Special Pediatric Surgery Forums
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quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "Anorectal manometry is sometimes used to diagnose HD; however, its diagnostic accuracy is limited in children under the age of 12 months. It is a helpful adjunct in diagnosing older children who struggle with constipation due to a delayed diagnosis of HD. One of the characteristics of HD is that patients cannot relax their internal anal sphincter in response to rectal distension, otherwise known as the rectoanal inhibitory reflex (RAIR). Anorectal manometry can screen for the absence of this reflex, which is…
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quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "Classically, it had been considered that an ileoanal pull-through should not be performed until urinary continence was achieved. The main reason for this recommendation was to avoid severe irritation of the perineal skin due to frequent stooling after proctocolectomy which could be improved if the child could sit on the potty. However, the treatment of perineal skin and in the medical management of hypermotility with loperamide and resins in combination with irrigations have so improved that waiting on the p…
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Quote from "The SAGES Manual of Pediatric Minimally Invasive Surgery" by Danielle S. Walsh, Todd A. Ponsky, Nicholas E. Bruns - "Suction rectal biopsy is the gold standard for making the diagnosis. There is a normal paucity of ganglia in the region of the internal sphincter; therefore the biopsy should be taken at least 1–2 cm above the dentate line. Acetylcholinesterase staining will demonstrate hypertrophied nerve trunks and a lack of normal ganglia in classical HD. Loss of calretinin immunostaining is also consistent with the diagnosis of HD [23]."
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quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "A colonic resection based solely on a frozen section must be avoided in patients who have an aganglionic zone proximal to the left colon. This is because proximal to the splenic flexure you cannot expect to see hypertrophic nerves (the sacral plexus does not innervate that bowel). Therefore, you are completely dependent upon your pathologist identifying ganglion cells on frozen section which is prone to sampling bias /false negatives. This is due to artifact in the tissue that can occur from the freezing pro…
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Quote from "Pediatric Surgery (Springer Surgery Atlas)" by Prem Puri, Michael E. Höllwarth - "If the surgeon does not have a clear and reliable image that shows the rectum located below the coccyx, he or she should never approach a patient posterior sagittally without a colostomy and without a distal colostogram. The distal colostogram, which is by far the most valuable study in defining the anorectal anatomy, can be done in patients with anorectal malformations only when the patient already has a colostomy. We have seen catastrophic complications during the performance of posterior sagittal operations in male patients who did not have a distal colostogram." quote from "P…
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quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - 1. For all anal stenosis (and rectal atresia) cases you must check for a presacral mass. 2. For any such presacral mass, always make sure there is no dural component (pelvic plus spinal MRI) and, if present, involve neurosurgery. 3. If Currarino syndrome, genetic testing is warranted for the patient and first-degree relatives. 4. For management, removal of the mass is key which will likely solve much of the constipation. 5. If the anus is narrow that must be treated; an anal canal sparing technique can accomp…
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quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "It is crucial not to chase the anteriorly directed fistula toward the scrotum, as it runs parallel to the urethra. Attempting to trace this fistula surgically could lead to significant complications, including spongiosum bleeding and urethral injury. Instead, the focus should be on mobilizing the distal rectum and avoiding dissection of the anterior rectal wall to avoid a urethral injury."
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quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "while the AP view might misleadingly suggest an underdeveloped sacrum, the lateral view typically provides a more accurate representation. The pelvic tilt can distort the appearance of the sacrum and coccyx in the AP view, leading to a falsely low sacral ratio. The lateral view, however, allows for a more reliable calculation by minimizing distortions caused by patient positioning"
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quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "A recent study from the ARM-Net registry highlights the need for sufficient screening and vigilant management of high-grade VUR in ARM patients. This study underscores the fact that despite normal kidneys on US, a significant proportion of patients may still have high-grade VUR, necessitating prophylaxis. All patients with ARM should have a newborn screen renal US and, in most, a follow-up VCUG should be done to assess for VUR."
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Quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "The main differential of surgical diagnoses for an infant with a distal bowel obstruction are: • HD • Neonatal small left colon • Anorectal malformation • Jejuno-ileal atresia • Meconium ileus • Meconium plug syndrome Some medical causes of colonic distension include: • Hypothyroidism • Magnesium sulfate effect • Opiate effect • Milk protein allergy"
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quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "When the common channel is <3 cm, it is possible to mobilize the UG complex as a unit to the perineum, the TUM. In general, a urethral length of >1.5 cm is required to avoid urine leakage and to avoid pulling down the bladder neck out of the urogenital diaphragm with the mobilization. When the length of the common channel is >3 cm or the urethra is <1.5 cm, a UG separation is utilized, leaving the common channel untouched and adding to it the native urethra. With the UG separation, the vagina and…
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Quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "For patients with uterine abnormalities, obstruction of menses is possible, and surgical correction may become necessary. Pregnancies in patients with vaginal anomalies are often considered high risk, and delivery options need to be discussed with maternal fetal medicine. The pelvic floor muscles are often not normally developed or have been iatrogenically altered, making vaginal delivery after pregnancy more traumatic. This is especially true if the perineal body was divided during reconstruction. Most pati…
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quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "Low ARMs, like recto-vestibular and perineal fistula, tend to be associated with congenital rectal dilation above the fistula. The dilated rectum is prone to constipation, and early bowel management is recommended. Bowel management in this population utilizes laxatives and fiber to keep the rectum empty and avoid distention of the dilated rectum. The pelvic floor and sphincter muscle may be more robust in these distal malformations; however, incontinence is still possible, especially in the setting of an ass…
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quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "Up to 10% of female infants with ARM have associated gynecologic anomalies, including an absent vagina in less than 1% of cases. Vaginoscopy is helpful to characterize the fistula and check for a vagina. An absent vagina may not be immediately apparent in the setting of a recto-vestibular fistula, especially if the fistula is mistaken for a vagina and a rectovaginal fistula is assumed to be present. In fact, absence of the vagina is only recognized about 50% of the time prior to anorectoplasty. When an absen…
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quote from "Pediatric Surgery (Springer Surgery Atlas)" by Prem Puri, Michael E. Höllwarth - "Augmentation cystoplasty is now commonly performed at most pediatric urological centres. Bladder augmentation has three major goals: to provide a compliant bladder reservoir, to limit bladder contractility, and to increase bladder capacity. Augmentation cystoplasty should allow the urinary tract to remain intact while preserving renal function and providing urinary continence. Various substrates are utilized to augment the bladder; the most commonly used is a segment of ileum, but stomach and large bowel also have been used. Ileum has been demonstrated to be the least contractile…
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quote from "Pediatric Surgery (Springer Surgery Atlas)" by Prem Puri, Michael E. Höllwarth - "The site of the stoma on the skin is selected entirely for the patient’s convenience. The umbilicus provides a good passage and the best cosmetic result, but it is not an option in exstrophy patients. With patients in wheelchairs, the spine tends to become twisted with time, causing progressive abdominal compression, and the abdomen becomes hidden from the patient’s field of vision. For these patients, a stoma site close to the xiphisternum is the best option."
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quote from "Pediatric Surgery (Springer Surgery Atlas)" by Prem Puri, Michael E. Höllwarth - "The technique includes early closure of the bladder, posterior urethra, and abdominal wall, usually with pelvic osteotomy in the newborn period, subsequently followed by an early epispadias repair at 6 months to 1 year of age after testosterone stimulation by intramuscular injection. Around age 4–5 years, when adequate bladder capacity is reached and the child is ready to participate in a very structured preoperative and postoperative voiding program, a competent bladder neck is reconstructed, with bilateral ureteral reimplantation."
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quote from "Pediatric Surgery (Springer Surgery Atlas)" by Prem Puri, Michael E. Höllwarth - "Ureteral reflux in various degrees is seen in 100% of cases after closure. A preoperative ultrasound evaluation of the otherwise usually unaffected upper tracts is mandatory to determine the presence of two normal kidneys"
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