Stay Current In Pediatric Surgery

This podcast is a discussion between Dr. Todd Ponsky and Dr. Patricio C. Gargollo who is the senior associate consultant pediatric urology at the Mayo Clinic Rochester and associate professor of urology at the Mayo medical school. It is a bout pediatric urology mostly regarding external genitalia and this is going to be an overview for pediatric surgeons to get an idea about all the things that we probably should know about external genitalia as a relates to pediatric urology. Facilitator: Dr. Todd Ponsky Editors: Dr. Todd Ponsky, Dr. Sophia Abdulhai, Dr. Abdulraouf Lamoshi and Dr. Raghavendra Rao

Speaker: Dr. Robert L. Sheridan Facilitator: Dr. Todd Ponsky Editors: Dr. Todd Ponsky, Dr. Sophia Abdulhai, Dr. Abdulraof Lamoshi and Dr. Raghavendra Rao

Dr. Maisam A. Abu-El-Haija acute pancreatitis presentation, she is the medical director of pancreas care center, division of pediatric gastroenterology at Cincinnati Children's Hospital, with participation from some experts and audience

An interactive discussion about Wilms tumor between Todd Ponsky, MD, Avraham Schlager, and Peter Ehrlich, MD. Dr. Peter Ehrlich is a professor of pediatrics surgery at the University of Michigan C.S. Mott Children’s Hospital who is also a vice chair of surgery and renal tumor section of the children oncology group. Table of Contents 00:00 - Introduction 01:09 - Typical clinical case? 03:27 - Wilms tumor CT scan 04:48 - What after CT scan 06:10 - Therapeutic options 09:15 - Management of widespread tumor 10:18 - Intestinal invasion 10:57 - tumor upstaging 12:35 - Different therapeutic approaches 14:57 - Crossing midline tumor 15:35 - Lung lesion impact on the approach 17:15 - Biopsy technique 18:39 - Possibility of negative biopsy 19:18 - Central line type 23:02 - Chemotherapy regimen 25:02 - Stage I and II with lung lesion 27:39 - Need for lung lesion biopsy 29:02 - Lung lesion after nephrectomy 29:19 - Treatment without biopsy 30:08 - Differences between COG and SIOP 31:16 - Abdominal radiation criteria

An interactive discussion between Todd Ponsky, MD and Don Nakayama, MD about the history of pediatric surgery, specifically the evolution of the management of pyloric stenosis, Hirschprung disease and esophageal atresia. Dr. Nakayama is an adjunct professor of the department of surgery at the Herbert Wertheim College of Medicine at Florida International University and pediatric surgeon at Sacred Heart Medical Group. Table of Contents 00:00:00 Introduction 00:01:54 Origin of Pediatric Surgery 00:05:47 Historical events in medicine involving pediatric patients 00:07:21 How Dr. Nakayama became interested in the history of pediatric surgery 00:08:59 History of pyloric stenosis 00:11:38 First pyloric stenosis operations 00:14:46 Start of perioperative care of pyloric stenosis patients 00:18:04 History of Hirschsprung disease 00:23:08 The contributions of Dr. Swenson 00:25:16 Feud between Dr. Swenson and Dr. Gross 00:28:16 History of the Soave procedure 00:30:33 Story of the first PDA ligation 00:36:41 Feud bet

An interactive discussion about intestinal failure between Todd Ponsky, MD and Brad Warner, MD. Dr. Warner is the Jessie L. Ternberg, MD, PhD Distinguished Professor of Pediatric Surgery at Washington University School of Medicine and surgeon-in-chief for St. Louis Children’s Hospital in St. Louis, Missouri. Table of Contents 00:00 - Introduction 01:39 - What is intestinal failure? 02:50 - Required bowel length 05:39 - Nature history of short gut 07:07 - Mortality in intestinal failure 07:39 - Small bowel transplant candidacy 09:15 - Causes of short gut 09:42 - Medical management of short gut syndrome 12:40 - Primary prevention of TPN cholestasis 16:15 - Summary of medical management 18:03 - Importance of breast milk 19:19 - Formula selection 20:13 - Management of volume administered 21:47 - Surgical management of intestinal failure 24:21 - Surgical evaluation 27:26 - Surgical options 28:47 - Bowel lengthening procedures 29:59 - Bianchi procedure 31:45 - STEP procedure 36:07 - Bianchi procedure pearls 38:10

An discussion of the medical and operative management of necrotizing enterocolitis between Todd Ponsky, MD and Gail Besner, MD. Dr. Besner is a H. William Clatworthy Professor of Pediatric Surgery, Chief of the Department of Pediatric Surgery, Principal Investigator of the Center of Perinatal Research, and Associate Director of the Pediatric Surgery Training Program at Nationwide Children's Hospital. Table of Contents 00:00:00 Introduction 00:02:41 Work-up of NEC 00:04:02 Medications associated with NEC 00:05:24 Physical Examination 00:07:04 Laboratory Work 00:08:44 Imaging studies 00:09:15 When to Operate on NEC 00:10:45 Medical Management of NEC 00:12:23 Antibiotic regimen 00:13:19 Frequency of imaging studies 00:13:55 Length to continue medical management 00:14:39 Stricture after NEC 00:15:43 When to operate after medical management without absolute indication 00:17:11 Peritoneal drain versus laparotomy 00:19:42 Randomized control trials comparing peritoneal drain and laparotomy 00:22:51 How to ch

An interactive discussion about gastroschisis and omphalocele between Todd Ponsky, MD and Jacob "Jack" Langer, MD. Dr. Langer is professor of surgery at the University of Toronto and Head of the Division of General and Thoracic Surgery at The Hospital for Sick Children in Toronto, Canada. Table of Contents 00:00 - Introduction 03:56 - Prenatal counseling for gastroschisis 05:34 - Mode of delivery for gastroschisis 06:22 - Timing of delivery in gastroschisis 07:29 - Induction of labor in gastroschisis 08:34 - Location of delivery in gastroschisis 09:45 - Management of simple gastroschisis 11:46 - Bedside closure of gastroschisis 15:05 - Role of intubation in gastroschisis 16:54 - Does every patient require staged closure? 18:46 - Intestinal atresia and gastroschisis 20:50 - Management of association intestinal atresia 23:48 - Awaiting bowel function after gastroschisis repair 27:54 - Cryptorchidism and gastroschisis 28:26 - Prenatal counseling for omphalocele 30:06 - Mode, location, and timing of delivery in

This podcast discusses the work up and management of umbilical cord defects. Dr. Todd A. Ponsky is an associate professor of surgery and pediatrics and pediatric surgeon at Akron Children's Hospital. Dr. Kenneth S. Azarow is surgeon-in-chief for Doernbecher Children’s Hospital and Helen B. Tracy professor of pediatric surgery at Oregan Health and Science University. Time Markers: 00:00:00 Introduction 00:02:04 Timing of surgery 00:05:18 Diagnosing an incarcerated umbilical hernia 00:07:23 Anesthesia 00:08:24 Suture preference 00:08:49 Antibiotic use 00:10:09 Umbilicoplasty 00:12:30 Management of Gastroschisis 00:14:37 Management of Omphalocele 00:16:39 Use of mesh for umbilical hernia repairs 00:17:00 Do asymptomatic umbilical hernias require operative repair? 00:18:33 Work-up and management of drainage from umbilicus 00:20:54 Management of a granuloma 00:22:01 Operative management of urachal remnant 00:23:57 Workup and management of urachal anomalies 00:26:11 Operative management of a patent omphalomesen

This podcast discusses the work up, operative management, and follow-up management of tracheoesophageal fistulas. Dr. Todd Ponsky is an associate professor of surgery and pediatrics and pediatric surgeon at Akron Children's Hospital. Dr. Avraham Schlager is a pediatric surgeon at Akron Children's Hospital. Dr. Daniel von Allmen is the surgeon-in-chief, Lester W. Martin chair of pediatric surgery, senior vice president of the surgical services, and professor at University of Cincinnati department of surgery. Audio Index 00:00:00 Introduction 00:03:27 Diagnosis of TEF 00:06:21 Preoperative planning 00:07:09 Management of TEF with right sided aortic arch 00:09:00 Timing of Repair in stable patient 00:09:56 Management of patient with respiratory compromise prior to OR 00:10:58 Temporizing maneuvers to help improve respiratory function 00:13:26 Management of TEF in patients with duodenal atresia 00:14:29 Role of preoperative bronchoscopy 00:16:20 Positioning of endotracheal tube 00:17:09 Approaches to open

An interactive discussion about malignant and benign pediatric thyroid disorders between Todd Ponsky, MD and Diana Diesen, MD. Dr. Diesen is assistant professor of surgery and pediatric surgery fellowship program director at the University of Texas Southwestern Medical Center and is a member of the Children's Health Pediatric Thyroid Center at the Children's Medical Center of Dallas. Contents 00:00 Introduction 02:31 Asymptomatic thyroid nodule 03:00 History 04:08 Risks factors for thyroid nodules and cancers 04:25 Family history 04:56 Physical exam 05:24 Physical exam pearls 06:03 Concerning physical exam findings 06:56 Laboratory evaluation 07:42 Thyroid scintigraphy 08:08 Hot thyroid nodules 09:13 Nodule with normal TSH 09:26 Thyroid ultrasound 10:15 Thyroid cysts 10:52 Lesion size and FNA biopsy 11:53 Anesthesia for FNA 12:30 Lymph node evaluation 13:12 Suspicious lymph node features 13:40 Papillary thyroid cancer 14:34 Lobectomy vs thyroidectomy 16:05 Thyroidecomy technique 17:07 Use of nerve monitor 1

An interactive discussion about gastroesophageal reflux disease between Jeffrey Ponsky, MD and Michael Rosen, MD. Dr. Rosen is a professor of surgery at the Cleveland Clinic Lerner College of Medicine, and general surgery staff in department of surgery at Cleveland Clinic in Cleveland, OH. Dr. Ponsky, is a professor of surgery at the Cleveland Clinic Lerner College of Medicine and Department of Surgery at Cleveland Clinic. Table of Contents 00:01:06|GERD 00:01:16|Case presentation 40 year old woman with heartburn(00:01:16:30) 00:02:56|H2-blockers 00:03:19|Refractory symptoms after PPI 00:04:23|Role of EGD- assess esophagitis, and rule out Barrett’s 00:04:57|Frequency of EGD 00:06:17|Bravo-study performed with patient off PPI 00:07:13|Use of manometry done prior to operative intervention 00:07:41|Management after Bravo results 00:09:30|Workup for patient not responding to PPI management 00:11:04|What is manometry? 00:13:18|Surgical interventions to consider for GERD 00:13:54|Nissen Fundoplication 00:17:05|N

An interactive discussion about colorectal cancer between Jeffrey Ponsky, MD and Conor Delaney, MD, PhD. Dr. Delaney, is the chairman of the Digestive Disease and Surgery Institute at Cleveland Clinic, Cleveland, OH. Dr. Delaney is also a professor of surgery at Cleveland Clinic Lerner College of Medicine. Dr. Ponsky, is a professor of surgery at the Cleveland Clinic Lerner College of Medicine and staff surgeon in the department of Surgery at Cleveland Clinic, Cleveland, OH. Table of Contents 01:04:09|Role Of Colonoscopy For Screening And For Serrated Polyps 04:15:59|Rectal Cancers At 6cm In Today’s Era 08:17:45|Endoscopic Ultrasound And Preoperative Radiation 13:05:22|Preoperative radiation in node negative cancer 14:08:53|Differences Between T1a And T1b 15:58:44 |Endoscopic Submucosal Resection For Rectal Cancer 17:18:09|Preoperative Radiation For Rectal Cancer 18:57:32|Sigmoid Cancer 22:30:40|Approach To Cecal Cancer 23:57:48 |Laparoscopic Anastomosis 24:14:00|Genetic Workup

An interactive discussion about acute cholecystitis disease between Jeffrey Ponsky, MD and John Rodriguez, MD. Dr. Rodriguez is a general surgery staff surgeon in department of surgery at Cleveland Clinic in Cleveland, OH. Dr. Ponsky, is a professor of surgery at the Cleveland Clinic Lerner College of Medicine and Department of Surgery at Cleveland Clinic. Table of Contents 00:57:01|Acute Cholecystitis: Simple Versus Mitigating Cases 07:12:11|Management Of Cholecystostomy Tube 08:59:20|After The Tube: Operative Planning For Sick Patients 11:17:32|Operative Technique For Simple Acute Cholecystitis 15:18:54|Intra-operative Challenges 20:33:55|Cholangiograms 23:27:10|Transcystic Antegrade Sphincteroplasty 25:37:32|Difficult Dissections

In this episode, Dr. Marc Levitt from Nationwide Children’s Hospital discusses complications of anorectal malformations. This episode is brought to you by the Center for Colorectal and Pelvic Reconstruction at Nationwide Children’s Hospital. Our collaborative team performs more than 1,000 procedures each year for kids from around the world. Visit nationwidechildrens.org/CCPR for more information. Table of contents: 00:00 – Play from the beginning 02:29 – Missed perineal fistula in a male 04:47 – Does surgical correction of a missed perineal fistula improve constipation? 05:57 – Physical exam for perineal fistula 07:27 – Perineal fistula in a female 09:50 – Anal sphincter stimulation 12:12 – Recto-urethral fistula 13:53 – Missed cloaca 16:42 – Common colostomy problems 17:39 – Incompletely diverting loop colostomy 18:28 – Transverse colostomy 19:14 – Dr Levitt’s preferred colostomy 20:53 – Anoplasty techniques 23:17 – Distal colostogram 26:34 – Identifying the distal rectum 29:54 – PSARP vs laparoscopy 32:50

In this episode, Dr Jennifer Dietrich from Texas Children’s Hospital discusses ovarian torsion. Table of contents: 00:00 – PLAY FROM THE BEGINNING 01:33 – Evaluation of the adolescent with lower abdominal pain 02:49 – Ultrasound 04:29 – Ovarian blood flow 07:06 – Peripherally located follicle 08:06 – Ovarian mass or lesion 11:14 – What findings are suggestive of malignancy? 12:13 – Role for CT or MRI 13:16 – Are pelvic exams necessary? 13:58 – Labs 15:01 – Tumor markers 16:50 – When to operate with normal blood flow 19:40 – Classic presenation of ovarian torsion 21:09 – Difference between symptomatic ovarian cyst and ovarian torsion 22:38 – Operative technique 23:48 – Cystectomy vs fenestration 26:08 – Ovarian salvage 27:51 – Ovarian bivalve procedure 30:48 – Oophoropexy 35:00 – Tubo-ovarian abscess 35:53 – Pregnancy 37:57 – Ectopic pregnancy 39:49 – Endometriosis 42:15 – Post-operative management 43:26 – Oral contraceptives 44:19 – Surveillance 45:33 – Closing remarks Intro track is adapted from "I dunno"

An interactive discussion about pediatric lung lesions between Todd Ponsky, MD and Steve Rothenberg, MD. Dr. Rothenberg is Chief of Pediatric Surgery and the Chairman of the Department of Pediatrics at the Rocky Mountain Hospital for Children in Denver, CO. He is also faculty at Columbia University, College of Physicians and Surgeons in the Division of Pediatric Surgery as a Senior Consultant in Pediatric Minimal Access Surgery. Table of Contents 00:00 Introduction 02:46 Prenatal evaluation 04:11 Role of fetal MRI 04:30 Fetal imaging features 05:11 Choice of delivery location 06:01 Role of fetal intervention 07:09 Administration of corticosteroids 07:49 Cyst volume ratio 08:32 Spectrum of CPAM 11:16 Routine neonatal care 13:45 Role of neonatal MRI 15:15 Institutional variations in management 17:41 Decision to operate 20:10 Too small for thoracoscopic surgery? 21:59 Preoperative preparation 23:31 Anesthetic considerations 25:15 Avoidance of over-ventilation 26:36 Avoidance of high peak venti

An interactive discussion about inguinal hernia between Jeffrey Ponsky, MD and Michael Rosen, MD. Dr. Rosen is professor of surgery at Cleveland Clinic Lerner College of Medicine. Table of Contents 1:00:44 1 Introductions 2:02:45Work up for groin bulge 4:02:16 Role of watchful waiting 5:30:26 Contraindications to repair 7:02:27 Open versus laparoscopic approach 10:48:40 Front door or ceiling: TAPP vs TEP laparoscopic repair 12:11:05 Patient counseling 14:24:46 Incidental contralateral hernia: To fix or not to fix? 15:29:07 Special cases: Check your minimally invasive ego 17:26:17 Laparoscopic repair: technical tenants 21:10:48 You’ve stepped into it now: Which mesh? 24:19:40 Fixation of mesh? 25:21:55 Contaminated field: To mesh or not to 26:15:14 Femoral hernias: Best approach? 28:34:32 Complicated hernias: recurrent, bilateral, incarcerated 30:35:18 Summary

This episode is our first audio journal club. We discuss 5 papers today with our guests, Dr Dan von Allmen, Dr George Whit Holcomb, and Dr Aaron Lipskar. Table of contents: 00:00 Introduction 00:55 Corticosteroids for biliary atresia 05:21 Dr von Allmen’s comments 10:54 Antiseptic agents and surgical site infection 14:15 Dr Holcomb’s comments 20:17 Non-operative management of non-perforated appendicitis 25:19 Dr Holcomb’s comments 30:41 Enteral autonomy after intestinal failure 33:37 Dr Lipskar’s comments 36:41 Anesthesia neurotoxicity 40:27 Dr Lipskar’s comments Use of Corticosteroids After Hepatoportoenterostomy for Bile Drainage in Infants With Biliary Atresia: the START randomized clinical trial Discussed by Dr Dan von Allmen Bezerra JA, et al. Use of Corticosteroids After Hepatoportoenterostomy for Bile Drainage in Infants With Biliary Atresia: the START randomized clinical trial. JAMA. 2014 May 7;311(17):1750–10. Dr von Allmen’s comments: • Dr von Allmen would not use corticosteroids after Kasai p

An interactive discussion about cloacal exstrophy between Todd Ponsky, MD and Alberto Peña, MD. Dr. Peña is is the founding director of the Peña Colorectal Center at Cincinnati Children's Hospital and clinical professor of surgery at the University of Cincinnati Table of Contents 00:00 Introduction 01:24 What is cloacal exstrophy? 06:24 Management of cloacal exstrophy 07:56 Sexual function in males 11:38 Team approach 12:50 Role of the pediatric surgeon 13:21 Differentiating urothelium from intestinal mucosa 13:51 Bladder closure 14:04 End colostomy creation 15:11 Consequences of end ileostomy creation 16:41 Rescue operation 18:51 Common mistake: Failure to separate bowel from bladder 20:15 Pelvic osteotomies for pelvic approximation 21:37 End colostomy complications 23:23 Reversal of colostomy and pull-through 24:09 Bladder augmentation 24:41 Stoma reversal candidates 25:43 Importance of colon length preservation 26:29 Bowel management program through stoma 27:31 Age for stoma reversal