Journal of Pediatric Surgery Article Review: July 2023, PAPS Issue

Published: 2024-01-18

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Cecilia Genna — host
Speaker 2 — host
Mary Brindle — guest
Jamie Schnuck — guest
Bill Chu — guest

Chapters

0:00Cryoanalgesia for Pectus Excavatum Repair — Discussion of study comparing cryoanalgesia versus no cryoanalgesia in minimally invasive pectus excavatum repair, examining hospital length of stay, costs, and complication rates.
3:20Chest Tube Management After Lung Resection — Review of retrospective analysis of chest tube practices following pediatric lung resections, examining air leak rates and chest tube duration across lobectomies, diagnostic wedge resections, and excisional wedge resections.
6:08Laser Hair Reduction for Pilonidal Disease — Discussion of prospectively gathered data on laser hair reduction for pilonidal disease, examining number of sessions needed, recurrence rates, and variations by skin type and hair color.

Key claims

1:39Study period was 2011 to 2021 comparing patients who had cryoanalgesia versus those who hadn't — Mary Brindle
1:4844 patients total, 29 had cryoanalgesia — Cecilia Genna
1:48Patients with cryoanalgesia had 3.0 days hospital stay versus 5.4 days without — Cecilia Genna
2:00Hospital costs were less than $1000 difference, cheaper with cryoanesthesia — Cecilia Genna
2:2970% decrease in complication rates with cryoanalgesia, from 33% to 17% — Mary Brindle
2:18Cryoanalgesia equipment is incredibly expensive — Mary Brindle
3:48130 lung resections performed between 2013 and 2022 — Mary Brindle
3:5559 procedures were lobectomies (group 1), 19 diagnostic wedge resections (group 2), 52 excisional wedge resections (group 3) — Speaker 2
4:12Patients were less than 21 years of age, exclusion criteria was spontaneous pneumothorax — Jamie Schnuck
4:12In lobectomy group, 75% had no air leak with median chest tube duration of 2 days — Jamie Schnuck
4:30In diagnostic wedge resection group, nearly 90% had no air leak with median chest tube duration of 1 day — Speaker 2
4:39In excisional wedge resection group, 80% had no air leak with median chest tube duration of 1 day — Speaker 2
4:48Most chest tubes were removed on the first day after surgery and majority did not have an air leak — Jamie Schnuck
6:51198 patients total in pilonidal disease study, divided by skin types: 21 with types 1-2, 156 with types 3-4, 21 with types 5-6 — Cecilia Genna
6:59151 patients had dark color hair — Cecilia Genna
7:34To reach 75% hair reduction requires mean of 4.8 to 6.8 laser ablation sessions depending on skin and hair characteristics — Cecilia Genna
7:47Dark hair and skin types 5-6 were associated with higher recurrence rates — Cecilia Genna
7:47Overall recurrence rate was 6% — Cecilia Genna
6:44Pilonidal disease study data were prospectively gathered despite being retrospective study — Bill Chu
8:05Laser ablation for pilonidal disease costs money and insurance coverage varies — Mary Brindle
8:48All three papers were chosen as PAPS Award winners at annual conference — Mary Brindle

Open questions

Did patients undergoing lung resection need chest tubes at all, given high rates of no air leak?
Can we identify which lung resection patients are at less risk of air leak and avoid chest tube placement?
What are surgeon attitudes around chest tube management in pediatric lung resections?
Can chest tube management practices be studied prospectively to determine optimal approach?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Three Practical Refinements in Pediatric Surgery: Pain Control, Chest Tubes, and Pilonidal Recurrence

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why These Studies Matter

Pediatric surgery exists because children are not small adults — their physiology, healing capacity, and tolerance for intervention differ enough to demand specialized technique and judgment 8:48. The three studies reviewed here, all recognized at the Pacific Association of Pediatric Surgeons annual conference, address practical questions that shape daily care: how to control pain after chest wall reconstruction, when a chest tube is actually necessary after lung resection, and whether laser hair reduction can prevent pilonidal disease recurrence 8:48. None represents a paradigm shift, but each offers evidence to refine practice in a subspecialty where small gains in morbidity matter.

Cryoanalgesia for Pectus Repair

Minimally invasive pectus excavatum repair — placing a substernal bar to reshape the anterior chest wall — produces significant postoperative pain 1:39. The core problem is intercostal nerve trauma from bar placement and the mechanical stress of chest wall remodeling. Traditional management relies on epidural analgesia or systemic opioids, both of which carry risk and prolong hospital stay 1:39.

Cryoanalgesia freezes intercostal nerves intraoperatively, producing temporary nerve block that can last weeks 1:39. A Houston group compared patients who received cryoanalgesia during pectus repair against those who did not, over a period from 2011 to 2021 1:39 1:48. Patients who received cryoanalgesia had a median hospital stay of 3.0 days versus 5.4 days without it 1:48. Hospital costs were nearly $1,000 lower in the cryoanalgesia group despite the expense of the equipment itself 2:00 2:18. Complication rates dropped from 33% to 17% — a 70% relative reduction 2:29.

The cost finding is counterintuitive 2:00 2:18. Cryoanalgesia equipment is expensive, but the intervention pays for itself by shortening hospital stay and reducing complications that require additional care 2:18. For a referring clinician, the practical implication is straightforward: if your institution performs pectus repair, cryoanalgesia should be standard unless there is a specific contraindication 1:39 2:29. The technique is not experimental — it is now cost-effective and reduces morbidity 2:00 2:29 2:18.

Chest Tube Duration After Lung Resection

Pediatric lung resections are performed for congenital malformations, infection sequelae, and occasionally trauma or tumor 3:48. The reflex after any lung resection is to place a chest tube to evacuate air and fluid and monitor for air leak 3:48. The question is whether this reflex is always justified.

A Seattle group reviewed 130 lung resections performed between 2013 and 2022 in patients under 21 years of age, excluding spontaneous pneumothorax cases 3:48 4:12. They divided cases into three groups: lobectomies, diagnostic wedge resections, and excisional wedge resections 3:55. In the lobectomy group, 75% had no air leak and median chest tube duration was 2 days 4:12. In diagnostic wedge resections, nearly 90% had no air leak with a median duration of 1 day 4:30. Excisional wedge resections showed 80% with no air leak and a median duration of 1 day 4:39. Most chest tubes were removed on the first postoperative day, and the majority of patients never developed an air leak 4:48.

The clinical question this raises is whether chest tubes are necessary at all in low-risk cases, particularly diagnostic wedge resections where air leak rates approach the minority of cases 4:30 4:48. The trade-off is between routine placement in all patients — accepting the morbidity of tube insertion, pain, and restricted mobility — versus selective placement, accepting that a small number of patients may require urgent tube placement postoperatively if they develop a pneumothorax 3:48 4:48. The study does not resolve this tension, but it quantifies the risk clearly enough that institutions can make informed decisions about their own protocols 3:48 4:12 4:30 4:39.

Laser Hair Reduction for Pilonidal Disease

Pilonidal disease in adolescents and young adults is driven by hair penetration into the natal cleft, triggering chronic inflammation and sinus formation 6:51. Surgical excision addresses the sinus but does not address the hair, so recurrence rates remain high 6:51. Laser hair reduction targets the underlying mechanism 6:51.

A Stanford group prospectively tracked 198 patients treated between 2019 and 2022, categorizing them by Fitzpatrick skin type and hair color 6:51 6:59 6:44. Achieving 75% hair reduction required a mean of 4.8 to 6.8 laser sessions depending on skin and hair characteristics 7:34. Overall recurrence rate was 6% 7:47. Dark hair and skin types 5-6 were associated with higher recurrence 7:47.

The practical barrier is cost and insurance coverage, which varies widely 8:05. For a primary care physician managing an adolescent with pilonidal disease, the referral question is whether the patient is a candidate for laser therapy — meaning they have sufficient hair burden to justify it, insurance that will cover it, and the ability to complete multiple sessions over several months 6:51 7:34 8:05. The recurrence rate of 6% compares favorably to surgical excision alone, but the intervention is not trivial 7:47.

When to Involve Pediatric Surgery

For pectus excavatum, refer when the deformity is symptomatic — either causing cardiopulmonary compromise or significant psychosocial distress — and the patient is old enough for definitive repair, typically early adolescence 1:39. For pilonidal disease, refer after the first recurrence or if the initial presentation is complex with multiple sinuses 6:51. For lung resection, refer when imaging confirms a structural lesion requiring excision; the chest tube question is an intraoperative decision, not a referral criterion 3:48.

Takeaways from this story

Cryoanalgesia for pectus repair cuts hospital stay by 2 days and reduces complications 70% while remaining cost-effective.
After pediatric lung resection, 75-90% of patients have no air leak, raising the question of selective chest tube use.
Laser hair reduction for pilonidal disease achieves 6% recurrence but requires multiple sessions and insurance coverage varies.
Dark hair with skin types 5-6 shows higher pilonidal recurrence rates despite laser therapy.

Three Pediatric Surgery Studies That Change Daily Practice Decisions

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Teaching arc · AI-written, human-reviewed

Cryoanalgesia pays for itself through complications avoided

The equipment cost creates hesitation, but the economics reverse when you account for what happens downstream 2:18. In the Houston series comparing patients who received cryoanalgesia during pectus repair against those who did not, hospital stay dropped from 5.4 days to 3.0 days 1:48. More importantly, complication rates fell from 33% to 17% — a 70% reduction 2:29. The cost difference favored cryoanalgesia by less than $1000, meaning the expensive equipment paid for itself through shorter stays and fewer complications requiring intervention 2:00. The teaching point: when evaluating a costly intervention, the relevant comparison is not equipment price versus no equipment price, but total episode cost including the complications you prevent. Cryoanalgesia for pectus is now difficult to argue against on economic grounds.

Most pediatric lung resections produce no air leak on postoperative day one

The Seattle series of 130 lung resections between 2013 and 2022 stratified outcomes by procedure type: 59 lobectomies, 19 diagnostic wedge resections, and 52 excisional wedge resections 3:48 3:55. In the lobectomy group, 75% had no air leak with median chest tube duration of 2 days 4:12. The diagnostic wedge group performed even better — nearly 90% had no air leak with median tube duration of 1 day 4:30. Excisional wedge resections showed 80% with no air leak and 1-day median duration 4:39. Most chest tubes came out on postoperative day one, and most patients never leaked 4:48.

This creates the obvious question: if the majority of diagnostic wedge patients never leak, why place the tube at all? The answer requires balancing asymmetric risks. The patient who needs emergent reintervention because you omitted the tube represents a different magnitude of harm than the larger group who tolerate an unnecessary tube for a day. The study does not resolve that trade-off, but it quantifies the denominator — you now know what fraction of your patients derive no benefit from the tube. The next step is identifying preoperative or intraoperative features that predict those who will leak, allowing selective tube placement rather than universal placement.

Laser hair reduction for pilonidal disease requires sustained treatment and varies by phenotype

The Stanford protocol for pilonidal disease incorporates laser hair ablation as primary prevention against recurrence 6:44. In 198 patients divided by Fitzpatrick skin type — with types 1-2, types 3-4, and types 5-6 represented — the majority (151 patients) had dark hair 6:51 6:59. Achieving 75% hair reduction required a mean of 4.8 to 6.8 laser sessions depending on skin and hair characteristics 7:34. Overall recurrence rate was 6%, but dark hair and skin types 5-6 were associated with higher recurrence 7:47 7:47.

The practical implication: this is not a one-session adjunct. Families need to understand that effective hair reduction requires multiple treatments over months, and insurance coverage remains variable 8:05. The phenotype matters — patients with dark hair and darker skin require more sessions and still face higher recurrence risk. The 6% recurrence rate is low enough to justify the protocol, but the differential response by skin type means you cannot promise equivalent outcomes across your patient population. Set expectations accordingly at the initial consultation rather than discovering the coverage and compliance barriers after the first recurrence.

These studies share a common structure

All three papers were selected as PAPS Award winners, and all three address daily management decisions rather than rare scenarios 8:48. They quantify outcomes for interventions already in use — cryoanalgesia, chest tube placement, laser hair reduction — allowing you to counsel patients with institutional data rather than anecdote. The value lies not in discovering new techniques but in defining which patients benefit most and what realistic expectations look like when you apply these techniques at scale.

Takeaways from this story

Cryoanalgesia for pectus repair cuts complications 70% (33%→17%) and costs less than $1000 more despite expensive equipment
75-90% of pediatric lung resections have no air leak by postop day 1, raising the question of selective rather than universal tube placement
Laser hair reduction for pilonidal disease requires multiple sessions (mean 4.8-6.8) for 75% reduction; dark hair + skin types 5-6 have higher recurrence
Overall pilonidal recurrence rate of 6% with laser protocol justifies the multi-session commitment and insurance advocacy required

Topic overview

Three pediatric surgery studies from the July 2023 PAPS issue of Journal of Pediatric Surgery are reviewed: cryoanalgesia during minimally invasive pectus excavatum repair reduces hospital length of stay from 5.4 to 3.0 days and decreases complications from 33% to 17% while saving costs; chest tube management after pediatric lung resection shows 75-90% of patients have no air leak with median chest tube duration of 1-2 days, raising questions about necessity; and laser hair reduction for pilonidal disease requires 4.8-6.8 sessions to achieve 75% hair reduction with 6% recurrence rate, though dark hair and skin types 5-6 show higher recurrence.

Key takeaways

Cryoanalgesia in pectus repair cuts LOS from 5.4 to 3.0 days and complications from 33% to 17%, despite high equipment cost. (1:48)
After pediatric lung resection, 75-90% have no air leak with median chest tube duration 1-2 days—question routine prolonged use. (4:12)
Laser hair reduction for pilonidal disease needs 4.8-6.8 sessions for 75% reduction; dark hair/skin type 5-6 show higher recurrence. (7:34)

Keywords

pectus excavatum pilonidal disease spontaneous pneumothorax minimally invasive pectus excavatum repair cryoanalgesia lung resection lobectomy diagnostic wedge resection excisional wedge resection laser hair ablation chest tube placement Cincinnati Children's Hospital Alberta Childers Hospital University of Washington Stanford University

Hashtags

#PediatricSurgery #PectusExcavatum #PilonidalDisease #JournalClub

Transcript

Click "Show Transcript" to view the full text (9184 characters)

Hello everyone. Welcome back to another episode of the Stay Current podcast. I'm Cecilia Genna. I'm I'm Gdy, and we are research fellows at Cincinnati Children's Hospital. And along with Stay Current, we are sharing knowledge to improve child health around the globe. So today we have the July episode of the JPS podcast, which is the PPS episode. PABPS is Pacific Association of Pediatric Surgeons. And for that, we talked to the editor, Doctor Mary Brindle, who helped us choose these articles. I'm Mary Brindle. I'm a pediatric surgeon at Alberta Childers Hospital in Calgary, Alberta, Canada. So for today, we have 3 articles. The first one is about the impact of cryoalgesia. For pectus excavatum repair, the second one is about the chest tube management after a lung resection, and the third one is about hair reduction for pyelonidal disease that reduce recurrences. The articles are listed and linked in the description below. Follow along and read with us. The first article that we have is Impact of cryoanesthesia use during minimally invasivefectus excavatum repair on hospital days and total hospital cost among pediatric patients. And this is by Doctor Hedge, who is also a trainee, and the senior author is Doctor, Doctor Sao from Houston. She was Doctor Brindle, the editor that helped us choose this article. What they tried to see is how cryoanalgesia impacted in hospital days and hospital costs. Basically, the study was done 2011 to 2021, and they compared patients who had used cryo analgesia versus those who hadn't. They gather 44 patients, 29 of them had cryo analgesia, and what they found is that the ones that did have cryo had less hospital days. A 3.0 days versus a 5.4 days, and what was surprising for me is that the hospital costs were um a little bit cheaper in the ones that use cryonesthesia. It's less than $1000 difference between them. And this is incredibly expensive equipment. So with the fact that you're actually able to not just make that cost up and make it equivalent, but you're actually able to save costs, I think it's a very meaningful argument. Yes, true. And then you see this decrease in complication rates, a 70% decrease, so you go from about 33% complication rate for these patients down to 17%. So, I mean, I think it's a super. Valuable study. I really enjoy it. Um, it's one of the reasons why I liked it. Yes, um, I used to do PECU surgery back in Argentina, and I think that when you do PEC now you kind of must do cryo cause it really changed outcomes in patients. I don't think they look at it in this paper, but normally they also have less opioid use after the hospital. Yeah, so they didn't address that here, but in the next episode of August, we have two articles talking about the opiate requirements with cryo, so stay tuned to listen to August JPS. The 2nd paper of today is chest tube Management Following lung resection in pediatric Patients. A retrospective analysis. We talked to the first author in this paper. My name is Jamie Schnuck, and I am a 3rd year general surgery resident now at the University of Washington here in Seattle. They performed a cross-sectional study of pediatric patients undergoing lung resection to characterize chest tube practices and clarify the utility. And so this study looked at 130 lung resections that were done between 2013 and 2022. And this is Doctor Mary Bridle, 130 procedures met inclusion criteria, 59 of them were lobectomies, uh, they call them group 1, 19 of them diagnostic bed resections. These are group 2 and 52 of the excisional ventricular sections. These are group 3. Patients were less than 21 years of age, and our exclusion criteria really was if the patient had a spontaneous pneumothorax, and 75% of the group one patients had no air leak, and median chest tube duration was 2 days. In the group two, which was diagnostic bed sections, Nearly 90% of them had no air leak, and median chest tube duration was 1 day. In the last group, which was excisional wedge resections, 80% of them had no air leak, and median chest tube duration was 1 day. Yeah, I actually was pretty surprised that most chest tubes were removed on the first day after surgery, and a majority of those patients did not have an air leak either. And so the question that raises in my mind is, did they need the tube at all? Especially for diagnostic wedges that almost 90% had no air leak. And so, hey, let's find out which ones are like in less risk of having it and that. Just don't need a chest tube. One thing that makes it a little bit tough is that balance between those patients who might need a chest tube if you don't put it in, that need for an intervention that you had to planned versus this much larger potential benefit, more patients uh impacted who might never need the chest tube at all. So how do you balance a patient who needs to go back emergently for a procedure? Yeah, I wonder what their future. Goals are regarding this study are in the process of getting out another paper right now. Um, we did a survey actually on all of the pediatric surgeons that are in the Western Consortium of Pediatric Surgery, and the survey that we sent out was just about surgeon attitudes around chest tube management. I think the ultimate goal would be to take this one step further and see if we can do something prospectively. The 3rd paper for today is increasing amount of hair reduction using laser correlates with lower probability of recurrence in patients with pyelonidal disease. And we talked to the senior author in this paper. My name is Bill Chu. I'm an associate professor at Stanford University, uh working at Lucille Packard Children's Hospital. And they wanted to see how the laser ablation reduces a recurrence in patients with pyelonardial disease. And they look at the patients who've been presenting with pyelonidal disease between 2019 and 2022. So this is a retrospective study, but the data are actually were actually all prospectively gathered. So they had 198 patients, and they divided them according to the skin types. So they have 21 patients with skin types 1 and 2, 156 with skin times 3 and 4, and 21 with uh skin times 5 and 6, and of them, around 151 had dark color hair. So the patients that come to our clinic, they will get a picture taken of the extent of the pelonidal disease, but also the amount of hair that is in that area, and the patients will get started on shaving, abilation, um, and then subsequently and started on laser abilation. What they found is that to reach a 75% of hair reductions. Require a mean of 4.8 to 6.8 laser relation sessions. Dependent on different skin hair characteristics, and also dark hair and skin types 5 and 6 were associated with higher recurrence rates, and their recurrence rate was 6%. Here's what Doctor Brindle had to say. So, I mean, it's not, it's not just a one-time thing, and it also like it costs money. So that's the other thing where I think doing the study is important because right now, uh, a lot of insurance agencies will cover it, you know, in Canada, you do need to sort of uh advocate to the health systems to cover it. So having this data that shows its effectiveness, I think is actually, it's really useful to have. Yeah, I mean, it's, it's good to have something that adds to pyelonial disease, like to the knowledge of that, this and midline visive repair, I think it will change the treatment for our patients. Great. That was everything for today. But before we summarize, let's hear what Doctor Brindle had to say, because I think all three of them are, are really interesting. They were all chosen as the Pabst Award winners at our annual conference. And I will also say that each one of them, I think is important in the evolution of pediatric surgery, not necessarily like the revolution of it, but I think they're all really important for how we manage sort of day to day. Pediatric surgical care. Awesome. So now we are ready to summarize. We talked about the impact of cryoanalgesia in hospital days and um hospital costs, and we realized that cryo analgesia uh helps to reduce the hospital days significantly and doesn't increase um the hospital costs being even a little bit cheaper than the other one. Then we talk about the test tube management and What were the chances of having an air leak after um lobectomy, a diagnostic wedge, or even an excisional wedge, and we realized that more than 80% in wedges and almost 75% of lobectomies didn't had an air leak, so maybe in the future we can start by not even placing a chest tube after one of them. And finally, we talked about the laser ablation in pyonialysis, and how that helps to reduce recurrences, and how depending on your skin type and hair color, you will need more or less sessions to have a Recurrence rate reduced. Also, if you're interested in uh laser relation and effects of the recurrence of pyonardal disease, we have our podcast Casebooks Journal Review Palal Disease that we released earlier this year that we talked with uh Jose Campos around the case and uh the most important question is in the case management. So if you want to go check it out, it's a linked in the description below.

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