Update Course Rewind: 2024 Top Ten Key Takeaways
With Dr. Ramy Shaaban
Chapter 1 of 10 · Emerging & Future Directions
Hybrid OR collaboration
Introduction and Takeaway #10: Collaboration of Surgery and Interventional Radiology in the OR
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
At lower volume institutions where neonatologists are very involved with care, switching to early repair when only putting one or two children on ECMO per year for CDH is a challenge and requires whole team buy-in.
No matter how good you are at ERCP, you're going to get pancreatitis 10% of the time, and if the patient gets pancreatitis when you could have gone straight to surgery, that was a mistake.
Image-guided surgery uses real-time imaging like CT, MRI, ultrasound, or fluoroscopy to improve precision during procedures.
At Cincinnati Children's, interventional radiologists teach pediatric surgery fellows how to use ultrasound guidance for vascular access.
You don't have to have a hybrid OR to do surgery-interventional radiology collaboration; it can occur in a regular OR by bringing in an ultrasound machine.
A hybrid operating room eliminates the need to transfer patients between imaging and surgical areas and combines advanced imaging technology with a traditional surgical setup.
Cone beam CT is a CT scan performed on a C-arm fluoroscopy unit that rotates around the patient's point of interest, collecting multiple images which are stacked together to create a CT.
Cone beam CT can be used for identifying and protecting critical structures during surgery and at the end of the case to confirm vessel patency.
ChatGPT can be used in systematic review and meta-analysis to screen thousands of articles based on title and abstract, with prompts asking it to explain its screening decisions.
Jenny AI is an academic model that helps with research paper writing by providing suggestions that the user can accept or modify, and includes a built-in chatbot that can research topics, provide relevant answers, cite supporting papers, and format citations.
ChatGPT can be used to upload a guideline and create a training session with interactive questions for learning specific topics.
Cryoanalgesia is a minimally invasive procedure to alleviate pain during chest wall surgery by temporarily freezing the nerve.
For cryoanalgesia in pectus surgery, a double lumen endotracheal tube is used in all patients to deflate the lung on the side of the cryoablation, and the surgeon uses a thoracoscope to guide the cryoprobe through axillary incisions from T3 to T8.
After cryoanalgesia, intercostal nerve blocks are performed with subpleural injection of 0.25% marcaine with epinephrine, which works immediately as opposed to the 8 to 10 hour delay with the cryo nerve block.
The cryoanalgesia procedure takes about 15 seconds per interspace with a 2 minute freeze cycle starting at the third rib and working down.
The double lumen endotracheal tube helps reduce the risk of pneumothorax during cryoanalgesia.
Cryoanalgesia blocks sometimes don't work when surgeons use a single lumen tube and do the block too far anteriorly.
Cryoanalgesia is an effective tool for pediatric pectus procedures, controlling pain and decreasing hospital length of stay with few short-term complications.
The SEER protocol from Michigan used prenatal criteria to guide decisions on offering ECMO versus comfort care for severe unilateral CDH, and outcomes showed that survival was equivalent between groups, revealing clinicians are often wrong about who will benefit from ECMO.
If there is good prenatal counseling with the parents, ECMO should be pursued for every unilateral isolated CDH.
With bivalirudin anticoagulation, you don't have to wait for the ECMO circuit to equilibrate; it's very fast and you can operate after 8 hours of starting bivalirudin as long as levels are stable, which happens really soon, and it's a much easier surgical repair.
In cases of very severe isolated unilateral CDH, the patient should be considered a survivor until proven otherwise.
Early repair while on ECMO is safe and can offer physiological benefits with the optimal window between 8 to 24 hours.
The CO₂ laser emits infrared light in the spectrum of 920 to 1400 nm which is really well absorbed by water and biological tissues.
CO₂ laser is very effective for precise cutting and ablation, reduces blood loss, has reduced pain and edema, and shorter operative time.
In 56 circumcision cases using CO₂ laser with the sleeve technique, dorsal slit, and cyanoacrylate adhesive, the complication rate was only 3%.
CO₂ laser has been used for frenulectomy in 47 patients with low pain profile and no suture required.
CO₂ laser has been used for perianal fistulas with fistulotomy, pilonidal cysts with laser ablation of sinus tracts, labial fusion, and condylomatosis ablation.
Barriers to CO₂ laser adoption include high equipment costs, required training, and limited availability.
In thyroid surgery, the goal is to preserve the parathyroids and decrease the risk of hypocalcemia and the need for calcium supplementation both initially and over a long period of time.
A randomized controlled trial from France demonstrated that autofluorescence has shown to reduce rates of hypoparathyroidism and hypocalcemia following thyroidectomy.
With autofluorescence, you don't inject anything; the parathyroids naturally autofluoresce at that wavelength, and in addition you can inject ICG to look at the perfusion of the actual parathyroid glands.
Studies using the FluoBeam system and probe system noted hypocalcemia rates that were about 50% lower with using autofluorescence versus not using it.
A surgery-first pathway for pediatric biliary stone disease reduces resource utilization, including MRCP.
Before a gastroenterologist does an ERCP, often the patient has had an ultrasound and an MRCP, but predictive factors can be used to go straight to a procedure if needed, whether a combined procedure with laparoscopic cholecystectomy, an intraoperative cholangiogram, and potentially ERCP if needed.
With a surgery-first mindset, the stone clearance rate reflected by negative intraoperative cholangiogram was 86%, and if you just did flushing or got the catheter a little more into the common bile duct or reamed the sphincter, that success rate was in the 90s.
The key to treating biliary atresia is making an early diagnosis.
MMP-7 was identified about 10 years ago by Georgia Bizarro as a diagnostic biomarker for biliary atresia.
You have to get the Kasai procedure done as soon as possible; the sooner you get it done, the more likely you'll save the native liver.
Data from a recent Midwest study shows that every 10 day delay in Kasai treatment worsens outcomes by 20%.
MMP-7 is not a validated biomarker for biliary atresia; it's not perfect, the sensitivity is pretty good, but the cutoffs that different teams used vary because it's an assay that's still evolving.
At Cincinnati Children's, the commitment to patients with suspected biliary atresia is that within 7 days of showing up, if they have it, they're in the OR for Kasai.
REBOA (resuscitative endovascular balloon aortic occlusion) is a procedure to control bleeding in traumatic shock or cardiac arrest where a catheter is inserted through the femoral artery into the aorta and a balloon is inflated to stop blood flow, buying time for surgical intervention.
REBOA would be appropriate for a patient in traumatic shock if you could not get them to the operating room to actually control the source of bleeding.
REBOA is often compared to resuscitative thoracotomy, which opens the chest surgically to control the source of bleeding, since both techniques occlude the aorta.
REBOA seems to take longer than opening the abdomen or the chest if you're just needing to cross clamp the aorta.
REBOA can be performed in pediatric patients but is rarely done with no clear survival advantage over laparotomy.
Most surgeons favor laparotomy over REBOA for quickly treating shock in a controlled environment.
Patients presenting with wounds as their initial presentation for pilonidal disease tend to not always get to the finish line fully healed with a minimally invasive approach.
John Armstrong, while serving in the US Army, ran a clinic with a captive patient population where they implemented a protocol of weekly shaving for pilonidal disease and observed a dramatic improvement, significantly reducing the need for surgical intervention.
If you're not pushing hair removal and meticulous hygiene for pilonidal disease, you're probably going to end up operating on some people that might not need an operation.
For pilonidal disease hair removal, options include shaving, depilatory hair removal agents like Nair, or laser hair removal.
Many pilonidal disease patients are teenagers or people going to college who sometimes don't have anybody to help them with hair removal.
If there's a parent or an active caregiver involved, clipping is probably the easiest and simplest approach for pilonidal disease hair removal, and having someone do it once a week is recommended.