Jeff Ponsky

193 statements · 8 topics · summaries given as host listed separately

Pancreatitis · guest expert

Featured statements

Certainly if a patient comes in with deep jaundice or cholangitis, Remember that's jaundice, fever, right upper quadrant pain, sometimes sepsis, or the patient has what looks like gallstone pancreatitis. That's jaundice, abdominal pain, and elevated pancreatic enzymes. Those patients have to be looked at very carefully and are potential candidates to relieve common bile duct obstruction with emergency ERCP.
quote · Choledocholithiasis
I really like the right upper quadrant ultrasound better for the initial diagnosis of cholecystitis and biliary colic, because it shows you the anatomy of the gallbladder, it shows you the wall thickness of the gallbladder, it shows you whether there's pericholecystic fluid, and it shows you the stones in the gallbladder.
quote · Hepatobiliary & Colorectal Surgery
If you find in the right upper quadrant that they have a positive Murphy's sign, which is tenderness with a deep breath in the right upper quadrant that stops their breath, that's very elucidating and it may suggest cholecystitis.
quote · Hepatobiliary & Colorectal Surgery
From an ERCP standpoint, unless there's a persistent biliary obstruction or cholangitis, we're not jumping in to go do this case right away.
quote · ALL
Endoscopy for surgeons is a technique that they use to augment their surgical procedures.
quote · Achalasia
The geometry is critically important.
quote · Gastroesophageal Reflux Disease

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Jeff's statements about Achalasia 45 statements

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Endoscopy and Surgery

Quotation modern endoscopy really began, I believe modern endoscopy began with the Basil Hersowitz in the late 1950s when he, uh, integrated flexible fiber optic, uh, technology using, uh, uh, fiber optics and uh. And the fiber fiber optic uh uh cables uh to produce, uh, the endoscopic instruments which could go through the mouth or the rectum to produce uh images. Open
Statement Modern endoscopy began with Basil Hersowitz in the late 1950s when he integrated flexible fiber-optic technology using fiber-optic cables to produce endoscopic instruments which could go through the mouth or rectum to produce images. Open
Statement Surgeons and gastroenterologists were involved in endoscopy from the very beginning, with Hersowitz using the technology to examine the upper GI tract first, then the lower. Open
Statement Gastroenterologists such as Gene Oberholt and Jerry Way were involved in the beginning using the scope to develop diagnostic applications of endoscopy. Open
Quotation Surgeons were involved in a different way because surgeons saw the therapeutic applications of endoscopy. Open
Statement Surgeons saw the therapeutic applications of endoscopy and developed procedures including polypectomy using electrocautery (Hiromi Shia and Bill Wolf in New York). Open
Quotation wait a minute, as long as we're looking, let's take out a polyp. Let's put a metal wire around these polyps and apply electricity and take them out. Open
Quotation if we saw veins in the rectum, and we call them hemorrhoids and we banded them, why can't we do the same thing in the esophagus? Open
Statement Greg Stigman from Colorado applied the principle of banding hemorrhoids in the rectum to variceal banding in the esophagus. Open
Statement Michael Godard and Jeff Ponsky applied surgical principles of percutaneous techniques to place feeding tubes using the endoscope to guide the procedure. Open
Statement In Germany, Nipsa Hendra, a surgeon, developed the first stenting of the bile duct. Open
Statement Surgeons have been involved in the advances in endoscopy, particularly the therapeutic advances. Open
Quotation I can't imagine a bariatric or gastrointestinal surgeon today. Who doesn't want to look at their anastomosis and test their anastomosis after they've done it. Open
Statement Modern bariatric and gastrointestinal surgeons use endoscopy to look at their anastomosis and test their anastomosis after they've done it. Open
Statement Surgeons use endoscopy to stent leaks or perform therapeutic stenting of strictures. Open
Quotation Endoscopy for surgeons is a technique that they use to augment their surgical procedures. Open
Statement Endoscopy for surgeons today is a technique they use to augment their surgical procedures. Open
Statement Not all surgeons perform ERCP. Open
Statement Surgeons in bariatric surgery use endoscopy daily to assess the results of their surgery, look for leaks, stent leaks, put in drainage tubes, and improve the treatment of their complications. Open
Statement Endoscopic submucosal dissection can be performed even in the colon to remove T2 tumors and extensive spreading tumors without the need for surgery. Open
Statement Emory Gorgon at the Cleveland Clinic has a huge experience in endoscopic submucosal dissection. Open
Statement Pre-malignant and early malignant lesions in the esophagus are being removed endoscopically by both GI and surgery specialists. Open
Statement Division of the esophageal muscles to treat achalasia can now be performed endoscopically where surgery used to be required. Open
Quotation it's not to remove surgery to replace it, but to augment it, to choose the right procedure for the right patient. Open
Statement The purpose of endoscopic techniques is not to remove surgery but to augment it and choose the right procedure for the right patient. Open
Statement The only place surgeons and gastroenterologists fail is when they fail to work together. Open
Quotation The only place we fail is when we fail to work together. Open
Quotation The surgeon and the gastroenterologist must work together. Open
Statement The gastroenterology community is excellent at endoscopic ultrasound, which has led to tremendous therapeutic advances. Open
Statement The ultimate potential of endoscopic ultrasound won't be reached unless surgeons and gastroenterologists work together. Open
Statement At the Cleveland Clinic, surgeons and gastroenterologists work together, combining surgical techniques with endoscopic techniques. Open
Quotation surgeons and gastroenterologists working together augment the ability of endoscopy and extend the capacity of this specialty. Open
Quotation In 10 years from now, we won't even recognize what we are doing today. Open
Statement In 10 years, the field will have advanced so much that current practices won't be recognizable. Open
Quotation I think that transmural surgery, transmural working through it and sewing it up, we'll be able to do resections of pieces of bowel and take out tumors and then sew up the lumen. No problem. Open
Statement Future endoscopy will include transmural surgery, performing resections of pieces of bowel, removing tumors, and sewing up the lumen endoscopically. Open
Statement Future procedures will include gastrointestinal anastomosis performed endoscopically or using combined endoscopic and percutaneous techniques. Open
Statement Complications will be managed endoscopically in the future using ultrasound and endoscopy. Open
Statement New modalities will be integrated into endoscopy to deal with biliary disease, colonic disease, pancreatic disease, gastric disease, and inflammatory bowel disease. Open
Statement The integration of surgery and gastroenterology will improve the whole specialty. Open
Statement The robot refines surgical maneuvers and helps perform procedures better and more exactly. Open
Quotation The robot refines our maneuvers. It, it helps us to perform what we do better. And more exactly. Open
Statement Jeff Ponsky was initially a critic of the robot in laparoscopic surgery when it first began because it was expensive and he thought it unnecessary. Open
Quotation I was a a critic of the robot in the laparoscopic surgery when it first began. It was expensive, and I thought unnecessary. Now I would say we must integrate robotics into everything we do. Open
Statement Robotics must be integrated into everything surgeons do and will be used with flexible endoscopy just as it has been used with colorectal and intestinal surgery. Open
Jeff's statements about ALL 3 statements

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Update Course Rewind: Pediatric Biliary Stones - Preventing Gallstone Pancreatitis 2024

Quotation And I want to bring up one other scenario too for the audience, which is gallstone pancreatitis, which I think is a little bit different than our conventional show up with a stone in the duct. Open
Quotation From an ERCP standpoint, unless there's a persistent biliary obstruction or cholangitis, we're not jumping in to go do this case right away. Open
Statement From an ERCP standpoint, unless there's a persistent biliary obstruction or cholangitis, ERCP is not performed right away in gallstone pancreatitis. Open
Jeff's statements about Choledocholithiasis 27 statements

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Choledocholithiasis: Diagnosis and management

Statement Patients with gallstone pancreatitis (jaundice, abdominal pain, and elevated pancreatic enzymes) are potential candidates for emergency ERCP Open
Quotation Certainly if a patient comes in with deep jaundice or cholangitis, Remember that's jaundice, fever, right upper quadrant pain, sometimes sepsis, or the patient has what looks like gallstone pancreatitis. That's jaundice, abdominal pain, and elevated pancreatic enzymes. Those patients have to be looked at very carefully and are potential candidates to relieve common bile duct obstruction with emergency ERCP. Open
Statement Patients with deep jaundice or cholangitis (jaundice, fever, right upper quadrant pain, sometimes sepsis) are potential candidates for emergency ERCP to relieve common bile duct obstruction Open
Statement If a patient's pancreatitis improves the next day, there is no rush to do ERCP Open
Quotation The first thing to do in the management of a patient with suspected common bile duct stones is to get an intraoperative cholalangiogram. Open
Statement The first step in management of suspected common bile duct stones is to get an intraoperative cholangiogram Open
Statement Intraoperative cholangiogram should be done with fluoroscopy and not static X-rays Open
Statement The transcystic route is amenable to small stones, usually in the distal duct Open
Statement Glucagon can be used to relax the papilla of Vater to allow flushing or pushing tiny stones through Open
Statement It is not difficult to do a laparoscopic common bile duct exploration Open
Quotation It is not difficult to do a laparoscopic common bile duct exploration. Open
Statement For laparoscopic CBD exploration, a small incision of perhaps 1 centimeter is made in the anterior surface of the common bile duct Open
Statement Dissolvable suture such as Vicryl or chromic is used to secure the T-tube with one stitch distal and one proximal to the tube Open
Statement A drain should be placed in the foramen of Winslow after CBD exploration Open
Statement The back wall of the T-tube is cut off and sliced longitudinally before placement into the duct Open
Statement A 12 or 14 French T-tube is typically used for CBD closure after exploration Open
Quotation I think a surgeon has to choose what makes him most comfortable. And I think that when you look at the common duct, if the inflammation is great, if you're unfamiliar with laparoscopic suturing techniques and your exposure is not good, it's perfectly acceptable to open the patient. Open
Statement Conversion to open CBD exploration is acceptable when inflammation is great, the surgeon is unfamiliar with laparoscopic suturing techniques, or exposure is not good Open
Statement A Kocher maneuver cannot be done laparoscopically Open
Statement A Kocher maneuver is performed in open CBD exploration to take down the lateral peritoneum lateral to the duodenum, allowing traction on the common duct Open
Statement For stones impacted at the papilla, transduodenal sphincteroplasty can be performed by making a duodenotomy over the papilla and opening the papilla at the 11 o'clock position a few millimeters at a time Open
Statement Transduodenal sphincteroplasty is not very common anymore Open
Statement Many instruments for CBD exploration can be obtained from the urology cart because urologists use similar items for the ureter and ureteral stones Open
Statement The choledochoscope is an inexpensive tool which makes laparoscopic or open common bile duct exploration very easy Open
Statement Surgeons should be comfortable doing CBD stone exploration and management transcystically, laparoscopically, and open if needed Open
Statement Choledocholithiasis is a disease that belongs to the surgeons, and ERCP should be used as an adjunct Open
Quotation The common bile duct belongs to the surgeon and the surgeon should feel very comfortable in approaching it and taking care of the maladies which afflict it. Open
Jeff's statements about Foundations of Minimally Invasive & Endoscopic Surgery 45 statements

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Endoscopy and Surgery

Quotation modern endoscopy really began, I believe modern endoscopy began with the Basil Hersowitz in the late 1950s when he, uh, integrated flexible fiber optic, uh, technology using, uh, uh, fiber optics and uh. And the fiber fiber optic uh uh cables uh to produce, uh, the endoscopic instruments which could go through the mouth or the rectum to produce uh images. Open
Statement Modern endoscopy began with Basil Hersowitz in the late 1950s when he integrated flexible fiber-optic technology using fiber-optic cables to produce endoscopic instruments which could go through the mouth or rectum to produce images. Open
Statement Surgeons and gastroenterologists were involved in endoscopy from the very beginning, with Hersowitz using the technology to examine the upper GI tract first, then the lower. Open
Statement Gastroenterologists such as Gene Oberholt and Jerry Way were involved in the beginning using the scope to develop diagnostic applications of endoscopy. Open
Statement Surgeons saw the therapeutic applications of endoscopy and developed procedures including polypectomy using electrocautery (Hiromi Shia and Bill Wolf in New York). Open
Quotation Surgeons were involved in a different way because surgeons saw the therapeutic applications of endoscopy. Open
Quotation wait a minute, as long as we're looking, let's take out a polyp. Let's put a metal wire around these polyps and apply electricity and take them out. Open
Statement Greg Stigman from Colorado applied the principle of banding hemorrhoids in the rectum to variceal banding in the esophagus. Open
Quotation if we saw veins in the rectum, and we call them hemorrhoids and we banded them, why can't we do the same thing in the esophagus? Open
Statement Michael Godard and Jeff Ponsky applied surgical principles of percutaneous techniques to place feeding tubes using the endoscope to guide the procedure. Open
Statement In Germany, Nipsa Hendra, a surgeon, developed the first stenting of the bile duct. Open
Statement Surgeons have been involved in the advances in endoscopy, particularly the therapeutic advances. Open
Statement Modern bariatric and gastrointestinal surgeons use endoscopy to look at their anastomosis and test their anastomosis after they've done it. Open
Quotation I can't imagine a bariatric or gastrointestinal surgeon today. Who doesn't want to look at their anastomosis and test their anastomosis after they've done it. Open
Statement Surgeons use endoscopy to stent leaks or perform therapeutic stenting of strictures. Open
Quotation Endoscopy for surgeons is a technique that they use to augment their surgical procedures. Open
Statement Endoscopy for surgeons today is a technique they use to augment their surgical procedures. Open
Statement Not all surgeons perform ERCP. Open
Statement Surgeons in bariatric surgery use endoscopy daily to assess the results of their surgery, look for leaks, stent leaks, put in drainage tubes, and improve the treatment of their complications. Open
Statement Endoscopic submucosal dissection can be performed even in the colon to remove T2 tumors and extensive spreading tumors without the need for surgery. Open
Statement Emory Gorgon at the Cleveland Clinic has a huge experience in endoscopic submucosal dissection. Open
Statement Pre-malignant and early malignant lesions in the esophagus are being removed endoscopically by both GI and surgery specialists. Open
Statement Division of the esophageal muscles to treat achalasia can now be performed endoscopically where surgery used to be required. Open
Statement The purpose of endoscopic techniques is not to remove surgery but to augment it and choose the right procedure for the right patient. Open
Quotation it's not to remove surgery to replace it, but to augment it, to choose the right procedure for the right patient. Open
Quotation The only place we fail is when we fail to work together. Open
Statement The only place surgeons and gastroenterologists fail is when they fail to work together. Open
Quotation The surgeon and the gastroenterologist must work together. Open
Statement The gastroenterology community is excellent at endoscopic ultrasound, which has led to tremendous therapeutic advances. Open
Statement The ultimate potential of endoscopic ultrasound won't be reached unless surgeons and gastroenterologists work together. Open
Statement At the Cleveland Clinic, surgeons and gastroenterologists work together, combining surgical techniques with endoscopic techniques. Open
Quotation surgeons and gastroenterologists working together augment the ability of endoscopy and extend the capacity of this specialty. Open
Statement In 10 years, the field will have advanced so much that current practices won't be recognizable. Open
Quotation In 10 years from now, we won't even recognize what we are doing today. Open
Statement Future endoscopy will include transmural surgery, performing resections of pieces of bowel, removing tumors, and sewing up the lumen endoscopically. Open
Quotation I think that transmural surgery, transmural working through it and sewing it up, we'll be able to do resections of pieces of bowel and take out tumors and then sew up the lumen. No problem. Open
Statement Future procedures will include gastrointestinal anastomosis performed endoscopically or using combined endoscopic and percutaneous techniques. Open
Statement Complications will be managed endoscopically in the future using ultrasound and endoscopy. Open
Statement New modalities will be integrated into endoscopy to deal with biliary disease, colonic disease, pancreatic disease, gastric disease, and inflammatory bowel disease. Open
Statement The integration of surgery and gastroenterology will improve the whole specialty. Open
Quotation The robot refines our maneuvers. It, it helps us to perform what we do better. And more exactly. Open
Statement The robot refines surgical maneuvers and helps perform procedures better and more exactly. Open
Quotation I was a a critic of the robot in the laparoscopic surgery when it first began. It was expensive, and I thought unnecessary. Now I would say we must integrate robotics into everything we do. Open
Statement Jeff Ponsky was initially a critic of the robot in laparoscopic surgery when it first began because it was expensive and he thought it unnecessary. Open
Statement Robotics must be integrated into everything surgeons do and will be used with flexible endoscopy just as it has been used with colorectal and intestinal surgery. Open
Jeff's statements about Gastroesophageal Reflux Disease 10 statements

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Gastroesopheal Reflux Disease

Statement Barrett's esophagus may be subtle and asymptomatic, with risk of progression through low-grade and high-grade dysplasia to gastric cancer Open
Statement The geometry of the Nissen wrap is the most important part of the operation; incorrect geometry (grabbing posterior greater curve too low) can trap fundus above the wrap Open
Quotation The geometry of the Nissen wrap is the most important part of the operation. Open

Gastroesophageal Reflux Disease

Statement Before doing routine manometry for reflux workup, achalasia cases requiring Heller myotomy were rare; now with routine manometry, achalasia is found more frequently because patients with achalasia can have heartburn from food stasis and fermentation in the esophagus Open
Statement The geometry of the wrap is critically important; if it doesn't look right after putting it together, take it down and reestablish it Open
Statement A common mistake is grabbing the posterior greater curve too low on the left when creating the wrap, which results in being too high on the right and too low on the left, trapping a portion of the fundus above Open
Quotation The geometry is critically important. Open
Quotation For once, I might have to agree with you. You might do it better than I do. Open
Statement An alternative approach for pseudoachalasia is to take down the Nissen, do a long Heller myotomy, and convert to a Toupet (opening the wrap and pinning at 180 degrees on both sides) to provide some antireflux protection Open
Statement A trick for taking down the wrap is to get between the wrap and esophagus on the left side by wiggling an instrument between them Open
Jeff's statements about Hepatobiliary & Colorectal Surgery 50 statements

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Cholecystitis- Drs Jeffrey Ponsky and Rae Hanke

Statement Cholecystitis is an obstructive diverticulopathy, similar to appendicitis or diverticulitis of the colon, involving blind pouches with narrow outlets that can become obstructed. Open
Quotation cholecystitis is a type of disease which I like to call an obstructive diverticulopathy, much like appendicitis or diverticulitis of the colon. Open
Statement When the cystic duct becomes obstructed by a stone or mucus plug, gallbladder contents increase due to secretion while arterial inflow at 120 mmHg continues but venous outflow at 7-8 mmHg is overcome, trapping blood within the gallbladder wall. Open
Quotation The arterial blood continues to come in at 120 mm of mercury, but the Venus outflow, which is only about 7 or 8 mm of mercury, is soon overcome. Open
Statement Biliary colic occurs when the obstructing stone falls away early in the process, allowing the patient to become asymptomatic, and this can recur with multiple episodes of intense pain. Open
Statement Without relief of obstruction, the gallbladder may undergo ischemia, leading to pericholecystic fluid, empyema, and subhepatic abscess. Open
Quotation what we've learned from this is that when a patient comes in with acute cholecystitis, we have to act definitively and quickly. Open
Statement Acalculous cholecystitis occurs when the gallbladder becomes atonic in patients who haven't been eating for a long time or are critically ill, with continued fluid secretion and poor emptying despite absence of stones. Open
Quotation we've always made the joke that patients who were likely to get gallstones were fair, fat, 40 and fertile. Open
Statement Southwestern Indians and patients in South America have a high incidence of gallstones due to genetic predispositions. Open
Statement Patients with hemolytic diseases such as sickle cell anemia or spherocytosis can develop bile salt stones. Open
Statement Patients with rapid weight loss from diets or weight loss surgery develop gallstones with increased frequency. Open
Statement Biliary colic typically presents with right upper quadrant pain and nausea, often with vomiting, 20 minutes to 2 hours after eating due to cholecystokinin secretion from duodenal mucosa in response to fat. Open
Quotation it's important as a surgeon, we jump to cholecystitis because that's what we're most familiar with, it's certainly the most common thing we see, but we have to as a physician, stand back, take a deep breath and think of other potential causes which might not require surgery. Open
Statement Murphy's sign—tenderness with a deep breath in the right upper quadrant that stops the patient's breath—suggests cholecystitis but can be present in other conditions including pancreatitis. Open
Quotation If you find in the right upper quadrant that they have a positive Murphy's sign, which is tenderness with a deep breath in the right upper quadrant that stops their breath, that's very elucidating and it may suggest cholecystitis. Open
Statement Transaminases are elevated out of proportion in hepatocellular disease, while alkaline phosphatase and GGT are elevated out of proportion in biliary duct obstruction. Open
Statement Right upper quadrant ultrasound is superior to CT scan for initial diagnosis of cholecystitis and biliary colic because it shows gallbladder anatomy, wall thickness, pericholecystic fluid, stones in the gallbladder, and common bile duct diameter. Open
Quotation I really like the right upper quadrant ultrasound better for the initial diagnosis of cholecystitis and biliary colic, because it shows you the anatomy of the gallbladder, it shows you the wall thickness of the gallbladder, it shows you whether there's pericholecystic fluid, and it shows you the stones in the gallbladder. Open
Statement CT scan is better than ultrasound when pancreatitis is suspected or there is any question about the pancreas. Open
Quotation You're talking to someone who does ERCP for his career, and I would love to do every patient you find, but I think it's important that we outline the correct and most appropriate use of these advanced imaging techniques. Open
Statement ERCP should not be performed for minimal bilirubin elevation (less than 2) or acute pancreatitis that improves in the first day, as studies show two-thirds of these patients have a normal duct because they passed the stone. Open
Statement ERCP should be performed when bilirubin is 4 or higher and not improving, as other conditions like ampullary tumors and ductal problems could cause elevated bilirubin. Open
Quotation I don't take a patient with real or deep jaundice to the operating room for gallbladder operation without an advanced biliary imaging like an ERCP or an MRCP. Period. Open
Statement Patients should not be taken to the operating room for gallbladder operation with deep jaundice without advanced biliary imaging like ERCP or MRCP. Open
Statement Intraoperative cholangiogram should be performed if there is elevated bilirubin, abnormal liver functions, dilated duct on ultrasound, or recent pancreatitis—this is called selective cholangiography. Open
Statement HIDA scan evaluates gallbladder function rather than anatomy; if the gallbladder does not fill, this indicates cystic duct obstruction and acalculous cholecystitis. Open
Statement CCK cholecystography with IV cholecystokinin or fatty meal evaluates gallbladder motility; a normal gallbladder has an ejection fraction over 35%, while ejection fraction less than 35% indicates biliary dyskinesia. Open
Statement Current practice is to perform surgery during the index hospitalization after patient stabilization, rather than the old approach of bed rest, NPO, IV antibiotics, discharge, and delayed surgery in six weeks. Open
Statement Percutaneous transhepatic cholecystostomy to vent the gallbladder can be used in unstable patients (such as recent MI) with acute cholecystitis, allowing delayed surgery when the patient is lower risk. Open
Statement Antibiotic coverage for cholecystitis should target E. coli, Enterococcus, Klebsiella, and Enterobacter, with cephalosporins and fluoroquinolones being appropriate choices. Open
Statement The cystic duct can have aberrant entries including into the right hepatic duct, an accessory right hepatic duct, or can run parallel with the common duct in a common sheath all the way to the papilla of Vater. Open
Quotation The gallbladder is a organ that is waiting for you to make a mistake. You have to always assume, even if it's the easiest case you ever did, always assume that it's ready to get you because it is. Open
Statement Anatomical variations include double gallbladder, totally intrahepatic gallbladder, and cystic artery that can flip over the cystic duct. Open
Statement Calot's triangle is bordered by the cystic duct below and the cystic artery above. Open
Quotation here's where you don't rush. You want to make that cystic duct long. You want to keep rubbing it gently, bluntly to get length on it. Open
Quotation does everyone agree? We see the critical view of safety, we see the cystic duct, we see the cystic artery, we can see where the common duct is. Open
Statement The critical view of safety requires visualization of the cystic duct, cystic artery, and location of the common duct before dividing any structures. Open
Quotation Don't be in a rush to get out. Sometimes you will see a little spot of bile. That could be a duct of Luschka. Open
Statement The gallbladder bed should be inspected with the abdomen deflated after removing the gallbladder, as pneumoperitoneum pressure can mask bleeding. Open
Statement Conversion to open surgery is indicated for dense adhesions, unclear anatomy, unplanned bleeding, or lack of progress, and is a management decision rather than a failure. Open
Quotation Converting to open is a decision that you make in the management of a disease and it's not a failure. It's an option. Open
Statement Post-operative tachycardia, hypotension, or requirement for fluid pushes in the recovery room is not normal and may indicate acute bleeding from the cystic artery, requiring immediate return to the operating room. Open
Statement A patient presenting to the emergency department 2-3 days post-operatively with right upper quadrant pain should be assumed to have a complication, most often a bile leak. Open
Quotation if you get called by the emergency department because three days later or two days later that patient is there with right upper quadrant pain, you should assume there's a complication and most often it could be a bile leak. Open
Statement For suspected bile leak, CT scan showing fluid in the gallbladder fossa should be tapped by radiology to confirm bile, followed by pigtail catheter placement and immediate ERCP. Open
Quotation Right then my heart is beating fast because I'm worrying that I might have injured the common bile duct and praying that it's just a cystic duct leak or a duct of Luschka. Open
Statement A biliary stent lowers pressure in the normal direction to zero, allowing bile leak from cystic duct or duct of Luschka to heal within days, with stent removal at six weeks. Open
Statement Retained common bile duct stones can be removed with ERCP with a 95% success rate. Open
Statement A patient with cholecystitis should not leave the hospital until they have their operation performed. Open
Jeff's statements about Pancreatitis 6 statements

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Update Course Rewind: Pediatric Biliary Stones - Preventing Gallstone Pancreatitis 2024

Quotation And I want to bring up one other scenario too for the audience, which is gallstone pancreatitis, which I think is a little bit different than our conventional show up with a stone in the duct. Open
Quotation And I want to bring up one other scenario too for the audience, which is gallstone pancreatitis, which I think is a little bit different than our conventional show up with a stone in the duct. Open
Statement From an ERCP standpoint, unless there's a persistent biliary obstruction or cholangitis, ERCP is not performed right away in gallstone pancreatitis. Open
Statement From an ERCP standpoint, unless there's a persistent biliary obstruction or cholangitis, ERCP is not performed right away in gallstone pancreatitis. Open
Quotation From an ERCP standpoint, unless there's a persistent biliary obstruction or cholangitis, we're not jumping in to go do this case right away. Open
Quotation From an ERCP standpoint, unless there's a persistent biliary obstruction or cholangitis, we're not jumping in to go do this case right away. Open
Jeff's statements about Upper Gastrointestinal & Foregut Surgery 7 statements

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Gastroesophageal Reflux Disease

Statement Before doing routine manometry for reflux workup, achalasia cases requiring Heller myotomy were rare; now with routine manometry, achalasia is found more frequently because patients with achalasia can have heartburn from food stasis and fermentation in the esophagus Open
Statement The geometry of the wrap is critically important; if it doesn't look right after putting it together, take it down and reestablish it Open
Statement A common mistake is grabbing the posterior greater curve too low on the left when creating the wrap, which results in being too high on the right and too low on the left, trapping a portion of the fundus above Open
Quotation The geometry is critically important. Open
Quotation For once, I might have to agree with you. You might do it better than I do. Open
Statement An alternative approach for pseudoachalasia is to take down the Nissen, do a long Heller myotomy, and convert to a Toupet (opening the wrap and pinning at 180 degrees on both sides) to provide some antireflux protection Open
Statement A trick for taking down the wrap is to get between the wrap and esophagus on the left side by wiggling an instrument between them Open

Summaries Jeff gave as host · 8 summaries

Recaps of other experts' statements, not Jeff's own clinical position.

Summaries Jeff gave as host · Gastroesophageal Reflux Disease 5 summaries

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Gastroesopheal Reflux Disease

Host summary Jeff Ponsky summarizes what Dr. Michael Rosen said: The 'triangle of air' below the esophagus after hiatal closure, described by Ron Hinder, indicates appropriate hiatal tightness Open
Host summary Jeff Ponsky summarizes what Dr. Michael Rosen said: David Ratner described an approach of taking down the Nissen, doing a long Heller, and converting to Toupet to open the wrap at 180 degrees on both sides Open

Gastroesophageal Reflux Disease

Host summary Jeff Ponsky summarizes what Dr. Michael Rosen said: The Bravo capsule is placed 6 centimeters above the EG junction and can measure 48 hours of pH data Open
Host summary Jeff Ponsky summarizes what Dr. Michael Rosen said: Nissen fundoplication doesn't work well in morbidly obese patients Open
Host summary Jeff Ponsky summarizes what Dr. Michael Rosen said: There's some evidence that even taking both vagus nerves may not matter Open
Summaries Jeff gave as host · Upper Gastrointestinal & Foregut Surgery 3 summaries

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Gastroesophageal Reflux Disease

Host summary Jeff Ponsky summarizes what Dr. Michael Rosen said: The Bravo capsule is placed 6 centimeters above the EG junction and can measure 48 hours of pH data Open
Host summary Jeff Ponsky summarizes what Dr. Michael Rosen said: Nissen fundoplication doesn't work well in morbidly obese patients Open
Host summary Jeff Ponsky summarizes what Dr. Michael Rosen said: There's some evidence that even taking both vagus nerves may not matter Open