Lizzy Lee from Cincinnati Children's discusses a study examining the link between maternal hyperglycemia during pregnancy and adult offspring overweight and obesity. The research found that higher and more variable maternal blood sugar, especially in the third trimester, was linked to increased adult obesity risk in offspring. Interestingly, birth weight did not fully mediate this long-term effect but had its own independent association with adult BMI, suggesting a more complex interplay of factors.

Narrated by Lizzy Lee, PA-C & Maggie Koenig, this podcast, a rewind from the 2025 Pediatric Surgery Update Course, delves into crucial updates in Necrotizing Enterocolitis (NEC) management. Leading pediatric surgeons Drs. Augusto Zani, Simon Eaton, & Dan Ostlie discuss diagnostic challenges, highlighting the superior sensitivity of ultrasound over X-rays for early detection of surgical NEC indicators. The panel also debates various surgical interventions, including primary anastomosis versus ostomy, and examines emerging evidence on optimizing recovery outcomes for neonates with NEC.

Part 3 – How to Manage Bowel Size Discrepancy

Part 3 of 3: A second atresia has been found, the remaining bowel is genuinely short, and every centimeter matters. The final challenge is connecting a hugely dilated proximal segment to a much smaller distal bowel without sacrificing critical length.

KEY TAKEAWAYS
• After resecting another atresia, irrigate the distal bowel again and confirm patency all the way to the rectum.
• When the bowel ends are similar in caliber, a routine anastomosis may be appropriate.
• Patency is not the same as function. An anastomosis can be technically open but still behave like an obstruction when there is a severe caliber mismatch.
• Resection of the dilated proximal segment may improve the size match, but it can sacrifice too much bowel when the remaining intestinal length is limited.
• Tapering enteroplasty can reduce the caliber of the dilated bowel while preserving length and mucosal surface area.
• Avoid over-tapering. A lumen that is too narrow can create a new obstruction, particularly in neonatal bowel with limited motility.
• The operation is only the beginning. Protocol-driven postoperative care from an experienced intestinal rehabilitation team is critical during the following weeks and months.

The goal is not simply to create an anastomosis. It is to preserve enough functional bowel to support the child for life.

Watch to see what Dr. Michael Helmrath and Dr. Paul Wales from Cincinnati Children's say about this case.

Watch all parts on our page.

Learn more about the Intestinal Rehab Center at CCHMC: https://www.cincinnatichildrens.org/service/i/intestinal-rehabilitation?utm_source=youtube&utm_medium=social&utm_campaign&utm_content=ap_sbxtctqtfa

Made possible by Cincinnati Children’s

#PediatricSurgery #NeonatalSurgery #NeonatalObstruction #IlealAtresia #JejunoilealAtresia #BowelAtresia #TaperingEnteroplasty #BowelAnastomosis #ShortBowelSyndrome #IntestinalRehabilitation #IntestinalFailure #NICU #NewbornSurgery #SurgicalEducation #MedicalEducation #ClinicalReasoning #ClinicalChronicles

Part 1 – Evaluating a Baby With Bilious Vomiting

Part 1 of 3: A term newborn presents with bilious emesis, abdominal distension, and no passage of meconium. What should you do first?

KEY TAKEAWAYS
• Bilious emesis in a newborn must be treated as malrotation with midgut volvulus until proven otherwise.
• A stable, nontoxic baby with a soft abdomen and multiple dilated bowel loops extending distally may suggest a distal intestinal obstruction.
• Clinical appearance and the abdominal X-ray can guide your suspicion, but they do not definitively exclude malrotation.
• An upper GI study is used to evaluate the position of the duodenojejunal junction and formally assess for malrotation.
• Once malrotation has been excluded, additional imaging—such as a contrast enema—can help define the cause and level of the obstruction.

Thanks to Dr. Michael Helmrath and Dr. Paul Wales at Cincinnati Children's for their guidance on this case.

What would you do next? Watch Part 2 to see why the operation was canceled, all videos on our page.

Learn more about the Intestinal Rehab Center at CCHMC: https://www.cincinnatichildrens.org/service/i/intestinal-rehabilitation?utm_source=youtube&utm_medium=social&utm_campaign&utm_content=ap_lwi1g2kdx0

Made possible by Cincinnati Children's

#PediatricSurgery #NeonatalSurgery #NeonatalObstruction #BiliousEmesis #Malrotation #MidgutVolvulus #BowelObstruction #IlealAtresia #NICU #NewbornCare #MedicalEducation #SurgicalEducation #PediatricSurgeon #ClinicalReasoning #WhatWouldYouDo

Part 2 – Operative Management of Jejunoileal Atresia

Part 2 of 3: The contrast enema shows a microcolon, confirming that the distal bowel has never been used and strongly suggesting a congenital mechanical obstruction.
The diagnosis is most likely jejunoileal atresia—but with volvulus excluded, does this baby need an operation at 2:30 AM?

KEY TAKEAWAYS
• A microcolon on contrast enema suggests a longstanding prenatal obstruction, such as jejunoileal atresia.
• Once malrotation with volvulus has been excluded, the baby can be resuscitated and taken to the operating room under controlled conditions rather than undergoing an unnecessary emergency laparotomy.
• The entire bowel should be examined and measured because preserving intestinal length may determine the child’s long-term nutritional and intestinal outcome.
• Do not resect excessive proximal bowel simply to achieve normal caliber. Bowel length is critical.
• Before creating an anastomosis, cannulate and irrigate the distal bowel to confirm patency all the way to the rectum.
• Never assume there is only one atresia. A second downstream obstruction may be hidden in the collapsed distal bowel.

Prove the distal bowel before you commit.

Watch to see what Dr. Michael Helmrath and Dr. Paul Wales from Cincinnati Children's say about this case.

Watch Part 3 to see how the discovery of a second atresia changes the operative plan, all videos on our page.

Learn more about the Intestinal Rehab Center at CCHMC: https://www.cincinnatichildrens.org/service/i/intestinal-rehabilitation?utm_source=youtube&utm_medium=social&utm_campaign&utm_content=ap_iactfgtah6

Made possible by Cincinnati Children’s

#PediatricSurgery #NeonatalSurgery #NeonatalObstruction #JejunoilealAtresia #IlealAtresia #Microcolon #BowelAtresia #BowelObstruction #ShortBowelSyndrome #IntestinalRehabilitation #NICU #NewbornSurgery #SurgicalEducation #MedicalEducation #ClinicalReasoning #WhatWouldYouDo

Case Chronicles – Teaching Files: Case of Neonatal Obstruction
A term newborn with bilious emesis — from first evaluation through operative management of jejunoileal atresia

A term newborn presents with bilious emesis, abdominal distension, and no passage of meconium. This three-part teaching file follows the case from the initial workup through a complex operation, with commentary from Dr. Michael Helmrath and Dr. Paul Wales at Cincinnati Children's.

CHAPTERS
0:00 Part 1 – Evaluating a Baby With Bilious Vomiting
1:39 Part 2 – Operative Management of Jejunoileal Atresia
3:30 Part 3 – How to Manage Bowel Size Discrepancy

PART 1 — EVALUATING A BABY WITH BILIOUS VOMITING

Key takeaways:

Bilious emesis in a newborn must be treated as malrotation with midgut volvulus until proven otherwise.
A stable, nontoxic baby with a soft abdomen and multiple dilated bowel loops extending distally may suggest a distal intestinal obstruction.
Clinical appearance and the abdominal X-ray can guide your suspicion, but they do not definitively exclude malrotation.
An upper GI study is used to evaluate the position of the duodenojejunal junction and formally assess for malrotation.
Once malrotation has been excluded, additional imaging — such as a contrast enema — can help define the cause and level of the obstruction.

PART 2 — OPERATIVE MANAGEMENT OF JEJUNOILEAL ATRESIA

The contrast enema shows a microcolon, confirming that the distal bowel has never been used and strongly suggesting a congenital mechanical obstruction. The diagnosis is most likely jejunoileal atresia — but with volvulus excluded, does this baby need an operation at 2:30 AM?

Key takeaways:

A microcolon on contrast enema suggests a longstanding prenatal obstruction, such as jejunoileal atresia.
Once malrotation with volvulus has been excluded, the baby can be resuscitated and taken to the operating room under controlled conditions rather than undergoing an unnecessary emergency laparotomy.
The entire bowel should be examined and measured, because preserving intestinal length may determine the child's long-term nutritional and intestinal outcome.
Do not resect excessive proximal bowel simply to achieve normal caliber. Bowel length is critical.
Before creating an anastomosis, cannulate and irrigate the distal bowel to confirm patency all the way to the rectum.
Never assume there is only one atresia. A second downstream obstruction may be hidden in the collapsed distal bowel.

Prove the distal bowel before you commit.

PART 3 — HOW TO MANAGE BOWEL SIZE DISCREPANCY

A second atresia has been found, the remaining bowel is genuinely short, and every centimeter matters. The final challenge is connecting a hugely dilated proximal segment to a much smaller distal bowel without sacrificing critical length.

Key takeaways:

After resecting another atresia, irrigate the distal bowel again and confirm patency all the way to the rectum.
When the bowel ends are similar in caliber, a routine anastomosis may be appropriate.
Patency is not the same as function. An anastomosis can be technically open but still behave like an obstruction when there is a severe caliber mismatch.
Resection of the dilated proximal segment may improve the size match, but it can sacrifice too much bowel when the remaining intestinal length is limited.
Tapering enteroplasty can reduce the caliber of the dilated bowel while preserving length and mucosal surface area.
Avoid over-tapering. A lumen that is too narrow can create a new obstruction, particularly in neonatal bowel with limited motility.
The operation is only the beginning. Protocol-driven postoperative care from an experienced intestinal rehabilitation team is critical during the following weeks and months.

The goal is not simply to create an anastomosis. It is to preserve enough functional bowel to support the child for life.

WITH THANKS TO
Dr. Michael Helmrath and Dr. Paul Wales, Cincinnati Children's Hospital Medical Center, for their guidance on this case.

Learn more about the Intestinal Rehabilitation Center at Cincinnati Children's:
https://www.cincinnatichildrens.org/service/i/intestinal-rehabilitation

Made possible by Cincinnati Children's.

More teaching files and case series on our channel — subscribe for new cases.

#PediatricSurgery #NeonatalSurgery #JejunoilealAtresia #NeonatalObstruction #BiliousEmesis #Malrotation #MidgutVolvulus #BowelObstruction #Microcolon #TaperingEnteroplasty #ShortBowelSyndrome #IntestinalRehabilitation #NICU #SurgicalEducation #medicaleducation

Don't forget to like and subscribe to see more entertaining medical educational videos!

See more lectures, articles, and more on the Stay Current app: https://www.globalcastmd.com/stay-current-app-download

This video, featuring experts from Cincinnati Children's, discusses the challenging management of recurrent tracheoesophageal fistula (TEF) years after initial repair. Dr. Douglas von Allmen presents a clinical scenario and highlights the risk of recurrent laryngeal nerve (RLN) injury during re-repair. The episode emphasizes a transtracheal approach to improve surgical exposure and minimize potential harm to the RLN, thereby reducing long-term voice and aspiration issues.

This video, featuring Dr. P. Ben Ham III, discusses sacral nerve stimulation (SNS) as a treatment option for children with severe fecal incontinence and constipation refractory to conventional medical therapies. It presents a clinical scenario of a 13-year-old male and reviews the technique, efficacy, and potential complications of SNS in pediatric patients. The discussion highlights improved continence rates and important considerations regarding its current FDA approval status for children.

Topics to be discussed:
• Metastatic Ewing’s Sarcoma
• High-Grade Ovarian Pathology
• Radical Surgical Interventions
• Clinical Success Stories

This video recaps key highlights from the 13th Annual Pediatric Surgery Update Course, focusing on nerve monitoring in pediatric thyroid surgery. Dr. Ben Ham discuss clinical scenarios, the utility of TI-RADS in children, and the role of intraoperative nerve monitoring (IONM) in preventing recurrent laryngeal nerve injury. The discussion covers current guidelines, surgeon expertise, and advancements in monitoring devices for pediatric patients.

This video, featuring Dr. Douglas von Allmen from Cincinnati Children's Hospital, explores the management of branchial cleft cysts. It discusses a clinical scenario of a child with a painless neck swelling and delves into the congenital nature of these cysts. The video highlights the comparison between endoscopic cauterization and open surgical excision, emphasizing the benefits of the endoscopic approach in reducing morbidity and avoiding recurrent laryngeal nerve injury for specific cyst types.

Don't forget to like and subscribe to see more entertaining medical educational videos!

See more lectures, articles, and more on the Stay Current app: https://www.globalcastmd.com/stay-current-app-download

Dr. Lizzy Lee from Cincinnati Children's discusses a national multidisciplinary survey on the availability and use of bowel ultrasound (BUS) for diagnosing necrotizing enterocolitis (NEC). The study found that while BUS is available in many Level 4 NICUs, routine utilization is inconsistent due to barriers like lack of standardized protocols, limited provider training, and uncertainty in guiding treatment decisions. This article highlights the need for better evidence, standardized guidelines, and improved clinician training to enhance BUS adoption for NEC.

Alain Cuna, Julie D Thai, Kera McNelis, Loren Berman, Katie Huff, Sujir Pritha Nayak, Amy E O'Connell, Catherine J Hunter, Hala Chaaban, Eshanika Manchanda, Amina M Bhatia, Kate Louise M Mangona, Leeann Pavlek, Parvesh Garg, Lauren C Frazer, Mohan Pammi, Catalina Le Cacheux, Bhuvaneshwari Jagadesan, Toby D Yanowitz, Irfan Ahmad, Muralidhar H Premkumar

Objective: To characterize availability, utilization, and barriers to bowel ultrasound (BUS) for necrotizing enterocolitis (NEC).

Methods: A survey of neonatologists, surgeons, and radiologists at Children's Hospitals' Neonatal Consortium (CHNC) sites. Quantitative data were analyzed descriptively; open-ended responses underwent thematic analysis.

Results: In total, 104 respondents from 42/46 institutions participated. BUS was available at 83% of level IV NICU sites, with 64% reporting 24/7 availability. However, only 42% of affiliated level III NICUs had BUS available. BUS was primarily used alongside radiographs in cases of diagnostic uncertainty and variably used to guide surgical decisions. Radiologists frequently used protocols while neonatologists and surgeons reported limited training and few institutional guidelines. Key barriers included lack of standardization, inadequate training, and unclear clinical utility.

Conclusion: BUS is increasingly available in level IV NICUs but less so in level III NICUs. Even when available, clinical integration is inconsistent due to gaps in standardization, training, and supporting evidence.

This video, featuring Dr. Beth Rymeski from Cincinnati Children's, details the procedural aspects of Fetoscopic Endoluminal Tracheal Occlusion (FETO). It explains how a fetoscope is used to insert and inflate a balloon in the fetal trachea, facilitating fluid buildup and lung expansion to prevent pulmonary hypoplasia in babies with Congenital Diaphragmatic Hernia (CDH). The video provides an inside look at the navigation and key steps involved in this intricate fetal surgery.

Lizzie Lee from Cincinnati Children's discusses a study on pediatric pulmonary vein stenosis (PVS), a rare but serious condition. The research compares surgical and catheter-based interventions, revealing high recurrence rates for both approaches. It emphasizes the need for ongoing surveillance and multidisciplinary care for affected children.

Daiji Takajo, Paul J Critser, Awais Ashfaq, Russel Hirsch

Background: Pulmonary vein stenosis (PVS) is a rare but serious condition in children, often requiring surgical or catheter-based interventions. The initial optimal treatment strategy remains unclear due to disease complexity, progression, and high rates of recurrence.

Methods: In this retrospective, single-center study, we identified children with primary or secondary PVS from a cardiac catheterization and surgical database between 2015 and 2023. Patients with single ventricle physiology were excluded. Demographics and outcomes were compared between patients who underwent catheter-based intervention only and those who underwent at least one surgical pulmonary vein repair, with or without subsequent catheter-based reintervention. Reintervention following surgical repair was assessed using Kaplan-Meier analysis.

Results: Among 56 children with biventricular physiology and PVS (33 males, 59%), 16 (29%) underwent at least one surgical repair at a median age of 9 months (IQR 4-20), while 40 (71%) were managed with catheter-based interventions alone. Surgical repair was more frequently performed in patients with bilateral or complex disease, particularly those without prematurity or with coexisting congenital heart defects requiring open-heart surgery. Over time, catheter-based approaches became increasingly preferred. Overall, 92% of surgical patients required reintervention, most within the first year. Mortality did not significantly differ between groups (p = 0.294). In the surgical group, elevated right ventricular/systemic systolic pressure ratio (HR: 1.25, p = 0.048) and the presence of scimitar syndrome (HR: 8.25, p = 0.011) were associated with increased mortality.

Conclusions: Surgical pulmonary vein repair remains an important option, particularly in cases where catheter-based intervention is not feasible due to anatomical challenges or when multiple pulmonary veins are severely affected. However, recurrent pulmonary vein re-intervention is common, regardless of whether the initial approach was surgical or catheter-based.

https://pubmed.ncbi.nlm.nih.gov/41995823/

This video explores innovative technologies for central line management, focusing on solutions for blocked superior vena cava (SVC). Dr. Nathan Fagan discusses the MeritMedical Surfacer system for image-guided SVC recanalization via a femoral approach. The presentation also delves into the potential of 4D intracardiac echo catheters for radiation-free recanalization and reviews transhepatic and translumbar access as last-resort options when traditional venous access is lost.

Lizzy Lee from Cincinnati Children's discusses a pertinent study on the utility of invasive genetic testing, specifically Fluorescence In Situ Hybridization (FISH), prior to fetal surgery. The research questions whether FISH provides additional actionable information when non-invasive screening methods like ultrasounds and cell-free DNA already indicate a low risk for aneuploidy. The findings suggest that for carefully selected low-risk pregnancies, non-invasive screening may be sufficient, potentially avoiding the FISH procedure.

Ethan Lorence, Katelyn Seither, Hua He, Kara B Markham, Beatrix Wong

Objective: Current inclusion criteria for fetal surgery at most centers include the absence of multiple major anomalies and a normal chromosome analysis or fluorescence in situ hybridization (FISH) for aneuploidy. We evaluated the concordance of FISH with non-invasive screening methodologies to determine if invasive genetic testing provides additional information on fetal surgery candidacy.

Methods: A retrospective chart review was performed on 963 pregnancies evaluated for fetal surgery at the Cincinnati Children's Hospital Fetal Care Center between July 1, 2018 and July 31, 2023 for genetic testing results, fetal imaging, and surgical candidacy.

Results: FISH was concordant with screening results in 100% of pregnancies whose imaging and cell-free fetal DNA screening suggested a fetus at low risk for trisomy 21, trisomy 18, trisomy 13, and sex chromosome aneuploidies. Pregnancies with multiple congenital anomalies were significantly more likely to have abnormal genetic testing compared to pregnancies with isolated anomalies (52% vs. 17%, P = 0.0009).

Conclusions: In this study cohort, FISH did not provide additional information for the risk-benefit analysis of fetal surgery and introduced additional risk to the pregnancy due to the need for invasive fetal DNA collection.

This video discusses the critical challenge of maintaining surgical skills for rare procedures like posterior sagittal anorectoplasties (PSARP) due to low case volumes in pediatric surgery. It introduces a novel high-fidelity, 3D-printed PSARP simulator developed by researchers from leading children's hospitals. The simulator, which accurately replicates complex anatomy and haptics, has been validated as an effective teaching tool that reliably differentiates expert from novice surgeons.

Claire A Ostertag-Hill, Prathima Nandivada, Aaron P Garrison, Richard J Wood, Michael G Silver, Gregory Loan, Stephen F Wilson, Belinda Hsi Dickie

Background: The reconstruction of anorectal malformations (ARMs) is a technical but reproducible operation. The average number of ARM repairs performed by U.S. pediatric surgery trainees is 15 with recertifying pediatric surgeons performing an average of only 2 ARM repairs annually. The aim of this study was to investigate the validity of a surgical simulator that replicates the steps of repair.

Study design: A high-fidelity ARM simulator was designed using digital modeling software packages and fabricated using 3D-printing, hand-sculpting, and multi-stage silicone injection molding techniques. A cross-sectional observational study was performed at an international surgical meeting, recruiting 27 surgeons (n = 11 experts, n = 16 novice). Each participant performed a posterior sagittal anorectoplasty (PSARP) on the model and completed a questionnaire on the model's realism and didactic value. Each session of the simulation was recorded and independently assessed by 3 experienced pediatric colorectal surgeons (raters) using a standardized general skills (OSATS) and PSARP step-specific assessment tools.

Results: All items, including anatomical structures, haptics, and procedural steps, were evaluated as significantly better than neutral (p-values 0.003 to ‹0.0001). Significant differences between the groups were observed for multiple items in the OSATS checklist, including respect for tissue (p = 0.017), instrument handling (p = 0.012), flow of operation (p = 0.004), and knowledge of specific procedure (p = 0.014). Additionally, there were significant differences in performance by experts and novices on all PSARP steps as evaluated by experienced pediatric colorectal raters (p-values 0.005 to 0.046).

Conclusion: Evaluation of a newly developed high-fidelity, 3D-printed anorectal malformation surgical simulator demonstrated face, content, and discriminant construct validity. Given the low number of PSARPs performed annually by surgical fellows and attendings, this simulator can offer a high-fidelity training tool.

Dr. Nathan Fagan, a Pediatric Interventional Radiologist from Akron Children's Hospital, presents a clinical scenario on central line management from the 13th Annual Pediatric Surgery Update Course. He discusses diagnosing and managing a malfunctioning subclavian dual-lumen port, highlighting how proper access assessment can prevent unnecessary port removal. The video also covers interventional radiology techniques like sharp recanalization of the Superior Vena Cava (SVC) to restore vascular access for complex patients.

Dr. Todd Ponsky from Cincinnati Children's Hospital leads an interactive course discussing controversies and various techniques for inguinal hernia repair, particularly focusing on the laparoscopic approach. He presents patient scenarios and audience polls on management of issues like an unconfirmed groin bulge, incidental patent processus vaginalis (PPV), and contralateral evaluation during surgery. The discussion delves into the advantages of laparoscopic repair, especially for incarcerated hernias in preemies and adolescents, while also addressing concerns related to cosmesis, pain, and potential infertility risks.