Jason Frischer
1459 statements · 32 topics · summaries given as host listed separately
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 statements
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.
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Colorectal / ARM & Hirschsprung
A few key tips to irrigation for those listening to me, an irrigation is instilling a, a small aloquat of saline, usually warm saline. Somewhere between 20 and 40 mLs um at a time. And it's infusing, instilling it in and getting it removed, whether that be by withdrawing from, with a catheter, so that you evacuate that saline and not just infuse it into the lumen of the colon, I think is important.
The overriding principle in this patient population is the overriding principle of bowel preservation, right? The small intestine can be shortened in some of these patients. Some of these patients have nutritional concerns, not immediately, but long term. In general, I think the theme should be preserve all bowel.
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Cloacal Exstrophy
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.
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Anorectal Malformation
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
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Abdominal Wall Defects
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.
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Colorectal / ARM & Hirschsprung
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Jason's statements about Abdominal Wall Defects 34 statements
Open the Abdominal Wall Defects collection →
Gastroschisis and sutureless abdominal wall closure
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Many patients who underwent sutureless repair were done in more recent cohorts and tended towards less interventions.
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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.
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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.
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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.
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The finding of increased antibiotics needed after sutured repair was expected due to tissue manipulation.
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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.
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The consortium is working on operationalizing protocolization of gastroschisis closure across member institutions for a more prospective study with long-term follow-up.
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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.
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Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
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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.
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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
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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
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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
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Awake reduction can be successful if performed slowly, with stomach emptying, colon decompression, oral sucrose, and gradual abdominal wall stretching.
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Cincinnati Children's feeding protocol is based on patient tolerance and data from resource-limited settings where TPN is unavailable and feeding is mandatory.
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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
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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
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The multi-institutional study showed inconclusive results due to significant variation in feeding protocols across institutions.
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The reduction in surgical site infections with protocol feeding was likely due to decreased care variability rather than the feeding protocol itself.
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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
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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.
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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
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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).
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After implementing a feeding protocol, Cincinnati Children's reduced gastroschisis length of stay by 10 days over two years.
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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
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Cincinnati Children's gastroschisis protocol includes prenatal care coordination with obstetricians and neonatologists, with surgery continuing to follow patients throughout hospitalization.
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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
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The most important aspects of gastroschisis feeding are defining institutional tolerance criteria, adhering to protocol, and continuously evaluating the infant's condition.
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For significant feeding intolerance, Cincinnati Children's protocol calls for stopping feeds for six hours, though this is not clearly evidence-based.
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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
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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.
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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.
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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.
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Jason's statements about Anorectal Malformation 129 statements
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The Colorectal Quiz Episode 1: ARM - Low Bulbar Fistula
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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.
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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.
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Well-formed buttocks, visible sphincter mechanism location, and well-developed sacrum together predict good prognosis for continence.
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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.
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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.
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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.
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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.
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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.
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A bulbar fistula is located at the elbow of the urethra, using anatomic nomenclature based on the urethral location.
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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.
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Colorectal Quiz Episode 2: When to redo a PSARP
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For anorectoplasty, if you don't get it perfect, you might not have the best outcomes, which separates it from other surgical procedures.
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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.
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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?
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Colorectal Quiz Episode 13: Newborn ARM Part 2
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My conversation with the family often involves that this will keratinize and look like a normal peroneal body over time.
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Perineal groove with mucosal lining will keratinize and look like normal perineal body over time
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Surgical intervention for perineal groove is indicated only if secreting mucus, causing irritation, or developing ulcers
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Vestibular fistula is very common in females and needs formal repair with hole transposed to center of sphincter
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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
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Patients diagnosed with vestibular fistula at 6-12 months who have dilated rectosigmoid need diversion as first step, then repair
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To evaluate for vestibular fistula, pull labia towards examiner with both hands to visualize vaginal opening and urethra
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Colorectal Quiz Episode 14: ARM Newborn Part 3
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Cross-table lateral films can be obtained early and then around 24 hours later in cases where there is no evidence of fistula on exam.
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If the air column stops at about the 4th sacral vertebral body with a large distance between the air column and the sphincter marker, the patient should be considered for diversion and distal colostogram to delineate anatomy.
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if you look at the film on the left, the air column stops at about the 4th sacral vertebral body, give or take a little bit. And so, what, and you could see where the marker is or the BB is, uh, where the, where the sphincter complex appears to be located. There's a large distance between those.
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When the air column is very close to where the anticipated anal opening should be located, primary anoplasty may be performed.
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the air column is very close to where the anticipated anal opening should be located. And this is a case where you could take your barley bush, potentially, and make a nick, uh, a scratch, and, and do your anoplasty.
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Whether to perform primary anoplasty in cases with close air column depends on individual surgeon comfort and the level of post-operative care available at the institution.
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that common wall or, or that wall between the rectum and the urethra is a lot closer and a lot longer. Of a common wall, then I think some people anticipate.
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The common wall between the rectum and the urethra is closer and longer than some people anticipate.
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A patient at 24 hours with no obvious fistula and cross-table lateral showing air column not very distal needs a colostomy.
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The Colorectal Quiz Episode 23: Hirschsprung Disease - The Soiling Patient...
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Can I scare you for a moment? Can we talk scientifically for one minute? I know this is crazy.
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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.
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Blood supply changes occur at the dentate line (splanchnic versus systemic), and there is also innervation in that area.
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The nerves located at the dentate line region tell you gas, liquid, solid; how hard, how long, and how tight to squeeze.
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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?
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Preserving the dentate line region is key because injury to that region affects a patient's ability to be continent.
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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.
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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.
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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.
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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).
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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.
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Patients with no dentate line and patulous sphincters who are soiling develop severe skin irritation from sitting in pull-ups or diapers.
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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.
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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.
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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.
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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.
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Whether hypermotile patients can empty on their own versus needing mechanical emptying to maintain social continence depends on their sphincter function.
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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.
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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.
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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.
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Nutrition in Hirschsprung patients is very important; some patients are very sensitive to certain foods, particularly lactose.
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Paying attention to diet (whether breastfed infants or older children) is important because lactose is particularly problematic in some Hirschsprung patients.
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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.
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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.
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Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula
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When neurologic anomalies are found in anorectal malformation patients, gynecological anomalies are more likely, especially on the same side.
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when you do find neurologic anomalies. That leads to more likely gynecological anomalies as well, especially on the same side.
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Colorectal Quiz Episode 29: Female ARM-Post Op Management
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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.
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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.
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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.
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Colorectal Quiz Episode 38: Transitional Care in Colorectal Surgery
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MRI with specific protocols and endorectal ultrasound can help determine whether the anoplasty is within the muscle complex.
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The transition model includes joint clinic visits and collaborative operating, which is key to successful handoff.
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Freestanding children's hospitals face greater challenges than integrated hospitals because they are completely separate entities both physically and financially.
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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.
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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.
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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.
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Colorectal Quiz Episode 1 - Low Bulbar Fistua
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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.
Open
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Cross-table lateral is performed with the baby prone, positioning the buttock at the highest point where air will rise.
Open
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A marker should be placed where the anus is thought to be appropriate on the cross-table lateral to allow measurements and inform operative approach.
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Well-formed buttocks, visible sphincter mechanism location, and well-developed sacrum together indicate likely good prognosis for continence.
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Quotation
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 gonna hit is that air pocket, which is the distal rectum.
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When a fistula is very close to the rectum, it is important to identify the proper dissection plane between the two structures.
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A bulbar fistula is located at the elbow of the urethra, using anatomic nomenclature.
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Colorectal Quiz: Episode 43
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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.
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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).
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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.
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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.
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If appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel.
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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.
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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.
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Using a 10 French tube (not 8), leaving it in for a month, and cathing twice a day can minimize stenosis rate.
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Leaving indwelling tubes in Malones increases the amount of prolapse, likely due to pressure on the appendiceal base pushing up mucosa.
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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.
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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.
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Colorectal Quiz: Episode 40
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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.
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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.
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If a neovagina bridge is functioning well without problems, there may be no reason to remove it later.
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Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies
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In a cardiac patient with an external opening from ARM, the typical approach is to dilate as long as they're evacuating okay.
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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.
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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.
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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
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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.
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Dissecting in with a mosquito, making sure you're in, not touching any vessel before you insufflate, and also clear the line of air
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I've seen teenagers and young adults with those beads that never went away. So, yeah, you've got to scrape that off
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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.
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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.
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Colorectal Quiz Episode 29: Female ARM
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Dr. Frisher uses a midline catheter (not PICC line) with D10 until the repair is confirmed healed, typically five to seven days NPO.
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Approximately 20% of patients in the dilation study required a redo operation, either local or total, with most being local procedures.
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Colorectal Quiz: Episode 2
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In higher malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated
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Alternative approach for borderline anatomy: let the child try their current anatomy first; if it works well, stay with it; if not, consider redo
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The Colorectal Quiz: Episode 1
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Pre-sacral masses are rare in typical imperforate anus but occur in almost half of anal stenosis or rectal atresia cases, requiring MRI
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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.
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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.
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Cross-table lateral x-ray should be obtained at approximately 24 hours of life to assess gas column height and guide surgical planning
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Well-formed buttocks, good muscle, true sphincter mechanism area, and well-developed sacrum together indicate likely good prognosis
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With air column 8.8mm from skin, primary posterior sagittal anorectoplasty is a reasonable option based on imaging
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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.
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Should never try to go in blind—must know what structure will be encountered before making posterior sagittal incision
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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.
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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.
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Fistula can be very close to rectum, making proper plane dissection along urethra important
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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.
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Jason's statements about Anorectal Malformations & Cloacal Reconstruction 7 statements
Open the Anorectal Malformations & Cloacal Reconstruction collection →
Colorectal Quiz Episode 1 - Low Bulbar Fistua
Statement
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.
Open
Statement
Cross-table lateral is performed with the baby prone, positioning the buttock at the highest point where air will rise.
Open
Statement
A marker should be placed where the anus is thought to be appropriate on the cross-table lateral to allow measurements and inform operative approach.
Open
Statement
Well-formed buttocks, visible sphincter mechanism location, and well-developed sacrum together indicate likely good prognosis for continence.
Open
Quotation
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 gonna hit is that air pocket, which is the distal rectum.
Open
Statement
When a fistula is very close to the rectum, it is important to identify the proper dissection plane between the two structures.
Open
Statement
A bulbar fistula is located at the elbow of the urethra, using anatomic nomenclature.
Open
Jason's statements about Anorectal Malformations & Cloacal Reconstruction 7 statements
Open the Anorectal Malformations & Cloacal Reconstruction collection →
Colorectal Quiz Episode 1 - Low Bulbar Fistua
Statement
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.
Open
Statement
Cross-table lateral is performed with the baby prone, positioning the buttock at the highest point where air will rise.
Open
Statement
A marker should be placed where the anus is thought to be appropriate on the cross-table lateral to allow measurements and inform operative approach.
Open
Statement
Well-formed buttocks, visible sphincter mechanism location, and well-developed sacrum together indicate likely good prognosis for continence.
Open
Quotation
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 gonna hit is that air pocket, which is the distal rectum.
Open
Statement
When a fistula is very close to the rectum, it is important to identify the proper dissection plane between the two structures.
Open
Statement
A bulbar fistula is located at the elbow of the urethra, using anatomic nomenclature.
Open
Jason's statements about Cloaca 5 statements
Colorectal Quiz Episode 17: Cloaca Part 1
Quotation
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.
Open
Colorectal Quiz Episode 18: Cloaca Part 2
Statement
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.
Open
Colorectal Quiz: Episode 40
Statement
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.
Open
Quotation
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.
Open
Statement
If a neovagina bridge is functioning well without problems, there may be no reason to remove it later.
Open
Jason's statements about Cloacal Exstrophy 4 statements
Open the Cloacal Exstrophy collection →
Colorectal Quiz Episode 33: Cloaca Exstrophy
Statement
Two major surgical decision points in cloacal exstrophy are: (1) whether the omphalocele is large or small enough to close the abdominal wall, and (2) the staging of the exstrophy procedure—whether to just bring bladder plates together in a multi-stage approach or to close the bladder and bring the symphysis pubis together.
Open
Quotation
The overriding principle in this patient population is the overriding principle of bowel preservation, right? The small intestine can be shortened in some of these patients. Some of these patients have nutritional concerns, not immediately, but long term. In general, I think the theme should be preserve all bowel.
Open
Statement
The overriding principle in cloacal exstrophy management is bowel preservation, as small intestine can be shortened and some patients have long-term nutritional concerns.
Open
Statement
One reason for not performing early pull-through in cloacal exstrophy is concern about rash and managing a perineal stoma.
Open
Jason's statements about Colorectal / ARM & Hirschsprung 450 statements
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Hirschsprung Disease - Imperforate Anus - Rectal Prolapse: Update Course 2015
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
Post-Hirschsprung complications divide into two categories: obstructive symptoms (enterocolitis, failure to thrive, distention) and soiling issues (true incontinence vs pseudo-incontinence from constipation).
Open
Statement
Post-Hirschsprung complications divide into two categories: obstructive symptoms (enterocolitis, failure to thrive, distention) and soiling issues (true incontinence vs pseudo-incontinence from constipation).
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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).
Open
Statement
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.
Open
Statement
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).
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Quotation
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.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
Rectal prolapse workup should distinguish full-thickness prolapse from partial-thickness (mucosal) prolapse based on physical examination appearance.
Open
Statement
Rectal prolapse workup should distinguish full-thickness prolapse from partial-thickness (mucosal) prolapse based on physical examination appearance.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
Sclerosing agent injection for rectal prolapse has high recurrence rates; patients who fail this approach and require subsequent rectopexy have difficult reoperative dissection.
Open
Quotation
I can tell you when it recurs to re-operate on those patients is not going to matter at all.
Open
Quotation
I can tell you when it recurs to re-operate on those patients is not going to matter at all.
Open
Statement
Sclerosing agent injection for rectal prolapse has high recurrence rates; patients who fail this approach and require subsequent rectopexy have difficult reoperative dissection.
Open
Statement
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).
Open
Statement
Resection and rectopexy for rectal prolapse may be preferable when constipation control is difficult, but has higher complication rate compared to rectopexy alone.
Open
Statement
Laparoscopic rectopexy for rectal prolapse can be performed as same-day surgery or with next-day discharge in current practice.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Hirschsprung Disease: Update Course 2015
Quotation
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
Open
Statement
The safest approach to Hirschsprung surgery involves some form of biopsy (laparoscopic or full-thickness through umbilicus) prior to definitive pull-through.
Open
Statement
Leveling colostomy may be the safest approach when institutional pathology expertise in reading Hirschsprung biopsies is limited or unavailable.
Open
Statement
Leveling colostomy represents a three-stage procedure for Hirschsprung disease management.
Open
Quotation
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.
Open
Statement
Prolonged transanal dissection (approaching 4 hours) should prompt consideration of converting to laparoscopic approach to avoid excessive sphincter stretching.
Open
Statement
Laparoscopic mobilization with 3-millimeter ports can be completed in approximately 45 minutes for appropriate cases.
Open
Statement
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.
Open
Statement
Complications after Hirschsprung surgery are divided into two categories: obstructive symptoms (including enterocolitis, failure to thrive, abdominal distention) and soiling issues.
Open
Statement
Soiling after Hirschsprung surgery is further classified into true incontinence and pseudo-incontinence.
Open
Statement
Obstructive symptoms after Hirschsprung surgery require differentiation between anatomic problems and pathologic problems.
Open
Statement
True fecal incontinence after Hirschsprung surgery can result from injury to the sphincter or injury to the dentate line.
Open
Statement
Pseudo-incontinence after Hirschsprung surgery may be caused by underlying constipation.
Open
Statement
Workup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia evaluating dentate line position, stricture, stretched sphincter, and anatomic twists.
Open
Hirschsprung's Disease
Quotation
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.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
The classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel.
Open
Statement
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.
Open
Statement
In total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema.
Open
Statement
Approximately 10% of newborns with Hirschsprung's disease may lack the typical findings on a contrast enema.
Open
Statement
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.
Open
Statement
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.
Open
Statement
Full thickness biopsy technique should be considered for patients older than six months, or when a suction biopsy is inadequate.
Open
Quotation
The three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry.
Open
Quotation
The second part of a diagnostic workup for Hirschsprung's disease, and most important, is the rectal biopsy. It is the true definitive diagnosis.
Open
Statement
Approximately 10% of newborns with Hirschsprung's disease may lack the typical findings on a contrast enema.
Open
Statement
The classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel.
Open
Statement
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.
Open
Statement
In total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema.
Open
Statement
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.
Open
Statement
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.
Open
Statement
Full thickness biopsy technique should be considered for patients older than six months, or when a suction biopsy is inadequate.
Open
Quotation
The three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry.
Open
Quotation
The second part of a diagnostic workup for Hirschsprung's disease, and most important, is the rectal biopsy. It is the true definitive diagnosis.
Open
Statement
Any patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis.
Open
Statement
In Hirschsprung's disease, anorectal manometry shows a lack of the rectoanal inhibitory reflex (RAIR).
Open
Statement
The rectoanal inhibitory reflex may be absent in other conditions as well, and some children have a false positive test.
Open
Statement
The rectoanal inhibitory reflex may be absent in other conditions as well, and some children have a false positive test.
Open
Statement
Any patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis.
Open
Statement
In Hirschsprung's disease, anorectal manometry shows a lack of the rectoanal inhibitory reflex (RAIR).
Open
Quotation
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.
Open
Statement
The three goals of surgical management are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity.
Open
Quotation
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.
Open
Statement
The three goals of surgical management are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity.
Open
Statement
A con of the Suave procedure is that the aganglionic cuff can become stiff enough to cause an obstruction or outlet obstruction.
Open
Statement
In the Suave procedure, the actual anastomosis is performed within a cuff of aganglionic rectum.
Open
Statement
The Suave procedure theoretically causes less injury to pelvic structures, nerves, urethra and vagina.
Open
Statement
The Suave procedure involves performing a mucosectomy from a transanal approach slightly above the dentate line and pulling through the normal bowel.
Open
Statement
In the Swenson procedure, it is very important to be cautious about injuring the urethra as it's quite close, especially in boys.
Open
Statement
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.
Open
Statement
The Suave procedure involves performing a mucosectomy from a transanal approach slightly above the dentate line and pulling through the normal bowel.
Open
Statement
In the Suave procedure, the actual anastomosis is performed within a cuff of aganglionic rectum.
Open
Statement
The Suave procedure theoretically causes less injury to pelvic structures, nerves, urethra and vagina.
Open
Statement
A con of the Suave procedure is that the aganglionic cuff can become stiff enough to cause an obstruction or outlet obstruction.
Open
Statement
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.
Open
Statement
In the Swenson procedure, it is very important to be cautious about injuring the urethra as it's quite close, especially in boys.
Open
Statement
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.
Open
Quotation
When we treat these patients with enterocolitis, it is important to provide fluid resuscitation, digital rectal exam, and colonic irrigations.
Open
Quotation
Hirschsprung's-associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth.
Open
Statement
For enterocolitis, antibiotics including metronidazole or broad-spectrum antibiotics are added depending on the severity of presentation.
Open
Statement
Treatment of enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations.
Open
Statement
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.
Open
Statement
Hirschsprung's-associated enterocolitis is likely an inflammatory condition secondary to bacterial overgrowth.
Open
Quotation
When we treat these patients with enterocolitis, it is important to provide fluid resuscitation, digital rectal exam, and colonic irrigations.
Open
Quotation
Hirschsprung's-associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth.
Open
Statement
For enterocolitis, antibiotics including metronidazole or broad-spectrum antibiotics are added depending on the severity of presentation.
Open
Statement
Treatment of enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations.
Open
Statement
Hirschsprung's-associated enterocolitis is likely an inflammatory condition secondary to bacterial overgrowth.
Open
Statement
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.
Open
Statement
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.
Open
Statement
For patients without anatomic problems after pull-through, treatment can include bowel management, Botox injection to relieve sphincter tone, or motility studies.
Open
Statement
For patients with anatomic problems after pull-through, you typically have to revise the pull through.
Open
Statement
For patients without anatomic problems after pull-through, treatment can include bowel management, Botox injection to relieve sphincter tone, or motility studies.
Open
Statement
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.
Open
Statement
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.
Open
Statement
For patients with anatomic problems after pull-through, you typically have to revise the pull through.
Open
The Colorectal Quiz Episode 1: ARM - Low Bulbar Fistula
Statement
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.
Open
Statement
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.
Open
Statement
Well-formed buttocks, visible sphincter mechanism location, and well-developed sacrum together predict good prognosis for continence.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Quotation
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.
Open
Quotation
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.
Open
Statement
A bulbar fistula is located at the elbow of the urethra, using anatomic nomenclature based on the urethral location.
Open
Quotation
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.
Open
Colorectal Quiz Episode 2: When to redo a PSARP
Statement
For anorectoplasty, if you don't get it perfect, you might not have the best outcomes, which separates it from other surgical procedures.
Open
Statement
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.
Open
Quotation
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.
Open
Quotation
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?
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
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.
Open
Colorectal Quiz Episode 3: Hirschsprung Disease
Statement
In Hirschsprung disease, the aganglionic rectum appears narrow due to spasm and inability to relax, while the ganglionated proximal bowel is dilated, creating the recto-sigmoid ratio
Open
Statement
The crypts are located above the dentate line, so optimal biopsy location is at least 1-2 cm above the dentate line
Open
The Colorectal Quiz Episode 3.5: Proximal Hirschsprung Disease
Quotation
Yeah. And I think you could make guesses about this. But like you said, it's hard on a newborn film to really discern small and large bowel. And you can get fooled.
Open
Statement
It is hard on a newborn film to really discern small and large bowel, and you can get fooled.
Open
Statement
Patients with proximal Hirschsprung disease are at risk of perforation, usually in the cecum.
Open
Quotation
So they were quick to point out that we're lucky this patient didn't show up with a perforation. And usually they perforate in the cecum.
Open
Statement
To get a perforation, you need distension, and if you have a transition zone at the hepatic flexure, then all the pressure is in the right colon.
Open
Statement
A baby that doesn't have a competent ileosecal valve might be saved from perforation because pressure can decompress into the small bowel.
Open
Statement
You are obligated at some point, maybe after resuscitation, to get a rectal biopsy in a patient with suspected Hirschsprung disease.
Open
Statement
Proximal Hirschsprung disease and distal Hirschsprung disease require two different operative approaches.
Open
Quotation
Two different operative approaches for the same disease because one is more proximal and more complicated and the other is more distal.
Open
The Colorectal Quiz Episode 4: Classic Hirschsprung disease - Surgical Technique
Statement
With proper laparoscopic dissection, the transanal portion of a primary Hirschsprung pull-through should take well under one hour.
Open
Quotation
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.
Open
Quotation
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.
Open
Statement
With proper laparoscopic dissection, the transanal portion of a primary Hirschsprung pull-through should take well under one hour.
Open
Statement
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.
Open
Statement
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.
Open
The Colorectal Quiz Episode 8: Motility Disorders Part 1
Statement
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
Open
Statement
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
Open
Quotation
I think back in the day, Mark, yeah, we, we didn't understand the sphincter and the major role it played.
Open
Statement
In the past, surgeons did not understand the major role the sphincter played in many patients
Open
The Colorectal Quiz Episode 10: Total Colonic Hirschsprung Disease Part 1
Statement
The age cutoff for switching from suction rectal biopsy to full-thickness biopsy is around 6 months
Open
Quotation
My cutoff is around 6 months when I switch from suction rectal biopsy to full thickness biopsy.
Open
Quotation
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.
Open
Statement
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
Open
Statement
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
Open
The Colorectal Quiz Episode 11: Total Colonic Hirschsprung's Part 2
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
And so I have the families put some stool in the diaper and expose that skin to stool for a little.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
Dr. Fisher checks urine sodium a few weeks after ileostomy creation prior to discharge and again a month or two later.
Open
Quotation
For this case, I typically do an ileoanal anastomosis, a straight pull through, but there are a few other options.
Open
Statement
Dr. Fisher typically performs an ileoanal anastomosis (straight pull-through) for total colonic Hirschsprung disease.
Open
Statement
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.
Open
Statement
Family comfort with rectal irrigations is an important consideration when planning surgery.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Colorectal Quiz Episode 13: Newborn ARM Part 2
Quotation
My conversation with the family often involves that this will keratinize and look like a normal peroneal body over time.
Open
Quotation
My conversation with the family often involves that this will keratinize and look like a normal peroneal body over time.
Open
Statement
Perineal groove with mucosal lining will keratinize and look like normal perineal body over time
Open
Statement
Perineal groove with mucosal lining will keratinize and look like normal perineal body over time
Open
Statement
Surgical intervention for perineal groove is indicated only if secreting mucus, causing irritation, or developing ulcers
Open
Statement
Surgical intervention for perineal groove is indicated only if secreting mucus, causing irritation, or developing ulcers
Open
Statement
Vestibular fistula is very common in females and needs formal repair with hole transposed to center of sphincter
Open
Statement
Vestibular fistula is very common in females and needs formal repair with hole transposed to center of sphincter
Open
Statement
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
Open
Statement
Patients diagnosed with vestibular fistula at 6-12 months who have dilated rectosigmoid need diversion as first step, then repair
Open
Statement
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
Open
Statement
Patients diagnosed with vestibular fistula at 6-12 months who have dilated rectosigmoid need diversion as first step, then repair
Open
Statement
To evaluate for vestibular fistula, pull labia towards examiner with both hands to visualize vaginal opening and urethra
Open
Statement
To evaluate for vestibular fistula, pull labia towards examiner with both hands to visualize vaginal opening and urethra
Open
Colorectal Quiz Episode 14: ARM Newborn Part 3
Statement
Cross-table lateral films can be obtained early and then around 24 hours later in cases where there is no evidence of fistula on exam.
Open
Statement
If the air column stops at about the 4th sacral vertebral body with a large distance between the air column and the sphincter marker, the patient should be considered for diversion and distal colostogram to delineate anatomy.
Open
Quotation
if you look at the film on the left, the air column stops at about the 4th sacral vertebral body, give or take a little bit. And so, what, and you could see where the marker is or the BB is, uh, where the, where the sphincter complex appears to be located. There's a large distance between those.
Open
Quotation
the air column is very close to where the anticipated anal opening should be located. And this is a case where you could take your barley bush, potentially, and make a nick, uh, a scratch, and, and do your anoplasty.
Open
Statement
When the air column is very close to where the anticipated anal opening should be located, primary anoplasty may be performed.
Open
Statement
Whether to perform primary anoplasty in cases with close air column depends on individual surgeon comfort and the level of post-operative care available at the institution.
Open
Quotation
that common wall or, or that wall between the rectum and the urethra is a lot closer and a lot longer. Of a common wall, then I think some people anticipate.
Open
Statement
The common wall between the rectum and the urethra is closer and longer than some people anticipate.
Open
Statement
A patient at 24 hours with no obvious fistula and cross-table lateral showing air column not very distal needs a colostomy.
Open
Colorectal Quiz Episode 15: Bowel Management in Spinal Patients - Need for a UrologistPart 1
Statement
Senna-induced perineal rash is thought to be a chemical burn rather than a true allergy, presenting with blistering.
Open
Statement
Senna rash is treated with silver sulfadiazine and resolves with time; some patients tolerate senna upon reintroduction.
Open
Statement
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.
Open
Quotation
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.
Open
Quotation
that care coordination, collaboration with the urologist might be the most beneficial thing we could do for our patients.
Open
Colorectal Quiz Episode 16: Bowel Management in Spinal Patients - Need for a Urologist Part 2
Statement
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
Open
Quotation
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.
Open
Statement
The colorectal team benefits from using the appendix portion closer to the cecum which has a stronger blood supply
Open
Statement
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
Open
Statement
Extending the Malone channel by 2-3 cm using suturing or stapling can be extremely helpful in preventing leakage
Open
Statement
Rectal irrigation using pressurized water systems made for patients with hand difficulties is an alternative to Malone and Mitrofanoff procedures
Open
Statement
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
Open
Statement
The primary determinant of orifice location is where the appendix reaches and its blood supply
Open
Statement
Laxity of the pelvic floor and anal canal is a huge issue in spinal patients, especially when doing retrograde enemas
Open
Colorectal Quiz Episode 17: Cloaca Part 1
Quotation
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.
Open
Colorectal Quiz Episode 18: Cloaca Part 2
Statement
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.
Open
Colorectal Collaboration: Neurogastroenterology/Motility Disorders
Quotation
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.
Open
Statement
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.
Open
Quotation
I want to stress that we shouldn't resort to resection right away just because we have one abnormal finding.
Open
Statement
Resection should not be performed immediately based on one abnormal finding; multiple factors must be considered.
Open
Statement
The first step in evaluating a patient with suspected motility disorder is to ensure normal anatomy, which can be assessed with contrast studies.
Open
Colorectal Quiz Episode 19: Hirschsprung Disease - The Obstructed Patient Part 1
Quotation
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.
Open
Statement
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.
Open
Statement
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).
Open
Quotation
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.
Open
Statement
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.
Open
Statement
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.
Open
Quotation
I think we all agree we get the contrast study before going to the operating room for a rectal exam
Open
Statement
A lateral view on contrast enema is important because it provides significant information about the presacral space and distal rectum anatomy.
Open
The Colorectal Quiz Episode 20: Hirschsprung Disease Obstruction Part 2
Statement
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
Open
Quotation
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.
Open
Statement
Initial treatment for obstructed Hirschsprung's patient must include rectal irrigation, done early
Open
Statement
Every institution should have a protocol for obstructed Hirschsprung's patients to ensure quick and efficient response
Open
Statement
Systematic workup for obstructed Hirschsprung's includes: resuscitation, imaging studies, and comprehensive rectal exam under anesthesia
Open
The Colorectal Quiz Episode 21: The History of Hirschsprung Disease
Statement
Doctor Martin developed the Martin procedure, an extended Duhamel procedure that leaves a longer aganglionic segment of rectum for long-segment Hirschsprung disease.
Open
Statement
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.
Open
Statement
Doctor Martin's ulcerative colitis technique predated the J-pouch, which later modified his approach.
Open
The Colorectal Quiz Episode 22: Hirschsprung Disease - the Soiling Patient Part 1
Statement
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.
Open
Statement
Sphincters should be assessed with the patient awake; examination under anesthesia makes it harder to assess sphincter function.
Open
Statement
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.
Open
Colorectal Quiz Episode 26: Perianal Crohn's Disease
Statement
If terminal ileum cannot be intubated, gastroenterologists may treat presumptively and re-scope after a few months of treatment when inflammation has decreased.
Open
Statement
The highest risk factors for lymphoma with biologic therapy are male gender, teenage age, and combination therapy with methotrexate.
Open
Statement
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.
Open
Statement
In pediatric patients, unlike adult patients, the first presenting factor for Crohn's disease can often be perianal disease.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
Source control of infection must be achieved before starting immunosuppressive therapy including steroids and biologics.
Open
Statement
If an abscess is not adequately drained, reimaging should be performed before giving biologics or steroids.
Open
Statement
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).
Open
Statement
Inflammatory markers including fecal calprotectin, ESR, and CRP should be checked before removing a seton to ensure systemic disease is under control.
Open
Statement
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.
Open
Hirschsprung Disease in Brief
Statement
Hirschsprung disease is a congenital anomaly of the GI tract that results in a functional bowel obstruction.
Open
Quotation
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.
Open
Statement
Failure to pass meconium within the first 48 hours of life is typical of Hirschsprung's disease.
Open
Statement
Hirschsprung disease is associated with Wordenberg syndrome and congenital central hyperventilation (Andine's curse).
Open
Statement
The RET gene is a predisposing genetic condition associated with Hirschsprung disease.
Open
Statement
The three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry.
Open
Quotation
The classic finding is a transition zone in the rectosigmoid, but that transition zone really can be located anywhere within the bowel.
Open
Statement
The classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel.
Open
Quotation
The second part of a diagnostic workup for Hirschsprung's disease, and most important, is the rectal biopsy. It is the true definitive diagnosis.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
Suction rectal biopsy technique is typically used for patients less than 6 months of age.
Open
Statement
Full thickness rectal biopsy technique should be considered for patients older than 6 months or when a suction biopsy is inadequate.
Open
Statement
Any patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
The Duamel procedure involves performing a pouch with an anastomosis of aganglionic and ganglionated bowel.
Open
Statement
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.
Open
Statement
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.
Open
Statement
Hirschsprung's associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth.
Open
Statement
A child with enterocolitis presents with abdominal distention, vomiting, fever, and change in bowel habits.
Open
Statement
Treatment for enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations.
Open
Statement
Depending on the severity of enterocolitis, broad-spectrum antibiotics are sometimes added, and patients are usually started on metronidazole.
Open
Quotation
Hirschsprung's associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth.
Open
The Colorectal Quiz Episode 23: Hirschsprung Disease - The Soiling Patient...
Quotation
Can I scare you for a moment? Can we talk scientifically for one minute? I know this is crazy.
Open
Statement
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.
Open
Statement
Blood supply changes occur at the dentate line (splanchnic versus systemic), and there is also innervation in that area.
Open
Quotation
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?
Open
Statement
The nerves located at the dentate line region tell you gas, liquid, solid; how hard, how long, and how tight to squeeze.
Open
Statement
Preserving the dentate line region is key because injury to that region affects a patient's ability to be continent.
Open
Statement
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.
Open
Statement
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.
Open
Quotation
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.
Open
Quotation
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.
Open
Statement
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).
Open
Statement
Patients with no dentate line and patulous sphincters who are soiling develop severe skin irritation from sitting in pull-ups or diapers.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
Whether hypermotile patients can empty on their own versus needing mechanical emptying to maintain social continence depends on their sphincter function.
Open
Quotation
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.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
Nutrition in Hirschsprung patients is very important; some patients are very sensitive to certain foods, particularly lactose.
Open
Statement
Paying attention to diet (whether breastfed infants or older children) is important because lactose is particularly problematic in some Hirschsprung patients.
Open
Statement
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.
Open
Quotation
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.
Open
Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula
Statement
When neurologic anomalies are found in anorectal malformation patients, gynecological anomalies are more likely, especially on the same side.
Open
Quotation
when you do find neurologic anomalies. That leads to more likely gynecological anomalies as well, especially on the same side.
Open
Colorectal Quiz Episode 29: Female ARM-Post Op Management
Statement
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.
Open
Quotation
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.
Open
Quotation
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.
Open
Colorectal Quiz Episode 37: The Yancey-Soave story of the original surgical descriptions for Hirschsprung disease
Statement
Dr. Newman brought Dr. Yancey's story to the attention of the Hirschsprung interest group at APSA.
Open
Statement
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.
Open
Quotation
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.
Open
Colorectal Quiz Episode 38: Transitional Care in Colorectal Surgery
Statement
MRI with specific protocols and endorectal ultrasound can help determine whether the anoplasty is within the muscle complex.
Open
Statement
The transition model includes joint clinic visits and collaborative operating, which is key to successful handoff.
Open
Statement
Freestanding children's hospitals face greater challenges than integrated hospitals because they are completely separate entities both physically and financially.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Colorectal Quiz: Episode 46
Statement
In anorectal malformation patients with perforation, the sigmoid colon typically perforates with a linear, longitudinal tear along the taenia.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
Cold saline used for irrigations in small children can significantly change the child's body temperature, so warm saline should be used.
Open
Statement
Sawtoothing in the rectum on contrast enema represents hyperperistalsis and is very classic for Hirschsprung disease, particularly when associated with enterocolitis.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
When performing ileostomy for Hirschsprung diversion, frozen section should be done on the ileostomy to ensure it will function.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Colorectal Quiz: Episode 43
Statement
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.
Open
Statement
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).
Open
Statement
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.
Open
Quotation
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.
Open
Statement
If appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel.
Open
Statement
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.
Open
Statement
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.
Open
Statement
Using a 10 French tube (not 8), leaving it in for a month, and cathing twice a day can minimize stenosis rate.
Open
Statement
Leaving indwelling tubes in Malones increases the amount of prolapse, likely due to pressure on the appendiceal base pushing up mucosa.
Open
Statement
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.
Open
Statement
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.
Open
Colorectal Quiz: Episode 40
Statement
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.
Open
Quotation
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.
Open
Statement
If a neovagina bridge is functioning well without problems, there may be no reason to remove it later.
Open
Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies
Statement
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.
Open
Statement
In a cardiac patient with an external opening from ARM, the typical approach is to dilate as long as they're evacuating okay.
Open
Quotation
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
Open
Statement
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.
Open
Statement
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.
Open
Quotation
Dissecting in with a mosquito, making sure you're in, not touching any vessel before you insufflate, and also clear the line of air
Open
Statement
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.
Open
Quotation
I've seen teenagers and young adults with those beads that never went away. So, yeah, you've got to scrape that off
Open
Statement
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.
Open
Colorectal Quiz Episode 29: Female ARM
Statement
Dr. Frisher uses a midline catheter (not PICC line) with D10 until the repair is confirmed healed, typically five to seven days NPO.
Open
Statement
Approximately 20% of patients in the dilation study required a redo operation, either local or total, with most being local procedures.
Open
The Colorectal Quiz Episode 21: The History of Hirschsprung Disease
Statement
Dr. Martin was the first surgeon-in-chief and pediatric surgeon at Cincinnati Children's Hospital.
Open
Statement
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.
Open
Quotation
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.
Open
The Colorectal Quiz Episode 4
Quotation
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.
Open
Statement
Frozen section biopsy must include submucosa to avoid missing hypertrophic nerves in submucosal layer while finding ganglion cells in seromuscular layer
Open
Statement
Mesenteric dissection should stay close to bowel wall, not deep in mesentery, to reduce bleeding
Open
Statement
Must preserve arcade along left colon and sigmoid to get enough length to reach pelvis
Open
Quotation
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.
Open
Statement
Resection margin should be approximately five centimeters above biopsy site where bowel looks good
Open
Colorectal Quiz: Episode 2
Statement
In higher malformations such as bladder neck fistula in boys, the sphincter complex is sometimes more anterior than anticipated
Open
Statement
Alternative approach for borderline anatomy: let the child try their current anatomy first; if it works well, stay with it; if not, consider redo
Open
The Colorectal Quiz: Episode 1
Statement
Pre-sacral masses are rare in typical imperforate anus but occur in almost half of anal stenosis or rectal atresia cases, requiring MRI
Open
Quotation
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.
Open
Statement
Cross-table lateral x-ray should be obtained at approximately 24 hours of life to assess gas column height and guide surgical planning
Open
Quotation
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.
Open
Statement
Well-formed buttocks, good muscle, true sphincter mechanism area, and well-developed sacrum together indicate likely good prognosis
Open
Statement
With air column 8.8mm from skin, primary posterior sagittal anorectoplasty is a reasonable option based on imaging
Open
Quotation
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.
Open
Statement
Should never try to go in blind—must know what structure will be encountered before making posterior sagittal incision
Open
Quotation
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.
Open
Statement
Fistula can be very close to rectum, making proper plane dissection along urethra important
Open
Quotation
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.
Open
Quotation
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.
Open
Jason's statements about Congenital Diaphragmatic Hernia 21 statements
Open the Congenital Diaphragmatic Hernia collection →
Neonatal Gastric Volvulus with Dr. Jason Frischer
Quotation
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.
Open
Quotation
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.
Open
Statement
60% of gastric volvulus cases in the pediatric population happen in the first year of life, with about 21% in the first month.
Open
Quotation
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.
Open
Statement
In a 4-month-old child with gastric volvulus, acute presentation is more likely than chronic.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
Chronic gastric volvulus is more related to laxity of the gastric ligaments including gastrophrenic, gastrosplenic, gastrocolic, and gastrohepatic ligaments.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
Then, and flip the stomach up and over that way, so it's going sort of behind. The stomach and back over it.
Open
Statement
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.
Open
Quotation
When the pylorus is at, right next to the GE junction or near the GE junction, and above the body of the stomach.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Jason's statements about Congenital Lung Lesions (CPAM) 15 statements
Open the Congenital Lung Lesions (CPAM) collection →
Complications and Beyond
Statement
In asymptomatic newborns with prenatally diagnosed lung lesions, most US practitioners obtain chest X-ray initially in NICU
Open
Statement
CT angiography for congenital lung lesions is typically performed at 3-6 months in clinic rather than in NICU for asymptomatic patients
Open
Statement
CT angiography for congenital lung lesions is typically performed at 3-6 months in clinic rather than in NICU for asymptomatic patients
Open
Statement
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
Open
Statement
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
Open
Statement
Obtain proximal control or partially cut across vessel with energy device to detect failure before complete division
Open
Statement
Obtain proximal control or partially cut across vessel with energy device to detect failure before complete division
Open
Statement
When using staplers, visualize the stapler end, use appropriate staple size for tissue, and leave extra tissue around stapler edge for adequate coaptation
Open
Statement
When using staplers, visualize the stapler end, use appropriate staple size for tissue, and leave extra tissue around stapler edge for adequate coaptation
Open
Statement
Newborn with esophageal atresia, dextrocardia, and respiratory instability at birth suggests complex anatomy beyond typical EA/TEF
Open
Statement
Newborn with esophageal atresia, dextrocardia, and respiratory instability at birth suggests complex anatomy beyond typical EA/TEF
Open
Statement
Echo findings of mesocardia, hypoplastic pulmonary arteries, persistent left SVC, and dilated right ventricle indicate significant cardiac anomalies
Open
Statement
Echo findings of mesocardia, hypoplastic pulmonary arteries, persistent left SVC, and dilated right ventricle indicate significant cardiac anomalies
Open
Statement
Esophageal lung is rare congenital anomaly with approximately 30 reported cases where bronchus arises directly from esophagus rather than trachea
Open
Statement
Esophageal lung is rare congenital anomaly with approximately 30 reported cases where bronchus arises directly from esophagus rather than trachea
Open
Jason's statements about Congenital Pulmonary Airway Malformation 7 statements
Open the Congenital Pulmonary Airway Malformation collection →
Complications and Beyond
Statement
CT angiography for congenital lung lesions is typically performed at 3-6 months in clinic rather than in NICU for asymptomatic patients
Open
Statement
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
Open
Statement
Obtain proximal control or partially cut across vessel with energy device to detect failure before complete division
Open
Statement
When using staplers, visualize the stapler end, use appropriate staple size for tissue, and leave extra tissue around stapler edge for adequate coaptation
Open
Statement
Newborn with esophageal atresia, dextrocardia, and respiratory instability at birth suggests complex anatomy beyond typical EA/TEF
Open
Statement
Echo findings of mesocardia, hypoplastic pulmonary arteries, persistent left SVC, and dilated right ventricle indicate significant cardiac anomalies
Open
Statement
Esophageal lung is rare congenital anomaly with approximately 30 reported cases where bronchus arises directly from esophagus rather than trachea
Open
Jason's statements about Constipation 18 statements
Open the Constipation collection →
The Colorectal Quiz Episode 8: Motility Disorders Part 1
Statement
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
Open
Statement
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
Open
Quotation
I think back in the day, Mark, yeah, we, we didn't understand the sphincter and the major role it played.
Open
Statement
In the past, surgeons did not understand the major role the sphincter played in many patients
Open
Colorectal Quiz Episode 16: Bowel Management in Spinal Patients - Need for a Urologist Part 2
Quotation
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.
Open
Statement
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
Open
Statement
The colorectal team benefits from using the appendix portion closer to the cecum which has a stronger blood supply
Open
Statement
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
Open
Statement
Extending the Malone channel by 2-3 cm using suturing or stapling can be extremely helpful in preventing leakage
Open
Statement
Rectal irrigation using pressurized water systems made for patients with hand difficulties is an alternative to Malone and Mitrofanoff procedures
Open
Statement
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
Open
Statement
The primary determinant of orifice location is where the appendix reaches and its blood supply
Open
Statement
Laxity of the pelvic floor and anal canal is a huge issue in spinal patients, especially when doing retrograde enemas
Open
Jason's statements about Crohn's Disease 35 statements
Open the Crohn's Disease collection →
Colorectal Quiz Episode 19: Hirschsprung Disease - The Obstructed Patient Part 1
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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).
Open
Statement
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.
Open
Statement
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.
Open
Quotation
I think we all agree we get the contrast study before going to the operating room for a rectal exam
Open
Statement
A lateral view on contrast enema is important because it provides significant information about the presacral space and distal rectum anatomy.
Open
Colorectal Quiz Episode 26: Perianal Crohn's Disease
Statement
If terminal ileum cannot be intubated, gastroenterologists may treat presumptively and re-scope after a few months of treatment when inflammation has decreased.
Open
Statement
The highest risk factors for lymphoma with biologic therapy are male gender, teenage age, and combination therapy with methotrexate.
Open
Statement
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.
Open
Statement
In pediatric patients, unlike adult patients, the first presenting factor for Crohn's disease can often be perianal disease.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
Source control of infection must be achieved before starting immunosuppressive therapy including steroids and biologics.
Open
Statement
If an abscess is not adequately drained, reimaging should be performed before giving biologics or steroids.
Open
Statement
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).
Open
Statement
Inflammatory markers including fecal calprotectin, ESR, and CRP should be checked before removing a seton to ensure systemic disease is under control.
Open
Statement
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.
Open
Colorectal Quiz: Episode 43
Statement
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.
Open
Statement
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).
Open
Statement
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.
Open
Quotation
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.
Open
Statement
If appendix is short and stumpy, it is best for the Malone and the Mitrofanoff should be made from small bowel.
Open
Statement
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.
Open
Statement
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.
Open
Statement
Using a 10 French tube (not 8), leaving it in for a month, and cathing twice a day can minimize stenosis rate.
Open
Statement
Leaving indwelling tubes in Malones increases the amount of prolapse, likely due to pressure on the appendiceal base pushing up mucosa.
Open
Statement
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.
Open
Statement
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.
Open
Jason's statements about Enterocolitis 80 statements
Open the Enterocolitis collection →
Hirschsprung Disease - Imperforate Anus - Rectal Prolapse: Update Course 2015
Quotation
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
Post-Hirschsprung complications divide into two categories: obstructive symptoms (enterocolitis, failure to thrive, distention) and soiling issues (true incontinence vs pseudo-incontinence from constipation).
Open
Statement
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.
Open
Statement
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).
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
Rectal prolapse workup should distinguish full-thickness prolapse from partial-thickness (mucosal) prolapse based on physical examination appearance.
Open
Statement
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.
Open
Statement
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.
Open
Quotation
I can tell you when it recurs to re-operate on those patients is not going to matter at all.
Open
Statement
Sclerosing agent injection for rectal prolapse has high recurrence rates; patients who fail this approach and require subsequent rectopexy have difficult reoperative dissection.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Hirschsprung Disease: Update Course 2015
Statement
The safest approach to Hirschsprung surgery involves some form of biopsy (laparoscopic or full-thickness through umbilicus) prior to definitive pull-through.
Open
Quotation
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
Open
Statement
Leveling colostomy may be the safest approach when institutional pathology expertise in reading Hirschsprung biopsies is limited or unavailable.
Open
Statement
Leveling colostomy represents a three-stage procedure for Hirschsprung disease management.
Open
Statement
Prolonged transanal dissection (approaching 4 hours) should prompt consideration of converting to laparoscopic approach to avoid excessive sphincter stretching.
Open
Quotation
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.
Open
Statement
Laparoscopic mobilization with 3-millimeter ports can be completed in approximately 45 minutes for appropriate cases.
Open
Statement
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.
Open
Statement
Complications after Hirschsprung surgery are divided into two categories: obstructive symptoms (including enterocolitis, failure to thrive, abdominal distention) and soiling issues.
Open
Statement
Soiling after Hirschsprung surgery is further classified into true incontinence and pseudo-incontinence.
Open
Statement
Obstructive symptoms after Hirschsprung surgery require differentiation between anatomic problems and pathologic problems.
Open
Statement
True fecal incontinence after Hirschsprung surgery can result from injury to the sphincter or injury to the dentate line.
Open
Statement
Pseudo-incontinence after Hirschsprung surgery may be caused by underlying constipation.
Open
Statement
Workup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia evaluating dentate line position, stricture, stretched sphincter, and anatomic twists.
Open
Hirschsprung's Disease
Quotation
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.
Open
Statement
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.
Open
Statement
Approximately 10% of newborns with Hirschsprung's disease may lack the typical findings on a contrast enema.
Open
Statement
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.
Open
Statement
Full thickness biopsy technique should be considered for patients older than six months, or when a suction biopsy is inadequate.
Open
Statement
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.
Open
Quotation
The second part of a diagnostic workup for Hirschsprung's disease, and most important, is the rectal biopsy. It is the true definitive diagnosis.
Open
Quotation
The three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry.
Open
Statement
The classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel.
Open
Statement
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.
Open
Statement
In total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema.
Open
Statement
The rectoanal inhibitory reflex may be absent in other conditions as well, and some children have a false positive test.
Open
Statement
Any patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis.
Open
Statement
In Hirschsprung's disease, anorectal manometry shows a lack of the rectoanal inhibitory reflex (RAIR).
Open
Quotation
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.
Open
Statement
The three goals of surgical management are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity.
Open
Statement
A con of the Suave procedure is that the aganglionic cuff can become stiff enough to cause an obstruction or outlet obstruction.
Open
Statement
The Suave procedure theoretically causes less injury to pelvic structures, nerves, urethra and vagina.
Open
Statement
In the Suave procedure, the actual anastomosis is performed within a cuff of aganglionic rectum.
Open
Statement
In the Swenson procedure, it is very important to be cautious about injuring the urethra as it's quite close, especially in boys.
Open
Statement
The Suave procedure involves performing a mucosectomy from a transanal approach slightly above the dentate line and pulling through the normal bowel.
Open
Statement
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.
Open
Statement
Hirschsprung's-associated enterocolitis is likely an inflammatory condition secondary to bacterial overgrowth.
Open
Statement
Treatment of enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations.
Open
Statement
For enterocolitis, antibiotics including metronidazole or broad-spectrum antibiotics are added depending on the severity of presentation.
Open
Quotation
When we treat these patients with enterocolitis, it is important to provide fluid resuscitation, digital rectal exam, and colonic irrigations.
Open
Quotation
Hirschsprung's-associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth.
Open
Statement
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.
Open
Statement
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.
Open
Statement
For patients without anatomic problems after pull-through, treatment can include bowel management, Botox injection to relieve sphincter tone, or motility studies.
Open
Statement
For patients with anatomic problems after pull-through, you typically have to revise the pull through.
Open
Statement
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.
Open
Colorectal Quiz Episode 3: Hirschsprung Disease
Statement
In Hirschsprung disease, the aganglionic rectum appears narrow due to spasm and inability to relax, while the ganglionated proximal bowel is dilated, creating the recto-sigmoid ratio
Open
Statement
The crypts are located above the dentate line, so optimal biopsy location is at least 1-2 cm above the dentate line
Open
The Colorectal Quiz Episode 22: Hirschsprung Disease - the Soiling Patient Part 1
Statement
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.
Open
Statement
Sphincters should be assessed with the patient awake; examination under anesthesia makes it harder to assess sphincter function.
Open
Statement
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.
Open
Jason's statements about Esophageal Atresia 8 statements
Open the Esophageal Atresia collection →
Complications and Beyond
Statement
In asymptomatic newborns with prenatally diagnosed lung lesions, most US practitioners obtain chest X-ray initially in NICU
Open
Statement
CT angiography for congenital lung lesions is typically performed at 3-6 months in clinic rather than in NICU for asymptomatic patients
Open
Statement
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
Open
Statement
Obtain proximal control or partially cut across vessel with energy device to detect failure before complete division
Open
Statement
When using staplers, visualize the stapler end, use appropriate staple size for tissue, and leave extra tissue around stapler edge for adequate coaptation
Open
Statement
Newborn with esophageal atresia, dextrocardia, and respiratory instability at birth suggests complex anatomy beyond typical EA/TEF
Open
Statement
Echo findings of mesocardia, hypoplastic pulmonary arteries, persistent left SVC, and dilated right ventricle indicate significant cardiac anomalies
Open
Statement
Esophageal lung is rare congenital anomaly with approximately 30 reported cases where bronchus arises directly from esophagus rather than trachea
Open
Jason's statements about Etiologies (Gastroschisis/NEC/Atresia/Volvulus) 55 statements
Open the Etiologies (Gastroschisis/NEC/Atresia/Volvulus) collection →
Gastroschisis and sutureless abdominal wall closure
Statement
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.
Open
Quotation
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.
Open
Statement
Many patients who underwent sutureless repair were done in more recent cohorts and tended towards less interventions.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
The finding of increased antibiotics needed after sutured repair was expected due to tissue manipulation.
Open
Statement
The consortium is working on operationalizing protocolization of gastroschisis closure across member institutions for a more prospective study with long-term follow-up.
Open
Statement
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.
Open
Neonatal Gastric Volvulus with Dr. Jason Frischer
Quotation
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.
Open
Statement
60% of gastric volvulus cases in the pediatric population happen in the first year of life, with about 21% in the first month.
Open
Quotation
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.
Open
Statement
In a 4-month-old child with gastric volvulus, acute presentation is more likely than chronic.
Open
Quotation
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.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
Chronic gastric volvulus is more related to laxity of the gastric ligaments including gastrophrenic, gastrosplenic, gastrocolic, and gastrohepatic ligaments.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
Then, and flip the stomach up and over that way, so it's going sort of behind. The stomach and back over it.
Open
Statement
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.
Open
Quotation
When the pylorus is at, right next to the GE junction or near the GE junction, and above the body of the stomach.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
Statement
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.
Open
Quotation
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
Open
Quotation
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
Open
Statement
Awake reduction can be successful if performed slowly, with stomach emptying, colon decompression, oral sucrose, and gradual abdominal wall stretching.
Open
Quotation
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
Open
Statement
Cincinnati Children's feeding protocol is based on patient tolerance and data from resource-limited settings where TPN is unavailable and feeding is mandatory.
Open
Quotation
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
Open
Statement
The multi-institutional study showed inconclusive results due to significant variation in feeding protocols across institutions.
Open
Quotation
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
Open
Statement
The reduction in surgical site infections with protocol feeding was likely due to decreased care variability rather than the feeding protocol itself.
Open
Quotation
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
Open
Statement
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.
Open
Quotation
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
Open
Quotation
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
Open
Statement
After implementing a feeding protocol, Cincinnati Children's reduced gastroschisis length of stay by 10 days over two years.
Open
Statement
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).
Open
Statement
Cincinnati Children's gastroschisis protocol includes prenatal care coordination with obstetricians and neonatologists, with surgery continuing to follow patients throughout hospitalization.
Open
Statement
The most important aspects of gastroschisis feeding are defining institutional tolerance criteria, adhering to protocol, and continuously evaluating the infant's condition.
Open
Quotation
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
Open
Statement
For significant feeding intolerance, Cincinnati Children's protocol calls for stopping feeds for six hours, though this is not clearly evidence-based.
Open
Quotation
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
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Jason's statements about Fecal Incontinence 9 statements
Open the Fecal Incontinence collection →
Colorectal Quiz Episode 37: The Yancey-Soave story of the original surgical descriptions for Hirschsprung disease
Statement
Dr. Newman brought Dr. Yancey's story to the attention of the Hirschsprung interest group at APSA.
Open
Quotation
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.
Open
Statement
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.
Open
The Colorectal Quiz Episode 21: The History of Hirschsprung Disease
Statement
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.
Open
Statement
Dr. Martin was the first surgeon-in-chief and pediatric surgeon at Cincinnati Children's Hospital.
Open
Quotation
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.
Open
Jason's statements about Gastroschisis 34 statements
Open the Gastroschisis collection →
Gastroschisis and sutureless abdominal wall closure
Statement
Many patients who underwent sutureless repair were done in more recent cohorts and tended towards less interventions.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
The finding of increased antibiotics needed after sutured repair was expected due to tissue manipulation.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
The consortium is working on operationalizing protocolization of gastroschisis closure across member institutions for a more prospective study with long-term follow-up.
Open
Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
Statement
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.
Open
Quotation
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
Open
Quotation
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
Open
Statement
Awake reduction can be successful if performed slowly, with stomach emptying, colon decompression, oral sucrose, and gradual abdominal wall stretching.
Open
Quotation
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
Open
Statement
Cincinnati Children's feeding protocol is based on patient tolerance and data from resource-limited settings where TPN is unavailable and feeding is mandatory.
Open
Quotation
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
Open
Quotation
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
Open
Statement
The reduction in surgical site infections with protocol feeding was likely due to decreased care variability rather than the feeding protocol itself.
Open
Statement
The multi-institutional study showed inconclusive results due to significant variation in feeding protocols across institutions.
Open
Quotation
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
Open
Statement
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.
Open
Quotation
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
Open
Statement
After implementing a feeding protocol, Cincinnati Children's reduced gastroschisis length of stay by 10 days over two years.
Open
Statement
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).
Open
Quotation
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
Open
Statement
Cincinnati Children's gastroschisis protocol includes prenatal care coordination with obstetricians and neonatologists, with surgery continuing to follow patients throughout hospitalization.
Open
Statement
The most important aspects of gastroschisis feeding are defining institutional tolerance criteria, adhering to protocol, and continuously evaluating the infant's condition.
Open
Quotation
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
Open
Quotation
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
Open
Statement
For significant feeding intolerance, Cincinnati Children's protocol calls for stopping feeds for six hours, though this is not clearly evidence-based.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Jason's statements about Hirschsprung disease 236 statements
Open the Hirschsprung disease collection →
Hirschsprung Disease - Imperforate Anus - Rectal Prolapse: Update Course 2015
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
Post-Hirschsprung complications divide into two categories: obstructive symptoms (enterocolitis, failure to thrive, distention) and soiling issues (true incontinence vs pseudo-incontinence from constipation).
Open
Statement
Post-Hirschsprung complications divide into two categories: obstructive symptoms (enterocolitis, failure to thrive, distention) and soiling issues (true incontinence vs pseudo-incontinence from constipation).
Open
Statement
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.
Open
Statement
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.
Open
Statement
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).
Open
Statement
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.
Open
Statement
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.
Open
Statement
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).
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Quotation
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.
Open
Quotation
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.
Open
Statement
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.
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Statement
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.
Open
Statement
Rectal prolapse workup should distinguish full-thickness prolapse from partial-thickness (mucosal) prolapse based on physical examination appearance.
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Statement
Rectal prolapse workup should distinguish full-thickness prolapse from partial-thickness (mucosal) prolapse based on physical examination appearance.
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Statement
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.
Open
Statement
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.
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Statement
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.
Open
Statement
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.
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Quotation
I can tell you when it recurs to re-operate on those patients is not going to matter at all.
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Quotation
I can tell you when it recurs to re-operate on those patients is not going to matter at all.
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Statement
Sclerosing agent injection for rectal prolapse has high recurrence rates; patients who fail this approach and require subsequent rectopexy have difficult reoperative dissection.
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Statement
Sclerosing agent injection for rectal prolapse has high recurrence rates; patients who fail this approach and require subsequent rectopexy have difficult reoperative dissection.
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Statement
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).
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Statement
Resection and rectopexy for rectal prolapse may be preferable when constipation control is difficult, but has higher complication rate compared to rectopexy alone.
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Statement
Laparoscopic rectopexy for rectal prolapse can be performed as same-day surgery or with next-day discharge in current practice.
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Statement
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.
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Statement
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.
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Statement
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.
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Statement
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.
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Statement
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.
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Statement
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.
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Hirschsprung Disease: Update Course 2015
Statement
The safest approach to Hirschsprung surgery involves some form of biopsy (laparoscopic or full-thickness through umbilicus) prior to definitive pull-through.
Open
Quotation
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
Open
Statement
Leveling colostomy may be the safest approach when institutional pathology expertise in reading Hirschsprung biopsies is limited or unavailable.
Open
Statement
Leveling colostomy represents a three-stage procedure for Hirschsprung disease management.
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Quotation
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.
Open
Statement
Prolonged transanal dissection (approaching 4 hours) should prompt consideration of converting to laparoscopic approach to avoid excessive sphincter stretching.
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Statement
Laparoscopic mobilization with 3-millimeter ports can be completed in approximately 45 minutes for appropriate cases.
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Statement
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.
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Statement
Complications after Hirschsprung surgery are divided into two categories: obstructive symptoms (including enterocolitis, failure to thrive, abdominal distention) and soiling issues.
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Statement
Soiling after Hirschsprung surgery is further classified into true incontinence and pseudo-incontinence.
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Statement
Obstructive symptoms after Hirschsprung surgery require differentiation between anatomic problems and pathologic problems.
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Statement
True fecal incontinence after Hirschsprung surgery can result from injury to the sphincter or injury to the dentate line.
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Statement
Pseudo-incontinence after Hirschsprung surgery may be caused by underlying constipation.
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Statement
Workup for post-Hirschsprung complications includes water-soluble contrast enema and exam under anesthesia evaluating dentate line position, stricture, stretched sphincter, and anatomic twists.
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Hirschsprung's Disease
Statement
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.
Open
Statement
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.
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Quotation
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.
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Quotation
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.
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Statement
Approximately 10% of newborns with Hirschsprung's disease may lack the typical findings on a contrast enema.
Open
Statement
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.
Open
Statement
Full thickness biopsy technique should be considered for patients older than six months, or when a suction biopsy is inadequate.
Open
Quotation
The three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry.
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Statement
The classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel.
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Statement
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.
Open
Quotation
The second part of a diagnostic workup for Hirschsprung's disease, and most important, is the rectal biopsy. It is the true definitive diagnosis.
Open
Quotation
The three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry.
Open
Statement
Full thickness biopsy technique should be considered for patients older than six months, or when a suction biopsy is inadequate.
Open
Statement
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.
Open
Statement
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.
Open
Statement
The classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel.
Open
Statement
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.
Open
Statement
In total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema.
Open
Statement
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.
Open
Quotation
The second part of a diagnostic workup for Hirschsprung's disease, and most important, is the rectal biopsy. It is the true definitive diagnosis.
Open
Statement
In total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema.
Open
Statement
Approximately 10% of newborns with Hirschsprung's disease may lack the typical findings on a contrast enema.
Open
Statement
Any patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis.
Open
Statement
The rectoanal inhibitory reflex may be absent in other conditions as well, and some children have a false positive test.
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Statement
Any patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis.
Open
Statement
In Hirschsprung's disease, anorectal manometry shows a lack of the rectoanal inhibitory reflex (RAIR).
Open
Statement
In Hirschsprung's disease, anorectal manometry shows a lack of the rectoanal inhibitory reflex (RAIR).
Open
Statement
The rectoanal inhibitory reflex may be absent in other conditions as well, and some children have a false positive test.
Open
Quotation
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.
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Quotation
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.
Open
Statement
The three goals of surgical management are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity.
Open
Statement
The three goals of surgical management are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity.
Open
Statement
A con of the Suave procedure is that the aganglionic cuff can become stiff enough to cause an obstruction or outlet obstruction.
Open
Statement
The Suave procedure theoretically causes less injury to pelvic structures, nerves, urethra and vagina.
Open
Statement
In the Suave procedure, the actual anastomosis is performed within a cuff of aganglionic rectum.
Open
Statement
The Suave procedure involves performing a mucosectomy from a transanal approach slightly above the dentate line and pulling through the normal bowel.
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Statement
In the Swenson procedure, it is very important to be cautious about injuring the urethra as it's quite close, especially in boys.
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Statement
In the Swenson procedure, it is very important to be cautious about injuring the urethra as it's quite close, especially in boys.
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Statement
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.
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Statement
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.
Open
Statement
A con of the Suave procedure is that the aganglionic cuff can become stiff enough to cause an obstruction or outlet obstruction.
Open
Statement
The Suave procedure theoretically causes less injury to pelvic structures, nerves, urethra and vagina.
Open
Statement
In the Suave procedure, the actual anastomosis is performed within a cuff of aganglionic rectum.
Open
Statement
The Suave procedure involves performing a mucosectomy from a transanal approach slightly above the dentate line and pulling through the normal bowel.
Open
Statement
Hirschsprung's-associated enterocolitis is likely an inflammatory condition secondary to bacterial overgrowth.
Open
Statement
For enterocolitis, antibiotics including metronidazole or broad-spectrum antibiotics are added depending on the severity of presentation.
Open
Statement
Treatment of enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations.
Open
Statement
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.
Open
Statement
Hirschsprung's-associated enterocolitis is likely an inflammatory condition secondary to bacterial overgrowth.
Open
Quotation
Hirschsprung's-associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth.
Open
Quotation
When we treat these patients with enterocolitis, it is important to provide fluid resuscitation, digital rectal exam, and colonic irrigations.
Open
Quotation
When we treat these patients with enterocolitis, it is important to provide fluid resuscitation, digital rectal exam, and colonic irrigations.
Open
Quotation
Hirschsprung's-associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth.
Open
Statement
For enterocolitis, antibiotics including metronidazole or broad-spectrum antibiotics are added depending on the severity of presentation.
Open
Statement
Treatment of enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations.
Open
Statement
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.
Open
Statement
For patients with anatomic problems after pull-through, you typically have to revise the pull through.
Open
Statement
For patients with anatomic problems after pull-through, you typically have to revise the pull through.
Open
Statement
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.
Open
Statement
For patients without anatomic problems after pull-through, treatment can include bowel management, Botox injection to relieve sphincter tone, or motility studies.
Open
Statement
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.
Open
Statement
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.
Open
Statement
For patients without anatomic problems after pull-through, treatment can include bowel management, Botox injection to relieve sphincter tone, or motility studies.
Open
Statement
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.
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Colorectal Quiz Episode 3: Hirschsprung Disease
Statement
In Hirschsprung disease, the aganglionic rectum appears narrow due to spasm and inability to relax, while the ganglionated proximal bowel is dilated, creating the recto-sigmoid ratio
Open
Statement
The crypts are located above the dentate line, so optimal biopsy location is at least 1-2 cm above the dentate line
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The Colorectal Quiz Episode 3.5: Proximal Hirschsprung Disease
Quotation
Yeah. And I think you could make guesses about this. But like you said, it's hard on a newborn film to really discern small and large bowel. And you can get fooled.
Open
Statement
It is hard on a newborn film to really discern small and large bowel, and you can get fooled.
Open
Statement
To get a perforation, you need distension, and if you have a transition zone at the hepatic flexure, then all the pressure is in the right colon.
Open
Quotation
So they were quick to point out that we're lucky this patient didn't show up with a perforation. And usually they perforate in the cecum.
Open
Statement
Patients with proximal Hirschsprung disease are at risk of perforation, usually in the cecum.
Open
Statement
A baby that doesn't have a competent ileosecal valve might be saved from perforation because pressure can decompress into the small bowel.
Open
Statement
You are obligated at some point, maybe after resuscitation, to get a rectal biopsy in a patient with suspected Hirschsprung disease.
Open
Quotation
Two different operative approaches for the same disease because one is more proximal and more complicated and the other is more distal.
Open
Statement
Proximal Hirschsprung disease and distal Hirschsprung disease require two different operative approaches.
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The Colorectal Quiz Episode 4: Classic Hirschsprung disease - Surgical Technique
Quotation
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.
Open
Statement
With proper laparoscopic dissection, the transanal portion of a primary Hirschsprung pull-through should take well under one hour.
Open
Statement
With proper laparoscopic dissection, the transanal portion of a primary Hirschsprung pull-through should take well under one hour.
Open
Quotation
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.
Open
Statement
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.
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Statement
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.
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The Colorectal Quiz Episode 8: Motility Disorders Part 1
Statement
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
Open
Statement
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
Open
Statement
In the past, surgeons did not understand the major role the sphincter played in many patients
Open
Quotation
I think back in the day, Mark, yeah, we, we didn't understand the sphincter and the major role it played.
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The Colorectal Quiz Episode 10: Total Colonic Hirschsprung Disease Part 1
Statement
The age cutoff for switching from suction rectal biopsy to full-thickness biopsy is around 6 months
Open
Quotation
My cutoff is around 6 months when I switch from suction rectal biopsy to full thickness biopsy.
Open
Statement
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
Open
Quotation
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.
Open
Statement
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
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The Colorectal Quiz Episode 20: Hirschsprung Disease Obstruction Part 2
Statement
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
Open
Quotation
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.
Open
Statement
Initial treatment for obstructed Hirschsprung's patient must include rectal irrigation, done early
Open
Statement
Every institution should have a protocol for obstructed Hirschsprung's patients to ensure quick and efficient response
Open
Statement
Systematic workup for obstructed Hirschsprung's includes: resuscitation, imaging studies, and comprehensive rectal exam under anesthesia
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The Colorectal Quiz Episode 21: The History of Hirschsprung Disease
Statement
Doctor Martin developed the Martin procedure, an extended Duhamel procedure that leaves a longer aganglionic segment of rectum for long-segment Hirschsprung disease.
Open
Statement
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.
Open
Statement
Doctor Martin's ulcerative colitis technique predated the J-pouch, which later modified his approach.
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The Colorectal Quiz Episode 22: Hirschsprung Disease - the Soiling Patient Part 1
Statement
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.
Open
Statement
Sphincters should be assessed with the patient awake; examination under anesthesia makes it harder to assess sphincter function.
Open
Statement
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.
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The Colorectal Quiz Episode 23: Hirschsprung Disease - The Soiling Patient...
Quotation
Can I scare you for a moment? Can we talk scientifically for one minute? I know this is crazy.
Open
Statement
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.
Open
Statement
Blood supply changes occur at the dentate line (splanchnic versus systemic), and there is also innervation in that area.
Open
Quotation
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?
Open
Statement
The nerves located at the dentate line region tell you gas, liquid, solid; how hard, how long, and how tight to squeeze.
Open
Statement
Preserving the dentate line region is key because injury to that region affects a patient's ability to be continent.
Open
Statement
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.
Open
Statement
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.
Open
Quotation
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.
Open
Quotation
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.
Open
Statement
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).
Open
Statement
Patients with no dentate line and patulous sphincters who are soiling develop severe skin irritation from sitting in pull-ups or diapers.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Quotation
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.
Open
Statement
Whether hypermotile patients can empty on their own versus needing mechanical emptying to maintain social continence depends on their sphincter function.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
Nutrition in Hirschsprung patients is very important; some patients are very sensitive to certain foods, particularly lactose.
Open
Statement
Paying attention to diet (whether breastfed infants or older children) is important because lactose is particularly problematic in some Hirschsprung patients.
Open
Quotation
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.
Open
Statement
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.
Open
Colorectal Quiz Episode 37: The Yancey-Soave story of the original surgical descriptions for Hirschsprung disease
Statement
Dr. Newman brought Dr. Yancey's story to the attention of the Hirschsprung interest group at APSA.
Open
Statement
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.
Open
Quotation
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.
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Colorectal Quiz: Episode 46
Statement
In anorectal malformation patients with perforation, the sigmoid colon typically perforates with a linear, longitudinal tear along the taenia.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
Cold saline used for irrigations in small children can significantly change the child's body temperature, so warm saline should be used.
Open
Statement
Sawtoothing in the rectum on contrast enema represents hyperperistalsis and is very classic for Hirschsprung disease, particularly when associated with enterocolitis.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
When performing ileostomy for Hirschsprung diversion, frozen section should be done on the ileostomy to ensure it will function.
Open
Statement
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.
Open
Statement
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.
Open
Quotation
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.
Open
Colorectal Quiz: Episode 40
Statement
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.
Open
Quotation
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.
Open
Statement
If a neovagina bridge is functioning well without problems, there may be no reason to remove it later.
Open
The Colorectal Quiz Episode 21: The History of Hirschsprung Disease
Statement
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.
Open
Statement
Dr. Martin was the first surgeon-in-chief and pediatric surgeon at Cincinnati Children's Hospital.
Open
Quotation
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.
Open
The Colorectal Quiz Episode 4
Quotation
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.
Open
Statement
Frozen section biopsy must include submucosa to avoid missing hypertrophic nerves in submucosal layer while finding ganglion cells in seromuscular layer
Open
Statement
Mesenteric dissection should stay close to bowel wall, not deep in mesentery, to reduce bleeding
Open
Quotation
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.
Open
Statement
Must preserve arcade along left colon and sigmoid to get enough length to reach pelvis
Open
Statement
Resection margin should be approximately five centimeters above biopsy site where bowel looks good
Open
Jason's statements about Hirschsprung Disease: Diagnosis to Long-Term Management 16 statements
Open the Hirschsprung Disease: Diagnosis to Long-Term Management collection →
Colorectal Quiz: Episode 46 - Hirschsprung's Disease
Quotation
I think I agree, Mark. If you see free air, I don't think irrigation is the thing to do. You're going to stir up the pot, but, uh, an irrigation typically is going to be the lifesaver for these children, these types, these types of situations.
Open
Statement
Irrigation technique requires instilling small aliquots of saline (20-40 mL at a time) and then evacuating it rather than just infusing into the colon lumen.
Open
Quotation
A few key tips to irrigation for those listening to me, an irrigation is instilling a, a small aloquat of saline, usually warm saline. Somewhere between 20 and 40 mLs um at a time. And it's infusing, instilling it in and getting it removed, whether that be by withdrawing from, with a catheter, so that you evacuate that saline and not just infuse it into the lumen of the colon, I think is important.
Open
Statement
Experts recommend waiting minimum 4 weeks after treating enterocolitis before performing definitive pull-through surgery, as long as the patient is receiving good irrigations and growing and healthy otherwise.
Open
Quotation
I would wait minimum 4 weeks from getting healthy. Um, after treating enterocolitis, maybe even longer, uh, before doing this. And I think there's good literature out there from the PCPLC and Michael Rawlins on outcomes of Hirschprung's disease and delayed treatment, and delayed might be the wrong term, but just doing the definitive surgery, they looked at about 3 months out and had similar outcomes.
Open
Statement
Literature from the PCPLC and Michael Rawlins shows that delayed definitive surgery for Hirschsprung disease (around 3 months out) has similar outcomes to earlier surgery.
Open
Statement
When mapping the colon without frozen section available, biopsies should be taken from left colon, transverse colon, and hepatic flexure/distal ascending colon, as cecal pull-throughs do not succeed very well.
Open
Quotation
Do not biopsy the appendix. That's not helpful. Save the appendix for maybe future use.
Open
Statement
Modern telemedicine technology allows pathologists to evaluate H&E stained slides for ganglion cells via Zoom using a camera and microscope, enabling better surgical planning in resource-limited settings and potentially saving 80% of colons in rectosigmoid Hirschsprung disease.
Open
Statement
Ileostomy is preferred over colostomy for diversion in Hirschsprung disease because colonic diversion can shorten the mesentery through division and inflammation, making subsequent pull-through technically more difficult with inadequate reach.
Open
Quotation
I'm a fan of doing ileostomies in these cases where, where we need to divert. And we have time and we're in a, a place where we're able to keep the patients hydrated well.
Open
Quotation
I do a lot of pull-throughs of patients that have a diverting colostomy. And I find it sometimes hard to get it to reach. I think the mesentery is shortened a little bit, um, cause it's divided and then it gets inflamed.
Open
Statement
Botox injection at the anal sphincter at time of ileostomy closure is being studied prospectively but is not 100% effective, as some patients in the protocol still developed enterocolitis.
Open
Statement
Families should be sent home with irrigation equipment and taught irrigation technique before pull-through surgery, with parents practicing the technique, to avoid having catheters go through the anastomosis post-operatively when issues arise.
Open
Jason's statements about Hirschsprung Disease: Diagnosis to Long-Term Management 16 statements
Open the Hirschsprung Disease: Diagnosis to Long-Term Management collection →
Colorectal Quiz: Episode 46 - Hirschsprung's Disease
Quotation
I think I agree, Mark. If you see free air, I don't think irrigation is the thing to do. You're going to stir up the pot, but, uh, an irrigation typically is going to be the lifesaver for these children, these types, these types of situations.
Open
Statement
Irrigation technique requires instilling small aliquots of saline (20-40 mL at a time) and then evacuating it rather than just infusing into the colon lumen.
Open
Quotation
A few key tips to irrigation for those listening to me, an irrigation is instilling a, a small aloquat of saline, usually warm saline. Somewhere between 20 and 40 mLs um at a time. And it's infusing, instilling it in and getting it removed, whether that be by withdrawing from, with a catheter, so that you evacuate that saline and not just infuse it into the lumen of the colon, I think is important.
Open
Statement
Experts recommend waiting minimum 4 weeks after treating enterocolitis before performing definitive pull-through surgery, as long as the patient is receiving good irrigations and growing and healthy otherwise.
Open
Quotation
I would wait minimum 4 weeks from getting healthy. Um, after treating enterocolitis, maybe even longer, uh, before doing this. And I think there's good literature out there from the PCPLC and Michael Rawlins on outcomes of Hirschprung's disease and delayed treatment, and delayed might be the wrong term, but just doing the definitive surgery, they looked at about 3 months out and had similar outcomes.
Open
Statement
Literature from the PCPLC and Michael Rawlins shows that delayed definitive surgery for Hirschsprung disease (around 3 months out) has similar outcomes to earlier surgery.
Open
Statement
When mapping the colon without frozen section available, biopsies should be taken from left colon, transverse colon, and hepatic flexure/distal ascending colon, as cecal pull-throughs do not succeed very well.
Open
Quotation
Do not biopsy the appendix. That's not helpful. Save the appendix for maybe future use.
Open
Statement
Modern telemedicine technology allows pathologists to evaluate H&E stained slides for ganglion cells via Zoom using a camera and microscope, enabling better surgical planning in resource-limited settings and potentially saving 80% of colons in rectosigmoid Hirschsprung disease.
Open
Statement
Ileostomy is preferred over colostomy for diversion in Hirschsprung disease because colonic diversion can shorten the mesentery through division and inflammation, making subsequent pull-through technically more difficult with inadequate reach.
Open
Quotation
I'm a fan of doing ileostomies in these cases where, where we need to divert. And we have time and we're in a, a place where we're able to keep the patients hydrated well.
Open
Quotation
I do a lot of pull-throughs of patients that have a diverting colostomy. And I find it sometimes hard to get it to reach. I think the mesentery is shortened a little bit, um, cause it's divided and then it gets inflamed.
Open
Statement
Botox injection at the anal sphincter at time of ileostomy closure is being studied prospectively but is not 100% effective, as some patients in the protocol still developed enterocolitis.
Open
Statement
Families should be sent home with irrigation equipment and taught irrigation technique before pull-through surgery, with parents practicing the technique, to avoid having catheters go through the anastomosis post-operatively when issues arise.
Open
Jason's statements about Hirschsprung's-associated Enterocolitis 13 statements
Open the Hirschsprung's-associated Enterocolitis collection →
Colorectal Quiz Episode 19: Hirschsprung Disease - The Obstructed Patient Part 1
Statement
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.
Open
Quotation
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.
Open
Quotation
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.
Open
Statement
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).
Open
Statement
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.
Open
Statement
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.
Open
Quotation
I think we all agree we get the contrast study before going to the operating room for a rectal exam
Open
Statement
A lateral view on contrast enema is important because it provides significant information about the presacral space and distal rectum anatomy.
Open
The Colorectal Quiz Episode 20: Hirschsprung Disease Obstruction Part 2
Statement
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
Open
Quotation
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.
Open
Statement
Initial treatment for obstructed Hirschsprung's patient must include rectal irrigation, done early
Open
Statement
Every institution should have a protocol for obstructed Hirschsprung's patients to ensure quick and efficient response
Open
Statement
Systematic workup for obstructed Hirschsprung's includes: resuscitation, imaging studies, and comprehensive rectal exam under anesthesia
Open
Jason's statements about Inflammatory Bowel Disease 16 statements
Open the Inflammatory Bowel Disease collection →
Colorectal Quiz Episode 26: Perianal Crohn's Disease
Statement
If terminal ileum cannot be intubated, gastroenterologists may treat presumptively and re-scope after a few months of treatment when inflammation has decreased.
Open
Statement
The highest risk factors for lymphoma with biologic therapy are male gender, teenage age, and combination therapy with methotrexate.
Open
Statement
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.
Open
Statement
In pediatric patients, unlike adult patients, the first presenting factor for Crohn's disease can often be perianal disease.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
Source control of infection must be achieved before starting immunosuppressive therapy including steroids and biologics.
Open
Statement
If an abscess is not adequately drained, reimaging should be performed before giving biologics or steroids.
Open
Statement
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).
Open
Statement
Inflammatory markers including fecal calprotectin, ESR, and CRP should be checked before removing a seton to ensure systemic disease is under control.
Open
Statement
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.
Open
Jason's statements about Intestinal Rehab 66 statements
Open the Intestinal Rehab collection →
Gastroschisis and sutureless abdominal wall closure
Statement
Many patients who underwent sutureless repair were done in more recent cohorts and tended towards less interventions.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
The finding of increased antibiotics needed after sutured repair was expected due to tissue manipulation.
Open
Statement
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.
Open
Statement
The consortium is working on operationalizing protocolization of gastroschisis closure across member institutions for a more prospective study with long-term follow-up.
Open
Statement
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.
Open
The Colorectal Quiz Episode 8: Motility Disorders Part 1
Statement
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
Open
Statement
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
Open
Statement
In the past, surgeons did not understand the major role the sphincter played in many patients
Open
Quotation
I think back in the day, Mark, yeah, we, we didn't understand the sphincter and the major role it played.
Open
Colorectal Collaboration: Neurogastroenterology/Motility Disorders
Quotation
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.
Open
Statement
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.
Open
Quotation
I want to stress that we shouldn't resort to resection right away just because we have one abnormal finding.
Open
Statement
Resection should not be performed immediately based on one abnormal finding; multiple factors must be considered.
Open
Statement
The first step in evaluating a patient with suspected motility disorder is to ensure normal anatomy, which can be assessed with contrast studies.
Open
Neonatal Gastric Volvulus with Dr. Jason Frischer
Quotation
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.
Open
Quotation
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.
Open
Statement
60% of gastric volvulus cases in the pediatric population happen in the first year of life, with about 21% in the first month.
Open
Quotation
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.
Open
Statement
In a 4-month-old child with gastric volvulus, acute presentation is more likely than chronic.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
Chronic gastric volvulus is more related to laxity of the gastric ligaments including gastrophrenic, gastrosplenic, gastrocolic, and gastrohepatic ligaments.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
Then, and flip the stomach up and over that way, so it's going sort of behind. The stomach and back over it.
Open
Quotation
When the pylorus is at, right next to the GE junction or near the GE junction, and above the body of the stomach.
Open
Statement
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
Statement
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.
Open
Quotation
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
Open
Quotation
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
Open
Statement
Awake reduction can be successful if performed slowly, with stomach emptying, colon decompression, oral sucrose, and gradual abdominal wall stretching.
Open
Quotation
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
Open
Statement
Cincinnati Children's feeding protocol is based on patient tolerance and data from resource-limited settings where TPN is unavailable and feeding is mandatory.
Open
Quotation
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
Open
Statement
The multi-institutional study showed inconclusive results due to significant variation in feeding protocols across institutions.
Open
Quotation
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
Open
Statement
The reduction in surgical site infections with protocol feeding was likely due to decreased care variability rather than the feeding protocol itself.
Open
Quotation
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
Open
Quotation
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
Open
Statement
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.
Open
Quotation
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
Open
Statement
After implementing a feeding protocol, Cincinnati Children's reduced gastroschisis length of stay by 10 days over two years.
Open
Statement
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).
Open
Statement
Cincinnati Children's gastroschisis protocol includes prenatal care coordination with obstetricians and neonatologists, with surgery continuing to follow patients throughout hospitalization.
Open
Quotation
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
Open
Statement
The most important aspects of gastroschisis feeding are defining institutional tolerance criteria, adhering to protocol, and continuously evaluating the infant's condition.
Open
Quotation
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
Open
Statement
For significant feeding intolerance, Cincinnati Children's protocol calls for stopping feeds for six hours, though this is not clearly evidence-based.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Jason's statements about Malrotation 12 statements
Open the Malrotation collection →
The Colorectal Quiz Episode 3.5: Proximal Hirschsprung Disease
Quotation
Yeah. And I think you could make guesses about this. But like you said, it's hard on a newborn film to really discern small and large bowel. And you can get fooled.
Open
Statement
It is hard on a newborn film to really discern small and large bowel, and you can get fooled.
Open
Quotation
So they were quick to point out that we're lucky this patient didn't show up with a perforation. And usually they perforate in the cecum.
Open
Statement
Patients with proximal Hirschsprung disease are at risk of perforation, usually in the cecum.
Open
Statement
To get a perforation, you need distension, and if you have a transition zone at the hepatic flexure, then all the pressure is in the right colon.
Open
Statement
A baby that doesn't have a competent ileosecal valve might be saved from perforation because pressure can decompress into the small bowel.
Open
Statement
You are obligated at some point, maybe after resuscitation, to get a rectal biopsy in a patient with suspected Hirschsprung disease.
Open
Quotation
Two different operative approaches for the same disease because one is more proximal and more complicated and the other is more distal.
Open
Statement
Proximal Hirschsprung disease and distal Hirschsprung disease require two different operative approaches.
Open
Jason's statements about Motility / Pseudo-obstruction 11 statements
Open the Motility / Pseudo-obstruction collection →
The Colorectal Quiz Episode 8: Motility Disorders Part 1
Statement
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
Open
Statement
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
Open
Statement
In the past, surgeons did not understand the major role the sphincter played in many patients
Open
Quotation
I think back in the day, Mark, yeah, we, we didn't understand the sphincter and the major role it played.
Open
Colorectal Collaboration: Neurogastroenterology/Motility Disorders
Quotation
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.
Open
Statement
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.
Open
Statement
Resection should not be performed immediately based on one abnormal finding; multiple factors must be considered.
Open
Quotation
I want to stress that we shouldn't resort to resection right away just because we have one abnormal finding.
Open
Statement
The first step in evaluating a patient with suspected motility disorder is to ensure normal anatomy, which can be assessed with contrast studies.
Open
Jason's statements about Myelomeningocele 9 statements
Open the Myelomeningocele collection →
Colorectal Quiz Episode 15: Bowel Management in Spinal Patients - Need for a UrologistPart 1
Statement
Senna-induced perineal rash is thought to be a chemical burn rather than a true allergy, presenting with blistering.
Open
Statement
Senna rash is treated with silver sulfadiazine and resolves with time; some patients tolerate senna upon reintroduction.
Open
Statement
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.
Open
Quotation
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.
Open
Quotation
that care coordination, collaboration with the urologist might be the most beneficial thing we could do for our patients.
Open
Jason's statements about Omphalocele 4 statements
Open the Omphalocele collection →
Colorectal Quiz Episode 33: Cloaca Exstrophy
Statement
Two major surgical decision points in cloacal exstrophy are: (1) whether the omphalocele is large or small enough to close the abdominal wall, and (2) the staging of the exstrophy procedure—whether to just bring bladder plates together in a multi-stage approach or to close the bladder and bring the symphysis pubis together.
Open
Quotation
The overriding principle in this patient population is the overriding principle of bowel preservation, right? The small intestine can be shortened in some of these patients. Some of these patients have nutritional concerns, not immediately, but long term. In general, I think the theme should be preserve all bowel.
Open
Statement
The overriding principle in cloacal exstrophy management is bowel preservation, as small intestine can be shortened and some patients have long-term nutritional concerns.
Open
Statement
One reason for not performing early pull-through in cloacal exstrophy is concern about rash and managing a perineal stoma.
Open
Jason's statements about Perineal Fistula 18 statements
Open the Perineal Fistula collection →
Colorectal Quiz Episode 13: Newborn ARM Part 2
Statement
Perineal groove with mucosal lining will keratinize and look like normal perineal body over time
Open
Quotation
My conversation with the family often involves that this will keratinize and look like a normal peroneal body over time.
Open
Statement
Surgical intervention for perineal groove is indicated only if secreting mucus, causing irritation, or developing ulcers
Open
Statement
Vestibular fistula is very common in females and needs formal repair with hole transposed to center of sphincter
Open
Statement
Patients diagnosed with vestibular fistula at 6-12 months who have dilated rectosigmoid need diversion as first step, then repair
Open
Statement
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
Open
Statement
To evaluate for vestibular fistula, pull labia towards examiner with both hands to visualize vaginal opening and urethra
Open
Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula
Quotation
when you do find neurologic anomalies. That leads to more likely gynecological anomalies as well, especially on the same side.
Open
Statement
When neurologic anomalies are found in anorectal malformation patients, gynecological anomalies are more likely, especially on the same side.
Open
Colorectal Quiz Episode 29: Female ARM-Post Op Management
Statement
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.
Open
Quotation
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.
Open
Quotation
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.
Open
Colorectal Quiz Episode 29: Female ARM
Statement
Dr. Frisher uses a midline catheter (not PICC line) with D10 until the repair is confirmed healed, typically five to seven days NPO.
Open
Statement
Approximately 20% of patients in the dilation study required a redo operation, either local or total, with most being local procedures.
Open
Jason's statements about Rectal Prolapse 12 statements
Open the Rectal Prolapse collection →
Colorectal Quiz Episode 2: When to redo a PSARP
Statement
For anorectoplasty, if you don't get it perfect, you might not have the best outcomes, which separates it from other surgical procedures.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
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?
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Statement
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.
Open
Jason's statements about Spina Bifida 22 statements
Open the Spina Bifida collection →
Colorectal Quiz Episode 15: Bowel Management in Spinal Patients - Need for a UrologistPart 1
Statement
Senna-induced perineal rash is thought to be a chemical burn rather than a true allergy, presenting with blistering.
Open
Statement
Senna rash is treated with silver sulfadiazine and resolves with time; some patients tolerate senna upon reintroduction.
Open
Statement
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.
Open
Quotation
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.
Open
Quotation
that care coordination, collaboration with the urologist might be the most beneficial thing we could do for our patients.
Open
Colorectal Quiz Episode 16: Bowel Management in Spinal Patients - Need for a Urologist Part 2
Quotation
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.
Open
Statement
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
Open
Statement
The colorectal team benefits from using the appendix portion closer to the cecum which has a stronger blood supply
Open
Statement
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
Open
Statement
Extending the Malone channel by 2-3 cm using suturing or stapling can be extremely helpful in preventing leakage
Open
Statement
Rectal irrigation using pressurized water systems made for patients with hand difficulties is an alternative to Malone and Mitrofanoff procedures
Open
Statement
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
Open
Statement
The primary determinant of orifice location is where the appendix reaches and its blood supply
Open
Statement
Laxity of the pelvic floor and anal canal is a huge issue in spinal patients, especially when doing retrograde enemas
Open
Jason's statements about Total Colonic Aganglionosis 5 statements
Open the Total Colonic Aganglionosis collection →
The Colorectal Quiz Episode 10: Total Colonic Hirschsprung Disease Part 1
Quotation
My cutoff is around 6 months when I switch from suction rectal biopsy to full thickness biopsy.
Open
Statement
The age cutoff for switching from suction rectal biopsy to full-thickness biopsy is around 6 months
Open
Quotation
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.
Open
Statement
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
Open
Statement
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
Open
Jason's statements about Trisomy 21 85 statements
Open the Trisomy 21 collection →
Hirschsprung's Disease
Statement
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.
Open
Quotation
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.
Open
Statement
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.
Open
Quotation
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.
Open
Statement
In total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema.
Open
Statement
The classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel.
Open
Statement
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.
Open
Statement
Approximately 10% of newborns with Hirschsprung's disease may lack the typical findings on a contrast enema.
Open
Statement
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.
Open
Statement
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.
Open
Statement
Full thickness biopsy technique should be considered for patients older than six months, or when a suction biopsy is inadequate.
Open
Quotation
The three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry.
Open
Quotation
The second part of a diagnostic workup for Hirschsprung's disease, and most important, is the rectal biopsy. It is the true definitive diagnosis.
Open
Statement
The classic finding on contrast enema is a transition zone in the rectosigmoid, but that transition zone can be located anywhere within the bowel.
Open
Statement
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.
Open
Statement
In total colonic Hirschsprung's disease, a foreshortened or question mark colon can be seen on contrast enema.
Open
Statement
Approximately 10% of newborns with Hirschsprung's disease may lack the typical findings on a contrast enema.
Open
Statement
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.
Open
Statement
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.
Open
Statement
Full thickness biopsy technique should be considered for patients older than six months, or when a suction biopsy is inadequate.
Open
Quotation
The three studies that should be considered for evaluating for Hirschsprung's disease include contrast enema, rectal biopsy, and possibly anorectal manometry.
Open
Quotation
The second part of a diagnostic workup for Hirschsprung's disease, and most important, is the rectal biopsy. It is the true definitive diagnosis.
Open
Statement
In Hirschsprung's disease, anorectal manometry shows a lack of the rectoanal inhibitory reflex (RAIR).
Open
Statement
The rectoanal inhibitory reflex may be absent in other conditions as well, and some children have a false positive test.
Open
Statement
Any patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis.
Open
Statement
The rectoanal inhibitory reflex may be absent in other conditions as well, and some children have a false positive test.
Open
Statement
In Hirschsprung's disease, anorectal manometry shows a lack of the rectoanal inhibitory reflex (RAIR).
Open
Statement
Any patient with an absent RAIR must undergo a rectal biopsy for confirmation of the diagnosis.
Open
Statement
The three goals of surgical management are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity.
Open
Quotation
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.
Open
Quotation
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.
Open
Statement
The three goals of surgical management are: identify the extent of the aganglionic segment, resect that segment, and restore the bowel to its continuity.
Open
Statement
The Suave procedure theoretically causes less injury to pelvic structures, nerves, urethra and vagina.
Open
Statement
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.
Open
Statement
In the Swenson procedure, it is very important to be cautious about injuring the urethra as it's quite close, especially in boys.
Open
Statement
The Suave procedure involves performing a mucosectomy from a transanal approach slightly above the dentate line and pulling through the normal bowel.
Open
Statement
In the Suave procedure, the actual anastomosis is performed within a cuff of aganglionic rectum.
Open
Statement
The Suave procedure theoretically causes less injury to pelvic structures, nerves, urethra and vagina.
Open
Statement
A con of the Suave procedure is that the aganglionic cuff can become stiff enough to cause an obstruction or outlet obstruction.
Open
Statement
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.
Open
Statement
In the Swenson procedure, it is very important to be cautious about injuring the urethra as it's quite close, especially in boys.
Open
Statement
The Suave procedure involves performing a mucosectomy from a transanal approach slightly above the dentate line and pulling through the normal bowel.
Open
Statement
In the Suave procedure, the actual anastomosis is performed within a cuff of aganglionic rectum.
Open
Statement
A con of the Suave procedure is that the aganglionic cuff can become stiff enough to cause an obstruction or outlet obstruction.
Open
Statement
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.
Open
Statement
Treatment of enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations.
Open
Quotation
When we treat these patients with enterocolitis, it is important to provide fluid resuscitation, digital rectal exam, and colonic irrigations.
Open
Statement
For enterocolitis, antibiotics including metronidazole or broad-spectrum antibiotics are added depending on the severity of presentation.
Open
Quotation
Hirschsprung's-associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth.
Open
Statement
Hirschsprung's-associated enterocolitis is likely an inflammatory condition secondary to bacterial overgrowth.
Open
Quotation
When we treat these patients with enterocolitis, it is important to provide fluid resuscitation, digital rectal exam, and colonic irrigations.
Open
Quotation
Hirschsprung's-associated enterocolitis is poorly understood and likely is an inflammatory condition secondary to bacterial overgrowth.
Open
Statement
Hirschsprung's-associated enterocolitis is likely an inflammatory condition secondary to bacterial overgrowth.
Open
Statement
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.
Open
Statement
Treatment of enterocolitis includes fluid resuscitation, digital rectal exam, and colonic irrigations.
Open
Statement
For enterocolitis, antibiotics including metronidazole or broad-spectrum antibiotics are added depending on the severity of presentation.
Open
Statement
For patients with anatomic problems after pull-through, you typically have to revise the pull through.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
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.
Open
Statement
For patients without anatomic problems after pull-through, treatment can include bowel management, Botox injection to relieve sphincter tone, or motility studies.
Open
Statement
For patients without anatomic problems after pull-through, treatment can include bowel management, Botox injection to relieve sphincter tone, or motility studies.
Open
Statement
For patients with anatomic problems after pull-through, you typically have to revise the pull through.
Open
The Colorectal Quiz Episode 1: ARM - Low Bulbar Fistula
Statement
Cross-table lateral radiograph is obtained at approximately 24 hours of life to visualize the rectal gas column position
Open
Statement
Cross-table lateral is performed with the baby prone and a bump under the buttocks to position the buttock as the highest point where air will rise
Open
Statement
A marker should be placed at the expected anal location on cross-table lateral to enable distance measurements
Open
Statement
Well-formed buttocks and visible sphincter mechanism location on physical exam contribute to good prognosis
Open
Quotation
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.
Open
Statement
Low bulbar fistulas are located very close to the rectum, requiring careful plane dissection
Open
Hirschsprung Disease in Brief
Statement
Hirschsprung disease is a congenital anomaly of the GI tract that results in a functional bowel obstruction.
Open
Statement
Failure to pass meconium within the first 48 hours of life is typical of Hirschsprung's disease.
Open
Quotation
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.
Open
Statement
The RET gene is a predisposing genetic condition associated with Hirschsprung disease.
Open
Statement
Hirschsprung disease is associated with Wordenberg syndrome and congenital central hyperventilation (Andine's curse).
Open
Summaries Jason gave as host · 41 summaries
Recaps of other experts' statements, not Jason's own clinical position.
Summaries Jason gave as host · Abdominal Wall Defects 2 summaries
Open the Abdominal Wall Defects collection →
Gastroschisis and sutureless abdominal wall closure
Host summary
Jason Frischer summarizes what Dr. Jason Fraser said: Initial small studies showed that some sutureless patients had a high umbilical hernia repair rate, or at least a high umbilical hernia rate.
Open
Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
Host summary
Jason Frischer summarizing the discussion: Some institutions ignore bilious emesis or bilious NG residuals completely during gastroschisis feeding advancement.
Open
Summaries Jason gave as host · Anorectal Malformation 4 summaries
Open the Anorectal Malformation collection →
Colorectal Quiz Episode 2: When to redo a PSARP
Host summary
Jason Frischer summarizes what Dr. Marc Levitt said: 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.
Open
Colorectal Quiz Episode 29: Female ARM-Post Op Management
Host summary
Jason Frischer summarizing the discussion: 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).
Open
Colorectal Quiz: Episode 40
Host summary
Jason Frischer summarizing the discussion: 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.
Open
Host summary
Jason Frischer summarizing the discussion: 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.
Open
Summaries Jason gave as host · Cloaca 2 summaries
Colorectal Quiz: Episode 40
Host summary
Jason Frischer summarizing the discussion: 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.
Open
Host summary
Jason Frischer summarizing the discussion: 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.
Open
Summaries Jason gave as host · Colorectal / ARM & Hirschsprung 9 summaries
Open the Colorectal / ARM & Hirschsprung collection →
Hirschsprung Disease - Imperforate Anus - Rectal Prolapse: Update Course 2015
Host summary
Jason Frischer summarizing the discussion: 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).
Open
Host summary
Jason Frischer summarizing the discussion: Resection and rectopexy for rectal prolapse may be preferable when constipation control is difficult, but has higher complication rate compared to rectopexy alone.
Open
Host summary
Jason Frischer summarizing the discussion: Laparoscopic rectopexy for rectal prolapse can be performed as same-day surgery or with next-day discharge in current practice.
Open
Hirschsprung Disease: Update Course 2015
Host summary
Jason Frischer summarizing the discussion: Jack Langer published an algorithm for working up patients with problems after Hirschsprung disease.
Open
Colorectal Quiz Episode 16: Bowel Management in Spinal Patients - Need for a Urologist Part 2
Host summary
Jason Frischer summarizing the discussion: Fecal impaction can push on the bladder and change the angle of the ureter entering the bladder, causing reflux
Open
Host summary
Jason Frischer summarizing the discussion: The last steps of combined procedures should be maturing the Mitrofanoff, maturing the Malone, then closing the abdomen
Open
Colorectal Quiz Episode 29: Female ARM-Post Op Management
Host summary
Jason Frischer summarizing the discussion: 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).
Open
Colorectal Quiz: Episode 40
Host summary
Jason Frischer summarizing the discussion: 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.
Open
Host summary
Jason Frischer summarizing the discussion: 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.
Open
Summaries Jason gave as host · Congenital Lung Lesions (CPAM) 1 summary
Open the Congenital Lung Lesions (CPAM) collection →
Complications and Beyond
Host summary
Jason Frischer summarizing the discussion: In asymptomatic newborns with prenatally diagnosed lung lesions, most US practitioners obtain chest X-ray initially in NICU
Open
Summaries Jason gave as host · Congenital Pulmonary Airway Malformation 1 summary
Open the Congenital Pulmonary Airway Malformation collection →
Complications and Beyond
Host summary
Jason Frischer summarizing the discussion: In asymptomatic newborns with prenatally diagnosed lung lesions, most US practitioners obtain chest X-ray initially in NICU
Open
Summaries Jason gave as host · Constipation 2 summaries
Open the Constipation collection →
Colorectal Quiz Episode 16: Bowel Management in Spinal Patients - Need for a Urologist Part 2
Host summary
Jason Frischer summarizing the discussion: Fecal impaction can push on the bladder and change the angle of the ureter entering the bladder, causing reflux
Open
Host summary
Jason Frischer summarizing the discussion: The last steps of combined procedures should be maturing the Mitrofanoff, maturing the Malone, then closing the abdomen
Open
Summaries Jason gave as host · Enterocolitis 4 summaries
Open the Enterocolitis collection →
Hirschsprung Disease - Imperforate Anus - Rectal Prolapse: Update Course 2015
Host summary
Jason Frischer summarizing the discussion: 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).
Open
Host summary
Jason Frischer summarizing the discussion: Resection and rectopexy for rectal prolapse may be preferable when constipation control is difficult, but has higher complication rate compared to rectopexy alone.
Open
Host summary
Jason Frischer summarizing the discussion: Laparoscopic rectopexy for rectal prolapse can be performed as same-day surgery or with next-day discharge in current practice.
Open
Hirschsprung Disease: Update Course 2015
Host summary
Jason Frischer summarizing the discussion: Jack Langer published an algorithm for working up patients with problems after Hirschsprung disease.
Open
Summaries Jason gave as host · Etiologies (Gastroschisis/NEC/Atresia/Volvulus) 2 summaries
Open the Etiologies (Gastroschisis/NEC/Atresia/Volvulus) collection →
Gastroschisis and sutureless abdominal wall closure
Host summary
Jason Frischer summarizes what Dr. Jason Fraser said: Initial small studies showed that some sutureless patients had a high umbilical hernia repair rate, or at least a high umbilical hernia rate.
Open
Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
Host summary
Jason Frischer summarizing the discussion: Some institutions ignore bilious emesis or bilious NG residuals completely during gastroschisis feeding advancement.
Open
Summaries Jason gave as host · Gastroschisis 2 summaries
Open the Gastroschisis collection →
Gastroschisis and sutureless abdominal wall closure
Host summary
Jason Frischer summarizes what Dr. Jason Fraser said: Initial small studies showed that some sutureless patients had a high umbilical hernia repair rate, or at least a high umbilical hernia rate.
Open
Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
Host summary
Jason Frischer summarizing the discussion: Some institutions ignore bilious emesis or bilious NG residuals completely during gastroschisis feeding advancement.
Open
Summaries Jason gave as host · Hirschsprung disease 6 summaries
Open the Hirschsprung disease collection →
Hirschsprung Disease - Imperforate Anus - Rectal Prolapse: Update Course 2015
Host summary
Jason Frischer summarizing the discussion: 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).
Open
Host summary
Jason Frischer summarizing the discussion: Resection and rectopexy for rectal prolapse may be preferable when constipation control is difficult, but has higher complication rate compared to rectopexy alone.
Open
Host summary
Jason Frischer summarizing the discussion: Laparoscopic rectopexy for rectal prolapse can be performed as same-day surgery or with next-day discharge in current practice.
Open
Hirschsprung Disease: Update Course 2015
Host summary
Jason Frischer summarizing the discussion: Jack Langer published an algorithm for working up patients with problems after Hirschsprung disease.
Open
Colorectal Quiz: Episode 40
Host summary
Jason Frischer summarizing the discussion: 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.
Open
Host summary
Jason Frischer summarizing the discussion: 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.
Open
Summaries Jason gave as host · Intestinal Rehab 2 summaries
Open the Intestinal Rehab collection →
Gastroschisis and sutureless abdominal wall closure
Host summary
Jason Frischer summarizes what Dr. Jason Fraser said: Initial small studies showed that some sutureless patients had a high umbilical hernia repair rate, or at least a high umbilical hernia rate.
Open
Update Course 2022 - UPDATES IN GASTROSCHISIS FEEDING PROTOCOLS - Jason Fraser, Beth Rymeski, and Steven Lee
Host summary
Jason Frischer summarizing the discussion: Some institutions ignore bilious emesis or bilious NG residuals completely during gastroschisis feeding advancement.
Open
Summaries Jason gave as host · Perineal Fistula 1 summary
Open the Perineal Fistula collection →
Colorectal Quiz Episode 29: Female ARM-Post Op Management
Host summary
Jason Frischer summarizing the discussion: 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).
Open
Summaries Jason gave as host · Rectal Prolapse 1 summary
Open the Rectal Prolapse collection →
Colorectal Quiz Episode 2: When to redo a PSARP
Host summary
Jason Frischer summarizes what Dr. Marc Levitt said: 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.
Open
Summaries Jason gave as host · Spina Bifida 2 summaries
Open the Spina Bifida collection →
Colorectal Quiz Episode 16: Bowel Management in Spinal Patients - Need for a Urologist Part 2
Host summary
Jason Frischer summarizing the discussion: Fecal impaction can push on the bladder and change the angle of the ureter entering the bladder, causing reflux
Open
Host summary
Jason Frischer summarizing the discussion: The last steps of combined procedures should be maturing the Mitrofanoff, maturing the Malone, then closing the abdomen
Open