It's time for the December. OK, it's time for the December episode of our Journal of Pediatric Surgery Journal Club. I'm Rod Gerardo. I'm Ellen Ancisco. We're research residents at Cincinnati Children's Hospital. We have 3 articles brought to you, selected by one of the editors. Who we actually got a chance to talk to. I'm, uh, I'm Doctor George W. Holker the 3rd, and I'm the editor in chief of the Journal of Pediatric Surgery. So the first one is called Enhancing Recovery after Minimally Invasive Surgery in Children, a Systematic Review of the Literature and meta-analysis. This one comes from Paris, Paris, France. It does. And if you want to read along with us, you can scroll down under the media player, click on the link, we're gonna give you the link to all of these articles. Uh, so this one, like the title suggests, it's a systematic review and meta-analysis, um, and we're looking at articles that Looked into using ERAS protocols after minimally invasive surgeries. They defined as thoracoscopy, laparoscopy, or retroperitoneoscopy. I don't think I pronounced that right, in pediatric patients. Um, and they went way back. They went all the way back to 1975. We were fortunate enough to hear the details of this from one of the authors. So, my name is uh Louise Montalva. I'm a pediatric surgeon. From Paris, France, I've been currently working as a fellow in Robert Dere University Hospital for just a little bit over than 1 year. They found 9 articles that they included in their meta-analysis. We only selected 9 studies. There was only after all this selection, there was only 9 studies that actually looked into enhanced recovery after surgery, after mini invasive surgery. And I, I know that we talked about ERRAS a lot. Specifically in this article, they are looking at the length of stay, the complication rate, and then the readmission rate for these patients who went on ERRAS after minimally invasive surgery. Yeah, and overall, they found no difference in complications, um, but the length of stay and the 30-day readmission rate was lower after ERAS. We see that phase of decrease, decrease in length of, uh, stay. Uh, but there's no increase in readmission rates. I think they actually decreased actually in children with enhanced recovery after surgery, which was a surprise because we expected it to be higher, and there was no increase in the complication rates, which is also quite reassuring because if we shorten the stay but we have more complications, this doesn't make sense, so. So we actually find the same results in the literature compared to what we found in our departments. Todd pointed out, I mean, ERAS is not new, but I think the concept of reducing length of stay is especially key in this time when we have COVID and, and we're trying to get people out of the hospital as soon as possible. So, I'll tell you the, the relevance to today is that, you know, what ERAS has taught us. is that we can push the limits on, on some of the traditional thinking of how these patients need to stay in the hospital for a while, get traditional narcotics and all these long therapies, and in this crazy pandemic as we're trying to figure out how to mobilize hospital beds and get patients out of the hospital, ERAS kind of set us up for that. And ERRAS has kind of shown us that we can, that we can abbreviate the hospital stay of a lot of these patients. So, um, this is just helpful as we're starting to look at how we can, um, shorten hospital stays and see if we can get patients out. ERAS might help us. And here's what Doctor Holcomb thought. And I think that we all think that minimally invasive surgery. Reduces um uh post-operative discomfort, reduces hospitalization, but in fact, these authors were able to find that article show, show that if an ERAS is applied, then you can get further reduction in these um postoperative parameters. So I think it's, I, I, I think this study opens up Uh, some eyes that there are ways to get even further improve the advantages with minimally invasive surgery. Even if at your hospital, you're not sold on ERAS or, or people around you are not sold on it, then you can still start to get in the mindset of Earlier discharge, so what I would recommend would be starting to implement ERA strategies, but without trying to discharge the kid earlier, just thinking, would the kid be able to be discharged now, like try to evaluate if the child would be discharged without actually discharging him yet if you're a bit scared about these ERAS protocols. I think that would be a good first step would be actually to. Like simulate a discharge kind of instead of actually discharge discharging him yet. If you want to read the finer details about the components of their ERAS protocol, they break it down really nicely in their article. Again, you can open up the link. For us, the ultimate goal of ERAS is same day discharge. For us, the most important is That the kid is able the night after the surgery or the day after the surgery, the kid can go back to his normal life, go home, and his family also. That is the most important. Kids, all they want to do is get up and run around, run around, uh, in the, in the department. So why not run around at home, really, than staying in bed, so. Mm, we are lucky to have the ideal candidates in pediatric surgery. All right, cool. Uh, next one. Next one is association of operative approach with outcomes in neonates with esophageal atresia and tracheoesophageal fistula. And this one comes from Johns Hopkins, and we talked to the senior author. Hi, everyone. I'm Sean Kamisaki. I'm a pediatric, uh, general surgeon at the Johns Hopkins Children's Center in Baltimore, Maryland. So they looked back from, from 2014 to 2018, they looked at neonates that went, uh, underwent operative repair for an esophageal atresia and tracheoesophageal fistula, and then they looked at the approach, either open approach or thoracoscopy, and if they subsequently converted to an open procedure. One of the motivations for doing the study was to understand Uh, currently, what the, the current state is and how much better or worse the thoracoscopic approach is. We are also uh interested in over that time period. Uh, whether or not there was a trend, uh, or change in the use of thoracoscopy over that time period. I think it was kind of impressive actually that they had almost 900 neonates in this study. One of the major messages or findings of this paper was that only about 16% of uh operative approaches were thoracoscopic, and so the vast majority of esophageal fistula in this country, at least, is, is approached through the uh traditional open thoracotomy. I actually was not surprised that the rate of thoracoscopic surgery was so low, uh, but I think it really just validates that. Uh, so Doctor Kunosaki was surprised about this 50% conversion rate. And that's uh something that really nobody likes to talk about or, um, it's not well reported in the literature, and so, So that was a little bit unexpected that it was so high, but perhaps uh really is a testament to how challenging uh the thoracoscopic repair is and so, um, that was, uh, I thought a very interesting finding. Even though there was a relative, you know, high conversion rate, um, they didn't see an increased rate of complications in those patients. It lends to um uh a common um Saying that many surgeons have is that it's OK to convert to open. Here's what Doctor Holcomb thought. We haven't really seen much lately in the literature. On comparing perioperative outcomes with the open operation and the corproscopic operation. And there, and as I mentioned, there are limitations to this study. Uh, I don't think we'll ever get a prospective randomized trial comparing the two. so I think, uh, anytime we can look at comparative data, it's, uh, it's helpful. To me, the punchline of this is, A, You can do this safely, thoracoscopically. You can open if you have to, but You know, you're not gonna cause more complications necessarily. This brings up an interesting point in that how do we do, how do we Increase adoption of a new challenging technique in surgery. And we've tried courses, which some could argue don't really work because one day of trying something isn't really enough. Um, really, you need regular practice and mentorship with someone who does it, and it really almost has to be done as part of your fellowship. I do think that a mentorship program. That involves in-person mentorship followed by telementoring is probably the only way that we're going to measurably get practicing surgeons doing this. However, in time, those numbers will increase because more and more people will be doing this during their fellowship. I think there are two major areas of next steps in order to try to improve outcomes and improve the, the use of thoracoscopic repair and esophageal atresia. Uh, the first is simulators. Um, simulators have been around for, for over a decade now, and, um, quite honestly, they're getting, uh, quite good and, and doing, uh, an anastomosis in a 3 kg, uh, chest is, is one of the most technically challenging exercises, uh, that we do as, as pediatric surgeons. And so I only see, uh, the need and the usefulness of these simulators to be, uh, Um, better. But I think, uh, a more mentored approach, uh, even, uh, through telemedicine, if that's even a possibility in the future you, you can envision, uh, may help to, uh, increase the utilization of this cause, cause ultimately I do think the long term outcomes are, are, are likely to be better with the thoracoscopic approach. Perfect. Next article. Yeah. So the last one is called long-term outcomes and Satisfaction rates after costal cartilage resection for slipping rib syndrome, and this one is out of Children's Mercy Hospital in Kansas City. And again, we talked to the senior author, Doctor Saint Peter. Yeah, I'm Sean Saint Peter, uh, surgeon in chief, senior vice president at Children's Mercy Hospital in Kansas City. So, uh, this was a retrospective chart review, kind of a follow-up on Children's Mercy's previous publication about slipped rib syndrome or slipping rib syndrome. And here, they uh looked at patients from 2006 to 2020. Well, well, the reason we continue to look at this is because it's sort of an emerging, um, I'd say problem in that it's being recognized more frequently and it's also an emerging technique. The reason that we embark in this work is that we need to know what, what is the ultimate outcome of this operation and are these people getting better. Um, it seems from the natural history, they're typically not going to get better with conservative management, and that's what you'll see when you look at the, the, the patients' presentations in this article, is that they're frequently symptomatic for years. And in many cases, they've been to a multitude of physicians in multiple disciplines, and sometimes they've traveled from city to city. Ended up with 49 patients who underwent a total of 67 operations, and then they kind of characterized the symptomatology and then the patient population. And then looked into um post-operative uh outcomes. And the patient that's had a reasonable result from a local injection and then uh had the, the pain recur is, uh, that, that for starters is a reasonable candidate. Uh, but then you typically can, can palpate the area. Somewhere between 9 and 11 in the, in the anterolateral costal margin and, and replicate the pain, then it, it'll be tender, they'll jump and the, um, the hooking maneuver that people describe, I wouldn't do that cause that hurts on everybody. Um, but if you, if you're pressing in that area, you'll typically be able to Um, replicate the pain. In, in a better case, you'll be able to, to feel the pop. Some folks can replicate it for you. They'll just, they can, they can turn to the side or flex their abdomen, and you'll be able to feel the rib pop. Uh, in some cases, you can see it move. And then, um, if you press on the sides of the chest simultaneously, that will frequently replicate the pain in the anterior position where they're having the pain. And that is also a pretty telltale. And if I'm being honest, I actually knew absolute zero about this before this came across our emails, and I had got a chance to read it. Um, That's probably because I'm a junior resident, but um it also sounds like Todd doesn't see this very often either, and here's what he thought. It's good to know that this data shows that it works, and it's just, it's, it's, it's an important paper to uh make the surgeon aware of the diagnosis, and then it's something you need to consider when they have Have this sort of right upper quadrant or left upper quadrant pain. Dr. Holcomb pointed out the good thing about this paper was like the long-term follow-up. I think it's one of the bigger cohorts of these patients that we have for outcomes, and there's like a 4.5 year follow-up, you know, it shows overall good, good outcomes like we talked about with the costal cartilage resection for slipping ri syndrome in these patients. There's little in the literature. Of, about this, this disease, but I think it's fairly commonly seen by pediatric surgeons. And I'll bet that Uh, many pediatric surgeons aren't sure perhaps what it is or, you know, how to, how to take care of it. I guess the, the other thing to know for people listening, if, if this isn't something you're doing is just to have it as a consideration in patients that are coming with, you know, this pain. I agree. I think the take-home point here is, hey, look, here are the things that Someone with slipped rib syndrome is gonna complain about, and here is the demographic data, and If medical management doesn't work, hey, guess what? Surgery is OK too. So, what's our summarization? For the summarization, here's 3 articles I, I feel like these are 3 articles that um I guess I would say, here's 3 articles that are informative and could affect your practice. They won't necessarily affect everyone's practice, because some people are already doing these things. But If you don't know a lot about some, you know, slipped rip syndrome or you're not using ERS protocols, or you're not doing your esophageal atresia repairs thoracoscopically, you know, here are a few articles that might be trying to nudge you in a certain direction. If you like this episode, if you like this series, let us know. Leave a review, leave a comment, whether you're coming to us from social media, YouTube, Apple Podcasts, SoundCloud, Spotify, Stitcher, whatever. Download the State Current Pediatric Surgery app. But until next time, I'm Rod. I'm Ellen, and remember, knowledge, knowledge, it should be free. It's always really close. That was, that was good.
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