urology, and gynecology teams reviewing all patients to ensure comprehensive (not just focused) evaluation. ↗
▶ Ep 2 · 44:12
clinical Long-term MiraLax literature is scant; many patients do fine on it. A class action lawsuit against MiraLax occurred 1–2 years ago but has not been heard about recently. ↗
▶ Ep 2 · 44:12
clinical Long-term MiraLax literature is scant; many patients do fine on it. A class action lawsuit against MiraLax occurred 1–2 years ago but has not been heard about recently. ↗
▶ Ep 2 · 45:00
clinical A couple of studies suggested MiraLax may have less-than-ideal neurodevelopmental outcomes, but these have not been reproduced; it is something to be thoughtful about when prescribing. ↗
▶ Ep 2 · 45:00
clinical A couple of studies suggested MiraLax may have less-than-ideal neurodevelopmental outcomes, but these have not been reproduced; it is something to be thoughtful about when prescribing. ↗
▶ Ep 2 · 46:05
clinical Fleet phosphate enema causes the most irritation with long-term use, making colon look like a 'lead pipe' (very stiff, lacking mobility and pliability); it is used intermittently as rescue enema, not for long-term maintenance. ↗
▶ Ep 2 · 46:05
clinical Fleet phosphate enema causes the most irritation with long-term use, making colon look like a 'lead pipe' (very stiff, lacking mobility and pliability); it is used intermittently as rescue enema, not for long-term maintenance. ↗
▶ Ep 2 · 47:14
clinical Solesta is not FDA approved for children; it is used in patients with patulous (open) anus as a filler to close the anal canal and help with fecal incontinence. ↗
▶ Ep 2 · 47:14
clinical Solesta is not FDA approved for children; it is used in patients with patulous (open) anus as a filler to close the anal canal and help with fecal incontinence. ↗
▶ Ep 2 · 48:13
clinical Solesta can be used in any age patient; Cincinnati has used it in patients 3–4 years old and older, with mixed results but little side effect (small infection risk). ↗
▶ Ep 2 · 48:13
clinical Solesta can be used in any age patient; Cincinnati has used it in patients 3–4 years old and older, with mixed results but little side effect (small infection risk). ↗
▶ Ep 2 · 48:31
clinical Solesta or sacral nerve stimulator may help patients transition from enemas to laxatives when prior attempts have failed, depending on individual anal canal anatomy and situation. ↗
▶ Ep 2 · 48:31
clinical Solesta or sacral nerve stimulator may help patients transition from enemas to laxatives when prior attempts have failed, depending on individual anal canal anatomy and situation. ↗
▶ Ep 2 · 49:17
clinical Sacral nerve stimulator results in spina bifida patients are mixed; some respond positively, others do not. Literature and research exist on this. ↗
▶ Ep 2 · 49:17
clinical Sacral nerve stimulator results in spina bifida patients are mixed; some respond positively, others do not. Literature and research exist on this. ↗
▶ Ep 2 · 49:36
clinical Sacral nerve stimulator in spina bifida requires adequate sacrum anatomy and presence of third sacral foramina (opening where third sacral nerve exits sacrum to innervate pelvis). ↗
▶ Ep 2 · 49:36
clinical Sacral nerve stimulator in spina bifida requires adequate sacrum anatomy and presence of third sacral foramina (opening where third sacral nerve exits sacrum to innervate pelvis). ↗
▶ Ep 2 · 51:56
clinical Botox is a muscle relaxant that relaxes the anal sphincter; it is used in Hirschsprung's disease patients with high anal resting pressures. ↗
▶ Ep 2 · 51:56
clinical Botox is a muscle relaxant that relaxes the anal sphincter; it is used in Hirschsprung's disease patients with high anal resting pressures. ↗
▶ Ep 2 · 52:19
clinical Solesta is hyaluronic acid polymer, a gel filling agent that closes a wide-open (patulous) anal canal; it acts very differently from Botox. ↗
▶ Ep 2 · 52:19
clinical Solesta is hyaluronic acid polymer, a gel filling agent that closes a wide-open (patulous) anal canal; it acts very differently from Botox. ↗
▶ Ep 2 · 55:06
clinical Hirschsprung's patients can potty train around the same age as other children; some will have harder time with continence depending on post-surgical anal canal anatomy and development. ↗
▶ Ep 2 · 55:06
clinical Hirschsprung's patients can potty train around the same age as other children; some will have harder time with continence depending on post-surgical anal canal anatomy and development. ↗
▶ Ep 2 · 55:30
clinical Hirschsprung's evaluation requires contrast enema to assess surgical anatomy of anal canal and entire colon, plus repeat biopsy because initial frozen section may show adequate nerve cells but later those cells may be less abundant (transition zone). ↗
▶ Ep 2 · 55:30
clinical Hirschsprung's evaluation requires contrast enema to assess surgical anatomy of anal canal and entire colon, plus repeat biopsy because initial frozen section may show adequate nerve cells but later those cells may be less abundant (transition zone). ↗
▶ Ep 2 · 56:58
clinical Anorectal malformation is abnormal development of where colon/rectum ends up (where it 'lands' in development); there is a wide spectrum in males and females. ↗
▶ Ep 2 · 56:58
clinical Anorectal malformation is abnormal development of where colon/rectum ends up (where it 'lands' in development); there is a wide spectrum in males and females. ↗
▶ Ep 2 · 57:13
clinical In anorectal malformation, rectum can land outside anal canal/sphincter complex on skin just above that area, outside vagina in girls, anywhere along urinary tract in boys (with fistula causing stool to come out urinary tract), or connected to bladder in more complex cases. ↗
▶ Ep 2 · 57:13
clinical In anorectal malformation, rectum can land outside anal canal/sphincter complex on skin just above that area, outside vagina in girls, anywhere along urinary tract in boys (with fistula causing stool to come out urinary tract), or connected to bladder in more complex cases. ↗
▶ Ep 2 · 57:53
clinical Anorectal malformation diagnosis requires good physical exam and sometimes imaging. ↗
▶ Ep 2 · 57:53
clinical Anorectal malformation diagnosis requires good physical exam and sometimes imaging. ↗

Hirschsprung Disease - Imperforate Anus - Rectal Prolapse: Update Course 2015

▶ Ep 14 · 4:22
opinion A pure transanal Hirschsprung dissection is not necessarily less invasive than laparoscopic approach; prolonged torquing in the anal canal may be more traumatic than three small abdominal incisions. ↗
▶ Ep 14 · 4:22
quote I, I don't believe that a pure trans anal is necessarily less invasive. In other words, I believe that putting 3 incisions on the abdomen is actually less invasive in my hands, in my hands, certainly not in your guys' hands, but in my hands, I'm gonna be torquing in that anal canal much more than if I had done it laparoscopically and freed everything up from the abdominal approach. ↗
▶ Ep 14 · 4:22
opinion A pure transanal Hirschsprung dissection is not necessarily less invasive than laparoscopic approach; prolonged torquing in the anal canal may be more traumatic than three small abdominal incisions. ↗
▶ Ep 14 · 4:22
quote I, I don't believe that a pure trans anal is necessarily less invasive. In other words, I believe that putting 3 incisions on the abdomen is actually less invasive in my hands, in my hands, certainly not in your guys' hands, but in my hands, I'm gonna be torquing in that anal canal much more than if I had done it laparoscopically and freed everything up from the abdominal approach. ↗
▶ Ep 14 · 5:46
clinical For standard rectosigmoid Hirschsprung disease (6-10 cm up), transanal dissection can be completed in the same timeframe as laparoscopic mobilization if the surgeon knows the level from a good contrast study. ↗
▶ Ep 14 · 5:46
clinical For standard rectosigmoid Hirschsprung disease (6-10 cm up), transanal dissection can be completed in the same timeframe as laparoscopic mobilization if the surgeon knows the level from a good contrast study. ↗
▶ Ep 14 · 6:12
clinical Post-Hirschsprung complications divide into two categories: obstructive symptoms (enterocolitis, failure to thrive, distention) and soiling issues (true incontinence vs pseudo-incontinence from constipation). ↗
▶ Ep 14 · 6:12
clinical Post-Hirschsprung complications divide into two categories: obstructive symptoms (enterocolitis, failure to thrive, distention) and soiling issues (true incontinence vs pseudo-incontinence from constipation). ↗
▶ Ep 14 · 7:25
clinical Workup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia looking for dentate line position, stricture, stretched sphincter, and twists; if no anatomic cause is found, perform biopsy. ↗
▶ Ep 14 · 7:25
clinical Workup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia looking for dentate line position, stricture, stretched sphincter, and twists; if no anatomic cause is found, perform biopsy. ↗
▶ Ep 14 · 9:04
clinical For Hirschsprung pull-through, dissection should start approximately 1 cm above the dentate line (defined as the transition from squamous to columnar epithelium, at the bottom of the anal columns). ↗
▶ Ep 14 · 9:04
clinical Going only 0.5 cm above the dentate line in a newborn may result in 2.5-3 cm of aganglionic segment remaining when the child reaches 7 years old, creating an ultra-short segment Hirschsprung situation with constipation. ↗
▶ Ep 14 · 9:04
clinical For Hirschsprung pull-through, dissection should start approximately 1 cm above the dentate line (defined as the transition from squamous to columnar epithelium, at the bottom of the anal columns). ↗
▶ Ep 14 · 9:04
clinical Going only 0.5 cm above the dentate line in a newborn may result in 2.5-3 cm of aganglionic segment remaining when the child reaches 7 years old, creating an ultra-short segment Hirschsprung situation with constipation. ↗
▶ Ep 14 · 9:43
opinion Injury to the dentate line during Hirschsprung pull-through can cause devastating fecal incontinence; it is better to risk leaving ultra-short segment aganglionosis (manageable with laxatives) than to injure the dentate line. ↗
▶ Ep 14 · 9:43
quote I want to ensure, because, and maybe we have a biased population in what we see, that I do not injure the dentate line because the patients who are rendered potentially fecally incontinent due to injury to the dentate line is a devastating injury for those patients. ↗
▶ Ep 14 · 9:43
opinion Injury to the dentate line during Hirschsprung pull-through can cause devastating fecal incontinence; it is better to risk leaving ultra-short segment aganglionosis (manageable with laxatives) than to injure the dentate line. ↗
▶ Ep 14 · 9:43
quote I want to ensure, because, and maybe we have a biased population in what we see, that I do not injure the dentate line because the patients who are rendered potentially fecally incontinent due to injury to the dentate line is a devastating injury for those patients. ↗
▶ Ep 14 · 10:39
clinical In ulcerative colitis or FAP patients undergoing J-pouch creation, dissection goes right at the top of the columns, or even slightly lower if polyps are present in that region. ↗
▶ Ep 14 · 10:39
clinical In ulcerative colitis or FAP patients undergoing J-pouch creation, dissection goes right at the top of the columns, or even slightly lower if polyps are present in that region. ↗
▶ Ep 14 · 11:39
clinical The dentate line is variably defined in anatomic literature and textbooks; different sources point to different locations within the anal columns when labeling the dentate or pectinate line. ↗
▶ Ep 14 · 11:39
clinical The dentate line is variably defined in anatomic literature and textbooks; different sources point to different locations within the anal columns when labeling the dentate or pectinate line. ↗
▶ Ep 14 · 17:17
clinical The traditional teaching that newborn meconium is sterile and therefore anorectal malformation repair should be done in the newborn period (before dilations introduce bacteria) is questioned; some surgeons repair at any age with stool present and feed early postoperatively with similar complication rates. ↗
▶ Ep 14 · 17:17
clinical The traditional teaching that newborn meconium is sterile and therefore anorectal malformation repair should be done in the newborn period (before dilations introduce bacteria) is questioned; some surgeons repair at any age with stool present and feed early postoperatively with similar complication rates. ↗
▶ Ep 14 · 17:27
clinical Conservative postoperative management of anorectal malformation repair includes keeping the patient NPO for approximately one week with hyperalimentation (a 'medical colostomy'), though there is no data supporting this practice over early feeding. ↗
▶ Ep 14 · 17:27
clinical Conservative postoperative management of anorectal malformation repair includes keeping the patient NPO for approximately one week with hyperalimentation (a 'medical colostomy'), though there is no data supporting this practice over early feeding. ↗
▶ Ep 14 · 17:50
quote I know there are a number of pediatric surgeons that will repair an anorectal malformation at whatever age with dirty stool and feed the child the day 1 or 2 days post-op when they recover from the anesthesia, and I'm sure that incidence of complication is probably similar. ↗
▶ Ep 14 · 17:50
quote I know there are a number of pediatric surgeons that will repair an anorectal malformation at whatever age with dirty stool and feed the child the day 1 or 2 days post-op when they recover from the anesthesia, and I'm sure that incidence of complication is probably similar. ↗
▶ Ep 14 · 18:54
clinical When vestibular fistula is discovered intraoperatively to have an absent vagina, management depends on prognosis for bowel control: if good prognosis, use graft (colon or small bowel) to create vagina and bring rectum down; if poor prognosis (sacral agenesis, tethered cord), use the rectum/fistula as vagina and bring proximal colon down as pull-through. ↗
▶ Ep 14 · 18:54
clinical When vestibular fistula is discovered intraoperatively to have an absent vagina, management depends on prognosis for bowel control: if good prognosis, use graft (colon or small bowel) to create vagina and bring rectum down; if poor prognosis (sacral agenesis, tethered cord), use the rectum/fistula as vagina and bring proximal colon down as pull-through. ↗
▶ Ep 14 · 20:09
clinical Rectal prolapse workup should distinguish full-thickness prolapse from partial-thickness (mucosal) prolapse based on physical examination appearance. ↗
▶ Ep 14 · 20:09
clinical Rectal prolapse workup should distinguish full-thickness prolapse from partial-thickness (mucosal) prolapse based on physical examination appearance. ↗
▶ Ep 14 · 20:49
clinical Testing for cystic fibrosis in children presenting with rectal prolapse is traditional teaching and a board exam answer, but in clinical practice rarely identifies new CF cases; most CF patients with prolapse are already diagnosed. ↗
▶ Ep 14 · 20:49
clinical Testing for cystic fibrosis in children presenting with rectal prolapse is traditional teaching and a board exam answer, but in clinical practice rarely identifies new CF cases; most CF patients with prolapse are already diagnosed. ↗
▶ Ep 14 · 21:19
clinical Initial management of rectal prolapse includes treating constipation and limiting toilet sitting time to 5 minutes; surgical intervention is considered after 6 months to 2 years of failed medical management. ↗
▶ Ep 14 · 21:19
clinical Initial management of rectal prolapse includes treating constipation and limiting toilet sitting time to 5 minutes; surgical intervention is considered after 6 months to 2 years of failed medical management. ↗
▶ Ep 14 · 22:45
clinical Sclerosing agent injection for rectal prolapse has high recurrence rates; patients who fail this approach and require subsequent rectopexy have difficult reoperative dissection. ↗
▶ Ep 14 · 22:45
quote I can tell you when it recurs to re-operate on those patients is not going to matter at all. ↗
▶ Ep 14 · 22:45
clinical Sclerosing agent injection for rectal prolapse has high recurrence rates; patients who fail this approach and require subsequent rectopexy have difficult reoperative dissection. ↗
▶ Ep 14 · 22:45
quote I can tell you when it recurs to re-operate on those patients is not going to matter at all. ↗
▶ Ep 14 · 23:02
epidemiological Transabdominal approaches for rectal prolapse (rectopexy with or without resection) have approximately 5% recurrence rate, compared to 15-20% recurrence for transanal approaches (transanal pull-through or Altmeier procedure). ↗
▶ Ep 14 · 23:02
host_summary Transabdominal approaches for rectal prolapse (rectopexy with or without resection) have approximately 5% recurrence rate, compared to 15-20% recurrence for transanal approaches (transanal pull-through or Altmeier procedure). ↗
▶ Ep 14 · 23:36
host_summary Resection and rectopexy for rectal prolapse may be preferable when constipation control is difficult, but has higher complication rate compared to rectopexy alone. ↗
▶ Ep 14 · 23:36
clinical Resection and rectopexy for rectal prolapse may be preferable when constipation control is difficult, but has higher complication rate compared to rectopexy alone. ↗
▶ Ep 14 · 23:56
clinical Laparoscopic rectopexy for rectal prolapse can be performed as same-day surgery or with next-day discharge in current practice. ↗
▶ Ep 14 · 23:56
host_summary Laparoscopic rectopexy for rectal prolapse can be performed as same-day surgery or with next-day discharge in current practice. ↗
▶ Ep 14 · 24:10
clinical Mesh erosion is a known complication of ventral mesh rectopexy, but the procedure can be effective for refractory rectal prolapse after multiple failed transabdominal repairs. ↗
▶ Ep 14 · 24:10
clinical Mesh erosion is a known complication of ventral mesh rectopexy, but the procedure can be effective for refractory rectal prolapse after multiple failed transabdominal repairs. ↗
▶ Ep 14 · 24:10
clinical Ventral mesh rectopexy is a newer procedure popularized by the Cleveland Clinic for rectal prolapse; it involves placing mesh on the anterior rectum surface, elevating the rectum without posterior dissection, and tacking mesh to the sacral promontory. ↗
▶ Ep 14 · 24:10
clinical Ventral mesh rectopexy is a newer procedure popularized by the Cleveland Clinic for rectal prolapse; it involves placing mesh on the anterior rectum surface, elevating the rectum without posterior dissection, and tacking mesh to the sacral promontory. ↗
▶ Ep 14 · 24:55
clinical Ventral mesh rectopexy aims to change the angle between rectum and anal canal; younger patients with rectal prolapse have a straighter rectum-to-anal-canal angle that becomes more acute with age. ↗
▶ Ep 14 · 24:55
clinical Ventral mesh rectopexy aims to change the angle between rectum and anal canal; younger patients with rectal prolapse have a straighter rectum-to-anal-canal angle that becomes more acute with age. ↗

Hirschsprung Disease: Update Course 2015

▶ Ep 35 · 0:22
quote I recall having a full day of uh Hirschprung's webcast, and now I get 5 minutes. ↗
▶ Ep 35 · 3:06
opinion The safest approach to Hirschsprung surgery involves some form of biopsy (laparoscopic or full-thickness through umbilicus) prior to definitive pull-through. ↗
▶ Ep 35 · 3:06
quote I, every time that I do a primary trans anal, I get. I tighten up a little bit to make sure that I'm confident that I can do, and I have an exit strategy in mind if I get in trouble ↗
▶ Ep 35 · 3:46
opinion Leveling colostomy may be the safest approach when institutional pathology expertise in reading Hirschsprung biopsies is limited or unavailable. ↗
▶ Ep 35 · 4:03
clinical Leveling colostomy represents a three-stage procedure for Hirschsprung disease management. ↗
▶ Ep 35 · 5:07
opinion Prolonged transanal dissection (approaching 4 hours) should prompt consideration of converting to laparoscopic approach to avoid excessive sphincter stretching. ↗
▶ Ep 35 · 5:07
quote Belinda and I talk about this a lot, and it's about a comfort level and how fit, I take, I watch the clock how long I'm doing a trans anal dissection because I do not want to be stretching on those sphincters for 4 hours trying to dig up in a dark hole when I could put a scope in. ↗
▶ Ep 35 · 5:30
clinical Laparoscopic mobilization with 3-millimeter ports can be completed in approximately 45 minutes for appropriate cases. ↗
▶ Ep 35 · 5:46
clinical Standard rectosigmoid Hirschsprung disease (6-10 centimeters proximal) can be completed transanally in approximately 2 hours when the level is known from a good contrast study. ↗
▶ Ep 35 · 6:12
clinical Complications after Hirschsprung surgery are divided into two categories: obstructive symptoms (including enterocolitis, failure to thrive, abdominal distention) and soiling issues. ↗
▶ Ep 35 · 6:31
clinical Soiling after Hirschsprung surgery is further classified into true incontinence and pseudo-incontinence. ↗
▶ Ep 35 · 6:45
clinical Obstructive symptoms after Hirschsprung surgery require differentiation between anatomic problems and pathologic problems. ↗
▶ Ep 35 · 6:52
clinical True fecal incontinence after Hirschsprung surgery can result from injury to the sphincter or injury to the dentate line. ↗
▶ Ep 35 · 7:04
clinical Pseudo-incontinence after Hirschsprung surgery may be caused by underlying constipation. ↗
▶ Ep 35 · 7:08
host_summary Jack Langer published an algorithm for working up patients with problems after Hirschsprung disease. ↗
▶ Ep 35 · 7:25
clinical Workup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia evaluating dentate line position, stricture, stretched sphincter, and anatomic twists. ↗

Hirschsprung Disease: Update Course 2013

▶ Ep 53 · 8:56
epidemiological Female patients may have higher risk of long-segment disease, with 50-50 incidence of long-segment in girls ↗
▶ Ep 53 · 8:56
epidemiological Female patients may have higher risk of long-segment disease, with 50-50 incidence of long-segment in girls ↗
▶ Ep 53 · 32:05
clinical Transanal resection of massively dilated colon in older children causes enormous sphincter stretch and impairs postoperative continence; laparoscopic dissection to pelvic floor is preferred ↗
▶ Ep 53 · 32:05
clinical Transanal resection of massively dilated colon in older children causes enormous sphincter stretch and impairs postoperative continence; laparoscopic dissection to pelvic floor is preferred ↗
▶ Ep 53 · 33:42
quote that patient was at a well-known institution in Ohio. And had, was seen by GI and had multiple biopsies that were normal. Those were done by colonoscopy ↗
▶ Ep 53 · 33:42
clinical Colonoscopic biopsies can miss Hirschsprung disease; rectal biopsy is more reliable ↗
▶ Ep 53 · 33:42
quote that patient was at a well-known institution in Ohio. And had, was seen by GI and had multiple biopsies that were normal. Those were done by colonoscopy ↗
▶ Ep 53 · 33:42
clinical Colonoscopic biopsies can miss Hirschsprung disease; rectal biopsy is more reliable ↗
▶ Ep 53 · 34:04
quote just caution to watch out what type of biopsy was performed and how Hirschprung's was ruled out ↗
▶ Ep 53 · 34:04
quote just caution to watch out what type of biopsy was performed and how Hirschprung's was ruled out ↗

Hirschsprung's Disease

▶ Ep 73 · 0:35
clinical Some infants with Hirschsprung's disease do pass meconium. ↗
▶ Ep 73 · 0:35
quote More than 95% of neonates pass meconium within the first 48 hours of life, and failure to pass meconium is typical of Hirschsprung's disease. ↗
▶ Ep 73 · 0:35
clinical More than 95% of neonates pass meconium within the first 48 hours of life, and failure to pass meconium is typical of Hirschsprung's disease. ↗
▶ Ep 73 · 0:35
clinical Some infants with Hirschsprung's disease do pass meconium. ↗
▶ Ep 73 · 0:35
quote More than 95% of neonates pass meconium within the first 48 hours of life, and failure to pass meconium is typical of Hirschsprung's disease. ↗
▶ Ep 73 · 0:35
clinical More than 95% of neonates pass meconium within the first 48 hours of life, and failure to pass meconium is typical of Hirschsprung's disease. ↗
▶ Ep 73 · 1:57
clinical In total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema. ↗
▶ Ep 73 · 1:57
epidemiological Approximately 10% of newborns with Hirschsprung's disease may lack the typical findings on a contrast enema. ↗
▶ Ep 73 · 1:57
clinical The classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel. ↗
▶ Ep 73 · 1:57
epidemiological Approximately 10% of newborns with Hirschsprung's disease may lack the typical findings on a contrast enema. ↗
▶ Ep 73 · 1:57
clinical A rectosigmoid ratio of less than 1.0 is suggestive of Hirschsprung's disease, meaning the aganglionic bowel is contracted and narrow compared to the dilated ganglionated bowel more proximal. ↗
▶ Ep 73 · 1:57
clinical In total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema. ↗
▶ Ep 73 · 1:57
clinical Rectal biopsy is the true definitive diagnosis for Hirschsprung disease. ↗
▶ Ep 73 · 1:57
quote The three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry. ↗
▶ Ep 73 · 1:57
quote The second part of a diagnostic workup for Hirschsprung's disease, and most important, is the rectal biopsy. It is the true definitive diagnosis. ↗
▶ Ep 73 · 1:57
clinical Typical features on rectal biopsy include absence of ganglion cells, presence of hypertrophic nerves, abnormal pattern of cholinesterase staining, and an absence of calretinine staining. ↗
▶ Ep 73 · 1:57
clinical To be considered an adequate biopsy, it must be taken from the rectum at least one centimeter above the dentate line and must include both mucosa and submucosal layers. ↗
▶ Ep 73 · 1:57
clinical Suction biopsy technique is typically used for patients less than six months of age. ↗
▶ Ep 73 · 1:57
clinical Full thickness biopsy technique should be considered for patients older than six months, or when a suction biopsy is inadequate. ↗
▶ Ep 73 · 1:57
quote The second part of a diagnostic workup for Hirschsprung's disease, and most important, is the rectal biopsy. It is the true definitive diagnosis. ↗
▶ Ep 73 · 1:57
quote The three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry. ↗
▶ Ep 73 · 1:57
clinical Suction biopsy technique is typically used for patients less than six months of age. ↗
▶ Ep 73 · 1:57
clinical To be considered an adequate biopsy, it must be taken from the rectum at least one centimeter above the dentate line and must include both mucosa and submucosal layers. ↗
▶ Ep 73 · 1:57
clinical Typical features on rectal biopsy include absence of ganglion cells, presence of hypertrophic nerves, abnormal pattern of cholinesterase staining, and an absence of calretinine staining. ↗
▶ Ep 73 · 1:57
clinical Full thickness biopsy technique should be considered for patients older than six months, or when a suction biopsy is inadequate. ↗
▶ Ep 73 · 1:57
clinical Rectal biopsy is the true definitive diagnosis for Hirschsprung disease. ↗
▶ Ep 73 · 1:57
clinical The classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel. ↗
▶ Ep 73 · 1:57
clinical A rectosigmoid ratio of less than 1.0 is suggestive of Hirschsprung's disease, meaning the aganglionic bowel is contracted and narrow compared to the dilated ganglionated bowel more proximal. ↗
▶ Ep 73 · 4:23
guideline Any patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis. ↗
▶ Ep 73 · 4:23
clinical The rectoanal inhibitory reflex may be absent in other conditions as well, and some children have a false positive test. ↗
▶ Ep 73 · 4:23
guideline Any patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis. ↗
▶ Ep 73 · 4:23
clinical The rectoanal inhibitory reflex may be absent in other conditions as well, and some children have a false positive test. ↗
▶ Ep 73 · 4:23
clinical In Hirschsprung's disease, anorectal manometry shows a lack of the rectoanal inhibitory reflex (RAIR). ↗
▶ Ep 73 · 4:23
clinical In Hirschsprung's disease, anorectal manometry shows a lack of the rectoanal inhibitory reflex (RAIR). ↗
▶ Ep 73 · 6:42
quote There are three goals to the surgical management of Hirschsprung's disease. First, identify the extent of the aganglionic segment. Second, resect that segment. And third, restore the bowel to its continuity. ↗
▶ Ep 73 · 6:42
quote There are three goals to the surgical management of Hirschsprung's disease. First, identify the extent of the aganglionic segment. Second, resect that segment. And third, restore the bowel to its continuity. ↗
▶ Ep 73 · 6:42
clinical The three goals of surgical management are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity. ↗
▶ Ep 73 · 6:42
clinical The three goals of surgical management are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity. ↗
▶ Ep 73 · 7:36
clinical The Suave procedure involves performing a mucosectomy from a transanal approach slightly above the dentate line and pulling through the normal bowel. ↗
▶ Ep 73 · 7:36
opinion The Suave procedure theoretically causes less injury to pelvic structures, nerves, urethra and vagina. ↗
▶ Ep 73 · 7:36
clinical In the Swenson procedure, it is very important to be cautious about injuring the urethra as it's quite close, especially in boys. ↗
▶ Ep 73 · 7:36
clinical The Suave procedure involves performing a mucosectomy from a transanal approach slightly above the dentate line and pulling through the normal bowel. ↗
▶ Ep 73 · 7:36
clinical A con of the Suave procedure is that the aganglionic cuff can become stiff enough to cause an obstruction or outlet obstruction. ↗
▶ Ep 73 · 7:36
clinical In the Swenson procedure, it is very important to be cautious about injuring the urethra as it's quite close, especially in boys. ↗
▶ Ep 73 · 7:36
clinical In the Swenson procedure, you pull down the aganglionic bowel and perform a full thickness anastomosis one to two centimeters above the dentate line, leaving the most minimal amount of aganglionic bowel possible. ↗
▶ Ep 73 · 7:36
clinical In the Swenson procedure, you pull down the aganglionic bowel and perform a full thickness anastomosis one to two centimeters above the dentate line, leaving the most minimal amount of aganglionic bowel possible. ↗
▶ Ep 73 · 7:36
clinical A con of the Suave procedure is that the aganglionic cuff can become stiff enough to cause an obstruction or outlet obstruction. ↗
▶ Ep 73 · 7:36
opinion The Suave procedure theoretically causes less injury to pelvic structures, nerves, urethra and vagina. ↗
▶ Ep 73 · 7:36
clinical In the Suave procedure, the actual anastomosis is performed within a cuff of aganglionic rectum. ↗
▶ Ep 73 · 7:36
clinical In the Suave procedure, the actual anastomosis is performed within a cuff of aganglionic rectum. ↗
▶ Ep 73 · 12:34
clinical Hirschsprung's-associated enterocolitis is likely an inflammatory condition secondary to bacterial overgrowth. ↗
▶ Ep 73 · 12:34
quote Hirschsprung's-associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth. ↗
▶ Ep 73 · 12:34
clinical For enterocolitis, antibiotics including metronidazole or broad-spectrum antibiotics are added depending on the severity of presentation. ↗
▶ Ep 73 · 12:34
quote When we treat these patients with enterocolitis, it is important to provide fluid resuscitation, digital rectal exam, and colonic irrigations. ↗
▶ Ep 73 · 12:34
clinical Hirschsprung's-associated enterocolitis is likely an inflammatory condition secondary to bacterial overgrowth. ↗
▶ Ep 73 · 12:34
clinical A child with enterocolitis presents with abdominal distension, vomiting, fever, and change in bowel habits that could be either diarrhea or not passing stool at all. ↗
▶ Ep 73 · 12:34
clinical Treatment of enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations. ↗
▶ Ep 73 · 12:34
clinical For enterocolitis, antibiotics including metronidazole or broad-spectrum antibiotics are added depending on the severity of presentation. ↗
▶ Ep 73 · 12:34
quote When we treat these patients with enterocolitis, it is important to provide fluid resuscitation, digital rectal exam, and colonic irrigations. ↗
▶ Ep 73 · 12:34
quote Hirschsprung's-associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth. ↗
▶ Ep 73 · 12:34
clinical Treatment of enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations. ↗
▶ Ep 73 · 12:34
clinical A child with enterocolitis presents with abdominal distension, vomiting, fever, and change in bowel habits that could be either diarrhea or not passing stool at all. ↗
▶ Ep 73 · 14:51
clinical For patients without anatomic problems after pull-through, treatment can include bowel management, Botox injection to relieve sphincter tone, or motility studies. ↗
▶ Ep 73 · 14:51
clinical Anatomic problems after pull-through can include a twist in the pull through, an obstructing cuff, a non-functioning Duhamel pouch, or a transition zone or continued aganglionic segment. ↗
▶ Ep 73 · 14:51
clinical For patients not doing well after pull-through, if there is a stricture at the anastomosis, it needs to be addressed either through dilations or revising the pull through procedure. ↗
▶ Ep 73 · 14:51
clinical For patients without anatomic problems after pull-through, treatment can include bowel management, Botox injection to relieve sphincter tone, or motility studies. ↗
▶ Ep 73 · 14:51
clinical For patients not doing well after pull-through, if there is a stricture at the anastomosis, it needs to be addressed either through dilations or revising the pull through procedure. ↗
▶ Ep 73 · 14:51
clinical Anatomic problems after pull-through can include a twist in the pull through, an obstructing cuff, a non-functioning Duhamel pouch, or a transition zone or continued aganglionic segment. ↗
▶ Ep 73 · 14:51
clinical For patients with anatomic problems after pull-through, you typically have to revise the pull through. ↗
▶ Ep 73 · 14:51
clinical For patients with anatomic problems after pull-through, you typically have to revise the pull through. ↗

The Colorectal Quiz Episode 1: ARM - Low Bulbar Fistula

▶ Ep 84 · 4:11
quote I always worry about a missed presacral mass. ↗
▶ Ep 84 · 5:08
clinical Cross-table lateral X-ray should be obtained at approximately 24 hours of life to assess the air column position relative to the perineal skin, with the baby positioned prone to allow air to rise to the buttocks. ↗
▶ Ep 84 · 6:28
clinical The cross-table lateral film should include a marker at the expected anal location to allow measurement of the distance between the air column and the perineal skin. ↗
▶ Ep 84 · 7:47
clinical Well-formed buttocks, visible sphincter mechanism location, and well-developed sacrum together predict good prognosis for continence. ↗
▶ Ep 84 · 8:25
quote Well, I have two answers for you, Mark. I think if I was sitting in a hotel room, being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. ↗
▶ Ep 84 · 9:58
quote It goes without saying and, and one of our, I think one of our big teaching points is you should never try to go in blind. ↗
▶ Ep 84 · 9:58
clinical The surgeon should never attempt posterior sagittal approach blind; imaging must confirm that the first structure encountered will be the air pocket of the distal rectum. ↗
▶ Ep 84 · 11:37
quote We both agree that probably in real life, we would have done a primary posterior sagittal approach on this patient, and we would have found the rectum, and we could have made that rectum reach the perineum and done our anoplasty. How do we handle this? Because I didn't know that there was a fistula there. This is troublesome. ↗
▶ Ep 84 · 12:34
quote You can see this fistula is very close to the rectum. And if you're going to dissect that free, and along the urethra, um, it's important to make sure that you know that those two structures are not very far apart, and getting that into that proper plane is very important. ↗
▶ Ep 84 · 12:55
clinical A bulbar fistula is located at the elbow of the urethra, using anatomic nomenclature based on the urethral location. ↗
▶ Ep 84 · 13:00
quote The reason why Doctor Levitt or Mark is saying that. It's a bulbar fistula, it's at the elbow. You can see it's at the elbow of the urethra. And tell us that the uh the nomenclature we like to use is an anatomic pure anatomic nomenclature saying that it's a bulbar fistula. ↗

Colorectal Quiz Episode 2: When to redo a PSARP

▶ Ep 85 · 0:00
opinion For anorectoplasty, if you don't get it perfect, you might not have the best outcomes, which separates it from other surgical procedures. ↗
▶ Ep 85 · 0:40
opinion A lot of surgeons agree that oftentimes your first shot might be your only shot to give this patient a good outcome and the right anatomy. ↗
▶ Ep 85 · 1:20
quote How many patients, Jason, have you seen on laxatives that comes with an anus in the wrong place? How many patients have you seen having had a cecostomy with perfect anatomy? That's the real frustrating one. Right? A lot. ↗
▶ Ep 85 · 5:50
quote I can tell you, the family doesn't really care how technically elegant is your analplasty. What they care about is whether that analplasty that you make is going to work. And is the child going to be clean and in normal underwear and just like all the other kids? ↗
▶ Ep 85 · 5:50
opinion The family doesn't really care how technically elegant is your analplasty. What they care about is whether that analplasty that you make is going to work and is the child going to be clean and in normal underwear. ↗
▶ Ep 85 · 6:25
clinical The higher the malformation, the worse the prognosis. ↗
▶ Ep 85 · 6:35
clinical A sacrum ratio of 0.7 or greater usually means normal or close to normal sphincters and good muscle tone, indicating that spine innervation of that area is probably good. ↗
▶ Ep 85 · 6:40
clinical Patients can come with associated spinal anomaly, most commonly tethered cord, but the worst is a myelomeningocele, and those patients have much more trouble with continence. ↗
▶ Ep 85 · 7:44
clinical It's amazingly common to have a mislocated anus, either because the surgeon misses where the center is during laparoscopic pull-through or opens the PSARP incision first. ↗
▶ Ep 85 · 8:05
clinical A key pitfall is opening the PSARP incision first; instead, mark the sphincters first, then open the PSARP so you don't get confused when placing the anoplasty in the correct location. ↗
▶ Ep 85 · 8:05
quote A key pitfall is not do that. Mark the sphincters first, then open the PSARP because then you don't get confused at the end when you're trying to place the anoplasty in the correct location. ↗
▶ Ep 85 · 10:19
clinical In higher malformations such as a bladder neck fistula in a boy, the sphincter complex isn't always where you think it's going to be and is sometimes more anterior than anticipated. ↗
▶ Ep 85 · 15:19
opinion An alternative approach for borderline cases is to let the child take their car out for a ride first and see how it works—if it drives well, stay with that anatomy; if not, then consider the redo. ↗

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

▶ Ep 88 · 6:37
clinical With proper laparoscopic dissection, the transanal portion of a primary Hirschsprung pull-through should take well under one hour. ↗
▶ Ep 88 · 6:37
clinical With proper laparoscopic dissection, the transanal portion of a primary Hirschsprung pull-through should take well under one hour. ↗
▶ Ep 88 · 6:37
quote Previously, we used to do this transanally, it would take a few hours. Now, the transanal dissection should be usually way under 1 hour, especially in a primary pull-through point. ↗
▶ Ep 88 · 6:37
quote Previously, we used to do this transanally, it would take a few hours. Now, the transanal dissection should be usually way under 1 hour, especially in a primary pull-through point. ↗
▶ Ep 88 · 12:26
clinical For distal Hirschsprung disease, only distal branches of the IMA need to be taken, but for left colon involvement, the IMA itself may need to be taken to achieve adequate reach. ↗
▶ Ep 88 · 12:26
clinical For distal Hirschsprung disease, only distal branches of the IMA need to be taken, but for left colon involvement, the IMA itself may need to be taken to achieve adequate reach. ↗

The Colorectal Quiz Episode 8: Motility Disorders Part 1

▶ Ep 91 · 6:29
quote It's saying that this is not a Monet, that is for certain. ↗
▶ Ep 91 · 7:12
clinical Contrast studies are not great predictors of how patients will respond to medical or surgical management; normal-looking colons may not respond while abnormal-appearing colons may respond well ↗
▶ Ep 91 · 8:06
clinical Water-soluble contrast (not barium) is used for contrast enemas because it helps empty the colon and acts as a cleanout for patients starting new medical therapy ↗
▶ Ep 91 · 10:51
quote I think back in the day, Mark, yeah, we, we didn't understand the sphincter and the major role it played. ↗
▶ Ep 91 · 10:51
opinion In the past, surgeons did not understand the major role the sphincter played in many patients ↗

The Colorectal Quiz Episode 9: Motility Disorders Part 2

▶ Ep 93 · 8:02
clinical Many patients undergoing colonic manometry have normal results, meaning they have slow transit but normal HAPCs. ↗

The Colorectal Quiz Episode 10: Total Colonic Hirschsprung Disease Part 1

▶ Ep 94 · 7:26
clinical The age cutoff for switching from suction rectal biopsy to full-thickness biopsy is around 6 months ↗
▶ Ep 94 · 7:26
clinical The age cutoff for switching from suction rectal biopsy to full-thickness biopsy is around 6 months ↗
▶ Ep 94 · 7:26
quote My cutoff is around 6 months when I switch from suction rectal biopsy to full thickness biopsy. ↗
▶ Ep 94 · 7:26
quote My cutoff is around 6 months when I switch from suction rectal biopsy to full thickness biopsy. ↗
▶ Ep 94 · 8:38
quote If the patient is doing well and able to be managed with irrigations, would love to have my final diagnosis of Hirschprung's disease through the rectal biopsy before entering the abdomen. ↗
▶ Ep 94 · 8:38
quote If the patient is doing well and able to be managed with irrigations, would love to have my final diagnosis of Hirschprung's disease through the rectal biopsy before entering the abdomen. ↗
▶ Ep 94 · 8:38
clinical If the patient is doing well and can be managed with irrigations, it is preferable to have final pathology diagnosis of Hirschsprung disease from rectal biopsy before entering the abdomen ↗
▶ Ep 94 · 8:38
clinical If the patient is doing well and can be managed with irrigations, it is preferable to have final pathology diagnosis of Hirschsprung disease from rectal biopsy before entering the abdomen ↗
▶ Ep 94 · 9:13
clinical Standard biopsy locations during operative mapping include rectosigmoid, proximal sigmoid around the left colon, splenic flexure/transverse colon, and right colon or hepatic flexure area ↗
▶ Ep 94 · 9:13
clinical Standard biopsy locations during operative mapping include rectosigmoid, proximal sigmoid around the left colon, splenic flexure/transverse colon, and right colon or hepatic flexure area ↗

The Colorectal Quiz Episode 11: Total Colonic Hirschsprung's Part 2

▶ Ep 95 · 3:35
quote So I'm in the exact same boat. ↗
▶ Ep 95 · 3:35
clinical Dr. Fisher waits until the child has good growth and more solid stool on table food diet, sometimes adding thickeners to achieve thicker stool consistency. ↗
▶ Ep 95 · 3:35
quote So I'm in the exact same boat. ↗
▶ Ep 95 · 3:35
clinical Dr. Fisher waits until the child has good growth and more solid stool on table food diet, sometimes adding thickeners to achieve thicker stool consistency. ↗
▶ Ep 95 · 3:38
quote So how do you get them to the point where they're having more solid stool, you know, when they're on more of a solid diet and table food diet, and maybe we even add some thickeners to their diet so that their stool becomes more thick. ↗
▶ Ep 95 · 3:38
quote So how do you get them to the point where they're having more solid stool, you know, when they're on more of a solid diet and table food diet, and maybe we even add some thickeners to their diet so that their stool becomes more thick. ↗
▶ Ep 95 · 4:12
clinical Dr. Fisher uses a skin training technique where families take stool from the ostomy bag and place it in the diaper for 15-20 minutes to expose virgin buttock skin to stool before pull-through. ↗
▶ Ep 95 · 4:12
clinical Dr. Fisher uses a skin training technique where families take stool from the ostomy bag and place it in the diaper for 15-20 minutes to expose virgin buttock skin to stool before pull-through. ↗
▶ Ep 95 · 4:27
quote The skin, the buttock skin, has not really seen or been exposed to stool. ↗
▶ Ep 95 · 4:27
quote The skin, the buttock skin, has not really seen or been exposed to stool. ↗
▶ Ep 95 · 4:32
quote And so I have the families put some stool in the diaper and expose that skin to stool for a little. ↗
▶ Ep 95 · 4:32
quote And so I have the families put some stool in the diaper and expose that skin to stool for a little. ↗
▶ Ep 95 · 5:19
clinical For patients with long-standing ileostomies and high output who are not growing well, checking urine sodium (which reflects total body sodium, not just blood sodium) is a key component for growth assessment. ↗
▶ Ep 95 · 5:19
quote But the one thing that I learned checking a urine sodium, the total body sodium and not just the blood sodium, is a key component for these patients, which is obviously important in growth. ↗
▶ Ep 95 · 5:19
quote But the one thing that I learned checking a urine sodium, the total body sodium and not just the blood sodium, is a key component for these patients, which is obviously important in growth. ↗
▶ Ep 95 · 5:19
clinical For patients with long-standing ileostomies and high output who are not growing well, checking urine sodium (which reflects total body sodium, not just blood sodium) is a key component for growth assessment. ↗
▶ Ep 95 · 5:34
clinical Dr. Fisher checks urine sodium a few weeks after ileostomy creation prior to discharge and again a month or two later. ↗
▶ Ep 95 · 5:34
clinical Dr. Fisher checks urine sodium a few weeks after ileostomy creation prior to discharge and again a month or two later. ↗
▶ Ep 95 · 5:49
clinical Low total body sodium can be treated with salt tablets or salt addition. ↗
▶ Ep 95 · 5:49
clinical Low total body sodium can be treated with salt tablets or salt addition. ↗
▶ Ep 95 · 8:00
quote For this case, I typically do an ileoanal anastomosis, a straight pull through, but there are a few other options. ↗
▶ Ep 95 · 8:00
quote For this case, I typically do an ileoanal anastomosis, a straight pull through, but there are a few other options. ↗
▶ Ep 95 · 8:00
clinical Dr. Fisher typically performs an ileoanal anastomosis (straight pull-through) for total colonic Hirschsprung disease. ↗
▶ Ep 95 · 8:00
clinical Dr. Fisher typically performs an ileoanal anastomosis (straight pull-through) for total colonic Hirschsprung disease. ↗
▶ Ep 95 · 9:57
clinical Dr. Fisher makes a game-time decision on whether to divert after ileoanal anastomosis based on anastomotic appearance, blood supply, tension, and nutritional optimization; if any concerns exist, he diverts and returns 6-8 weeks later to close the ileostomy. ↗
▶ Ep 95 · 9:57
quote I talk to the families and I, I say it's a game time decision. ↗
▶ Ep 95 · 9:57
clinical Dr. Fisher makes a game-time decision on whether to divert after ileoanal anastomosis based on anastomotic appearance, blood supply, tension, and nutritional optimization; if any concerns exist, he diverts and returns 6-8 weeks later to close the ileostomy. ↗
▶ Ep 95 · 9:57
quote I talk to the families and I, I say it's a game time decision. ↗
▶ Ep 95 · 10:57
clinical Family comfort with rectal irrigations is an important consideration when planning surgery. ↗
▶ Ep 95 · 10:57
clinical Family comfort with rectal irrigations is an important consideration when planning surgery. ↗
▶ Ep 95 · 11:26
clinical Dr. Fisher's first-line medication treatment is loperamide. ↗
▶ Ep 95 · 11:26
clinical Dr. Fisher's first-line medication treatment is loperamide. ↗
▶ Ep 95 · 12:07
clinical Lomotil (diphenoxylate-atropine) is a controlled substance in the United States. ↗
▶ Ep 95 · 12:07
clinical Lomotil (diphenoxylate-atropine) is a controlled substance in the United States. ↗
▶ Ep 95 · 12:24
quote I give the Botox immediately, um, when we have intestinal continuity, and I see the child at 2 weeks post-op just for a routine check. ↗
▶ Ep 95 · 12:24
clinical Dr. Fisher gives Botox immediately when intestinal continuity is established. ↗
▶ Ep 95 · 12:24
clinical Dr. Fisher gives Botox immediately when intestinal continuity is established. ↗
▶ Ep 95 · 12:24
quote I give the Botox immediately, um, when we have intestinal continuity, and I see the child at 2 weeks post-op just for a routine check. ↗
▶ Ep 95 · 12:34
clinical Dr. Fisher sees the child at 2 weeks post-op for routine check (eating, growth, rash assessment) and does not check the anastomosis until 4 weeks. ↗
▶ Ep 95 · 12:34
clinical Dr. Fisher sees the child at 2 weeks post-op for routine check (eating, growth, rash assessment) and does not check the anastomosis until 4 weeks. ↗
▶ Ep 95 · 12:38
quote I don't check the anastomosis until 4 weeks. ↗
▶ Ep 95 · 12:38
quote I don't check the anastomosis until 4 weeks. ↗
▶ Ep 95 · 12:41
clinical At 4 weeks in clinic, Dr. Fisher performs an anastomosis check using Hagar dilators to size to the appropriate size for the child's age. ↗
▶ Ep 95 · 12:41
clinical At 4 weeks in clinic, Dr. Fisher performs an anastomosis check using Hagar dilators to size to the appropriate size for the child's age. ↗
▶ Ep 95 · 13:05
clinical Dr. Fisher starts with a 7 or 8 Hagar dilator in clinic and gently sizes up to resistance, not to stretch but to check size; for a child who had pull-through at around 10 months, the proper size should be 13 or 14 Hagar dilator. ↗
▶ Ep 95 · 13:05
clinical Dr. Fisher starts with a 7 or 8 Hagar dilator in clinic and gently sizes up to resistance, not to stretch but to check size; for a child who had pull-through at around 10 months, the proper size should be 13 or 14 Hagar dilator. ↗
▶ Ep 95 · 13:13
quote One, I'm not here to stretch it out. ↗
▶ Ep 95 · 13:13
quote One, I'm not here to stretch it out. ↗

Colorectal Quiz Episode 13: Newborn ARM Part 2

▶ Ep 98 · 4:45
quote My conversation with the family often involves that this will keratinize and look like a normal peroneal body over time. ↗
▶ Ep 98 · 4:45
clinical Perineal groove with mucosal lining will keratinize and look like normal perineal body over time ↗
▶ Ep 98 · 4:45
quote My conversation with the family often involves that this will keratinize and look like a normal peroneal body over time. ↗
▶ Ep 98 · 4:45
clinical Perineal groove with mucosal lining will keratinize and look like normal perineal body over time ↗
▶ Ep 98 · 5:00
clinical Surgical intervention for perineal groove is indicated only if secreting mucus, causing irritation, or developing ulcers ↗
▶ Ep 98 · 5:00
clinical Surgical intervention for perineal groove is indicated only if secreting mucus, causing irritation, or developing ulcers ↗
▶ Ep 98 · 9:35
clinical Vestibular fistula is very common in females and needs formal repair with hole transposed to center of sphincter ↗
▶ Ep 98 · 9:35
clinical Vestibular fistula is very common in females and needs formal repair with hole transposed to center of sphincter ↗
▶ Ep 98 · 10:22
clinical Purpose of diversion in ARM repair is to avoid perineal body dehiscence ↗
▶ Ep 98 · 10:22
clinical For vestibular fistula diagnosed in newborn period, options are primary repair if baby is well, or allow stooling through fistula for couple months then elective repair without stoma ↗
▶ Ep 98 · 10:22
clinical Patients diagnosed with vestibular fistula at 6-12 months who have dilated rectosigmoid need diversion as first step, then repair ↗
▶ Ep 98 · 10:22
clinical For vestibular fistula diagnosed in newborn period, options are primary repair if baby is well, or allow stooling through fistula for couple months then elective repair without stoma ↗
▶ Ep 98 · 10:22
clinical Purpose of diversion in ARM repair is to avoid perineal body dehiscence ↗
▶ Ep 98 · 10:22
clinical Patients diagnosed with vestibular fistula at 6-12 months who have dilated rectosigmoid need diversion as first step, then repair ↗
▶ Ep 98 · 14:11
clinical To evaluate for vestibular fistula, pull labia towards examiner with both hands to visualize vaginal opening and urethra ↗
▶ Ep 98 · 14:11
clinical To evaluate for vestibular fistula, pull labia towards examiner with both hands to visualize vaginal opening and urethra ↗

Colorectal Quiz Episode 15: Bowel Management in Spinal Patients - Need for a UrologistPart 1

▶ Ep 100 · 5:30
clinical Senna-induced perineal rash is thought to be a chemical burn rather than a true allergy, presenting with blistering. ↗
▶ Ep 100 · 5:30
quote it's almost like a chemical burn. The cause they're blistered usually. ↗
▶ Ep 100 · 5:30
clinical Senna-induced perineal rash is thought to be a chemical burn rather than a true allergy, presenting with blistering. ↗
▶ Ep 100 · 5:30
quote it's almost like a chemical burn. The cause they're blistered usually. ↗
▶ Ep 100 · 5:38
clinical Senna rash is treated with silver sulfadiazine and resolves with time; some patients tolerate senna upon reintroduction. ↗
▶ Ep 100 · 5:38
quote We treat it with silver sulfadiazine, and they've all gotten better with time. ↗
▶ Ep 100 · 5:38
clinical Senna rash is treated with silver sulfadiazine and resolves with time; some patients tolerate senna upon reintroduction. ↗
▶ Ep 100 · 5:38
quote We treat it with silver sulfadiazine, and they've all gotten better with time. ↗
▶ Ep 100 · 5:47
clinical Timing senna doses in the early morning so that bowel movements occur during the day (when diapers are changed promptly) reduces the risk of senna rash. ↗
▶ Ep 100 · 5:47
clinical Timing senna doses in the early morning so that bowel movements occur during the day (when diapers are changed promptly) reduces the risk of senna rash. ↗
▶ Ep 100 · 5:53
quote what we've done is we timed the dose of Senna in these patients, usually in the early morning, so that they're pooping during the day. And their diapers changed rather quickly versus potentially being in a diaper over a long period of time at night. ↗
▶ Ep 100 · 5:53
quote what we've done is we timed the dose of Senna in these patients, usually in the early morning, so that they're pooping during the day. And their diapers changed rather quickly versus potentially being in a diaper over a long period of time at night. ↗
▶ Ep 100 · 8:31
clinical Bisacodyl can be administered as an enema or suppository in infants. ↗
▶ Ep 100 · 8:31
clinical Bisacodyl can be administered as an enema or suppository in infants. ↗
▶ Ep 100 · 10:11
quote If there's one take-home message from this podcast, you just said it ↗
▶ Ep 100 · 10:11
quote If there's one take-home message from this podcast, you just said it ↗
▶ Ep 100 · 10:31
quote that care coordination, collaboration with the urologist might be the most beneficial thing we could do for our patients. ↗
▶ Ep 100 · 10:31
quote that care coordination, collaboration with the urologist might be the most beneficial thing we could do for our patients. ↗

Colorectal Quiz Episode 16: Bowel Management in Spinal Patients - Need for a Urologist Part 2

▶ Ep 101 · 1:17
quote When you get that really short stumpy appendix, whether it be from splitting it, and the urologist, if I have a 7 centimeter appendix, the urologist takes 6.25 centimeters and I get 0.75. ↗
▶ Ep 101 · 1:17
clinical When a 7 cm appendix is shared between urology and colorectal surgery, the urologist typically takes 6.25 cm leaving only 0.75 cm for colorectal use ↗
▶ Ep 101 · 1:17
clinical When a 7 cm appendix is shared between urology and colorectal surgery, the urologist typically takes 6.25 cm leaving only 0.75 cm for colorectal use ↗
▶ Ep 101 · 1:17
quote When you get that really short stumpy appendix, whether it be from splitting it, and the urologist, if I have a 7 centimeter appendix, the urologist takes 6.25 centimeters and I get 0.75. ↗
▶ Ep 101 · 1:55
clinical The colorectal team benefits from using the appendix portion closer to the cecum which has a stronger blood supply ↗
▶ Ep 101 · 1:55
clinical The colorectal team benefits from using the appendix portion closer to the cecum which has a stronger blood supply ↗
▶ Ep 101 · 2:05
clinical A short appendiceal stump can be extended by suturing or using a laparoscopic non-cutting linear stapler along the cecal wall to add 2-3 cm of length ↗
▶ Ep 101 · 2:05
clinical A short appendiceal stump can be extended by suturing or using a laparoscopic non-cutting linear stapler along the cecal wall to add 2-3 cm of length ↗
▶ Ep 101 · 2:34
clinical One of the problems with Malone appendicostomy is leakage ↗
▶ Ep 101 · 2:34
clinical One of the problems with Malone appendicostomy is leakage ↗
▶ Ep 101 · 2:47
clinical The longer the Malone channel, the less likely it is to leak ↗
▶ Ep 101 · 2:47
clinical The longer the Malone channel, the less likely it is to leak ↗
▶ Ep 101 · 2:52
quote The longer the channel, the less likely that Malone's going to leak. ↗
▶ Ep 101 · 2:52
quote The longer the channel, the less likely that Malone's going to leak. ↗
▶ Ep 101 · 2:55
clinical Extending the Malone channel by 2-3 cm using suturing or stapling can be extremely helpful in preventing leakage ↗
▶ Ep 101 · 2:55
clinical Extending the Malone channel by 2-3 cm using suturing or stapling can be extremely helpful in preventing leakage ↗
▶ Ep 101 · 3:43
clinical Rectal irrigation using pressurized water systems made for patients with hand difficulties is an alternative to Malone and Mitrofanoff procedures ↗
▶ Ep 101 · 3:43
clinical Rectal irrigation using pressurized water systems made for patients with hand difficulties is an alternative to Malone and Mitrofanoff procedures ↗
▶ Ep 101 · 4:25
clinical Coloplast makes a rectal irrigation device for self-administration of enemas ↗
▶ Ep 101 · 4:25
clinical Coloplast makes a rectal irrigation device for self-administration of enemas ↗
▶ Ep 101 · 8:39
clinical Fecal impaction can push on the bladder and change the angle of the ureter entering the bladder, causing reflux ↗
▶ Ep 101 · 8:39
host_summary Fecal impaction can push on the bladder and change the angle of the ureter entering the bladder, causing reflux ↗
▶ Ep 101 · 9:43
clinical At Cincinnati Children's, 99% of Malones are placed in the umbilicus and almost all Mitrofanoffs are in the right lower quadrant with a tunnel channel through the rectus to prevent leakage ↗
▶ Ep 101 · 9:43
clinical At Cincinnati Children's, 99% of Malones are placed in the umbilicus and almost all Mitrofanoffs are in the right lower quadrant with a tunnel channel through the rectus to prevent leakage ↗
▶ Ep 101 · 10:21
clinical The primary determinant of orifice location is where the appendix reaches and its blood supply ↗
▶ Ep 101 · 10:21
clinical The primary determinant of orifice location is where the appendix reaches and its blood supply ↗
▶ Ep 101 · 10:51
host_summary The last steps of combined procedures should be maturing the Mitrofanoff, maturing the Malone, then closing the abdomen ↗
▶ Ep 101 · 10:51
clinical The last steps of combined procedures should be maturing the Mitrofanoff, maturing the Malone, then closing the abdomen ↗
▶ Ep 101 · 11:09
clinical Laxity of the pelvic floor and anal canal is a huge issue in spinal patients, especially when doing retrograde enemas ↗
▶ Ep 101 · 11:09
clinical Laxity of the pelvic floor and anal canal is a huge issue in spinal patients, especially when doing retrograde enemas ↗

Colorectal Quiz Episode 17: Cloaca Part 1

▶ Ep 102 · 11:30
quote This is huge. This is why, this is real time, and we all know a book chapter takes five years to, three to five years to get published. ↗
▶ Ep 102 · 11:30
quote This is huge. This is why, this is real time, and we all know a book chapter takes five years to, three to five years to get published. ↗

Colorectal Quiz Episode 18: Cloaca Part 2

▶ Ep 103 · 4:50
clinical During cystoscopy it is important to look for cervices to understand Müllerian development (one vagina vs. two, presence of uterus) and to identify ureteral orifices, which in complex malformations may attach anomalously low to the bladder or bladder neck. ↗
▶ Ep 103 · 4:50
clinical During cystoscopy it is important to look for cervices to understand Müllerian development (one vagina vs. two, presence of uterus) and to identify ureteral orifices, which in complex malformations may attach anomalously low to the bladder or bladder neck. ↗

Colorectal Collaboration: Neurogastroenterology/Motility Disorders

▶ Ep 104 · 10:31
opinion The management approach at Cincinnati Children's is to maximize medical therapy and understand anatomic and functional issues before resorting to surgical intervention and potential resection. ↗
▶ Ep 104 · 10:31
quote But I think our management style now here at Cincinnati Children's has been to try to maximize medical therapy, understand the anatomic and functional issues, and then if we can't overcome those issues with medical management, resort to surgical intervention and potential resection. ↗
▶ Ep 104 · 11:04
opinion Resection should not be performed immediately based on one abnormal finding; multiple factors must be considered. ↗
▶ Ep 104 · 11:04
quote I want to stress that we shouldn't resort to resection right away just because we have one abnormal finding. ↗
▶ Ep 104 · 12:13
clinical The first step in evaluating a patient with suspected motility disorder is to ensure normal anatomy, which can be assessed with contrast studies. ↗
▶ Ep 104 · 12:13
quote One, you have to ensure normal anatomy. ↗

Colorectal Quiz Episode 19: Hirschsprung Disease - The Obstructed Patient Part 1

▶ Ep 105 · 4:51
quote I think one key thing to talk about with all our listeners is when you do that exam, make sure you step to the side. A little bit funny, but a little bit, you don't wanna be in the way of what could be coming out. ↗
▶ Ep 105 · 4:51
clinical When performing initial rectal exam on a distended child with suspected enterocolitis, step to the side because there may be an explosive release of stool and gas. ↗
▶ Ep 105 · 4:51
quote I think one key thing to talk about with all our listeners is when you do that exam, make sure you step to the side. A little bit funny, but a little bit, you don't wanna be in the way of what could be coming out. ↗
▶ Ep 105 · 4:51
clinical When performing initial rectal exam on a distended child with suspected enterocolitis, step to the side because there may be an explosive release of stool and gas. ↗
▶ Ep 105 · 12:06
clinical For a patient with prior Hirschsprung diagnosis presenting sick, assume Hirschsprung-associated enterocolitis; treatment with rectal irrigations, IV fluids, and antibiotics will not cause harm even if the diagnosis is different (e.g., Crohn's disease, E. coli enterocolitis). ↗
▶ Ep 105 · 12:06
quote If you have a patient that comes in with a diagnosis of Hirschprung's in the past and comes with, comes in sick, you have to assume it's Hirschprung's associated enterocolitis. ↗
▶ Ep 105 · 12:06
clinical For a patient with prior Hirschsprung diagnosis presenting sick, assume Hirschsprung-associated enterocolitis; treatment with rectal irrigations, IV fluids, and antibiotics will not cause harm even if the diagnosis is different (e.g., Crohn's disease, E. coli enterocolitis). ↗
▶ Ep 105 · 12:06
quote If you have a patient that comes in with a diagnosis of Hirschprung's in the past and comes with, comes in sick, you have to assume it's Hirschprung's associated enterocolitis. ↗
▶ Ep 105 · 14:58
guideline Families should not undergo Hirschsprung pull-through surgery until they can demonstrate ability to perform rectal irrigations, and they should be discharged with supplies to perform irrigations at home. ↗
▶ Ep 105 · 14:58
guideline Families should not undergo Hirschsprung pull-through surgery until they can demonstrate ability to perform rectal irrigations, and they should be discharged with supplies to perform irrigations at home. ↗
▶ Ep 105 · 18:19
clinical In a logical workup, obtain the contrast study before going to the OR for rectal exam under anesthesia, as it may reveal findings that guide the surgical approach. ↗
▶ Ep 105 · 18:19
clinical In a logical workup, obtain the contrast study before going to the OR for rectal exam under anesthesia, as it may reveal findings that guide the surgical approach. ↗
▶ Ep 105 · 18:33
quote I think we all agree we get the contrast study before going to the operating room for a rectal exam ↗
▶ Ep 105 · 18:33
quote I think we all agree we get the contrast study before going to the operating room for a rectal exam ↗
▶ Ep 105 · 19:43
clinical A lateral view on contrast enema is important because it provides significant information about the presacral space and distal rectum anatomy. ↗
▶ Ep 105 · 19:43
clinical A lateral view on contrast enema is important because it provides significant information about the presacral space and distal rectum anatomy. ↗

The Colorectal Quiz Episode 20: Hirschsprung Disease Obstruction Part 2

▶ Ep 107 · 4:26
clinical Botox is being studied to prevent enterocolitis with the theory of chemo-denervating nerves in the area instead of permanent stretch or anatomic destruction from surgery ↗
▶ Ep 107 · 4:26
clinical Botox is being studied to prevent enterocolitis with the theory of chemo-denervating nerves in the area instead of permanent stretch or anatomic destruction from surgery ↗
▶ Ep 107 · 11:11
quote Is now, let's say 3 centimeters, or 4, or 5. Well, is that the problem that this kid did well until that cuff got to a length, that's a ganglionic, and now it's causing obstructive problems. ↗
▶ Ep 107 · 11:11
quote Is now, let's say 3 centimeters, or 4, or 5. Well, is that the problem that this kid did well until that cuff got to a length, that's a ganglionic, and now it's causing obstructive problems. ↗
▶ Ep 107 · 17:23
guideline Initial treatment for obstructed Hirschsprung's patient must include rectal irrigation, done early ↗
▶ Ep 107 · 17:23
guideline Initial treatment for obstructed Hirschsprung's patient must include rectal irrigation, done early ↗
▶ Ep 107 · 17:28
guideline Every institution should have a protocol for obstructed Hirschsprung's patients to ensure quick and efficient response ↗
▶ Ep 107 · 17:28
guideline Every institution should have a protocol for obstructed Hirschsprung's patients to ensure quick and efficient response ↗
▶ Ep 107 · 17:41
guideline Systematic workup for obstructed Hirschsprung's includes: resuscitation, imaging studies, and comprehensive rectal exam under anesthesia ↗
▶ Ep 107 · 17:41
guideline Systematic workup for obstructed Hirschsprung's includes: resuscitation, imaging studies, and comprehensive rectal exam under anesthesia ↗

The Colorectal Quiz Episode 21: The History of Hirschsprung Disease

▶ Ep 108 · 10:08
clinical Doctor Martin developed the Martin procedure, an extended Duhamel procedure that leaves a longer aganglionic segment of rectum for long-segment Hirschsprung disease. ↗
▶ Ep 108 · 10:08
clinical Doctor Martin developed the Martin procedure, an extended Duhamel procedure that leaves a longer aganglionic segment of rectum for long-segment Hirschsprung disease. ↗
▶ Ep 108 · 10:40
clinical In 1977, Doctor Martin was the first to apply the endorectal pull-through technique used in Hirschsprung disease to the surgical treatment of ulcerative colitis, performing total proctocolectomy with ileoanal anastomosis. ↗
▶ Ep 108 · 10:40
clinical In 1977, Doctor Martin was the first to apply the endorectal pull-through technique used in Hirschsprung disease to the surgical treatment of ulcerative colitis, performing total proctocolectomy with ileoanal anastomosis. ↗
▶ Ep 108 · 11:19
clinical Doctor Martin's ulcerative colitis technique predated the J-pouch, which later modified his approach. ↗
▶ Ep 108 · 11:19
clinical Doctor Martin's ulcerative colitis technique predated the J-pouch, which later modified his approach. ↗

The Colorectal Quiz Episode 22: Hirschsprung Disease - the Soiling Patient Part 1

▶ Ep 109 · 5:07
clinical Pathology can change over time; cases exist where ganglion cells were present at pull-through but absent with hypertrophic nerves 7 years later when problems developed. ↗
▶ Ep 109 · 5:07
clinical Pathology can change over time; cases exist where ganglion cells were present at pull-through but absent with hypertrophic nerves 7 years later when problems developed. ↗
▶ Ep 109 · 9:58
clinical Sphincters should be assessed with the patient awake; examination under anesthesia makes it harder to assess sphincter function. ↗
▶ Ep 109 · 9:58
clinical Sphincters should be assessed with the patient awake; examination under anesthesia makes it harder to assess sphincter function. ↗
▶ Ep 109 · 16:07
clinical During normal bowel movements, sphincters relax and the anus opens with some mucosal descent, but as soon as sphincters tighten, the mucosa retracts back in; prolapse at rest indicates damaged muscles and/or mucosa brought too low at anastomosis. ↗
▶ Ep 109 · 16:07
clinical During normal bowel movements, sphincters relax and the anus opens with some mucosal descent, but as soon as sphincters tighten, the mucosa retracts back in; prolapse at rest indicates damaged muscles and/or mucosa brought too low at anastomosis. ↗

Colorectal Quiz Episode 26: Perianal Crohn's Disease

▶ Ep 115 · 4:36
clinical If terminal ileum cannot be intubated, gastroenterologists may treat presumptively and re-scope after a few months of treatment when inflammation has decreased. ↗
▶ Ep 115 · 4:36
clinical If terminal ileum cannot be intubated, gastroenterologists may treat presumptively and re-scope after a few months of treatment when inflammation has decreased. ↗
▶ Ep 115 · 6:52
clinical The highest risk factors for lymphoma with biologic therapy are male gender, teenage age, and combination therapy with methotrexate. ↗
▶ Ep 115 · 6:52
clinical The highest risk factors for lymphoma with biologic therapy are male gender, teenage age, and combination therapy with methotrexate. ↗
▶ Ep 115 · 9:00
epidemiological Male gender over the age of 10, and presence of a fistula are risk factors with much higher incidence of Crohn's disease being diagnosed in patients presenting with perianal lesions to the emergency room. ↗
▶ Ep 115 · 9:00
epidemiological Male gender over the age of 10, and presence of a fistula are risk factors with much higher incidence of Crohn's disease being diagnosed in patients presenting with perianal lesions to the emergency room. ↗
▶ Ep 115 · 9:29
clinical In pediatric patients, unlike adult patients, the first presenting factor for Crohn's disease can often be perianal disease. ↗
▶ Ep 115 · 9:29
clinical In pediatric patients, unlike adult patients, the first presenting factor for Crohn's disease can often be perianal disease. ↗
▶ Ep 115 · 12:25
quote I don't like to make holes when there aren't holes there. ↗
▶ Ep 115 · 12:25
quote I don't like to make holes when there aren't holes there. ↗
▶ Ep 115 · 12:31
clinical The mucosa heals first compared to skin in perianal disease, so leaving a mucosal opening without a seton risks recurrent abscess when biologics heal the mucosa. ↗
▶ Ep 115 · 12:31
quote The thing that's going to heal first is the mucosa. ↗
▶ Ep 115 · 12:31
quote The thing that's going to heal first is the mucosa. ↗
▶ Ep 115 · 12:31
clinical The mucosa heals first compared to skin in perianal disease, so leaving a mucosal opening without a seton risks recurrent abscess when biologics heal the mucosa. ↗
▶ Ep 115 · 13:12
clinical Making a large cruciate incision and packing a perianal abscess in a child with undiagnosed Crohn's disease may result in non-healing and potentially require colostomy or ileostomy. ↗
▶ Ep 115 · 13:12
clinical Making a large cruciate incision and packing a perianal abscess in a child with undiagnosed Crohn's disease may result in non-healing and potentially require colostomy or ileostomy. ↗
▶ Ep 115 · 13:20
quote You may have bought that kid a colostomy or ileostomy. ↗
▶ Ep 115 · 13:20
quote You may have bought that kid a colostomy or ileostomy. ↗
▶ Ep 115 · 14:15
clinical Hydrogen peroxide is preferred over methylene blue for identifying fistula tracts because it is neater; 3% hydrogen peroxide in a syringe with 16-20 gauge angiocath is used with a speculum in the anus. ↗
▶ Ep 115 · 14:15
clinical Hydrogen peroxide is preferred over methylene blue for identifying fistula tracts because it is neater; 3% hydrogen peroxide in a syringe with 16-20 gauge angiocath is used with a speculum in the anus. ↗
▶ Ep 115 · 14:54
clinical When a fistula opening cannot be found despite hydrogen peroxide testing, a seton should not be placed at that time to avoid creating a hole where there isn't one. ↗
▶ Ep 115 · 14:54
clinical When a fistula opening cannot be found despite hydrogen peroxide testing, a seton should not be placed at that time to avoid creating a hole where there isn't one. ↗
▶ Ep 115 · 17:17
clinical Source control of infection must be achieved before starting immunosuppressive therapy including steroids and biologics. ↗
▶ Ep 115 · 17:17
clinical If an abscess is not adequately drained, reimaging should be performed before giving biologics or steroids. ↗
▶ Ep 115 · 17:17
clinical If an abscess is not adequately drained, reimaging should be performed before giving biologics or steroids. ↗
▶ Ep 115 · 17:17
clinical Source control of infection must be achieved before starting immunosuppressive therapy including steroids and biologics. ↗
▶ Ep 115 · 19:23
clinical Before removing a seton, the bottom must look better, drainage must be better, the patient must be symptom-free, and they must have reached steady state of biologic (loading dose plus at least 3 more doses, typically 2-3 months from start). ↗
▶ Ep 115 · 19:23
clinical Before removing a seton, the bottom must look better, drainage must be better, the patient must be symptom-free, and they must have reached steady state of biologic (loading dose plus at least 3 more doses, typically 2-3 months from start). ↗
▶ Ep 115 · 19:55
clinical Inflammatory markers including fecal calprotectin, ESR, and CRP should be checked before removing a seton to ensure systemic disease is under control. ↗
▶ Ep 115 · 19:55
clinical Inflammatory markers including fecal calprotectin, ESR, and CRP should be checked before removing a seton to ensure systemic disease is under control. ↗
▶ Ep 115 · 20:49
clinical The initial Remicade paper from 1998 or 1999 in the New England Journal of Medicine was on perianal disease and demonstrated improved healing time and improved length of time between recurrence when combination of seton and infliximab is used versus either separately. ↗
▶ Ep 115 · 20:49
clinical The initial Remicade paper from 1998 or 1999 in the New England Journal of Medicine was on perianal disease and demonstrated improved healing time and improved length of time between recurrence when combination of seton and infliximab is used versus either separately. ↗

Hirschsprung Disease in Brief

▶ Ep 116 · 0:33
clinical Hirschsprung disease is a congenital anomaly of the GI tract that results in a functional bowel obstruction. ↗
▶ Ep 116 · 1:11
quote More than 95% of neonates pass meconium within the first 48 hours of life. And failure to pass meconium is typical of Hirschsprung's disease. ↗
▶ Ep 116 · 1:11
clinical Failure to pass meconium within the first 48 hours of life is typical of Hirschsprung's disease. ↗
▶ Ep 116 · 1:11
clinical More than 95% of neonates pass meconium within the first 48 hours of life. ↗
▶ Ep 116 · 1:43
clinical The RET gene is a predisposing genetic condition associated with Hirschsprung disease. ↗
▶ Ep 116 · 1:43
clinical Hirschsprung disease is associated with Wordenberg syndrome and congenital central hyperventilation (Andine's curse). ↗
▶ Ep 116 · 1:43
epidemiological Only 1 to 2% of patients with trisomy 21 have Hirschsprung's disease. ↗
▶ Ep 116 · 1:43
epidemiological Up to 10% of children with Hirschsprung's disease will have trisomy 21. ↗
▶ Ep 116 · 1:43
epidemiological About 10% of children with Hirschsprung disease will have a positive family history. ↗
▶ Ep 116 · 2:25
guideline The three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry. ↗
▶ Ep 116 · 2:42
clinical The classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel. ↗
▶ Ep 116 · 2:42
quote The classic finding is a transition zone in the rectosigmoid, but that transition zone really can be located anywhere within the bowel. ↗
▶ Ep 116 · 3:14
clinical A rectosigmoid ratio of less than 1.0 is suggestive of Hirschsprung's disease. ↗
▶ Ep 116 · 3:49
quote The second part of a diagnostic workup for Hirschsprung's disease, and most important, is the rectal biopsy. It is the true definitive diagnosis. ↗
▶ Ep 116 · 3:49
guideline Rectal biopsy is the true definitive diagnosis for Hirschsprung disease. ↗
▶ Ep 116 · 4:04
clinical Typical features on rectal biopsy include absence of ganglion cells, presence of hypertrophic nerves, abnormal pattern of colon esterase staining, and an absence of calretinine staining. ↗
▶ Ep 116 · 4:04
quote Typical features on the biopsy include absence of ganglion cells, presence of hypertrophic nerves, abnormal pattern of colon esterase staining, and an absence of calretinine staining. ↗
▶ Ep 116 · 4:04
guideline To be considered an adequate rectal biopsy, it must be taken from the rectum at least 1 cm above the dentate line and must include both mucosa and submucosal layers. ↗
▶ Ep 116 · 4:29
guideline Suction rectal biopsy technique is typically used for patients less than 6 months of age. ↗
▶ Ep 116 · 4:29
guideline Full thickness rectal biopsy technique should be considered for patients older than 6 months or when a suction biopsy is inadequate. ↗
▶ Ep 116 · 5:42
guideline Any patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis. ↗
▶ Ep 116 · 7:29
quote There are three goals to the surgical management of Hirschsprung disease. First, identify the extent of the aganglionic segment. Second, resect that segment. And third, restore the bowel to its continuity. ↗
▶ Ep 116 · 7:29
guideline The three goals of surgical management of Hirschsprung disease are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity. ↗
▶ Ep 116 · 7:59
clinical The Suave procedure is a mucosectomy where you leave a cuff of aganglionic bowel and bring the ganglionated bowel through that cuff of rectum and perform the anastomosis. ↗
▶ Ep 116 · 7:59
clinical The three procedures for Hirschsprung disease (Swensen, Suave, Duamel) all involve a transanal approach of removing the aganglionic colon and pulling down healthy colon and sewing it to the anus. ↗
▶ Ep 116 · 7:59
clinical The Swensen technique is a full thickness dissection and anastomosis. ↗
▶ Ep 116 · 7:59
clinical The Duamel procedure involves performing a pouch with an anastomosis of aganglionic and ganglionated bowel. ↗
▶ Ep 116 · 9:15
guideline Depending on the severity of enterocolitis, broad-spectrum antibiotics are sometimes added, and patients are usually started on metronidazole. ↗
▶ Ep 116 · 9:15
clinical Hirschsprung's associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth. ↗
▶ Ep 116 · 9:15
clinical A child with enterocolitis presents with abdominal distention, vomiting, fever, and change in bowel habits. ↗
▶ Ep 116 · 9:15
guideline Enterocolitis must be recognized as potential enterocolitis and treated urgently. ↗
▶ Ep 116 · 9:15
guideline Treatment for enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations. ↗
▶ Ep 116 · 9:15
quote Hirschsprung's associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth. ↗

The Colorectal Quiz Episode 23: Hirschsprung Disease - The Soiling Patient...

▶ Ep 118 · 2:44
quote Can I scare you for a moment? Can we talk scientifically for one minute? I know this is crazy. ↗
▶ Ep 118 · 3:08
clinical The dentate (or pectinate) line is the transition from squamous epithelium to columnar epithelium, located about 2/3 of the way up the anal canal. ↗
▶ Ep 118 · 3:25
clinical Blood supply changes occur at the dentate line (splanchnic versus systemic), and there is also innervation in that area. ↗
▶ Ep 118 · 3:54
quote I talk about that dentate line in the area where the nerves are located that tell you gas, liquid, solid. How hard do I need to squeeze, how long do I have to squeeze for, how tight do I have to squeeze? ↗
▶ Ep 118 · 3:54
clinical The nerves located at the dentate line region tell you gas, liquid, solid; how hard, how long, and how tight to squeeze. ↗
▶ Ep 118 · 4:15
clinical Preserving the dentate line region is key because injury to that region affects a patient's ability to be continent. ↗
▶ Ep 118 · 6:11
clinical In children with anorectal malformation, Hirschsprung disease, spinal conditions, or combinations thereof, the ability to sense stool in the rectum or neorectum region is critical to success; the right consistency and bulk of stool is very important. ↗
▶ Ep 118 · 6:45
clinical If clinicians make stool too soft or too loose with medications, they put a child on the edge of having control or not and throw them over that edge, preventing success. ↗
▶ Ep 118 · 6:59
quote And if we make it too soft or too loose, we're putting a child or a person who is on the teeter of having control or not, and you throw them over that edge, and, and you just won't be successful. ↗
▶ Ep 118 · 11:16
quote I mean, it makes sense that they should if the muscle is intact, right, because this is no different than an anorectal malformation, anastomosis. That's right. But it's, it's, it's rectum or colon mucosa to skin. ↗
▶ Ep 118 · 11:16
clinical A Hirschsprung patient with missing dentate line and intact muscle should be able to achieve continence, similar to an anorectal malformation anastomosis (rectum or colon mucosa to skin). ↗
▶ Ep 118 · 12:08
clinical Patients with no dentate line and patulous sphincters who are soiling develop severe skin irritation from sitting in pull-ups or diapers. ↗
▶ Ep 118 · 12:08
quote That is a patient with no dentate line and pattula sphincters, and you clearly see with the skin changes around that, that this patient has really struggled and has been soiling and, and, and sitting in, in pull-ups or a diaper, really causing severe skin irritation. ↗
▶ Ep 118 · 18:17
quote This, this is, these are the harder patients to take care of, and the trick that I use is you have to constipate them. And then if they're able to empty with continence on their own, then great. If they're not, then you have to mechanically help them empty. ↗
▶ Ep 118 · 18:17
clinical For hypermotile patients (stooling 7-8 times a day), the approach is to constipate them first, then figure out how to empty them in a time-controlled fashion. ↗
▶ Ep 118 · 18:35
clinical Whether hypermotile patients can empty on their own versus needing mechanical emptying to maintain social continence depends on their sphincter function. ↗
▶ Ep 118 · 18:35
quote But it, it's, it's like, it sounds counterintuitive, but at least the way I treat these patients, I constipate them, and then I empty them. ↗
▶ Ep 118 · 18:58
quote But that's how I sort of explain it to the families. It sounds weird, but we're gonna constipate you, and then we have to figure out how to empty you in a time-controlled fashion. ↗
▶ Ep 118 · 22:42
clinical Some Hirschsprung patients who have a good operation have super strong sphincters that just need a little relaxation to allow passage of stool until they learn proper sphincter coordination for evacuation. ↗
▶ Ep 118 · 23:10
clinical Botox helps train sphincters in Hirschsprung patients; anorectal manometry can provide objective data showing resting pressures are usually on the higher end of normal, and some patients need extra relaxation to allow them to go. ↗
▶ Ep 118 · 23:31
clinical Nutrition in Hirschsprung patients is very important; some patients are very sensitive to certain foods, particularly lactose. ↗
▶ Ep 118 · 23:50
clinical Paying attention to diet (whether breastfed infants or older children) is important because lactose is particularly problematic in some Hirschsprung patients. ↗
▶ Ep 118 · 24:26
quote None. We have to get it right the first time. ↗
▶ Ep 118 · 24:29
opinion Every Hirschsprung patient should be able to do well; they might need help and might need mechanical evacuations or Botox, but all should be able to get on the right track. ↗
▶ Ep 118 · 24:29
quote And if you don't get it right, you gotta use these techniques and this algorithm to figure out what's wrong, cause we could get every patient doing well. They might need help, and they might need mechanical evacuations, Botox, etc. but we could, we all should be able to get these patients on the right track. ↗

Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula

▶ Ep 119 · 15:22
quote when you do find neurologic anomalies. That leads to more likely gynecological anomalies as well, especially on the same side. ↗
▶ Ep 119 · 15:22
clinical When neurologic anomalies are found in anorectal malformation patients, gynecological anomalies are more likely, especially on the same side. ↗

Colorectal Quiz Episode 29: Female ARM-Post Op Management

▶ Ep 120 · 7:17
clinical Dr. Fisher's protocol for perineal body primary repair (no stoma) is 5-7 days NPO on D10 via midline catheter (not PICC line) until the repair is confirmed healed. ↗
▶ Ep 120 · 8:03
quote Just because it's published doesn't mean it works. ↗
▶ Ep 120 · 13:51
quote My only concern is what's the continence rate of your patients? ↗
▶ Ep 120 · 14:20
host_summary In the dilation trial, 4 patients required redo operations for stricture: 2 in the dilation arm (who didn't actually dilate) and 2 in the non-dilation arm. Additional patients required Heineke-Mikulicz procedures (3 in one group, 47 total procedures mentioned). ↗
▶ Ep 120 · 15:01
quote I guess my question is somewhere around 20% required a redo either local or total operation. Most just like local, but what did a functional out in the end of the game, all the parents want is their kid pooping in the potty. And we don't know that answer. ↗
▶ Ep 120 · 15:24
quote That's a very valid point. So what you're saying, wait, wait, Mark agreed with me. ↗
▶ Ep 120 · 19:00
quote And when I was working with Mark here, I know, especially in the older patients that we were doing redos on, used to teach me to make the anoplasty maybe a little larger. ↗

Colorectal Quiz Episode 37: The Yancey-Soave story of the original surgical descriptions for Hirschsprung disease

▶ Ep 136 · 12:26
clinical Dr. Newman brought Dr. Yancey's story to the attention of the Hirschsprung interest group at APSA. ↗
▶ Ep 136 · 12:26
clinical Dr. Newman brought Dr. Yancey's story to the attention of the Hirschsprung interest group at APSA. ↗
▶ Ep 136 · 15:06
quote I was reading the operative note from one of my fellows who provided the history of the patient. I had to do a reoperation on the patient. And the history read that this five-year-old child is status post a Yancey Suave procedure in such and such date and had an asthmatic stricture. ↗
▶ Ep 136 · 15:06
clinical A fellow at Children's National wrote an operative note describing a patient as status post a 'Yancey-Suave procedure,' indicating the terminology has become part of standard practice. ↗
▶ Ep 136 · 15:06
clinical A fellow at Children's National wrote an operative note describing a patient as status post a 'Yancey-Suave procedure,' indicating the terminology has become part of standard practice. ↗
▶ Ep 136 · 15:06
quote I was reading the operative note from one of my fellows who provided the history of the patient. I had to do a reoperation on the patient. And the history read that this five-year-old child is status post a Yancey Suave procedure in such and such date and had an asthmatic stricture. ↗

Colorectal Quiz Episode 38: Transitional Care in Colorectal Surgery

▶ Ep 158 · 3:59
clinical MRI with specific protocols and endorectal ultrasound can help determine whether the anoplasty is within the muscle complex. ↗
▶ Ep 158 · 14:05
opinion The transition model includes joint clinic visits and collaborative operating, which is key to successful handoff. ↗
▶ Ep 158 · 14:54
opinion Freestanding children's hospitals face greater challenges than integrated hospitals because they are completely separate entities both physically and financially. ↗
▶ Ep 158 · 15:14
clinical In Cincinnati, ARM patients still come to the colorectal center at the children's hospital whether they are 12 or 40 years old, partnering with an adult colorectal surgeon; collaborative operating occurs at the University of Cincinnati with adult colorectal surgeons, adult neurologists for urology, and pediatric urologists who have privileges at the university. ↗
▶ Ep 158 · 18:58
opinion Adult hospitals are much more adept and skilled at managing perioperative complications like pulmonary embolism or myocardial infarction; such events in a children's hospital lead to many meetings and potential for poor outcomes. ↗
▶ Ep 158 · 19:33
clinical Physicians and surgeons are making progress on transition, but the greater struggle is providing intensive bowel management training for 35-year-old patients; pediatric centers are adept at bowel management for patients of any age, but currently adult patients requiring intensive outpatient bowel management are still being seen at children's hospitals. ↗
▶ Ep 158 · 24:21
quote This is the future. ↗

Colorectal Quiz: Episode 47

▶ Ep 224 · 6:29
guideline Anorectal manometry is not part of the standard initial workup for anorectal malformation patients; it is saved for circumstances that are difficult to figure out. ↗
▶ Ep 224 · 6:29
clinical There are many ways to tell if the anus is in the proper position, such as electrical stimulation and rectal ultrasound or MRI. ↗
▶ Ep 224 · 6:29
quote We don't typically do anorectal manometry in our anorectal malformation patients as part of the standard initial workup. I never say never and I never say always, but it's not part of our standard evaluation. ↗
▶ Ep 224 · 6:29
quote We don't typically do anorectal manometry in our anorectal malformation patients as part of the standard initial workup. I never say never and I never say always, but it's not part of our standard evaluation. ↗
▶ Ep 224 · 6:29
clinical There are many ways to tell if the anus is in the proper position, such as electrical stimulation and rectal ultrasound or MRI. ↗
▶ Ep 224 · 6:29
guideline Anorectal manometry is not part of the standard initial workup for anorectal malformation patients; it is saved for circumstances that are difficult to figure out. ↗
▶ Ep 224 · 9:40
quote This is one of those things I always wonder, cause we all have a few patients that have this anatomy like chicken or the egg. Like what came first? ↗
▶ Ep 224 · 9:40
quote This is one of those things I always wonder, cause we all have a few patients that have this anatomy like chicken or the egg. Like what came first? ↗
▶ Ep 224 · 16:49
quote I think this patient is going to be a bowel management candidate. And I doubt they will ever achieve successful bowel control anyway, given the quality of their pelvis, the amount of quadruple regression that they have. ↗
▶ Ep 224 · 16:49
clinical A sacral ratio of 0.45 indicates the sacrum is not great and the perineal musculature is probably not great. ↗
▶ Ep 224 · 16:49
quote I think this patient is going to be a bowel management candidate. And I doubt they will ever achieve successful bowel control anyway, given the quality of their pelvis, the amount of quadruple regression that they have. ↗
▶ Ep 224 · 16:49
clinical A sacral ratio of 0.45 indicates the sacrum is not great and the perineal musculature is probably not great. ↗
▶ Ep 224 · 16:49
clinical A patient with sacral ratio 0.45 is likely to be a bowel management candidate and will probably never achieve successful bowel control given the quality of their pelvis and amount of caudal regression. ↗
▶ Ep 224 · 16:49
clinical A patient with sacral ratio 0.45 is likely to be a bowel management candidate and will probably never achieve successful bowel control given the quality of their pelvis and amount of caudal regression. ↗
▶ Ep 224 · 17:18
clinical Dr. Levitt has had some patients with good success with continence where the sigmoid is able to feel some distension after resection and sigmoid pull-through, but it is not the expectation. ↗
▶ Ep 224 · 17:18
host_summary Dr. Levitt has had some patients with good success with continence where the sigmoid is able to feel some distension after resection and sigmoid pull-through, but it is not the expectation. ↗

Colorectal Quiz: Episode 46

▶ Ep 225 · 6:27
clinical In anorectal malformation patients with perforation, the sigmoid colon typically perforates with a linear, longitudinal tear along the taenia. ↗
▶ Ep 225 · 6:27
clinical In anorectal malformation patients with perforation, the sigmoid colon typically perforates with a linear, longitudinal tear along the taenia. ↗
▶ Ep 225 · 7:34
quote You need to break the cycle of the physiologic obstruction. They are obstructed both at the sphincter level and in the aganglionic segment. And you have to break that cycle by getting a tube across it and then a lumen of that tube then to allow for egress of that stool because it's the stasis that's the problem. It's the stasis, the bacterial overgrowth. That overgrowth leads to translocation and that's where the sepsis comes in. ↗
▶ Ep 225 · 7:34
clinical The pathophysiology of Hirschsprung enterocolitis involves physiologic obstruction at both the sphincter level and in the aganglionic segment, leading to stasis, bacterial overgrowth, translocation, and sepsis. ↗
▶ Ep 225 · 7:34
clinical The pathophysiology of Hirschsprung enterocolitis involves physiologic obstruction at both the sphincter level and in the aganglionic segment, leading to stasis, bacterial overgrowth, translocation, and sepsis. ↗
▶ Ep 225 · 7:34
quote You need to break the cycle of the physiologic obstruction. They are obstructed both at the sphincter level and in the aganglionic segment. And you have to break that cycle by getting a tube across it and then a lumen of that tube then to allow for egress of that stool because it's the stasis that's the problem. It's the stasis, the bacterial overgrowth. That overgrowth leads to translocation and that's where the sepsis comes in. ↗
▶ Ep 225 · 8:41
clinical Cold saline used for irrigations in small children can significantly change the child's body temperature, so warm saline should be used. ↗
▶ Ep 225 · 8:41
clinical Cold saline used for irrigations in small children can significantly change the child's body temperature, so warm saline should be used. ↗
▶ Ep 225 · 10:55
clinical Sawtoothing in the rectum on contrast enema represents hyperperistalsis and is very classic for Hirschsprung disease, particularly when associated with enterocolitis. ↗
▶ Ep 225 · 10:55
clinical Sawtoothing in the rectum on contrast enema represents hyperperistalsis and is very classic for Hirschsprung disease, particularly when associated with enterocolitis. ↗
▶ Ep 225 · 13:33
opinion If a patient has recovered from enterocolitis and irrigations are going well with reliable family, it is reasonable to send them home for 1-2 months before definitive operation rather than operating at 2 weeks. ↗
▶ Ep 225 · 13:33
quote If it was a reliable family and irrigations were going well, I probably would have sent them home for a couple, a month or two, and then brought them back for their definitive operation. ↗
▶ Ep 225 · 13:33
quote If it was a reliable family and irrigations were going well, I probably would have sent them home for a couple, a month or two, and then brought them back for their definitive operation. ↗
▶ Ep 225 · 13:33
opinion If a patient has recovered from enterocolitis and irrigations are going well with reliable family, it is reasonable to send them home for 1-2 months before definitive operation rather than operating at 2 weeks. ↗
▶ Ep 225 · 14:29
clinical Literature from the PCPLC and Michael Rollins shows that delayed definitive surgery for Hirschsprung disease (around 3 months out) has similar outcomes, so it is okay to wait as long as patient receives good irrigations and is growing and healthy. ↗
▶ Ep 225 · 14:29
clinical Literature from the PCPLC and Michael Rollins shows that delayed definitive surgery for Hirschsprung disease (around 3 months out) has similar outcomes, so it is okay to wait as long as patient receives good irrigations and is growing and healthy. ↗
▶ Ep 225 · 14:29
quote I agree with Mark. I would wait minimum four weeks from getting healthy after treating enterocolitis, maybe even longer before doing this. And I think there's good literature out there from the PCPLC and Michael Rollins on outcomes of Hirschsprung's disease and delayed treatment and delayed mepeter, wrong term. But just doing the definitive surgery, they looked at about three months out and had similar outcomes. ↗
▶ Ep 225 · 14:29
quote I agree with Mark. I would wait minimum four weeks from getting healthy after treating enterocolitis, maybe even longer before doing this. And I think there's good literature out there from the PCPLC and Michael Rollins on outcomes of Hirschsprung's disease and delayed treatment and delayed mepeter, wrong term. But just doing the definitive surgery, they looked at about three months out and had similar outcomes. ↗
▶ Ep 225 · 17:23
clinical If mapping the colon without frozen section available, the entire colon should be mapped (left colon, transverse colon, and hepatic flexure/right colon) to avoid missing ganglionic segments. ↗
▶ Ep 225 · 17:23
clinical If mapping the colon without frozen section available, the entire colon should be mapped (left colon, transverse colon, and hepatic flexure/right colon) to avoid missing ganglionic segments. ↗
▶ Ep 225 · 22:52
quote I'm a fan of doing ileostomies in these cases where we need to divert and we have time and we're in a place where we're able to keep the patients hydrated well. ↗
▶ Ep 225 · 22:52
quote I'm a fan of doing ileostomies in these cases where we need to divert and we have time and we're in a place where we're able to keep the patients hydrated well. ↗
▶ Ep 225 · 22:52
clinical In settings where patients can be kept well hydrated with easy healthcare access, ileostomy is preferred over colostomy for diversion because colostomy mesentery becomes shortened and inflamed after division, making subsequent pull-through technically difficult with inadequate reach. ↗
▶ Ep 225 · 22:52
clinical In settings where patients can be kept well hydrated with easy healthcare access, ileostomy is preferred over colostomy for diversion because colostomy mesentery becomes shortened and inflamed after division, making subsequent pull-through technically difficult with inadequate reach. ↗
▶ Ep 225 · 23:41
clinical When performing ileostomy for Hirschsprung diversion, frozen section should be done on the ileostomy to ensure it will function. ↗
▶ Ep 225 · 23:41
clinical When performing ileostomy for Hirschsprung diversion, frozen section should be done on the ileostomy to ensure it will function. ↗
▶ Ep 225 · 26:54
clinical Cincinnati group is conducting a non-randomized study of Botox injection at the anal sphincter at time of ileostomy closure, with retrospective baseline comparison and prospective data collection currently in mid-30s patients; some patients in the protocol have still developed enterocolitis, so it is not 100% effective. ↗
▶ Ep 225 · 26:54
clinical Cincinnati group is conducting a non-randomized study of Botox injection at the anal sphincter at time of ileostomy closure, with retrospective baseline comparison and prospective data collection currently in mid-30s patients; some patients in the protocol have still developed enterocolitis, so it is not 100% effective. ↗
▶ Ep 225 · 28:04
clinical Families should be sent home with equipment to irrigate and taught how to irrigate before the pull-through so they can practice, ensuring they know the technique before discharge and avoiding catheter passage through fresh anastomosis post-op day 5. ↗
▶ Ep 225 · 28:04
clinical Families should be sent home with equipment to irrigate and taught how to irrigate before the pull-through so they can practice, ensuring they know the technique before discharge and avoiding catheter passage through fresh anastomosis post-op day 5. ↗
▶ Ep 225 · 28:04
quote We send the families home with the equipment to irrigate. That's a must, right? And also we teach how to irrigate before we do our pull through so that they are, and make the parents practice whether the child has enterocolitis or not pre-op so that they know how to do it. ↗
▶ Ep 225 · 28:04
quote We send the families home with the equipment to irrigate. That's a must, right? And also we teach how to irrigate before we do our pull through so that they are, and make the parents practice whether the child has enterocolitis or not pre-op so that they know how to do it. ↗

Colorectal Quiz: Episode 46

▶ Ep 226 · 4:52
quote Free air, irrigation, you could irrigate, but I don't, the time it takes to irrigate, you're not getting to OR that fast for anything. ↗
▶ Ep 226 · 6:27
clinical In anorectal malformation patients with perforation, the sigmoid colon perforates as a linear longitudinal tear along the tenia. ↗
▶ Ep 226 · 6:34
quote Yeah, so that typically is the sigmoid colon, right? And it's a very, it's a linear, like a longitudinal tear along the tinea. I've seen it a couple of times in patients who had delayed diagnosis of imperforate anus. ↗
▶ Ep 226 · 6:53
quote I think, Mark, I think I've seen perfs in transverse colon, too, but when I go in and you take a baby to your OR with free air and you find a perf in the cecum, that to me sort of cries rectal biopsy. ↗
▶ Ep 226 · 6:53
clinical When a baby goes to OR with free air and a perforation is found in the cecum, this strongly suggests Hirschsprung disease and should prompt rectal biopsy; most such patients would receive an ileostomy. ↗
▶ Ep 226 · 7:34
clinical Proper irrigation technique requires breaking the cycle of physiologic obstruction at both the sphincter level and in the aganglionic segment by getting a tube across and allowing egress of stool, because stasis leads to bacterial overgrowth, translocation, and sepsis. ↗
▶ Ep 226 · 7:34
quote It's very important. You need to break the cycle of the physiologic obstruction. They are obstructed both at the sphincter level and in the aganglionic segment. And you have to break that cycle by getting a tube across it and then a lumen of that tube then to allow for egress of that stool because it's the stasis that's the problem. It's the stasis, the bacterial overgrowth. That overgrowth leads to translocation and that's where the sepsis comes in. ↗
▶ Ep 226 · 8:41
clinical Cold saline should not be used for irrigations in small children because it can significantly change the child's temperature. ↗
▶ Ep 226 · 8:41
quote Some people have different methods. We typically say until about clear. Just make sure you're using warm saline because in a small child, cold saline can really change the temperature of the child. ↗
▶ Ep 226 · 10:55
clinical Sawtoothing visible in the rectum on contrast enema represents hyperperistalsis and is very classic for Hirschsprung disease, particularly when associated with enterocolitis. ↗
▶ Ep 226 · 10:55
quote Well, I would even add that there's hyperperistalsis. You can actually see the enero colitis more in the left colon. And the sawtoothing is the rectum is hyperperistaltic. That's very classic for Hirschsprung's disease. ↗
▶ Ep 226 · 13:33
quote Yeah, I, um, that contrast study I would have read as a little bit of enterocolitis still happening, even though the patient was clinically well. If it was a reliable family and irrigations were going well, I probably would have sent them home for a couple, a month or two, and then brought them back for their definitive operation. ↗
▶ Ep 226 · 13:33
opinion In a patient who has recovered from enterocolitis with successful irrigations and is being fed, the appropriate approach is to send them home on irrigations and return for definitive operation in 1-2 months. ↗
▶ Ep 226 · 14:07
clinical Literature from the PCPLC and Michael Rollins shows that delayed definitive surgery for Hirschsprung disease (approximately 3 months out) has similar outcomes to earlier surgery, supporting that it is safe to wait as long as irrigations are successful and the patient is growing and healthy. ↗
▶ Ep 226 · 14:07
opinion The minimum wait time after treating enterocolitis before performing definitive Hirschsprung surgery should be 4 weeks, possibly even longer. ↗
▶ Ep 226 · 14:29
quote I agree with Mark. I would wait minimum four weeks from getting healthy after treating enterocolitis, maybe even longer before doing this. And I think there's good literature out there from the PCPLC and Michael Rollins on outcomes of Hirschsprung's disease and delayed treatment and delayed mepeter, wrong term. But just doing the definitive surgery, they looked at about three months out and had similar outcomes. ↗
▶ Ep 226 · 16:33
quote I have seen patients, I don't know if you've seen this scenario, Jason, where someone has done this mapping, but they never sampled the right colon. And then the patient has an ileostomy and the sigmoid and left colon are no good. And they have concluded that the patient has total colonic. Maybe they sent the appendix, which is a complete mistake. ↗
▶ Ep 226 · 17:14
clinical If mapping the colon without frozen section available, the entire colon should be mapped (left colon, transverse colon, and hepatic flexure/right colon), because incomplete mapping can lead to incorrect conclusions about the extent of disease. ↗
▶ Ep 226 · 17:23
opinion Pull-through should not extend past the hepatic flexure into distal ascending colon because Soave pull-throughs do not succeed very well with that anatomy. ↗
▶ Ep 226 · 17:23
quote So I think there's two scenarios, whether you have frozen section or not. If you have frozen section available and you get ganglion cells, then I don't think you need to do further mapping. If you don't have areas we go and operate or areas that don't have frozen section, I think you need to map the whole colon. ↗
▶ Ep 226 · 22:52
quote I'm a fan of doing ileostomies in these cases where we need to divert and we have time and we're in a place where we're able to keep the patients hydrated well. ↗
▶ Ep 226 · 23:41
quote I agree exactly. And I would do exactly the same thing. I would map and then do an ileostomy. I would do a frozen section on the ileostomy just to make absolutely certain that it's going to function. ↗
▶ Ep 226 · 23:41
clinical When performing ileostomy for Hirschsprung diversion, frozen section should be done on the ileostomy to ensure it will function. ↗
▶ Ep 226 · 26:54
clinical The Cincinnati protocol now applies Botox at the anal sphincter at the time of restoring intestinal continuity; prospective data collection is ongoing with patients in the mid-30s, though some patients in the protocol have definitely developed enterocolitis, so it is not 100% foolproof. ↗
▶ Ep 226 · 26:54
quote Then the group in Cincinnati with Dr. Helmrath and Dr. Frischer have altered the protocol to apply Botox at the anal sphincter at the time of restoring intestinal continuity. So we've been doing that. I don't have data to share that of an outcome. I will say, I know we have a few patients that definitely got enteroclitis that were in the protocol. So it's definitely not 100% full proof. And we definitely have increased diaper rash issues. So we know we're putting it in the right place. ↗
▶ Ep 226 · 28:04
quote We send the families home with the equipment to irrigate. That's a must, right? And also we teach how to irrigate before we do our pull through so that they are, and make the parents practice whether the child has enterocolitis or not pre-op so that they know how to do it. Because I don't love that catheter going through the anastomosis post-up day five when they're ready to go home or, and having issues. So I think you're dead on. Education is so key and preparing the families for this is life-saving. ↗
▶ Ep 226 · 28:04
clinical Families should be sent home with irrigation equipment and taught how to irrigate before the pull-through surgery, with parents practicing the technique so they know how to do it, because having a catheter go through the anastomosis post-op day 5 when ready for discharge can cause issues. ↗

Colorectal Quiz: Episode 43

▶ Ep 227 · 5:37
epidemiological About 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff, but about 40% of the time you cannot make it work. ↗
▶ Ep 227 · 5:37
epidemiological About 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff, but about 40% of the time you cannot make it work. ↗
▶ Ep 227 · 7:37
clinical The longer the appendix, the less likely it will leak based on Poiseuille's law (flow through a tube based on radius to fourth power and length). ↗
▶ Ep 227 · 7:37
clinical The longer the appendix, the less likely it will leak based on Poiseuille's law (flow through a tube based on radius to fourth power and length). ↗
▶ Ep 227 · 8:35
clinical Dr. Frischer and Levitt did 10 Malones in a row without plicating and five leaked, so they decided to plicate them all and have not had a leakage in several years. ↗
▶ Ep 227 · 8:35
quote So we plicate them all. And I haven't had a leakage in a long, long time, several years. So I think it's a very effective strategy. ↗
▶ Ep 227 · 8:35
quote So we plicate them all. And I haven't had a leakage in a long, long time, several years. So I think it's a very effective strategy. ↗
▶ Ep 227 · 8:35
clinical Dr. Frischer and Levitt did 10 Malones in a row without plicating and five leaked, so they decided to plicate them all and have not had a leakage in several years. ↗
▶ Ep 227 · 9:03
clinical If appendix is 7 centimeters or greater it can be split, requiring minimum 2 centimeters for the Malone and 5 centimeters minimum for the Mitrofanoff. ↗
▶ Ep 227 · 9:03
clinical If appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel. ↗
▶ Ep 227 · 9:03
clinical If appendix is 5 to 7 centimeters, that is not enough to share and should go for the Mitrofanoff because long term the Mitrofanovs do much better, requiring a neo-Malone. ↗
▶ Ep 227 · 9:03
clinical If appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel. ↗
▶ Ep 227 · 9:03
clinical If appendix is 5 to 7 centimeters, that is not enough to share and should go for the Mitrofanoff because long term the Mitrofanovs do much better, requiring a neo-Malone. ↗
▶ Ep 227 · 9:03
clinical If appendix is 7 centimeters or greater it can be split, requiring minimum 2 centimeters for the Malone and 5 centimeters minimum for the Mitrofanoff. ↗
▶ Ep 227 · 16:13
clinical Using a 10 French tube (not 8), leaving it in for a month, and cathing twice a day can minimize stenosis rate. ↗
▶ Ep 227 · 16:13
clinical Using a 10 French tube (not 8), leaving it in for a month, and cathing twice a day can minimize stenosis rate. ↗
▶ Ep 227 · 16:54
clinical Leaving indwelling tubes in Malones increases the amount of prolapse, likely due to pressure on the appendiceal base pushing up mucosa. ↗
▶ Ep 227 · 16:54
clinical Leaving indwelling tubes in Malones increases the amount of prolapse, likely due to pressure on the appendiceal base pushing up mucosa. ↗
▶ Ep 227 · 17:45
clinical Urologists almost never get stenosis of Mitrofanovs because they catheterize every four hours; applying this to Malones by cathing twice daily has reduced stenosis rate. ↗
▶ Ep 227 · 17:45
clinical Urologists almost never get stenosis of Mitrofanovs because they catheterize every four hours; applying this to Malones by cathing twice daily has reduced stenosis rate. ↗
▶ Ep 227 · 20:00
clinical For lost Malone access, blow up a balloon on a Foley catheter to occlude the umbilicus and inject dye under pressure to find any micro hole tract. ↗
▶ Ep 227 · 20:00
clinical For lost Malone access, blow up a balloon on a Foley catheter to occlude the umbilicus and inject dye under pressure to find any micro hole tract. ↗

Colorectal Quiz: Episode 43

▶ Ep 228 · 5:37
epidemiological About 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff; about 40% of the time you cannot make it work. ↗
▶ Ep 228 · 5:37
epidemiological About 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff; about 40% of the time you cannot make it work. ↗
▶ Ep 228 · 7:37
clinical Flow of fluid through a tube is based on Poiseuille's law: radius to the fourth power and length. A longer appendix or narrower appendix affects flow probability. ↗
▶ Ep 228 · 7:37
clinical Flow of fluid through a tube is based on Poiseuille's law: radius to the fourth power and length. A longer appendix or narrower appendix affects flow probability. ↗
▶ Ep 228 · 8:35
clinical The longer the appendix, the less likely it will leak and you should not need to plicate. ↗
▶ Ep 228 · 8:35
epidemiological In a study of 10 malones done in a row without plicating, five leaked, leading to the decision to plicate all malones. ↗
▶ Ep 228 · 8:35
clinical Plicating all malones is a very effective strategy; no leakage has occurred in several years using this approach. ↗
▶ Ep 228 · 8:35
epidemiological In a study of 10 malones done in a row without plicating, five leaked, leading to the decision to plicate all malones. ↗
▶ Ep 228 · 8:35
clinical The longer the appendix, the less likely it will leak and you should not need to plicate. ↗
▶ Ep 228 · 8:35
clinical Plicating all malones is a very effective strategy; no leakage has occurred in several years using this approach. ↗
▶ Ep 228 · 9:03
clinical If appendix is seven centimeters or greater it can be split, requiring minimum two centimeters for Malone and five centimeters minimum for Mitrofanoff. ↗
▶ Ep 228 · 9:03
clinical If appendix is five to seven centimeters, that is not enough to share and should go for the Mitrofanoff because long term the Mitrofanovs do much better, requiring a neo-Malone. ↗
▶ Ep 228 · 9:03
clinical If appendix is five to seven centimeters, that is not enough to share and should go for the Mitrofanoff because long term the Mitrofanovs do much better, requiring a neo-Malone. ↗
▶ Ep 228 · 9:03
clinical If appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel. ↗
▶ Ep 228 · 9:03
clinical If appendix is seven centimeters or greater it can be split, requiring minimum two centimeters for Malone and five centimeters minimum for Mitrofanoff. ↗
▶ Ep 228 · 9:03
clinical If appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel. ↗
▶ Ep 228 · 10:00
clinical For patients with appendix 4-7 centimeters, 90% of appendix can be given to urologist with extension of appendiceal stump into cecum using non-cutting endo-TA stapler or hand-sewn non-absorbable braided suture. ↗
▶ Ep 228 · 10:00
clinical For patients with appendix 4-7 centimeters, 90% of appendix can be given to urologist with extension of appendiceal stump into cecum using non-cutting endo-TA stapler or hand-sewn non-absorbable braided suture. ↗
▶ Ep 228 · 12:08
clinical Pay attention to ileocecal valve location when creating Malone and plication to avoid obstruction at the ileocecal valve. ↗
▶ Ep 228 · 12:08
clinical Pay attention to ileocecal valve location when creating Malone and plication to avoid obstruction at the ileocecal valve. ↗
▶ Ep 228 · 16:13
clinical Using a 10 French tube instead of 8, leaving it in for a month, and cathing twice a day has reduced the incidence of stenosis. ↗
▶ Ep 228 · 16:13
clinical Using a 10 French tube instead of 8, leaving it in for a month, and cathing twice a day has reduced the incidence of stenosis. ↗
▶ Ep 228 · 16:54
clinical Leaving tubes in prevents stenosis but increases the chance of leakage because the valve is no longer as pertinent with a stent across it. ↗
▶ Ep 228 · 16:54
clinical Leaving tubes in prevents stenosis but increases the chance of leakage because the valve is no longer as pertinent with a stent across it. ↗
▶ Ep 228 · 16:54
clinical Prolonged stenting increases prolapse rate due to pressure on the appendiceal base pushing up mucosa. ↗
▶ Ep 228 · 16:54
clinical Prolonged stenting increases prolapse rate due to pressure on the appendiceal base pushing up mucosa. ↗
▶ Ep 228 · 17:45
clinical Urologists almost never get stenosis of Mitrofanoff because they cath every four hours; cathing the Malone twice a day has reduced stenosis rate. ↗
▶ Ep 228 · 17:45
clinical Urologists almost never get stenosis of Mitrofanoff because they cath every four hours; cathing the Malone twice a day has reduced stenosis rate. ↗
▶ Ep 228 · 18:20
clinical For recurrent leakage after two wraps, consider whether appendix length is a problem and whether channel needs lengthening. ↗
▶ Ep 228 · 18:20
clinical For recurrent leakage after two wraps, consider whether appendix length is a problem and whether channel needs lengthening. ↗
▶ Ep 228 · 20:00
clinical Blowing up a balloon on Foley catheter to occlude umbilicus and injecting dye creates pressurized system that will find any micro-hole tract still present. ↗
▶ Ep 228 · 20:00
clinical Blowing up a balloon on Foley catheter to occlude umbilicus and injecting dye creates pressurized system that will find any micro-hole tract still present. ↗

Colorectal Quiz: Episode 40

▶ Ep 229 · 11:35
clinical Options for vaginal reconstruction when native vagina cannot reach include: dilating the existing introitus, opening the area and laying in a buccal graft, or waiting for tissue engineering options expected within 20 years or less. ↗
▶ Ep 229 · 11:35
clinical Options for vaginal reconstruction when native vagina cannot reach include: dilating the existing introitus, opening the area and laying in a buccal graft, or waiting for tissue engineering options expected within 20 years or less. ↗
▶ Ep 229 · 12:14
quote I think it's going to be, there are people right now taking a few vaginal cells and growing them and hopeful, just like you said, Mark, we're going to have some great tissue engineering that will assist us and make this a easier and better procedure for our patients. ↗
▶ Ep 229 · 12:14
quote I think it's going to be, there are people right now taking a few vaginal cells and growing them and hopeful, just like you said, Mark, we're going to have some great tissue engineering that will assist us and make this a easier and better procedure for our patients. ↗
▶ Ep 229 · 13:09
opinion If a neovagina bridge is functioning well without problems, there may be no reason to remove it later. ↗
▶ Ep 229 · 13:09
opinion If a neovagina bridge is functioning well without problems, there may be no reason to remove it later. ↗
▶ Ep 229 · 15:57
opinion Fred Reichman used to say 'you are judged by what you are willing to stop for'—surgeons must be willing to stop when uncertain, get more information or help, rather than plowing through. ↗
▶ Ep 229 · 15:57
quote Fred Reichman used to say, you are judged by what you are willing to stop for. And as surgeons, you have to be willing to say, hold on, I'm not exactly sure what I'm dealing with here. I'm going to stop. I'm going to get more information. I'm going to go get some help. I'm not going to plow through. ↗
▶ Ep 229 · 15:57
host_summary Fred Reichman used to say 'you are judged by what you are willing to stop for'—surgeons must be willing to stop when uncertain, get more information or help, rather than plowing through. ↗
▶ Ep 229 · 15:57
quote Fred Reichman used to say, you are judged by what you are willing to stop for. And as surgeons, you have to be willing to say, hold on, I'm not exactly sure what I'm dealing with here. I'm going to stop. I'm going to get more information. I'm going to go get some help. I'm not going to plow through. ↗

Colorectal Quiz: Episode 40

▶ Ep 230 · 5:32
quote Wait, is this Meyer-Rotakansky-Kuster-Hauser syndrome? ↗
▶ Ep 230 · 5:32
quote Wait, is this Meyer-Rotakansky-Kuster-Hauser syndrome? ↗
▶ Ep 230 · 11:35
opinion The introitus in this case is potentially dilatable in the future to create a functional vagina. ↗
▶ Ep 230 · 11:35
opinion The introitus in this case is potentially dilatable in the future to create a functional vagina. ↗
▶ Ep 230 · 12:14
opinion Tissue engineering options for vaginal reconstruction are expected to be available within 20 years or perhaps even shorter, with researchers currently growing vaginal cells. ↗
▶ Ep 230 · 12:14
quote There are people right now taking a few vaginal cells and growing them. ↗
▶ Ep 230 · 12:14
opinion Tissue engineering options for vaginal reconstruction are expected to be available within 20 years or perhaps even shorter, with researchers currently growing vaginal cells. ↗
▶ Ep 230 · 12:14
quote There are people right now taking a few vaginal cells and growing them. ↗
▶ Ep 230 · 13:09
quote I think you need it when there's a problem. If there's no problem, why go in and remove tissue, whether it be bowel or whatever you have as your graft? ↗
▶ Ep 230 · 13:09
opinion If a neovagina functions well and causes no problems, there is no reason to remove it later even if it is bowel or another graft material. ↗
▶ Ep 230 · 13:09
opinion If a neovagina functions well and causes no problems, there is no reason to remove it later even if it is bowel or another graft material. ↗
▶ Ep 230 · 13:09
quote I think you need it when there's a problem. If there's no problem, why go in and remove tissue, whether it be bowel or whatever you have as your graft? ↗
▶ Ep 230 · 14:50
quote I applaud you, Chris, and your partners for going in thinking you're going to do this big reconstruction, encounter something that you weren't expecting and doing the safe thing. ↗
▶ Ep 230 · 14:50
quote I applaud you, Chris, and your partners for going in thinking you're going to do this big reconstruction, encounter something that you weren't expecting and doing the safe thing. ↗
▶ Ep 230 · 15:57
quote As surgeons, you have to be willing to say, hold on, I'm not exactly sure what I'm dealing with here. I'm going to stop. I'm going to get more information. I'm going to go get some help. I'm not going to plow through. ↗
▶ Ep 230 · 15:57
opinion Fred Reichman used to say that surgeons are judged by what they are willing to stop for. ↗
▶ Ep 230 · 15:57
guideline If a surgeon is uncertain about vascular anatomy during an operation, they should stop, gather more information, and reconfront the situation rather than proceeding blindly. ↗
▶ Ep 230 · 15:57
quote Fred Reichman used to say, you are judged by what you are willing to stop for. ↗
▶ Ep 230 · 15:57
guideline If a surgeon is uncertain about vascular anatomy during an operation, they should stop, gather more information, and reconfront the situation rather than proceeding blindly. ↗
▶ Ep 230 · 15:57
quote Fred Reichman used to say, you are judged by what you are willing to stop for. ↗
▶ Ep 230 · 15:57
quote As surgeons, you have to be willing to say, hold on, I'm not exactly sure what I'm dealing with here. I'm going to stop. I'm going to get more information. I'm going to go get some help. I'm not going to plow through. ↗
▶ Ep 230 · 15:57
opinion Fred Reichman used to say that surgeons are judged by what they are willing to stop for. ↗

Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies

▶ Ep 231 · 4:36
quote Do you automatically get an echo on every one of your anorectal malformation babies? ↗
▶ Ep 231 · 4:36
quote Do you automatically get an echo on every one of your anorectal malformation babies? ↗
▶ Ep 231 · 7:24
clinical In a cardiac patient with an external opening from ARM, the typical approach is to dilate as long as they're evacuating okay. ↗
▶ Ep 231 · 7:24
opinion For perineal fistula or vestibular fistula in a female, one can consider just dilating with good evacuation and letting the cardiac situation play itself out. ↗
▶ Ep 231 · 7:24
clinical In a cardiac patient with an external opening from ARM, the typical approach is to dilate as long as they're evacuating okay. ↗
▶ Ep 231 · 7:24
opinion For perineal fistula or vestibular fistula in a female, one can consider just dilating with good evacuation and letting the cardiac situation play itself out. ↗
▶ Ep 231 · 7:48
quote My concern would be if you're going to have a significant cardiac lesion that's going to likely require early surgery, you have a blue baby. You're having a lesion that a patient isn't oxygenating well. And then I worry about the healing of that repair ↗
▶ Ep 231 · 7:48
clinical In a blue baby with significant cardiac lesion requiring early surgery where patient isn't oxygenating well, there is concern about healing of an ARM repair. ↗
▶ Ep 231 · 7:48
quote My concern would be if you're going to have a significant cardiac lesion that's going to likely require early surgery, you have a blue baby. You're having a lesion that a patient isn't oxygenating well. And then I worry about the healing of that repair ↗
▶ Ep 231 · 7:48
clinical In a blue baby with significant cardiac lesion requiring early surgery where patient isn't oxygenating well, there is concern about healing of an ARM repair. ↗
▶ Ep 231 · 11:08
clinical For umbilical access in laparoscopy, dissect in with a mosquito, ensure you're in the peritoneum without touching any vessel before insufflation, and clear the line of air. ↗
▶ Ep 231 · 11:08
clinical For umbilical access in laparoscopy, dissect in with a mosquito, ensure you're in the peritoneum without touching any vessel before insufflation, and clear the line of air. ↗
▶ Ep 231 · 11:08
quote Dissecting in with a mosquito, making sure you're in, not touching any vessel before you insufflate, and also clear the line of air ↗
▶ Ep 231 · 11:08
quote Dissecting in with a mosquito, making sure you're in, not touching any vessel before you insufflate, and also clear the line of air ↗
▶ Ep 231 · 13:56
clinical The white beads along the raphe should be scraped off during repair, as they can persist into teenage years and young adulthood if left alone. ↗
▶ Ep 231 · 13:56
quote I've seen teenagers and young adults with those beads that never went away. So, yeah, you've got to scrape that off ↗
▶ Ep 231 · 13:56
quote I've seen teenagers and young adults with those beads that never went away. So, yeah, you've got to scrape that off ↗
▶ Ep 231 · 13:56
clinical The white beads along the raphe should be scraped off during repair, as they can persist into teenage years and young adulthood if left alone. ↗
▶ Ep 231 · 14:23
clinical For a 50-50 perineal fistula (half within muscle complex, half anterior), leave the anterior wall as it's the danger zone, mobilize posteriorly to fill the anal sphincter, creating an 80-20 reconstruction. ↗
▶ Ep 231 · 14:23
clinical For a 50-50 perineal fistula (half within muscle complex, half anterior), leave the anterior wall as it's the danger zone, mobilize posteriorly to fill the anal sphincter, creating an 80-20 reconstruction. ↗

Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies

▶ Ep 232 · 4:36
quote Do you automatically get an echo on every one of your anorectal malformation babies? ↗
▶ Ep 232 · 4:36
quote Do you automatically get an echo on every one of your anorectal malformation babies? ↗
▶ Ep 232 · 7:24
clinical In a cardiac patient with an external ARM opening, the typical approach is to dilate as long as they're evacuating okay, allowing the cardiac situation to play itself out. ↗
▶ Ep 232 · 7:24
clinical In a cardiac patient with an external ARM opening, the typical approach is to dilate as long as they're evacuating okay, allowing the cardiac situation to play itself out. ↗
▶ Ep 232 · 7:48
quote My concern would be if you're going to have a significant cardiac lesion that's going to likely require early surgery, you have a blue baby. You're having a lesion that a patient isn't oxygenating well. And then I worry about the healing of that repair. ↗
▶ Ep 232 · 7:48
clinical The concern with early ARM repair in a blue baby with significant cardiac lesion requiring early surgery is the healing of that repair when the patient isn't oxygenating well. ↗
▶ Ep 232 · 7:48
clinical The concern with early ARM repair in a blue baby with significant cardiac lesion requiring early surgery is the healing of that repair when the patient isn't oxygenating well. ↗
▶ Ep 232 · 7:48
quote My concern would be if you're going to have a significant cardiac lesion that's going to likely require early surgery, you have a blue baby. You're having a lesion that a patient isn't oxygenating well. And then I worry about the healing of that repair. ↗
▶ Ep 232 · 11:21
quote It is important to irrigate as much as you can ↗
▶ Ep 232 · 11:21
quote It is important to irrigate as much as you can ↗
▶ Ep 232 · 11:21
clinical Dr. Levitt's technique for distal irrigation involves having someone look laparoscopically while he passes the tube into the distal segment and does the irrigation under direct visualization. ↗
▶ Ep 232 · 11:21
host_summary Dr. Levitt's technique for distal irrigation involves having someone look laparoscopically while he passes the tube into the distal segment and does the irrigation under direct visualization. ↗

Colorectal Quiz Episode 29: Female ARM

▶ Ep 233 · 7:17
clinical Dr. Frisher uses a midline catheter (not PICC line) with D10 until the repair is confirmed healed, typically five to seven days NPO. ↗
▶ Ep 233 · 7:17
clinical Dr. Frisher uses a midline catheter (not PICC line) with D10 until the repair is confirmed healed, typically five to seven days NPO. ↗
▶ Ep 233 · 15:02
clinical Approximately 20% of patients in the dilation study required a redo operation, either local or total, with most being local procedures. ↗
▶ Ep 233 · 15:02
clinical Approximately 20% of patients in the dilation study required a redo operation, either local or total, with most being local procedures. ↗

Colorectal Quiz Episode 29: Female ARM

▶ Ep 234 · 7:17
clinical Frischer uses midline catheter (not PICC line) with D10 for 5-7 days NPO after primary perineal body repair. ↗
▶ Ep 234 · 7:17
clinical Frischer uses midline catheter (not PICC line) with D10 for 5-7 days NPO after primary perineal body repair. ↗
▶ Ep 234 · 14:04
quote My only concern is what's the continence rate of your patients? You have a percent of looking at, right? You're somewhere in the order of 15 to 20, 22% got redo operations, mostly local. ↗
▶ Ep 234 · 14:04
quote My only concern is what's the continence rate of your patients? You have a percent of looking at, right? You're somewhere in the order of 15 to 20, 22% got redo operations, mostly local. ↗
▶ Ep 234 · 15:02
host_summary Approximately 20% of patients in the dilation RCT required redo operations (either local or total), with most requiring only local revision. ↗
▶ Ep 234 · 15:02
clinical Approximately 20% of patients in the dilation RCT required redo operations (either local or total), with most requiring only local revision. ↗
▶ Ep 234 · 15:23
clinical Long-term continence outcomes are unknown for patients who developed strictures and underwent revision in the non-dilation group. ↗
▶ Ep 234 · 15:23
clinical Long-term continence outcomes are unknown for patients who developed strictures and underwent revision in the non-dilation group. ↗
▶ Ep 234 · 16:30
clinical Full continence can be restored with redo surgery for stricture, based on available data for longer strictures requiring full redo. ↗
▶ Ep 234 · 16:30
clinical Full continence can be restored with redo surgery for stricture, based on available data for longer strictures requiring full redo. ↗

The Colorectal Quiz Episode 21: The History of Hirschsprung Disease

▶ Ep 236 · 5:05
quote He united us. Yeah. In a way. And he doesn't even know it. ↗
▶ Ep 236 · 5:05
quote He united us. Yeah. In a way. And he doesn't even know it. ↗
▶ Ep 236 · 9:40
quote It's a super duper Duhamel. ↗
▶ Ep 236 · 9:40
clinical Dr. Martin developed the Martin procedure, an expansion of the Duhamel for long-segment Hirschsprung disease, leaving a longer aganglionated segment of rectum and pulling through ganglionated bowel. ↗
▶ Ep 236 · 9:40
clinical Dr. Martin developed the Martin procedure, an expansion of the Duhamel for long-segment Hirschsprung disease, leaving a longer aganglionated segment of rectum and pulling through ganglionated bowel. ↗
▶ Ep 236 · 9:40
clinical Dr. Martin was the first surgeon-in-chief and pediatric surgeon at Cincinnati Children's Hospital. ↗
▶ Ep 236 · 9:40
quote It's a super duper Duhamel. ↗
▶ Ep 236 · 9:40
clinical Dr. Martin was the first surgeon-in-chief and pediatric surgeon at Cincinnati Children's Hospital. ↗
▶ Ep 236 · 14:13
quote I think that's the who's who of Hirschsprung's right there. ↗
▶ Ep 236 · 14:13
quote I think that's the who's who of Hirschsprung's right there. ↗
▶ Ep 236 · 14:47
quote I have a feeling we're going to have way more discussions about Hirschsprung disease because just because, because I think it's a fascinating disease that there are so many intricacies. You just mentioned dentorocolitis. We could talk forever about that. ↗
▶ Ep 236 · 14:47
quote I have a feeling we're going to have way more discussions about Hirschsprung disease because just because, because I think it's a fascinating disease that there are so many intricacies. You just mentioned dentorocolitis. We could talk forever about that. ↗

Colorectal Quiz Episode 18: Cloaca Part 2

▶ Ep 237 · 1:45
quote Yeah, so we usually do it at about five to six months. ↗
▶ Ep 237 · 1:45
quote Yeah, so we usually do it at about five to six months. ↗
▶ Ep 237 · 1:45
clinical Definitive diagnostic workup for cloaca is usually performed at about 5-6 months of age ↗
▶ Ep 237 · 1:45
clinical Definitive diagnostic workup for cloaca is usually performed at about 5-6 months of age ↗
▶ Ep 237 · 4:34
clinical During cystoscopy it is important to look for cervices to determine if there is one or two vaginas and assess Müllerian development ↗
▶ Ep 237 · 4:34
clinical During cystoscopy it is important to look for cervices to determine if there is one or two vaginas and assess Müllerian development ↗
▶ Ep 237 · 4:50
quote I think it's also important to look for cervices and see if you have one vagina, two vaginas. Do you have a cervix, which will sort of be the front door? Is there a uterus behind there? ↗
▶ Ep 237 · 4:50
quote I think it's also important to look for cervices and see if you have one vagina, two vaginas. Do you have a cervix, which will sort of be the front door? Is there a uterus behind there? ↗
▶ Ep 237 · 5:00
clinical Surgeons should look for ureteral orifices during cystoscopy because in complex malformations there can be anomalous ureteral attachments to the bladder or bladder neck that come in very low and could be treacherous ↗
▶ Ep 237 · 5:00
clinical Surgeons should look for ureteral orifices during cystoscopy because in complex malformations there can be anomalous ureteral attachments to the bladder or bladder neck that come in very low and could be treacherous ↗
▶ Ep 237 · 7:41
opinion Endoscopy performed by general pediatric surgeons has value in determining whether a cloaca is straightforward or complex, helping surgeons decide whether to refer to a specialized center ↗
▶ Ep 237 · 7:41
opinion Endoscopy performed by general pediatric surgeons has value in determining whether a cloaca is straightforward or complex, helping surgeons decide whether to refer to a specialized center ↗
▶ Ep 237 · 8:30
quote I can tell you, as recently as 10 or 15 years ago, there was a lot more redoing of cloacas that was required because I think surgeons attempted a repair and then realized that it was much more complicated than they had imagined. ↗
▶ Ep 237 · 8:30
clinical As recently as 10-15 years ago, there was much more redoing of cloacas required because surgeons attempted repairs without adequate evaluation and realized the cases were more complicated than imagined ↗
▶ Ep 237 · 8:30
clinical As recently as 10-15 years ago, there was much more redoing of cloacas required because surgeons attempted repairs without adequate evaluation and realized the cases were more complicated than imagined ↗
▶ Ep 237 · 8:30
quote I can tell you, as recently as 10 or 15 years ago, there was a lot more redoing of cloacas that was required because I think surgeons attempted a repair and then realized that it was much more complicated than they had imagined. ↗
▶ Ep 237 · 9:00
opinion Lower confluence cloacas are elegant operations if the surgeon knows how to perform them, while higher confluence cases with vaginal replacements and ectopic ureters should be done at specialized centers ↗
▶ Ep 237 · 9:00
opinion Lower confluence cloacas are elegant operations if the surgeon knows how to perform them, while higher confluence cases with vaginal replacements and ectopic ureters should be done at specialized centers ↗
▶ Ep 237 · 19:00
quote The definition is of urethral length because I think some people may consider that from the single orifice all the way to the bladder neck and I don't think that's what you're alluding to. ↗
▶ Ep 237 · 19:00
quote The definition is of urethral length because I think some people may consider that from the single orifice all the way to the bladder neck and I don't think that's what you're alluding to. ↗

The Colorectal Quiz Episode 4

▶ Ep 239 · 10:19
clinical Frozen section biopsy must include submucosa to avoid missing hypertrophic nerves in submucosal layer while finding ganglion cells in seromuscular layer ↗
▶ Ep 239 · 10:19
quote they must see submucosa. And if you send them a biopsy without submucosa, our pathologist will say, hey, where's the submucosa? Because you want to make sure, again, that you don't find ganglion cells in the seromuscular layer and hypertrophic nerves in the submucosal layer. ↗
▶ Ep 239 · 10:19
clinical Frozen section biopsy must include submucosa to avoid missing hypertrophic nerves in submucosal layer while finding ganglion cells in seromuscular layer ↗
▶ Ep 239 · 10:19
quote they must see submucosa. And if you send them a biopsy without submucosa, our pathologist will say, hey, where's the submucosa? Because you want to make sure, again, that you don't find ganglion cells in the seromuscular layer and hypertrophic nerves in the submucosal layer. ↗
▶ Ep 239 · 11:00
clinical Mesenteric dissection should stay close to bowel wall, not deep in mesentery, to reduce bleeding ↗
▶ Ep 239 · 11:00
clinical Mesenteric dissection should stay close to bowel wall, not deep in mesentery, to reduce bleeding ↗
▶ Ep 239 · 12:26
clinical Must preserve arcade along left colon and sigmoid to get enough length to reach pelvis ↗
▶ Ep 239 · 12:26
quote You need to be very careful of preserving that arcade along the left colon and sigmoid colon so you could get enough distance to reach the pelvis. ↗
▶ Ep 239 · 12:26
clinical Must preserve arcade along left colon and sigmoid to get enough length to reach pelvis ↗
▶ Ep 239 · 12:26
quote You need to be very careful of preserving that arcade along the left colon and sigmoid colon so you could get enough distance to reach the pelvis. ↗
▶ Ep 239 · 16:06
clinical Resection margin should be approximately five centimeters above biopsy site where bowel looks good ↗
▶ Ep 239 · 16:06
clinical Resection margin should be approximately five centimeters above biopsy site where bowel looks good ↗

Colorectal Quiz: Episode 2

▶ Ep 240 · 1:46
quote That's the real frustrating one. ↗
▶ Ep 240 · 1:46
quote That's the real frustrating one. ↗
▶ Ep 240 · 10:19
clinical In higher malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated ↗
▶ Ep 240 · 10:19
clinical In higher malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated ↗
▶ Ep 240 · 15:20
opinion Alternative approach for borderline anatomy: let the child try their current anatomy first; if it works well, stay with it; if not, consider redo ↗
▶ Ep 240 · 15:20
opinion Alternative approach for borderline anatomy: let the child try their current anatomy first; if it works well, stay with it; if not, consider redo ↗

The Colorectal Quiz Episode 4

▶ Ep 241 · 6:33
quote the transanal dissection should be usually way under an hour, especially in a primary pull-through point. ↗
▶ Ep 241 · 6:33
clinical The transanal dissection should usually take way under an hour, especially in a primary pull-through. ↗
▶ Ep 241 · 6:33
clinical The transanal dissection should usually take way under an hour, especially in a primary pull-through. ↗
▶ Ep 241 · 6:33
quote the transanal dissection should be usually way under an hour, especially in a primary pull-through point. ↗
▶ Ep 241 · 12:35
clinical For distal disease, only distal branches of the IMA need to be taken, but for left colon or splenic flexure involvement, the IMA itself might need to be taken. ↗
▶ Ep 241 · 12:35
clinical For distal disease, only distal branches of the IMA need to be taken, but for left colon or splenic flexure involvement, the IMA itself might need to be taken. ↗

Colorectal Quiz: Episode 2

▶ Ep 242 · 10:19
quote Patients like patients who have a higher malformation, such as a bladder neck, sometimes those sphincter complexes are sort of more anterior than you think that you're anticipating it might be. ↗
▶ Ep 242 · 10:19
clinical In higher malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated. ↗
▶ Ep 242 · 10:19
quote Patients like patients who have a higher malformation, such as a bladder neck, sometimes those sphincter complexes are sort of more anterior than you think that you're anticipating it might be. ↗
▶ Ep 242 · 10:19
clinical In higher malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated. ↗
▶ Ep 242 · 15:20
opinion An alternative approach for borderline anatomy is to be more conservative and let the child take their car out for a ride first to see how it works before considering redo. ↗
▶ Ep 242 · 15:20
opinion An alternative approach for borderline anatomy is to be more conservative and let the child take their car out for a ride first to see how it works before considering redo. ↗

The Colorectal Quiz: Episode 1

▶ Ep 243 · 4:15
quote if it's an anal stenosis or a rectal atresia defect, then you need to be very worried about finding a pre-sacral mass. And almost half the time, you'll find one. And those patients will end up getting an MRI. ↗
▶ Ep 243 · 4:15
epidemiological Pre-sacral masses are rare in typical imperforate anus but occur in almost half of anal stenosis or rectal atresia cases, requiring MRI ↗
▶ Ep 243 · 4:15
epidemiological Pre-sacral masses are rare in typical imperforate anus but occur in almost half of anal stenosis or rectal atresia cases, requiring MRI ↗
▶ Ep 243 · 4:15
quote if it's an anal stenosis or a rectal atresia defect, then you need to be very worried about finding a pre-sacral mass. And almost half the time, you'll find one. And those patients will end up getting an MRI. ↗
▶ Ep 243 · 5:05
guideline Cross-table lateral x-ray should be obtained at approximately 24 hours of life to assess gas column height and guide surgical planning ↗
▶ Ep 243 · 5:05
quote We typically get at about the 24-hour mark, give or take a few hours, a cross table lateral to see what does the gas column look like in this patient? Is there a low gas column that looks like it's almost touching the skin or is it pretty high up? And that might dictate what your next steps might be. ↗
▶ Ep 243 · 5:05
quote We typically get at about the 24-hour mark, give or take a few hours, a cross table lateral to see what does the gas column look like in this patient? Is there a low gas column that looks like it's almost touching the skin or is it pretty high up? And that might dictate what your next steps might be. ↗
▶ Ep 243 · 5:05
guideline Cross-table lateral x-ray should be obtained at approximately 24 hours of life to assess gas column height and guide surgical planning ↗
▶ Ep 243 · 7:36
clinical Well-formed buttocks, good muscle, true sphincter mechanism area, and well-developed sacrum together indicate likely good prognosis ↗
▶ Ep 243 · 7:36
clinical Well-formed buttocks, good muscle, true sphincter mechanism area, and well-developed sacrum together indicate likely good prognosis ↗
▶ Ep 243 · 8:25
opinion With air column 8.8mm from skin, primary posterior sagittal anorectoplasty is a reasonable option based on imaging ↗
▶ Ep 243 · 8:25
quote I have two answers for you, Mark. I think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me. ↗
▶ Ep 243 · 8:25
quote I have two answers for you, Mark. I think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me. ↗
▶ Ep 243 · 8:25
opinion With air column 8.8mm from skin, primary posterior sagittal anorectoplasty is a reasonable option based on imaging ↗
▶ Ep 243 · 9:57
guideline Should never try to go in blind—must know what structure will be encountered before making posterior sagittal incision ↗
▶ Ep 243 · 9:57
quote you should never try to go in blind, right? We're going in with knowing that if we make a posterior sagittal incision right now, the first thing we're going to hit is that air pocket, which is the distal rectum. ↗
▶ Ep 243 · 9:57
guideline Should never try to go in blind—must know what structure will be encountered before making posterior sagittal incision ↗
▶ Ep 243 · 9:57
quote you should never try to go in blind, right? We're going in with knowing that if we make a posterior sagittal incision right now, the first thing we're going to hit is that air pocket, which is the distal rectum. ↗
▶ Ep 243 · 12:34
clinical Bulbar fistula nomenclature refers to anatomic location at the elbow of the urethra ↗
▶ Ep 243 · 12:34
clinical Fistula can be very close to rectum, making proper plane dissection along urethra important ↗
▶ Ep 243 · 12:34
clinical Bulbar fistula nomenclature refers to anatomic location at the elbow of the urethra ↗
▶ Ep 243 · 12:34
quote The reason why Dr. Levitt or Mark is saying that it's a bulbar fistula is it's at the elbow. You can see it's at the elbow of the urethra. And tell us that the nomenclature we like to use is an anatomic, pure anatomic nomenclature saying that it's a bulbar fistula. ↗
▶ Ep 243 · 12:34
quote you can see this fistula is very close to the rectum. And if you're going to dissect that free and along the urethra, it's important to make sure that you know that those two structures are not very far apart. And getting that into that proper plane is very important. ↗
▶ Ep 243 · 12:34
clinical Fistula can be very close to rectum, making proper plane dissection along urethra important ↗
▶ Ep 243 · 12:34
quote you can see this fistula is very close to the rectum. And if you're going to dissect that free and along the urethra, it's important to make sure that you know that those two structures are not very far apart. And getting that into that proper plane is very important. ↗
▶ Ep 243 · 12:34
quote The reason why Dr. Levitt or Mark is saying that it's a bulbar fistula is it's at the elbow. You can see it's at the elbow of the urethra. And tell us that the nomenclature we like to use is an anatomic, pure anatomic nomenclature saying that it's a bulbar fistula. ↗

The Colorectal Quiz: Episode 1

▶ Ep 244 · 4:15
epidemiological Pre-sacral mass is rare in typical imperforate anus but occurs in almost half of anal stenosis or rectal atresia cases ↗
▶ Ep 244 · 4:15
clinical Patients with anal stenosis or rectal atresia and pre-sacral mass will need MRI evaluation ↗
▶ Ep 244 · 4:15
clinical Patients with anal stenosis or rectal atresia and pre-sacral mass will need MRI evaluation ↗
▶ Ep 244 · 4:15
epidemiological Pre-sacral mass is rare in typical imperforate anus but occurs in almost half of anal stenosis or rectal atresia cases ↗
▶ Ep 244 · 5:05
quote We typically get at about the 24-hour mark, give or take a few hours, a cross table lateral to see what does the gas column look like in this patient? Is there a low gas column that looks like it's almost touching the skin or is it pretty high up? And that might dictate what your next steps might be. ↗
▶ Ep 244 · 5:05
clinical Cross-table lateral x-ray is typically obtained at about 24 hours of life, give or take a few hours, to visualize the gas column position ↗
▶ Ep 244 · 5:05
quote We typically get at about the 24-hour mark, give or take a few hours, a cross table lateral to see what does the gas column look like in this patient? Is there a low gas column that looks like it's almost touching the skin or is it pretty high up? And that might dictate what your next steps might be. ↗
▶ Ep 244 · 5:05
clinical Cross-table lateral x-ray is typically obtained at about 24 hours of life, give or take a few hours, to visualize the gas column position ↗
▶ Ep 244 · 7:36
clinical Well-formed buttocks, good muscle mass, and identifiable sphincter mechanism location on physical exam contribute to favorable prognosis in anorectal malformation ↗
▶ Ep 244 · 7:36
clinical Well-formed buttocks, good muscle mass, and identifiable sphincter mechanism location on physical exam contribute to favorable prognosis in anorectal malformation ↗
▶ Ep 244 · 8:25
quote I have two answers for you, Mark. I think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me. ↗
▶ Ep 244 · 8:25
quote I have two answers for you, Mark. I think if I was sitting in a hotel room being examined by a bunch of board examiners, my answer would likely be a diverting stoma in real life, which is what we're discussing here. What would we do on a Tuesday afternoon? I think this air column is, if you're going to get this x-ray and base your decision-making on where the air column is and what's going on, I'm pretty apt to say I might perform a primary posterior sagittal anorectoplasty with this type of imaging in front of me. ↗
▶ Ep 244 · 9:57
quote It goes without saying, and one of our, I think one of our big teaching points is you should never try to go in blind, right? We're going in with knowing that if we make a posterior sagittal incision right now, the first thing we're going to hit is that air pocket, which is the distal rectum. ↗
▶ Ep 244 · 9:57
quote It goes without saying, and one of our, I think one of our big teaching points is you should never try to go in blind, right? We're going in with knowing that if we make a posterior sagittal incision right now, the first thing we're going to hit is that air pocket, which is the distal rectum. ↗
▶ Ep 244 · 12:34
clinical A bulbar fistula is named for its location at the elbow of the urethra, using pure anatomic nomenclature ↗
▶ Ep 244 · 12:34
clinical A bulbar fistula is named for its location at the elbow of the urethra, using pure anatomic nomenclature ↗
Congenital Diaphragmatic Hernia 21 entries

Neonatal Gastric Volvulus with Dr. Jason Frischer

▶ Ep 9 · 1:10
quote I've seen it associated with congenital diaphragmatic hernias a few times, and I think that's when we have a high suspicion for it. ↗
▶ Ep 9 · 1:33
quote 60% happen in the first year of life in the pediatric population, and so about 21% in the first month and over a third in the first year of life. ↗
▶ Ep 9 · 1:33
epidemiological 60% of gastric volvulus cases in the pediatric population happen in the first year of life, with about 21% in the first month. ↗
▶ Ep 9 · 1:58
clinical In a 4-month-old child with gastric volvulus, acute presentation is more likely than chronic. ↗
▶ Ep 9 · 1:58
quote If the child's like 4 months old, is it more likely, are you're more likely to have an acute problem or a chronic problem? So they're acute. ↗
▶ Ep 9 · 2:45
quote That's the big one, I think, right there. I think a little bit of bloody aspirate from the. Logo can't advance it. Funny looking stomach bubble on the X-ray. ↗
▶ Ep 9 · 2:47
clinical A little bit of bloody aspirate from the NG tube and a funny looking stomach bubble on X-ray are key findings in gastric volvulus. ↗
▶ Ep 9 · 3:10
clinical Chronic gastric volvulus is more related to laxity of the gastric ligaments including gastrophrenic, gastrosplenic, gastrocolic, and gastrohepatic ligaments. ↗
▶ Ep 9 · 3:10
quote Those are more to do with the laxity of the gastric ligaments, and the stomach has ligamentous attachments basically surrounding the entire stomach from gastrophrenic, gastrosplenic, gastrocolic. And of course. Gastropatic ligament. ↗
▶ Ep 9 · 3:43
quote The first one, the first and most common is organoaxial volvulus. ↗
▶ Ep 9 · 3:43
clinical Organoaxial volvulus is the first and most common type of gastric volvulus. ↗
▶ Ep 9 · 3:55
quote They describe a line that's drawn on this diagram between the GE junction and the pylorus, and it's spinning around that axis. The greater curvature then sort of flips up and over and becomes more superior than the lesser curvature. ↗
▶ Ep 9 · 3:55
clinical In organoaxial volvulus, the stomach spins around an axis drawn between the GE junction and the pylorus, with the greater curvature flipping up and over to become more superior than the lesser curvature. ↗
▶ Ep 9 · 4:18
clinical In mesenteroaxial volvulus, rotation occurs around a line through the middle of the stomach from lesser to greater curvature, with the stomach flipping behind and back over. ↗
▶ Ep 9 · 4:34
quote Then, and flip the stomach up and over that way, so it's going sort of behind. The stomach and back over it. ↗
▶ Ep 9 · 4:46
quote When the pylorus is at, right next to the GE junction or near the GE junction, and above the body of the stomach. ↗
▶ Ep 9 · 4:46
clinical In gastric volvulus, when filled with contrast, the pylorus appears right next to or near the GE junction and above the body of the stomach. ↗
▶ Ep 9 · 6:08
clinical In mesenteroaxial volvulus, the duodenum may fill above or superior to the GE junction because the pylorus has flipped up and over or behind and over the top of the stomach. ↗
▶ Ep 9 · 6:22
quote Mesentero axial favulus. Again, this is the sort of pylorus flipping up and over or behind and over the top of the stomach, and then therefore, your pylorus is located all the way up here. ↗
▶ Ep 9 · 8:40
quote Also, you always want to check the viability of the stomach. So, right, if this is chronically volvulized or been volvulized for a couple of days, uh, at least looking at the cirrhosa and looking at the blood flow. ↗
▶ Ep 9 · 8:40
clinical When managing gastric volvulus found during CDH repair, viability of the stomach must always be checked, especially if chronically volvulized or volvulized for a couple of days, by looking at the serosa and blood flow. ↗
Congenital Lung Lesions (CPAM) 16 entries

Complications and Beyond

▶ Ep 22 · 2:45
host_summary In asymptomatic newborns with prenatally diagnosed lung lesions, most US practitioners obtain chest X-ray initially in NICU ↗
▶ Ep 22 · 2:45
clinical In asymptomatic newborns with prenatally diagnosed lung lesions, most US practitioners obtain chest X-ray initially in NICU ↗
▶ Ep 22 · 4:45
clinical CT angiography for congenital lung lesions is typically performed at 3-6 months in clinic rather than in NICU for asymptomatic patients ↗
▶ Ep 22 · 4:45
clinical CT angiography for congenital lung lesions is typically performed at 3-6 months in clinic rather than in NICU for asymptomatic patients ↗
▶ Ep 22 · 17:23
clinical When using energy devices for vessel control, leave enough remnant tissue so the vessel doesn't retract if seal fails, allowing purchase for clip or suture ↗
▶ Ep 22 · 17:23
clinical When using energy devices for vessel control, leave enough remnant tissue so the vessel doesn't retract if seal fails, allowing purchase for clip or suture ↗
▶ Ep 22 · 17:47
clinical Obtain proximal control or partially cut across vessel with energy device to detect failure before complete division ↗
▶ Ep 22 · 17:47
clinical Obtain proximal control or partially cut across vessel with energy device to detect failure before complete division ↗
▶ Ep 22 · 17:56
clinical When using staplers, visualize the stapler end, use appropriate staple size for tissue, and leave extra tissue around stapler edge for adequate coaptation ↗
▶ Ep 22 · 17:56
clinical When using staplers, visualize the stapler end, use appropriate staple size for tissue, and leave extra tissue around stapler edge for adequate coaptation ↗
▶ Ep 22 · 46:59
clinical Newborn with esophageal atresia, dextrocardia, and respiratory instability at birth suggests complex anatomy beyond typical EA/TEF ↗
▶ Ep 22 · 46:59
clinical Newborn with esophageal atresia, dextrocardia, and respiratory instability at birth suggests complex anatomy beyond typical EA/TEF ↗
▶ Ep 22 · 48:23
clinical Echo findings of mesocardia, hypoplastic pulmonary arteries, persistent left SVC, and dilated right ventricle indicate significant cardiac anomalies ↗
▶ Ep 22 · 48:23
clinical Echo findings of mesocardia, hypoplastic pulmonary arteries, persistent left SVC, and dilated right ventricle indicate significant cardiac anomalies ↗
▶ Ep 22 · 1:04:12
epidemiological Esophageal lung is rare congenital anomaly with approximately 30 reported cases where bronchus arises directly from esophagus rather than trachea ↗
▶ Ep 22 · 1:04:12
epidemiological Esophageal lung is rare congenital anomaly with approximately 30 reported cases where bronchus arises directly from esophagus rather than trachea ↗
Congenital Pulmonary Airway Malformation 8 entries

Complications and Beyond

▶ Ep 17 · 2:45
host_summary In asymptomatic newborns with prenatally diagnosed lung lesions, most US practitioners obtain chest X-ray initially in NICU ↗
▶ Ep 17 · 4:45
clinical CT angiography for congenital lung lesions is typically performed at 3-6 months in clinic rather than in NICU for asymptomatic patients ↗
▶ Ep 17 · 17:23
clinical When using energy devices for vessel control, leave enough remnant tissue so the vessel doesn't retract if seal fails, allowing purchase for clip or suture ↗
▶ Ep 17 · 17:47
clinical Obtain proximal control or partially cut across vessel with energy device to detect failure before complete division ↗
▶ Ep 17 · 17:56
clinical When using staplers, visualize the stapler end, use appropriate staple size for tissue, and leave extra tissue around stapler edge for adequate coaptation ↗
▶ Ep 17 · 46:59
clinical Newborn with esophageal atresia, dextrocardia, and respiratory instability at birth suggests complex anatomy beyond typical EA/TEF ↗
▶ Ep 17 · 48:23
clinical Echo findings of mesocardia, hypoplastic pulmonary arteries, persistent left SVC, and dilated right ventricle indicate significant cardiac anomalies ↗
▶ Ep 17 · 1:04:12
epidemiological Esophageal lung is rare congenital anomaly with approximately 30 reported cases where bronchus arises directly from esophagus rather than trachea ↗
Constipation 20 entries

The Colorectal Quiz Episode 8: Motility Disorders Part 1

▶ Ep 4 · 6:29
quote It's saying that this is not a Monet, that is for certain. ↗
▶ Ep 4 · 7:12
clinical Contrast studies are not great predictors of how patients will respond to medical or surgical management; normal-looking colons may not respond while abnormal-appearing colons may respond well ↗
▶ Ep 4 · 8:06
clinical Water-soluble contrast (not barium) is used for contrast enemas because it helps empty the colon and acts as a cleanout for patients starting new medical therapy ↗
▶ Ep 4 · 10:51
quote I think back in the day, Mark, yeah, we, we didn't understand the sphincter and the major role it played. ↗
▶ Ep 4 · 10:51
opinion In the past, surgeons did not understand the major role the sphincter played in many patients ↗

Colorectal Quiz Episode 16: Bowel Management in Spinal Patients - Need for a Urologist Part 2

▶ Ep 5 · 1:17
clinical When a 7 cm appendix is shared between urology and colorectal surgery, the urologist typically takes 6.25 cm leaving only 0.75 cm for colorectal use ↗
▶ Ep 5 · 1:17
quote When you get that really short stumpy appendix, whether it be from splitting it, and the urologist, if I have a 7 centimeter appendix, the urologist takes 6.25 centimeters and I get 0.75. ↗
▶ Ep 5 · 1:55
clinical The colorectal team benefits from using the appendix portion closer to the cecum which has a stronger blood supply ↗
▶ Ep 5 · 2:05
clinical A short appendiceal stump can be extended by suturing or using a laparoscopic non-cutting linear stapler along the cecal wall to add 2-3 cm of length ↗
▶ Ep 5 · 2:34
clinical One of the problems with Malone appendicostomy is leakage ↗
▶ Ep 5 · 2:47
clinical The longer the Malone channel, the less likely it is to leak ↗
▶ Ep 5 · 2:52
quote The longer the channel, the less likely that Malone's going to leak. ↗
▶ Ep 5 · 2:55
clinical Extending the Malone channel by 2-3 cm using suturing or stapling can be extremely helpful in preventing leakage ↗
▶ Ep 5 · 3:43
clinical Rectal irrigation using pressurized water systems made for patients with hand difficulties is an alternative to Malone and Mitrofanoff procedures ↗
▶ Ep 5 · 4:25
clinical Coloplast makes a rectal irrigation device for self-administration of enemas ↗
▶ Ep 5 · 8:39
host_summary Fecal impaction can push on the bladder and change the angle of the ureter entering the bladder, causing reflux ↗
▶ Ep 5 · 9:43
clinical At Cincinnati Children's, 99% of Malones are placed in the umbilicus and almost all Mitrofanoffs are in the right lower quadrant with a tunnel channel through the rectus to prevent leakage ↗
▶ Ep 5 · 10:21
clinical The primary determinant of orifice location is where the appendix reaches and its blood supply ↗
▶ Ep 5 · 10:51
host_summary The last steps of combined procedures should be maturing the Mitrofanoff, maturing the Malone, then closing the abdomen ↗
▶ Ep 5 · 11:09
clinical Laxity of the pelvic floor and anal canal is a huge issue in spinal patients, especially when doing retrograde enemas ↗
Enterocolitis 85 entries

Hirschsprung Disease - Imperforate Anus - Rectal Prolapse: Update Course 2015

▶ Ep 3 · 4:22
opinion A pure transanal Hirschsprung dissection is not necessarily less invasive than laparoscopic approach; prolonged torquing in the anal canal may be more traumatic than three small abdominal incisions. ↗
▶ Ep 3 · 4:22
quote I, I don't believe that a pure trans anal is necessarily less invasive. In other words, I believe that putting 3 incisions on the abdomen is actually less invasive in my hands, in my hands, certainly not in your guys' hands, but in my hands, I'm gonna be torquing in that anal canal much more than if I had done it laparoscopically and freed everything up from the abdominal approach. ↗
▶ Ep 3 · 5:46
clinical For standard rectosigmoid Hirschsprung disease (6-10 cm up), transanal dissection can be completed in the same timeframe as laparoscopic mobilization if the surgeon knows the level from a good contrast study. ↗
▶ Ep 3 · 6:12
clinical Post-Hirschsprung complications divide into two categories: obstructive symptoms (enterocolitis, failure to thrive, distention) and soiling issues (true incontinence vs pseudo-incontinence from constipation). ↗
▶ Ep 3 · 7:25
clinical Workup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia looking for dentate line position, stricture, stretched sphincter, and twists; if no anatomic cause is found, perform biopsy. ↗
▶ Ep 3 · 9:04
clinical For Hirschsprung pull-through, dissection should start approximately 1 cm above the dentate line (defined as the transition from squamous to columnar epithelium, at the bottom of the anal columns). ↗
▶ Ep 3 · 9:04
clinical Going only 0.5 cm above the dentate line in a newborn may result in 2.5-3 cm of aganglionic segment remaining when the child reaches 7 years old, creating an ultra-short segment Hirschsprung situation with constipation. ↗
▶ Ep 3 · 9:43
opinion Injury to the dentate line during Hirschsprung pull-through can cause devastating fecal incontinence; it is better to risk leaving ultra-short segment aganglionosis (manageable with laxatives) than to injure the dentate line. ↗
▶ Ep 3 · 9:43
quote I want to ensure, because, and maybe we have a biased population in what we see, that I do not injure the dentate line because the patients who are rendered potentially fecally incontinent due to injury to the dentate line is a devastating injury for those patients. ↗
▶ Ep 3 · 10:39
clinical In ulcerative colitis or FAP patients undergoing J-pouch creation, dissection goes right at the top of the columns, or even slightly lower if polyps are present in that region. ↗
▶ Ep 3 · 11:39
clinical The dentate line is variably defined in anatomic literature and textbooks; different sources point to different locations within the anal columns when labeling the dentate or pectinate line. ↗
▶ Ep 3 · 17:17
clinical The traditional teaching that newborn meconium is sterile and therefore anorectal malformation repair should be done in the newborn period (before dilations introduce bacteria) is questioned; some surgeons repair at any age with stool present and feed early postoperatively with similar complication rates. ↗
▶ Ep 3 · 17:27
clinical Conservative postoperative management of anorectal malformation repair includes keeping the patient NPO for approximately one week with hyperalimentation (a 'medical colostomy'), though there is no data supporting this practice over early feeding. ↗
▶ Ep 3 · 17:50
quote I know there are a number of pediatric surgeons that will repair an anorectal malformation at whatever age with dirty stool and feed the child the day 1 or 2 days post-op when they recover from the anesthesia, and I'm sure that incidence of complication is probably similar. ↗
▶ Ep 3 · 18:54
clinical When vestibular fistula is discovered intraoperatively to have an absent vagina, management depends on prognosis for bowel control: if good prognosis, use graft (colon or small bowel) to create vagina and bring rectum down; if poor prognosis (sacral agenesis, tethered cord), use the rectum/fistula as vagina and bring proximal colon down as pull-through. ↗
▶ Ep 3 · 20:09
clinical Rectal prolapse workup should distinguish full-thickness prolapse from partial-thickness (mucosal) prolapse based on physical examination appearance. ↗
▶ Ep 3 · 20:49
clinical Testing for cystic fibrosis in children presenting with rectal prolapse is traditional teaching and a board exam answer, but in clinical practice rarely identifies new CF cases; most CF patients with prolapse are already diagnosed. ↗
▶ Ep 3 · 21:19
clinical Initial management of rectal prolapse includes treating constipation and limiting toilet sitting time to 5 minutes; surgical intervention is considered after 6 months to 2 years of failed medical management. ↗
▶ Ep 3 · 22:45
quote I can tell you when it recurs to re-operate on those patients is not going to matter at all. ↗
▶ Ep 3 · 22:45
clinical Sclerosing agent injection for rectal prolapse has high recurrence rates; patients who fail this approach and require subsequent rectopexy have difficult reoperative dissection. ↗
▶ Ep 3 · 23:02
host_summary Transabdominal approaches for rectal prolapse (rectopexy with or without resection) have approximately 5% recurrence rate, compared to 15-20% recurrence for transanal approaches (transanal pull-through or Altmeier procedure). ↗
▶ Ep 3 · 23:36
host_summary Resection and rectopexy for rectal prolapse may be preferable when constipation control is difficult, but has higher complication rate compared to rectopexy alone. ↗
▶ Ep 3 · 23:56
host_summary Laparoscopic rectopexy for rectal prolapse can be performed as same-day surgery or with next-day discharge in current practice. ↗
▶ Ep 3 · 24:10
clinical Ventral mesh rectopexy is a newer procedure popularized by the Cleveland Clinic for rectal prolapse; it involves placing mesh on the anterior rectum surface, elevating the rectum without posterior dissection, and tacking mesh to the sacral promontory. ↗
▶ Ep 3 · 24:10
clinical Mesh erosion is a known complication of ventral mesh rectopexy, but the procedure can be effective for refractory rectal prolapse after multiple failed transabdominal repairs. ↗
▶ Ep 3 · 24:55
clinical Ventral mesh rectopexy aims to change the angle between rectum and anal canal; younger patients with rectal prolapse have a straighter rectum-to-anal-canal angle that becomes more acute with age. ↗

Hirschsprung Disease: Update Course 2015

▶ Ep 7 · 0:22
quote I recall having a full day of uh Hirschprung's webcast, and now I get 5 minutes. ↗
▶ Ep 7 · 3:06
quote I, every time that I do a primary trans anal, I get. I tighten up a little bit to make sure that I'm confident that I can do, and I have an exit strategy in mind if I get in trouble ↗
▶ Ep 7 · 3:06
opinion The safest approach to Hirschsprung surgery involves some form of biopsy (laparoscopic or full-thickness through umbilicus) prior to definitive pull-through. ↗
▶ Ep 7 · 3:46
opinion Leveling colostomy may be the safest approach when institutional pathology expertise in reading Hirschsprung biopsies is limited or unavailable. ↗
▶ Ep 7 · 4:03
clinical Leveling colostomy represents a three-stage procedure for Hirschsprung disease management. ↗
▶ Ep 7 · 5:07
opinion Prolonged transanal dissection (approaching 4 hours) should prompt consideration of converting to laparoscopic approach to avoid excessive sphincter stretching. ↗
▶ Ep 7 · 5:07
quote Belinda and I talk about this a lot, and it's about a comfort level and how fit, I take, I watch the clock how long I'm doing a trans anal dissection because I do not want to be stretching on those sphincters for 4 hours trying to dig up in a dark hole when I could put a scope in. ↗
▶ Ep 7 · 5:30
clinical Laparoscopic mobilization with 3-millimeter ports can be completed in approximately 45 minutes for appropriate cases. ↗
▶ Ep 7 · 5:46
clinical Standard rectosigmoid Hirschsprung disease (6-10 centimeters proximal) can be completed transanally in approximately 2 hours when the level is known from a good contrast study. ↗
▶ Ep 7 · 6:12
clinical Complications after Hirschsprung surgery are divided into two categories: obstructive symptoms (including enterocolitis, failure to thrive, abdominal distention) and soiling issues. ↗
▶ Ep 7 · 6:31
clinical Soiling after Hirschsprung surgery is further classified into true incontinence and pseudo-incontinence. ↗
▶ Ep 7 · 6:45
clinical Obstructive symptoms after Hirschsprung surgery require differentiation between anatomic problems and pathologic problems. ↗
▶ Ep 7 · 6:52
clinical True fecal incontinence after Hirschsprung surgery can result from injury to the sphincter or injury to the dentate line. ↗
▶ Ep 7 · 7:04
clinical Pseudo-incontinence after Hirschsprung surgery may be caused by underlying constipation. ↗
▶ Ep 7 · 7:08
host_summary Jack Langer published an algorithm for working up patients with problems after Hirschsprung disease. ↗
▶ Ep 7 · 7:25
clinical Workup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia evaluating dentate line position, stricture, stretched sphincter, and anatomic twists. ↗

Hirschsprung Disease: Update Course 2013

▶ Ep 11 · 8:56
epidemiological Female patients may have higher risk of long-segment disease, with 50-50 incidence of long-segment in girls ↗
▶ Ep 11 · 32:05
clinical Transanal resection of massively dilated colon in older children causes enormous sphincter stretch and impairs postoperative continence; laparoscopic dissection to pelvic floor is preferred ↗
▶ Ep 11 · 33:42
quote that patient was at a well-known institution in Ohio. And had, was seen by GI and had multiple biopsies that were normal. Those were done by colonoscopy ↗
▶ Ep 11 · 33:42
clinical Colonoscopic biopsies can miss Hirschsprung disease; rectal biopsy is more reliable ↗
▶ Ep 11 · 34:04
quote just caution to watch out what type of biopsy was performed and how Hirschprung's was ruled out ↗

Hirschsprung's Disease

▶ Ep 13 · 0:35
quote More than 95% of neonates pass meconium within the first 48 hours of life, and failure to pass meconium is typical of Hirschsprung's disease. ↗
▶ Ep 13 · 0:35
clinical More than 95% of neonates pass meconium within the first 48 hours of life, and failure to pass meconium is typical of Hirschsprung's disease. ↗
▶ Ep 13 · 0:35
clinical Some infants with Hirschsprung's disease do pass meconium. ↗
▶ Ep 13 · 1:57
clinical The classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel. ↗
▶ Ep 13 · 1:57
quote The second part of a diagnostic workup for Hirschsprung's disease, and most important, is the rectal biopsy. It is the true definitive diagnosis. ↗
▶ Ep 13 · 1:57
clinical A rectosigmoid ratio of less than 1.0 is suggestive of Hirschsprung's disease, meaning the aganglionic bowel is contracted and narrow compared to the dilated ganglionated bowel more proximal. ↗
▶ Ep 13 · 1:57
clinical In total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema. ↗
▶ Ep 13 · 1:57
epidemiological Approximately 10% of newborns with Hirschsprung's disease may lack the typical findings on a contrast enema. ↗
▶ Ep 13 · 1:57
clinical Rectal biopsy is the true definitive diagnosis for Hirschsprung disease. ↗
▶ Ep 13 · 1:57
clinical Typical features on rectal biopsy include absence of ganglion cells, presence of hypertrophic nerves, abnormal pattern of cholinesterase staining, and an absence of calretinine staining. ↗
▶ Ep 13 · 1:57
quote The three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry. ↗
▶ Ep 13 · 1:57
clinical Full thickness biopsy technique should be considered for patients older than six months, or when a suction biopsy is inadequate. ↗
▶ Ep 13 · 1:57
clinical To be considered an adequate biopsy, it must be taken from the rectum at least one centimeter above the dentate line and must include both mucosa and submucosal layers. ↗
▶ Ep 13 · 1:57
clinical Suction biopsy technique is typically used for patients less than six months of age. ↗
▶ Ep 13 · 4:23
guideline Any patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis. ↗
▶ Ep 13 · 4:23
clinical The rectoanal inhibitory reflex may be absent in other conditions as well, and some children have a false positive test. ↗
▶ Ep 13 · 4:23
clinical In Hirschsprung's disease, anorectal manometry shows a lack of the rectoanal inhibitory reflex (RAIR). ↗
▶ Ep 13 · 6:42
clinical The three goals of surgical management are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity. ↗
▶ Ep 13 · 6:42
quote There are three goals to the surgical management of Hirschsprung's disease. First, identify the extent of the aganglionic segment. Second, resect that segment. And third, restore the bowel to its continuity. ↗
▶ Ep 13 · 7:36
clinical In the Swenson procedure, it is very important to be cautious about injuring the urethra as it's quite close, especially in boys. ↗
▶ Ep 13 · 7:36
opinion The Suave procedure theoretically causes less injury to pelvic structures, nerves, urethra and vagina. ↗
▶ Ep 13 · 7:36
clinical In the Swenson procedure, you pull down the aganglionic bowel and perform a full thickness anastomosis one to two centimeters above the dentate line, leaving the most minimal amount of aganglionic bowel possible. ↗
▶ Ep 13 · 7:36
clinical The Suave procedure involves performing a mucosectomy from a transanal approach slightly above the dentate line and pulling through the normal bowel. ↗
▶ Ep 13 · 7:36
clinical A con of the Suave procedure is that the aganglionic cuff can become stiff enough to cause an obstruction or outlet obstruction. ↗
▶ Ep 13 · 7:36
clinical In the Suave procedure, the actual anastomosis is performed within a cuff of aganglionic rectum. ↗
▶ Ep 13 · 12:34
clinical Hirschsprung's-associated enterocolitis is likely an inflammatory condition secondary to bacterial overgrowth. ↗
▶ Ep 13 · 12:34
clinical Treatment of enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations. ↗
▶ Ep 13 · 12:34
clinical A child with enterocolitis presents with abdominal distension, vomiting, fever, and change in bowel habits that could be either diarrhea or not passing stool at all. ↗
▶ Ep 13 · 12:34
clinical For enterocolitis, antibiotics including metronidazole or broad-spectrum antibiotics are added depending on the severity of presentation. ↗
▶ Ep 13 · 12:34
quote When we treat these patients with enterocolitis, it is important to provide fluid resuscitation, digital rectal exam, and colonic irrigations. ↗
▶ Ep 13 · 12:34
quote Hirschsprung's-associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth. ↗
▶ Ep 13 · 14:51
clinical For patients without anatomic problems after pull-through, treatment can include bowel management, Botox injection to relieve sphincter tone, or motility studies. ↗
▶ Ep 13 · 14:51
clinical Anatomic problems after pull-through can include a twist in the pull through, an obstructing cuff, a non-functioning Duhamel pouch, or a transition zone or continued aganglionic segment. ↗
▶ Ep 13 · 14:51
clinical For patients not doing well after pull-through, if there is a stricture at the anastomosis, it needs to be addressed either through dilations or revising the pull through procedure. ↗
▶ Ep 13 · 14:51
clinical For patients with anatomic problems after pull-through, you typically have to revise the pull through. ↗

The Colorectal Quiz Episode 22: Hirschsprung Disease - the Soiling Patient Part 1

▶ Ep 18 · 5:07
clinical Pathology can change over time; cases exist where ganglion cells were present at pull-through but absent with hypertrophic nerves 7 years later when problems developed. ↗
▶ Ep 18 · 9:58
clinical Sphincters should be assessed with the patient awake; examination under anesthesia makes it harder to assess sphincter function. ↗
▶ Ep 18 · 16:07
clinical During normal bowel movements, sphincters relax and the anus opens with some mucosal descent, but as soon as sphincters tighten, the mucosa retracts back in; prolapse at rest indicates damaged muscles and/or mucosa brought too low at anastomosis. ↗
Esophageal Atresia 8 entries

Complications and Beyond

▶ Ep 2 · 2:45
clinical In asymptomatic newborns with prenatally diagnosed lung lesions, most US practitioners obtain chest X-ray initially in NICU ↗
▶ Ep 2 · 4:45
clinical CT angiography for congenital lung lesions is typically performed at 3-6 months in clinic rather than in NICU for asymptomatic patients ↗
▶ Ep 2 · 17:23
clinical When using energy devices for vessel control, leave enough remnant tissue so the vessel doesn't retract if seal fails, allowing purchase for clip or suture ↗
▶ Ep 2 · 17:47
clinical Obtain proximal control or partially cut across vessel with energy device to detect failure before complete division ↗
▶ Ep 2 · 17:56
clinical When using staplers, visualize the stapler end, use appropriate staple size for tissue, and leave extra tissue around stapler edge for adequate coaptation ↗
▶ Ep 2 · 46:59
clinical Newborn with esophageal atresia, dextrocardia, and respiratory instability at birth suggests complex anatomy beyond typical EA/TEF ↗
▶ Ep 2 · 48:23
clinical Echo findings of mesocardia, hypoplastic pulmonary arteries, persistent left SVC, and dilated right ventricle indicate significant cardiac anomalies ↗
▶ Ep 2 · 1:04:12
epidemiological Esophageal lung is rare congenital anomaly with approximately 30 reported cases where bronchus arises directly from esophagus rather than trachea ↗
Etiologies (Gastroschisis/NEC/Atresia/Volvulus) 57 entries

Gastroschisis and sutureless abdominal wall closure

▶ Ep 31 · 7:20
opinion Due to the heterogeneity of gastroschisis, patients able to undergo primary repair probably had more favorable bowel and theoretically would have less hospital stay and feed faster. ↗
▶ Ep 31 · 7:20
opinion Many patients who underwent sutureless repair were done in more recent cohorts and tended towards less interventions. ↗
▶ Ep 31 · 7:20
quote I think it was probably what we were expecting, I think, for a couple of reasons. One, due to the heterogeneity of this disease, you know, especially with gastroschisis, a lot of the patients that were able to undergo, you know, especially a primary repair, they probably had more favorable bowel. And then those patients, you know, theoretically would have less hospital stay and theoretically feed faster and things like that. ↗
▶ Ep 31 · 8:05
quote Moreover, too, if you think about just the way that we close a sutured repair, you mobilize flaps from the skin and flaps from the fascia. So there's always, you know, redness around the incision, bruising around the incision. And so, you know, even that tissue manipulation is going to put you at higher risk for a potential infection or calling it erythema infection. ↗
▶ Ep 31 · 8:05
clinical In sutured repair, mobilizing flaps from the skin and fascia causes redness and bruising around the incision, which puts patients at higher risk for potential infection. ↗
▶ Ep 31 · 8:05
opinion The finding of increased antibiotics needed after sutured repair was expected due to tissue manipulation. ↗
▶ Ep 31 · 8:50
clinical The consortium is working on operationalizing protocolization of gastroschisis closure across member institutions for a more prospective study with long-term follow-up. ↗
▶ Ep 31 · 8:50
clinical The next phase of the study is examining the same patients over several years of follow-up to assess growth and umbilical hernia repair rates. ↗
▶ Ep 31 · 8:50
host_summary Initial small studies showed that some sutureless patients had a high umbilical hernia repair rate, or at least a high umbilical hernia rate. ↗

Neonatal Gastric Volvulus with Dr. Jason Frischer

▶ Ep 43 · 1:10
quote I've seen it associated with congenital diaphragmatic hernias a few times, and I think that's when we have a high suspicion for it. ↗
▶ Ep 43 · 1:33
quote 60% happen in the first year of life in the pediatric population, and so about 21% in the first month and over a third in the first year of life. ↗
▶ Ep 43 · 1:33
epidemiological 60% of gastric volvulus cases in the pediatric population happen in the first year of life, with about 21% in the first month. ↗
▶ Ep 43 · 1:58
quote If the child's like 4 months old, is it more likely, are you're more likely to have an acute problem or a chronic problem? So they're acute. ↗
▶ Ep 43 · 1:58
clinical In a 4-month-old child with gastric volvulus, acute presentation is more likely than chronic. ↗
▶ Ep 43 · 2:45
quote That's the big one, I think, right there. I think a little bit of bloody aspirate from the. Logo can't advance it. Funny looking stomach bubble on the X-ray. ↗
▶ Ep 43 · 2:47
clinical A little bit of bloody aspirate from the NG tube and a funny looking stomach bubble on X-ray are key findings in gastric volvulus. ↗
▶ Ep 43 · 3:10
quote Those are more to do with the laxity of the gastric ligaments, and the stomach has ligamentous attachments basically surrounding the entire stomach from gastrophrenic, gastrosplenic, gastrocolic. And of course. Gastropatic ligament. ↗
▶ Ep 43 · 3:10
clinical Chronic gastric volvulus is more related to laxity of the gastric ligaments including gastrophrenic, gastrosplenic, gastrocolic, and gastrohepatic ligaments. ↗
▶ Ep 43 · 3:43
clinical Organoaxial volvulus is the first and most common type of gastric volvulus. ↗
▶ Ep 43 · 3:43
quote The first one, the first and most common is organoaxial volvulus. ↗
▶ Ep 43 · 3:55
clinical In organoaxial volvulus, the stomach spins around an axis drawn between the GE junction and the pylorus, with the greater curvature flipping up and over to become more superior than the lesser curvature. ↗
▶ Ep 43 · 3:55
quote They describe a line that's drawn on this diagram between the GE junction and the pylorus, and it's spinning around that axis. The greater curvature then sort of flips up and over and becomes more superior than the lesser curvature. ↗
▶ Ep 43 · 4:18
clinical In mesenteroaxial volvulus, rotation occurs around a line through the middle of the stomach from lesser to greater curvature, with the stomach flipping behind and back over. ↗
▶ Ep 43 · 4:34
quote Then, and flip the stomach up and over that way, so it's going sort of behind. The stomach and back over it. ↗
▶ Ep 43 · 4:46
clinical In gastric volvulus, when filled with contrast, the pylorus appears right next to or near the GE junction and above the body of the stomach. ↗
▶ Ep 43 · 4:46
quote When the pylorus is at, right next to the GE junction or near the GE junction, and above the body of the stomach. ↗
▶ Ep 43 · 6:08
clinical In mesenteroaxial volvulus, the duodenum may fill above or superior to the GE junction because the pylorus has flipped up and over or behind and over the top of the stomach. ↗
▶ Ep 43 · 6:22
quote Mesentero axial favulus. Again, this is the sort of pylorus flipping up and over or behind and over the top of the stomach, and then therefore, your pylorus is located all the way up here. ↗
▶ Ep 43 · 8:40
clinical When managing gastric volvulus found during CDH repair, viability of the stomach must always be checked, especially if chronically volvulized or volvulized for a couple of days, by looking at the serosa and blood flow. ↗
▶ Ep 43 · 8:40
quote Also, you always want to check the viability of the stomach. So, right, if this is chronically volvulized or been volvulized for a couple of days, uh, at least looking at the cirrhosa and looking at the blood flow. ↗

Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee

▶ Ep 46 · 3:10
clinical Jason Fraser's institution starts feeding immediately after dressing placement as long as the baby is not sick, not having horrible output, and not vomiting. ↗
▶ Ep 46 · 3:10
quote we start feeding essentially you have to put the dressing on uh as long as the baby's not sick not having horrible output not puking or anything like that ↗
▶ Ep 46 · 3:54
quote we don't innovate our babies at all so we put the dressing plastic dressing on and as long as the kid's not you know has voluminous output we'll try to start start feedings on it ↗
▶ Ep 46 · 3:54
clinical Fraser's institution does not intubate gastroschisis babies for reduction. ↗
▶ Ep 46 · 5:13
quote if you try to just keep pushing and pushing pushing the baby kind of can squirm and stuff but if you go slow if you empty out the stomach if you kind of squish out the colon a little bit and you go slow you give the baby some sweeties the nurses are there to kind of relax the baby you have a couple people that that are there doing it you go slow you slowly kind of push things in you stretch out the belly a little bit ↗
▶ Ep 46 · 5:13
clinical Awake reduction can be successful if performed slowly, with stomach emptying, colon decompression, oral sucrose, and gradual abdominal wall stretching. ↗
▶ Ep 46 · 6:19
quote it's really just based upon patient tolerance and it's kind of based upon some of the data that's out there from the rest of the world where they don't have tpn and so they just you have to feed the kid if the kid does okay then they keep going ↗
▶ Ep 46 · 6:19
clinical Cincinnati Children's feeding protocol is based on patient tolerance and data from resource-limited settings where TPN is unavailable and feeding is mandatory. ↗
▶ Ep 46 · 10:30
epidemiological The multi-institutional study showed inconclusive results due to significant variation in feeding protocols across institutions. ↗
▶ Ep 46 · 10:30
opinion The reduction in surgical site infections with protocol feeding was likely due to decreased care variability rather than the feeding protocol itself. ↗
▶ Ep 46 · 10:30
quote a lot of the inconclusivity from the the study showed that you know most likely due to the fact that there was lots of different feeding protocols that were used uh across our member institutions ↗
▶ Ep 46 · 10:50
quote the ssi thing was probably just because patients that were fed via protocol were cared for via protocol and so that they actually had less variability and less uh less changes uh in the way that these these patients are not you know look for ↗
▶ Ep 46 · 11:20
epidemiological Cincinnati Children's average gastroschisis length of stay was 49 days before protocol implementation, which was astronomically higher than comparable NICUs in their cooperative network. ↗
▶ Ep 46 · 11:20
quote our length of stay for gastroschisis and cincinnati was astronomically higher than like any other nick micu in the cooperative network that we worked with so we sat down we're like what is going on here so our average length of stay was 49 days ↗
▶ Ep 46 · 12:10
epidemiological Cincinnati Children's has seen a decrease in time from first feed to full feeds but has not yet reduced the time from admission to first feed (except in 2020). ↗
▶ Ep 46 · 12:10
quote we instituted this uh a feeding protocol we spent a lot of time trying to get people to follow it and and making some adjustments and over two years we dropped the length of stay by 10 days and the mix of patients is not different ↗
▶ Ep 46 · 12:10
epidemiological After implementing a feeding protocol, Cincinnati Children's reduced gastroschisis length of stay by 10 days over two years. ↗
▶ Ep 46 · 14:20
clinical Cincinnati Children's gastroschisis protocol includes prenatal care coordination with obstetricians and neonatologists, with surgery continuing to follow patients throughout hospitalization. ↗
▶ Ep 46 · 15:17
host_summary Some institutions ignore bilious emesis or bilious NG residuals completely during gastroschisis feeding advancement. ↗
▶ Ep 46 · 16:00
opinion The most important aspects of gastroschisis feeding are defining institutional tolerance criteria, adhering to protocol, and continuously evaluating the infant's condition. ↗
▶ Ep 46 · 16:00
quote the most important thing that kind of keeps showing up is the fact that we really need to define what your own institution has for tolerance and to kind of stay on the protocol and then really just look at the infant condition as you continue to go is the most important thing ↗
▶ Ep 46 · 16:40
clinical For significant feeding intolerance, Cincinnati Children's protocol calls for stopping feeds for six hours, though this is not clearly evidence-based. ↗
▶ Ep 46 · 16:40
quote yes you can have a protocol yes you know you need to follow it but the most really you really need to continually evaluate the patient as they continue to go to make sure that you know yes your protocol is working but also to the patient does okay throughout ↗
▶ Ep 46 · 17:22
clinical One recent Cincinnati Children's gastroschisis patient who was primarily reduced on day of life zero was discharged at approximately two weeks and remained well at two-week follow-up, though this is an outlier on the faster end. ↗
▶ Ep 46 · 17:22
epidemiological Cincinnati Children's current average gastroschisis length of stay is 30 to 34 days. ↗
▶ Ep 46 · 18:14
epidemiological Cincinnati Children's has not seen any aspirations with their early aggressive feeding approach, though they acknowledge they are still early in implementation and continue to monitor data. ↗
▶ Ep 46 · 18:56
clinical At Cincinnati Children's, approximately two-thirds of gastroschisis cases cannot be reduced immediately and are placed in a silo for gradual reduction followed by sutureless closure, with feeds started after closure. ↗
Fecal Incontinence 9 entries

Colorectal Quiz Episode 37: The Yancey-Soave story of the original surgical descriptions for Hirschsprung disease

▶ Ep 6 · 12:26
clinical Dr. Newman brought Dr. Yancey's story to the attention of the Hirschsprung interest group at APSA. ↗
▶ Ep 6 · 15:06
quote I was reading the operative note from one of my fellows who provided the history of the patient. I had to do a reoperation on the patient. And the history read that this five-year-old child is status post a Yancey Suave procedure in such and such date and had an asthmatic stricture. ↗
▶ Ep 6 · 15:06
clinical A fellow at Children's National wrote an operative note describing a patient as status post a 'Yancey-Suave procedure,' indicating the terminology has become part of standard practice. ↗

The Colorectal Quiz Episode 21: The History of Hirschsprung Disease

▶ Ep 6 · 5:05
quote He united us. Yeah. In a way. And he doesn't even know it. ↗
▶ Ep 6 · 9:40
clinical Dr. Martin developed the Martin procedure, an expansion of the Duhamel for long-segment Hirschsprung disease, leaving a longer aganglionated segment of rectum and pulling through ganglionated bowel. ↗
▶ Ep 6 · 9:40
clinical Dr. Martin was the first surgeon-in-chief and pediatric surgeon at Cincinnati Children's Hospital. ↗
▶ Ep 6 · 9:40
quote It's a super duper Duhamel. ↗
▶ Ep 6 · 14:13
quote I think that's the who's who of Hirschsprung's right there. ↗
▶ Ep 6 · 14:47
quote I have a feeling we're going to have way more discussions about Hirschsprung disease because just because, because I think it's a fascinating disease that there are so many intricacies. You just mentioned dentorocolitis. We could talk forever about that. ↗
Gastroschisis 36 entries

Gastroschisis and sutureless abdominal wall closure

▶ Ep 14 · 7:20
opinion Many patients who underwent sutureless repair were done in more recent cohorts and tended towards less interventions. ↗
▶ Ep 14 · 7:20
opinion Due to the heterogeneity of gastroschisis, patients able to undergo primary repair probably had more favorable bowel and theoretically would have less hospital stay and feed faster. ↗
▶ Ep 14 · 7:20
quote I think it was probably what we were expecting, I think, for a couple of reasons. One, due to the heterogeneity of this disease, you know, especially with gastroschisis, a lot of the patients that were able to undergo, you know, especially a primary repair, they probably had more favorable bowel. And then those patients, you know, theoretically would have less hospital stay and theoretically feed faster and things like that. ↗
▶ Ep 14 · 8:05
quote Moreover, too, if you think about just the way that we close a sutured repair, you mobilize flaps from the skin and flaps from the fascia. So there's always, you know, redness around the incision, bruising around the incision. And so, you know, even that tissue manipulation is going to put you at higher risk for a potential infection or calling it erythema infection. ↗
▶ Ep 14 · 8:05
clinical In sutured repair, mobilizing flaps from the skin and fascia causes redness and bruising around the incision, which puts patients at higher risk for potential infection. ↗
▶ Ep 14 · 8:05
opinion The finding of increased antibiotics needed after sutured repair was expected due to tissue manipulation. ↗
▶ Ep 14 · 8:50
host_summary Initial small studies showed that some sutureless patients had a high umbilical hernia repair rate, or at least a high umbilical hernia rate. ↗
▶ Ep 14 · 8:50
clinical The consortium is working on operationalizing protocolization of gastroschisis closure across member institutions for a more prospective study with long-term follow-up. ↗
▶ Ep 14 · 8:50
clinical The next phase of the study is examining the same patients over several years of follow-up to assess growth and umbilical hernia repair rates. ↗

Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee

▶ Ep 18 · 3:10
clinical Jason Fraser's institution starts feeding immediately after dressing placement as long as the baby is not sick, not having horrible output, and not vomiting. ↗
▶ Ep 18 · 3:10
quote we start feeding essentially you have to put the dressing on uh as long as the baby's not sick not having horrible output not puking or anything like that ↗
▶ Ep 18 · 3:54
quote we don't innovate our babies at all so we put the dressing plastic dressing on and as long as the kid's not you know has voluminous output we'll try to start start feedings on it ↗
▶ Ep 18 · 3:54
clinical Fraser's institution does not intubate gastroschisis babies for reduction. ↗
▶ Ep 18 · 5:13
clinical Awake reduction can be successful if performed slowly, with stomach emptying, colon decompression, oral sucrose, and gradual abdominal wall stretching. ↗
▶ Ep 18 · 5:13
quote if you try to just keep pushing and pushing pushing the baby kind of can squirm and stuff but if you go slow if you empty out the stomach if you kind of squish out the colon a little bit and you go slow you give the baby some sweeties the nurses are there to kind of relax the baby you have a couple people that that are there doing it you go slow you slowly kind of push things in you stretch out the belly a little bit ↗
▶ Ep 18 · 6:19
quote it's really just based upon patient tolerance and it's kind of based upon some of the data that's out there from the rest of the world where they don't have tpn and so they just you have to feed the kid if the kid does okay then they keep going ↗
▶ Ep 18 · 6:19
clinical Cincinnati Children's feeding protocol is based on patient tolerance and data from resource-limited settings where TPN is unavailable and feeding is mandatory. ↗
▶ Ep 18 · 10:30
epidemiological The multi-institutional study showed inconclusive results due to significant variation in feeding protocols across institutions. ↗
▶ Ep 18 · 10:30
opinion The reduction in surgical site infections with protocol feeding was likely due to decreased care variability rather than the feeding protocol itself. ↗
▶ Ep 18 · 10:30
quote a lot of the inconclusivity from the the study showed that you know most likely due to the fact that there was lots of different feeding protocols that were used uh across our member institutions ↗
▶ Ep 18 · 10:50
quote the ssi thing was probably just because patients that were fed via protocol were cared for via protocol and so that they actually had less variability and less uh less changes uh in the way that these these patients are not you know look for ↗
▶ Ep 18 · 11:20
quote our length of stay for gastroschisis and cincinnati was astronomically higher than like any other nick micu in the cooperative network that we worked with so we sat down we're like what is going on here so our average length of stay was 49 days ↗
▶ Ep 18 · 11:20
epidemiological Cincinnati Children's average gastroschisis length of stay was 49 days before protocol implementation, which was astronomically higher than comparable NICUs in their cooperative network. ↗
▶ Ep 18 · 12:10
epidemiological After implementing a feeding protocol, Cincinnati Children's reduced gastroschisis length of stay by 10 days over two years. ↗
▶ Ep 18 · 12:10
quote we instituted this uh a feeding protocol we spent a lot of time trying to get people to follow it and and making some adjustments and over two years we dropped the length of stay by 10 days and the mix of patients is not different ↗
▶ Ep 18 · 12:10
epidemiological Cincinnati Children's has seen a decrease in time from first feed to full feeds but has not yet reduced the time from admission to first feed (except in 2020). ↗
▶ Ep 18 · 14:20
clinical Cincinnati Children's gastroschisis protocol includes prenatal care coordination with obstetricians and neonatologists, with surgery continuing to follow patients throughout hospitalization. ↗
▶ Ep 18 · 15:17
host_summary Some institutions ignore bilious emesis or bilious NG residuals completely during gastroschisis feeding advancement. ↗
▶ Ep 18 · 16:00
opinion The most important aspects of gastroschisis feeding are defining institutional tolerance criteria, adhering to protocol, and continuously evaluating the infant's condition. ↗
▶ Ep 18 · 16:00
quote the most important thing that kind of keeps showing up is the fact that we really need to define what your own institution has for tolerance and to kind of stay on the protocol and then really just look at the infant condition as you continue to go is the most important thing ↗
▶ Ep 18 · 16:40
quote yes you can have a protocol yes you know you need to follow it but the most really you really need to continually evaluate the patient as they continue to go to make sure that you know yes your protocol is working but also to the patient does okay throughout ↗
▶ Ep 18 · 16:40
clinical For significant feeding intolerance, Cincinnati Children's protocol calls for stopping feeds for six hours, though this is not clearly evidence-based. ↗
▶ Ep 18 · 17:22
clinical One recent Cincinnati Children's gastroschisis patient who was primarily reduced on day of life zero was discharged at approximately two weeks and remained well at two-week follow-up, though this is an outlier on the faster end. ↗
▶ Ep 18 · 17:22
epidemiological Cincinnati Children's current average gastroschisis length of stay is 30 to 34 days. ↗
▶ Ep 18 · 18:14
epidemiological Cincinnati Children's has not seen any aspirations with their early aggressive feeding approach, though they acknowledge they are still early in implementation and continue to monitor data. ↗
▶ Ep 18 · 18:56
clinical At Cincinnati Children's, approximately two-thirds of gastroschisis cases cannot be reduced immediately and are placed in a silo for gradual reduction followed by sutureless closure, with feeds started after closure. ↗
Hirschsprung disease 49 entries

Bowel Management Updates & Innovations with Live Q&A: April 2018

▶ Ep 1 · 0:15
clinical The Colorectal Center patient population includes anorectal malformations (imperforate anus), Hirschsprung's disease, spina bifida, sacrococcygeal teratomas, trauma patients, and refractory constipation. ↗
▶ Ep 1 · 0:15
clinical The Colorectal Center patient population includes anorectal malformations (imperforate anus), Hirschsprung's disease, spina bifida, sacrococcygeal teratomas, trauma patients, and refractory constipation. ↗
▶ Ep 1 · 2:32
clinical Appendicostomy (Malone/MAC/ACE procedure) involves bringing the appendix to the belly button with a valve mechanism to prevent reflux, allowing patients to independently administer flushes through the colon over 10–15 minutes, then sit on toilet for approximately 45 minutes to empty. ↗
▶ Ep 1 · 2:32
clinical Appendicostomy (Malone/MAC/ACE procedure) involves bringing the appendix to the belly button with a valve mechanism to prevent reflux, allowing patients to independently administer flushes through the colon over 10–15 minutes, then sit on toilet for approximately 45 minutes to empty. ↗
▶ Ep 1 · 3:42
clinical Sacral nerve stimulator is not FDA approved for children under 18, but is performed off-label; it acts like a heart pacemaker, stimulating the third sacral nerve to improve bowel and urinary continence outcomes. ↗
▶ Ep 1 · 3:42
clinical Sacral nerve stimulator is not FDA approved for children under 18, but is performed off-label; it acts like a heart pacemaker, stimulating the third sacral nerve to improve bowel and urinary continence outcomes. ↗
▶ Ep 1 · 4:41
clinical Sacral nerve stimulator is a two-stage procedure (test phase and permanent phase) and has been performed at Cincinnati Children's for almost 3 years. ↗
▶ Ep 1 · 4:41
clinical Sacral nerve stimulator is a two-stage procedure (test phase and permanent phase) and has been performed at Cincinnati Children's for almost 3 years. ↗
▶ Ep 1 · 4:53
clinical Solesta is an injection of hyaluronic acid polymer that fills space in the anal canal, used in patients with patulous (more open) anuses to help gain control. ↗
▶ Ep 1 · 4:53
clinical Solesta is an injection of hyaluronic acid polymer that fills space in the anal canal, used in patients with patulous (more open) anuses to help gain control. ↗
▶ Ep 1 · 7:27
clinical Patients with deformed sacrums have lower likelihood of success with bowel management using medication alone (not on enema program). ↗
▶ Ep 1 · 7:27
clinical Patients with deformed sacrums have lower likelihood of success with bowel management using medication alone (not on enema program). ↗
▶ Ep 1 · 7:50
clinical Malone procedure requires prior success with enemas because it only changes the route of administration; surgical procedure should not be performed on patients unsuccessful with enema program. ↗
▶ Ep 1 · 7:50
clinical Malone procedure requires prior success with enemas because it only changes the route of administration; surgical procedure should not be performed on patients unsuccessful with enema program. ↗
▶ Ep 1 · 8:17
clinical Malone procedure is typically performed starting at age 5 years and older, most commonly between ages 5 and 10–12 years. ↗
▶ Ep 1 · 8:17
clinical Malone procedure is typically performed starting at age 5 years and older, most commonly between ages 5 and 10–12 years. ↗
▶ Ep 1 · 8:53
clinical Vomiting after enema can be caused by high-volume enema with irritant causing colon distention and discomfort. ↗
▶ Ep 1 · 8:53
clinical Vomiting after enema can be caused by high-volume enema with irritant causing colon distention and discomfort. ↗
▶ Ep 1 · 10:59
guideline Sacral nerve stimulator indication per manufacturer requires 50% improvement on symptoms; patient must have tried non-surgical bowel management first. ↗
▶ Ep 1 · 10:59
guideline Sacral nerve stimulator indication per manufacturer requires 50% improvement on symptoms; patient must have tried non-surgical bowel management first. ↗
▶ Ep 1 · 11:17
clinical Sacral nerve stimulator requires normal sacrum; it is the least invasive option compared to Malone or Solesta when bowel management is working or needs improvement. ↗
▶ Ep 1 · 11:17
clinical Sacral nerve stimulator requires normal sacrum; it is the least invasive option compared to Malone or Solesta when bowel management is working or needs improvement. ↗
▶ Ep 1 · 11:49
clinical Using hybrid OR with 3D imaging, sacral nerve stimulator can be placed in patients with very abnormal sacrums by identifying anatomy in real-time. ↗
▶ Ep 1 · 11:49
clinical Using hybrid OR with 3D imaging, sacral nerve stimulator can be placed in patients with very abnormal sacrums by identifying anatomy in real-time. ↗
▶ Ep 1 · 13:45
clinical For failed redo Hirschsprung's pull-through, redo surgery can almost always create a channel for stool evacuation via rectum/anus, even after 1–3 prior redos; very few patients end up with ileostomy if goal is rectal evacuation. ↗
▶ Ep 1 · 13:45
clinical For failed redo Hirschsprung's pull-through, redo surgery can almost always create a channel for stool evacuation via rectum/anus, even after 1–3 prior redos; very few patients end up with ileostomy if goal is rectal evacuation. ↗
▶ Ep 1 · 17:18
clinical The large intestine (colon) primarily absorbs water; in adults it can absorb up to 1 liter of water per day. When colon is removed, stool becomes softer/looser because less water is absorbed. ↗
▶ Ep 1 · 17:18
clinical The large intestine (colon) primarily absorbs water; in adults it can absorb up to 1 liter of water per day. When colon is removed, stool becomes softer/looser because less water is absorbed. ↗
▶ Ep 1 · 17:46
clinical Bowel management sometimes requires using Imodium to constipate/harden stool, then using enema to empty it—thickening stool first, then mechanically emptying. ↗
▶ Ep 1 · 17:46
clinical Bowel management sometimes requires using Imodium to constipate/harden stool, then using enema to empty it—thickening stool first, then mechanically emptying. ↗
▶ Ep 1 · 19:12
opinion There is no perfect surgery for constipation; if there were, all surgeons would recommend and perform it. ↗
▶ Ep 1 · 19:12
opinion There is no perfect surgery for constipation; if there were, all surgeons would recommend and perform it. ↗
▶ Ep 1 · 19:12
quote There is no perfect surgery for constipation. If we had it, we would all recommend it and do it. ↗
▶ Ep 1 · 19:12
quote There is no perfect surgery for constipation. If we had it, we would all recommend it and do it. ↗
▶ Ep 1 · 19:20
clinical Transanal colon/rectum resection is minimally invasive but carries risk of post-surgical incontinence in some patients. ↗
▶ Ep 1 · 19:20
clinical Transanal colon/rectum resection is minimally invasive but carries risk of post-surgical incontinence in some patients. ↗
▶ Ep 1 · 19:56
clinical Colon resection for constipation may lessen treatment burden (e.g., reduce laxative dose from 10 to 5 squares of Ex-Lax) but this outcome is not guaranteed. ↗
▶ Ep 1 · 19:56
clinical Colon resection for constipation may lessen treatment burden (e.g., reduce laxative dose from 10 to 5 squares of Ex-Lax) but this outcome is not guaranteed. ↗
▶ Ep 1 · 20:22
clinical Before colon resection, offer sacral nerve stimulator and perform manometry (colonic and anorectal) to identify non-functioning colon segments or outlet problems (sphincter dysfunction). ↗
▶ Ep 1 · 20:22
clinical Before colon resection, offer sacral nerve stimulator and perform manometry (colonic and anorectal) to identify non-functioning colon segments or outlet problems (sphincter dysfunction). ↗
▶ Ep 1 · 20:55
clinical Anorectal manometry can reveal paradoxical sphincter function where child squeezes when trying to relax and vice versa; Botox works in younger children, physical therapy and biofeedback in older children for this. ↗
▶ Ep 1 · 20:55
clinical Anorectal manometry can reveal paradoxical sphincter function where child squeezes when trying to relax and vice versa; Botox works in younger children, physical therapy and biofeedback in older children for this. ↗
▶ Ep 1 · 22:31
clinical Colon resection is a big surgery requiring bowel anastomosis with associated risks; once colon is resected, it cannot be replaced. All other treatments (sacral nerve, enemas, laxatives) are reversible. ↗
▶ Ep 1 · 22:31
clinical Colon resection is a big surgery requiring bowel anastomosis with associated risks; once colon is resected, it cannot be replaced. All other treatments (sacral nerve, enemas, laxatives) are reversible. ↗
▶ Ep 1 · 25:25
opinion Senna laxative is like insulin for a diabetic—a necessary medication to help move bowels in severe constipation; dose may change over time but patients are not 'addicted' to it. ↗
▶ Ep 1 · 25:25
opinion Senna laxative is like insulin for a diabetic—a necessary medication to help move bowels in severe constipation; dose may change over time but patients are not 'addicted' to it. ↗
▶ Ep 1 · 25:29
quote I sort of say it's like insulin for a diabetic. A diabetic needs insulin to lower their blood blood glucose levels. A patient who has severe constipation needs a laxative stimulant to help move their bowels. ↗
▶ Ep 1 · 25:29
quote I sort of say it's like insulin for a diabetic. A diabetic needs insulin to lower their blood blood glucose levels. A patient who has severe constipation needs a laxative stimulant to help move their bowels. ↗
▶ Ep 1 · 26:48
clinical Stimulant laxatives (Senna, Dulcolax) make the colon squeeze/push stool forward and reduce water absorption time, resulting in softer stool—two mechanisms that benefit the patient population. ↗