637 timestamped statements
across 26 topics
— auto-found in recorded discussions, each timestamp jumps to the exact moment.
Summaries Meera gave as host are listed separately below.
So a lot a lot of times people do just active motion. So watching them, seeing if they seem to splint. Um, I think you don't want to necessarily like force them one direction or another because you if they're not comfortable doing that, you may cause them an injury. Um, so a lot of times we will just take off the collar and observe them and see if they see like they seem like they're uncomfortable. We do, you know, palpate obviously along the midline, um, looking for for tenderness and some response, but it's a little bit challenging.
One of the issues also with peg is the difficulty in changing it then over to a button tube and the trauma of doing that to a child in the office and so I don't know what other institutions practices are but at ours children actually get a second anesthetic if they get a peg because they go back to the OR with the GI folks to get the peg removed under endoscopic and then they change it to a to a button.
The idea behind it is that it's both diagnostic and therapeutic. Because Gastrografin can be seen on X-rays, you can follow its progress through the bowel and tell whether or not the obstruction has resolved. But the thought is that also as a hyperosmolar agent, it draws water from the bowel edema into the lumen of the bowel, helping to resolve the obstruction.
If on the first attempt we're not able to reduce the intussusception, then the air enema can be repeated every hour for three times with monitoring in between the attempts as long as the intussusceptum continues to reduce, the patient doesn't have free air, and they remain clinically stable.
Your differential diagnosis includes an umbilical hernia, which is obviously the most common, a ureachal cyst, a patent phallo mesenteric duct, umbilical granuloma, or an umbilical polyp, or in some instances, If there's significant erythema, you might consider umphalitis.
And unlike in adults, we don't use mesh when we're repairing a child's umbilical hernia. But it is really important to make sure when you do that repair that you get all the way back to normal fashion. And that you're not closing hernia sac to hernia sac.
Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos
▶Ep 6 · 16:49
quoteI think in little kids, you can easily put in stam sutures, and I think that saves you when the tube dislodges. You don't have it dislodge, you know, in the stomach drop away as you might with the PEG, but that's just a personal practice.↗
▶Ep 6 · 20:29
quoteOne of the issues also with peg is the difficulty in changing it then over to a button tube and the trauma of doing that to a child in the office and so I don't know what other institutions practices are but at ours children actually get a second anesthetic if they get a peg because they go back to the OR with the GI folks to get the peg removed under endoscopic and then they change it to a to a button.↗
▶Ep 6 · 20:29
clinicalPEG 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's statements about Adhesive Small Bowel Obstruction17 statements
Gastrografin Protocol for Adhesive Small Bowel Obstruction (SBO)
▶Ep 1 · 0:00
epidemiologicalGastrografin use for adhesive small bowel obstruction began in the adult population approximately 10 years ago.↗
▶Ep 1 · 0:00
clinicalGastrografin is both diagnostic (visible on X-rays to track bowel transit) and therapeutic (hyperosmolar agent draws water from bowel edema into lumen).↗
▶Ep 1 · 0:30
quoteThe idea behind it is that it's both diagnostic and therapeutic. Because Gastrografin can be seen on X-rays, you can follow its progress through the bowel and tell whether or not the obstruction has resolved. But the thought is that also as a hyperosmolar agent, it draws water from the bowel edema into the lumen of the bowel, helping to resolve the obstruction.↗
▶Ep 1 · 2:00
guidelineGastrografin is not appropriate for patients with concern for strangulation or peritonitis, who should be considered for immediate operative intervention.↗
▶Ep 1 · 2:00
guidelinePatients with active malignancy are excluded from the Cincinnati Children's Gastrografin protocol.↗
▶Ep 1 · 2:00
quoteGastrografin should only be used in the management of adhesive small bowel obstructions, which is to say it's not appropriate for patients who have never had an operation.↗
▶Ep 1 · 2:00
guidelineGastrografin should only be used for adhesive small bowel obstructions, not in patients who have never had an operation.↗
▶Ep 1 · 2:20
quoteAdditionally, it's not for use in patients with concern for strangulation or those with peritonitis. Those patients should be considered for an immediate operative intervention.↗
▶Ep 1 · 3:00
guidelineNasogastric decompression should be performed for at least one hour, or longer if the NG continues to drain bilious fluid.↗
▶Ep 1 · 3:00
guidelineThe NG tube is clamped for 8 to 10 hours after Gastrografin administration, but can be unclamped at any time if the patient is nauseated or vomiting.↗
▶Ep 1 · 3:00
guidelineGastrografin dosing is age-based and diluted in water to a 50% solution.↗
▶Ep 1 · 3:00
guidelineImaging confirmation of small bowel obstruction is performed with two-view abdominal X-ray or CT.↗
▶Ep 1 · 4:00
guidelineIf contrast has not reached the cecum at 10 hours, another X-ray is obtained at 24 hours.↗
▶Ep 1 · 4:00
guidelineA portable plain film is obtained at 10 hours; if contrast is in or past the cecum, the NG tube is removed and diet can be advanced.↗
▶Ep 1 · 4:00
guidelineIf contrast has not reached the cecum by 24 hours, strong consideration is given to operative exploration.↗
▶Ep 1 · 5:00
guidelineSerial abdominal exams every four hours are required throughout the protocol to ensure the patient has not progressed to peritonitis or developed an indication for urgent operative intervention.↗
▶Ep 1 · 5:00
opinionCincinnati Children's has had great success using Gastrografin for management of adhesive small bowel obstructions in children.↗
Meera's statements about Appendicitis12 statements
Update Course 2021: DEI – CONCORDANCE AND POST OP COMPLICATION STUDIES
▶Ep 15 · 5:38
opinionRace is a social construct, not a biological one, challenging historical arguments that genetic factors explain health disparities such as hypertension in African-Americans.↗
▶Ep 15 · 5:38
quoterace is a social construct and not a biologic one↗
▶Ep 15 · 11:54
epidemiologicalGastroschisis 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.↗
▶Ep 15 · 13:40
clinicalEmergency 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.↗
▶Ep 15 · 25:03
opinionAddressing 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.↗
▶Ep 15 · 25:03
opinionPipeline programs to increase diversity must start early—not at the college level—to provide opportunities to underrepresented groups.↗
▶Ep 15 · 25:03
clinicalThe 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.↗
▶Ep 15 · 29:43
quotewe can't do those things in isolation of the communities we serve↗
▶Ep 15 · 29:43
opinionCommunity-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.↗
Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos
▶Ep 17 · 16:49
quoteI think in little kids, you can easily put in stam sutures, and I think that saves you when the tube dislodges. You don't have it dislodge, you know, in the stomach drop away as you might with the PEG, but that's just a personal practice.↗
▶Ep 17 · 20:29
quoteOne of the issues also with peg is the difficulty in changing it then over to a button tube and the trauma of doing that to a child in the office and so I don't know what other institutions practices are but at ours children actually get a second anesthetic if they get a peg because they go back to the OR with the GI folks to get the peg removed under endoscopic and then they change it to a to a button.↗
▶Ep 17 · 20:29
clinicalPEG 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.↗
Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos
▶Ep 10 · 16:49
quoteI think in little kids, you can easily put in stam sutures, and I think that saves you when the tube dislodges. You don't have it dislodge, you know, in the stomach drop away as you might with the PEG, but that's just a personal practice.↗
▶Ep 10 · 20:29
clinicalPEG 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.↗
▶Ep 10 · 20:29
quoteOne of the issues also with peg is the difficulty in changing it then over to a button tube and the trauma of doing that to a child in the office and so I don't know what other institutions practices are but at ours children actually get a second anesthetic if they get a peg because they go back to the OR with the GI folks to get the peg removed under endoscopic and then they change it to a to a button.↗
Meera's statements about Cervical Spine Injury19 statements
Cervical Spine Clearance - APSA Practice Gaps 2019
▶Ep 2 · 4:51
epidemiologicalAbout 50% of injuries in children under eight are bony and about 50% are ligamentous or spinal cord injury without radiological abnormality↗
▶Ep 2 · 7:34
guidelineChildren where you're concerned about child abuse need a skeletal survey as part of their evaluation, and as part of that skeletal survey, you need at least a single view of the cervical spine↗
▶Ep 2 · 8:30
quoteSo a lot a lot of times people do just active motion. So watching them, seeing if they seem to splint. Um, I think you don't want to necessarily like force them one direction or another because you if they're not comfortable doing that, you may cause them an injury. Um, so a lot of times we will just take off the collar and observe them and see if they see like they seem like they're uncomfortable. We do, you know, palpate obviously along the midline, um, looking for for tenderness and some response, but it's a little bit challenging.↗
▶Ep 2 · 9:36
quoteI do think and we'll come back to this, but one of the biggest points, I think in thinking about cervical spine clearance is you need a protocol. You need some guideline that your institution follows. There was a recent study done by the uh it's an orthopedic group that looks at pediatric spine injury and they found that 46% of places don't have a protocol for cervical spine clearance in children. So you need some sort of pathway and you can decide based on and the evidence gives you lots of options for how to proceed, but you need some sort of pathway.↗
▶Ep 2 · 9:36
epidemiological46% of institutions don't have a protocol for cervical spine clearance in children↗
▶Ep 2 · 10:18
epidemiologicalCervical spine injury occurs in 1 to 2% of all pediatric traumas↗
▶Ep 2 · 10:38
epidemiologicalIn older children, 70 to 80% of cervical spine injuries are bony injuries↗
▶Ep 2 · 10:58
epidemiologicalIn children less than or equal to eight years old, about 50% will have isolated fractures and 50% will have ligamentous injury, dislocations or spinal cord injury without radiologic abnormality↗
▶Ep 2 · 11:28
epidemiological60 to 80% of vertebral injuries in kids will be in their cervical spine compared to 34 to 40% of vertebral injuries in adults↗
▶Ep 2 · 11:48
epidemiologicalThe AAST study looked at over 12,000 kids who'd undergone blunt trauma and found 87 cervical spine injuries (0.6%)↗
▶Ep 2 · 12:32
clinicalFour independent predictors of cervical spine injury in children under three were identified: GCS less than 14, GCS eye of one, involvement in motor vehicle crash, and age greater than or equal to two years↗
▶Ep 2 · 13:12
clinicalPatients with cervical spine injury score of zero to one points had a negative predictive value for cervical spine injury of over 99% and did not need imaging↗
▶Ep 2 · 13:42
guidelinePatients with neck pain and splinting need imaging and would automatically fall out of the no imaging category↗
▶Ep 2 · 13:42
clinicalFive patients in the AAST study had a cervical spine injury score less than two but actually had injury; these patients had concurrent significant traumatic injuries including facial fracture, skull fracture, long bone fractures, loss of consciousness, and neck pain or splinting↗
▶Ep 2 · 14:32
guidelineFor skeletal survey in suspected child abuse, a lateral view is used as the single cervical spine view↗
▶Ep 2 · 14:32
guidelineIf using imaging to clear cervical spine (not just for skeletal survey), you need two views at least: an AP and lateral↗
▶Ep 2 · 17:02
guidelinePatients with abnormal neurologic exam cannot be clinically cleared and need an MRI↗
▶Ep 2 · 17:02
guidelineCT is not commonly done in kids for cervical spine injury because most injuries are not bony but ligamentous, so MRI is preferred if cross-sectional imaging is needed↗
▶Ep 2 · 17:02
clinicalIn unreliable patients, you can leave them in a collar, wait till they calm down or pain is under control, then reexamine and may be able to clinically clear them at that point↗
Meera's statements about Colorectal / ARM & Hirschsprung22 statements
clinicalSystemic signs of concern include fever, lethargy, age-adjusted tachycardia, tachypnea, hypotension, or oliguria↗
▶Ep 67 · 0:21
guidelinePapers by Pastor et al and Gosain et al outline frameworks and clinical guidelines for management of enterocolitis↗
▶Ep 67 · 0:21
guidelineThe guideline is most appropriate for patients with either known or suspected Hirschsprung's who present with GI symptoms and/or fever↗
▶Ep 67 · 0:21
clinicalGI symptoms in HAEC include abdominal distension, vomiting, no or minimal stool, foul smelling stool, or explosive diarrhea↗
▶Ep 67 · 2:00
guidelineIrrigations should not be delayed for patients to get an x-ray↗
▶Ep 67 · 2:00
guidelineIrrigations should be repeated as frequently as every eight hours, but even every six or four hours as needed for sicker patients↗
▶Ep 67 · 2:00
guidelineIf the patient is less than four weeks out from surgery, fellows should discuss the rectal exam with an attending surgeon prior to performing it↗
▶Ep 67 · 2:00
quoteHere at Cincinnati Children's, we like to call that lifesaving saltwater.↗
▶Ep 67 · 2:00
guidelinePatients should be seen and evaluated as soon as possible, ideally within one hour by someone with clinical expertise such as a surgical fellow or attending↗
7th Annual Pediatric Surgery Update Course 2019 - FULL SHOW
▶Ep 2 · 59:25
epidemiological60 to 80% of vertebral injuries in kids are in the cervical spine compared to 30 to 40% in adults↗
▶Ep 2 · 59:25
epidemiologicalIn older children, 70 to 80% of cervical spine injuries are bony injuries following adult patterns↗
▶Ep 2 · 59:25
epidemiologicalCervical spine injury is about 1 to 2% of all pediatric traumas↗
▶Ep 2 · 59:25
epidemiologicalIn younger children less than or equal to 8 years, about 50% have isolated fractures and 50% have ligamentous injury, dislocations, or SCIWORA↗
▶Ep 2 · 59:25
clinicalFor cervical spine clearance imaging in children, use AP and lateral x-rays; if cross-sectional imaging needed, use MRI not CT because most injuries are ligamentous not bony↗
▶Ep 2 · 59:25
epidemiological46% of institutions don't have a protocol for cervical spine clearance in children↗
▶Ep 2 · 59:25
clinicalPatients with cervical spine injury score of 0-1 points had negative predictive value over 99% and did not need imaging↗
▶Ep 2 · 59:25
epidemiologicalAAST study of over 12,000 children with blunt trauma found 0.6% had cervical spine injury; four independent predictors were GCS less than 14, involved in motor vehicle crash, age greater than or equal to 2 years↗
Meera's statements about Etiologies (Gastroschisis/NEC/Atresia/Volvulus)45 statements
Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos
▶Ep 44 · 16:49
quoteI think in little kids, you can easily put in stam sutures, and I think that saves you when the tube dislodges. You don't have it dislodge, you know, in the stomach drop away as you might with the PEG, but that's just a personal practice.↗
▶Ep 44 · 20:29
clinicalPEG 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.↗
▶Ep 44 · 20:29
quoteOne of the issues also with peg is the difficulty in changing it then over to a button tube and the trauma of doing that to a child in the office and so I don't know what other institutions practices are but at ours children actually get a second anesthetic if they get a peg because they go back to the OR with the GI folks to get the peg removed under endoscopic and then they change it to a to a button.↗
Malrotation with Dr. Meera Kotagal
▶Ep 48 · 1:17
quoteIn the fourth week of gestation, that's really when we start to see development of the bowel. And as the bowel grows in length, it actually herniates into the yolk sac and along the umbilical cord and the SMA axis.↗
▶Ep 48 · 1:17
clinicalIn the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis.↗
▶Ep 48 · 1:44
clinicalNormal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant.↗
▶Ep 48 · 2:22
clinicalNon-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure.↗
▶Ep 48 · 2:22
clinicalIntestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation.↗
▶Ep 48 · 2:22
clinicalIn non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation.↗
▶Ep 48 · 2:22
quoteWe used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.↗
▶Ep 48 · 2:22
clinicalMalrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus.↗
▶Ep 48 · 3:49
clinicalComplications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery).↗
▶Ep 48 · 3:49
quoteAbout one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 48 · 3:49
clinicalRotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses.↗
▶Ep 48 · 3:49
clinicalChildren with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy.↗
▶Ep 48 · 3:49
clinicalAs children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases.↗
▶Ep 48 · 3:49
epidemiologicalAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 48 · 3:49
epidemiologicalAbout 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 48 · 3:49
quoteAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 48 · 4:49
quoteWe think of midget volvulus as the number one surgical emergency in pediatric surgery and so missing that is a significant problem.↗
▶Ep 48 · 4:49
clinicalOther symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension.↗
▶Ep 48 · 4:49
clinicalIn the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal.↗
▶Ep 48 · 4:49
quoteIn the neonatal period, the most critical symptom to be really aware of is biliosemesis. Even if they have a normal appearing x-ray, those kids really need to be evaluated for midgut volvulus.↗
▶Ep 48 · 4:49
clinicalAfter detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability.↗
▶Ep 48 · 4:49
clinicalSurgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation.↗
▶Ep 48 · 4:49
opinionMidgut volvulus is considered the number one surgical emergency in pediatric surgery.↗
▶Ep 48 · 4:49
clinicalContrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test.↗
▶Ep 48 · 4:49
clinicalOn upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position.↗
▶Ep 48 · 4:49
clinicalUpper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned.↗
▶Ep 48 · 4:49
clinicalMalrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it.↗
▶Ep 48 · 4:49
clinicalThe differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis.↗
▶Ep 48 · 4:49
clinicalLate signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia.↗
▶Ep 48 · 8:33
quoteYou can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation.↗
▶Ep 48 · 8:54
clinicalThe reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms.↗
▶Ep 48 · 8:54
clinicalThe Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible.↗
▶Ep 48 · 10:01
opinionLaparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus.↗
▶Ep 48 · 10:01
quoteAbout a quarter of patients who undergo a LADS procedure will have an intestinal obstruction related to small bowel obstruction related to their OTCU bowel disease from their LADS procedure.↗
▶Ep 48 · 10:01
opinionSome believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus.↗
▶Ep 48 · 10:01
opinionThere is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications.↗
▶Ep 48 · 10:01
clinicalIn younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly.↗
▶Ep 48 · 10:01
opinionDecisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion.↗
▶Ep 48 · 10:01
opinionThere is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach.↗
▶Ep 48 · 10:01
opinionDr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically.↗
▶Ep 48 · 10:01
opinionLaparoscopic approach may reduce the risk of postoperative bowel obstruction.↗
▶Ep 48 · 10:01
epidemiologicalAbout one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease.↗
Meera's statements about Favorable Histology Wilms Tumor20 statements
Clinical & Research Update: Renal Tumors with Drs. Ethan Smith, Lindsay Haacker, Michael Daugherty, and Meera Kotagal
▶Ep 3 · 8:27
clinicalTumors larger than 12 centimeters have an increased risk of intraoperative spill.↗
▶Ep 3 · 8:27
quoteTumors that are bigger than 12 centimeters, um, have an increased risk of intraoperative spill.↗
▶Ep 3 · 9:55
clinicalThe lymph node stations important for Wilms tumor include left renal hilar, periaortic, and aortic cable window.↗
▶Ep 3 · 10:18
guidelineAt least one lymph node must be sampled to be eligible for the current COG trial (AREN 2231).↗
▶Ep 3 · 10:18
quoteFor the most recent and current, um, COG trial, you do need to have at least one lymph node sampled in order to be eligible for the trial.↗
▶Ep 3 · 12:22
clinicalEnhanced recovery protocol includes preoperative carbohydrate load, regional anesthesia, no drains, early feeding (clears on post-op day 0, regular diet on post-op day 1), and IV fluids off on post-op day 1.↗
▶Ep 3 · 13:20
epidemiologicalLength of stay with ERAS protocol is 3 to 4 days shorter than historical practice.↗
▶Ep 3 · 13:20
quoteOur, our length of stay is probably 3 to 4 days shorter than it used to be just by virtue of us being able to feed kids sooner.↗
▶Ep 3 · 13:40
epidemiologicalNG tube placement post-operatively is rare with ERAS; only one or two patients required it over 4-5 years.↗
▶Ep 3 · 31:39
quoteWhen you have bilateral disease, um, each side gets its own local stage, and that really impacts the long-term, uh, management.↗
▶Ep 3 · 31:39
clinicalIn bilateral Wilms tumor, each side gets its own local stage, which impacts long-term management.↗
▶Ep 3 · 55:20
quoteSurgery is a real mainstay of management for the TFERCC patients and, um, and being aggressive about that is important.↗
▶Ep 3 · 55:20
clinicalSurgery is a mainstay of management for TFE RCC and provides meaningful survival benefit even in metastatic disease.↗
▶Ep 3 · 1:06:58
quoteThe standard of care is to say that things that are below the level of the hepatic veins, um, and then that infra uh hepatic cava should be done with an upfront resection.↗
▶Ep 3 · 1:06:58
clinicalIVC thrombus below the level of the hepatic veins should be resected upfront; intrahepatic extension warrants neoadjuvant chemotherapy.↗
▶Ep 3 · 1:07:14
clinicalThrombectomy must be performed in continuity with the nephrectomy specimen; transecting the thrombus upstages the patient to stage 3.↗
▶Ep 3 · 1:07:14
quoteIf you transect that thrombus or take out the mass and then go to do your cable thrombus, you are upstaging that patient and so they become a stage 3 as a result.↗
▶Ep 3 · 1:08:02
quoteIt was relatively adherent. A lot of times what we will do is actually make our, um, especially, you know, if you're coming from the right side, so you can open up the renal vein and then just extend on the lateral margin of the cava.↗
▶Ep 3 · 1:10:01
clinicalTumor thrombus is more adherent to the vessel wall after chemotherapy than in upfront resection.↗
▶Ep 3 · 1:10:55
clinicalFor IVC thrombus extending above the diaphragm, a thoracoabdominal approach with cardiac surgery support and potential bypass is used.↗
Meera's statements about Gunshot Wound14 statements
quoteFirearm injuries leading cause of death for kids unfortunately in the United States now, luckily not necessarily the same around the world.↗
▶Ep 3 · 0:53
epidemiologicalFirearm injuries are the leading cause of death for kids in the United States, though not necessarily the same around the world.↗
▶Ep 3 · 2:59
epidemiologicalSchool shootings are a tiny percentage of pediatric firearm injuries.↗
▶Ep 3 · 2:59
epidemiologicalAccording to the American College of Surgeons non-fatal firearm study, 50-60% of pediatric firearm injuries are assault related, with many being bystander injuries.↗
clinicalIn the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis.↗
▶Ep 57 · 1:17
quoteIn the fourth week of gestation, that's really when we start to see development of the bowel. And as the bowel grows in length, it actually herniates into the yolk sac and along the umbilical cord and the SMA axis.↗
▶Ep 57 · 1:44
clinicalNormal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant.↗
▶Ep 57 · 2:22
clinicalIn non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation.↗
▶Ep 57 · 2:22
clinicalMalrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus.↗
▶Ep 57 · 2:22
clinicalIntestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation.↗
▶Ep 57 · 2:22
clinicalNon-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure.↗
▶Ep 57 · 2:22
quoteWe used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.↗
▶Ep 57 · 3:49
epidemiologicalAbout 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 57 · 3:49
quoteAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 57 · 3:49
clinicalAs children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases.↗
▶Ep 57 · 3:49
clinicalChildren with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy.↗
▶Ep 57 · 3:49
clinicalRotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses.↗
▶Ep 57 · 3:49
clinicalComplications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery).↗
▶Ep 57 · 3:49
epidemiologicalAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 57 · 3:49
quoteAbout one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 57 · 4:49
clinicalUpper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned.↗
▶Ep 57 · 4:49
clinicalAfter detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability.↗
▶Ep 57 · 4:49
quoteIn the neonatal period, the most critical symptom to be really aware of is biliosemesis. Even if they have a normal appearing x-ray, those kids really need to be evaluated for midgut volvulus.↗
▶Ep 57 · 4:49
quoteWe think of midget volvulus as the number one surgical emergency in pediatric surgery and so missing that is a significant problem.↗
▶Ep 57 · 4:49
opinionMidgut volvulus is considered the number one surgical emergency in pediatric surgery.↗
▶Ep 57 · 4:49
clinicalContrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test.↗
▶Ep 57 · 4:49
clinicalOn upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position.↗
▶Ep 57 · 4:49
clinicalMalrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it.↗
▶Ep 57 · 4:49
clinicalThe differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis.↗
▶Ep 57 · 4:49
clinicalLate signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia.↗
▶Ep 57 · 4:49
clinicalOther symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension.↗
▶Ep 57 · 4:49
clinicalIn the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal.↗
▶Ep 57 · 4:49
clinicalSurgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation.↗
▶Ep 57 · 8:33
quoteYou can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation.↗
▶Ep 57 · 8:54
clinicalThe reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms.↗
▶Ep 57 · 8:54
clinicalThe Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible.↗
▶Ep 57 · 10:01
opinionLaparoscopic approach may reduce the risk of postoperative bowel obstruction.↗
▶Ep 57 · 10:01
epidemiologicalAbout one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease.↗
▶Ep 57 · 10:01
opinionLaparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus.↗
▶Ep 57 · 10:01
opinionDecisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion.↗
▶Ep 57 · 10:01
clinicalIn younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly.↗
▶Ep 57 · 10:01
opinionThere is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications.↗
▶Ep 57 · 10:01
quoteAbout a quarter of patients who undergo a LADS procedure will have an intestinal obstruction related to small bowel obstruction related to their OTCU bowel disease from their LADS procedure.↗
▶Ep 57 · 10:01
opinionThere is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach.↗
▶Ep 57 · 10:01
opinionDr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically.↗
▶Ep 57 · 10:01
opinionSome believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus.↗
Meera's statements about Hirschsprung's-associated Enterocolitis22 statements
guidelinePapers by Pastor et al and Gosain et al outline frameworks and clinical guidelines for management of enterocolitis↗
▶Ep 1 · 0:21
guidelineThe guideline is most appropriate for patients with either known or suspected Hirschsprung's who present with GI symptoms and/or fever↗
▶Ep 1 · 0:21
clinicalSystemic signs of concern include fever, lethargy, age-adjusted tachycardia, tachypnea, hypotension, or oliguria↗
▶Ep 1 · 0:21
clinicalGI symptoms in HAEC include abdominal distension, vomiting, no or minimal stool, foul smelling stool, or explosive diarrhea↗
▶Ep 1 · 2:00
guidelineIf the patient is less than four weeks out from surgery, fellows should discuss the rectal exam with an attending surgeon prior to performing it↗
▶Ep 1 · 2:00
guidelinePatients should be seen and evaluated as soon as possible, ideally within one hour by someone with clinical expertise such as a surgical fellow or attending↗
▶Ep 1 · 2:00
quoteHere at Cincinnati Children's, we like to call that lifesaving saltwater.↗
▶Ep 1 · 2:00
guidelineIrrigations should be repeated as frequently as every eight hours, but even every six or four hours as needed for sicker patients↗
clinicalDirect hernias are pretty rare in children and are much more commonly found in adolescents.↗
▶Ep 7 · 1:26
epidemiologicalThe incidence of inguinal hernias increases to about 13% in premature infants who are less than 32 weeks of gestational age.↗
▶Ep 7 · 1:26
epidemiologicalMost inguinal hernias in children are largely indirect, over 90%.↗
▶Ep 7 · 1:26
epidemiologicalThe incidence of inguinal hernias overall ranges from about 1% to 5% in full-term newborns.↗
▶Ep 7 · 1:26
epidemiologicalFemoral hernias are very rare in children and, as in adults, are more common in females.↗
▶Ep 7 · 1:59
clinicalThe right processus vaginalis usually obliterates after the left, which explains the higher prevalence of right-sided hernias.↗
▶Ep 7 · 1:59
clinicalInguinal hernias occur as a result of the failure of the processus vaginalis to fuse.↗
▶Ep 7 · 1:59
clinicalIndirect inguinal hernias in children are a congenital anomaly, meaning that they've occurred in development and are present at the time of birth.↗
▶Ep 7 · 2:47
clinicalThe number one risk factor for inguinal hernias in children is prematurity.↗
▶Ep 7 · 2:47
quoteThe number one risk factor for inguinal hernias in children is prematurity.↗
▶Ep 7 · 2:47
clinicalOther factors associated with an increased risk of inguinal hernias in kids include male sex, family history of inguinal hernias, a history of undescended testicle or hydrocele, and a connective tissue disorder.↗
▶Ep 7 · 4:31
quoteMore than half of incarcerations are in patients that are less than six months, and then two-thirds of incarcerations are in patients who are less than a year.↗
▶Ep 7 · 4:31
clinicalIf corrected gestational age is less than 60 weeks, patients have a high risk for premature apnea postoperatively and need to be admitted after surgery to monitor.↗
▶Ep 7 · 4:31
epidemiologicalMore than half of incarcerations are in patients that are less than six months, and two-thirds of incarcerations are in patients who are less than a year.↗
▶Ep 7 · 5:59
clinicalFor hernia reduction, one hand guides the contents through the inguinal ring and the other hand applies gentle, steady pressure, which must be maintained in a slow, gentle fashion.↗
▶Ep 7 · 5:59
clinicalOne of the most important things in being able to reduce an incarcerated hernia is helping to keep the patient calm, sometimes requiring pain control and sedation.↗
▶Ep 7 · 5:59
quoteOne of the most important things, I think, in being able to reduce an incarcerated hernia is helping to keep the patient calm.↗
▶Ep 7 · 5:59
quoteYou have to keep applying pressure in a slow, gentle fashion and not just kind of come and go with your hands, because that gentle, slow pressure is what allows you to reduce the hernia.↗
▶Ep 7 · 7:34
clinicalIf you can reduce an incarcerated inguinal hernia, you want to go to the OR within the first 24 to 72 hours after the reduction.↗
▶Ep 7 · 8:57
clinicalThe most important point in pediatric inguinal hernia repair is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open.↗
▶Ep 7 · 8:57
quoteUnlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia.↗
▶Ep 7 · 8:57
quoteThe most important point is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open.↗
▶Ep 7 · 8:57
clinicalUnlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia.↗
▶Ep 7 · 9:25
quoteAs with all operations, the most important thing is that you do the operation that you're comfortable with.↗
▶Ep 7 · 9:31
clinicalThe outcomes between pediatric laparoscopic repairs and open repairs are thought to be similar, although there is some controversy on this topic.↗
▶Ep 7 · 9:44
clinicalIf a child needs an orchidopexy in addition to their hernia repair, most would approach that hernia in an open fashion.↗
▶Ep 7 · 10:54
clinicalA floor repair should be considered in children who have longstanding or very large hernias where the floor might be blown out or unsupported.↗
▶Ep 7 · 11:10
epidemiologicalThe most common complications after inguinal hernia repair in children are superficial site infection, which occur in less than 1% of kids, and recurrence, with rates varying from 1% to 5%.↗
▶Ep 7 · 11:10
clinicalRare complications include testicular atrophy or damage to the vas deferens.↗
▶Ep 7 · 12:19
clinicalIn general, we don't try to limit activities in children after a hernia repair; most children can return to normal activities within one to two days.↗
▶Ep 7 · 12:31
quoteIn general for children, we don't do this. Most children can return to normal activities within one to two days.↗
▶Ep 7 · 13:26
clinicalA lot of times, once the patient is put under anesthesia, an incarcerated hernia that was unable to be reduced in the emergency department may actually spontaneously reduce with the patient's relaxation.↗
▶Ep 7 · 13:49
clinicalIf a patient has an undescended testicle that's palpable in the inguinal canal, you should plan to do an orchiopexy at the time of your inguinal hernia repair.↗
▶Ep 7 · 14:18
clinicalChildren with an absent vas deferens noted on hernia repair should be worked up for cystic fibrosis or for unilateral renal agenesis in the post-op period.↗
▶Ep 7 · 14:35
clinicalIf patients are having significant testicular pain after a hernia repair, the main concern is testicular ischemia, best evaluated with ultrasound looking for Doppler flow.↗
▶Ep 7 · 14:35
clinicalIn cases of testicular ischemia after hernia repair, patients are monitored and observed with pain control, and surgeons only remove a necrotic testicle, not necessarily one that is partially ischemic.↗
Pediatric Inguinal Hernia in Brief: Presentation, Workup, Diagnosis, Perioperative Considerations
▶Ep 11 · 0:00
quoteInguinal hernia repair is the second most common surgery performed by pediatric surgeons.↗
▶Ep 11 · 0:00
epidemiologicalInguinal hernia repair is the second most common surgery performed by pediatric surgeons.↗
▶Ep 11 · 1:00
epidemiologicalThe incidence of inguinal hernias overall ranges from about 1% to 5% in full-term newborns.↗
▶Ep 11 · 1:15
epidemiologicalThe incidence of inguinal hernias increases to about 13% in premature infants who are less than 32 weeks of gestational age.↗
▶Ep 11 · 1:30
epidemiologicalMost inguinal hernias in children are largely indirect, over 90%.↗
▶Ep 11 · 1:40
clinicalDirect hernias are pretty rare in children and are much more commonly found in adolescence.↗
▶Ep 11 · 1:50
epidemiologicalFemoral hernias are very rare in children, and as in adults, are more common in females.↗
▶Ep 11 · 2:10
clinicalIndirect inguinal hernias in children are a congenital anomaly, meaning that they've occurred in development and are present at the time of birth.↗
▶Ep 11 · 2:25
clinicalIndirect inguinal hernias occur as a result of the failure of the processus vaginalis to fuse.↗
▶Ep 11 · 2:45
clinicalThe right processus vaginalis usually obliterates after the left, which explains the higher prevalence of right-sided hernias.↗
▶Ep 11 · 2:45
quoteThe right processus vaginalis usually obliterates after the left, so that explains the higher prevalence of right-sided hernias.↗
▶Ep 11 · 3:30
quoteThe number one risk factor for inguinal hernias in children is prematurity.↗
▶Ep 11 · 3:30
clinicalThe number one risk factor for inguinal hernias in children is prematurity.↗
▶Ep 11 · 7:00
quoteIt's actually kind of alarming. I mean, more than half of the incarcerations that we see are in patients that are less than six months old.↗
▶Ep 11 · 7:00
epidemiologicalMore than half of the incarcerations that we see are in patients that are less than six months old.↗
▶Ep 11 · 7:15
epidemiologicalTwo-thirds of incarcerations are in those patients that are less than a year.↗
▶Ep 11 · 7:30
clinicalIf the corrected gestational age is less than 60 weeks, premature patients are at a pretty increased risk of post-operative apnea, so you got to admit those patients after you do the repair.↗
▶Ep 11 · 9:30
clinicalOne of the most important things in being able to reduce an incarcerated hernia is helping to keep the patient calm, sometimes that means pain control and sedation.↗
▶Ep 11 · 9:30
quoteOne of the most important things I think in being able to reduce an incarcerated hernia is helping to keep the patient calm.↗
▶Ep 11 · 10:20
clinicalYou have to keep applying pressure in a slow, gentle fashion and not just kind of come and go with your hands, because that gentle, slow pressure is what allows you to release the hernia.↗
▶Ep 11 · 10:50
quoteBut the most valuable piece of this technique, patience.↗
▶Ep 11 · 11:30
clinicalIf you can reduce an incarcerated hernia, then you want to go to the OR within the first 24 to 72 hours after the reduction.↗
▶Ep 11 · 13:30
quoteThe most important point is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open.↗
▶Ep 11 · 13:30
clinicalThe most important point in pediatric inguinal hernia repair is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open.↗
▶Ep 11 · 14:10
clinicalUnlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia.↗
▶Ep 11 · 14:10
quoteUnlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia.↗
▶Ep 11 · 14:25
opinionThe outcomes between pediatric laparoscopic repairs and open repairs are thought to be similar, although there is some controversy on this topic.↗
▶Ep 11 · 14:55
clinicalIf you're considering that the child needs an orchidopexy in addition to their hernia repair, then most would approach that hernia in an open fashion.↗
▶Ep 11 · 15:35
clinicalA floor repair should be considered in children who have long-standing or very large hernias, where you note that the floor might be blown out or unsupported.↗
▶Ep 11 · 16:25
epidemiologicalSuperficial site infections occur in less than 1% of kids after inguinal hernia repair.↗
▶Ep 11 · 16:40
epidemiologicalThe rates of recurrence after pediatric inguinal hernia repair vary from 1 to 5% depending on which studies you look at.↗
▶Ep 11 · 17:25
clinicalIn general, we don't try to limit activities in children after a hernia repair, and most children can return to normal activities within one to two days.↗
▶Ep 11 · 19:45
clinicalIf a patient does have an undescended testicle that's palpable in the inguinal canal, then you should plan to do an orchidopexy at the time of your inguinal hernia repair.↗
▶Ep 11 · 20:30
clinicalChildren with an absent vas deferens noted on hernia repair should be worked up for cystic fibrosis or for unilateral renal agenesis in the post-op period.↗
▶Ep 11 · 21:10
clinicalIf patients are having significant testicular pain after a hernia repair, the thing that concerns you most is testicular ischemia, and the best way to evaluate that is to get an ultrasound looking for Doppler flow.↗
▶Ep 11 · 21:40
clinicalIn general, patients with testicular ischemia after hernia repair are monitored and observed with pain control and we only frankly remove a necrotic testicle and not necessarily one that is partially ischemic.↗
Meera's statements about Intestinal Rehab45 statements
Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos
▶Ep 60 · 16:49
quoteI think in little kids, you can easily put in stam sutures, and I think that saves you when the tube dislodges. You don't have it dislodge, you know, in the stomach drop away as you might with the PEG, but that's just a personal practice.↗
▶Ep 60 · 20:29
quoteOne of the issues also with peg is the difficulty in changing it then over to a button tube and the trauma of doing that to a child in the office and so I don't know what other institutions practices are but at ours children actually get a second anesthetic if they get a peg because they go back to the OR with the GI folks to get the peg removed under endoscopic and then they change it to a to a button.↗
▶Ep 60 · 20:29
clinicalPEG 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.↗
Malrotation with Dr. Meera Kotagal
▶Ep 70 · 1:17
quoteIn the fourth week of gestation, that's really when we start to see development of the bowel. And as the bowel grows in length, it actually herniates into the yolk sac and along the umbilical cord and the SMA axis.↗
▶Ep 70 · 1:17
clinicalIn the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis.↗
▶Ep 70 · 1:44
clinicalNormal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant.↗
▶Ep 70 · 2:22
clinicalMalrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus.↗
▶Ep 70 · 2:22
clinicalIntestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation.↗
▶Ep 70 · 2:22
clinicalIn non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation.↗
▶Ep 70 · 2:22
clinicalNon-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure.↗
▶Ep 70 · 2:22
quoteWe used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.↗
▶Ep 70 · 3:49
quoteAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 70 · 3:49
quoteAbout one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 70 · 3:49
clinicalChildren with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy.↗
▶Ep 70 · 3:49
clinicalAs children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases.↗
▶Ep 70 · 3:49
epidemiologicalAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 70 · 3:49
epidemiologicalAbout 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 70 · 3:49
clinicalComplications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery).↗
▶Ep 70 · 3:49
clinicalRotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses.↗
▶Ep 70 · 4:49
clinicalOn upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position.↗
▶Ep 70 · 4:49
clinicalIn the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal.↗
▶Ep 70 · 4:49
clinicalMalrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it.↗
▶Ep 70 · 4:49
clinicalAfter detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability.↗
▶Ep 70 · 4:49
clinicalSurgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation.↗
▶Ep 70 · 4:49
opinionMidgut volvulus is considered the number one surgical emergency in pediatric surgery.↗
▶Ep 70 · 4:49
clinicalContrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test.↗
▶Ep 70 · 4:49
clinicalOther symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension.↗
▶Ep 70 · 4:49
clinicalUpper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned.↗
▶Ep 70 · 4:49
clinicalThe differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis.↗
▶Ep 70 · 4:49
quoteIn the neonatal period, the most critical symptom to be really aware of is biliosemesis. Even if they have a normal appearing x-ray, those kids really need to be evaluated for midgut volvulus.↗
▶Ep 70 · 4:49
quoteWe think of midget volvulus as the number one surgical emergency in pediatric surgery and so missing that is a significant problem.↗
▶Ep 70 · 4:49
clinicalLate signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia.↗
▶Ep 70 · 8:33
quoteYou can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation.↗
▶Ep 70 · 8:54
clinicalThe Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible.↗
▶Ep 70 · 8:54
clinicalThe reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms.↗
▶Ep 70 · 10:01
opinionThere is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach.↗
▶Ep 70 · 10:01
opinionSome believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus.↗
▶Ep 70 · 10:01
opinionLaparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus.↗
▶Ep 70 · 10:01
epidemiologicalAbout one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease.↗
▶Ep 70 · 10:01
opinionDr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically.↗
▶Ep 70 · 10:01
opinionThere is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications.↗
▶Ep 70 · 10:01
clinicalIn younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly.↗
▶Ep 70 · 10:01
quoteAbout a quarter of patients who undergo a LADS procedure will have an intestinal obstruction related to small bowel obstruction related to their OTCU bowel disease from their LADS procedure.↗
▶Ep 70 · 10:01
opinionDecisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion.↗
▶Ep 70 · 10:01
opinionLaparoscopic approach may reduce the risk of postoperative bowel obstruction.↗
Meera's statements about Intussusception15 statements
guidelineThe guideline is for evaluation and management of patients who present to the ER with a history suggestive of intussusception.↗
▶Ep 5 · 1:00
quoteIndications for an urgent surgery consult include an acute abdomen, abnormal vital signs, if the patient's ill appearing or if there are other concerns from the ED providers.↗
▶Ep 5 · 1:00
guidelineIndications for urgent surgery consult include acute abdomen, abnormal vital signs, ill-appearing patient, or other concerns from ED providers.↗
▶Ep 5 · 2:00
guidelineOnce evaluated by a surgeon, a decision is made whether the patient needs emergent OR; if stable and not needing urgent intervention, the next step is ultrasound.↗
▶Ep 5 · 3:00
guidelineIf ultrasound is positive for intussusception, a surgical consult is called if not previously obtained.↗
▶Ep 5 · 3:30
guidelinePatients with positive ultrasound undergo air enema, and surgeons must be aware of the patient prior to the enema.↗
▶Ep 5 · 4:00
quoteSurgeons must be aware of the patient prior to obtaining the air enema, and in-person evaluation can occur before or after the enema if the patient is clinically stable.↗
▶Ep 5 · 4:00
guidelineIn-person surgical evaluation can occur before or after the air enema if the patient is clinically stable.↗
▶Ep 5 · 4:30
guidelineIf air enema successfully reduces the intussusception, patients are observed in the ED for four hours, then have a PO trial and can be discharged if clinically well.↗
▶Ep 5 · 5:00
guidelineIf the first air enema attempt fails to reduce the intussusception, the enema can be repeated every hour for up to three times with monitoring in between, as long as the intussusceptum continues to reduce, there is no free air, and the patient remains clinically stable.↗
▶Ep 5 · 5:00
quoteIf on the first attempt we're not able to reduce the intussusception, then the air enema can be repeated every hour for three times with monitoring in between the attempts as long as the intussusceptum continues to reduce, the patient doesn't have free air, and they remain clinically stable.↗
▶Ep 5 · 6:00
quoteIn our protocol, a fellow or an attending surgeon should be notified if the patient is undergoing more than one air enema.↗
▶Ep 5 · 6:00
guidelineA fellow or attending surgeon should be notified if the patient is undergoing more than one air enema.↗
▶Ep 5 · 6:30
guidelineIf the intussusceptum cannot be completely reduced after three air enema attempts, the patient goes to the OR for manual reduction.↗
▶Ep 5 · 7:00
opinionThis guideline may not apply to all patients.↗
clinicalIn the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis.↗
▶Ep 6 · 1:17
quoteIn the fourth week of gestation, that's really when we start to see development of the bowel. And as the bowel grows in length, it actually herniates into the yolk sac and along the umbilical cord and the SMA axis.↗
▶Ep 6 · 1:44
clinicalNormal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant.↗
▶Ep 6 · 2:22
quoteWe used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.↗
▶Ep 6 · 2:22
clinicalMalrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus.↗
▶Ep 6 · 2:22
clinicalNon-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure.↗
▶Ep 6 · 2:22
clinicalIn non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation.↗
▶Ep 6 · 2:22
clinicalIntestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation.↗
▶Ep 6 · 3:49
clinicalComplications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery).↗
▶Ep 6 · 3:49
quoteAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 6 · 3:49
clinicalAs children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases.↗
▶Ep 6 · 3:49
epidemiologicalAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 6 · 3:49
epidemiologicalAbout 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 6 · 3:49
quoteAbout one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 6 · 3:49
clinicalChildren with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy.↗
▶Ep 6 · 3:49
clinicalRotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses.↗
▶Ep 6 · 4:49
clinicalIn the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal.↗
▶Ep 6 · 4:49
clinicalOther symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension.↗
▶Ep 6 · 4:49
clinicalLate signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia.↗
▶Ep 6 · 4:49
clinicalOn upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position.↗
▶Ep 6 · 4:49
clinicalContrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test.↗
▶Ep 6 · 4:49
opinionMidgut volvulus is considered the number one surgical emergency in pediatric surgery.↗
▶Ep 6 · 4:49
clinicalSurgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation.↗
▶Ep 6 · 4:49
clinicalAfter detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability.↗
▶Ep 6 · 4:49
quoteIn the neonatal period, the most critical symptom to be really aware of is biliosemesis. Even if they have a normal appearing x-ray, those kids really need to be evaluated for midgut volvulus.↗
▶Ep 6 · 4:49
quoteWe think of midget volvulus as the number one surgical emergency in pediatric surgery and so missing that is a significant problem.↗
▶Ep 6 · 4:49
clinicalThe differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis.↗
▶Ep 6 · 4:49
clinicalUpper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned.↗
▶Ep 6 · 4:49
clinicalMalrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it.↗
▶Ep 6 · 8:33
quoteYou can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation.↗
▶Ep 6 · 8:54
clinicalThe Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible.↗
▶Ep 6 · 8:54
clinicalThe reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms.↗
▶Ep 6 · 10:01
opinionLaparoscopic approach may reduce the risk of postoperative bowel obstruction.↗
▶Ep 6 · 10:01
epidemiologicalAbout one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease.↗
▶Ep 6 · 10:01
opinionLaparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus.↗
▶Ep 6 · 10:01
opinionSome believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus.↗
▶Ep 6 · 10:01
quoteAbout a quarter of patients who undergo a LADS procedure will have an intestinal obstruction related to small bowel obstruction related to their OTCU bowel disease from their LADS procedure.↗
▶Ep 6 · 10:01
clinicalIn younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly.↗
▶Ep 6 · 10:01
opinionThere is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach.↗
▶Ep 6 · 10:01
opinionThere is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications.↗
▶Ep 6 · 10:01
opinionDecisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion.↗
▶Ep 6 · 10:01
opinionDr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically.↗
clinicalIn the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis.↗
▶Ep 6 · 1:17
quoteIn the fourth week of gestation, that's really when we start to see development of the bowel. And as the bowel grows in length, it actually herniates into the yolk sac and along the umbilical cord and the SMA axis.↗
▶Ep 6 · 1:44
clinicalNormal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant.↗
▶Ep 6 · 2:22
quoteWe used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.↗
▶Ep 6 · 2:22
clinicalIn non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation.↗
▶Ep 6 · 2:22
clinicalNon-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure.↗
▶Ep 6 · 2:22
clinicalIntestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation.↗
▶Ep 6 · 2:22
clinicalMalrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus.↗
▶Ep 6 · 3:49
epidemiologicalAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 6 · 3:49
quoteAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 6 · 3:49
quoteAbout one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 6 · 3:49
epidemiologicalAbout 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 6 · 3:49
clinicalComplications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery).↗
▶Ep 6 · 3:49
clinicalAs children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases.↗
▶Ep 6 · 3:49
clinicalChildren with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy.↗
▶Ep 6 · 3:49
clinicalRotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses.↗
▶Ep 6 · 4:49
opinionMidgut volvulus is considered the number one surgical emergency in pediatric surgery.↗
▶Ep 6 · 4:49
clinicalAfter detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability.↗
▶Ep 6 · 4:49
quoteWe think of midget volvulus as the number one surgical emergency in pediatric surgery and so missing that is a significant problem.↗
▶Ep 6 · 4:49
quoteIn the neonatal period, the most critical symptom to be really aware of is biliosemesis. Even if they have a normal appearing x-ray, those kids really need to be evaluated for midgut volvulus.↗
▶Ep 6 · 4:49
clinicalSurgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation.↗
▶Ep 6 · 4:49
clinicalContrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test.↗
▶Ep 6 · 4:49
clinicalOn upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position.↗
▶Ep 6 · 4:49
clinicalUpper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned.↗
▶Ep 6 · 4:49
clinicalMalrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it.↗
▶Ep 6 · 4:49
clinicalThe differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis.↗
▶Ep 6 · 4:49
clinicalLate signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia.↗
▶Ep 6 · 4:49
clinicalOther symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension.↗
▶Ep 6 · 4:49
clinicalIn the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal.↗
▶Ep 6 · 8:33
quoteYou can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation.↗
▶Ep 6 · 8:54
clinicalThe Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible.↗
▶Ep 6 · 8:54
clinicalThe reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms.↗
▶Ep 6 · 10:01
quoteAbout a quarter of patients who undergo a LADS procedure will have an intestinal obstruction related to small bowel obstruction related to their OTCU bowel disease from their LADS procedure.↗
▶Ep 6 · 10:01
opinionDecisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion.↗
▶Ep 6 · 10:01
clinicalIn younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly.↗
▶Ep 6 · 10:01
opinionThere is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications.↗
▶Ep 6 · 10:01
opinionThere is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach.↗
▶Ep 6 · 10:01
opinionDr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically.↗
▶Ep 6 · 10:01
opinionLaparoscopic approach may reduce the risk of postoperative bowel obstruction.↗
▶Ep 6 · 10:01
epidemiologicalAbout one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease.↗
▶Ep 6 · 10:01
opinionLaparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus.↗
▶Ep 6 · 10:01
opinionSome believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus.↗
Meera's statements about Midgut Volvulus42 statements
quoteIn the fourth week of gestation, that's really when we start to see development of the bowel. And as the bowel grows in length, it actually herniates into the yolk sac and along the umbilical cord and the SMA axis.↗
▶Ep 4 · 1:17
clinicalIn the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis.↗
▶Ep 4 · 1:44
clinicalNormal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant.↗
▶Ep 4 · 2:22
clinicalIntestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation.↗
▶Ep 4 · 2:22
clinicalNon-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure.↗
▶Ep 4 · 2:22
clinicalMalrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus.↗
▶Ep 4 · 2:22
quoteWe used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.↗
▶Ep 4 · 2:22
clinicalIn non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation.↗
▶Ep 4 · 3:49
clinicalChildren with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy.↗
▶Ep 4 · 3:49
quoteAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 4 · 3:49
quoteAbout one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 4 · 3:49
clinicalRotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses.↗
▶Ep 4 · 3:49
clinicalAs children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases.↗
▶Ep 4 · 3:49
epidemiologicalAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 4 · 3:49
epidemiologicalAbout 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 4 · 3:49
clinicalComplications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery).↗
▶Ep 4 · 4:49
clinicalOther symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension.↗
▶Ep 4 · 4:49
clinicalMalrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it.↗
▶Ep 4 · 4:49
clinicalLate signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia.↗
▶Ep 4 · 4:49
clinicalIn the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal.↗
▶Ep 4 · 4:49
clinicalSurgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation.↗
▶Ep 4 · 4:49
clinicalAfter detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability.↗
▶Ep 4 · 4:49
quoteIn the neonatal period, the most critical symptom to be really aware of is biliosemesis. Even if they have a normal appearing x-ray, those kids really need to be evaluated for midgut volvulus.↗
▶Ep 4 · 4:49
quoteWe think of midget volvulus as the number one surgical emergency in pediatric surgery and so missing that is a significant problem.↗
▶Ep 4 · 4:49
opinionMidgut volvulus is considered the number one surgical emergency in pediatric surgery.↗
▶Ep 4 · 4:49
clinicalContrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test.↗
▶Ep 4 · 4:49
clinicalOn upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position.↗
▶Ep 4 · 4:49
clinicalUpper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned.↗
▶Ep 4 · 4:49
clinicalThe differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis.↗
▶Ep 4 · 8:33
quoteYou can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation.↗
▶Ep 4 · 8:54
clinicalThe reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms.↗
▶Ep 4 · 8:54
clinicalThe Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible.↗
▶Ep 4 · 10:01
opinionThere is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach.↗
▶Ep 4 · 10:01
opinionDecisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion.↗
▶Ep 4 · 10:01
epidemiologicalAbout one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease.↗
▶Ep 4 · 10:01
opinionLaparoscopic approach may reduce the risk of postoperative bowel obstruction.↗
▶Ep 4 · 10:01
opinionDr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically.↗
▶Ep 4 · 10:01
quoteAbout a quarter of patients who undergo a LADS procedure will have an intestinal obstruction related to small bowel obstruction related to their OTCU bowel disease from their LADS procedure.↗
▶Ep 4 · 10:01
opinionThere is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications.↗
▶Ep 4 · 10:01
clinicalIn younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly.↗
▶Ep 4 · 10:01
opinionSome believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus.↗
▶Ep 4 · 10:01
opinionLaparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus.↗
Meera's statements about Midgut Volvulus42 statements
quoteIn the fourth week of gestation, that's really when we start to see development of the bowel. And as the bowel grows in length, it actually herniates into the yolk sac and along the umbilical cord and the SMA axis.↗
▶Ep 3 · 1:17
clinicalIn the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis.↗
▶Ep 3 · 1:44
clinicalNormal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant.↗
▶Ep 3 · 2:22
quoteWe used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.↗
▶Ep 3 · 2:22
clinicalIntestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation.↗
▶Ep 3 · 2:22
clinicalIn non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation.↗
▶Ep 3 · 2:22
clinicalNon-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure.↗
▶Ep 3 · 2:22
clinicalMalrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus.↗
▶Ep 3 · 3:49
clinicalComplications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery).↗
▶Ep 3 · 3:49
epidemiologicalAbout 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 3 · 3:49
quoteAbout one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus.↗
▶Ep 3 · 3:49
clinicalAs children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases.↗
▶Ep 3 · 3:49
epidemiologicalAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 3 · 3:49
clinicalRotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses.↗
▶Ep 3 · 3:49
clinicalChildren with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy.↗
▶Ep 3 · 3:49
quoteAbout 70% of those who will have a midgut volvulus will present in the first year of life.↗
▶Ep 3 · 4:49
clinicalOn upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position.↗
▶Ep 3 · 4:49
clinicalAfter detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability.↗
▶Ep 3 · 4:49
clinicalOther symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension.↗
▶Ep 3 · 4:49
quoteIn the neonatal period, the most critical symptom to be really aware of is biliosemesis. Even if they have a normal appearing x-ray, those kids really need to be evaluated for midgut volvulus.↗
▶Ep 3 · 4:49
quoteWe think of midget volvulus as the number one surgical emergency in pediatric surgery and so missing that is a significant problem.↗
▶Ep 3 · 4:49
clinicalThe differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis.↗
▶Ep 3 · 4:49
clinicalContrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test.↗
▶Ep 3 · 4:49
clinicalIn the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal.↗
▶Ep 3 · 4:49
clinicalSurgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation.↗
▶Ep 3 · 4:49
clinicalMalrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it.↗
▶Ep 3 · 4:49
clinicalUpper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned.↗
▶Ep 3 · 4:49
opinionMidgut volvulus is considered the number one surgical emergency in pediatric surgery.↗
▶Ep 3 · 4:49
clinicalLate signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia.↗
▶Ep 3 · 8:33
quoteYou can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation.↗
▶Ep 3 · 8:54
clinicalThe Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible.↗
▶Ep 3 · 8:54
clinicalThe reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms.↗
▶Ep 3 · 10:01
clinicalIn younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly.↗
▶Ep 3 · 10:01
opinionLaparoscopic approach may reduce the risk of postoperative bowel obstruction.↗
▶Ep 3 · 10:01
epidemiologicalAbout one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease.↗
▶Ep 3 · 10:01
opinionLaparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus.↗
▶Ep 3 · 10:01
opinionDecisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion.↗
▶Ep 3 · 10:01
opinionDr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically.↗
▶Ep 3 · 10:01
opinionThere is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach.↗
▶Ep 3 · 10:01
opinionThere is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications.↗
▶Ep 3 · 10:01
opinionSome believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus.↗
▶Ep 3 · 10:01
quoteAbout a quarter of patients who undergo a LADS procedure will have an intestinal obstruction related to small bowel obstruction related to their OTCU bowel disease from their LADS procedure.↗
Meera's statements about Neuroblastoma34 statements
epidemiologicalNeuroblastoma makes up about 8 to 10% of all pediatric cancers and about 15% of cancer-related deaths.↗
▶Ep 17 · 0:23
epidemiologicalNeuroblastoma makes up about 8 to 10% of all pediatric cancers and about 15% of cancer-related deaths.↗
▶Ep 17 · 0:48
quoteFor folks who have relapsed high risk neuroblastoma, the survival rate is 0.↗
▶Ep 17 · 0:48
epidemiologicalFor patients with relapsed high risk neuroblastoma, the survival rate is 0%.↗
▶Ep 17 · 0:48
epidemiologicalFor patients with relapsed high risk neuroblastoma, the survival rate is 0%.↗
▶Ep 17 · 0:48
quoteFor folks who have relapsed high risk neuroblastoma, the survival rate is 0.↗
▶Ep 17 · 2:17
clinical90% of neuroblastomas have elevated HVA and VMA (catecholamine metabolites).↗
▶Ep 17 · 2:17
clinical90% of neuroblastomas have elevated HVA and VMA (catecholamine metabolites).↗
▶Ep 17 · 2:22
clinicalNeuroblastomas are not typically thought of as causing elevated blood pressure despite producing catecholamines.↗
▶Ep 17 · 2:22
clinicalNeuroblastomas are not typically thought of as causing elevated blood pressure despite producing catecholamines.↗
▶Ep 17 · 5:09
quoteThe best way to think about IDRFs are things that touch things that are important, touching the vessels, touching the brachial plaque, touching the trachea, all of those things count as IDRS.↗
▶Ep 17 · 5:09
clinicalImage-defined risk factors (IDRFs) are best understood as things that touch important structures: vessels, brachial plexus, or trachea.↗
▶Ep 17 · 5:09
clinicalImage-defined risk factors (IDRFs) are best understood as things that touch important structures: vessels, brachial plexus, or trachea.↗
▶Ep 17 · 5:09
quoteThe best way to think about IDRFs are things that touch things that are important, touching the vessels, touching the brachial plaque, touching the trachea, all of those things count as IDRS.↗
▶Ep 17 · 7:15
guidelineIntermediate risk neuroblastoma patients receive neoadjuvant chemotherapy with 2, 4, 6, or 8 cycles depending on chromosomal factors, followed by surgical resection.↗
▶Ep 17 · 7:15
guidelineIntermediate risk neuroblastoma patients receive neoadjuvant chemotherapy with 2, 4, 6, or 8 cycles depending on chromosomal factors, followed by surgical resection.↗
▶Ep 17 · 7:38
clinicalThe key surgical principle for neuroblastoma resection is to stay on the vessels and work from normal to abnormal anatomy.↗
▶Ep 17 · 7:38
clinicalThe key surgical principle for neuroblastoma resection is to stay on the vessels and work from normal to abnormal anatomy.↗
▶Ep 17 · 7:52
quoteThe closer you are to the vessels, the safer you are.↗
▶Ep 17 · 7:52
quoteThe closer you are to the vessels, the safer you are.↗
▶Ep 17 · 8:22
clinicalImage-defined risk factors (IDRFs) are associated with increased risk of surgical complications.↗
▶Ep 17 · 8:22
clinicalImage-defined risk factors (IDRFs) are associated with increased risk of surgical complications.↗
▶Ep 17 · 9:13
clinicalWhen percutaneous core biopsies are performed by experienced practitioners who obtain multiple cores, the adequacy of these biopsies significantly improves and they are not inferior to open surgical biopsies.↗
▶Ep 17 · 9:13
clinicalWhen percutaneous core biopsies are performed by experienced practitioners who obtain multiple cores, the adequacy of these biopsies significantly improves and they are not inferior to open surgical biopsies.↗
▶Ep 17 · 9:33
clinicalAt Cincinnati Children's, radiologists obtain 25 cores from different parts of neuroblastoma tumors during percutaneous biopsy.↗
▶Ep 17 · 9:33
clinicalAt Cincinnati Children's, radiologists obtain 25 cores from different parts of neuroblastoma tumors during percutaneous biopsy.↗
▶Ep 17 · 10:44
clinicalFor neuroblastoma, unlike most tumors, the goal is to get as much tumor as possible but complete resection of every ounce of tumor is not expected.↗
▶Ep 17 · 10:44
clinicalFor neuroblastoma, unlike most tumors, the goal is to get as much tumor as possible but complete resection of every ounce of tumor is not expected.↗
▶Ep 17 · 10:55
clinicalTumor extending into neural foramina or other difficult locations should not be aggressively pursued; the goal is maximal safe resection without causing harm.↗
▶Ep 17 · 10:55
quoteThere's tumor that extends into the neural foramina or that extends into other places, you're not going to go chasing it.↗
▶Ep 17 · 10:55
clinicalTumor extending into neural foramina or other difficult locations should not be aggressively pursued; the goal is maximal safe resection without causing harm.↗
▶Ep 17 · 10:55
quoteThere's tumor that extends into the neural foramina or that extends into other places, you're not going to go chasing it.↗
▶Ep 17 · 12:48
guidelineThe observation protocol for infants with neuroblastoma has been expanded from primary adrenal tumors to L1 tumors in children under 6 months.↗
▶Ep 17 · 12:48
guidelineThe observation protocol for infants with neuroblastoma has been expanded from primary adrenal tumors to L1 tumors in children under 6 months.↗
Meera's statements about Pectus Carinatum5 statements
clinicalOvarian torsion may present with sharp onset of pain and a palpable or tender pelvic mass on exam; ultrasound does not always definitively diagnose torsion.↗
▶Ep 11 · 41:10
clinicalSymptomatic cholelithiasis patients often have had more than one episode of pain, while acute cholecystitis tends to be more abrupt in onset.↗
▶Ep 11 · 41:40
clinicalAppendicitis pain often starts periumbilical and migrates to the right lower quadrant as localized peritoneal inflammation develops.↗
▶Ep 11 · 42:20
clinicalSingle-incision laparoscopic appendectomy is performed through an umbilical incision, mobilizing the cecum and appendix to remove the appendix through the belly button.↗
▶Ep 11 · 55:13
clinicalMesenteric adenopathy is a secondary sign that can be associated with appendicitis but also occurs with gastroenteritis or mesenteric adenitis, requiring consideration of the whole clinical picture.↗
Meera's statements about Pediatric Oncology37 statements
epidemiologicalNeuroblastoma makes up about 8 to 10% of all pediatric cancers and about 15% of cancer-related deaths.↗
▶Ep 525 · 0:48
quoteFor folks who have relapsed high risk neuroblastoma, the survival rate is 0.↗
▶Ep 525 · 0:48
epidemiologicalFor patients with relapsed high risk neuroblastoma, the survival rate is 0%.↗
▶Ep 525 · 2:17
clinical90% of neuroblastomas have elevated HVA and VMA (catecholamine metabolites).↗
▶Ep 525 · 2:22
clinicalNeuroblastomas are not typically thought of as causing elevated blood pressure despite producing catecholamines.↗
▶Ep 525 · 5:09
quoteThe best way to think about IDRFs are things that touch things that are important, touching the vessels, touching the brachial plaque, touching the trachea, all of those things count as IDRS.↗
▶Ep 525 · 5:09
clinicalImage-defined risk factors (IDRFs) are best understood as things that touch important structures: vessels, brachial plexus, or trachea.↗
▶Ep 525 · 7:15
guidelineIntermediate risk neuroblastoma patients receive neoadjuvant chemotherapy with 2, 4, 6, or 8 cycles depending on chromosomal factors, followed by surgical resection.↗
▶Ep 525 · 7:38
clinicalThe key surgical principle for neuroblastoma resection is to stay on the vessels and work from normal to abnormal anatomy.↗
▶Ep 525 · 7:52
quoteThe closer you are to the vessels, the safer you are.↗
▶Ep 525 · 8:22
clinicalImage-defined risk factors (IDRFs) are associated with increased risk of surgical complications.↗
▶Ep 525 · 9:13
clinicalWhen percutaneous core biopsies are performed by experienced practitioners who obtain multiple cores, the adequacy of these biopsies significantly improves and they are not inferior to open surgical biopsies.↗
▶Ep 525 · 9:33
clinicalAt Cincinnati Children's, radiologists obtain 25 cores from different parts of neuroblastoma tumors during percutaneous biopsy.↗
▶Ep 525 · 10:44
clinicalFor neuroblastoma, unlike most tumors, the goal is to get as much tumor as possible but complete resection of every ounce of tumor is not expected.↗
▶Ep 525 · 10:55
clinicalTumor extending into neural foramina or other difficult locations should not be aggressively pursued; the goal is maximal safe resection without causing harm.↗
▶Ep 525 · 10:55
quoteThere's tumor that extends into the neural foramina or that extends into other places, you're not going to go chasing it.↗
▶Ep 525 · 12:48
guidelineThe observation protocol for infants with neuroblastoma has been expanded from primary adrenal tumors to L1 tumors in children under 6 months.↗
Clinical & Research Update: Renal Tumors with Drs. Ethan Smith, Lindsay Haacker, Michael Daugherty, and Meera Kotagal
▶Ep 685 · 8:27
clinicalTumors larger than 12 centimeters have an increased risk of intraoperative spill.↗
▶Ep 685 · 8:27
quoteTumors that are bigger than 12 centimeters, um, have an increased risk of intraoperative spill.↗
▶Ep 685 · 9:55
clinicalThe lymph node stations important for Wilms tumor include left renal hilar, periaortic, and aortic cable window.↗
▶Ep 685 · 10:18
quoteFor the most recent and current, um, COG trial, you do need to have at least one lymph node sampled in order to be eligible for the trial.↗
▶Ep 685 · 10:18
guidelineAt least one lymph node must be sampled to be eligible for the current COG trial (AREN 2231).↗
▶Ep 685 · 12:22
clinicalEnhanced recovery protocol includes preoperative carbohydrate load, regional anesthesia, no drains, early feeding (clears on post-op day 0, regular diet on post-op day 1), and IV fluids off on post-op day 1.↗
▶Ep 685 · 13:20
quoteOur, our length of stay is probably 3 to 4 days shorter than it used to be just by virtue of us being able to feed kids sooner.↗
▶Ep 685 · 13:20
epidemiologicalLength of stay with ERAS protocol is 3 to 4 days shorter than historical practice.↗
▶Ep 685 · 13:40
epidemiologicalNG tube placement post-operatively is rare with ERAS; only one or two patients required it over 4-5 years.↗
▶Ep 685 · 31:39
clinicalIn bilateral Wilms tumor, each side gets its own local stage, which impacts long-term management.↗
▶Ep 685 · 31:39
quoteWhen you have bilateral disease, um, each side gets its own local stage, and that really impacts the long-term, uh, management.↗
▶Ep 685 · 55:20
clinicalSurgery is a mainstay of management for TFE RCC and provides meaningful survival benefit even in metastatic disease.↗
▶Ep 685 · 55:20
quoteSurgery is a real mainstay of management for the TFERCC patients and, um, and being aggressive about that is important.↗
▶Ep 685 · 1:06:58
clinicalIVC thrombus below the level of the hepatic veins should be resected upfront; intrahepatic extension warrants neoadjuvant chemotherapy.↗
▶Ep 685 · 1:06:58
quoteThe standard of care is to say that things that are below the level of the hepatic veins, um, and then that infra uh hepatic cava should be done with an upfront resection.↗
▶Ep 685 · 1:07:14
quoteIf you transect that thrombus or take out the mass and then go to do your cable thrombus, you are upstaging that patient and so they become a stage 3 as a result.↗
▶Ep 685 · 1:07:14
clinicalThrombectomy must be performed in continuity with the nephrectomy specimen; transecting the thrombus upstages the patient to stage 3.↗
▶Ep 685 · 1:08:02
quoteIt was relatively adherent. A lot of times what we will do is actually make our, um, especially, you know, if you're coming from the right side, so you can open up the renal vein and then just extend on the lateral margin of the cava.↗
▶Ep 685 · 1:10:01
clinicalTumor thrombus is more adherent to the vessel wall after chemotherapy than in upfront resection.↗
▶Ep 685 · 1:10:55
clinicalFor IVC thrombus extending above the diaphragm, a thoracoabdominal approach with cardiac surgery support and potential bypass is used.↗
Meera's statements about Perforated Appendicitis3 statements
Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos
▶Ep 2 · 16:49
quoteI think in little kids, you can easily put in stam sutures, and I think that saves you when the tube dislodges. You don't have it dislodge, you know, in the stomach drop away as you might with the PEG, but that's just a personal practice.↗
▶Ep 2 · 20:29
clinicalPEG 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.↗
▶Ep 2 · 20:29
quoteOne of the issues also with peg is the difficulty in changing it then over to a button tube and the trauma of doing that to a child in the office and so I don't know what other institutions practices are but at ours children actually get a second anesthetic if they get a peg because they go back to the OR with the GI folks to get the peg removed under endoscopic and then they change it to a to a button.↗
Meera's statements about Pilonidal Disease1 statement
clinicalSome surgeons use sinus endoscopy (cystoscope) after pit excision to identify and remove remaining hair and granulation tissue from the cavity↗
Meera's statements about Pyloric Stenosis9 statements
clinicalUltrasound criteria for pyloric stenosis are muscle width greater than 3 millimeters and length greater than 14 millimeters.↗
▶Ep 7 · 0:00
clinicalLabs in pyloric stenosis most often demonstrate a hypochloremic, hypokalemic metabolic alkalosis.↗
▶Ep 7 · 0:00
clinicalPyloric stenosis presents with progressive nonbilious emesis and sometimes a palpable olive in the epigastrium.↗
▶Ep 7 · 0:10
quotePyloric stenosis is incredibly common in pediatric surgery, and ensuring that we effectively manage patients preoperatively is a key to their safety intraoperatively.↗
▶Ep 7 · 2:00
guidelinePotassium is added to IV fluids once urine output has been confirmed.↗
▶Ep 7 · 2:00
guidelineMaintenance IV fluid is started at one and a half times the maintenance rate in pyloric stenosis patients.↗
▶Ep 7 · 2:30
opinionThere is a trend in the literature that isotonic fluids should be used instead of hypotonic fluids in pediatric patients, though evidence is still developing in this age population.↗
▶Ep 7 · 3:00
guidelinePatients go to the OR for pyloromyotomy once their bicarb level is less than 30, their chloride is greater than 100, and their potassium is normal.↗
▶Ep 7 · 3:30
guidelinePostoperative management includes a short NPO period of around two hours followed by ad lib feeding with breast milk or formula.↗
Meera's statements about Umbilical Hernia21 statements
clinicalThe differential diagnosis of umbilical bulge includes umbilical hernia, urachal cyst, patent omphalomesenteric duct, umbilical granuloma, umbilical polyp, and omphalitis (when significant erythema is present).↗
▶Ep 7 · 0:34
clinicalUmbilical hernia is the most common cause of umbilical bulge in infants.↗
▶Ep 7 · 0:34
quoteYour differential diagnosis includes an umbilical hernia, which is obviously the most common, a ureachal cyst, a patent phallo mesenteric duct, umbilical granuloma, or an umbilical polyp, or in some instances, If there's significant erythema, you might consider umphalitis.↗
▶Ep 7 · 0:34
quoteThe History and physical are really important in the evaluation of a young child with an umbilical bulge.↗
▶Ep 7 · 1:00
clinicalUrine draining from the umbilicus is associated with a patent urachus.↗
▶Ep 7 · 1:00
quoteFor example, urine draining from the umbilicus would be associated with a patent urachus, whereas if you see succus, you might consider it a patent lymphalamassenteric duct.↗
▶Ep 7 · 1:00
clinicalSuccus draining from the umbilicus suggests a patent omphalomesenteric duct.↗
▶Ep 7 · 1:56
quoteAn umbilical polyp is a small remnant of the phallo mesenteric duct, which happens to extend from the umbilicus. Usually this is something that we can excise.↗
▶Ep 7 · 1:56
clinicalAn umbilical polyp is a small remnant of the omphalomesenteric duct extending from the umbilicus that can be excised.↗
▶Ep 7 · 1:56
clinicalAn umbilical granuloma is granulation tissue or asymptomatic pink tissue at the base of the umbilicus, often seen in very small infants shortly after umbilical cord separation, treated with silver nitrate.↗
▶Ep 7 · 1:56
quoteAn umbilical granuloma, granulation tissue or asymptomatic pink tissue that usually is at the base of the umbilicus. We often see that. Very small infants shortly after the umbilical cord has separated, and the treatment for that is silver nitrate.↗
▶Ep 7 · 2:42
quoteThe primary risk factor for umbilical hernias is prematurity. African-American infants are 8 times more likely to have an umbilical hernia compared to Caucasians.↗
▶Ep 7 · 2:42
epidemiologicalAfrican-American infants are 8 times more likely to have an umbilical hernia compared to Caucasians.↗
▶Ep 7 · 2:42
epidemiologicalThe primary risk factor for umbilical hernias is prematurity.↗
▶Ep 7 · 3:09
clinicalSmall umbilical hernia defects are more likely to close spontaneously compared to larger defects (those over 1 to 1.5 centimeters).↗
▶Ep 7 · 3:09
epidemiological85% of infant umbilical hernias will close on their own.↗
▶Ep 7 · 3:09
quoteAnd that's due to the fact that 85% of infant umbilical hernias will close on their own. Small defects are more likely to close spontaneously compared to larger defects, those that are over 1 centimeter or 1 centimeter and a half.↗
▶Ep 7 · 3:28
clinicalPediatric umbilical hernia repair does not use mesh, unlike adult repairs.↗
▶Ep 7 · 3:28
quoteAnd unlike in adults, we don't use mesh when we're repairing a child's umbilical hernia. But it is really important to make sure when you do that repair that you get all the way back to normal fashion. And that you're not closing hernia sac to hernia sac.↗
▶Ep 7 · 3:28
clinicalRoutine pediatric umbilical hernias are repaired as an outpatient procedure.↗
▶Ep 7 · 3:28
clinicalDuring pediatric umbilical hernia repair, it is important to close normal fascia to normal fascia, not hernia sac to hernia sac.↗
Summaries Meera gave as host
· 49 summaries
Recaps of what the experts said, with Meera as narrator — not Meera's own clinical position, and never cited in answers.
Summaries Meera gave as host · Abdominal Wall Defects8 summaries
7th Annual Pediatric Surgery Update Course 2019 - FULL SHOW
▶Ep 15 · 59:25
host summaryMeera Kotagal summarizing the discussion: 60 to 80% of vertebral injuries in kids are in the cervical spine compared to 30 to 40% in adults↗
▶Ep 15 · 59:25
host summaryMeera Kotagal summarizing the discussion: In older children, 70 to 80% of cervical spine injuries are bony injuries following adult patterns↗
▶Ep 15 · 59:25
host summaryMeera Kotagal summarizing the discussion: Cervical spine injury is about 1 to 2% of all pediatric traumas↗
▶Ep 15 · 59:25
host summaryMeera Kotagal summarizing the discussion: In younger children less than or equal to 8 years, about 50% have isolated fractures and 50% have ligamentous injury, dislocations, or SCIWORA↗
▶Ep 15 · 59:25
host summaryMeera Kotagal summarizing the discussion: 46% of institutions don't have a protocol for cervical spine clearance in children↗
▶Ep 15 · 59:25
host summaryMeera Kotagal summarizing the discussion: For cervical spine clearance imaging in children, use AP and lateral x-rays; if cross-sectional imaging needed, use MRI not CT because most injuries are ligamentous not bony↗
▶Ep 15 · 59:25
host summaryMeera Kotagal summarizing the discussion: Patients with cervical spine injury score of 0-1 points had negative predictive value over 99% and did not need imaging↗
▶Ep 15 · 59:25
host summaryMeera Kotagal summarizing the discussion: AAST study of over 12,000 children with blunt trauma found 0.6% had cervical spine injury; four independent predictors were GCS less than 14, involved in motor vehicle crash, age greater than or equal to 2 years↗
Summaries Meera gave as host · Appendicitis5 summaries
Update Course 2021: DEI – CONCORDANCE AND POST OP COMPLICATION STUDIES
▶Ep 15 · 7:10
host summaryMeera Kotagal summarizing the discussion: 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.↗
▶Ep 15 · 7:10
host summaryMeera Kotagal summarizing the discussion: 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.↗
▶Ep 15 · 13:40
host summaryMeera Kotagal summarizing the discussion: 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.↗
▶Ep 15 · 24:11
host summaryMeera Kotagal summarizing the discussion: Racial concordance between physician and newborn affected neonatal mortality but did not impact maternal mortality in the Florida study.↗
▶Ep 15 · 25:03
host summaryMeera Kotagal summarizing the discussion: 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.↗
Summaries Meera gave as host · Etiologies (Gastroschisis/NEC/Atresia/Volvulus)8 summaries
7th Annual Pediatric Surgery Update Course 2019 - FULL SHOW
▶Ep 21 · 59:25
host summaryMeera Kotagal summarizing the discussion: 46% of institutions don't have a protocol for cervical spine clearance in children↗
▶Ep 21 · 59:25
host summaryMeera Kotagal summarizing the discussion: Patients with cervical spine injury score of 0-1 points had negative predictive value over 99% and did not need imaging↗
▶Ep 21 · 59:25
host summaryMeera Kotagal summarizing the discussion: AAST study of over 12,000 children with blunt trauma found 0.6% had cervical spine injury; four independent predictors were GCS less than 14, involved in motor vehicle crash, age greater than or equal to 2 years↗
▶Ep 21 · 59:25
host summaryMeera Kotagal summarizing the discussion: Cervical spine injury is about 1 to 2% of all pediatric traumas↗
▶Ep 21 · 59:25
host summaryMeera Kotagal summarizing the discussion: In older children, 70 to 80% of cervical spine injuries are bony injuries following adult patterns↗
▶Ep 21 · 59:25
host summaryMeera Kotagal summarizing the discussion: In younger children less than or equal to 8 years, about 50% have isolated fractures and 50% have ligamentous injury, dislocations, or SCIWORA↗
▶Ep 21 · 59:25
host summaryMeera Kotagal summarizing the discussion: 60 to 80% of vertebral injuries in kids are in the cervical spine compared to 30 to 40% in adults↗
▶Ep 21 · 59:25
host summaryMeera Kotagal summarizing the discussion: For cervical spine clearance imaging in children, use AP and lateral x-rays; if cross-sectional imaging needed, use MRI not CT because most injuries are ligamentous not bony↗
Summaries Meera gave as host · Gunshot Wound3 summaries
host summaryMeera Kotagal summarizing the discussion: The more fresh frozen plasma (FFP) you give, the lower your mortality is in balanced resuscitation↗
▶Ep 4 · 4:40
host summaryMeera Kotagal summarizing the discussion: The closer you are to 1:1:1 ratio is better and this has been shown in kids, not just adult data↗
▶Ep 4 · 4:40
host summaryMeera Kotagal summarizing the discussion: The main idea is, the more fresh frozen plasma, or FFP you give, the lower your mortality is. The closer you are 1-1-1 is better and these guys have shown this in kids.↗
Summaries Meera gave as host · Inguinal Hernia3 summaries
Pediatric Inguinal Hernia in Brief: Presentation, Workup, Diagnosis, Perioperative Considerations
▶Ep 11 · 12:10
host summaryMeera Kotagal summarizing a resource: Now that with laparoscopy, you don't necessarily need to wait because it's really not that much more difficult in a laparoscopic case if there's swelling. In fact, sometimes the edema can help lift the peritoneum off.↗
▶Ep 11 · 12:10
host summaryMeera Kotagal summarizing a resource: Dr. Todd Ponsky states that with laparoscopy, you don't necessarily need to wait for bowel edema to come down because it's really not that much more difficult in a laparoscopic case if there's swelling, and sometimes the edema can help lift the peritoneum off.↗
▶Ep 11 · 12:45
host summaryMeera Kotagal summarizing a resource: Dr. Todd Ponsky suggests that if it's in the middle of the day and you have time availability and a patient has an incarcerated hernia, you could not even try to reduce it in the emergency room and just go straight to the operating room under laparoscopy.↗
Summaries Meera gave as host · Intestinal Rehab8 summaries
7th Annual Pediatric Surgery Update Course 2019 - FULL SHOW
▶Ep 30 · 59:25
host summaryMeera Kotagal summarizing the discussion: 46% of institutions don't have a protocol for cervical spine clearance in children↗
▶Ep 30 · 59:25
host summaryMeera Kotagal summarizing the discussion: Patients with cervical spine injury score of 0-1 points had negative predictive value over 99% and did not need imaging↗
▶Ep 30 · 59:25
host summaryMeera Kotagal summarizing the discussion: AAST study of over 12,000 children with blunt trauma found 0.6% had cervical spine injury; four independent predictors were GCS less than 14, involved in motor vehicle crash, age greater than or equal to 2 years↗
▶Ep 30 · 59:25
host summaryMeera Kotagal summarizing the discussion: 60 to 80% of vertebral injuries in kids are in the cervical spine compared to 30 to 40% in adults↗
▶Ep 30 · 59:25
host summaryMeera Kotagal summarizing the discussion: In younger children less than or equal to 8 years, about 50% have isolated fractures and 50% have ligamentous injury, dislocations, or SCIWORA↗
▶Ep 30 · 59:25
host summaryMeera Kotagal summarizing the discussion: Cervical spine injury is about 1 to 2% of all pediatric traumas↗
▶Ep 30 · 59:25
host summaryMeera Kotagal summarizing the discussion: For cervical spine clearance imaging in children, use AP and lateral x-rays; if cross-sectional imaging needed, use MRI not CT because most injuries are ligamentous not bony↗
▶Ep 30 · 59:25
host summaryMeera Kotagal summarizing the discussion: In older children, 70 to 80% of cervical spine injuries are bony injuries following adult patterns↗
Summaries Meera gave as host · Pectus Carinatum2 summaries
host summaryMeera Kotagal summarizing the discussion: In the Midwest Pediatric Consortium study, about 67% of children treated non-operatively for appendicitis did not require appendectomy within the next year.↗
▶Ep 11 · 45:20
host summaryMeera Kotagal summarizing the discussion: In the CODA study (adult randomized trial), 40% of patients with an appendicolith failed non-operative management and required surgery within the first 90 days.↗
Summaries Meera gave as host · Pediatric Oncology8 summaries
7th Annual Pediatric Surgery Update Course 2019 - FULL SHOW
▶Ep 210 · 59:25
host summaryMeera Kotagal summarizing the discussion: Patients with cervical spine injury score of 0-1 points had negative predictive value over 99% and did not need imaging↗
▶Ep 210 · 59:25
host summaryMeera Kotagal summarizing the discussion: 60 to 80% of vertebral injuries in kids are in the cervical spine compared to 30 to 40% in adults↗
▶Ep 210 · 59:25
host summaryMeera Kotagal summarizing the discussion: Cervical spine injury is about 1 to 2% of all pediatric traumas↗
▶Ep 210 · 59:25
host summaryMeera Kotagal summarizing the discussion: In older children, 70 to 80% of cervical spine injuries are bony injuries following adult patterns↗
▶Ep 210 · 59:25
host summaryMeera Kotagal summarizing the discussion: In younger children less than or equal to 8 years, about 50% have isolated fractures and 50% have ligamentous injury, dislocations, or SCIWORA↗
▶Ep 210 · 59:25
host summaryMeera Kotagal summarizing the discussion: AAST study of over 12,000 children with blunt trauma found 0.6% had cervical spine injury; four independent predictors were GCS less than 14, involved in motor vehicle crash, age greater than or equal to 2 years↗
▶Ep 210 · 59:25
host summaryMeera Kotagal summarizing the discussion: For cervical spine clearance imaging in children, use AP and lateral x-rays; if cross-sectional imaging needed, use MRI not CT because most injuries are ligamentous not bony↗
▶Ep 210 · 59:25
host summaryMeera Kotagal summarizing the discussion: 46% of institutions don't have a protocol for cervical spine clearance in children↗
Summaries Meera gave as host · Pyloric Stenosis4 summaries
host summaryMeera Kotagal summarizing a resource: The Dalton et al. framework from Kansas City predicts the number of fluid boluses needed based on the original chloride level, so labs do not need to be rechecked between each bolus in children likely to require two or three saline boluses.↗
▶Ep 7 · 1:30
host summaryMeera Kotagal summarizing a resource: In their study, they found that the amount of fluid boluses necessary could be predicted by the original chloride level.↗
▶Ep 7 · 3:30
host summaryMeera Kotagal summarizing a resource: Randomized controlled trials by Markel et al. and Adebe et al. found that ad lib feeding compared to protocolized feeding is associated with equivalent or shorter hospital stays.↗
▶Ep 7 · 3:30
host summaryMeera Kotagal summarizing a resource: Ad lib feeding may result in more emesis but there were no complications associated with that emesis in the Markel and Adebe trials.↗
