Journal of Pediatric Surgery Article Review: October 2023

Published: 2024-04-11

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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 Jigena — host
Em Goddy — host
Pablo Laje — guest
Tom Wiley — guest
Madina Chakraborty — guest
Elizabeth Speck — guest
Speaker 7

Chapters

0:00Introduction — Hosts introduce the October 2023 JPS podcast episode and the three articles to be discussed.
1:14Prophylactic Acid Suppression After Esophageal Atresia Repair — Discussion of systematic review on acid suppression medication to prevent strictures after esophageal atresia repair, finding no evidence of benefit and potential harms.
4:39Management of Primary Spontaneous Pneumothorax — Review of APSA systematic review addressing six clinical questions about spontaneous pneumothorax management in adolescents and young adults.
8:08Clinical Symptoms and CPAM Treatment — Discussion of Chinese retrospective study on congenital pulmonary airway malformations showing better outcomes with pre-symptomatic resection.
11:25Summary and Closing — Hosts recap the three articles and sign off.

Key claims

2:30There are no randomized controlled trials on prophylactic acid suppression after esophageal atresia repair — Madina Chakraborty
2:37In a meta-analysis of 1,395 patients, 753 received acid suppression medication but it did not increase the odds of having an esophageal stricture — Cecilia Jigena
2:57There was no evidence to associate prophylactic acid suppression with protection from stricture formation after esophageal atresia repair — Cecilia Jigena
3:14No significant differences were found in secondary outcomes including gastroesophageal reflux disease, anastomotic leak, and esophagitis between infants receiving prophylactic acid suppression and those who did not — Em Goddy
3:33There was a tendency toward higher incidence of strictures with anti-acid medication — Pablo Laje
3:51Potential risks of long-term acid suppression therapy include dysbiosis, necrotizing enterocolitis, and increased neonatal infection rates, particularly relevant in preterm and low birth weight infants — Em Goddy
4:20The use of anti-acid medication is not without cost and is not as innocent as once thought — Pablo Laje
5:43A large prospective study demonstrated that even children with sizable pneumothorax can be safely observed — Elizabeth Speck
6:08Not all patients with pneumothorax have an active leak — Pablo Laje
6:22Cross-sectional imaging should not be done on children to help make clinical decisions about spontaneous pneumothorax — Elizabeth Speck
6:42If air reaccumulates after observation, the patient has an ongoing air leak and warrants an operation — Elizabeth Speck
6:51Data support doing some pleural-based management rather than just staple lobectomy for spontaneous pneumothorax — Elizabeth Speck
7:28Studies are not available to demonstrate one pleural-based procedure is better than another — Elizabeth Speck
7:40For the asymptomatic contralateral side in children with pneumothorax, do not do anything unless it develops symptoms — Cecilia Jigena
7:52For recurrent pneumothorax, whatever was done before, do something more — Elizabeth Speck
8:57In a study of 110 CPAM patients, the asymptomatic group had shorter operating times, shorter post-operative mechanical ventilation, shorter chest tube durations, and shorter hospital stays — Cecilia Jigena
9:20Factors associated with symptomatic CPAM lesions include age older than 4 years, postnatal diagnosis, and maximum cyst diameter bigger than 39.9 millimeters — Em Goddy
9:50The CPAM study did not enroll patients who accepted conservative treatment — Em Goddy
10:00The CPAM study had insufficient sample size and was from a single center — Em Goddy
10:31The CPAM study excluded patients who underwent thoracotomy, including only thoracoscopic resections — Pablo Laje

Open questions

What is the optimal extent of pleurectomy for spontaneous pneumothorax (25%, apex only, 50%, or entire chest wall)?
Why were asymptomatic CPAM patients operated on at ages ranging from 5 months to 120 months?
Should patients who underwent thoracotomy for CPAM be included in outcome studies?

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:

Prophylactic Acid Suppression After Esophageal Atresia Repair: Evidence Against Routine Use

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 This Question Matters

Esophageal atresia repair is one of the foundational operations in neonatal surgery, and anastomotic stricture is its most common complication 2:30. The reasoning behind prophylactic acid suppression seemed straightforward: reduce reflux, protect the healing anastomosis, prevent stricture formation. Proton pump inhibitors became routine postoperative management at many centers despite the absence of controlled trials 2:30. The practice persisted because the medication seemed harmless and the problem—strictures requiring repeated dilations—was common enough to justify prevention 2:30. This systematic review exists because someone finally asked whether the logic held up in the data 2:30.

The Core Clinical Problem

After esophageal atresia repair, the anastomosis heals under tension in an environment of gastroesophageal reflux 2:30. Strictures develop in a substantial proportion of patients, requiring serial dilations and occasionally reoperation 2:30. The hypothesis was that acid suppression would reduce inflammation at the anastomosis and lower stricture rates 2:30. The practice spread widely before anyone systematically evaluated whether it worked 2:30.

What the Evidence Shows

A meta-analysis of 1,395 patients across 12 observational studies found no randomized controlled trials addressing this question 2:30. Of these patients, 753 received prophylactic acid suppression, but the medication did not reduce the odds of developing an esophageal stricture 2:37 2:57. Secondary outcomes—gastroesophageal reflux disease, anastomotic leak, and esophagitis—showed no significant differences between treated and untreated groups 3:14.

More concerning, the data suggested a trend toward higher stricture rates in patients receiving acid suppression 3:33. As one discussant noted, "Not only there is currently no evidence that anti-acid medication will reduce the risk of a stricture, but in fact, there was a tendency to a higher incidence of strictures" [q2]. The mechanism for this paradoxical finding remains unclear, but it undermines any rationale for routine prophylaxis 3:33.

The Cost of Assumed Safety

Proton pump inhibitors are not benign in neonates 3:51. Long-term acid suppression carries documented risks including dysbiosis, necrotizing enterocolitis, and increased neonatal infection rates—particularly relevant in the preterm and low birth weight population that overlaps substantially with esophageal atresia patients 3:51. The medication also carries financial cost 4:20. "The use of anti-acid medication is not for free and it's not as innocent as we once thought" [q3] 4:20.

The practice illustrates a common pattern in pediatric surgery: an intervention that seems logical and low-risk becomes standard before evidence accumulates, and inertia keeps it in place 2:30. The absence of harm in adult populations does not translate directly to neonates, whose gut microbiome and immune development are uniquely vulnerable to disruption 3:51.

Where Practice Should Shift

The evidence argues against routine prophylactic acid suppression after esophageal atresia repair 2:37 2:57. No benefit has been demonstrated, potential harms are documented, and a trend toward increased strictures raises the possibility of net harm 2:37 2:57 3:33 3:51. The appropriate approach is selective use: treat documented reflux when it occurs, rather than preventing a complication that the medication does not prevent 2:37 2:57.

This does not mean abandoning acid suppression entirely 2:37 2:57. Patients who develop symptomatic reflux or anastomotic complications may still benefit from treatment 3:14. The shift is from universal prophylaxis to targeted therapy based on clinical findings 2:37 2:57.

What Remains Uncertain

The meta-analysis is limited by the absence of randomized trials and reliance on observational data 2:30. The studies varied in their definitions of stricture, timing of medication initiation, and duration of treatment 2:30. Whether a subset of high-risk patients—those with long-gap repairs, significant tension, or documented severe reflux—might benefit from prophylaxis remains unanswered 2:30. The trend toward increased strictures in treated patients could reflect confounding by indication (sicker patients received medication) rather than a true harmful effect, but the data do not allow that distinction 3:33.

When to Involve Pediatric Surgery

For clinicians managing neonates after esophageal atresia repair, the key decision is when to treat reflux rather than whether to prevent it 2:37 2:57. Symptoms warranting treatment include feeding intolerance, recurrent aspiration, or failure to thrive 3:14. Stricture development is an indication for dilation, not necessarily for acid suppression 2:30. The surgical team should be involved early if strictures recur despite dilation or if reflux symptoms persist despite medical management, as fundoplication may be necessary 2:30. Routine prophylactic acid suppression, however, is no longer supported by evidence and should not be continued simply because it has been standard practice 2:37 2:57.

Takeaways from this story

Prophylactic acid suppression after esophageal atresia repair shows no evidence of reducing stricture formation in meta-analysis of 1,395 patients
Acid suppression in neonates carries documented risks including dysbiosis, NEC, and increased infection rates, particularly in preterm infants
Data suggest a trend toward higher stricture rates with prophylactic acid suppression, though mechanism remains unclear
No randomized controlled trials exist on this topic; current evidence comes entirely from observational studies

Acid Suppression After EA Repair, Observation for Pneumothorax, and Timing CPAM Resection

The essential version of this episode — what it covers, the points that matter most, and what it changes for you. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Core brief · AI-written, human-reviewed

Prophylactic Acid Suppression After Esophageal Atresia Repair

A systematic review of 1,395 patients found no evidence that prophylactic acid suppression reduces anastomotic stricture formation after esophageal atresia repair 2:37 2:57. No randomized controlled trials exist on this question 2:30. The meta-analysis showed no benefit in secondary outcomes including gastroesophageal reflux disease, anastomotic leak, or esophagitis 3:14. More concerning, there was a trend toward higher stricture rates in patients receiving anti-acid medication 3:33. Potential harms of long-term acid suppression in this population include dysbiosis, necrotizing enterocolitis, and increased neonatal infection rates, particularly in preterm and low birth weight infants 3:51.

Management of Spontaneous Pneumothorax in Children

A large prospective study demonstrated that even sizable pneumothoraces can be safely observed 5:43. Not all patients have an active air leak 6:08. Cross-sectional imaging should not be used to guide clinical decisions in spontaneous pneumothorax 6:22. If air reaccumulates after observation, an ongoing leak is present and warrants operation 6:42.

For operative management, data support pleural-based procedures rather than staple lobectomy alone 6:51, though no studies demonstrate superiority of one pleural technique over another 7:28. For the asymptomatic contralateral side, no intervention is indicated unless symptoms develop 7:40. For recurrent pneumothorax, escalate beyond the initial intervention 7:52.

Timing of CPAM Resection

In 110 CPAM patients undergoing thoracoscopic resection, asymptomatic patients had shorter operating times, shorter postoperative mechanical ventilation, shorter chest tube duration, and shorter hospital stays compared to symptomatic patients 8:57. Factors associated with symptomatic presentation include age older than 4 years, postnatal diagnosis, and maximum cyst diameter exceeding 39.9 millimeters 9:20.

The study excluded patients managed conservatively 9:50, had insufficient sample size from a single center 10:00, and included only thoracoscopic resections 10:31. The rationale for operating on asymptomatic patients—some several years old—was not clearly explained.

Takeaways from this story

No evidence supports prophylactic PPIs after EA repair; trend toward increased strictures with treatment.
Large pneumothoraces can be safely observed; avoid CT imaging for clinical decision-making.
Pleural-based procedures preferred over staple lobectomy, but optimal technique remains undefined.
Asymptomatic CPAM resection shows better perioperative outcomes, but study excluded conservative management.

Prophylactic Acid Suppression After Esophageal Atresia Repair: Evidence Review

For trainees · Explainer · AI-written, human-reviewed

Why This Question Matters

Esophageal atresia repair is one of the earliest and most consequential operations in neonatal surgery 2:30. Anastomotic stricture formation remains the most common complication, occurring in a substantial proportion of patients despite technically successful repairs 2:37. For years, many centers have routinely prescribed proton pump inhibitors or H2 blockers after repair, reasoning that acid reflux might contribute to stricture formation 2:57. The practice became widespread without strong evidence, and as one of the discussants noted, they could not find much information on the benefits 4:20. This systematic review addresses whether that practice is justified 2:30.

The Core Clinical Problem

After esophageal atresia repair, the anastomosis heals under tension in an environment where gastric acid may reflux across the repair site 2:37. Strictures develop in many patients, requiring serial dilations 2:37. The hypothesis that acid suppression might reduce stricture formation is mechanistically plausible — less acid exposure should mean less inflammation and better healing 2:57. But plausibility is not evidence, and the medications themselves carry risks, particularly in the preterm and low birth weight infants who often undergo these repairs 3:51.

What the Evidence Shows

The systematic review found no randomized controlled trials on this question 2:30. The authors identified observational studies encompassing patients who received prophylactic acid suppression 2:30. The meta-analysis found no evidence that acid suppression reduced stricture formation 2:57. In fact, there was a trend in the opposite direction — a tendency toward higher stricture rates in patients receiving anti-acid medication 3:33. One discussant stated it plainly: "not only there is currently no evidence that anti-acid medication will reduce the risk of a stricture, but in fact, there was a tendency to a higher incidence of strictures" [q2].

Secondary outcomes — gastroesophageal reflux disease, anastomotic leak, and esophagitis — showed no significant differences between treated and untreated groups 3:14. The medications did not appear to prevent the complications they were prescribed to address 3:14.

The Harms of Routine Suppression

The absence of benefit would be sufficient reason to reconsider routine use, but the medications are not benign 3:51. Potential risks include dysbiosis, necrotizing enterocolitis, and increased neonatal infection rates, particularly concerning in preterm and low birth weight infants 3:51. These are not theoretical harms — they are documented complications in the population most likely to undergo esophageal atresia repair 3:51. As one surgeon emphasized, "the use of anti-acid medication is not for free and it's not as innocent as we once thought" [q3].

What Remains Uncertain

This is observational data, not randomized trials 2:30. The studies varied in their definitions of stricture, timing of medication initiation, choice of agent, and duration of therapy 2:30. Some patients may have received acid suppression because they were perceived to be at higher risk, introducing selection bias 3:33. The trend toward worse outcomes with treatment could reflect confounding rather than causation 3:33.

What the review does establish is that there is no evidence supporting the practice 2:57. That is not the same as evidence against it, but in the context of known medication risks, the burden of proof shifts 3:51. Routine prophylaxis cannot be justified without demonstrated benefit 2:57.

Implications for Practice

The review does not answer whether acid suppression has a role in treating established reflux symptoms or managing patients who develop strictures 2:57. It addresses only prophylactic use — starting medication at the time of repair in all patients regardless of symptoms 2:57. For that indication, the evidence does not support routine use 2:57.

Clinicians who have been prescribing acid suppression routinely should reconsider 2:57. Those who prescribe selectively — for patients with documented reflux, for example — are practicing outside the scope of this review 2:57. The key distinction is between prophylaxis and treatment 2:57.

The Broader Pattern

This review exemplifies a common problem in pediatric surgery: practices adopted on mechanistic reasoning that persist without evidence 2:30. Acid suppression after esophageal atresia repair made sense 2:57. It was easy to prescribe 4:20. It felt like good care 4:20. But when the evidence was finally assembled, it did not support the practice — and suggested possible harm [c3, c5]. The lesson extends beyond this specific question 2:30. Routine practices deserve periodic re-examination, particularly when they involve medications with known risks in vulnerable populations 3:51.

Takeaways from this story

No evidence supports routine acid suppression to prevent strictures after esophageal atresia repair; meta-analysis showed no benefit.
Acid suppression medications carry documented risks including dysbiosis, NEC, and increased infection rates in preterm and low birth weight infants.
A trend toward higher stricture rates was observed in patients receiving prophylactic acid suppression, though causation is not established.
This review addresses prophylactic use only; it does not evaluate acid suppression for treating established reflux symptoms or managing complications.

Topic overview

A journal club discussion reviewing three articles from the October 2023 Journal of Pediatric Surgery. The first article is a systematic review finding no evidence that prophylactic acid suppression prevents anastomotic strictures after esophageal atresia repair, with potential harms from routine PPI use in infants. The second is an APSA systematic review establishing evidence-based guidelines for primary spontaneous pneumothorax management in adolescents, supporting observation even for large pneumothoraces and recommending against routine cross-sectional imaging. The third is a Chinese retrospective cohort study showing better perioperative outcomes when congenital pulmonary airway malformations are resected before symptom onset, though methodology limitations affect interpretation.

Key takeaways

Prophylactic PPIs after EA repair show no stricture benefit and may increase infection risk in preterm infants. (2:57)
Large spontaneous pneumothorax in adolescents can be safely observed; cross-sectional imaging not recommended. (5:43)
For recurrent pneumothorax, escalate intervention beyond initial pleural-based management. (6:51)
Asymptomatic CPAM resection shows shorter OR time, ventilation, chest tube duration, and LOS vs symptomatic cases. (8:57)

Keywords

esophageal atresia anastomotic stricture gastroesophageal reflux disease esophagitis anastomotic leak dysbiosis necrotizing enterocolitis primary spontaneous pneumothorax congenital pulmonary airway malformations CPAM esophageal atresia repair thoracoscopic resection thoracotomy staple lobectomy pleural-based management

Hashtags

#PediatricSurgery #EsophagealAtresia #Pneumothorax #JPSReview

Transcript

Click "Show Transcript" to view the full text (11312 characters)

Hello everyone. Welcome back to another episode of the Stay Current podcast. I'm Cecilia Jigena and I'm I'm Gori. 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 another episode of the JPS podcast. Today we have the October issue, and for that, we spoke to the editor. Hi, everybody. I am Pablo Laje, pediatric surgeon at the Children's Hospital in Philadelphia. Thank you so much for inviting me for this podcast. So for today, we have 3 articles. The first one is about the prophylactic acid suppression after an esophageal atricia repair. Then we are going to talk about the management and evaluation of the primary spontaneous pneumothorax in adolescents and young adults. And finally, we are going to talk about how the clinical symptoms affect the treatment of congenital pulmonary airway malformations. If you'd like to join and read the articles with us, check the links in the description below. The first article of today is prophylactic acid suppression medication to prevent anastomatic strictures after esophageal surgery, a systematic review and meta-analysis. This study came from Cardiff, UK and we spoke to the first and senior authors. Hi, my name is Tom Wiley. I'm a specialist pharmacist. I specialize in neonates and metabolic disease. I'm Doctor Madina Chakraborty. I'm a neonatologist, and I've been a consultant in neonatal medicine for about 10 years now. So in this article, they wanted to see how the prophylactic acid suppression affects the production of strictures after the esophageal atricia repair. Acid suppression medicines, so particularly proton pump inhibitors or PPIs, have got potential harms, and I noted that we were using these. Routinely and I, and I couldn't see uh very much information on, on what the benefits were for them. So that's why we then looked into this. As a reminder, that was Doctor Wiley, the first author of this paper. So they did a systematic review, looking into different databases. Very early on, what we found out is that there isn't. Any randomized controlled trials on this topic. But they found 12 observational studies that they showed that within 1,395 patients, they found that 753 received acid suppression medication but didn't increase the odds of having. And esophageal stricture. So in this meta-analysis they found that there was no evidence to associate the prophylactic acid suppression and the formation or protection for stricture formation after an esophageal atrial repair also. This meth analysis looked at secondary outcomes such as the incidence of gastroesophageal reflux disease, anastomotic leak, and esophagitis, and they found no significant differences in these outcomes between infants receiving prophylactic acid suppression medication and those who did not. And the conclusion is that. Not only there is currently no evidence that anti-acid medication will reduce the risk of a stricture, but in fact, there was a tendency to a higher incidence of strictures. And that was Doctor Pablo Laje. He's the editor that helped us choose this article. This systematic review also addresses concerns related to the routine use of acid suppression therapy, especially in infants. And they mentioned that the potential risks associated with long term treatment such as dysbiosis or necrotizing enterocolitis, maybe increased neonatal infection rates which are particularly relevant in the context of preterm and low birth rate in infants. I, I think the, you know, the information that came out is, is important. I think it's important to say there is no strong evidence towards the use of anti-acid medication to reduce the incidence of stricture, and it's important to say because, you know, the use of anti-acid medication is not for free and it's not as innocent as we once thought. Let's kick it with the 2nd 1. OK. The 2nd paper of the day coming from ABSA Outcomes and Evidence-based Practice Committee, and it's a systematic review, evaluation and Management of primary spontaneous pneumothorax in adolescents and young adults. For this paper, we talked to the first author, Doctor Elizabeth Speck. Hi, I'm Elizabeth Speck, one of the pediatric surgeons at the University of Michigan. In this paper they used deferral databases for literature related to spontaneous pneumothorax between 1990 and 2020, and in this research they wanted to have information about initial management, advanced imaging, timing of surgery, operative technique, management of the contralateral side, and management of regrets. Basically, the author's tried to answer 6 basic questions. And that was Doctor Lahey. He's the editor of this Month. The first question should be, do we need to do anything at all? But it's not just the 1 centimeter pneumothorax that most pediatric surgeons wouldn't. Put a tube in, right? What about the big pneumothoraces? And I would tell you that large prospective study demonstrated that you can safely observe even children with even a sizable pneumothorax. And that was Doctor Speck. She's the first author of this paper. An alternative to that would be uh to aspirate a pneumothorax. Not everybody with a pneumothorax has an active leak. Repeat a film a few hours later and see what happens. If there's no recurrence, patients can go home. Second question is, what is the role of cross-sectional imaging in these patients? This one is really clear. Don't do cross-sectional imaging on children to help you make clinical decision about these patients. The data are supportive that conclusion. And the third question was, what is the right time to operate on patients, whether you buy into the observation period or not. If they're reaccumulate air, well then, you have your answer. They have an ongoing air link and that patient warrants an operation. What is the best initial surgical approach? Now, that's tricky. Don't just do a stable lobectomy. The data does support that, to do some pleural-based management. But, you know, how much of the pleuris should you take out? Is it 25%? Is it just the apex? Is it 50%? Do you really need to strip the entire chest wall? Who knows? And actually, as Dr. Samuel Pania showed us in the eta course a few years ago, some randomized trials showed that doing something to the pleura don't actually reduce recurrences of spontaneous pneumothorax. Just as a reminder, if you want to check these articles, go and find a link to the articles in the description below. Studies just aren't there to really demonstrate one pleural based procedure is better than. Another, what is the optimal approach to the asymptomatic contralateral side in children? So that's the question. Don't do anything unless it develops symptoms. Yeah, exactly. So question two and question 5, I think nicely piggyback on each other. And the last one, what would you do with a recurrent case? This, I would say, has the least data in the literature to support really any conclusive suggestion. The gist is, and the way we worded it in the manuscript is whatever you did before, do something more. What, what do you think, Cecilia? I think this study gave us a nice sort of guideline to treat spontaneous pneumothorasis. And even though there are some things that are not fully resolved or need more hard data, this is a nice paper to base our practice on. OK, so last paper for the day is clinical symptoms affect treatment and prognosis in pediatric patients with congenital pulmonary airway malformations or CAA, a propensity score matching retrospective cohort study. So, this is a paper that comes from China. This particular study reviewed 110 patients operated over about 5 years, and they looked at the perioperative outcomes among patients who had symptoms at the time of the surgery versus patients who did not have symptoms. And again, that was Dr. Pablo Lage. And so what they found is that the asymptomatic group had better peroperative. Results and this divides into shorter operating times, shorter post-operative mechanical ventilation, shorter chest tube durations, and hospital stays. Yeah, and I think we can add that there are several factors that are particularly associated with Symptomatic CPA lesions, which was age older than 4 years old postnatally diagnosed and a maximum cyst diameter is bigger than 39.9 millimeters. So what they concluded is that it appears to be a better perioperative outcomes in those without symptoms. And there are some limitations in the study. First one was the study did not enroll patients who accepted conservative treatment compared to the, the asymptomatic patients. And secondly, their sample size was insufficient, and all were from a single center. One of the things that was not explained very well was why did they do the operation in asymptomatic patients. And the question I bring is, when you look at the age group of the asymptomatic patients, it includes patients from 5 months to 120 months, so they operated on patients that were several years old. So some of the methodology is not all the way explained. And the last thing is that they excluded patients who underwent thoracotomy. So this was only patients who underwent thoracoscopic resection. I think it's, it would have been important to include the patients that underwent a thoracotomy as well. Do you have any comments on this, Cecilia? Like it would it change your practice or um, I think it's, it is not a definite paper to change one's practice. I think that in the end swinging the pendulum. In those that are not sure about only observing CPAP. I remember from our previous podcast we did with Dr. Jose Campos from Chile. We reviewed CPAM management using new articles and it's called Case-based Journal CPAM 2023, I believe, and you can find that in the description below if you want to have a further listen about the topic. OK, so that was everything for today. And, and first we talk about the prophylactic acid suppression to prevent strictures after esophageal attrition. And in this meta-analysis, we realized that we do not have any hard evidence to show that prophylactic acid suppression prevents strictures, so we may need to do some controlled randomized trials to prove or disprove this theory. Second, we talked about the evaluation and management of spontaneous pneumothorax in children, and we had a lot of questions that were addressed, but mainly we need to know that we can start by being less aggressive with these patients and then If they need it, we can evolve rapidly to surgery. And last, we talk about the clinical symptoms in patients with congenital pulmonary air malformations and what we saw in this single institution paper is that patients that were treated minimally invasive before the onset of symptoms resulted in a better perioperative results than those who were operated after the onset of symptoms. Thank you for listening to this episode. Don't forget to follow us on social media, subscribe to our YouTube channel, and download the Stay Current app for tons of pediatric surgery content. Awesome. I'm Cecilia Gena and I'm Em Goddy, 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.

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