We're back with the November issue of JPS article highlights. This time we're talking to Dr. Pablo Laje and authors Dr. Frederick Rescorla and Dr. Niloufar Hafezi.
Hosts: Ellen Encisco & Rod Gerardo
Articles: Rubalcava NS, Overman RE, Hirschl RB, Thirumoorthi AS. Central Line Placement at ECMO Decannulation: A Missed Opportunity. Journal of Pediatric Surgery. https://www.jpedsurg.org/article/S0022-3468(21)00184-6/fulltext Hafezi N, Carpenter KL, Colgate CL, et al.
Partial splenectomy in children: Long-term reoperative outcomes☆. Journal of Pediatric Surgery. 2021 Jan 8. https://www.jpedsurg.org/article/S0022-3468(21)00018-X/fulltext Elhattab A, Elsaied A, Wafa T, et al.
Thoracoscopic surgery for congenital lung malformations: Does previous infection really matter?. Journal of Pediatric Surgery. 2021 Jan 27. https://www.jpedsurg.org/article/S0022-3468(21)00086-5/fulltext
100:00:04,320 --> 00:00:04,840Hello.
200:00:04,920 --> 00:00:09,320We are back with our December issue.
300:00:09,520 --> 00:00:10,240Right November.
400:00:10,240 --> 00:00:12,400November, November.
500:00:12,400 --> 00:00:14,080Sorry, I'm jumping ahead.
600:00:14,080 --> 00:00:16,560Releasing December. Yeah.
700:00:16,880 --> 00:00:18,120I'm Rod Gerardo.
800:00:18,120 --> 00:00:19,480I'm Ellen Encisco.
900:00:19,480 --> 00:00:21,720We're research residents at Cincinnati Children's.
1000:00:22,240 --> 00:00:25,000Again, we have three articles that we're going to feature.
1100:00:25,000 --> 00:00:28,840But these are ones that may make me change what I do every day.
1200:00:28,840 --> 00:00:33,520So I thought it was those were the were the ones with these topics.
1300:00:33,520 --> 00:00:38,120Handpicked from one of the editors, one of everyone's favorite Editor.
1400:00:38,640 --> 00:00:39,440Hi, everybody.
1500:00:39,440 --> 00:00:41,520My name is Pablo Laje i'm one of the attending surgeons
1600:00:41,520 --> 00:00:43,320at the Children's Hospital in Philadelphia.
1700:00:43,320 --> 00:00:46,600So the first article is called Central Line Placement
1800:00:46,800 --> 00:00:49,680at ECMO decannulation a missed opportunity.
1900:00:50,160 --> 00:00:52,360And this is out of the University of Michigan.
2000:00:52,760 --> 00:00:56,280This was a single institution retrospective study.
2100:00:56,400 --> 00:01:00,440I think I think it's important to say the main question here is should we go
2200:01:00,440 --> 00:01:05,400ahead and place a central line at the time of ECMO decannulation?
2300:01:05,800 --> 00:01:09,720Because a lot of times I think I think common practice is not to do that.
2400:01:10,000 --> 00:01:12,72040% ultimately required a central
2500:01:13,320 --> 00:01:16,200venous line within 30 days after ECMO decannulation.
2600:01:16,640 --> 00:01:19,000Which is probably a lot.
2700:01:20,440 --> 00:01:21,480Here's what Todd thought.
2800:01:21,480 --> 00:01:23,320Almost never.
2900:01:24,400 --> 00:01:25,640That's what, that's what I suspected.
3000:01:25,640 --> 00:01:26,560And that is why
3100:01:26,560 --> 00:01:30,360I think this is a single institution experience, because that's just the way
3200:01:30,360 --> 00:01:31,600they do it there.
3300:01:31,600 --> 00:01:35,600But I will tell you that and I've worked at multiple institutions.
3400:01:35,600 --> 00:01:38,480So, I've worked at five children's hospitals
3500:01:38,760 --> 00:01:42,240considering, you know, including where I trained.
3600:01:42,240 --> 00:01:46,480And I think I've had to do that twice
3700:01:47,160 --> 00:01:49,400and I've never had to go back
3800:01:49,560 --> 00:01:52,880and reinsert a line afterwards.
3900:01:53,640 --> 00:01:56,160I mean, you can also kind of turn it around, say 60%
4000:01:57,000 --> 00:02:00,160didn't need it after a month.
4100:02:00,160 --> 00:02:02,400Or at least that's how Dr. Laje kind of saw it.
4200:02:02,400 --> 00:02:05,840The typical case of whether you want to see things
4300:02:05,840 --> 00:02:09,000on this side of the coin or the opposite side of the coin, you may say,
4400:02:09,720 --> 00:02:12,600Well, you know, if you have 40% of babies
4500:02:13,160 --> 00:02:16,040needing a center line sometime after the cannulation
4600:02:16,400 --> 00:02:19,920you should actually put it in all of them because, you know, 40% will need it.
4700:02:20,120 --> 00:02:23,000Or you can say the opposite only 40%, will need one.
4800:02:23,000 --> 00:02:26,880So why would you put a line in the other 60%, right?
4900:02:27,840 --> 00:02:32,160Perhaps it's not surprising to those listening in neonates,
5000:02:33,120 --> 00:02:35,520you know, babies less than 28 days.
5100:02:35,520 --> 00:02:38,040They primarily needed it for access.
5200:02:38,760 --> 00:02:41,280A lot of them are CDH babies.
5300:02:41,280 --> 00:02:44,880And then in the older children or babies, the primary reason
5400:02:44,880 --> 00:02:49,200for needing a line after medication was hemodialysis.
5500:02:49,680 --> 00:02:53,000If you just need access, then just use a picc line.
5600:02:53,280 --> 00:02:57,760So really, this is about a trend that in older patients
5700:02:58,520 --> 00:03:01,560leaving a central line, maybe reasonable
5800:03:01,560 --> 00:03:03,840because they'll need hemodialysis more often,
5900:03:04,640 --> 00:03:08,280maybe to pose yourselves the question at the time of the cannulation at least
6000:03:08,600 --> 00:03:10,960to make sure that the baby
6100:03:11,440 --> 00:03:14,360will not need a central line shortly after it.
6200:03:14,640 --> 00:03:18,480You know, if there is a borderline situation, maybe that's a good idea.
6300:03:18,880 --> 00:03:22,520Dr. Laje did point out that, you know, this may not change his practice,
6400:03:22,520 --> 00:03:26,360but it would make him kind of think more about.
6500:03:27,400 --> 00:03:28,800The possibility of
6600:03:28,800 --> 00:03:32,760needing a central line later down the road at the time of decannulation.
6700:03:32,760 --> 00:03:35,040Yeah, I think that's fair to say.
6800:03:35,480 --> 00:03:38,720Not every kid needs a central line, but
6900:03:39,600 --> 00:03:42,840maybe we should consider it for those patients who maybe are
7000:03:42,960 --> 00:03:44,120a little bit more sick than others.
7100:03:44,120 --> 00:03:48,720Now, now that I read this, I will take a closer look at every case
7200:03:48,720 --> 00:03:53,080and say, Well, the baby doesn't need it now, so I'm not going to put it for sure.
7300:03:53,480 --> 00:03:55,440But we are sure that
7400:03:55,440 --> 00:03:58,840the baby is not going to benefit from it in that in the next two days.
7500:03:59,280 --> 00:04:03,360Oh, and if you want to read this article, scroll down to the video player.
7600:04:03,360 --> 00:04:05,320We're going to give you the link to it
7700:04:05,320 --> 00:04:07,440so you could read along with us when we talk about them.
7800:04:07,440 --> 00:04:12,440Yeah, so it's called thoracoscopic surgery for congenital lung malformations.
7900:04:12,600 --> 00:04:15,120Does previous infection really matter?
8000:04:15,120 --> 00:04:17,440And this one is from Paris.
8100:04:17,440 --> 00:04:18,320Excuse me.
8200:04:18,320 --> 00:04:21,560It was her multiple places, mainly Paris, someone from Egypt.
8300:04:21,880 --> 00:04:25,280This one was pretty interesting, I think, for multiple reasons.
8400:04:25,320 --> 00:04:28,320one is, if the listener hasn't
8500:04:28,320 --> 00:04:33,120already heard our hour long podcast on CPAMS from a few months ago,
8600:04:33,120 --> 00:04:35,280definitely jump out here and listen to that.
8700:04:35,280 --> 00:04:38,160It's called the full story on CPAMS, and I think we kind of
8800:04:38,880 --> 00:04:40,320touched on this a little bit.
8900:04:40,320 --> 00:04:43,280But now this is we get to do a deep dive on this specifically.
9000:04:43,760 --> 00:04:49,760Yeah, this was a retrospective study, and they're basically looking at patients
9100:04:50,040 --> 00:04:54,000over a nine year period who had congenital malformations
9200:04:54,160 --> 00:04:57,200Well I think their main question was like if they because they divided it by people
9300:04:57,200 --> 00:05:01,520who had a prior infection versus those who didn't before resection.
9400:05:02,000 --> 00:05:05,120These article supports the idea that, you know,
9500:05:05,520 --> 00:05:08,880a number of patients will will have a pneumonias,
9600:05:08,880 --> 00:05:12,720and when that happens, the indication for the surgery becomes obvious.
9700:05:12,720 --> 00:05:16,240And when that happens, the surgery is a lot more difficult.
9800:05:16,280 --> 00:05:18,840I mean, and they they really did a nice comparison.
9900:05:18,840 --> 00:05:21,240They had about 30 and 60.
10000:05:21,240 --> 00:05:24,28030 with infections before and 60 without infections before.
10100:05:24,840 --> 00:05:27,520And you know, every single parameter that you look at, you know,
10200:05:27,560 --> 00:05:30,800time of the operation needed, transfusions need for reoperations.
10300:05:31,000 --> 00:05:34,640More conversions the operative time was longer.
10400:05:34,880 --> 00:05:38,880All those things were worse within the group that had previous infections.
10500:05:38,920 --> 00:05:42,280But there weren't any differences with their complications.
10600:05:42,280 --> 00:05:43,080Complications.
10700:05:43,080 --> 00:05:46,000I was so worried to hear what the conclusion was going to be.
10800:05:46,000 --> 00:05:48,320I'm so happy that they concluded this.
10900:05:48,400 --> 00:05:49,840Listen, here's a story.
11000:05:49,840 --> 00:05:53,880In general, one of the fears that someone has on doing a thoracoscopic
11100:05:53,880 --> 00:05:58,200lobectomy to me is that in a small baby, it's going to be challenging.
11200:05:59,520 --> 00:06:00,240And so
11300:06:00,240 --> 00:06:03,480the natural instinct is to wait to let them get bigger.
11400:06:03,920 --> 00:06:06,720So you have more room and more space to do the operation.
11500:06:07,240 --> 00:06:09,200And that is a fallacy.
11600:06:09,200 --> 00:06:13,360A lung that was infected is going to be
11700:06:13,880 --> 00:06:16,960a more difficult lung to operate on.
11800:06:17,280 --> 00:06:21,760And the main reason to to do it early is not only is it easier,
11900:06:22,040 --> 00:06:25,520but you have a much less chance of having an infection beforehand.
12000:06:25,520 --> 00:06:28,960And so it's clean, pristine virgin planes.
12100:06:29,280 --> 00:06:32,960If having an infection before surgery makes it more difficult,
12200:06:33,720 --> 00:06:36,000then we should operate sooner in order
12300:06:36,000 --> 00:06:38,400to not give the baby time to have an infection.
12400:06:39,280 --> 00:06:41,760And sooner is a moving target.
12500:06:42,000 --> 00:06:45,280So I was trained at six to eight months.
12600:06:46,000 --> 00:06:48,000Now I'm down to three months.
12700:06:48,000 --> 00:06:51,920Quite early, actually, our averaging in hundreds of these is about eight weeks.
12800:06:53,160 --> 00:06:54,600So, you
12900:06:54,600 --> 00:06:57,120know, we're talking obviously asymptomatic lesions.
13000:06:57,800 --> 00:07:00,120You know, we let the babies go home, bond with the family.
13100:07:00,520 --> 00:07:03,000We get a follow up CAT scan around four weeks of age
13200:07:03,000 --> 00:07:06,000and sometime, you know, around eight, ten weeks.
13300:07:06,280 --> 00:07:07,880We do the elective lobectomy.
13400:07:07,880 --> 00:07:11,080Does not necessarily change what you're already doing,
13500:07:11,120 --> 00:07:13,640do what you're already doing it and they suggest most,
13600:07:13,880 --> 00:07:18,080you know, doing it before, you know No it won't change what I what I do, but
13700:07:18,840 --> 00:07:22,200keep thinking that what we do is the right thing, which is to attack
13800:07:22,200 --> 00:07:25,240these lesions before we before they get complicated.
13900:07:25,360 --> 00:07:28,280Are you going to cut these out early when you're a big, bad pediatric surgeon?
14000:07:29,200 --> 00:07:30,200Probably. Probably.
14100:07:30,960 --> 00:07:35,560Once I once I learned how to do the operation and feel confident doing it.
14200:07:35,560 --> 00:07:35,840Right.
14300:07:35,840 --> 00:07:39,840Theres a lot of steps to get to that point.
14400:07:39,840 --> 00:07:40,520Yeah.
14500:07:40,520 --> 00:07:42,400Perfect that's great. So then we can just move
14600:07:42,400 --> 00:07:44,760on for the next one and You know, just keep doing these.
14700:07:45,080 --> 00:07:49,040Partial splenectomy in children long term re operative outcomes.
14800:07:49,280 --> 00:07:50,880And this one comes from.
14900:07:50,880 --> 00:07:52,760I'm Frederick Rescorla I'm one of the pediatric surgeons
15000:07:52,760 --> 00:07:55,160from Indianapolis at Riley Hospital for Children.
15100:07:55,320 --> 00:07:59,840I'm Nily Halfezi I'm a current PGY 3 at Baystate UMass,
15200:08:00,200 --> 00:08:04,000and I was the previous clinical research fellow at Indiana University.
15300:08:04,600 --> 00:08:05,760In this article.
15400:08:05,760 --> 00:08:07,800It was a retrospective review.
15500:08:07,800 --> 00:08:11,880We basically we chose to look at our long term outcomes
15600:08:11,880 --> 00:08:16,080and partial splenectomy to get a gauge for what happens
15700:08:16,160 --> 00:08:21,120after these kids continue to grow and continue to
15800:08:22,400 --> 00:08:24,800retain some of that splenic function.
15900:08:24,800 --> 00:08:26,360When Nily kind of came up with this.
16000:08:26,360 --> 00:08:28,400We thought It would be useful
16100:08:28,400 --> 00:08:31,640if we could kind of like figure out what our numbers were saying, actually
16200:08:31,640 --> 00:08:33,200counsel families ahead of time and say.
16300:08:33,200 --> 00:08:35,560Hey, this is the risk.
16400:08:35,560 --> 00:08:38,720We reviewed all of the cases and all of the patients who underwent
16500:08:38,760 --> 00:08:40,160a partial splenectomy.
16600:08:40,160 --> 00:08:42,68017 years from 2002 to 2019.
16700:08:42,720 --> 00:08:47,840From there, we were able to split up to basically to two groups
16800:08:47,840 --> 00:08:50,480those who underwent a partial splenectomy
16900:08:50,480 --> 00:08:53,920and did not require a subsequent operation.
17000:08:54,360 --> 00:08:59,080And those who did undergo the partial and then subsequently underwent
17100:08:59,080 --> 00:09:00,240a total splenectomy.
17200:09:00,240 --> 00:09:02,480And how often they needed a cholecystectomy.
17300:09:02,800 --> 00:09:05,880And they really wanted to do this, which Nily described to, you know,
17400:09:05,960 --> 00:09:08,600kind of inform their discussion with families.
17500:09:08,920 --> 00:09:12,640And what we looked at then after we divided into the two groups,
17600:09:12,640 --> 00:09:15,920was we compared several metrics.
17700:09:15,960 --> 00:09:18,960Would there be anything that we can find that that could be
17800:09:18,960 --> 00:09:22,040a predictor for subsequent reoperation?
17900:09:22,600 --> 00:09:23,040I'm sorry.
18000:09:23,040 --> 00:09:25,440What were the indications for these patients?
18100:09:26,560 --> 00:09:29,320They all had hemolytic anemia's of some sort like that.
18200:09:29,360 --> 00:09:31,720I think the most common was hereditary spherocytosis.
18300:09:32,480 --> 00:09:33,480Yeah. Yeah.
18400:09:33,480 --> 00:09:35,360The other ones there were like three patients
18500:09:35,360 --> 00:09:39,400who either had splenomegaly or hereditary hereditary pyropoikilocytosis.
18600:09:40,120 --> 00:09:43,360So as far as your results were you were you at all surprised.
18700:09:43,400 --> 00:09:47,640It sounds like the about 29% completion rate was similar
18800:09:47,640 --> 00:09:51,360to other results, but what did you think of that finding?
18900:09:51,680 --> 00:09:54,560The 30% is on the higher end of what's
19000:09:54,880 --> 00:09:58,000been recorded in the literature so far.
19100:09:58,000 --> 00:10:02,120These partial splenectomy are are not undergoing completions
19200:10:02,120 --> 00:10:05,560until years after the initial
19300:10:06,680 --> 00:10:08,600initial index precedure.
19400:10:08,600 --> 00:10:11,080And from my perspective, it's really good to see this data
19500:10:11,080 --> 00:10:13,560because I feel like when I talk to my family,
19600:10:13,560 --> 00:10:16,840I can really tell them this is the rate that your child will need
19700:10:16,840 --> 00:10:20,280a subsequent total splenectomy, and you have to make sure that your worth.
19800:10:20,800 --> 00:10:22,840You're happy accepting that risk.
19900:10:22,920 --> 00:10:26,000They can go through the rest of those years where they're
20000:10:26,000 --> 00:10:30,240fairly high risk for a post splenectomy sepsis, although it's a low risk,
20100:10:31,560 --> 00:10:32,760with the spleen intact.
20200:10:32,760 --> 00:10:36,960And if you're willing to do it, then we do it, even though it says there,
20300:10:36,960 --> 00:10:41,280that partial splenectomy has gained acceptance among pediatric surgeons.
20400:10:41,640 --> 00:10:46,200I don't think that that represents everybody's practice.
20500:10:46,240 --> 00:10:49,200I mean, at least where I work
20600:10:49,600 --> 00:10:52,120is very uncommon to do a patial splenectomy.
20700:10:52,560 --> 00:10:56,160OK, so the conclusion of this paper is if you feel comfortable
20800:10:56,160 --> 00:11:00,000doing a partial splenectomy, it works 70% of the time.
20900:11:00,360 --> 00:11:03,280But then after reading these and having the good results,
21000:11:03,760 --> 00:11:08,000I thought that this is something that will seriously consider interesting study.
21100:11:08,080 --> 00:11:09,040It's good.
21200:11:09,040 --> 00:11:10,920Anything by Rescorla I trust.
21300:11:10,920 --> 00:11:13,040He seems pretty cool.
21400:11:13,040 --> 00:11:16,800If you are listening to this and you are one of the authors for this
21500:11:16,960 --> 00:11:19,760These papers like reach out to us, we'd love to hear from you as well.
21600:11:20,160 --> 00:11:22,640Otherwise, get ready for next month.
21700:11:22,640 --> 00:11:26,040We're already gearing up to do our December
21800:11:26,640 --> 00:11:30,120Articles podcast, so keep an eye out for that.
21900:11:30,400 --> 00:11:33,400Can I add one thing you can put this back in if you want?
22000:11:33,560 --> 00:11:35,440I would just add, like
22100:11:35,440 --> 00:11:38,160all of these articles are pretty practice based like Dr.
22200:11:38,160 --> 00:11:40,840Laje pointed out. Things that might actually change your practice.
22300:11:41,120 --> 00:11:44,320But until then, I'm Rod, I'm Ellen.
22400:11:44,560 --> 00:11:47,120And remember, knowledge should be free.
22500:11:47,800 --> 00:11:48,160Nice.
