And we are back with your February JPS article Review podcast. As always, it's Rod Gerardo. I am joined by Ellen and Cisco, and today we have a new research resident with us. Uh, I am Brittany Levy. I'm a research resident. At University of Kentucky in Lexington and looking forward to joining the state current team. This issue was a special issue. This is the BPS issue. Doctor Mark Davenport helped us to the articles. I'm Mark Davenport. I'm the UK and Irish editor for the Journal of Pediatric Surgery, and the majority of papers in this issue are derived from the sixty-seventh annual. British Association of Pediatric Surgeons, Congress. So the first one is called Building Human Renal Tracts, and this was written by Dr. Adrian Wolf. I'm the chair of pediatric Science in the University of Manchester. He gives an overview of research and development of renal tracts from pluripotent stem cells. My main interest was always to try and work out why. Babies are sometimes born without kidneys or without normal kidneys or without normal lower urinary tract, creating renal organoids with glomerular differentiation. So, the two things we're trying to do now are to model these human genetic, kidney and urinary tract diseases with these organoid models, but also in parallel, where we're interested to see if we can You know, grow a whole new renal tract from pluripotent stem cells. For the practicing pediatric surgeon, I think it's difficult sometimes to grasp how do you apply a microscopic study like this. It seems to be there are at least two really great applications to consider. One of them is pediatric renal transplant. They use those tissues as replacement therapy instead of A formal kidney transplant. One day these could be functionally useful in actually a living patient. The other is testing novel therapies on an in vitro kidney. Children that are born with abnormal kidneys identify the gene that's gone wrong. We make stem cells from their blood samples. We grow their organoids in culture. And what we're looking for there is to kind of reproduce the disease in a dish. We're trying to look for what we call druggable targets. So, we've really come a long way, there are still a few limitations and growing a ureter is pretty difficult. Without a ureter, of course, you know, you can have a little kidney and even if it could make urine, the urine would have nowhere to go. There's also a problem of the very small size of these tissues that, as I've mentioned, a few millimeters across. So, um, if you're going to use them as renal replacement therapy, You'd have to implant, you know, hundreds of them, into a person. And then identifying how we're going to get a blood supply, that's another big problem. We cannot connect these little kidney organoids to a big artery. The, the glomeruli in them could never really make much urine because they wouldn't have high pressure, high flow going into them. One of the key applications that Doctor Wolf mentioned was understanding the pathophysiology of renal conditions using these organoids. This is gonna be like the big technology of the next decade, is organoids. All right, so the next study we have, it's called esophageal lengthening by traction in esophageal atresia, the UK Experience. We were lucky enough to talk to the first author. Hi, I'm Kirsty Brennan. I'm a consultant pediatric. Surgeon at the Evelina London Children's Hospital. So this was a retrospective study, basically a cumulative experience on esophageal lengthening by traction or OLBT for patients with long gap esophageal atresia. So we emailed the UK Network of Pediatric Upper GI surgeons and asked them to complete a survey that we designed to give us an idea of the type of patients who are having lengthening procedures, when. They were having them, how long they were leaving the stitches in. They found that 16 out of the 22 patients in whom it was attempted, or 73% of them, had a successful esophageal anastomosis after their lengthening procedure. The results are variable. In some babies, it works really well, uh, uh, and it seems to bring the esophagus together when it's going to be difficult. Um, and in other babies, it doesn't always work so well. What was good to know was that the babies. It doesn't work so well, all managed to have a cervical esophagostomy and survive. And reconstruction typically using a gastric transposition. And what was also interesting is that even when you get the esophagus together, there were the 3 deaths we had after anastomosis, not completely a shock, but was surprising. It seems to reflect what is happening in the real world, and clearly it's not universally successful, and its role in the management of long esophageal atresia, I think will still remain controversial. It's very difficult to know what's happening if you're not a specialist center, and I think this helps back up a knowledge of what's happening in non-specialist centers and the fact that probably this should be a specialist center procedure and, and that we need to work out and define how we go about bringing these babies to the right centers. The big takeaway point here was really determining if multiple centers should be doing this operation because there are so few of them or should they all be. Cohorted together so that you would have a better experience. All of these articles as usual, are posted underneath the media player. Can't forget that part. Our next article is called Centralization of Pediatric Surgical Care in the Netherlands, Lessons Learned. Hi, my name is Mark Rinan. I'm a pediatric surgeon and I'm a full professor of pediatric surgical oncology in Utrecht in the Netherlands. Overall, The study looked to see how centralization of care has been successful in the Netherlands. The Netherlands is a small country with only 17 million people, so you can imagine that, say, esophageal atresia, there's about 30 to 40 cases a year, and we have 6 pediatric surgical centers. Overall determining the difficulties in their process for the main pediatric surgery. Um, procedures and where they should be done. As you can imagine, this is a real gradual process. And in 2014, uh, started with the, the, the only hospital in the Netherlands where you could be operated on. For your oncology diagnosis. Then in 2015, we started with the abdominal and thoracic and head and neck cases. Then in 2018, his hospital got neurosurgical and orthopedic oncology. So now every oncological diagnosis is now done in Utrecht in our hospital. And then we're able to improve outcomes based on And cohorting those patients at specialized centers. So from the remaining 5 pediatric surgical centers, only 1 hospital is now doing biliary atresia and cholodocal cysts. From the esophalageal atresia cases, they're only done in 3 hospitals now. Anorectal malformations and Hirstpruom are done in 4 hospitals out of the 6. When I visited the Netherlands, that was the part that impressed me the most. Having single centers like that in a place like the United States, which is much, much larger, would not be feasible. The other thing is the reimbursement system. You know, we, in the United States, it's a different system. Uh, we're reimbursed on volume. And not an easy thing to do, so not surprisingly, there was a degree of resistance to uh within these centers in giving up what is a major part of our practice. But they found that in the end. Uh, outcomes overall were better when you have certain centers focusing on certain pathologies. And our results improved dramatically as well. So it wasn't just that there were two surgeons got together and they were just better at it, but now they operate together and they operate more often. We do about 30 neurovasomas a year. We do about 35 renal tumors a year. So you, you do get better at it. And if you're good at something, it becomes nicer to do it. Uh, the last It is called Building Towards Equitable Access to Safe Surgery for Every Child. So, hi, I am David Cunningham. He is the CEO of an organization called Kids Operating Room. And today I'm sitting in my office in Edinburgh, Scotland. And if you haven't heard of KidSOR, its aim is to provide modern operating theater facilities for the use of local surgeons in centers in sub-Saharan Africa and Latin America. Because we're sending all around the world, uh, we actually have a base here in the UK which, uh, where everything is, is brought into, tested, packed, cleared for customs, and then shipped from here. And then they're up to the point where they are sending a new OR every 12 days. We have opened 50 operating rooms in 22 different countries, and it's not always just about the construction and sending out the physical pieces of the operating room. So we support pediatric surgery residency program. That is run either by CSECSA. That's the College of East, Central and Southern Africa. Yeah. That's the West African College of Surgeons. Along with some key partners, particularly work closely with Smile Train, but others too. Create a solution, scale it, and make it sustainable. Our local teams are on hand to To unpack with local engineers who will then recommission all of the equipment, do local training, provide training to the local engineer. When we leave, it is a fully functioning operating room. It's interesting because I talked to one of the employees at a large medical device company and I said, why don't you send all these things to these developing nations so they can do laparoscopy. And he said, when we send it there, they don't know how to fix it when it breaks. So Kids OR finds a way to uh technology solutions. And so if there's a problem, the local hostel engineer can do a video call with our guys, and we can actually walk them. Through the exact bit of equipment, we can do some tests. We can uh remotely diagnose problems. It's truly remarkable. We'll have 75 operating rooms open by the end of this year. We don't consider that to be the end point. I think the end point is where there is enough capacity that every child can access care. I just want to put a plug out there that if anyone can Recommend someone for a peace prize. I think Kids OR should be, should be on the docket. What a great feel-good moment to close on. So with that, that is the February JPS issue highlights chosen from Doctor Davenport, given to you in this podcast format. If you like this episode, if you hate it, Go ahead and leave us a comment, leave us a review whether you're following us on social media or if you're listening on the state current pediatric surgery app. But until next time, I'm Rod. I'm Ellen. I'm Brittany. And remember, knowledge should be free. Usually, Ellen and I try to say that at the same time and we stopped doing it because it never lands. Yeah, I know, it's cute.
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