# Appendicitis — GCMD Library living collection

Everything in the library about appendicitis — built automatically from dossiers that name it.

Updated: n/a · 29 episodes · 406 cited statements

## Episodes
### Diagnosis & Workup
- [Quality Improvement Campaign Improved Utilization of Rapid Sequence MRI for Diagnosis of Pediatric Appendicitis](https://team.globalcastmd.com/watch/quality-improvement-campaign-improved-utilization-of-rapid-sequence-mri-for-diagnosis-of-pediatric-appendicitis-8051) — video · [machine version](https://team.globalcastmd.com/watch/quality-improvement-campaign-improved-utilization-of-rapid-sequence-mri-for-diagnosis-of-pediatric-appendicitis-8051.md)

### Acute Management
- [Evaluación y Tratamiento del Dolor en Urgencias](https://team.globalcastmd.com/watch/evaluacio-n-y-tratamiento-del-dolor-en-urgencias-5443) — video · 47:38 · [machine version](https://team.globalcastmd.com/watch/evaluacio-n-y-tratamiento-del-dolor-en-urgencias-5443.md)

### Surgical Management
- [Appendicitis Irrigation Technique with ZERO Abscesses!](https://team.globalcastmd.com/watch/appendicitis-irrigation-technique-with-zero-abscesses-316) — video · [machine version](https://team.globalcastmd.com/watch/appendicitis-irrigation-technique-with-zero-abscesses-316.md)
- [Peritoneal Access](https://team.globalcastmd.com/watch/peritoneal-access-2294) — video · [machine version](https://team.globalcastmd.com/watch/peritoneal-access-2294.md)
- [Perforated Appendicitis](https://team.globalcastmd.com/watch/perforated-appendicitis-2312) — video · 18:22 · [machine version](https://team.globalcastmd.com/watch/perforated-appendicitis-2312.md)
- [Update Course Rewind: Perforated Appendicitis 2019](https://team.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934) — podcast · 12:08 · [machine version](https://team.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934.md)
- [SILS Appendectomy by Dr. Nelson Rosen](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859) — video · 10:57 · [machine version](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859.md)
- [Dr. Krysta Sutyak - Best of the Best in Pediatric Surgery 2025](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038) — video · 7:55 · [machine version](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038.md)
- [Narrated Dipes appy](https://team.globalcastmd.com/watch/narrated-dipes-appy-11946) — video · 3:23 · [machine version](https://team.globalcastmd.com/watch/narrated-dipes-appy-11946.md)

### Evidence & Research
- [Standardization of Care for Pediatric Perforated Appendicitis](https://team.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389) — video · 2:20 · [machine version](https://team.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389.md)
- [Appendicitis Management & APPY Trial: Update Course 2016](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549) — video · 31:55 · [machine version](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549.md)
- [Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929) — podcast · 44:19 · [machine version](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929.md)
- [Non-Operative Management of Appendicitis: 2018 Pediatric Surgery Practice Gap #2](https://team.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462) — video · 1:21 · [machine version](https://team.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462.md)
- [Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308) — podcast · 44:19 · [machine version](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308.md)
- [Journal Club: Appendicitis in 2021](https://team.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416) — podcast · 15:06 · [machine version](https://team.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416.md)
- [Update Course 2021: DEI – CONCORDANCE AND POST OP COMPLICATION STUDIES](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414) — video · [machine version](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414.md)
- [Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819) — video · 27:50 · [machine version](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819.md)
- [Quick Literature Updates Episode 11](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954) — video · [machine version](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954.md)
- [Journal of Pediatric Surgery Article Review: November 2023](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559) — podcast · 12:26 · [machine version](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559.md)
- [2025 Pediatric Surgery Update Course - Updates in Pediatric Surgery feat. non-JPS Journals](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897) — video · 22:32 · [machine version](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897.md)
- [Quick Literature Updates Ep 24](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235) — video · 4:42 · [machine version](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235.md)

### In-Depth Reviews
- [Hirschsprung Disease Part I with Marc Levitt](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933) — podcast · 59:20 · [machine version](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933.md)
- [Appendicitis with Dr. Whit Holcomb](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939) — podcast · 58:22 · [machine version](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939.md)
- [Hirschsprung Disease Part I with Marc Levitt](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311) — podcast · 59:20 · [machine version](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311.md)
- [Evidence-based diagnosis and management of pediatric appendicitis with Dr. Whit Holcomb](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314) — podcast · 58:22 · [machine version](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314.md)
- [Update Course Rewind: Management of Appendicitis 2022](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674) — video · [machine version](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674.md)
- [Update Course 2023 - Update Course 2022 and Best of the Best Recap](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273) — video · 17:24 · [machine version](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273.md)

### Emerging & Future Directions
- [Top 10 AI Websites and Tools for Medical Research and Education](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594) — podcast · 23:58 · [machine version](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594.md)
- [Practical applications of generative AI in medical research and education](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595) — podcast · 23:58 · [machine version](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595.md)

## Chapters
- [0:04](https://team.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=4) Non-Operative Management of Appendicitis as 2018 Practice Gap #2 (Ep 7)
- [0:00](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=0) Introduction and Appendicitis Review (Ep 4)
- [5:10](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=310) Initial Evaluation and Diagnosis of Hirschsprung Disease (Ep 4)
- [12:36](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=756) Pathologic Confirmation and Surgical Timing (Ep 4)
- [17:50](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1070) Historical Evolution of Surgical Techniques (Ep 4)
- [27:53](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1673) Current Surgical Approach: Transanal Swenson (Ep 4)
- [32:15](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1935) Technical Details: Exposure and Dissection Plane (Ep 4)
- [37:13](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2233) Laparoscopic Approach and Biopsy Technique (Ep 4)
- [47:56](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2876) Postoperative Management (Ep 4)
- [56:08](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3368) Special Circumstance: Hepatic Flexure Transition Zone (Ep 4)
- [0:00](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=0) Introduction and Appendicitis Review (Ep 11)
- [5:10](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=310) Initial Evaluation and Diagnosis of Hirschsprung Disease (Ep 11)
- [12:36](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=756) Pathologic Confirmation and Surgical Timing (Ep 11)
- [17:50](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1070) Historical Evolution of Surgical Techniques (Ep 11)
- [27:53](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1673) Current Surgical Approach: Transanal Swenson (Ep 11)
- [32:15](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1935) Technical Details: Exposure and Dissection Plane (Ep 11)
- [37:13](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2233) Laparoscopic Approach and Biopsy Technique (Ep 11)
- [47:56](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2876) Postoperative Management (Ep 11)
- [56:08](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3368) Special Circumstance: Hepatic Flexure Transition Zone (Ep 11)
- [0:00](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=0) Introduction and series overview (Ep 10)
- [0:55](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=55) Corticosteroids after Kasai for biliary atresia (Dr. von Almen) (Ep 10)
- [10:54](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=654) Skin antiseptic agents and surgical site infections (Dr. Holcomb, part 1) (Ep 10)
- [20:18](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1218) Non-operative antibiotic treatment for non-perforated appendicitis (Dr. Holcomb, part 2) (Ep 10)
- [30:41](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1841) Predictors of enteral autonomy in pediatric intestinal failure (Dr. Lipskar, part 1) (Ep 10)
- [36:44](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2204) Anesthetic neurotoxicity in the developing brain (Dr. Lipskar, part 2) (Ep 10)
- [0:00](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=0) Introduction and series overview (Ep 5)
- [0:55](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=55) Corticosteroids after Kasai for biliary atresia (Dr. von Almen) (Ep 5)
- [10:54](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=654) Skin antiseptic agents and surgical site infections (Dr. Holcomb, part 1) (Ep 5)
- [20:18](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1218) Non-operative antibiotic treatment for non-perforated appendicitis (Dr. Holcomb, part 2) (Ep 5)
- [30:41](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1841) Predictors of enteral autonomy in pediatric intestinal failure (Dr. Lipskar, part 1) (Ep 5)
- [36:44](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2204) Anesthetic neurotoxicity in the developing brain (Dr. Lipskar, part 2) (Ep 5)
- [0:00](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=0) Introduction and Antibiotic Selection for Perforated Appendicitis (Ep 17)
- [6:37](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=397) Discussion of Appendicitis Antibiotic Trial Results (Ep 17)
- [9:08](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=548) Surgical Management of Necrotizing Enterocolitis (Ep 17)
- [14:56](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=896) Gastrostomy Tube Placement Technique Selection (Ep 17)
- [21:13](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1273) Bariatric Surgery in Adolescents and Thyroid Cancer Management (Ep 17)
- [25:49](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1549) Closing Remarks and APSA Announcement (Ep 17)
- [0:00](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=0) Introduction and Episode Overview (Ep 19)
- [0:46](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=46) Firearm vs Automobile Fatalities in Children (Ep 19)
- [2:11](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=131) Gabapentin for Pain Control After Appendectomy (Ep 19)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Non-operative management of perforated appendicitis has been known for a long time. (clinical) [Ep 7 · 0:19](https://team.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=19)
- Treating appendicitis with antibiotics had equal outcome measures compared to initial operative management. (clinical) [Ep 7 · 0:19](https://team.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=19)
- There was a 15% risk of recurrence of appendicitis at one-year follow-up with non-operative management. (clinical) [Ep 7 · 0:35](https://team.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=35)
- Non-operative management resulted in decreased hospital stays compared to operative management. (clinical) [Ep 7 · 0:35](https://team.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=35)
- Non-operative management resulted in decreased days of disability compared to operative management. (clinical) [Ep 7 · 0:35](https://team.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=35)
- Non-operative management of appendicitis is an option with risks and benefits that need to be taken into account. (guideline) [Ep 7 · 0:52](https://team.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=52)
- APSA was not making a flat out recommendation to start doing non-operative appendicitis. — Gibbons (opinion) [Ep 7 · 1:08](https://team.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=68)
- The data on non-operative appendicitis management is becoming more clear. — Gibbons (opinion) [Ep 7 · 1:14](https://team.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=74)
- The choice between operative and non-operative appendicitis management remains dealer's choice. — Gibbons (opinion) [Ep 7 · 1:06](https://team.globalcastmd.com/watch/non-operative-management-of-appendicitis-2018-pediatric-surgery-practice-gap-2-1462?t=66)
- The best treatment for Hirschsprung disease is irrigations using a large bore tube (20 French Foley) with warm saline, instilling 10-20 cc aliquots at a time and allowing fluid mixed with stool to drain back. — Marc Levitt (clinical) [Ep 4 · 8:43](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=523)
- It is very rare that Hirschsprung disease is a surgical emergency, but if you don't irrigate and overcome the distal obstruction, it will become an emergency. — Marc Levitt (clinical) [Ep 4 · 8:55](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=535)
- For rectal biopsy in suspected Hirschsprung disease, you must be at least 1 centimeter in from the dentate line. If you biopsy too close to the dentate line, everyone has an aganglionic segment there and you could get the wrong answer. — Marc Levitt (clinical) [Ep 4 · 12:38](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=758)
- The pathologist must report both the absence of ganglion cells AND the presence of hypertrophic nerves. The absence of ganglion cells alone is not Hirschsprung disease - that could be a biopsy taken too low. — Marc Levitt (clinical) [Ep 4 · 13:23](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=803)
- Hirschsprung disease has an immune component and the lining of the bowel (mucosa) is much more susceptible to bacterial translocation. Stasis in a Hirschsprung patient leads to bacterial translocation and a very sick baby from bacteremia. — Marc Levitt (clinical) [Ep 4 · 14:59](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=899)
- If irrigations are not working and the baby is ill, you need to divert. The recommendation is to divert in the ileum rather than doing a leveling colostomy, because frozen section can be inaccurate, particularly as you move higher in the colon. — Marc Levitt (clinical) [Ep 4 · 15:42](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=942)
- The Swenson operation involved full-thickness transabdominal dissection down below the peritoneal reflection. The operation was often done incorrectly with perirectal dissection done too wide, leading to fecal incontinence, urinary incontinence, sexual problems, and impotence. — Marc Levitt (clinical) [Ep 4 · 18:14](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1094)
- The Suave operation used a mucosal dissection to keep the outer rectal wall intact and avoid injury. The original Suave would leave the colon coming through the anus for a week before doing the coloanal anastomosis; Dr. Scott Boley modified it to do everything in one stage. — Marc Levitt (clinical) [Ep 4 · 19:28](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1168)
- The Duhamel operation leaves the original rectum in place, removes the aganglionic portion from the peritoneal reflection, and pulls ganglionic bowel in a retrorectal position, connecting the two lumens with a stapler. — Marc Levitt (clinical) [Ep 4 · 20:18](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1218)
- Of the four classic procedures (Swenson, Suave, Duhamel, Rabine), only the Swenson actually leaves behind virtually no Hirschsprung tissue. The others leave behind outer rectal wall or original rectum. Many patients did well despite this because ganglionic bowel, if it's good, can overcome a lot. — Marc Levitt (clinical) [Ep 4 · 21:18](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1278)
- Dr. Henrys in the Philippines pioneered primary pull-through operations (without initial colostomy) out of necessity because patients would never return to clinic due to social stigma against colostomies. — Marc Levitt (clinical) [Ep 4 · 22:19](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1339)
- Keith Jorgeson applied laparoscopic skills to Hirschsprung disease, doing the colonic work laparoscopically with a Suave dissection from above. Luis de la Torre and Jack Langer developed the transanal approach, starting the dissection from below. — Marc Levitt (clinical) [Ep 4 · 23:21](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1401)
- The current preferred approach is a transanal Swenson (full-thickness dissection). It is the purest operation, leaving behind no Hirschsprung except the very bottom just above the dentate line. If you find the right plane, it's elegant and bloodless. — Marc Levitt (opinion) [Ep 4 · 25:34](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1534)
- Dr. Orvar Swenson, who recently died at age 105, maintained that the Swenson operation was good all along and people just weren't doing it right, which gave it a bad reputation. — Marc Levitt (clinical) [Ep 4 · 26:23](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1583)
- Even Suave enthusiasts are making shorter and shorter cuffs over time. Jorgeson's original laparoscopic Suave recommended a 5 cm cuff; nowadays Langer and de la Torre do 1-1.5 cm cuffs, essentially approaching a Swenson. — Marc Levitt (clinical) [Ep 4 · 27:06](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1626)
- Laparoscopy is appropriate for all cases to find the transition zone level. A transanal-only approach is only appropriate when you have a very reachable, obvious transition zone at mid-sigmoid that you can comfortably reach transanally. — Marc Levitt (opinion) [Ep 4 · 28:50](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1730)
- There is significant morbidity from an overly aggressive transanal-only approach trying to reach the transition zone without going into the abdomen. If you're too aggressive transanally trying to visualize the dissection, you would have been better off with laparoscopic dissection. — Marc Levitt (clinical) [Ep 4 · 29:18](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1758)
- Total colonic Hirschsprung patients present differently: the diagnosis isn't made right away, the contrast study is not typical, and irrigations don't go well. These patients need laparoscopy first to find the biopsy location. — Marc Levitt (clinical) [Ep 4 · 31:18](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=1878)
- The biggest technical problems are: (1) surgeons don't give themselves good exposure and start dissection too low, injuring or resecting the dentate line, or (2) they give very aggressive exposure and overstretch the sphincters. — Marc Levitt (clinical) [Ep 4 · 34:09](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2049)
- Proper technique requires marking 1 cm proximal to the dentate line with a purple mark and placing 5-0 silk stitches circumferentially at that level. This preserves the anal canal, dentate line, plus an additional 1 cm of columnar epithelium before starting dissection. — Marc Levitt (clinical) [Ep 4 · 35:30](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2130)
- By definition, you're leaving behind 1 cm of columnar epithelium that is Hirschsprung disease, plus the internal sphincter which has a problem with relaxation. However, good ganglionic bowel is able to overcome that, and the baby eventually learns to relax the sphincter. — Marc Levitt (clinical) [Ep 4 · 36:39](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2199)
- The rectum doesn't really have a mesentery; the rectum's blood supply is intramural. As you get higher and reach the peritoneal reflection, that's when you start to see sigmoidal vessels where rectum transitions to sigmoid. — Marc Levitt (clinical) [Ep 4 · 38:19](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2299)
- The anterior rectum frees up much quicker than the posterior rectum. Break into the peritoneal reflection anteriorly first. In transanal-only cases, you can pull the sigmoid out anteriorly, do a full-thickness biopsy, and send it while continuing the posterior dissection. — Marc Levitt (clinical) [Ep 4 · 38:45](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2325)
- For laparoscopic biopsies through the umbilicus, a seromuscular biopsy (without violating mucosa) may show ganglion cells in the seromuscular layer but miss hypertrophic nerves in the submucosa. If using this technique, send a full-thickness biopsy later to confirm the level is appropriate. — Marc Levitt (clinical) [Ep 4 · 40:56](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2456)
- Pathologists must report not only ganglion cells but also the quality of nerves with actual micron measurements. Nerves should be 40 microns or less. Anything bigger than 40 microns is transition zone bowel. — Marc Levitt (clinical) [Ep 4 · 44:03](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2643)
- The concept of 'go 5 cm above the transition zone' is inaccurate. Transition zone is a spectrum - some are 10 cm, some are 3 cm. You need confirmatory biopsy with ganglion cell information and nerve quality measured in microns. — Marc Levitt (clinical) [Ep 4 · 44:20](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2660)
- It's preferable to take the IMA, preserve the arcade, and have the left colon and sigmoid nice and straight down into the perineum. This makes for an easy-to-irrigate baby. Many patients have not had enough of a pull-through with the entire sigmoid loop still there, requiring redo to remove more. — Marc Levitt (clinical) [Ep 4 · 45:57](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2757)
- For anything proximal to the splenic flexure, do colonic biopsies and an ileostomy and wait, because frozen section has been notoriously fraught with errors in those cases. There is no urgency. Another option is to take biopsies, quit without diverting, and return 3-4 days later for pull-through with permanent section results. — Marc Levitt (clinical) [Ep 4 · 47:02](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=2822)
- Postoperatively, wait until the belly is absolutely soft and flat with bowel function before feeding. Get an X-ray because abdominal distention is sometimes subclinical. This usually takes 3-4 days. Feeding too early risks the baby going home distended and returning with enterocolitis. — Marc Levitt (clinical) [Ep 4 · 53:23](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3203)
- Routine postoperative management: at one month, check the anus with Hagar dilators (not finger). Most babies need calibration rather than true dilation. The stimulation of passing the Hagar has value to help the baby more successfully empty. — Marc Levitt (clinical) [Ep 4 · 54:39](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3279)
- Flagyl is only used to treat enterocolitis, not routinely postoperatively. Give a pre-op dose of second-generation cephalosporin and maybe 2 post-op doses. — Marc Levitt (clinical) [Ep 4 · 55:52](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3352)
- Routine irrigations are only done postoperatively if the baby develops significant distention, which is rare. However, for total colonic patients after ileoanal pull-through, send all patients home on irrigations for 3 months. — Marc Levitt (clinical) [Ep 4 · 56:31](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3391)
- For hepatic flexure transition zone (rare), open the patient rather than laparoscopy. Take down the entire right colon, recognize the ileocolic vessel and how it feeds the vessel paralleling the right colon. Often need to take the right colic artery. De-rotate the colon so cecum is at the hepatic liver bed, then do pull-through down the right side of abdomen. — Marc Levitt (clinical) [Ep 4 · 57:05](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3425)
- If bringing de-rotated colon down the left side of abdomen, must mobilize the ligament of Treitz so the mesenteric vessel is not draped across the third portion of duodenum, which can cause duodenal obstruction. — Marc Levitt (clinical) [Ep 4 · 58:02](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=3482)
- The best treatment for Hirschsprung disease is irrigations using a large bore tube (20 French Foley) with warm saline, instilling 10-20 cc aliquots at a time and allowing fluid mixed with stool to drain back. — Marc Levitt (clinical) [Ep 11 · 8:43](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=523)
- It is very rare that Hirschsprung disease is a surgical emergency, but if you don't irrigate and overcome the distal obstruction, it will become an emergency. — Marc Levitt (clinical) [Ep 11 · 8:55](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=535)
- For rectal biopsy in suspected Hirschsprung disease, you must be at least 1 centimeter in from the dentate line. If you biopsy too close to the dentate line, everyone has an aganglionic segment there and you could get the wrong answer. — Marc Levitt (clinical) [Ep 11 · 12:38](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=758)
- The pathologist must report both the absence of ganglion cells AND the presence of hypertrophic nerves. The absence of ganglion cells alone is not Hirschsprung disease - that could be a biopsy taken too low. — Marc Levitt (clinical) [Ep 11 · 13:23](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=803)
- Hirschsprung disease has an immune component and the lining of the bowel (mucosa) is much more susceptible to bacterial translocation. Stasis in a Hirschsprung patient leads to bacterial translocation and a very sick baby from bacteremia. — Marc Levitt (clinical) [Ep 11 · 14:59](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=899)
- If irrigations are not working and the baby is ill, you need to divert. The recommendation is to divert in the ileum rather than doing a leveling colostomy, because frozen section can be inaccurate, particularly as you move higher in the colon. — Marc Levitt (clinical) [Ep 11 · 15:42](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=942)
- The Swenson operation involved full-thickness transabdominal dissection down below the peritoneal reflection. The operation was often done incorrectly with perirectal dissection done too wide, leading to fecal incontinence, urinary incontinence, sexual problems, and impotence. — Marc Levitt (clinical) [Ep 11 · 18:14](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1094)
- The Suave operation used a mucosal dissection to keep the outer rectal wall intact and avoid injury. The original Suave would leave the colon coming through the anus for a week before doing the coloanal anastomosis; Dr. Scott Boley modified it to do everything in one stage. — Marc Levitt (clinical) [Ep 11 · 19:28](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1168)
- The Duhamel operation leaves the original rectum in place, removes the aganglionic portion from the peritoneal reflection, and pulls ganglionic bowel in a retrorectal position, connecting the two lumens with a stapler. — Marc Levitt (clinical) [Ep 11 · 20:18](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1218)
- Of the four classic procedures (Swenson, Suave, Duhamel, Rabine), only the Swenson actually leaves behind virtually no Hirschsprung tissue. The others leave behind outer rectal wall or original rectum. Many patients did well despite this because ganglionic bowel, if it's good, can overcome a lot. — Marc Levitt (clinical) [Ep 11 · 21:18](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1278)
- Dr. Henrys in the Philippines pioneered primary pull-through operations (without initial colostomy) out of necessity because patients would never return to clinic due to social stigma against colostomies. — Marc Levitt (clinical) [Ep 11 · 22:19](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1339)
- Keith Jorgeson applied laparoscopic skills to Hirschsprung disease, doing the colonic work laparoscopically with a Suave dissection from above. Luis de la Torre and Jack Langer developed the transanal approach, starting the dissection from below. — Marc Levitt (clinical) [Ep 11 · 23:21](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1401)
- The current preferred approach is a transanal Swenson (full-thickness dissection). It is the purest operation, leaving behind no Hirschsprung except the very bottom just above the dentate line. If you find the right plane, it's elegant and bloodless. — Marc Levitt (opinion) [Ep 11 · 25:34](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1534)
- Dr. Orvar Swenson, who recently died at age 105, maintained that the Swenson operation was good all along and people just weren't doing it right, which gave it a bad reputation. — Marc Levitt (clinical) [Ep 11 · 26:23](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1583)
- Even Suave enthusiasts are making shorter and shorter cuffs over time. Jorgeson's original laparoscopic Suave recommended a 5 cm cuff; nowadays Langer and de la Torre do 1-1.5 cm cuffs, essentially approaching a Swenson. — Marc Levitt (clinical) [Ep 11 · 27:06](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1626)
- Laparoscopy is appropriate for all cases to find the transition zone level. A transanal-only approach is only appropriate when you have a very reachable, obvious transition zone at mid-sigmoid that you can comfortably reach transanally. — Marc Levitt (opinion) [Ep 11 · 28:50](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1730)
- There is significant morbidity from an overly aggressive transanal-only approach trying to reach the transition zone without going into the abdomen. If you're too aggressive transanally trying to visualize the dissection, you would have been better off with laparoscopic dissection. — Marc Levitt (clinical) [Ep 11 · 29:18](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1758)
- Total colonic Hirschsprung patients present differently: the diagnosis isn't made right away, the contrast study is not typical, and irrigations don't go well. These patients need laparoscopy first to find the biopsy location. — Marc Levitt (clinical) [Ep 11 · 31:18](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=1878)
- The biggest technical problems are: (1) surgeons don't give themselves good exposure and start dissection too low, injuring or resecting the dentate line, or (2) they give very aggressive exposure and overstretch the sphincters. — Marc Levitt (clinical) [Ep 11 · 34:09](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2049)
- Proper technique requires marking 1 cm proximal to the dentate line with a purple mark and placing 5-0 silk stitches circumferentially at that level. This preserves the anal canal, dentate line, plus an additional 1 cm of columnar epithelium before starting dissection. — Marc Levitt (clinical) [Ep 11 · 35:30](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2130)
- By definition, you're leaving behind 1 cm of columnar epithelium that is Hirschsprung disease, plus the internal sphincter which has a problem with relaxation. However, good ganglionic bowel is able to overcome that, and the baby eventually learns to relax the sphincter. — Marc Levitt (clinical) [Ep 11 · 36:39](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2199)
- The rectum doesn't really have a mesentery; the rectum's blood supply is intramural. As you get higher and reach the peritoneal reflection, that's when you start to see sigmoidal vessels where rectum transitions to sigmoid. — Marc Levitt (clinical) [Ep 11 · 38:19](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2299)
- The anterior rectum frees up much quicker than the posterior rectum. Break into the peritoneal reflection anteriorly first. In transanal-only cases, you can pull the sigmoid out anteriorly, do a full-thickness biopsy, and send it while continuing the posterior dissection. — Marc Levitt (clinical) [Ep 11 · 38:45](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2325)
- For laparoscopic biopsies through the umbilicus, a seromuscular biopsy (without violating mucosa) may show ganglion cells in the seromuscular layer but miss hypertrophic nerves in the submucosa. If using this technique, send a full-thickness biopsy later to confirm the level is appropriate. — Marc Levitt (clinical) [Ep 11 · 40:56](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2456)
- Pathologists must report not only ganglion cells but also the quality of nerves with actual micron measurements. Nerves should be 40 microns or less. Anything bigger than 40 microns is transition zone bowel. — Marc Levitt (clinical) [Ep 11 · 44:03](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2643)
- The concept of 'go 5 cm above the transition zone' is inaccurate. Transition zone is a spectrum - some are 10 cm, some are 3 cm. You need confirmatory biopsy with ganglion cell information and nerve quality measured in microns. — Marc Levitt (clinical) [Ep 11 · 44:20](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2660)
- It's preferable to take the IMA, preserve the arcade, and have the left colon and sigmoid nice and straight down into the perineum. This makes for an easy-to-irrigate baby. Many patients have not had enough of a pull-through with the entire sigmoid loop still there, requiring redo to remove more. — Marc Levitt (clinical) [Ep 11 · 45:57](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2757)
- For anything proximal to the splenic flexure, do colonic biopsies and an ileostomy and wait, because frozen section has been notoriously fraught with errors in those cases. There is no urgency. Another option is to take biopsies, quit without diverting, and return 3-4 days later for pull-through with permanent section results. — Marc Levitt (clinical) [Ep 11 · 47:02](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=2822)
- Postoperatively, wait until the belly is absolutely soft and flat with bowel function before feeding. Get an X-ray because abdominal distention is sometimes subclinical. This usually takes 3-4 days. Feeding too early risks the baby going home distended and returning with enterocolitis. — Marc Levitt (clinical) [Ep 11 · 53:23](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3203)
- Routine postoperative management: at one month, check the anus with Hagar dilators (not finger). Most babies need calibration rather than true dilation. The stimulation of passing the Hagar has value to help the baby more successfully empty. — Marc Levitt (clinical) [Ep 11 · 54:39](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3279)
- Flagyl is only used to treat enterocolitis, not routinely postoperatively. Give a pre-op dose of second-generation cephalosporin and maybe 2 post-op doses. — Marc Levitt (clinical) [Ep 11 · 55:52](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3352)
- Routine irrigations are only done postoperatively if the baby develops significant distention, which is rare. However, for total colonic patients after ileoanal pull-through, send all patients home on irrigations for 3 months. — Marc Levitt (clinical) [Ep 11 · 56:31](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3391)
- For hepatic flexure transition zone (rare), open the patient rather than laparoscopy. Take down the entire right colon, recognize the ileocolic vessel and how it feeds the vessel paralleling the right colon. Often need to take the right colic artery. De-rotate the colon so cecum is at the hepatic liver bed, then do pull-through down the right side of abdomen. — Marc Levitt (clinical) [Ep 11 · 57:05](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3425)
- If bringing de-rotated colon down the left side of abdomen, must mobilize the ligament of Treitz so the mesenteric vessel is not draped across the third portion of duodenum, which can cause duodenal obstruction. — Marc Levitt (clinical) [Ep 11 · 58:02](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=3482)
- Dr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results. — Daniel von Allmen (opinion) [Ep 10 · 5:31](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=331)
- Two proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant). — Daniel von Allmen (clinical) [Ep 10 · 9:09](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=549)
- The START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen. — Daniel von Allmen (clinical) [Ep 10 · 10:09](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=609)
- Dr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision). — Whit Holcomb (clinical) [Ep 10 · 16:30](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=990)
- Most pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice. — Whit Holcomb (opinion) [Ep 10 · 17:03](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1023)
- Chloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day. — Whit Holcomb (clinical) [Ep 10 · 18:16](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1096)
- Dr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics. — Whit Holcomb (opinion) [Ep 10 · 26:33](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1593)
- Immunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics. — Whit Holcomb (clinical) [Ep 10 · 27:00](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1620)
- The challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation. — Whit Holcomb (opinion) [Ep 10 · 27:22](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1642)
- Long-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis. — Whit Holcomb (opinion) [Ep 10 · 27:52](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1672)
- If appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk. — Whit Holcomb (opinion) [Ep 10 · 29:45](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1785)
- The protective effect of necrotizing enterocolitis on enteral autonomy is surprising and goes against understanding of that inflammatory illness, showing how much remains to be learned. — Aaron Lipskar (opinion) [Ep 10 · 33:55](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2035)
- The PIFCON study underscores the importance of managing children with intestinal failure in multidisciplinary intestinal rehab programs, where catheter-associated bloodstream infection elimination and cholestasis prevention have changed outcomes. — Aaron Lipskar (opinion) [Ep 10 · 36:11](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2171)
- Dr. Lipskar has not yet delayed an inguinal hernia repair for anesthetic concerns. — Aaron Lipskar (opinion) [Ep 10 · 40:53](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2453)
- At Cohen Children's Medical Center, circumcisions outside the neonatal period are done with general plus regional anesthesia. — Aaron Lipskar (clinical) [Ep 10 · 41:09](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2469)
- Regional anesthesia and agents like precedex may help decrease the amount of potentially neurotoxic general anesthesia; almost every laparoscopic, thoracoscopic, or open operation has a regional block option. — Aaron Lipskar (opinion) [Ep 10 · 41:31](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2491)
- Dr. Ponsky's chief of anesthesiology instituted a 'rule of two': defer elective operations until after age 2 and avoid two anesthetics in one year. — Todd Ponsky (clinical) [Ep 10 · 42:16](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2536)
- Dr. Ponsky now defers dermoid cyst excision in a 6-month-old until 18 months but does not delay inguinal hernia repair due to known incarceration risk in young infants. — Todd Ponsky (opinion) [Ep 10 · 42:31](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2551)
- A survey of ~150 parents in a primary care pediatrics office found the vast majority did not know anesthetic neurotoxicity was a major issue (Dr. Lipskar's unpublished study, to be presented at AAP). — Aaron Lipskar (clinical) [Ep 10 · 43:17](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2597)
- Dr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results. — Daniel von Allmen (opinion) [Ep 5 · 5:31](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=331)
- Two proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant). — Daniel von Allmen (clinical) [Ep 5 · 9:09](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=549)
- The START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen. — Daniel von Allmen (clinical) [Ep 5 · 10:09](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=609)
- Dr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision). — Whit Holcomb (clinical) [Ep 5 · 16:30](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=990)
- Most pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice. — Whit Holcomb (opinion) [Ep 5 · 17:03](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1023)
- Chloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day. — Whit Holcomb (clinical) [Ep 5 · 18:16](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1096)
- Dr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics. — Whit Holcomb (opinion) [Ep 5 · 26:33](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1593)
- Immunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics. — Whit Holcomb (clinical) [Ep 5 · 27:00](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1620)
- The challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation. — Whit Holcomb (opinion) [Ep 5 · 27:22](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1642)
- Long-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis. — Whit Holcomb (opinion) [Ep 5 · 27:52](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1672)
- If appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk. — Whit Holcomb (opinion) [Ep 5 · 29:45](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1785)
- The protective effect of necrotizing enterocolitis on enteral autonomy is surprising and goes against understanding of that inflammatory illness, showing how much remains to be learned. — Aaron Lipskar (opinion) [Ep 5 · 33:55](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2035)
- The PIFCON study underscores the importance of managing children with intestinal failure in multidisciplinary intestinal rehab programs, where catheter-associated bloodstream infection elimination and cholestasis prevention have changed outcomes. — Aaron Lipskar (opinion) [Ep 5 · 36:11](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2171)
- Dr. Lipskar has not yet delayed an inguinal hernia repair for anesthetic concerns. — Aaron Lipskar (opinion) [Ep 5 · 40:53](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2453)
- At Cohen Children's Medical Center, circumcisions outside the neonatal period are done with general plus regional anesthesia. — Aaron Lipskar (clinical) [Ep 5 · 41:09](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2469)
- Regional anesthesia and agents like precedex may help decrease the amount of potentially neurotoxic general anesthesia; almost every laparoscopic, thoracoscopic, or open operation has a regional block option. — Aaron Lipskar (opinion) [Ep 5 · 41:31](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2491)
- Dr. Ponsky's chief of anesthesiology instituted a 'rule of two': defer elective operations until after age 2 and avoid two anesthetics in one year. — Todd Ponsky (clinical) [Ep 5 · 42:16](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2536)
- Dr. Ponsky now defers dermoid cyst excision in a 6-month-old until 18 months but does not delay inguinal hernia repair due to known incarceration risk in young infants. — Todd Ponsky (opinion) [Ep 5 · 42:31](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2551)
- A survey of ~150 parents in a primary care pediatrics office found the vast majority did not know anesthetic neurotoxicity was a major issue (Dr. Lipskar's unpublished study, to be presented at AAP). — Aaron Lipskar (clinical) [Ep 5 · 43:17](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2597)
- The Chilean Society of Pediatric Surgery screens approximately 1,200 articles each month from non-pediatric surgical journals to identify the 3% relevant to pediatric surgery. — Jose Campos (clinical) [Ep 17 · 1:38](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=98)
- One participating hospital in the appendicitis antibiotic trial did not see a difference in abscess rates between the two antibiotic regimens in their cohort, while the overall study results were driven entirely by Phoenix Children's Hospital's experience. — Shawn St. Peter (clinical) [Ep 17 · 7:04](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=424)
- NSQIP-P national data shows no difference in abscess rates between ceftriaxone-metronidazole and piperacillin-tazobactam across much larger patient numbers. — Shawn St. Peter (epidemiological) [Ep 17 · 7:45](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=465)
- In the NEC trial, there was significant surgeon intention to treat, with most patients who received initial peritoneal drainage going to laparotomy shortly after drain placement. — Shawn St. Peter (clinical) [Ep 17 · 12:40](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=760)
- Peritoneal drainage for NEC often serves as a temporizing measure to stabilize septic patients before laparotomy rather than as definitive therapy. — Shawn St. Peter (opinion) [Ep 17 · 13:42](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=822)
- Peritoneal drainage started as a temporizing measure for NEC but morphed into a definitive management strategy in approximately 40-50% of surgeons' minds. (opinion) [Ep 17 · 14:10](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=850)
- The original description of percutaneous endoscopic gastrostomy (PEG) was done by Todd Ponsky Sr. — Jose Campos (clinical) [Ep 17 · 15:50](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=950)
- PEG tubes are difficult to change to button tubes, often requiring a second anesthetic with GI specialists to remove the PEG endoscopically before placing a button. — Meera Kotagal (clinical) [Ep 17 · 20:29](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1229)
- The article by Todd Ponsky Sr. and Mike Goddard on PEG tube placement remains the most cited article in the history of the Journal of Pediatric Surgery, with approximately three times the citations of the number two article. — Todd Ponsky (clinical) [Ep 17 · 17:36](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1056)
- The Teen Labs Consortium has been conducting NIH-funded prospective trials on bariatric surgery in adolescents since 2007. (clinical) [Ep 17 · 24:10](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1450)
- Sleeve gastrectomy is a very safe operation in adolescents with good long-term data showing resolution of comorbidities, especially in pre-diabetic and diabetic patients. (clinical) [Ep 17 · 23:14](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1394)
- The average time pediatric patients spend in bariatric surgery programs before proceeding to surgery is approximately nine months. (clinical) [Ep 17 · 25:11](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1511)
- Classic acute appendicitis presentation (pain migration to right lower quadrant, McBurney's point tenderness, elevated WBC and CRP, low-grade fever in thin patient with short symptom duration) can proceed directly to laparoscopic appendectomy without imaging — Whit Holcomb (clinical) [Ep 12 · 3:25](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=205)
- At Children's Mercy Hospital, emergency department physicians often perform imaging studies before surgical consultation, though this is at their discretion not surgeon direction — Whit Holcomb (clinical) [Ep 12 · 4:00](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=240)
- Symptom duration over 24-36 hours raises concern for perforation and warrants imaging starting with ultrasound — Whit Holcomb (clinical) [Ep 12 · 5:11](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=311)
- If ultrasound is not diagnostic but raises concern, proceed to CT scan; if ultrasound is diagnostic of appendicitis, CT is not needed — Whit Holcomb (clinical) [Ep 12 · 6:25](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=385)
- Non-visualization of appendix on CT at 4 days should show secondary signs of appendicitis and likely perforation; absence of both findings makes appendicitis unlikely though not zero — Whit Holcomb (clinical) [Ep 12 · 7:28](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=448)
- Children's Mercy uses IV contrast for CT and performs limited/focused CT scans to minimize radiation exposure; rectal contrast protocol was attempted but not adopted by ED physicians — Whit Holcomb (clinical) [Ep 12 · 8:40](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=520)
- Ceftriaxone and metronidazole is the most cost-effective antibiotic combination for appendicitis and has similar efficacy to triple antibiotic regimens — Whit Holcomb (clinical) [Ep 12 · 11:11](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=671)
- In 2008 Journal of Pediatric Surgery randomized trial of 100 patients, daily ceftriaxone/metronidazole showed no difference in abscess rate or wound infections versus ampicillin/gentamicin/clindamycin but resulted in lower antibiotic charges — Whit Holcomb (clinical) [Ep 12 · 14:18](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=858)
- Ceftriaxone dosing is 50 mg/kg once daily and metronidazole is 30 mg/kg once daily for appendicitis — Whit Holcomb (clinical) [Ep 12 · 15:11](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=911)
- Non-perforated appendicitis receives only single preoperative antibiotic dose with no postoperative antibiotics — Whit Holcomb (clinical) [Ep 12 · 12:58](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=778)
- Once-daily ceftriaxone/metronidazole dosing facilitates home health care transition if needed, does not require serum levels like gentamicin, and avoids gentamicin toxicities — Whit Holcomb (clinical) [Ep 12 · 13:29](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=809)
- Single-incision or double-incision laparoscopic approaches are used only for thin patients with non-perforated appendicitis — Whit Holcomb (clinical) [Ep 12 · 16:35](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=995)
- In double-incision approach, 5mm umbilical port is placed with 5mm suprapubic port for mobilization, then appendix is exteriorized through umbilicus for extracorporeal appendectomy — Whit Holcomb (clinical) [Ep 12 · 17:51](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1071)
- Locking grasper is essential when exteriorizing appendix to prevent dropping it back into abdomen — Whit Holcomb (clinical) [Ep 12 · 19:40](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1180)
- Fascial incision of 10-12mm is needed to safely exteriorize appendix because grasper creates U-shaped configuration rather than end-on grasp — Whit Holcomb (clinical) [Ep 12 · 20:53](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1253)
- Perforation is strictly defined as stool in the abdomen (fecalith in abdominal cavity) or a visible hole in the appendix; without these findings the patient does not have perforation — Whit Holcomb (clinical) [Ep 12 · 21:58](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1318)
- This strict perforation definition was necessary because literature uses terms like gangrenous, necrotic, and perforated inconsistently, all meaning different things to different surgeons — Whit Holcomb (clinical) [Ep 12 · 21:58](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1318)
- Children's Mercy has been sending non-perforated appendicitis patients home the same day (within 6 hours of surgery) for over a year with over 100 patients managed this way — Whit Holcomb (clinical) [Ep 12 · 25:46](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1546)
- Same-day discharge for non-perforated appendicitis uses local anesthesia in incisions, pain medications at home, and no postoperative antibiotics — Whit Holcomb (clinical) [Ep 12 · 25:46](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1546)
- Rationale for same-day discharge includes patient satisfaction, opening hospital beds for patients who need them, and preparing for potential future trials of antibiotics versus day-surgery appendectomy — Whit Holcomb (opinion) [Ep 12 · 27:33](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1653)
- October 2011 Annals of Surgery study randomized 360 patients (August 2009-November 2010) comparing single-incision to three-port laparoscopy for non-perforated appendicitis — Whit Holcomb (clinical) [Ep 12 · 28:30](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1710)
- Single-incision appendectomy showed no difference versus three-port in wound infection rate, time to regular diet, length of hospitalization, or time to return to full activity — Whit Holcomb (clinical) [Ep 12 · 28:30](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1710)
- Single-incision approach had longer operative time (5 minutes, statistically significant but not clinically relevant), more narcotic doses, greater surgical difficulty, and higher hospital charges than three-port — Whit Holcomb (clinical) [Ep 12 · 28:30](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1710)
- For single-incision approach, umbilical fascia is closed and interrupted plain sutures placed in umbilical skin; for three-port, umbilical incision closed similarly and 5mm port sites closed with 5-0 Vicryl in U-fashion — Whit Holcomb (clinical) [Ep 12 · 31:32](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1892)
- Interrupted plain sutures allow wound infection drainage while not requiring removal due to short half-life; wounds dressed with rolled gauze and Tegaderm — Whit Holcomb (clinical) [Ep 12 · 32:09](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1929)
- St. Peter study compared irrigation plus suction versus suction-only for perforated appendicitis and found no difference in abscess rate or location; both groups had approximately 20% postoperative abscess rate — Whit Holcomb (clinical) [Ep 12 · 33:00](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1980)
- Study used strict perforation definition (hole in appendix or fecalith in abdomen), not just distended, angry, necrotic, or gangrenous appendix — Whit Holcomb (clinical) [Ep 12 · 33:00](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1980)
- Across 6-7 appendectomy studies for perforated disease at Children's Mercy, abscess rate has consistently been 15-20%; Holcomb counsels families on 20% abscess risk — Whit Holcomb (clinical) [Ep 12 · 34:28](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2068)
- Surgeons reporting lower abscess rates for perforation likely include gangrenous/necrotic non-perforated cases in their perforated group, lowering the rate — Whit Holcomb (opinion) [Ep 12 · 34:28](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2068)
- At Children's Mercy, OR billing is $225 per minute; a $600 stapler is cost-effective if it saves 3 minutes of OR time — Whit Holcomb (clinical) [Ep 12 · 38:21](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2301)
- Children's Mercy surgeons use stapler for both mesoappendix and appendix because it can be justified as cost-effective under their per-minute billing model — Whit Holcomb (clinical) [Ep 12 · 38:21](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2301)
- Standard stapler load is used for appendix and vascular load for mesoappendix, which is another reason not to staple both simultaneously — Whit Holcomb (clinical) [Ep 12 · 38:21](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2301)
- In early 1990s at Vanderbilt, three children who had cautery used for appendectomy developed adjacent small bowel injuries requiring reoperation due to electrical arc — Whit Holcomb (clinical) [Ep 12 · 38:21](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2301)
- When using cautery for appendectomy, must carefully watch entire field to prevent electrical arc to adjacent small bowel loops — Whit Holcomb (clinical) [Ep 12 · 38:21](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2301)
- Murky fluid throughout abdomen in non-perforated appendicitis is very unusual and would prompt placement of additional port for better visualization and investigation of source — Whit Holcomb (clinical) [Ep 12 · 39:48](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2388)
- In single-incision approach, pelvic fluid should be suctioned before incising the bridge between ports because it becomes difficult to suction after appendix removal — Whit Holcomb (clinical) [Ep 12 · 39:48](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2388)
- For normal appendix found at surgery, if imaging study was done preoperatively, full small bowel run is often not performed; without prior imaging, full small bowel examination is done — Whit Holcomb (clinical) [Ep 12 · 41:15](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2475)
- Initial perforated appendicitis protocol at Children's Mercy was 5 days of IV antibiotics postoperatively, developed when beginning prospective randomized trials — Whit Holcomb (clinical) [Ep 12 · 42:05](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2525)
- Discharge criteria for perforated appendicitis: normal WBC on day 5, afebrile, tolerating regular diet; then discharged without oral antibiotics — Whit Holcomb (clinical) [Ep 12 · 42:05](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2525)
- If WBC elevated on day 5, patient receives 2 additional days of antibiotics and repeat WBC; if still elevated, receives 3 more days and CT scan to look for abscess — Whit Holcomb (clinical) [Ep 12 · 42:05](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2525)
- Almost all postoperative abscesses in perforated appendicitis develop while patient is in hospital, very few develop after discharge — Whit Holcomb (clinical) [Ep 12 · 42:05](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2525)
- Follow-up study randomized 100 patients (50 per group) comparing mandatory 5 days IV antibiotics versus early discharge with oral Augmentin to complete 7 total days if discharge criteria met — Whit Holcomb (clinical) [Ep 12 · 42:05](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2525)
- Early discharge study found no difference in postoperative abscess rate between groups; 40% of patients in early discharge group went home before day 5 — Whit Holcomb (clinical) [Ep 12 · 42:05](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2525)
- For well-defined abscess at 5-6 days symptom duration, two options exist: immediate appendectomy or non-operative management with interval appendectomy — Whit Holcomb (clinical) [Ep 12 · 46:12](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2772)
- At 3-4 days symptom duration, would operate; at 6-7 days with well-defined abscess, would treat non-operatively; 5 days is transition zone requiring clinical judgment — Whit Holcomb (clinical) [Ep 12 · 50:23](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3023)
- 2010 Journal of Pediatric Surgery study of 40 patients compared initial appendectomy versus initial non-operative management with interval appendectomy for well-defined abscess from perforated appendicitis — Whit Holcomb (clinical) [Ep 12 · 46:12](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2772)
- Study found no difference between immediate versus interval appendectomy in total length of hospitalization, recurrent abscess rates, or overall charges — Whit Holcomb (clinical) [Ep 12 · 46:12](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2772)
- Initial appendectomy took longer (61 minutes) versus interval appendectomy (42 minutes) — Whit Holcomb (clinical) [Ep 12 · 46:12](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2772)
- Holcomb prefers initial non-operative management with interval appendectomy because immediate operations can be difficult, patients have prolonged hospitalization, bad ileus, sometimes need NG tube, and risk recurrent abscess complications — Whit Holcomb (opinion) [Ep 12 · 46:12](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2772)
- Interval appendectomy is performed 8-10 weeks after non-operative abscess management and is becoming a day surgery procedure — Whit Holcomb (clinical) [Ep 12 · 46:12](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=2772)
- Even if abscess can be managed for 2 weeks non-operatively, that operation is much easier than going in early through dense inflammation and purulent material — Whit Holcomb (opinion) [Ep 12 · 51:01](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3061)
- Current data suggests 50-60% of patients could likely be managed non-operatively with antibiotics — Whit Holcomb (clinical) [Ep 12 · 52:18](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3138)
- High-quality studies on non-operative appendicitis management will emerge in next 5 years showing good percentage can be treated without operation — Whit Holcomb (opinion) [Ep 12 · 52:18](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3138)
- Long-term follow-up of 25-30 years will be needed to determine if non-operatively treated patients develop recurrent appendicitis years later — Whit Holcomb (opinion) [Ep 12 · 52:18](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3138)
- Inflammation and infection may cause appendiceal scarring leading to closed-loop obstruction and recurrent appendicitis, but this won't be known for 25-30 years — Whit Holcomb (opinion) [Ep 12 · 52:18](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3138)
- Current data is not mature enough to justify non-operative management, especially when patients can have surgery and go home same day returning to routine activities — Whit Holcomb (opinion) [Ep 12 · 52:18](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3138)
- Longer-term data (5, 10, 20 years) is needed to determine true recurrence rate after non-operative management; if patients return years later, this justifies interval appendectomy when young — Whit Holcomb (opinion) [Ep 12 · 56:15](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3375)
- Children's Mercy currently proceeds with interval laparoscopic appendectomy after non-operative abscess management because families do not want child at risk for recurrent appendicitis — Whit Holcomb (clinical) [Ep 12 · 57:28](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3448)
- The way pediatric surgery is done is quite variable and not standardized, especially appendicitis. — Todd Ponsky (opinion) [Ep 2 · 0:06](https://team.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6)
- The APPY trial is a multi-center randomized trial comparing appendectomy to non-operative treatment for non-perforated appendicitis. (clinical) [Ep 3 · 0:09](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=9)
- The initial working group included Agostino Piero, Nigel Hall, Simon Eaton, Thomas Wester, and several others, with the current group joining about 2.5 years ago. (clinical) [Ep 3 · 1:20](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=80)
- The first two rounds of funding failed, requiring modifications to sample size calculation and study design to make it more pragmatic. (clinical) [Ep 3 · 2:00](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=120)
- Appendicitis can be treated without surgery, as demonstrated by experience with complicated appendicitis where patients are treated to completion regardless of perforation severity. (clinical) [Ep 3 · 3:20](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=200)
- Bob Parry developed appendicitis in Ireland, was treated with antibiotics, and went a full year before having a recurrent bout requiring appendectomy. (clinical) [Ep 3 · 4:00](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=240)
- In the preference trial, any appendix that has to come out—even if due to parental preference after symptom resolution—must be considered a treatment failure because that reflects real-world practice. (clinical) [Ep 3 · 8:50](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=530)
- In the preference trial, parents of sicker-appearing children are less likely to choose non-operative management, even if objective measures like white count are similar. (clinical) [Ep 3 · 10:00](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=600)
- Patients who respond to antibiotics are literally normal the next day, going to school on Wednesday after discharge on Tuesday, whereas laparoscopic appendectomy patients restrict themselves for several days despite no formal restrictions. (clinical) [Ep 3 · 11:40](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=700)
- The APPY trial is designed as a non-inferiority study because non-operative management cannot possibly be superior to appendectomy, which has a 100% cure rate. (clinical) [Ep 3 · 13:20](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=800)
- The trial includes patients aged 5 to 16 with suspected non-perforated appendicitis, excluding those under 5 because they frequently have perforation regardless of presentation. (clinical) [Ep 3 · 14:10](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=850)
- The trial uses broad inclusion criteria without requiring specific Alvarado scores, PAS scores, or imaging findings, allowing surgeons to use their standard diagnostic approach for non-perforated appendicitis. (clinical) [Ep 3 · 15:00](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=900)
- Exclusion criteria include suspicion of perforation, more than two doses of antibiotics initiated at an outside facility, previous episode of appendicitis treated non-operatively, and systemic disease. (clinical) [Ep 3 · 15:50](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=950)
- The trial uses central randomization with minimization based on sex, center, and duration of symptoms to maintain balance across these factors. (clinical) [Ep 3 · 16:40](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1000)
- The protocol was modified to allow patients to go home the next day if doing well, rather than requiring 24-48 hour evaluations at fixed time points, because the original schedule was impractical for overnight enrollments. (clinical) [Ep 3 · 17:30](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1050)
- If patients are not better after initial therapy, they are given another day, but after 48 hours of IV therapy (by Wednesday morning), it is time to proceed with appendectomy because 3 days in the hospital is too much when the alternative is going home Monday. (clinical) [Ep 3 · 18:20](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1100)
- The primary outcome is treatment failure defined as an intervention for appendicitis requiring general anesthesia within 1 year in both groups, which essentially compares negative appendectomy versus recurrent appendicitis. (clinical) [Ep 3 · 19:10](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1150)
- The non-inferiority margin is 20% because polling showed most people consider failure rates in the twenties too high for non-operative management. (opinion) [Ep 3 · 20:00](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1200)
- The actual failure rate percentage is what matters to parents when counseling, not whether the trial concludes non-inferiority—some parents will accept 26% failure to avoid surgery while others won't accept 2%. (opinion) [Ep 3 · 20:45](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1245)
- As of the presentation, 52 patients have been enrolled: Stockholm 25, Helsinki 7, with Vancouver, Ontario, and Calgary recently receiving IRB approval. (clinical) [Ep 3 · 21:40](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1300)
- Early results show in the operative group: 4 perforations and 2 negative appendectomies. In the non-operative group: 1 readmitted for abscess, 3 failed early (didn't leave hospital), 4 failed after discharge (within 2-5 days), and 1 recurrence at 6 months. (epidemiological) [Ep 3 · 22:25](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1345)
- All recurrences and failures in the non-operative group have had confirmed appendicitis; no normal appendix has been removed yet. (clinical) [Ep 3 · 23:20](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1400)
- The two negative appendectomies in the operative group had imaging showing secondary signs like fluid but not visualizing the appendix. (clinical) [Ep 3 · 20:45](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1245)
- Of the 3 early failures in the non-operative group, 2 were due to parental impatience on the morning after enrollment, not giving the treatment a real chance. (clinical) [Ep 3 · 21:20](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1280)
- The reason for limiting antibiotics is that Augmentin is given daily in pediatric offices to thousands of children with sniffles who don't need it, whereas the APPY trial treats an active intra-abdominal bacterial infection. (opinion) [Ep 3 · 23:00](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1380)
- All perforated appendicitis cases are treated with antibiotics, and if complications develop, long-term antibiotics are used until resolution, so treating intra-abdominal infection is different from unnecessary antibiotic use. (clinical) [Ep 3 · 23:50](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1430)
- The value of the study is knowing the exact failure rates and outcomes to counsel patients who might want to avoid surgery or are in circumstances where surgery isn't immediately feasible, even if non-operative management proves inferior. (opinion) [Ep 3 · 25:07](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1507)
- No adult literature has examined long-term outcomes beyond one year for non-operative management of appendicitis. (epidemiological) [Ep 3 · 25:07](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1507)
- The trial plans to follow the cohort in perpetuity with annual telephone follow-up to determine recurrence rates at 5 years, 10 years, and beyond. (clinical) [Ep 3 · 25:40](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1540)
- Perforation is defined as a hole in the appendix or a fecolith in the abdomen—irrefutable proof of contamination—and is only an intraoperative diagnosis, not a preoperative one. (clinical) [Ep 3 · 27:25](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1645)
- The presence of a fecolith is an exclusion criterion in the Midwest Pediatric Surgery Consortium preference trial but not in the APPY trial. (clinical) [Ep 3 · 28:10](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1690)
- At Nationwide, a separate small population with appendicoliths was allowed enrollment, but that arm was stopped based on the failure rate. — Todd Ponsky (clinical) [Ep 3 · 29:02](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1742)
- In a cohort of patients with post-appendectomy abscesses, outcomes were relatively equivalent between drain and no drain, but the biggest abscesses and worst patients received drains. — Todd Ponsky (epidemiological) [Ep 3 · 29:56](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1796)
- After size-matching to 17.5 cm² (AP versus lateral in axial dimension), there was an advantage to not having a drain. — Todd Ponsky (epidemiological) [Ep 3 · 30:40](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1840)
- For abscesses less than 20 cm² (less than 4 x 5 cm), drains are typically discouraged because the advantage is small and drains add an extra anesthetic, procedure, and may increase length of stay. — Todd Ponsky (clinical) [Ep 3 · 31:10](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=1870)
- Classic appendicitis presentation (umbilical pain migrating to right lower quadrant, nausea, vomiting, WBC 14, low-grade fever, McBurney's point tenderness) can be taken directly to OR without imaging study — Whit Holcomb (clinical) [Ep 6 · 3:25](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=205)
- Symptom duration of 24-36 hours generally does not indicate perforation, but duration longer than 36 hours likely indicates perforation if appendicitis is present — Whit Holcomb (clinical) [Ep 6 · 5:11](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=311)
- Ultrasound may not be completely accurate for appendicitis diagnosis; if any concern on ultrasound, proceed to CT scan — Whit Holcomb (clinical) [Ep 6 · 6:25](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=385)
- Non-visualization of appendix on CT at 4 days should show secondary signs of appendicitis and perforation; if neither present, likelihood of appendicitis is low but not zero — Whit Holcomb (clinical) [Ep 6 · 7:28](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=448)
- Children's Mercy uses IV contrast and limited CT scan focused on appendicitis to minimize radiation exposure — Whit Holcomb (clinical) [Ep 6 · 8:40](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=520)
- Ceftriaxone (50 mg/kg) and metronidazole (30 mg/kg) once-daily dosing is the most cost-effective antibiotic combination for appendicitis and has similar efficacy to triple-antibiotic regimens — Whit Holcomb (clinical) [Ep 6 · 11:17](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=677)
- Prospective randomized trial (Journal of Pediatric Surgery 2008, 100 patients) found no difference in abscess rate or wound infections between ceftriaxone/metronidazole and ampicillin/gentamicin/clindamycin, with lower antibiotic charges for ceftriaxone/metronidazole — Whit Holcomb (clinical) [Ep 6 · 14:18](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=858)
- Non-perforated appendicitis patients receive only single preoperative dose of antibiotics; no postoperative antibiotics needed — Whit Holcomb (clinical) [Ep 6 · 13:20](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=800)
- Single-incision or double-incision laparoscopic approach used for thin patients with non-perforated appendicitis; three-port approach used for perforated cases — Whit Holcomb (clinical) [Ep 6 · 16:35](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=995)
- Locking grasper is important when exteriorizing appendix to prevent dropping it; non-locking graspers have resulted in several instances of appendix slipping off — Whit Holcomb (clinical) [Ep 6 · 20:13](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=1213)
- Perforation is strictly defined as stool in the abdomen (fecalith in peritoneal cavity) or a visible hole in the appendix — Whit Holcomb (clinical) [Ep 6 · 22:00](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=1320)
- Non-perforated appendicitis patients are discharged home same day (within 6 hours) if surgery completed by 7-8 PM; over 100 patients managed this way with minimal returns — Whit Holcomb (clinical) [Ep 6 · 24:45](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=1485)
- Annals of Surgery 2011 randomized trial (360 patients, non-perforated appendicitis): no difference in wound infection rate (3.3% single-incision vs 1.7% three-port, p=0.5), time to regular diet, length of stay, or return to activity between single-incision and three-port laparoscopy — Whit Holcomb (clinical) [Ep 6 · 28:37](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=1717)
- Single-incision laparoscopic appendectomy had 5 minutes longer operative time than three-port (statistically significant but not clinically relevant), higher surgical difficulty scores, and greater hospital charges — Whit Holcomb (clinical) [Ep 6 · 28:37](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=1717)
- Prospective study comparing irrigation plus suctioning versus suctioning alone in perforated appendicitis found no difference in abscess rate (both approximately 20%) or abscess location — Whit Holcomb (clinical) [Ep 6 · 33:00](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=1980)
- Abscess rate for perforated appendicitis has been consistently 15-20% across 6-7 prospective studies at Children's Mercy — Whit Holcomb (epidemiological) [Ep 6 · 34:42](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=2082)
- Surgeons who report lower abscess rates for perforation may be including gangrenous or necrotic appendicitis (not truly perforated) in their perforated group, which lowers the abscess rate — Whit Holcomb (opinion) [Ep 6 · 34:42](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=2082)
- At Children's Mercy, staplers are cost-effective for appendectomy when OR billing is $225/minute; if stapler costs $600 and saves 3 minutes, it is cost-effective — Whit Holcomb (clinical) [Ep 6 · 37:03](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=2223)
- Retrospective study of over 700 cases using electrocautery for mesoappendix showed minimal bleeding complications (one patient with factor 8 deficiency) — Todd Ponsky (clinical) [Ep 6 · 37:40](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=2260)
- Early 1990s at Vanderbilt: 3 children had adjacent small bowel injuries from cautery during laparoscopic appendectomy, requiring reoperation — Todd Ponsky (clinical) [Ep 6 · 38:22](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=2302)
- Standard protocol for perforated appendicitis: 5 days IV antibiotics (ceftriaxone and metronidazole once daily); discharge criteria are afebrile, normal WBC on day 5, tolerating regular diet — Whit Holcomb (clinical) [Ep 6 · 42:05](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=2525)
- Almost all postoperative abscesses in perforated appendicitis develop in-hospital, not after discharge — Whit Holcomb (clinical) [Ep 6 · 42:05](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=2525)
- Randomized trial comparing 5 days IV antibiotics versus early discharge with oral Augmentin (to complete 7 total days) found no difference in abscess rates; 40% of early-discharge group went home before day 5 — Whit Holcomb (clinical) [Ep 6 · 45:34](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=2734)
- Journal of Pediatric Surgery 2010 study (40 patients): immediate laparoscopic appendectomy versus initial non-operative management with interval appendectomy for well-defined abscess showed no difference in total hospitalization, recurrent abscess rates, or overall charges — Whit Holcomb (clinical) [Ep 6 · 49:23](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=2963)
- Immediate appendectomy for abscess takes longer than interval appendectomy (61 minutes vs 42 minutes) — Whit Holcomb (clinical) [Ep 6 · 49:23](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=2963)
- For well-defined abscess at 5-7 days, prefer initial non-operative management with interval appendectomy at 8-10 weeks; for 3-4 day presentations, still operate acutely — Whit Holcomb (opinion) [Ep 6 · 49:23](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=2963)
- Current data on non-operative appendicitis management is not mature enough to change practice; same-day surgery remains standard until more data available in 5 years — Whit Holcomb (opinion) [Ep 6 · 54:50](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=3290)
- Current practice at Children's Mercy: proceed with interval laparoscopic appendectomy at 8-10 weeks after non-operative management of perforated appendicitis; families prefer this to avoid future appendicitis episodes — Whit Holcomb (clinical) [Ep 6 · 57:28](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=3448)
- At the speaker's hospital, perforated appendicitis is defined as a visible hole in the appendix or a fecalith in the abdomen; if neither is seen, it is not classified as perforated. (clinical) [Ep 9 · 7:00](https://team.globalcastmd.com/watch/perforated-appendicitis-2312?t=420)
- Doctor Saint Peter developed the standardized perforation definition (hole or fecalith) for a prospective trial in the early 2000s, and it is still used at the speaker's institution. (clinical) [Ep 9 · 8:00](https://team.globalcastmd.com/watch/perforated-appendicitis-2312?t=480)
- The 18-19% abscess rates in both arms of the irrigation study are higher than some other studies because a standardized definition of perforation was used, ensuring only true perforated cases were included. (opinion) [Ep 9 · 10:47](https://team.globalcastmd.com/watch/perforated-appendicitis-2312?t=647)
- The Minnesota irrigation study had methodological problems: it was retrospective, had no definition of perforation, had no standard antibiotic usage over the 10-year period, and included only about 10 perforated cases per year. (opinion) [Ep 9 · 12:30](https://team.globalcastmd.com/watch/perforated-appendicitis-2312?t=750)
- Both arms of the irrigation trial had abscess rates of 18-19%, which is higher than some other studies, potentially due to the definition of perforation used. — Matt Carbon (clinical) [Ep 13 · 7:54](https://team.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=474)
- The best quality study on irrigation showed no difference in outcomes, while a more recent but less well-designed study showed a difference favoring standardized large-volume irrigation. — Whit Holcomb (opinion) [Ep 13 · 10:51](https://team.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=651)
- The postoperative antibiotic study did not examine postoperative abscess rates, which is the primary concern after uncomplicated appendectomy rather than surgical site infections. — Todd Ponsky (opinion) [Ep 14 · 11:20](https://team.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=680)
- Multicenter registry studies show pain is documented in only approximately 25-50% of pediatric emergency department cases — Conchita (epidemiological) [Ep 16 · 9:19](https://team.globalcastmd.com/watch/evaluacio-n-y-tratamiento-del-dolor-en-urgencias-5443?t=559)
- Pain assessment scales validated in calm research settings perform poorly in the chaotic emergency department environment, especially for children under 5 years of age — Javier Benito (clinical) [Ep 16 · 13:38](https://team.globalcastmd.com/watch/evaluacio-n-y-tratamiento-del-dolor-en-urgencias-5443?t=818)
- Both families and healthcare professionals systematically underestimate children's pain severity compared to child self-report on validated scales — Javier Benito (clinical) [Ep 16 · 15:00](https://team.globalcastmd.com/watch/evaluacio-n-y-tratamiento-del-dolor-en-urgencias-5443?t=900)
- Pain documentation rates are higher for traumatic injuries than for non-traumatic medical conditions in pediatric emergency departments — Patricia (epidemiological) [Ep 16 · 28:49](https://team.globalcastmd.com/watch/evaluacio-n-y-tratamiento-del-dolor-en-urgencias-5443?t=1729)
- Pediatricians have better integrated pain management protocols for trauma cases but struggle with non-traumatic presentations where diagnostic uncertainty exists — Patricia (opinion) [Ep 16 · 30:00](https://team.globalcastmd.com/watch/evaluacio-n-y-tratamiento-del-dolor-en-urgencias-5443?t=1800)
- Traditional surgical teaching held that analgesia before evaluation would mask diagnostic findings in acute abdomen, though this has been challenged — Conchita (clinical) [Ep 16 · 34:41](https://team.globalcastmd.com/watch/evaluacio-n-y-tratamiento-del-dolor-en-urgencias-5443?t=2081)
- The intranasal route provides systemic absorption comparable to intravenous administration while avoiding first-pass hepatic metabolism — Conchita (clinical) [Ep 16 · 39:20](https://team.globalcastmd.com/watch/evaluacio-n-y-tratamiento-del-dolor-en-urgencias-5443?t=2360)
- Lipophilic medications (fentanyl, ketamine) are ideal for intranasal administration due to excellent absorption across nasal mucosa — Conchita (clinical) [Ep 16 · 40:50](https://team.globalcastmd.com/watch/evaluacio-n-y-tratamiento-del-dolor-en-urgencias-5443?t=2450)
- Maximum intranasal volume should not exceed 5 milliliters per nostril for effective absorption — Conchita (clinical) [Ep 16 · 42:00](https://team.globalcastmd.com/watch/evaluacio-n-y-tratamiento-del-dolor-en-urgencias-5443?t=2520)
- Studies show intranasal ketorolac is non-inferior to opioids for moderate pain in pediatric patients — Conchita (clinical) [Ep 16 · 42:40](https://team.globalcastmd.com/watch/evaluacio-n-y-tratamiento-del-dolor-en-urgencias-5443?t=2560)
- In some Latin American countries, opioid availability is restricted to inpatient or palliative care settings, not available for emergency department use — Patricia (clinical) [Ep 16 · 45:00](https://team.globalcastmd.com/watch/evaluacio-n-y-tratamiento-del-dolor-en-urgencias-5443?t=2700)
- When pediatricians do prescribe opioids, evidence indicates they tend to use doses below recommended levels — Javier Benito (clinical) [Ep 16 · 45:00](https://team.globalcastmd.com/watch/evaluacio-n-y-tratamiento-del-dolor-en-urgencias-5443?t=2700)
- Pain assessment should be integrated as a mandatory vital sign at triage, similar to temperature, heart rate, and blood pressure — Patricia (guideline) [Ep 16 · 17:10](https://team.globalcastmd.com/watch/evaluacio-n-y-tratamiento-del-dolor-en-urgencias-5443?t=1030)
- Improving pediatric pain management requires institutional culture change and quality improvement methodology, not just additional education — Conchita (opinion) [Ep 16 · 12:47](https://team.globalcastmd.com/watch/evaluacio-n-y-tratamiento-del-dolor-en-urgencias-5443?t=767)
- Multimodal analgesia protocols should be established that allow pain treatment independent of definitive diagnosis — Pedro (guideline) [Ep 16 · 37:35](https://team.globalcastmd.com/watch/evaluacio-n-y-tratamiento-del-dolor-en-urgencias-5443?t=2255)
- This modification of single site appendectomy allows for 90 degree retraction using two umbilical ports (either 2.5 mm or 2 mm and 4 mm) through a 10 mm incision and a single 3 mm port in the suprapubic area below the bikini line. (clinical) [Ep 27 · 0:00](https://team.globalcastmd.com/watch/narrated-dipes-appy-11946?t=0)
- The small suprapubic incision results in an almost scarless defect. (clinical) [Ep 27 · 0:40](https://team.globalcastmd.com/watch/narrated-dipes-appy-11946?t=40)
- A 4 mm 30 degree lens is used for the procedure and the Maryland dissector has almost complete range of motion without conflict with the scope. (clinical) [Ep 27 · 1:20](https://team.globalcastmd.com/watch/narrated-dipes-appy-11946?t=80)
- A 5 mm hook is generally adequate to take the appendiceal mesentery in almost all cases. (clinical) [Ep 27 · 1:40](https://team.globalcastmd.com/watch/narrated-dipes-appy-11946?t=100)
- The mesentery is addressed near the base of the appendix to prevent excess cauterization and re-cauterizing the appendiceal artery numerous times. (clinical) [Ep 27 · 1:55](https://team.globalcastmd.com/watch/narrated-dipes-appy-11946?t=115)
- This procedure took just 10 minutes and the video is relatively unedited. (clinical) [Ep 27 · 2:15](https://team.globalcastmd.com/watch/narrated-dipes-appy-11946?t=135)
- The base of the appendix is compressed to ensure there is no fecolith at the base and that the tissue is adequately compressible to allow for use of the 5 mm stapler. (clinical) [Ep 27 · 2:45](https://team.globalcastmd.com/watch/narrated-dipes-appy-11946?t=165)
- It is important to apply the 5 mm stapler and allow it to compress for a full 10 seconds prior to firing to allow the 2 mm staplers to adequately get through the tissue and provide a safe seal. (clinical) [Ep 27 · 3:10](https://team.globalcastmd.com/watch/narrated-dipes-appy-11946?t=190)
- The 5 mm endoscopic specimen bag does not fit through a true 5 mm port. (clinical) [Ep 27 · 3:40](https://team.globalcastmd.com/watch/narrated-dipes-appy-11946?t=220)
- The 5 and 4 mm trocar sites are connected to remove the specimen through the umbilical site. (clinical) [Ep 27 · 4:00](https://team.globalcastmd.com/watch/narrated-dipes-appy-11946?t=240)
- At 2 weeks postoperatively, the scars are almost scarless. (clinical) [Ep 27 · 4:10](https://team.globalcastmd.com/watch/narrated-dipes-appy-11946?t=250)
- The Chilean Society of Pediatric Surgery Journal Hive team screens through 1200 articles each month using a method to select high-quality publications — Jose Campos (clinical) [Ep 25 · 0:48](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=48)
- The failure rate over 30% in nonoperative management of appendicitis is concerning, but nonoperative management is still safe with no adverse events in both groups (opinion) [Ep 25 · 6:37](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=397)
- In pediatric trauma, the cutoff of approximately 12 years or puberty is used as the breaking point for when to think about VTE prophylaxis — Katie Rossel (guideline) [Ep 25 · 11:04](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=664)
- VTE prophylaxis should be started as soon as the patient is stable unless there are contraindications like TBI, and conversations with neurosurgeons can often clarify when it is safe to start — Katie Rossel (clinical) [Ep 25 · 11:57](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=717)
- Only one in every 1000 appendectomy patients will have a tumor in the appendix, and not all are neuroendocrine tumors, meaning every surgeon will only treat a handful of these cases in their lifetime — Jose Campos (epidemiological) [Ep 25 · 13:37](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=817)
- Multiple retrospective studies and the large database study have shown that appendectomy alone is sufficient for appendiceal neuroendocrine tumors, and additional imaging is not needed because it does not change management (clinical) [Ep 25 · 17:18](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=1038)
- A review of 5000 children who had appendectomy at SickKids found about 30 had a carcinoid, only 10 underwent right hemicolectomy, and of these 10 maybe only half actually needed it (clinical) [Ep 25 · 17:44](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=1064)
- The biology of appendiceal neuroendocrine tumors is totally different in children compared to adults, and the behavior in pediatric patients and adolescents is entirely different than in adults, with margins not making a difference when doing appendectomy alone — Jose Campos (clinical) [Ep 25 · 18:51](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=1131)
- Previous studies on appendiceal neuroendocrine tumors drew the line at 15 years, but the database study compared up to 18 years, so conclusions are valid up to 18 years of age — Jose Campos (clinical) [Ep 25 · 19:35](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=1175)
- Majority of providers preferred to use MRI over CT scan in the midway feedback survey — Bailey Little (clinical) [Ep 23 · 3:49](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559?t=229)
- Persistent barriers to MRI use included lack of availability overnight, challenges with scheduling, and additional time required compared to CT scan — Bailey Little (clinical) [Ep 23 · 3:49](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559?t=229)
- Appendicitis is the most common diagnosis requiring urgent surgical treatment in the pediatric population. — Krysta Sutyak (epidemiological) [Ep 24 · 0:23](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=23)
- 34% of almost 34,000 children who underwent appendectomy in the United States from 2019 to 2021 were found to have perforation. — Krysta Sutyak (epidemiological) [Ep 24 · 0:50](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=50)
- Perforated appendicitis increases the risk for post-operative intraabdominal abscess with 10 to 30% of patients with perforation developing an abscess. — Krysta Sutyak (epidemiological) [Ep 24 · 1:10](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=70)
- At their institution from 2013 to 2019, development of post-operative abscess was associated with a length of stay increase of 6.1 days and an estimated incremental cost increase of $11,809 US per patient. — Krysta Sutyak (epidemiological) [Ep 24 · 1:30](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=90)
- Providone iodine has bactericidal properties, matching the pathogen profile seen most commonly in perforated appendicitis and abscess formation. — Krysta Sutyak (clinical) [Ep 24 · 2:10](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=130)
- In the 2016 pilot RCT, patients in the intervention arm received irrigation of the right lower quadrant and pelvis with PVI solution containing 0.1% available iodine compared to usual care in the control arm. — Krysta Sutyak (clinical) [Ep 24 · 2:25](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=145)
- The 2016 trial resulted in an 89% probability that PVI reduced the rate of abscess and a 96% probability of decreased length of stay. — Krysta Sutyak (clinical) [Ep 24 · 2:55](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=175)
- In secondary cost analysis of the 2016 trial, there was a mean cost difference between the PVI group and usual care group of $1,954 US, reflecting a 95% based in probability of reduced 30-day hospital costs. — Krysta Sutyak (epidemiological) [Ep 24 · 3:15](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=195)
- For all 50 participants in the 2016 trial, this was an estimated hospital cost savings of $98,000. — Krysta Sutyak (epidemiological) [Ep 24 · 3:40](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=220)
- Theoretical concerns about PVI use intraabdominally include potential adhesive disease, gastrointestinal effects or thyroid dysfunction. — Krysta Sutyak (clinical) [Ep 24 · 3:55](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=235)
- Of the 100 trial participants reviewed, 60% were male with a median age at the time of surgery of 9.5 years. — Krysta Sutyak (epidemiological) [Ep 24 · 4:25](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=265)
- 51% of trial participants had subsequent encounters within the electronic medical record, including 50% of those who received PVI therapy and 52% of those who received usual care. — Krysta Sutyak (epidemiological) [Ep 24 · 4:40](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=280)
- The median follow-up time was 7.3 years. — Krysta Sutyak (epidemiological) [Ep 24 · 4:55](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=295)
- Only seven of the 100 patients had an ED visit related to their appendicitis diagnosis with five in the usual care group and two in the PVI group. — Krysta Sutyak (epidemiological) [Ep 24 · 5:00](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=300)
- Three patients had a related readmission, all from the usual care group. — Krysta Sutyak (epidemiological) [Ep 24 · 5:15](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=315)
- Zero patients were identified as being diagnosed with chronic abdominal pain, diarrhea or small bowel obstruction. — Krysta Sutyak (clinical) [Ep 24 · 5:25](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=325)
- Five patients had encounters related to constipation with one from the usual care group and four from the PVI group. — Krysta Sutyak (epidemiological) [Ep 24 · 5:40](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=340)
- Two patients were identified as having thyroid related diagnosis since the time of surgery. — Krysta Sutyak (epidemiological) [Ep 24 · 5:55](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=355)
- One patient from the PVI group was diagnosed with thyroiditis after positive TPO antibodies were identified in the initial screening for the trial, which was determined by pediatric endocrinology to be unrelated to the PVI use. — Krysta Sutyak (clinical) [Ep 24 · 6:05](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=365)
- One patient from the usual care group was diagnosed with papillary thyroid carcinoma 7.5 years later at the age of 22. — Krysta Sutyak (clinical) [Ep 24 · 6:30](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=390)
- Children after PVI irrigation for perforated appendicitis did not demonstrate any adverse events, unexpected outcomes or differences in rates of biologically plausible conditions related to PVI. — Krysta Sutyak (clinical) [Ep 24 · 6:45](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=405)
- Both thyroid conditions identified were unrelated to the use of PVI. — Krysta Sutyak (clinical) [Ep 24 · 7:05](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=425)
- For the most part the usual care in the trial was no irrigation, though it was defined as usual care within their practice. — Krysta Sutyak (clinical) [Ep 24 · 6:04](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=364)
- A major limitation of the safety study is the retrospective nature and that data was only available for 50% of patients, though this was equal between groups. — Krysta Sutyak (opinion) [Ep 24 · 7:04](https://team.globalcastmd.com/watch/dr-krysta-sutyak-best-of-the-best-in-pediatric-surgery-2025-10038?t=424)
- The specialized laparoscope is described as a 10mm scope but will only fit through a 12mm trocar. (clinical) [Ep 21 · 2:00](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859?t=120)
- The degree of cecal mobilization varies depending on how mobile the appendix is initially and how thick the abdominal wall is. (clinical) [Ep 21 · 4:00](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859?t=240)
- If the appendix can come up to the liver laparoscopically, it will most likely be able to be delivered up through the abdominal wall. (clinical) [Ep 21 · 4:20](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859?t=260)
- The key to successful delivery is to get a good squeeze of the tip of the appendix with a locking grasper to have a firm grip. (clinical) [Ep 21 · 4:40](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859?t=280)
- Early in performing this procedure, it is beneficial to get a good intracorporeal view of the base ligature to ensure adequate flush ligation onto the cecum without leaving a segment of appendix. (clinical) [Ep 21 · 7:20](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859?t=440)
- When deciding between 1 or 3 port approach, factor in patient body habitus, duration of illness, and appendix size if imaging was obtained. (clinical) [Ep 21 · 8:10](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859?t=490)
- Obese or extremely muscular patients can have thick abdominal walls that make it difficult to deliver even a mildly inflamed appendix. (clinical) [Ep 21 · 8:20](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859?t=500)
- The challenge of delivery is compounded when the appendix is very thick and friable. (clinical) [Ep 21 · 8:30](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859?t=510)
- It is reasonable to start with the SILS approach even if not confident of finishing that way, using a 5-minute timer and reassessing progress. (opinion) [Ep 21 · 8:35](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859?t=515)
- If after 10 minutes of attempting SILS there is no significant forward progress, do not hesitate to convert to traditional intracorporeal approach with two additional trocars. (clinical) [Ep 21 · 8:55](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859?t=535)
- A 12mm trocar placed through the umbilicus by Veress needle technique will make an opening that in thin, small patients will be large enough to work through for appendectomy. (clinical) [Ep 21 · 9:20](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859?t=560)
- When the abdominal wall is thick or the appendix is thick and friable, the fascial opening may need to be enlarged to safely deliver the appendix. (clinical) [Ep 21 · 9:35](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859?t=575)
- If placing a trocar by open technique, it is helpful to start with a skin and fascial incision as large as possible while still concealing it within the umbilicus to avoid needing to enlarge the incision after failing initial delivery. (clinical) [Ep 21 · 9:45](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859?t=585)
- If gas is leaking around a large fascial incision, set insufflator flow on high; special trocars with a balloon on the tip can also be used to maintain a seal. (clinical) [Ep 21 · 10:05](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859?t=605)
- The suction irrigator should not be opened in routine cases, nor is it necessary if only suction is needed. (clinical) [Ep 21 · 10:20](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859?t=620)
- When ligating the mesoappendix, consider taking precaution against losing the divided end into the abdomen before the tie is set by flashing and reclamping the mesentery until the tie is complete. (clinical) [Ep 21 · 10:40](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859?t=640)
- When the appendiceal base is deep in the wound and hard to ligate by usual means, consider using endo loops to get the tie down into position. (clinical) [Ep 21 · 10:55](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859?t=655)
- If uncertain whether at the true appendiceal base when working through a small incision in a thick patient, ligate where the base is thought to be, leave the suture long on an external clamp, return the appendix to the abdomen, and re-explore laparoscopically to verify adequate ligation before completing appendectomy. (clinical) [Ep 21 · 11:05](https://team.globalcastmd.com/watch/sils-appendectomy-by-dr-nelson-rosen-7859?t=665)
- Race is a social construct, not a biological one, challenging historical arguments that genetic factors explain health disparities such as hypertension in African-Americans. — Meera Kotagal (opinion) [Ep 15 · 5:38](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414?t=338)
- Anchor bias—when an initial diagnostic decision causes subsequent providers to view the patient through that lens—may contribute to delayed diagnosis in patients presenting multiple times with the same complaint. — Dan (clinical) [Ep 15 · 4:03](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414?t=243)
- Toxic stress and allostatic load have neurobiological mechanisms that contribute to adverse health outcomes, educational attainment, and economic outcomes, with effects beginning in early childhood and even prenatally. — Garcia (clinical) [Ep 15 · 19:22](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414?t=1162)
- Maternal mortality between black and white mothers in the United States differs by over 300%, with young black women dying even when they are residents with access to prenatal care at health institutions. — Lee (epidemiological) [Ep 15 · 17:19](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414?t=1039)
- Higher infant mortality in black newborns may be a continuation of physiological stress experienced in utero, including higher prematurity rates. — Lee (clinical) [Ep 15 · 17:19](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414?t=1039)
- Emergency department literature shows disparities in pain treatment for patients with appendicitis and other conditions, with questions about whether pain is treated equally across patient populations. — Meera Kotagal (clinical) [Ep 15 · 13:40](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414?t=820)
- Gastroschisis mortality is close to zero in the United States due to TPN and NICU resources, but was close to 100% in many resource-limited settings, particularly due to unavailability of TPN and social concerns around the diagnosis. — Meera Kotagal (epidemiological) [Ep 15 · 11:54](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414?t=714)
- Pipeline programs to increase diversity must start early—not at the college level—to provide opportunities to underrepresented groups. — Meera Kotagal (opinion) [Ep 15 · 25:03](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414?t=1503)
- The University of Michigan's cultural complications curriculum provides a framework for surgical departments to discuss cases involving bias and gender schemas in a format similar to morbidity and mortality conferences. — Meera Kotagal (clinical) [Ep 15 · 25:03](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414?t=1503)
- Addressing health disparities requires moving beyond hospital walls to tackle social determinants of health and poverty at their roots, not just applying band-aids when patients present for care. — Meera Kotagal (opinion) [Ep 15 · 25:03](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414?t=1503)
- Community-based interventions must be done in partnership and solidarity with community voices, not in isolation, to understand problems from the community's perspective rather than institutional assumptions. — Meera Kotagal (opinion) [Ep 15 · 29:43](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414?t=1783)
- In a 10-year-old, spk_0 uses Veress needle through the fascia for peritoneal access. — Todd Ponsky (clinical) [Ep 8 · 0:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=0)
- Dissection and clamp passage (passing a hemostat through the umbilicus, removing it, then inserting the needle) is used by spk_0 only in four-week-old infants with pyloric stenosis, not in older children. — Todd Ponsky (clinical) [Ep 8 · 0:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=0)
- For extirpative operations like cholecystectomy, spk_0 uses Hasson technique. — Todd Ponsky (clinical) [Ep 8 · 0:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=0)
- Single-incision appendectomy can be performed in the obese 90th percentile and above pediatric population with outcomes comparable to three-trocar technique in terms of wound issues. — Todd Ponsky (clinical) [Ep 8 · 3:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=180)
- When using a wound protector during single-port appendectomy, the appendix never touches tissue as it is extracted, making wound complications comparable to or better than multi-port technique. — Todd Ponsky (clinical) [Ep 8 · 4:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=240)
- In obese teenagers, the distance between the posterior fascia at the umbilicus and the aorta is very short, with intestines lying on top. — Todd Ponsky (clinical) [Ep 8 · 7:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=420)
- Veress needles that produce a loud audible click after passing the peritoneum are preferred by some surgeons for confirmation of entry. — Todd Ponsky (clinical) [Ep 8 · 8:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=480)
- Veress needle insertion should not exceed more than a millimeter or two beyond the audible click of peritoneal entry. — Todd Ponsky (clinical) [Ep 8 · 9:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=540)
- The left upper quadrant does not contain iliac vessels, making it a safer access site than midline where iliac vein injury is a risk. — Todd Ponsky (clinical) [Ep 8 · 11:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=660)
- Step trocars are not designed to be placed with the sheath in place because the large step-off in diameter can deflect the abdominal wall and cause injury. — Todd Ponsky (clinical) [Ep 8 · 20:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=1200)
- When using step trocars, the Veress needle should be inserted first to safely insufflate, then the Veress needle with sheath should be inserted to place the sheath. — Todd Ponsky (clinical) [Ep 8 · 21:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=1260)
- The sheath adds obstruction when inserting the Veress needle, making insertion smoother without the sheath. — Todd Ponsky (clinical) [Ep 8 · 22:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=1320)
- In neonates, an infra-umbilical incision is made to avoid cannulating the umbilical vein, which enters through the center of the umbilicus. — Todd Ponsky (clinical) [Ep 8 · 23:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=1380)
- The umbilical vein travels up through the center of the umbilicus; an infra-umbilical incision should avoid the obliterated orifice at the base of the umbilicus. — Todd Ponsky (clinical) [Ep 8 · 24:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=1440)
- Lifting the umbilical stump with a clamp and inserting the Veress needle perpendicular to the now-vertical fascia (angled superiorly) is a technique to avoid the umbilical vein. — Todd Ponsky (clinical) [Ep 8 · 25:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=1500)
- CO2 embolization via the umbilical vein is a recently recognized complication that was not widely known until about a year ago. — Todd Ponsky (clinical) [Ep 8 · 28:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=1680)
- Clinically significant CO2 embolization results in 25% mortality. — Todd Ponsky (epidemiological) [Ep 8 · 32:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=1920)
- CO2 embolization presents with bradycardia, hypotension, and drop in end-tidal CO2. — Todd Ponsky (clinical) [Ep 8 · 31:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=1860)
- Immediate treatment for CO2 embolization includes desufflation, Trendelenburg positioning, and central venous line placement to aspirate gas. — Todd Ponsky (clinical) [Ep 8 · 34:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=2040)
- Several cases of CO2 embolization have required emergent ECMO at the start of pyloromyotomy. — Todd Ponsky (clinical) [Ep 8 · 35:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=2100)
- spk_0 now uses a sheathed technique but always inserts the trocar before insufflating, inspects with the telescope to confirm peritoneal entry, then begins insufflation. — Todd Ponsky (clinical) [Ep 8 · 35:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=2100)
- The team used ChatGPT for title and abstract screening as well as full text screening in a systematic review and meta-analysis (clinical) [Ep 28 · 2:11](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=131)
- The AI in organ transplantation paper using ChatGPT for screening was published — Carlos (clinical) [Ep 28 · 3:25](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=205)
- ChatGPT was asked to add a column explaining why it made each screening decision to allow for better understanding and prompt refinement — Carlos (clinical) [Ep 28 · 4:11](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=251)
- Inter-rater reliability between ChatGPT and human reviewers for title/abstract screening was excellent — Carlos (clinical) [Ep 28 · 4:32](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=272)
- Creating a custom GPT with serial prompts reduces variability in ChatGPT outputs compared to general search queries — Carlos (clinical) [Ep 28 · 5:52](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=352)
- ChatGPT was used as part of the methodology and reliability process, not for plagiarism or writing, with full disclosure in the paper — Carlos (guideline) [Ep 28 · 6:42](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=402)
- AI models help increase efficiency but humans must always be in the equation for medical and scientific work — Rami (opinion) [Ep 28 · 7:12](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=432)
- ChatGPT is a black box model with unknown training data and changing weights, requiring human oversight to interpret results — Rami (clinical) [Ep 28 · 7:38](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=458)
- Jenny AI is fine-tuned with research papers and can generate paper outlines, provide citations in preferred formats, and suggest summaries of papers to introduce — Rami (clinical) [Ep 28 · 8:11](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=491)
- Open Evidence was developed by Harvard team and Mayo Clinic, focuses on Elsevier library, and provides conversational answers with paper citations — Rami (clinical) [Ep 28 · 10:59](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=659)
- Most AI academic models are now on par with latest published research, searching specific libraries for recent articles — Rami (clinical) [Ep 28 · 10:26](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=626)
- JPS policy prohibits using generative AI to write papers; if disclosed, papers are unlikely to be accepted. Elsevier has tools to detect AI use (guideline) [Ep 28 · 13:17](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=797)
- Using AI for language enhancement and background information is acceptable in journal submissions, but not for generating paper content (guideline) [Ep 28 · 13:52](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=832)
- Fireflies includes action items feature that keeps users informed about next steps after meetings — Carlos (clinical) [Ep 28 · 16:54](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=1014)
- Cincinnati Children's hospital restricted use of meeting transcription tools due to security concerns about auto-recording, especially for legally sensitive meetings — Todd Ponsky (guideline) [Ep 28 · 17:26](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=1046)
- Cincinnati Children's now has Microsoft Co-pilot approved by the hospital for meeting transcription and note-taking — Todd Ponsky (guideline) [Ep 28 · 17:42](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=1062)
- ChatGPT can be used conversationally while driving to discuss and summarize books in a book club format — Todd Ponsky (clinical) [Ep 28 · 20:35](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=1235)
- AI-generated letters of recommendation tend to be overly enthusiastic and require toning down with additional prompts — Todd Ponsky (opinion) [Ep 28 · 21:49](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=1309)
- ChatGPT can create interactive training sessions from uploaded guidelines, avoiding hallucinations by using the guideline as source material — Carlos (clinical) [Ep 28 · 22:22](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=1342)
- ChatGPT can create problem-based learning activities, score responses, and provide feedback for medical education cases — Carlos (clinical) [Ep 28 · 23:09](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=1389)
- AI can generate Step 1 and Step 2 style medical cases in a step-by-step manner with feedback at the end — Rami (clinical) [Ep 28 · 23:25](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=1405)
- The team used ChatGPT for title/abstract screening and full-text screening in a systematic review of AI in organ transplantation, which was subsequently published (clinical) [Ep 29 · 2:49](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=169)
- ChatGPT was prompted to analyze an Excel sheet, screen articles using specified inclusion criteria, add columns indicating relevance (relevant/not relevant/maybe relevant), and provide explanations for each decision — Carlos Kalunga (clinical) [Ep 29 · 3:14](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=194)
- Inter-rater reliability between ChatGPT and human reviewers for systematic review screening was excellent — Carlos Kalunga (clinical) [Ep 29 · 4:28](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=268)
- Creating a custom GPT with serial prompts produces more consistent results than using general ChatGPT search, though slight differences may occur across multiple runs — Carlos Kalunga (clinical) [Ep 29 · 5:52](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=352)
- ChatGPT is used as part of methodology and reliability process in research, not for plagiarism or writing, and this is disclosed in journal submissions — Carlos Kalunga (guideline) [Ep 29 · 6:42](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=402)
- AI models help increase efficiency, which can lead to productivity, but a human must always be in the equation for medical and scientific work — Rami Shaaban (opinion) [Ep 29 · 7:12](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=432)
- ChatGPT is a black box model with unknown training data and changing weights, requiring human oversight to direct it and interpret its outputs — Rami Shaaban (clinical) [Ep 29 · 7:46](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=466)
- Genie AI is an academic model fine-tuned with research papers that can generate paper outlines, provide in-house chatbot assistance, cite papers, and format citations according to preferred specifications — Rami Shaaban (clinical) [Ep 29 · 8:03](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=483)
- Academic AI models like Genie AI are mostly on par with latest published research, though users must verify which library the model searches — Rami Shaaban (clinical) [Ep 29 · 9:46](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=586)
- OpenEvidence was developed by Harvard team and Mayo Clinic, focuses on Elsevier library, provides conversational answers while summarizing latest papers, and suggests related topics — Rami Shaaban (clinical) [Ep 29 · 10:59](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=659)
- Journal of Pediatric Surgery (Elsevier) policy permits using AI for background information and language enhancement but prohibits using generative AI to write papers; disclosure of prohibited use would likely result in rejection (guideline) [Ep 29 · 13:17](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=797)
- Elsevier has tools to detect if generative AI has been used to write papers (clinical) [Ep 29 · 13:41](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=821)
- Most journals permit ChatGPT use only to enhance writing style, not to create ideas — Carlos Kalunga (guideline) [Ep 29 · 14:39](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=879)
- Fireflies provides action items after meetings to keep participants informed of next steps — Carlos Kalunga (clinical) [Ep 29 · 16:54](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=1014)
- Cincinnati Children's Hospital restricted use of meeting transcription tools due to security concerns about auto-recording, particularly for legally sensitive or confidential meetings, and now requires use of approved Microsoft Co-pilot — Todd Ponsky (guideline) [Ep 29 · 17:26](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=1046)
- Cook Children's uses Microsoft Co-pilot as the only approved tool for note-taking, recording, and post-meeting analysis (guideline) [Ep 29 · 18:27](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=1107)
- Creating custom GPTs for repeated prompt sequences is straightforward and allows reuse of complex workflows — Todd Ponsky (opinion) [Ep 29 · 21:13](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=1273)
- ChatGPT can create interactive training sessions from clinical guidelines, generating problem-based learning activities with scoring and feedback, avoiding hallucinations by working from source documents — Carlos Kalunga (clinical) [Ep 29 · 22:22](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=1342)
- ChatGPT can generate medical cases in USMLE Step 1 or Step 2 format with step-by-step progression and end-of-case feedback when given appropriate prompts — Rami Shaaban (clinical) [Ep 29 · 23:25](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=1405)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- The negative appendectomy rate among hospitals is a median of 2.6% with a range from 0 to 17%, according to Kurt Newman's 2003 paper in Journal of Pediatric Surgery reviewing the PHIS database. — Nick Bruns summarizing the discussion [Ep 4 · 1:59](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=119)
- For incidental Meckel's diverticulum during laparoscopy, Zani's 2008 Annals of Surgery review recommended leaving it, stating the risk of complications is not worth the extremely low mortality rate of 0.001%. — Nick Bruns summarizing the discussion [Ep 4 · 2:44](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=164)
- The 50-year Mayo Clinic experience (Park et al., 2005, Annals of Surgery) recommended selective resection of Meckel's diverticulum based on four features: age less than 50, male sex, length greater than 2 cm, or presence of histologically abnormal tissue. — Nick Bruns summarizing the discussion [Ep 4 · 3:10](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=190)
- A Miami Children's Hospital paper (Al-Khoury et al., JAMA Surgery 2012) studied 200 consecutive non-perforated appendicitis patients. 80% were same-day discharges with similar complication and readmission rates compared to overnight stays. — Nick Bruns summarizing the discussion [Ep 4 · 4:28](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-933?t=268)
- The negative appendectomy rate among hospitals is a median of 2.6% with a range from 0 to 17%, according to Kurt Newman's 2003 paper in Journal of Pediatric Surgery reviewing the PHIS database. — Nick Bruns summarizing the discussion [Ep 11 · 1:59](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=119)
- For incidental Meckel's diverticulum during laparoscopy, Zani's 2008 Annals of Surgery review recommended leaving it, stating the risk of complications is not worth the extremely low mortality rate of 0.001%. — Nick Bruns summarizing the discussion [Ep 11 · 2:44](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=164)
- The 50-year Mayo Clinic experience (Park et al., 2005, Annals of Surgery) recommended selective resection of Meckel's diverticulum based on four features: age less than 50, male sex, length greater than 2 cm, or presence of histologically abnormal tissue. — Nick Bruns summarizing the discussion [Ep 11 · 3:10](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=190)
- A Miami Children's Hospital paper (Al-Khoury et al., JAMA Surgery 2012) studied 200 consecutive non-perforated appendicitis patients. 80% were same-day discharges with similar complication and readmission rates compared to overnight stays. — Nick Bruns summarizing the discussion [Ep 11 · 4:28](https://team.globalcastmd.com/watch/hirschsprung-disease-part-i-with-marc-levitt-311?t=268)
- The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy. — Daniel von Allmen summarizing the discussion [Ep 10 · 2:48](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=168)
- The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference. — Daniel von Allmen summarizing the discussion [Ep 10 · 3:32](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=212)
- High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo. — Daniel von Allmen summarizing the discussion [Ep 10 · 4:01](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=241)
- Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo. — Daniel von Allmen summarizing the discussion [Ep 10 · 4:39](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=279)
- Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events. — Daniel von Allmen summarizing the discussion [Ep 10 · 4:55](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=295)
- The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids. — Daniel von Allmen summarizing the discussion [Ep 10 · 7:11](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=431)
- A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other. — Whit Holcomb summarizing the discussion [Ep 10 · 11:20](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=680)
- Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol. — Whit Holcomb summarizing the discussion [Ep 10 · 13:49](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=829)
- The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge. — Whit Holcomb summarizing the discussion [Ep 10 · 14:20](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=860)
- Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days. — Whit Holcomb summarizing the discussion [Ep 10 · 14:48](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=888)
- A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year. — Whit Holcomb summarizing the discussion [Ep 10 · 20:35](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1235)
- Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation. — Whit Holcomb summarizing the discussion [Ep 10 · 22:42](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1362)
- In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate). — Whit Holcomb summarizing the discussion [Ep 10 · 23:14](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1394)
- Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization. — Whit Holcomb summarizing the discussion [Ep 10 · 24:35](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1475)
- Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation. — Whit Holcomb summarizing the discussion [Ep 10 · 24:55](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1495)
- The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned. — Whit Holcomb summarizing the discussion [Ep 10 · 25:20](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1520)
- Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment. — Whit Holcomb summarizing the discussion [Ep 10 · 29:19](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1759)
- A PIFCON multi-center cohort study of 272 children with intestinal failure (median follow-up 33 months) found enteral autonomy was achieved in 43%, 13% remained PN-dependent, and 43% died or underwent transplant. — Aaron Lipskar summarizing the discussion [Ep 10 · 31:31](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1891)
- Necrotizing enterocolitis as the underlying diagnosis, care at an intestinal rehab facility without a transplant center, and presence of an ileocecal valve were all statistically significantly associated with higher rates of enteral autonomy. — Aaron Lipskar summarizing the discussion [Ep 10 · 32:58](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1978)
- Residual small bowel length was also a statistically significant predictor of enteral autonomy, though less impressive than the other three variables. — Aaron Lipskar summarizing the discussion [Ep 10 · 33:19](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1999)
- A companion paper in the same journal (Journal of Pediatrics, July 2015) found necrotizing enterocolitis was a poor predictor of growth outcome in infants with short bowel syndrome. — Aaron Lipskar summarizing the discussion [Ep 10 · 34:46](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2086)
- Animal studies show that commonly used anesthetics and sedatives (propofol, etomidate, sevoflurane, isoflurane, ketamine) that increase GABA receptor activity or block glutamate receptors produce neurotoxic effects in laboratory animals from nematodes to nonhuman primates. — Aaron Lipskar summarizing the discussion [Ep 10 · 38:09](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2289)
- Observational studies in children undergoing early anesthesia offer conflicting results and are confounded by multiple factors, but suggest some children may have deficits—association, not causation. — Aaron Lipskar summarizing the discussion [Ep 10 · 38:43](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2323)
- SmartTots June 2014 statement concluded that animal data is sufficiently convincing to warrant large-scale clinical studies and recommended avoiding anesthesia in children under 3 unless urgent or potentially harmful if not attended to. — Aaron Lipskar summarizing the discussion [Ep 10 · 39:11](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2351)
- The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy. — Daniel von Allmen summarizing the discussion [Ep 5 · 2:48](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=168)
- The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference. — Daniel von Allmen summarizing the discussion [Ep 5 · 3:32](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=212)
- High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo. — Daniel von Allmen summarizing the discussion [Ep 5 · 4:01](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=241)
- Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo. — Daniel von Allmen summarizing the discussion [Ep 5 · 4:39](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=279)
- Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events. — Daniel von Allmen summarizing the discussion [Ep 5 · 4:55](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=295)
- The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids. — Daniel von Allmen summarizing the discussion [Ep 5 · 7:11](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=431)
- A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other. — Whit Holcomb summarizing the discussion [Ep 5 · 11:20](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=680)
- Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol. — Whit Holcomb summarizing the discussion [Ep 5 · 13:49](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=829)
- The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge. — Whit Holcomb summarizing the discussion [Ep 5 · 14:20](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=860)
- Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days. — Whit Holcomb summarizing the discussion [Ep 5 · 14:48](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=888)
- A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year. — Whit Holcomb summarizing the discussion [Ep 5 · 20:35](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1235)
- Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation. — Whit Holcomb summarizing the discussion [Ep 5 · 22:42](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1362)
- In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate). — Whit Holcomb summarizing the discussion [Ep 5 · 23:14](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1394)
- Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization. — Whit Holcomb summarizing the discussion [Ep 5 · 24:35](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1475)
- Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation. — Whit Holcomb summarizing the discussion [Ep 5 · 24:55](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1495)
- The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned. — Whit Holcomb summarizing the discussion [Ep 5 · 25:20](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1520)
- Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment. — Whit Holcomb summarizing the discussion [Ep 5 · 29:19](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1759)
- A PIFCON multi-center cohort study of 272 children with intestinal failure (median follow-up 33 months) found enteral autonomy was achieved in 43%, 13% remained PN-dependent, and 43% died or underwent transplant. — Aaron Lipskar summarizing the discussion [Ep 5 · 31:31](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1891)
- Necrotizing enterocolitis as the underlying diagnosis, care at an intestinal rehab facility without a transplant center, and presence of an ileocecal valve were all statistically significantly associated with higher rates of enteral autonomy. — Aaron Lipskar summarizing the discussion [Ep 5 · 32:58](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1978)
- Residual small bowel length was also a statistically significant predictor of enteral autonomy, though less impressive than the other three variables. — Aaron Lipskar summarizing the discussion [Ep 5 · 33:19](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1999)
- A companion paper in the same journal (Journal of Pediatrics, July 2015) found necrotizing enterocolitis was a poor predictor of growth outcome in infants with short bowel syndrome. — Aaron Lipskar summarizing the discussion [Ep 5 · 34:46](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2086)
- Animal studies show that commonly used anesthetics and sedatives (propofol, etomidate, sevoflurane, isoflurane, ketamine) that increase GABA receptor activity or block glutamate receptors produce neurotoxic effects in laboratory animals from nematodes to nonhuman primates. — Aaron Lipskar summarizing the discussion [Ep 5 · 38:09](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2289)
- Observational studies in children undergoing early anesthesia offer conflicting results and are confounded by multiple factors, but suggest some children may have deficits—association, not causation. — Aaron Lipskar summarizing the discussion [Ep 5 · 38:43](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2323)
- SmartTots June 2014 statement concluded that animal data is sufficiently convincing to warrant large-scale clinical studies and recommended avoiding anesthesia in children under 3 unless urgent or potentially harmful if not attended to. — Aaron Lipskar summarizing the discussion [Ep 5 · 39:11](https://team.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2351)
- A multi-institutional prospective randomized trial comparing piperacillin-tazobactam to ceftriaxone-metronidazole for perforated appendicitis was stopped at 75% enrollment when interim analysis favored the piperacillin-tazobactam group. — Jose Campos summarizing the discussion [Ep 17 · 4:40](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=280)
- Intra-abdominal abscess formation was significantly lower in the piperacillin-tazobactam group with an odds ratio of 4.8. — Jose Campos summarizing the discussion [Ep 17 · 5:30](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=330)
- The number needed to treat with piperacillin-tazobactam to prevent one intra-abdominal abscess was 5.7. — Jose Campos summarizing the discussion [Ep 17 · 5:50](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=350)
- Necrotizing enterocolitis treated surgically is associated with high mortality rates and poor neurodevelopmental outcomes. — Jose Campos summarizing the discussion [Ep 17 · 10:30](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=630)
- Two previous randomized controlled trials comparing surgical techniques for NEC both failed to enroll enough patients to answer the clinical question. — Jose Campos summarizing the discussion [Ep 17 · 10:50](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=650)
- A 20-center randomized controlled trial by Marty Blakely comparing initial laparotomy versus peritoneal drainage for NEC randomized 310 premature newborns. — Jose Campos summarizing the discussion [Ep 17 · 11:05](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=665)
- At 18 to 22 months of corrected age, the composite outcome of death and neurodevelopmental impairment was similar in both the laparotomy and peritoneal drainage groups in frequentist analysis. — Jose Campos summarizing the discussion [Ep 17 · 11:25](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=685)
- Bayesian analysis of the NEC trial showed a high probability of laparotomy being superior to peritoneal drainage. — Jose Campos summarizing the discussion [Ep 17 · 11:40](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=700)
- In the original papers by Ziggy Hein on peritoneal drainage for NEC, approximately one-third of patients died, one-third received laparotomy, and one-third were managed with drainage alone. — The host summarizing the discussion [Ep 17 · 13:51](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=831)
- A systematic review examining gastrostomy insertion techniques reviewed 900 publications, with 58 being used for final recommendations. — Jose Campos summarizing the discussion [Ep 17 · 18:20](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1100)
- Twelve studies directly compared outcomes between laparoscopic and percutaneous endoscopic gastrostomy, showing major complication rates were significantly less common with laparoscopic placement. — Jose Campos summarizing the discussion [Ep 17 · 18:50](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1130)
- The number needed to treat to prevent one major complication from PEG (by using laparoscopic approach instead) is 24. — Jose Campos summarizing the discussion [Ep 17 · 19:20](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1160)
- A database comparison of 3,000 patients with differentiated papillary thyroid cancer found no survival difference between total thyroidectomy and thyroid lobectomy. — Jose Campos summarizing the discussion [Ep 17 · 25:49](https://team.globalcastmd.com/watch/update-course-2022-top-publications-in-non-ped-surg-journals-jose-campos-5819?t=1549)
- Stevens et al. examined CDC Wonder database data between 1999 and 2020 for pediatric firearm and automobile fatalities. — Ellen Encisco summarizing a resource [Ep 19 · 0:46](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=46)
- Stevens et al. used the Gifford's Law Center annual gun law scorecard between 2014 and 2020 to assess state gun law scores. — Ellen Encisco summarizing a resource [Ep 19 · 0:46](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=46)
- In recent years, the fatality rate for firearms has surpassed the fatality rate for automobiles in children. — Ellen Encisco summarizing a resource [Ep 19 · 0:46](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=46)
- Stronger gun laws were associated with decreased fatality rates, with a 55% lower firearm fatality rate for states with the strongest gun laws compared to those with the weakest gun laws. — Ellen Encisco summarizing a resource [Ep 19 · 0:46](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=46)
- Gabapentin is an anticonvulsant often used off-label as part of multimodal pain control after major surgery. — Alex Halpern summarizing a resource [Ep 19 · 2:11](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=131)
- Lascano et al. performed a retrospective cohort study at Children's Hospital of LA looking at kids age 2 to 18 who underwent appendectomy for perforated appendicitis between 2014 and 2019. — Alex Halpern summarizing a resource [Ep 19 · 2:11](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=131)
- In the Lascano et al. study, kids who received gabapentin had decreased postoperative opioid use. — Alex Halpern summarizing a resource [Ep 19 · 2:11](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=131)
- In the Lascano et al. study, kids who received gabapentin had decreased postoperative length of stay. — Alex Halpern summarizing a resource [Ep 19 · 2:11](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=131)
- Frazier et al. conducted a retrospective study from the Midwest Pediatric Surgery Consortium following 375 patients with gastroschisis who underwent closure between 2013 and 2016. — Cecilia Gigena summarizing a resource [Ep 19 · 3:07](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=187)
- The overall rate for periumbilical hernias after gastroschisis closure was 22.7%. — Cecilia Gigena summarizing a resource [Ep 19 · 3:07](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=187)
- Periumbilical hernia rate was significantly higher in patients who underwent primary closure versus those who needed silo placement. — Cecilia Gigena summarizing a resource [Ep 19 · 3:07](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=187)
- Patients who underwent sutureless gastroschisis closures had 50% rates of persistent hernia. — Cecilia Gigena summarizing a resource [Ep 19 · 3:07](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=187)
- Only 16.4% of patients who underwent sutured gastroschisis closure had a persistent hernia. — Cecilia Gigena summarizing a resource [Ep 19 · 3:07](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=187)
- Spontaneous closure of periumbilical hernias after gastroschisis was seen in 38.8% of cases. — Cecilia Gigena summarizing a resource [Ep 19 · 3:07](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=187)
- Only 31.8% of patients with periumbilical hernias after gastroschisis needed surgery. — Cecilia Gigena summarizing a resource [Ep 19 · 3:07](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=187)
- Sutureless gastroschisis closures lead to more periumbilical hernias, but they can be managed as any other congenital umbilical hernia and have no additional risk. — Cecilia Gigena summarizing a resource [Ep 19 · 3:07](https://team.globalcastmd.com/watch/quick-literature-updates-episode-11-6954?t=187)
- The Donnati et al. study was an observational prospective study in Italy from 2013 to 2022 on 468 patients around 15 years old. — Lizzie Lee summarizes what Dr. Carlos Colunga said [Ep 26 · 1:03](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=63)
- Surgeons placed 733 pectus bars total across the 468 patients in the Donnati study. — Lizzie Lee summarizes what Dr. Carlos Colunga said [Ep 26 · 1:13](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=73)
- Bar dislocation is defined as when a pectus bar rotates more than 30 degrees out of place. — Lizzie Lee summarizes what Dr. Carlos Colunga said [Ep 26 · 1:21](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=81)
- Bridge fixation was significantly more stable than single bar fixation for pectus repair. — Lizzie Lee summarizes what Dr. Carlos Colunga said [Ep 26 · 1:28](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=88)
- None of the patients with bridge fixation had dislocated bars compared to those who underwent the single bar technique. — Lizzie Lee summarizes what Dr. Carlos Colunga said [Ep 26 · 1:33](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=93)
- Bridge fixation is the best technique for preventing bar dislocation in pectus excavatum patients. — Lizzie Lee summarizes what Dr. Carlos Colunga said [Ep 26 · 1:39](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=99)
- University of Split researchers developed a machine learning model to accurately identify appendicitis cases while minimizing unnecessary surgery. — Carlos Colunga summarizing a resource [Ep 26 · 2:14](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=134)
- The machine learning model was trained using data from 551 pediatric patients who underwent appendectomy, using their clinical, laboratory, and anthropometric information. — Carlos Colunga summarizing a resource [Ep 26 · 2:24](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=144)
- The best performing machine learning model achieved 99.7% sensitivity in identifying appendicitis cases. — Carlos Colunga summarizing a resource [Ep 26 · 2:37](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=157)
- The machine learning model has specificity that could potentially help reduce up to 17% of negative appendectomies in high risk patients. — Carlos Colunga summarizing a resource [Ep 26 · 2:37](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=157)
- The machine learning model can differentiate between complicated and uncomplicated appendicitis with a high degree of accuracy. — Carlos Colunga summarizing a resource [Ep 26 · 2:54](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=174)
- The machine learning model uses readily available clinical and lab data without using any advanced imaging. — Carlos Colunga summarizing a resource [Ep 26 · 2:54](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=174)
- The Rao et al. study is a multi-center retrospective study done in the US from 2018 to 2022. — Cecilia Gigena summarizes what Dr. Carlos Colunga said [Ep 26 · 3:34](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=214)
- The Rao study compared patients with suspected choledocholithiasis who underwent transcystic laparoscopic common bile duct exploration versus those who underwent ERCP first. — Cecilia Gigena summarizes what Dr. Carlos Colunga said [Ep 26 · 3:34](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=214)
- The Rao study included 252 patients total: 156 in the transcystic laparoscopic common bile duct exploration group and 96 in the ERCP-first group. — Cecilia Gigena summarizes what Dr. Carlos Colunga said [Ep 26 · 3:53](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=233)
- Patients who underwent transcystic laparoscopic common bile duct exploration had significantly less complication rates compared to ERCP-first patients. — Cecilia Gigena summarizes what Dr. Carlos Colunga said [Ep 26 · 4:02](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=242)
- Patients who underwent transcystic laparoscopic common bile duct exploration had lower length of stay compared to ERCP-first patients. — Cecilia Gigena summarizes what Dr. Carlos Colunga said [Ep 26 · 4:02](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=242)
- Attempting a transcystic laparoscopic common bile duct exploration may benefit pediatric choledocholithiasis patients. — Cecilia Gigena summarizes what Dr. Carlos Colunga said [Ep 26 · 4:16](https://team.globalcastmd.com/watch/quick-literature-updates-ep-24-11235?t=256)
- In Ponsky's inter-observer variation study published in Journal of Laparoendoscopic and Advanced Surgical Techniques, attending surgeons viewing same images agreed on perforation status only 25% of the time without defined criteria — Whit Holcomb summarizing a resource [Ep 12 · 23:41](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1421)
- Wound infection rate was 3.3% (6/180) for single-incision versus 1.7% (3/180) for three-port, p=0.5, not statistically different — Todd Ponsky summarizes what Dr. Whit Holcomb said [Ep 12 · 30:23](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=1823)
- Adult literature reports approximately 2/3 of appendicitis patients can be treated non-operatively without surgery, about 1/3 require operation — Whit Holcomb summarizing a resource [Ep 12 · 52:18](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3138)
- Nationwide Children's Hospital has performed work on non-operative appendicitis management and has ongoing prospective randomized trial; another multi-hospital trial is in planning stages — Whit Holcomb summarizing a resource [Ep 12 · 52:18](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3138)
- Non-operative candidates will likely be non-perforated appendicitis patients, though Marty Blakely's study shows some perforated patients can also be treated non-operatively — Whit Holcomb summarizing a resource [Ep 12 · 52:18](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3138)
- Los Angeles study showed approximately 10% of patients initially managed non-operatively for perforated appendicitis without interval appendectomy returned for recurrent appendicitis, but follow-up was only 1-1.5 years — Whit Holcomb summarizing a resource [Ep 12 · 56:15](https://team.globalcastmd.com/watch/evidence-based-diagnosis-and-management-of-pediatric-appendicitis-with-dr-whit-holcomb-314?t=3375)
- The hospital had a clinical pathway in place for about 30 years before implementing a new pathway in 2015. — Todd Ponsky summarizing a resource [Ep 2 · 0:06](https://team.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6)
- The new pathway initiated a disease severity classification for perforated appendicitis. — Todd Ponsky summarizing a resource [Ep 2 · 0:06](https://team.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6)
- The new pathway refined discharge criteria for perforated appendicitis. — Todd Ponsky summarizing a resource [Ep 2 · 0:06](https://team.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6)
- The new pathway standardized the operative technique for perforated appendicitis. — Todd Ponsky summarizing a resource [Ep 2 · 0:06](https://team.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6)
- The new pathway established criteria for the use of postoperative TPN in perforated appendicitis. — Todd Ponsky summarizing a resource [Ep 2 · 0:06](https://team.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6)
- The new pathway established criteria for the use of postoperative imaging in perforated appendicitis. — Todd Ponsky summarizing a resource [Ep 2 · 0:06](https://team.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6)
- The new pathway established criteria for the use of postoperative invasive procedures such as draining an abscess. — Todd Ponsky summarizing a resource [Ep 2 · 0:06](https://team.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6)
- The study prospectively evaluated outcomes of all children treated on the new standardized protocol over 20 months. — Todd Ponsky summarizing a resource [Ep 2 · 0:06](https://team.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6)
- The study compared prospective outcomes to all patients treated in the 58 months prior to standardization. — Todd Ponsky summarizing a resource [Ep 2 · 0:06](https://team.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6)
- Median follow-up time post-discharge was 14 days in the pre-standardized group. — Todd Ponsky summarizing a resource [Ep 2 · 0:06](https://team.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6)
- Median follow-up time post-discharge was 25 days in the post-standardized group. — Todd Ponsky summarizing a resource [Ep 2 · 0:06](https://team.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6)
- Standardization significantly reduced postoperative abscess in perforated appendicitis. — Todd Ponsky summarizing a resource [Ep 2 · 0:06](https://team.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6)
- Standardization significantly reduced hospital stay in perforated appendicitis. — Todd Ponsky summarizing a resource [Ep 2 · 0:06](https://team.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6)
- Standardization reduced the odds of developing a postoperative abscess by 4 times. — Todd Ponsky summarizing a resource [Ep 2 · 0:06](https://team.globalcastmd.com/watch/standardization-of-care-for-pediatric-perforated-appendicitis-389?t=6)
- In adult studies reviewing approximately 300 patients managed non-operatively versus 500 managed operatively, treatment failure trended toward favoring surgical approach, but complications favored non-operative management. — The host summarizing the discussion [Ep 3 · 5:50](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=350)
- Adult estimates of non-operative management success revolve around 80%, which was integral in developing the sample size for the randomized trial. — The host summarizing the discussion [Ep 3 · 7:00](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=420)
- Thomas Wester's pilot randomized trial in Sweden enrolled 50 patients, with 24 receiving antibiotics. 22 of 24 (92%) had initial resolution of symptoms, and one patient had recurrent appendicitis. — The host summarizing the discussion [Ep 3 · 8:00](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=480)
- At 77 patients in the preference trial, 30 chose non-operative treatment (about one-third), with 90% success at 30 days and fewer disability days, earlier return to school, and improved quality of life versus surgery. — The host summarizing the discussion [Ep 3 · 10:50](https://team.globalcastmd.com/watch/appendicitis-management-appy-trial-update-course-2016-549?t=650)
- Inter-observer variation study (Journal of Laparoendoscopic and Advanced Surgical Techniques) showed only 25% agreement among attending surgeons on perforation status when viewing operative images without defined criteria — Whit Holcomb summarizing a resource [Ep 6 · 23:41](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=1421)
- Adult literature and Nationwide Children's Hospital data suggest approximately 50-60% of non-perforated appendicitis patients could be managed with antibiotics alone; about one-third require operation — Whit Holcomb summarizing a resource [Ep 6 · 52:11](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=3131)
- Prospective randomized trials on non-operative appendicitis management are underway at Nationwide Children's Hospital and other hospital groups — Whit Holcomb summarizing a resource [Ep 6 · 52:11](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=3131)
- Los Angeles study: 10% recurrence rate of appendicitis without interval appendectomy after non-operative management, but follow-up only 1-1.5 years — Whit Holcomb summarizing a resource [Ep 6 · 56:15](https://team.globalcastmd.com/watch/appendicitis-with-dr-whit-holcomb-939?t=3375)
- In a 2010 study from Journal of Pediatric Surgery, 200 CT scans were reviewed by 6 surgeons (including 2 fellows) and 2 radiologists who were blinded to diagnosis, and reviewers correctly identified perforated versus non-perforated appendicitis in 72% of scans that had no abscesses. — The host summarizing the discussion [Ep 9 · 0:01](https://team.globalcastmd.com/watch/perforated-appendicitis-2312?t=1)
- Cases with abscesses were excluded from the CT scan accuracy study. — The host summarizing the discussion [Ep 9 · 2:28](https://team.globalcastmd.com/watch/perforated-appendicitis-2312?t=148)
- In Doctor Ponsky's 2009 study on inter-observer variation in assessment of appendiceal perforation, 110 surgeons (62 attendings and 48 fellows) from university, community, and children's hospitals reviewed images, and agreement among attendings in defining perforation was 27%. — The host summarizing the discussion [Ep 9 · 2:38](https://team.globalcastmd.com/watch/perforated-appendicitis-2312?t=158)
- Inter-observer and intra-observer variability in identifying perforated appendicitis from images was close to chance alone; when one image was turned upside down and flipped, surgeons did not agree with their own previous assessment. — The host summarizing the discussion [Ep 9 · 5:40](https://team.globalcastmd.com/watch/perforated-appendicitis-2312?t=340)
- When patients with stool in the abdomen or a hole in the appendix were grouped together as perforated, those without either finding had an abscess incidence of less than 5%. — Todd Ponsky summarizing the discussion [Ep 9 · 8:30](https://team.globalcastmd.com/watch/perforated-appendicitis-2312?t=510)
- In the two years before applying the standardized perforation definition, 292 non-perforated appendicitis cases had a 1.7% abscess rate and 131 perforated cases had a 14% abscess rate. — The host summarizing the discussion [Ep 9 · 9:20](https://team.globalcastmd.com/watch/perforated-appendicitis-2312?t=560)
- After applying the standardized definition for two years, the abscess rate dropped to 0.7% for non-perforated appendicitis and rose to 18% for perforated appendicitis, indicating that some perforated cases had been misclassified as non-perforated before the definition was used. — The host summarizing the discussion [Ep 9 · 9:50](https://team.globalcastmd.com/watch/perforated-appendicitis-2312?t=590)
- Doctor Saint Peter's prospective randomized study compared irrigation and suction versus suction alone during laparoscopic appendectomy for perforated appendicitis, with 110 patients in each arm and a minimum of 500cc irrigation (average 850cc) in the irrigation group. — The host summarizing the discussion [Ep 9 · 10:31](https://team.globalcastmd.com/watch/perforated-appendicitis-2312?t=631)
- The irrigation study found no difference between groups in abscess rate, length of hospitalization, hospital charges, or operative time, concluding there was no advantage to irrigation during laparoscopic appendectomy for perforated appendicitis. — The host summarizing the discussion [Ep 9 · 11:40](https://team.globalcastmd.com/watch/perforated-appendicitis-2312?t=700)
- A 2017 University of Minnesota retrospective study (432 patients over 10 years, 105 perforated) compared standardized large-volume irrigation (3-12 liters in small focused aliquots) by one surgeon to surgeon preference for irrigation by others, finding 0% abscess rate with standardized irrigation versus 19% with surgeon preference. — The host summarizing the discussion [Ep 9 · 11:27](https://team.globalcastmd.com/watch/perforated-appendicitis-2312?t=687)
- A 2018 meta-analysis of irrigation versus suction alone for laparoscopic appendectomy included 3 randomized trials and 2 retrospective studies with 2500 patients (4/5 adults) and found no difference in abscess development, wound infection, or length of hospitalization. — The host summarizing the discussion [Ep 9 · 14:20](https://team.globalcastmd.com/watch/perforated-appendicitis-2312?t=860)
- In the Minnesota study showing benefit from irrigation, the surgeon used a focused push-suck technique with small volumes (100cc at a time) rather than irrigating the whole abdomen. — The host summarizing the discussion [Ep 9 · 16:34](https://team.globalcastmd.com/watch/perforated-appendicitis-2312?t=994)
- In studies using the standardized perforation definition, the presence of exudate everywhere (without a visible hole or stool) did not correlate with increased abscess risk. — The host summarizing the discussion [Ep 9 · 17:03](https://team.globalcastmd.com/watch/perforated-appendicitis-2312?t=1023)
- In a study of 200 CT scans reviewed by 6 surgeons (including 2 fellows) and 2 radiologists, reviewers were only 72% accurate in determining whether an appendix was perforated or non-perforated. — Rod Gerardo summarizing the discussion [Ep 13 · 2:08](https://team.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=128)
- Among 110 surgeons (62 attendings and 48 fellows, including adult and pediatric surgeons from university, community, and children's hospitals), inter-observer agreement in defining intraoperative images as perforated or non-perforated appendicitis was 27%. — Rod Gerardo summarizing the discussion [Ep 13 · 4:00](https://team.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=240)
- In Doctor Ponsky's study, when the same laparoscopic image was shown upside down and flipped, surgeons did not agree with their own previous assessment, demonstrating intra-observer variability close to chance alone. — Whit Holcomb summarizing the discussion [Ep 13 · 5:15](https://team.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=315)
- At Kansas City (Doctor Saint Peter's group), perforated appendicitis is defined as a hole in the appendix or a fecalith in the abdomen. — Rod Gerardo summarizing the discussion [Ep 13 · 6:00](https://team.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=360)
- When patients did not have either a hole in the appendix or stool in the abdomen, the incidence of postoperative abscess was less than 5%. — Rod Gerardo summarizing the discussion [Ep 13 · 6:30](https://team.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=390)
- After implementing a standardized definition for perforated appendicitis, the non-perforation abscess rate decreased and the perforation abscess rate increased, suggesting previous misclassification of cases. — Rod Gerardo summarizing the discussion [Ep 13 · 7:00](https://team.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=420)
- In a randomized trial with 110 patients per arm using minimum 500cc irrigation (average 850cc), there was no difference in postoperative abscess rate, length of stay, hospital cost, or operative time between irrigation and no irrigation groups. — Rod Gerardo summarizing the discussion [Ep 13 · 7:54](https://team.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=474)
- In a study comparing standardized large-volume irrigation (3-12 liters in small focused aliquots) to surgeon preference irrigation, patients receiving standardized irrigation had 0% abscess rate versus 19% with surgeon discretion. — Whit Holcomb summarizing the discussion [Ep 13 · 8:40](https://team.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=520)
- A 2018 meta-analysis comparing suction alone versus irrigation in children and adults found no difference in the rate of postoperative abscess. — Whit Holcomb summarizing the discussion [Ep 13 · 10:09](https://team.globalcastmd.com/watch/update-course-rewind-perforated-appendicitis-2019-3934?t=609)
- The RIFT study prospectively evaluated 15 different clinical prediction models in children with right iliac fossa pain by calculating area under the curve and failure rates. — Jose Campos summarizing a resource [Ep 14 · 3:39](https://team.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=219)
- The Shira score had an area under the curve of 0.84 and a failure rate of 3%, making it the best performing model for ruling out appendicitis. — Rod Gerardo summarizes what Dr. Jose Campos said [Ep 14 · 4:11](https://team.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=251)
- A standardized ultrasound reporting template reduced equivocal reports from 27% to 9%. — Jose Campos summarizing a resource [Ep 14 · 4:56](https://team.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=296)
- The standardized ultrasound reporting reduced CT use from 19% to 9% without affecting negative laparotomy rates. — Jose Campos summarizing a resource [Ep 14 · 4:56](https://team.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=296)
- In a pilot RCT of non-perforated appendicitis, surgical failure rate was 0% versus 45% medical failure rate, with failure defined as requiring laparoscopic appendectomy during follow-up. — Jose Campos summarizing a resource [Ep 14 · 6:37](https://team.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=397)
- The non-operative versus appendectomy study randomized 26 patients to surgery and 24 to antibiotics. — Jose Campos summarizing a resource [Ep 14 · 6:37](https://team.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=397)
- Ceftriaxone plus metronidazole showed a 90% reduction in surgical site infection compared to cefoxitin for non-complicated appendicitis in a large NSQIP-based retrospective cohort study published in Annals of Surgery in 2020. — Jose Campos summarizing a resource [Ep 14 · 7:35](https://team.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=455)
- Dr. Sean Saint Peter and Whitt Holcomb defined perforated appendicitis in 2005 as a hole in the appendix or fecal material in the abdomen. — Jose Campos summarizing a resource [Ep 14 · 8:24](https://team.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=504)
- Four intraoperative findings correlate with complicated postoperative course for appendicitis: visible hole, abscess, fecal material, and diffuse fibrinopurulent exudate outside the right iliac fossa or pelvis. — Rod Gerardo summarizes what Dr. Jose Campos said [Ep 14 · 9:13](https://team.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=553)
- These four intraoperative findings were associated with higher adverse effects, higher length of stay, higher emergency visits, and higher use of hospital and patient resources after adjusting for all variables. — Todd Ponsky summarizes what Dr. Jose Campos said [Ep 14 · 9:56](https://team.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=596)
- Pus in the abdomen is a predictor of abscess in the recent study, which differs from Sean Saint Peter's study where it was not a predictor. — Rod Gerardo summarizes what Dr. Jose Campos said [Ep 14 · 10:07](https://team.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=607)
- A double-blind RCT of 243 patients randomized to two doses of postoperative antibiotics versus placebo found a significant reduction in skin infection rate from 6.6% to 0.8% for simple appendicitis. — Jose Campos summarizing a resource [Ep 14 · 10:33](https://team.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=633)
- A 6% baseline infection rate for simple appendicitis seems too high. — Rod Gerardo summarizes what Dr. Jose Campos said [Ep 14 · 11:08](https://team.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=668)
- A pre-post intervention study completely eliminated opioid prescriptions after non-perforated appendectomy and found no increase in self-reported pain or extra medication use via phone interviews and surgical follow-up. — Jose Campos summarizing a resource [Ep 14 · 12:05](https://team.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=725)
- After converting from opiates to Tylenol and/or Motrin for post-appendectomy pain, patients are fine and do not come back asking for opiates. — Rod Gerardo summarizes what Dr. Jose Campos said [Ep 14 · 12:45](https://team.globalcastmd.com/watch/journal-club-appendicitis-in-2021-4416?t=765)
- The 2022 Update Course had 1,467 registrants who attended live and 1,800 people who watched immediately after. — Cecilia summarizing a resource [Ep 20 · 1:23](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=83)
- Over 8,000 people visited the event page and watched videos from the 2022 Update Course. — Cecilia summarizing a resource [Ep 20 · 1:40](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=100)
- To combat implicit and explicit bias, one should stand up for people when they are being called out or championed in the moment, not in private places afterward. — Cecilia summarizing a resource [Ep 20 · 2:20](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=140)
- Small children do not necessarily need an IV line for hydration because they can be hydrated by mouth until 2 hours prior to surgery according to current fasting guidelines. — Cecilia summarizing a resource [Ep 20 · 2:45](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=165)
- Collimation (making the radiation field smaller) can produce better images without increasing radiation dose. — Cecilia summarizing a resource [Ep 20 · 3:05](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=185)
- If shielding patients during fluoroscopy, the shield must be placed on the bottom of the OR table, not on top of the patient, to be effective. — Cecilia summarizing a resource [Ep 20 · 3:30](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=210)
- CT for suspected airway foreign body in patients with reactive airway has over 94% sensitivity and specificity. — Cecilia summarizing a resource [Ep 20 · 4:00](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=240)
- Mechanical bowel preparation is not needed to reduce surgical site infections. — Cecilia summarizing a resource [Ep 20 · 4:25](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=265)
- In the NEC trial comparing drainage versus laparotomy, laparotomy showed better neurodevelopmental outcomes. — Cecilia summarizing a resource [Ep 20 · 5:10](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=310)
- Non-perforated appendicitis patients can be discharged on the same day of surgery. — Cecilia summarizing a resource [Ep 20 · 5:50](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=350)
- Dr. Sean St. Peter reduced abscess rates in perforated appendicitis from 20% to 10% by treating patients as if they are not sick. — Cecilia summarizing a resource [Ep 20 · 6:05](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=365)
- Non-surgical management of appendicitis has approximately 30% failure rate, making it not better than surgery, but it remains an option in certain cases. — Cecilia summarizing a resource [Ep 20 · 6:35](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=395)
- Congenital esophageal stenosis can be treated with dilations in most cases, with good outcomes and no need for resection. — Cecilia summarizing a resource [Ep 20 · 7:05](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=425)
- If congenital esophageal stenosis has a cartilage remnant, resection may be needed; otherwise dilation might be sufficient. — Cecilia summarizing a resource [Ep 20 · 7:35](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=455)
- Advocacy for pediatric gunshot injury prevention includes talking to parents at every visit about safe gun storage, not just after an injury occurs. — Cecilia summarizing a resource [Ep 20 · 8:10](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=490)
- After gastroschisis closure, patients can be fed as soon as possible as long as they are clinically stable. — Cecilia summarizing a resource [Ep 20 · 9:05](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=545)
- Feeding protocols improve outcomes in gastroschisis patients. — Cecilia summarizing a resource [Ep 20 · 9:25](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=565)
- Emesis is normal in gastroschisis patients after closure, so clinicians should not be alarmed by it. — Cecilia summarizing a resource [Ep 20 · 9:40](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=580)
- Asymptomatic spontaneous pneumomediastinum does not require hospital admission. — Cecilia summarizing a resource [Ep 20 · 10:50](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=650)
- Asymptomatic spontaneous pneumothorax does not require hospital admission. — Cecilia summarizing a resource [Ep 20 · 10:50](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=650)
- Straddle injuries with no active bleeding do not require hospital admission. — Cecilia summarizing a resource [Ep 20 · 11:10](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=670)
- Intussusceptions that resolve with water enema or air reduction do not require hospital admission. — Cecilia summarizing a resource [Ep 20 · 11:25](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=685)
- Low-grade solid organ injuries can be discharged from the emergency department. — Cecilia summarizing a resource [Ep 20 · 11:45](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=705)
- Most esophageal leaks can be managed by observation or chest drain without surgical intervention. — Cecilia summarizing a resource [Ep 20 · 12:10](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=730)
- For external esophageal fistulas in the neck or persistent leaks, an endo-vac (negative pressure device placed inside the esophagus at the leak site) is a good treatment option. — Cecilia summarizing a resource [Ep 20 · 12:30](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=750)
- After any esophageal leak (whether resolved with endo-vac, observation, or chest drain), stricture rates are increased, so patients should be monitored for strictures. — Cecilia summarizing a resource [Ep 20 · 13:00](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=780)
- Best of the Best 2022 had over 2,000 registered participants, 800 attended live, and represented 116 different countries. — Cecilia summarizing a resource [Ep 20 · 13:50](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=830)
- Rebecca Figueira from Hospital for Sick Children in Canada won the world winner award for Best of the Best 2022 for work on fetal vascular development in CDH, marking the second consecutive year this lab has won. — Cecilia summarizing a resource [Ep 20 · 15:00](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=900)
- For positive cutaneous melanoma, sentinel lymph node biopsy with ultrasound surveillance is sufficient instead of complete lymph node dissection. — Cecilia summarizing a resource [Ep 20 · 15:40](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=940)
- In pulmonary sequestrations, surgical treatment was found to be better than embolization in a multi-center European (especially Italian) comparison study. — Cecilia summarizing a resource [Ep 20 · 16:10](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=970)
- Tele-simulation is as effective as standard in-person simulation for surgical training; trainees trained by either method showed equivalent outcomes. — Cecilia summarizing a resource [Ep 20 · 16:40](https://team.globalcastmd.com/watch/update-course-2023-update-course-2022-and-best-of-the-best-recap-7273?t=1000)
- The APPY trial is an international multicenter study comparing appendectomy versus antibiotics for acute uncomplicated appendicitis in children, with 936 patients aged 5-16 years randomized across 11 hospitals — Jose Campos summarizing the discussion [Ep 25 · 4:33](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=273)
- In the APPY trial, treatment failure was defined differently in each arm: in the antibiotic group as appendectomy needed within one year, and in the surgical group as negative appendectomy or any procedure under general anesthesia related to appendicitis within one year — Jose Campos summarizing the discussion [Ep 25 · 4:33](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=273)
- At one year in the APPY trial, 31% of children in the antibiotic group failed treatment compared with 7% in the appendectomy group, with the 26.7% difference exceeding the pre-specified 20% non-inferiority margin — Jose Campos summarizing the discussion [Ep 25 · 4:33](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=273)
- Children in the antibiotic group of the APPY trial returned to school earlier and needed almost no pain medication — Jose Campos summarizing the discussion [Ep 25 · 6:10](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=370)
- The APPY trial had 10% of patients with incomplete data and consent refusal reasons were not collected — Jose Campos summarizing the discussion [Ep 25 · 6:10](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=370)
- Some guidelines recommend against DVT prophylaxis in pediatric trauma, and in the study only 50% of doctors caring for these children gave DVT prophylaxis — Jose Campos summarizing the discussion [Ep 25 · 7:25](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=445)
- A JAMA Surgery 2024 study prospectively evaluated 462 pediatric trauma patients with high risk for deep vein thrombosis across level one trauma centers, comparing outcomes based on whether prophylaxis was given and when it was initiated — Johan Karameez summarizing the discussion [Ep 25 · 9:28](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=568)
- No major bleeding event occurred in any patient who received anticoagulation in the DVT prophylaxis study — Johan Karameez summarizing the discussion [Ep 25 · 9:28](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=568)
- Patients who received DVT prophylaxis within 24 hours had a venous thromboembolism rate of 1.6%, while those who received it after 24 hours had a rate of 6.9%, nearly identical to the 5.3% in patients who never received prophylaxis — Johan Karameez summarizing the discussion [Ep 25 · 9:28](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=568)
- The DVT prophylaxis study had low adherence to VTE guidelines with almost half of patients never receiving prophylaxis and relatively low absolute numbers of VTE events restricting statistical power — Johan Karameez summarizing the discussion [Ep 25 · 10:36](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=636)
- The DVT prophylaxis study was powered to detect any adverse event and there was no adverse event whatsoever from prophylaxis — Jose Campos summarizing the discussion [Ep 25 · 13:06](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=786)
- A Journal of American College of Surgeons 2025 study using the National Cancer Database between 2004 and 2022 identified 1339 patients under 18 years with appendiceal neuroendocrine tumors, comparing appendectomy versus right hemicolectomy — Jose Campos summarizing the discussion [Ep 25 · 15:12](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=912)
- In the neuroendocrine tumor study, survival was excellent and equivalent between appendectomy and hemicolectomy groups: 99.9% at 5 years and 99.4% at 10 years without chemotherapy or additional treatment — Jose Campos summarizing the discussion [Ep 25 · 15:12](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=912)
- No forced disease progression occurred in children treated with appendectomy alone, even when high-risk features like tumor larger than 2 centimeters, positive margins, or positive lymph nodes were present — Jose Campos summarizing the discussion [Ep 25 · 15:12](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=912)
- The TOUCH trial was the first multicenter randomized control trial comparing stoma versus anastomosis in necrotizing enterocolitis, randomizing patients during laparotomy when both options were deemed feasible — Jose Campos summarizing the discussion [Ep 25 · 20:31](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=1231)
- The TOUCH trial found no difference in mortality or complications in general between stoma and anastomosis groups, but the stoma group had up to 19% of intestinal and stoma complications — Jose Campos summarizing the discussion [Ep 25 · 21:30](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=1290)
- In the TOUCH trial, the likelihood of being weaned from parenteral nutrition was much higher in the anastomosis group, and children were weaned 20 days earlier compared to the stoma group — Jose Campos summarizing the discussion [Ep 25 · 21:30](https://team.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-pediatric-surgery-feat-non-jps-journals-10897?t=1290)
- The MRI protocol was only for patients 7 years or older during normal MRI technologist hours — Cecilia Gigena summarizing the discussion [Ep 23 · 2:41](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559?t=161)
- If perforated appendicitis with suspected abscess, CT should be used instead of MRI because CT is better for abscess evaluation — Cecilia Gigena summarizing the discussion [Ep 23 · 2:41](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559?t=161)
- Following the quality improvement campaign, MRI rate increased almost tenfold while CT use decreased markedly — Cecilia Gigena summarizing the discussion [Ep 23 · 3:16](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559?t=196)
- The study included 101 patients who experienced 137 episodes of adhesive small bowel obstruction between 2000 and 2020 — Em Gootee summarizing the discussion [Ep 23 · 5:21](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559?t=321)
- Most adhesive small bowel obstructions occurred within the first 5 years of the index surgery — Em Gootee summarizing the discussion [Ep 23 · 5:21](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559?t=321)
- Around 90% of adhesive small bowel obstructions required surgery — Em Gootee summarizing the discussion [Ep 23 · 5:21](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559?t=321)
- The most frequent initial surgeries leading to adhesive small bowel obstruction were necrotizing enterocolitis, duodenal obstruction, and primary adhesive small bowel obstruction — Em Gootee summarizing the discussion [Ep 23 · 5:21](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559?t=321)
- 50% of adhesive small bowel obstructions had significant complications (Clavien-Dindo grade 2 or higher) — Em Gootee summarizing the discussion [Ep 23 · 5:21](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559?t=321)
- The median cost of managing one episode of adhesive small bowel obstruction was approximately $36,000 — Em Gootee summarizing the discussion [Ep 23 · 5:21](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559?t=321)
- 137 episodes in 20 years at one center resulted in nearly $50 million in costs — Em Gootee summarizing the discussion [Ep 23 · 5:21](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559?t=321)
- There is a lack of evidence regarding the effect of laparoscopic surgery and lack of comparative studies on whether laparoscopic surgery reduces long-term postoperative adhesive obstructions in pediatric patients — Cecilia Gigena summarizing the discussion [Ep 23 · 7:15](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559?t=435)
- The esophageal atresia study included 359 patients: 152 open operations and 217 thoracoscopic approaches, all type C (with distal fistula), between January 2010 and December 2021 — Em Gootee summarizing the discussion [Ep 23 · 8:45](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559?t=525)
- Surgical time is longer in the thoracoscopic group for esophageal atresia repair — Em Gootee summarizing the discussion [Ep 23 · 8:45](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559?t=525)
- There was no significant difference in complications such as leak or strictures between thoracoscopic and open esophageal atresia repair — Em Gootee summarizing the discussion [Ep 23 · 8:45](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559?t=525)
- With open esophageal atresia surgery, you highly likely have scoliosis and shoulder girdle weakness, which with thoracoscopic repair you can prevent 100% — Cecilia Gigena summarizing the discussion [Ep 23 · 9:37](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559?t=577)
- The Chinese center was able to change their practice from open to thoracoscopic esophageal atresia repair in about 10 years — Cecilia Gigena summarizing the discussion [Ep 23 · 10:01](https://team.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2023-8559?t=601)
- A mixed-method study done in Colorado aimed to reduce the rate of CT by implementing a quality improvement campaign to stimulate the use of rapid sequence MRI for appendicitis — Cecilia Gigena summarizing a resource [Ep 22 · 0:00](https://team.globalcastmd.com/watch/quality-improvement-campaign-improved-utilization-of-rapid-sequence-mri-for-diagnosis-of-pediatric-appendicitis-8051?t=0)
- The quality improvement campaign was implemented in May 2021 — Cecilia Gigena summarizing a resource [Ep 22 · 0:00](https://team.globalcastmd.com/watch/quality-improvement-campaign-improved-utilization-of-rapid-sequence-mri-for-diagnosis-of-pediatric-appendicitis-8051?t=0)
- The study retrospectively examined all patients with appendicitis from 2016 to 2022 — Cecilia Gigena summarizing a resource [Ep 22 · 0:00](https://team.globalcastmd.com/watch/quality-improvement-campaign-improved-utilization-of-rapid-sequence-mri-for-diagnosis-of-pediatric-appendicitis-8051?t=0)
- The campaign significantly reduced the rates of CT use while increasing the rates of rapid sequence MRI with similar diagnostic results — Cecilia Gigena summarizing a resource [Ep 22 · 0:00](https://team.globalcastmd.com/watch/quality-improvement-campaign-improved-utilization-of-rapid-sequence-mri-for-diagnosis-of-pediatric-appendicitis-8051?t=0)
- Rapid sequence MRI can be used instead of CT for equivocal ultrasound in suspected appendicitis — Cecilia Gigena summarizing a resource [Ep 22 · 0:00](https://team.globalcastmd.com/watch/quality-improvement-campaign-improved-utilization-of-rapid-sequence-mri-for-diagnosis-of-pediatric-appendicitis-8051?t=0)
- Perforation is defined as having a hole in the appendix or a fecalith in the abdomen, based on a 2008 paper that showed this classification impacted abscess rates in a clinically logical way. — Sueso Diah Quihena summarizing a resource [Ep 18 · 0:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=0)
- Gangrenous appendicitis is classified as non-perforated and patients typically fall into the group that would get sent home. — Sueso Diah Quihena summarizing a resource [Ep 18 · 0:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=0)
- The initial same-day discharge study in 2013-14 achieved 28% successful discharge rate. — Sueso Diah Quihena summarizing a resource [Ep 18 · 7:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=420)
- A recent study showed 87% successful same-day discharge rate for non-perforated appendicitis, which has become the norm. — Sueso Diah Quihena summarizing a resource [Ep 18 · 7:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=420)
- A 2012 randomized study comparing suction to irrigation (minimum 500 ccs, average 850 ccs) showed no difference in outcomes. — Sueso Diah Quihena summarizing a resource [Ep 18 · 7:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=420)
- A retrospective study using 3 to 12 liters of irrigation in 50 cc aliquots showed 0% abscess rate in irrigated patients compared to 18.9% in perforated appendicitis population. — Sueso Diah Quihena summarizing a resource [Ep 18 · 7:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=420)
- In Cincinnati's practice using suction without irrigation, no major difference in abscess rate has been observed. — Sueso Diah Quihena summarizing a resource [Ep 18 · 7:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=420)
- Discharge criteria for perforated appendicitis include patient being afebrile, having good pain control, and tolerating diet. — Sueso Diah Quihena summarizing a resource [Ep 18 · 15:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=900)
- Patients typically transition from clears to solids on day one, and by day two breakfast is about the fastest discharge timing typically seen. — Sueso Diah Quihena summarizing a resource [Ep 18 · 15:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=900)
- Previous trials showed a 20% abscess rate that was fixed across different antibiotic regimens and irrigation protocols. — Sueso Diah Quihena summarizing a resource [Ep 18 · 15:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=900)
- Abscess rate dropped to about 10% after changing practice to treat patients as healthy rather than sick. — Sueso Diah Quihena summarizing a resource [Ep 18 · 15:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=900)
- Cincinnati implemented a protocol using QI techniques and found no change in readmission rate for abscess when discharging patients by day two post-op. — Sueso Diah Quihena summarizing a resource [Ep 18 · 15:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=900)
- Eligibility criteria for non-operative management include symptoms less than 48 hours, imaging confirmation with appendiceal diameter less than 1.1 cm, no abscess/phlegmon/fecalith, and white count between 5 and 18. — Sueso Diah Quihena summarizing a resource [Ep 18 · 25:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=1500)
- The Cota trial was a pragmatic randomized control trial on the adult side examining non-operative management. — Sueso Diah Quihena summarizing a resource [Ep 18 · 25:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=1500)
- A patient and family choice study was conducted in the Midwest Pediatric Surgical Consortium examining non-operative management in children. — Sueso Diah Quihena summarizing a resource [Ep 18 · 25:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=1500)
- The multicenter trial was designed as a non-inferiority trial with a non-inferiority margin set at around 20% based on surgeon consensus. — Sueso Diah Quihena summarizing a resource [Ep 18 · 25:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=1500)
- Interim analysis shows approximately 31-32% one-year failure rate for non-operative management. — Sueso Diah Quihena summarizing a resource [Ep 18 · 25:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=1500)
- Not all failures of non-operative management had appendicitis on histology when they eventually had surgery. — Sueso Diah Quihena summarizing a resource [Ep 18 · 25:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=1500)
- Non-operative management showed a non-significant three extra days of school absence compared to surgical management. — Sueso Diah Quihena summarizing a resource [Ep 18 · 25:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=1500)
- Many patients treated non-operatively have an interval appendectomy, which can be scheduled electively and may provide better quality of life than admission. — Sueso Diah Quihena summarizing a resource [Ep 18 · 25:00](https://team.globalcastmd.com/watch/update-course-rewind-management-of-appendicitis-2022-6674?t=1500)
- African-American children with ASA 1-2 status had over threefold higher 30-day mortality after routine operations compared to other children in the NSQIP database study of 170,000+ children. — Meera Kotagal summarizing the discussion [Ep 15 · 7:10](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414?t=430)
- African-American children with ASA 1-2 status had 18% greater odds of post-operative complications and 7% greater odds of serious adverse events (cardiac arrest, sepsis) after routine operations. — Meera Kotagal summarizing the discussion [Ep 15 · 7:10](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414?t=430)
- Black newborns have a 58% reduction in mortality when treated by black physicians, based on Florida data from 1992-2015 covering 1.8 million births. — Meera Kotagal summarizing the discussion [Ep 15 · 13:40](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414?t=820)
- Racial concordance between physician and newborn affected neonatal mortality but did not impact maternal mortality in the Florida study. — Meera Kotagal summarizing the discussion [Ep 15 · 24:11](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414?t=1451)
- A highly educated black woman (e.g., a lawyer) has a higher risk of dying in childbirth than a white woman with only a high school education, as demonstrated by Collins from Chicago 20 years ago. — Garcia summarizing the discussion [Ep 15 · 19:22](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414?t=1162)
- Michael Marmot's work demonstrated that gainfully employed individuals in the UK National Health System had higher mortality rates the lower they were on the socioeconomic ladder, showing disparities are not unique to racial minorities. — Garcia summarizing the discussion [Ep 15 · 19:22](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414?t=1162)
- Living in the neighborhood around Cincinnati Children's Hospital and not leaving by age 10 has profound negative effects on life expectancy and life trajectory. — Meera Kotagal summarizing the discussion [Ep 15 · 25:03](https://team.globalcastmd.com/watch/update-course-2021-dei-concordance-and-post-op-complication-studies-5414?t=1503)
- Optical trocar (Optiview) is useful when not accessing through the umbilicus. — Todd Ponsky summarizing a resource [Ep 8 · 1:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=60)
- Keith Jorgenson taught the technique of inserting the trocar angled toward the spleen. — Todd Ponsky summarizing a resource [Ep 8 · 6:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=360)
- Scott Bollinger stated that performing the same technique repeatedly minimizes complications, while trying new techniques increases injury risk. — Todd Ponsky summarizing a resource [Ep 8 · 10:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=600)
- Steve Rothenberg presented 12 cases of CO2 embolization at IPEG, and he reports knowing of 15 total cases. — Todd Ponsky summarizing a resource [Ep 8 · 30:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=1800)
- Transesophageal echocardiography has been discussed as an urgent diagnostic tool for suspected CO2 embolization. — Todd Ponsky summarizing a resource [Ep 8 · 33:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=1980)
- Steve Rothenberg believes CO2 embolization can occur even without direct needle or trocar placement in the vein, possibly by damaging the vein during passage and allowing CO2 to enter the venous system during peritoneal insufflation. — Todd Ponsky summarizing a resource [Ep 8 · 36:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=2160)
- Steve Rothenberg's opinion is that infra-umbilical Hasson approach is safer, and all other techniques (not using infra-umbilical incision) are at risk for CO2 embolization. — Todd Ponsky summarizing a resource [Ep 8 · 37:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=2220)
- Steve Rothenberg states that two months is the age after which the umbilical vein is no longer a concern, though the source of this cutoff is unclear. — Todd Ponsky summarizing a resource [Ep 8 · 27:00](https://team.globalcastmd.com/watch/peritoneal-access-2294?t=1620)
- A prior study from Kansas City showed no difference in outcomes between irrigation and no irrigation in perforated appendicitis — Todd Ponsky summarizes what Dr. Maria Libertin said [Ep 1 · 0:00](https://team.globalcastmd.com/watch/appendicitis-irrigation-technique-with-zero-abscesses-316?t=0)
- The study 'Standardized Irrigation Technique Reduces Intra-abdominal Abscess After Appendectomy' by Leplant and Salsman was published in August 2018 Journal of Pediatric Surgery — Maria Libertin summarizing a resource [Ep 1 · 0:51](https://team.globalcastmd.com/watch/appendicitis-irrigation-technique-with-zero-abscesses-316?t=51)
- The University of Minnesota surgeon's technique uses peritoneal irrigation for serial dilution with multiple low aliquots and debridement of fibrous material — Maria Libertin summarizing a resource [Ep 1 · 0:51](https://team.globalcastmd.com/watch/appendicitis-irrigation-technique-with-zero-abscesses-316?t=51)
- For perforation, the technique uses up to 6 liters of normal saline — Maria Libertin summarizing a resource [Ep 1 · 0:51](https://team.globalcastmd.com/watch/appendicitis-irrigation-technique-with-zero-abscesses-316?t=51)
- For extensive peritonitis with or without interloop abscess, the technique uses 9 to 12 liters of normal saline — Maria Libertin summarizing a resource [Ep 1 · 0:51](https://team.globalcastmd.com/watch/appendicitis-irrigation-technique-with-zero-abscesses-316?t=51)
- Zero patients developed intra-abdominal abscess out of 140 patients after irrigation for serial dilution — Maria Libertin summarizing a resource [Ep 1 · 0:51](https://team.globalcastmd.com/watch/appendicitis-irrigation-technique-with-zero-abscesses-316?t=51)
- 18 out of 292 patients developed intra-abdominal abscess after discretionary irrigation — Maria Libertin summarizing a resource [Ep 1 · 0:51](https://team.globalcastmd.com/watch/appendicitis-irrigation-technique-with-zero-abscesses-316?t=51)
- The technique has drawbacks including tediousness and time added to the operation — Todd Ponsky summarizes what Dr. Maria Libertin said [Ep 1 · 2:16](https://team.globalcastmd.com/watch/appendicitis-irrigation-technique-with-zero-abscesses-316?t=136)
- The surgeon uses 50 cc aliquots with a total of 6 liters, which equals 120 irrigation cycles — Maria Libertin summarizing a resource [Ep 1 · 2:42](https://team.globalcastmd.com/watch/appendicitis-irrigation-technique-with-zero-abscesses-316?t=162)
- The group that did not use the intensive irrigation technique had approximately 6% post-operative abscess rate — Todd Ponsky summarizes what Dr. Maria Libertin said [Ep 1 · 3:04](https://team.globalcastmd.com/watch/appendicitis-irrigation-technique-with-zero-abscesses-316?t=184)
- ChatGPT can help organize literature review, analyze data within Excel sheets, and run statistical analysis — Em Gootee summarizing the discussion [Ep 28 · 1:28](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=88)
- Large language models can enhance efficiency and productivity in research by analyzing large datasets and helping with writing, especially valuable for international researchers — Em Gootee summarizing the discussion [Ep 28 · 12:27](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=747)
- ChatGPT cannot be listed as an author; most journals require AI use for writing style enhancement only, not idea creation — Em Gootee summarizing the discussion [Ep 28 · 14:20](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=860)
- MeetGeek and Fireflies synchronize with calendars, transcribe meetings, generate summaries, and assign action items per person — Em Gootee summarizing the discussion [Ep 28 · 15:31](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=931)
- Hospitals provide weekly AI guidelines on appropriate use of co-pilot for meeting summaries and information handling — Em Gootee summarizing the discussion [Ep 28 · 18:44](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=1124)
- Zoom AI companion allows late attendees to ask if their name was mentioned, what they were asked to do, and recap the meeting before they joined — Em Gootee summarizing the discussion [Ep 28 · 19:27](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=1167)
- Read Aloud GPT helps users listen to long emails or texts instead of reading, useful while walking or driving — Em Gootee summarizing the discussion [Ep 28 · 20:01](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=1201)
- Letter of Recommendation GPT generates drafts from uploaded CVs and cover letters, requiring personalization before use — Em Gootee summarizing the discussion [Ep 28 · 21:13](https://team.globalcastmd.com/watch/top-10-ai-websites-and-tools-for-medical-research-and-education-13594?t=1273)
- ChatGPT can help organize literature review, analyze data within Excel sheets, run statistical analysis, and assist in research design — Em Gootee summarizing the discussion [Ep 29 · 1:28](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=88)
- Large language models enhance efficiency and productivity in research by analyzing large datasets and assisting with writing, particularly valuable for international researchers who find editing easier than writing from scratch — Em Gootee summarizing the discussion [Ep 29 · 12:27](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=747)
- Early papers that listed ChatGPT as an author are no longer permitted; AI cannot be listed as an author — Em Gootee summarizing the discussion [Ep 29 · 14:14](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=854)
- MeetGeek and Fireflies synchronize with calendars, join meetings automatically, transcribe content, and send summaries with action items assigned per person — Em Gootee summarizing the discussion [Ep 29 · 15:31](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=931)
- Institutional-level AI tool use requires security preventions, especially for executive meetings, though lower-level meetings may have fewer restrictions — Em Gootee summarizing the discussion [Ep 29 · 18:04](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=1084)
- Cincinnati Children's sends weekly AI guidelines on appropriate use of co-pilot for meeting summaries and information sharing — Em Gootee summarizing the discussion [Ep 29 · 18:44](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=1124)
- Zoom AI companion allows late arrivals to ask if their name was mentioned, what they were asked to do, and recap the meeting up to their join time — Em Gootee summarizing the discussion [Ep 29 · 19:27](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=1167)
- Read Aloud GPT converts long emails and texts to audio format for listening while walking or driving, enabling conversation with ChatGPT about content like book summaries — Em Gootee summarizing the discussion [Ep 29 · 20:01](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=1201)
- Custom GPT for letter of recommendation accepts CV and cover letter uploads to generate drafts, but requires personalization as initial outputs may be overly enthusiastic — Em Gootee summarizing the discussion [Ep 29 · 21:00](https://team.globalcastmd.com/watch/practical-applications-of-generative-ai-in-medical-research-and-education-13595?t=1260)

## Changelog
- Oct 3: 2 items added automatically
- Sep 24: 10 items added automatically
- Sep 22: 1 item added automatically
- Sep 17: 4 items added automatically
- Sep 16: 1 item added automatically
- Sep 15: 3 items added automatically
- Sep 12: 1 item added automatically
- Sep 8: 2 items added automatically
- Sep 7: Published again automatically — condition is back above threshold
- Sep 7: 2 items added automatically
- Sep 7: 2 items no longer name appendicitis
- Sep 7: 2 items added automatically
- Sep 7: Unpublished automatically — folded or below threshold
- Sep 7: Audit reverted — short clips unhidden
- Sep 7: 3 items added automatically

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