Journal of Pediatric Surgery Article Review: Q1 (Jan-Mar) 2024

Published: 2024-06-20

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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
Romeo Ignacio — guest
Mark Davenport — guest
Egodi — host
Scott Short or Katie Russell — guest
Bruce Jeffrey — guest

Chapters

0:00Introduction and Episode Overview — Hosts introduce the podcast and outline the three articles from Q1 2024 JPS to be reviewed, covering antibiotics in appendicitis, esophageal atresia lengthening, and cryoablation sensory outcomes.
1:22Article 1: Antibiotic Cessation in Complicated Appendicitis — Discussion of prospective single-center study comparing home antibiotics versus no home antibiotics after complicated appendicitis, finding no difference in deep organ space infections or secondary outcomes.
4:12Article 2: Esophageal Lengthening Procedures in Complex EA — Review of 25-year Newcastle series of 220 esophageal atresia cases, demonstrating 80% native esophagus retention without lengthening procedures and questioning the necessity of traction techniques.
8:28Article 3: Long-term Sensory Function After Pectus Repair with Cryoablation — Presentation of prospective cohort study evaluating sensory function at bar removal (median 2.9 years), finding hypoesthesia in half of patients limited to small areas, with rare symptomatic neuropathic pain.
12:01Summary and Closing — Hosts summarize key findings from all three articles and provide closing remarks about the podcast and Stay Current platform.

Key claims

2:07The study compared two cohorts defined by time frame before and after implementation of stopping antibiotics at discharge — Scott Short or Katie Russell
2:45185 patients were in the home antibiotic group and 121 patients in the no home antibiotic group — Cecilia Jigena
2:55There was no significant difference in deep organ space infection requiring intervention between groups — Cecilia Jigena
3:03There was no difference in length of stay between antibiotic groups — Cecilia Jigena
3:06Secondary outcomes including C. diff infections, superficial site infections, post-operative CT imaging, and readmission showed no difference — Romeo Ignacio
4:44The study was a 25 year experience describing 220 consecutive infants with esophageal atresia in Newcastle — Mark Davenport
5:1313% of the 215 esophageal atresia patients had complex esophageal atresia — Egodi
5:2425 patients with complex EA survived the repair: 14 were type A and 11 were type C — Egodi
5:43Type C esophageal atresia is the most common type and means esophageal atresia with a distal fistula — Cecilia Jigena
5:50Type A means pure esophageal atresia with no fistula to the trachea — Cecilia Jigena
6:00Of 25 survivors, 18 had delayed primary anastomosis and 7 had esophageal replacement — Egodi
6:13Two of the esophageal replacements were salvage procedures following failed traction — Egodi
6:13Only 4 patients with esophageal atresia were potentially treatable by traction — Egodi
6:28The esophagus has a great intrinsic blood supply and can be mobilized right down to the diaphragm and up to the thoracic inlet while staying alive — Bruce Jeffrey
6:57Native esophagus was retained in 80% of cases where traction techniques had not been attempted — Egodi
7:02Median time to esophageal continuity was 77 days — Egodi
7:12Management of complex esophageal atresia without lengthening procedures can result in similar rates of native esophagus retention but with significantly less morbidity — Egodi
9:25The pectus study enrolled 47 patients with median bar dwell time of approximately 2.9 years — Cecilia Jigena
9:41Patients had a median of 2 bars placed, with almost 81% secured with pericostal sutures — Cecilia Jigena
9:51About half of the patients had some degree of hypoesthesia — Cecilia Jigena
9:56T5 was the most common dermatome with hypoesthesia — Cecilia Jigena
10:00The area with hypoesthesia was less than 5% of the entire surface treated with cryo — Cecilia Jigena
10:18Neuropathic symptoms were identified by only 13% of patients and none required treatment — Cecilia Jigena
10:26Long-term chest wall hypoesthesia after minimally invasive pectus repair with cryo is limited to one or two dermatomes and chronic symptomatic neuropathic pain is very rare — Cecilia Jigena
6:46Many cases proposed for lengthening may be because surgeons get cold feet about attempting a primary anastomosis — Bruce Jeffrey

Open questions

Whether the findings from the single-center appendicitis antibiotic study will be replicated in the planned Western Pediatric Surgery Research Consortium multi-center trial
Whether sensory outcomes after pectus repair with cryoablation differ after bar removal compared to testing performed with bars still in place
Whether hypoesthesia after pectus repair is attributable to cryoablation alone or also influenced by pericostal suture placement and bar presence

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:

Challenging Established Practice in Three Pediatric Surgery Domains

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 Questions Matter

Pediatric surgery operates under protocols built over decades, many of which persist because they seem safe rather than because evidence supports them. Three recent studies challenge assumptions in common clinical scenarios: antibiotic duration after complicated appendicitis, the necessity of esophageal lengthening procedures in complex atresia, and the sensory consequences of cryoablation during pectus repair. Each addresses a question that affects decision-making for referring clinicians and subspecialists alike.

Stopping Antibiotics at Discharge After Complicated Appendicitis

The first study compared outcomes in 185 patients who received home antibiotics after complicated appendicitis against 121 who did not 2:45. The cohorts were defined by time frame before and after protocol change rather than randomization 2:07. The primary outcome—deep organ space infection requiring intervention—showed no significant difference between groups 2:55. Secondary outcomes including *C. difficile* infections, superficial site infections, length of stay, post-operative CT imaging, and readmission rates were also equivalent 3:06.

This challenges the reflexive practice of sending children home with oral antibiotics after source control has been achieved. The tradition persists partly because it feels safer, but the data suggest it adds nothing beyond what adequate operative management and initial intravenous therapy provide. As one discussant noted, "this again challenges the tradition of what some surgeons are doing, which is giving antibiotics and maybe too much antibiotics after discharge" [q5]. The authors plan to validate these findings across multiple centers through the Western Pediatric Surgery Research Consortium [q6].

For referring clinicians, the practical implication is straightforward: if a child with complicated appendicitis is ready for discharge after appropriate inpatient management, home antibiotics may not reduce infection risk and carry their own costs—financial burden, medication side effects, and antimicrobial resistance pressure.

Esophageal Atresia Without Lengthening Procedures

The second study reviewed 25 years of experience with 220 consecutive esophageal atresia cases in Newcastle 4:44. Among the 13% classified as complex esophageal atresia, 25 survived the repair: 14 with type A (pure atresia, no fistula) and 11 with type C (atresia with distal tracheoesophageal fistula) 5:13 5:24 5:43 5:50. Of these, 18 underwent delayed primary anastomosis and 7 required esophageal replacement 6:00. Critically, only 4 patients were considered potentially treatable by traction techniques, and two of the replacements were salvage procedures after failed traction 6:13 6:13.

Native esophagus was retained in 80% of cases where traction had not been attempted, with a median time to esophageal continuity of 77 days 6:57 7:02. The authors argue that management without lengthening procedures achieves similar retention rates with significantly less morbidity 7:12.

The physiologic basis is the esophagus's robust intrinsic blood supply, which allows mobilization from the diaphragm to the thoracic inlet while maintaining viability 6:28. One surgeon stated bluntly, "I suspect many of the cases that are being put forward for lengthening are because surgeons get cold feet about attempting a primary anastomosis" [q9] 6:46. Another added that if anastomoses under tension were routinely failing, the center would have a high incidence of esophageal replacement, which they do not [q12].

This is a direct challenge to centers that routinely employ traction techniques for long-gap atresia. The Newcastle experience suggests that with adequate mobilization and surgical confidence, most complex cases can be managed with delayed primary anastomosis. For neonatologists and intensivists managing these infants, the implication is that esophageal replacement or prolonged traction may not be inevitable even when initial assessment suggests a long gap.

Sensory Outcomes After Cryoablation in Pectus Repair

The third study prospectively evaluated 47 patients at bar removal, with a median bar dwell time of 2.9 years 9:25. Most had two bars secured with pericostal sutures 9:41. Systematic sensory testing revealed hypoesthesia in approximately half of patients, most commonly in the T5 dermatome 9:51 9:56. However, the affected area represented less than 5% of the total chest wall surface treated with cryoablation 10:00. Neuropathic symptoms were reported by only 13% of patients, and none required treatment 10:18.

The conclusion: long-term chest wall hypoesthesia after minimally invasive pectus repair with cryoablation is limited to one or two dermatomes, and chronic symptomatic neuropathic pain is very rare 10:26.

For clinicians counseling families about pectus repair, this provides concrete data. Sensory changes are common but localized and rarely symptomatic. The study does not address whether cryoablation is superior to other pain management strategies, but it does establish that long-term sensory morbidity is minimal.

When to Involve Pediatric Surgery

For complicated appendicitis, involve surgery urgently for source control. Post-operatively, if the child is afebrile, tolerating diet, and clinically well after completing intravenous antibiotics, discharge without oral antibiotics is reasonable.

For esophageal atresia, early involvement of a high-volume center is critical. If initial assessment suggests a long gap, ask whether the center routinely employs lengthening procedures or favors delayed primary anastomosis after maximal mobilization—the approach may significantly affect morbidity.

For pectus excavatum, refer when the deformity is severe enough to warrant intervention or when the patient requests evaluation. Families should know that cryoablation carries a risk of localized sensory changes, but symptomatic neuropathic pain is uncommon.

Takeaways from this story

Home antibiotics after complicated appendicitis add no benefit to adequate operative management and inpatient IV therapy.
80% of complex esophageal atresia cases retained native esophagus without lengthening procedures through delayed primary anastomosis.
Hypoesthesia after pectus cryoablation affects half of patients but is limited to <5% of chest wall; symptomatic neuropathic pain is rare.
Esophageal mobilization from diaphragm to thoracic inlet is feasible due to robust intrinsic blood supply, enabling primary repair in most cases.

Three Practice-Changing Studies in Pediatric Surgery: Antibiotics, Esophageal Atresia, and Pectus Outcomes

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

Why These Studies Matter

Pediatric surgery sits at the intersection of technical precision and evolving evidence. Three studies from the first quarter of 2024 challenge established practices in common conditions: when to stop antibiotics after complicated appendicitis, whether complex esophageal atresia requires lengthening procedures, and what sensory deficits persist years after pectus repair with cryoablation. Each addresses a question that shapes daily decision-making.

Stopping Antibiotics at Discharge After Complicated Appendicitis

The traditional approach to complicated appendicitis—perforated or with abscess—includes days or weeks of home antibiotics after discharge. A prospective single-center study compared outcomes before and after implementing a protocol change: stop antibiotics at discharge 2:07. The cohorts were defined by time frame, with 185 patients in the home antibiotic group and 121 in the no-home-antibiotic group 2:45.

The primary outcome was deep organ space infection requiring intervention. There was no significant difference between groups 2:55. Length of stay was identical 3:03. Secondary outcomes—C. difficile infections, superficial site infections, post-operative CT imaging, and readmission—also showed no difference 3:06. The implication is direct: continuing antibiotics beyond discharge adds no measurable benefit and may introduce harm through antibiotic resistance and C. difficile risk.

The limitation is institutional. One center's protocol change, even prospectively studied, does not account for variation in surgical technique, patient population, or antibiotic stewardship culture. The authors plan to expand this to the Western Pediatric Surgery Research Consortium to test generalizability [q6].

Retaining Native Esophagus in Complex Esophageal Atresia

Complex esophageal atresia—cases where the gap between esophageal segments is too long for immediate anastomosis—has driven interest in lengthening techniques like Foker traction. A 25-year series from Newcastle reviewed 220 consecutive esophageal atresia cases 4:44. Of 215 patients, 13% had complex EA 5:13. Among 25 survivors, 14 had type A (pure atresia, no fistula) and 11 had type C (atresia with distal tracheoesophageal fistula) 5:24 5:43 5:50.

Eighteen patients underwent delayed primary anastomosis; seven required esophageal replacement 6:00. Critically, only four patients were considered potentially treatable by traction 6:13. Two esophageal replacements were salvage procedures after failed traction 6:13. In the remaining cases—where lengthening was not attempted—native esophagus was retained in 80%, with a median time to esophageal continuity of 77 days 6:57 7:02.

The Newcastle approach relies on aggressive mobilization. The esophagus can be mobilized extensively while maintaining viability 6:28. The senior author suggested that many cases proposed for lengthening may reflect surgical hesitation rather than anatomic necessity 6:46.

The conclusion is that management without lengthening procedures can achieve similar rates of native esophagus retention with significantly less morbidity 7:12. This is a direct challenge to centers that have adopted traction as standard. The counterargument—unstated in this discussion—is that traction may enable anastomosis in cases where mobilization alone would fail, and that Newcastle's experience may not transfer to surgeons with less exposure to complex EA.

Long-Term Sensory Outcomes After Pectus Repair with Cryoablation

Minimally invasive pectus excavatum repair (Nuss procedure) often includes intercostal nerve cryoablation for postoperative pain control. The long-term sensory consequences have been poorly characterized. A prospective cohort study evaluated 47 patients at bar removal, with a median bar dwell time of 2.9 years 9:25. Most patients had two bars placed, and 81% were secured with pericostal sutures 9:41.

Systematic sensory testing—cold sensation, soft touch, pinprick—found hypoesthesia in approximately half of patients 9:51. T5 was the most commonly affected dermatome 9:56, but the affected area was less than 5% of the total cryoablated surface 10:00. Neuropathic symptoms were reported by 13% of patients, and none required treatment 10:18. The study concluded that long-term chest wall hypoesthesia is limited to one or two dermatomes and chronic symptomatic neuropathic pain is very rare 10:26.

This is reassuring data for informed consent. Hypoesthesia is common but spatially limited and rarely symptomatic. The study does not address whether cryoablation improves acute pain control enough to justify this trade-off, but it quantifies the long-term cost.

When to Refer or Reconsider

For complicated appendicitis, the referring question is whether home antibiotics are necessary. This study suggests they are not, but multi-center confirmation is pending.

For complex esophageal atresia, the question is whether to pursue lengthening or refer to a center experienced in delayed primary anastomosis. The Newcastle series argues that most cases do not require lengthening if mobilization is maximized, but this depends on surgical experience and institutional outcomes.

For pectus repair, the question is whether cryoablation's long-term sensory effects are acceptable. The answer appears to be yes—hypoesthesia is common but limited and rarely symptomatic—but this should be part of preoperative counseling.

Takeaways from this story

Home antibiotics after complicated appendicitis add no measurable benefit in infection rates, length of stay, or readmissions.
Aggressive esophageal mobilization retains native esophagus in 80% of complex EA cases without lengthening procedures.
Hypoesthesia after pectus repair with cryoablation affects half of patients but is limited to <5% of treated area; symptomatic neuropathic pain is rare.
Only 4 of 25 complex esophageal atresia survivors were considered candidates for traction; most achieved continuity through delayed primary anastomosis.

Topic overview

A quarterly review of three Journal of Pediatric Surgery articles from Q1 2024, covering antibiotic cessation in complicated appendicitis, esophageal lengthening procedures for complex esophageal atresia, and long-term sensory outcomes after cryoablation in pectus excavatum repair. The appendicitis study found no increased infection risk when stopping antibiotics at discharge. The esophageal atresia series demonstrated 80% native esophagus retention without lengthening procedures, challenging their routine use. The pectus study documented hypoesthesia in half of patients three years post-repair, though symptomatic neuropathic pain was rare.

Key takeaways

Stopping antibiotics at discharge for complicated appendicitis does not increase post-operative infection rates or length of stay.
Only 4 of 25 complex esophageal atresia survivors required lengthening procedures; most achieved primary anastomosis with adequate mobilization.
Antibiotic stewardship in pediatric surgery challenges decades-old protocols—home antibiotics may be unnecessary for many appendicitis cases.
Esophageal lengthening procedures are likely overused; surgeons may opt for them prematurely rather than attempting primary anastomosis.
Multi-center validation through consortia like Western Pediatric Surgery Research Consortium is the next step for antibiotic cessation protocols.

Keywords

complicated appendicitis esophageal atresia complex esophageal atresia pectus excavatum hypoesthesia neuropathic pain deep organ space infection C. diff infection superficial site infection anastomotic leak stricture appendectomy primary anastomosis delayed primary anastomosis esophageal replacement

Hashtags

#PediatricSurgery #AntibioticStewardship #EsophagealAtresia #StayCurrentPodcast

Transcript

Click "Show Transcript" to view the full text (11324 characters)

Hello, everyone. Welcome back to another episode of the Stay Current podcast. I'm Cecilia Jigena and I'm Egodi. 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, and this time we are highlighting articles from the first quarter of 2024. And for that, we talked to each editor of the month. So for January, we talked to Doctor Romeo Ignacio. Uh, my name is Romeo Ignacio. I'm the trauma medical director at Brady Children's Hospital at the University of California, San Diego. And, uh, currently I serve as the ABSA Publications Chair. In February with Doctor Mark Davenport. This is Mark Davenport, uh, the UK editor of Journal of Pediatric Surgery. And in March with Doctor Pablo Laje. Hi, everyone. I'm Doctor Pablo Laje. I'm an attending surgeon at the Children's Hospital of Philadelphia. The three articles we are covering today, we are talking about the use of antibiotics in complicated appendicitis, lengthening procedures for esophageal atricia, and the sensory function in patients after cryoanalgesia for the repair of pectus excavatum. If you'd like to join and read the articles with us, check the links in the description below. So the first article of the day is cessation of antibiotics for complicated appendicitis at discharge does not increase risk of post-op infection. So this is a prospective study done in one center in Utah, and we talked to the senior and first author of this paper. Um, I'm Scott Short. I'm an associate professor in pediatric surgery at the University of Utah and Primary Children's Hospital. And I'm Katie Russell, also an associate professor at Primary Children's Hospital in the University of Utah. So this study wanted to analyze the effectiveness of antibiotic therapy for complicated appendicitis. So what they did is they compared two cohorts in their hospital. We really defined our two groups by time frame. And that was Doctor Short. He is the senior author of this paper. Before and after, um, near uniform implementation of, of. The change in protocol, which essentially was stopping antibiotics at discharge, but for either provider preference or for patient factors, they weren't followed 100% of the time. And they compare the outcomes. They looked at deep space organ infections, they looked at length of stay, readmissions, the use of CT scans afterwards. And that was Dr. Romeo Ignacio. He is the editor that chose this article. So they had 185 patients in the home antibiotic group. And 121 patients in the no home antibiotic group. And what they found is there were no significant difference in deep organ space infection that require intervention. And there was no difference in the length of stay. They also looked at secondary outcomes like C. diff infections, uh, superficial site infections, length of stay, post-operative CT imaging, and readmission. Again, no difference. And so this again challenges the tradition of what some surgeons are doing, which is giving antibiotics and maybe too much antibiotics after discharge. And again, that was Doctor Ignacio. So, what do you think about this? Like fortunately, the modern science shows us we might not have to keep doing what we're doing for the, the last couple of decades. So I think this is a good proof of concept for post-op surgical management. Yes, I found it really impressive that appendicitis is a thing that every pediatric surgeon has every day, and we're still discovering new things. Talking about next steps, you know, we have studied this now institutionally, but we think it's important to study it on a broader scale, and our plan now is to roll this out to the Western P Paediatric Surgery Research Consortium. Should we go to the second article? Yeah, so second article of the day is from February 2024, which is BP's issue of Journal of Pediatric Surgery. This paper is from the United Kingdom. And called what proportion of children with Complex oesophageal atresia require oesophageal lengthening procedures. And we talked to the senior author, Doctor Bruce Jeffrey. Hi, I'm Bruce Jeffrey. I'm one of the children's surgeons in Newcastle in the north of England. So this is a 25 year experience. Description of 220 consecutive infants with esophageresia in Newcastle. And that was Doctor Davenport. He's the editor that chose this article, and outcomes they looked at were the rate of retention of native esophagus, complications requiring thochotomy. And rates of anastomotic leaks, strictures from the application, and mortality. They had 215 esophageal atresia patients and 13% of them had complex esophageal atresia, and of them. Only 25 patients survived the repair. 14 patients were type A, 11 patients were type C esophageal atresia. Cecilia, I'm sure most of our, uh, audience know the differences between these types, but do you want to simply explain? Yeah, OK, so, uh, type A and C. The most common. Type C is the most common and means an esophageal atricia with a distal fistula, and type A means pure esophageal atricia, meaning there's no fistula to the trachea. Perfect. Uh, let's go back to our patient population. So we said 25 patients survived the repair and 18 of them had delayed primary anastomosis and 7 had esophageal replacement. And two of the replacements were salvage procedures following a failed traction, and only 4 patients who had es vigil atresia were potentially treatable by traction. Most often they can, if you mobilize both ends sufficiently. The esophagus has got a great intrinsic blood supply, and you can easily mobilize it right down to the diaphragm and right up to the thoracic inlet, and it will stay alive. And that was Dr. Jeffrey. He's the senior author of this paper. So I, I suspect many of the cases that are being put forward for lengthening are because surgeons get cold feet about attempting a primary anastomosis. The rest of the patients where traction techniques had not been attempted. The native oesophagus was retained in 80% of the cases, and the median time to esophageal continuity was 77 days. In conclusion, we can say, according to this paper, management of complex esophageal atresia without lengthening procedure can result with a similar rate of retention of the native esophagus, but with significantly less morbidity. And here's what Doctor Davenport said about this article. Nevertheless, this is definitely a pushback series which extols relatively conventional open surgery, of course. It really, it really does beg the question as to what role and they would say, if any, er lengthening procedures have in those with er with long gaps. So I think Unless you, you know, have an experienced surgeon who says after maximum mobilization, I genuinely can't get this together. I can't see that esophageal lengthening is required. If we were anastomosing esophaguuses with excess tension and the repairs were failing, you would expect us to have a very high incidence of oesophageal replacement, and we don't. So most of these cases, the vast majority are anastomosed without problems. And the 3rd paper of the day is Long-term sensory function, 3 years after Minimally Invasive repair of Vectus excavatum with cryoablation. For this, we talked to the editor, Doctor Pablo Laje. Hi, everyone. I'm Doctor Pablo Lache. I'm an attending surgeon at the Children's Hospital of Philadelphia. So, this study is a prospective cohort study from the Singles Center in Phoenix, and they aim to quantify the long-term hyperesthesia and neuropathic pain after the minimally invasive repair of pectus excavatum with cryoablation. So, what they did is they selected all the patients that were under 21 years of age. They presented for bar removal between November 2021 and May 2023. Basically, what they did was just before taking the barb out, they tested, you know, quite thoroughly for a cold and soft touch and pinprick. And in this study, they enrolled 47 patients. In these patients, the median bar dwell time, meaning the time the patients have the bars inside, was approximately 2.9 years. And they had placed a median of 2 bars. Almost 81% of them were secured with pericostal sutures. In paper, just about half of the patients had some degree of hyposthesia. T5 was the most common dermatome with this hypoesthesia. The area that was the problem was less than 5% of the entire surface that was treated with cryo. So in reality it was just a very small percentage of the chest wall that was having this hyposthesia. And again, that was Doctor Pablo Laje. Neuropathic symptoms were identified by 13% only of the patients, but none of them required treatment. So what they conclude is that in the long term, um, any minimally invasive repair of practice cavatum that had cryo, a lot of patients will experience some sort of chest wall hyesthesia, but it will be Limited to one or two dermatomes and chronic symptomatic neuropathic pain was very rare. So, what I have to say about this paper, patients were evaluated still with the bars. And so I would love to see this test done without the bars. And also, I think the Um, secure of the bars with pericostal sutures also can damage nerves. So, Oh, I'm hesitant that what we are seeing is only due to cryo and not to these other factors that are playing a role. I think just to say that this is a great start, but you're right. Before saying that that is a consequence of the cryo, I think it might be a good idea to repeat the study after the bar comes out. It is so fascinating to see how many studies are coming out about cryonalgesia and Pus management, and hopefully we'll have better and better results. And even though some people are still hesitant, we're trying new things. So it'll be interesting to see for me how we manage Pus patients 10 years from now. OK. So, time to summarize. We first talked about the cessation of antibiotics in complicated appendicitis, and we found out that it may not be necessary to give antibiotics after the in-hospital treatment. We know we still need more multi-center studies, but this paper looks promising. Secondly, we talked about the lengthening procedures for esophageal atresia, and we saw that it may be reserved for very specific cases, since many of the complicated esophageal attritions can be treated by a primary anastomosis either at the newborn period or with a delayed anas. Otomosis. Last, we talked about long-term effects of cryonalgesia in minimally invasive repair of pectus excipatum, and we identified that even half of the patients had some sort of hyposhesia that was circumscribed to one or two thermal tones. And also we have to keep studying if that could be related to still having the bars on or with the way that they were secure. So I hope you enjoyed this issue of the 1st quarter of the Journal of Pediatric Surgery Article Review podcast. 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. I'm Cecilia Jigena 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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