Behind The Knife: The Surgery Podcast

It’s hospital day five. The patient looked better yesterday… but now she’s hypotensive, on vasopressors, acidotic, and spiraling toward multi-organ failure. The CT scan doesn’t show perforation or megacolon, but your gut tells you this is going south. Do you keep pushing medical therapy… or is it time to operate?
Join Drs. Rushabh Dev, Jeffrey Coughenour, Kevin Bartow, Raymond Okeke, and Desra Fletcher from the Emergency General Surgery team in Tiger Country at Mizzou as they tackle one of the deadliest and most challenging diseases acute care surgeons face: fulminant Clostridioides difficile infection. 
In this Clinical Challenges episode, the panel discusses diagnostic stewardship, ASCRS recommendations, timing of operative intervention and technique, subtotal colectomy versus diverting loop ileostomy with lavage, and physiology that should push surgeons toward definitive source control. 
Through a real-world high-risk case vignette, the team explores the hardest question in emergency general surgery: when to stop hoping medical therapy will work and pull the operative trigger.

Hosts

Dr. Rushabh Dev FACS (Moderator, Surgical Attending) – Assistant Professor of Surgery, Associate PD ACS & SCCM Fellowship, SICU Medical Director, Lieutenant Commander United States Navy Reserve 

Dr. Jeffery Coughenour FACS (Surgical Attending) – Professor of Surgery and Emergency Medicine, Trauma Medical Director at the University of Missouri SOM

Dr. Kevin Bartow FACS (Surgical Attending) –Professor of Surgery, Minimally Invasive Surgeon and General Surgery. Department of General Surgery at the University of Missouri SOM

Raymond Okeke – Acute Care Surgery/Surgical Critical Care Fellow, University of Missouri School of Medicine 

Desra Fletcher – PGY 3 General Surgery Resident, University of Missouri School of Medicine 

Learning Objectives
By the end of this episode, listeners should be able to:

Define the spectrum of Clostridioides difficile infection (CDI), including non-severe, severe, and fulminant disease, and recognize the physiologic implications of fulminant colitis. 

Review contemporary diagnostic stewardship for CDI, including appropriate stool testing, pitfalls of PCR/NAAT interpretation, and the role and limitations of CT imaging in fulminant disease. 

Describe evidence-based medical management of fulminant CDI, including high-dose enteral vancomycin, intravenous metronidazole, rectal vancomycin for ileus, and principles of antimicrobial stewardship. 

Recognize the high-risk clinical features that should prompt urgent surgical evaluation, including worsening shock, vasopressor dependence, lactate elevation, organ failure, and evolving abdominal exam findings. 

Discuss the operative indications and timing for surgery in fulminant CDI and understand why delayed intervention contributes to mortality. 

Compare subtotal colectomy with end ileostomy versus diverting loop ileostomy with antegrade lavage, including current evidence, patient selection, limitations of the literature, and ASCRS recommendations. 

Review practical operative strategies for subtotal colectomy in unstable patients, including damage-control principles and common technical pitfalls. 

Apply clinical reasoning to a complex, high-risk case of fulminant CDI in a patient with decompensated cirrhosis, septic shock, and multi-organ dysfunction. 

References

ASCRS Clinical Practice Guidelines for *Clostridioides difficile* Infection (2021) 

Surgical Management of *Clostridium difficile* Colitis — Neal et al., 2011 (Loop Ileostomy + Lavage Protocol) 

Clinical Practice Guidelines for *Clostridioides difficile* Infection in Adults and Children (IDSA/SHEA, 2021 Update) 

Adjunctive Hyperbaric Oxygen and Surgical Outcomes in Necrotizing Soft Tissue Infections (Background discussion of severe infection physiology) 

Total Abdominal Colectomy Versus Diverting Loop Ileostomy for Fulminant CDI — Systematic Review & Meta-analysis 

Current Status of Surgical Therapy for Fulminant *Clostridioides difficile* Colitis 

Behind the Knife Episode 648 – Emergency General Surgery Journal Review: *Clostridioides difficile* Infection 

Bottom line: Fulminant C. diff is one of the few EGS diseases where the hardest decision is not what operation to perform — it’s recognizing when medical therapy has failed before the patient becomes unsalvageable.

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Dominate Surgery: A High-Yield Guide to Your Surgery Clerkship: https://behindtheknife.org/premium/dominate-surgery-a-high-yield-guide-to-your-surgery-clerkship
Dominate Surgery for APPs: A High-Yield Guide to Your Surgery Rotation: https://behindtheknife.org/premium/dominate-surgery-for-apps-a-high-yield-guide-to-your-surgery-rotation
Vascular Surgery Oral Board Review Course: https://behindtheknife.org/premium/vascular-surgery-oral-board-review
Colorectal Surgery Oral Board Review Course: https://behindtheknife.org/premium/colorectal-surgery-oral-board-review
Surgical Oncology Oral Board Review Course: https://behindtheknife.org/premium/surgical-oncology-oral-board-review
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The majority of non-fatal gunshot wound survivors walk away with a bullet still inside them. Most are discharged without a removal attempt, without a surveillance plan, and without a conversation about what comes next. This episode fills that gap.
Dr. Patrick Georgoff is joined by BIG T co-host Dr. Teddy Puzio (UT Houston), gun violence survivor and trauma surgeon Dr. Madhu Subramanian (Duke), and Dr. Tyler Simpson (Duke ACS Fellow) for a practical, honest conversation about one of trauma's most overlooked topics.
What we cover:

Epidemiology: how common retained fragments really are, and why the downstream burden is underappreciated

When to remove (and when not to): a framework for both index hospitalization and delayed removal

Forensic evidence: how to handle bullets in the OR without destroying their evidentiary value — and who to call when you don't know

Lead toxicity: the rare but real complication that can surface a decade later, which blood lead levels should prompt action, and when to call hematology or toxicology

The psychology: retained bullets are independently associated with depression and reduced return to work — and that belongs in the risk-benefit conversation

DOMINATE THE DAY
BIG T Trauma Full Series: https://behindtheknife.org/podcast-series/big-t-trauma
This episode of Big T Trauma was sponsored by Teleflex, a global provider of medical devices. Learn more at teleflex.com and at the Teleflex Trauma and Emergency Medicine LinkedIn page.
Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  
If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listen
Behind the Knife Premium: https://behindtheknife.org/premium
Oral Board Review: https://behindtheknife.org/oral-board
Oral Board Simulator: https://behindtheknife.org/oral-board/simulator
General Surgery Oral Board Review Course: https://behindtheknife.org/premium/general-surgery-oral-board-review
Trauma Surgery Video Atlas: https://behindtheknife.org/premium/trauma-surgery-video-atlas
Dominate Surgery: A High-Yield Guide to Your Surgery Clerkship: https://behindtheknife.org/premium/dominate-surgery-a-high-yield-guide-to-your-surgery-clerkship
Dominate Surgery for APPs: A High-Yield Guide to Your Surgery Rotation: https://behindtheknife.org/premium/dominate-surgery-for-apps-a-high-yield-guide-to-your-surgery-rotation
Vascular Surgery Oral Board Review Course: https://behindtheknife.org/premium/vascular-surgery-oral-board-review
Colorectal Surgery Oral Board Review Course: https://behindtheknife.org/premium/colorectal-surgery-oral-board-review
Surgical Oncology Oral Board Review Course: https://behindtheknife.org/premium/surgical-oncology-oral-board-review
Cardiothoracic Oral Board Review Course: https://behindtheknife.org/premium/cardiothoracic-surgery-oral-board-review
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In this episode, hosts Drs. Maya Hunt, Nicole Santucci, Bryanna Stukes and Zoe Zhou explore the parallels between the literacy crisis in America and current challenges in surgical education, drawing insights from the podcast "Sold a Story." They discuss how both systems advance learners without true competency, blame struggling students rather than examining flawed teaching methods, and look to the promise of competency-based education as a path forward. Beyond surgical training, they examine how declining literacy rates will directly impact how we communicate with and care for our future patients.
Episode Hosts:
–Dr. Maya Hunt, Indiana University
[email protected]

-Dr. Nicole Santucci, Washington University in St. Louis
[email protected]

-Dr. Bryanna Stukes, UT Southwestern
[email protected]

-Dr. Nanruoyi (Zoe) Zhou, Weill Cornell Medicine
[email protected]

–CoSEF: @surgedfellows, cosef.org

References:
1.        Sold A Story: How teaching kids to read went so wrong | podcast. Accessed February 22, 2026. https://features.apmreports.org/sold-a-story/.
2.        2024-2025 Literacy Statistics. National Literacy Institute. Accessed February 22, 2026. https://www.thenationalliteracyinstitute.com/2024-2025-literacy-statistics.
3.        Purdy AC, Smith BR, Amersi F, et al. Characteristics Associated With Outstanding General Surgery Residency Graduate Performance, as Rated by Surgical Educators. JAMA Surg. 2022;157(10):918-924. doi:10.1001/jamasurg.2022.3340 https://pubmed.ncbi.nlm.nih.gov/35947371/
4.        Santosa KB, Lussiez A, Bellomo TR, et al. Identifying Strategies for Struggling Surgery Residents. J Surg Res. 2022;273:147-154. doi:10.1016/j.jss.2021.12.026 https://pubmed.ncbi.nlm.nih.gov/35085942/

5.        Mattar SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg. 2013;258(3):440-449. doi:10.1097/SLA.0b013e3182a191ca https://pubmed.ncbi.nlm.nih.gov/24022436/

6.        George BC, Bohnen JD, Williams RG, et al. Readiness of US General Surgery Residents for Independent Practice. Ann Surg. 2017;266(4):582-594. doi:10.1097/SLA.0000000000002414 https://pubmed.ncbi.nlm.nih.gov/28742711/

7.        Brasel KJ, Lindeman B, Jones A, et al. Implementation of Entrustable Professional Activities in General Surgery: Results of a National Pilot Study. Ann Surg. 2023;278(4):578-586. doi:10.1097/SLA.0000000000005991 https://pubmed.ncbi.nlm.nih.gov/37436883/

Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  
If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listen
Behind the Knife Premium: https://behindtheknife.org/premium
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General Surgery Oral Board Review Course: https://behindtheknife.org/premium/general-surgery-oral-board-review
Trauma Surgery Video Atlas: https://behindtheknife.org/premium/trauma-surgery-video-atlas
Dominate Surgery: A High-Yield Guide to Your Surgery Clerkship: https://behindtheknife.org/premium/dominate-surgery-a-high-yield-guide-to-your-surgery-clerkship
Dominate Surgery for APPs: A High-Yield Guide to Your Surgery Rotation: https://behindtheknife.org/premium/dominate-surgery-for-apps-a-high-yield-guide-to-your-surgery-rotation
Vascular Surgery Oral Board Review Course: https://behindtheknife.org/premium/vascular-surgery-oral-board-review
Colorectal Surgery Oral Board Review Course: https://behindtheknife.org/premium/colorectal-surgery-oral-board-review
Surgical Oncology Oral Board Review Course: https://behindtheknife.org/premium/surgical-oncology-oral-board-review
Cardiothoracic Oral Board Review Course: https://behindtheknife.org/premium/cardiothoracic-surgery-oral-board-review
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Ileocolic resection is one of the most common operations performed for Crohn's disease, yet the optimal approach to anastomotic construction and mesenteric management remains an active area of debate. From the configuration of the anastomosis to the extent of mesenteric excision, emerging evidence suggests that surgical technique may play a meaningful role in disease outcomes. Join Drs. Jared Hendren, Elissa Dabaghi, Joseph Trunzo, Ajaratu Keshinro, and David Rosen as they discuss methods for ileocolic anastomosis in Crohn's disease while reviewing the latest literature.
Hosts: 
- Jared Hendren, MD
Institution: Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
- Elissa Dabaghi, MD
Institution: Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
- Joseph Trunzo, MD
Institution: Department of Colon and Rectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
X/Twitter @joseph_trunzo
- Ajaratu Keshinro, MD
Institution: Department of Colon and Rectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
X/Twitter- @AJKesh
- David Rosen, MD
Institution: Department of Colon and Rectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
X/Twitter- @davidrrosenmd
Learning Objectives: By the end of this episode, listeners will be able to:
1.     Evaluate the evidence for the Kono-S anastomosis in reducing postoperative recurrence after ileocolic resection for Crohn's disease
2.     Describe the role of the mesentery in driving recurrence and discuss how mesenteric-targeting surgical approaches may influence outcomes
3.     Interpret the results of recent randomized controlled trials on extended mesenteric excision and apply them to surgical decision-making in ileocolic resection for Crohn's disease
Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  
If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listen
Behind the Knife Premium: https://behindtheknife.org/premium
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Dominate Surgery: A High-Yield Guide to Your Surgery Clerkship: https://behindtheknife.org/premium/dominate-surgery-a-high-yield-guide-to-your-surgery-clerkship
Dominate Surgery for APPs: A High-Yield Guide to Your Surgery Rotation: https://behindtheknife.org/premium/dominate-surgery-for-apps-a-high-yield-guide-to-your-surgery-rotation
Vascular Surgery Oral Board Review Course: https://behindtheknife.org/premium/vascular-surgery-oral-board-review
Colorectal Surgery Oral Board Review Course: https://behindtheknife.org/premium/colorectal-surgery-oral-board-review
Surgical Oncology Oral Board Review Course: https://behindtheknife.org/premium/surgical-oncology-oral-board-review
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As cancer vaccines move into Phase II and III clinical trials, it is
increasingly important for surgeons to understand their role in this
evolving landscape. What exactly are these vaccines, how do they work,
and what should the surgical community know about their
implementation? Join BTK surgical education fellows Kara Button and
Michelle LaBella as they sit down with Professor Robert Jones to break
down the science of mRNA vaccines, the logistics of tissue
procurement, and the future of cancer care.
Hosts:
- Professor Robert Jones: Consultant Liver Surgeon, Liverpool University
Hospitals; UK National Institute for Healthcare Research, Co-Lead for
the Cancer Vaccine Innovation Pathway, Bowel Cancer UK and Royal
College of Surgeons UK Lead for Research into Advanced Bowel Cancer,
and UK Chief Investigator for the BNT122-01 trial.
https://www.linkedin.com/in/robert-jones-6103722a/
- Kara Button, DO: General Surgery Resident, Maine Medical Center;
Behind the Knife Surgical Education Fellow.
- Michelle LaBella, MD: General Surgery Resident; University of North
Carolina; Behind the Knife Surgical Education Fellow.
References:
https://clinicaltrials.biontech.com/trials/BNT122-01
Jones RP, Lee LYW, Corrie PG, et al. Individualized cancer vaccines
versus surveillance after adjuvant chemotherapy for surgically
resected high-risk stage 2 and stage 3 colorectal cancer: protocol for
a randomized trial. BJS. 2023;110(12):1883-1884.
doi:10.1093/bjs/znad332
https://pubmed.ncbi.nlm.nih.gov/37856683/
Tie J, Wang Y, Loree JM, et al. Circulating tumor DNA-guided adjuvant
therapy in locally advanced colon cancer: the randomized phase 2/3
DYNAMIC-III trial. Nat Med. 2025;31(12):4291-4300.
doi:10.1038/s41591-025-04030-w
https://pubmed.ncbi.nlm.nih.gov/41115959/
Rojas LA, Sethna Z, Soares KC, et al. Personalized RNA neoantigen
vaccines stimulate T cells in pancreatic cancer. Nature.
2023;618(7963):144-150. doi:10.1038/s41586-023-06063-y
https://pubmed.ncbi.nlm.nih.gov/37165196/
https://www.cancer.ox.ac.uk/research/lynchvax#:~:text=The%20LynchVax%20program%2C%20funded%20by,individuals%20with%20this%20genetic%20condition
Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  
If you liked this episode, check out our recent episodes here: https://behindtheknife.org/listen
Behind the Knife Premium: https://behindtheknife.org/premium
Oral Board Review: https://behindtheknife.org/oral-board
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General Surgery Oral Board Review Course: https://behindtheknife.org/premium/general-surgery-oral-board-review
Trauma Surgery Video Atlas: https://behindtheknife.org/premium/trauma-surgery-video-atlas
Dominate Surgery: A High-Yield Guide to Your Surgery Clerkship: https://behindtheknife.org/premium/dominate-surgery-a-high-yield-guide-to-your-surgery-clerkship
Dominate Surgery for APPs: A High-Yield Guide to Your Surgery Rotation: https://behindtheknife.org/premium/dominate-surgery-for-apps-a-high-yield-guide-to-your-surgery-rotation
Vascular Surgery Oral Board Review Course: https://behindtheknife.org/premium/vascular-surgery-oral-board-audio-review
Colorectal Surgery Oral Board Review Course: https://behindtheknife.org/premium/colorectal-surgery-oral-board-audio-review
Surgical Oncology Oral Board Review Course: https://behindtheknife.org/premium/surgical-oncology-oral-board-audio-review
Cardiothoracic Oral Board Review Course: https://behindtheknife.org/premium/cardiothoracic-surgery-oral-board-audio-review
Download our App:
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