We're back with the article review from the Journal of Pediatric Surgery. I'm Ellen Ancisco. I'm Brittany Levy. I'm Amel Bash. We're a research residents at the Cincinnati Children's Hospital, and this month, we're reviewing articles from the March issue of JPS. These articles were chosen by one of the editors, Doctor Pekaran. I'm Miko Bogannan. I'm a professor of pediatric surgery in, in the University of Helsinki Hospital for Children. Hospital in, in Finland. And as a reminder, all these articles you can find in the media player are linked below in the media player or wherever you're watching or listening if you want to follow along. So let's get started. So the first article is laparoscopic versus open appendicectomy for complicated appendicitis in children, and this article is coming out of India. It was a systematic review and meta-analysis of the current literature comparing the associations. Of laparoscopic appendectomy and open appendectomy for various postoperative outcomes. They looked at 4 randomized controlled trials and 36 case controlled trials, and they compared a few different outcomes. The overall findings show that laparoscopic appendectomy is associated with shorter length of stay, a lower rate of surgical site infection, and lower overall complication rate. But the rates of intra. Abdominal abscess, post-operative fever, pneumonia, and ileus are similar between the two groups. The only metric that favors for open appendectomy was the shorter operative time. And although many of us already perform most of the appendectomies laparoscopically, and findings of this meta-analysis surely support that practice. While here in the US, a lot of appendectomies are mostly laparoscopic. But around the world, open appendectomies is more frequent than we might think. And I have a friend who's a pediatric surgery resident back in Turkey. He told me that they prefer open appendectomies nearly half of the children, especially the ones with the lower BMIs. It's kind of interesting because as a resident and as a medical student, I've actually never seen an open appendectomy in a child, only for An adult patient with appendiceal cancer. So, these results don't seem surprising to me, but might be different when I consider places that have more open appendectomies in pediatric patients. I don't think it's a slam dunk that the laparoscopic appendectomy is necessarily better than the open appendectomy. I think there's two ways of doing it. Obviously, this won't change my practice, but it may change the practice of surgeons in other countries. This is specifically for complicated appendicitis, so I don't know if that makes some people more nervous to do it laparoscopically, and maybe they Just go ahead and open if they think it's gonna be more difficult because of it, because it's perforated or something. Non-complicated and complicated gappendicitis, that's a total different disease, as we all well know. And, and most of the non-complicated, probably in some centers already treated by antibiotics. But what's really interesting is that, do we need to treat part of them at all? And that's something we need to As in the, in the future studies. Let us know what you think about laparoscopic versus open appendectomy for complicated appendicitis. The next paper is Management and clinical Outcomes of congenital oesophageal stenosis in pediatric patients. Experience of a tertiary referral center. This paper is from a university hospital in Turkey. This is a relative A large series on a very rare and little studied uh congenital condition. The most common form of stenosis that we deal with is iatrogenic. Like we cause it. We do an anastomosis, it closes tight, we have to dilate it. But sometimes kids are born with it. And in their study of 19 patients, they successfully treated 14 with median of 5 dilatations, and 2 patients had some residual symptoms. And 3 were were operated on later on. And we spoke with the first author. He's an attending pediatric surgeon at Chukuroa University Faculty of Medicine Hospital. We got to talk to him over Zoom. Lucky for us, we have a Turkish translator. What makes us special with this step up approach is we see the surgery as a last resort, and we try to make the process as conservative as possible. And the big debate that we debate at our hospital all the time is, and this would be in Akron, do you dilate or do you resect? And here's why it's a debate. If you dilate, you have a risk of rupture, and that could be catastrophic. So a lot of people believe that you should just go straight to resection. A lot of discussion about multiple different kinds of congenital esophageal stenosis, if they have cartilaginous component or it's just a membranous component and how currently what to do is really dependent on those features. If it's cartilaginous, don't try to dilate, just go to resect. If there's no cartilage, then dilate. It's a good topic for discussion because maybe there's not a Whole consensus on what exactly to do, uh, whether you start with dilations or if you try to determine if they have cartilage, and then maybe they just go ahead and need surgery right away. A lot of people believe all comers, even those that have cartilage, you should try to do dilation first. I agree with starting with dilation in the membranous ones, but if there's cartilage, that's where I'm torn. First, we tried balloon dilatation for every patient, then we moved on to the surgery. According to the balloon dilatation results, even if we think that there is no benefit from the balloon dilatation, we continue to do that as long as it improves the patient's clinic. We had to move on to the surgery in cases such as recurring lung infections, growth retardation, and the times the patient wasn't healthy enough to even to be included in the dilatation program, and the results were hopeful. Out of 19 patients that underwent esophageal balloon dilation. 16 of them were successful, and the last 3 did require an operation, and overall, 17 patients were symptom-free after 48 months of follow-up. Based on their findings, I would be willing to try up to 5 dilatations before considering operative treatment. And in this sense, I think that this paper has a potential to, to change my practice also. And I was quite surprised that they achieved such a good results by By doing dilatations. So our last article is the use of expedited postoperative protocol for children undergoing appendicostomy reduces the length of hospitalization. This is from here in the US at the University of Utah. We talked to the first author. I'm Scott Short at uh Primary Children's Hospital in Salt Lake City, and I'm one of the faculty in the colorectal program. And the senior author. I'm Michael Rawlins, a pediatric surgeon at Primary Children's Hospital in Salt Lake City, Utah. I'm the director of our colorectal program. And this study really looked at an ERAS protocol, which is the hot new topic in pretty much all of pediatric surgery these days, and how that can improve length of stay, surgical site infections, and overall patient outcomes. We changed our, uh, postoperative protocol, um, based on the fact that, uh, many of our patients, uh, uh, displayed clinical signs that they were ready, uh, to initiate a diet, uh, immediately after surgery and Uh, historically, we, uh, did not initiate a diet following, uh, creation of an appendicostomy until the day after surgery. And in this study, uh, Short and co-workers showed that they were able to reduce hospital stay from 3 days to 1 after implementation of expedited plus over a protocol after appendicostomy. Without increasing complications or unplanned hospital visits. We've talked a number of times in different articles and different discussions about how ERAS and these protocols have helped get kids out of the hospital sooner, which has also been beneficial. I feel like we always say with COVID. And I think this is a nice example. We should continuously think ways to improve our daily practice and routine management protocols. From an actual implementation standpoint, I think implementing change in protocol is really important to make sure that your colleagues, your nurses, and your staff around you are, are supportive of you making these shifts in, in care management. About how just having a protocol seems to have beneficial, uh, beneficial effects, you know, whether or not you in your hospital are using this exact protocol after appendicostomies, um, just having some sort of standardization can be helpful. Another example of us figuring out that we can break dogma and, and make things more efficient for the patient. And Our own current protocol is very similar to their historical one, and based on this study, uh, further reduction in hospital stay seems to be achievable. So I, I definitely think that this study will change my practice and, and we'll, we'll give it a go and see. This time we've had other months where we have a lot of basic science, um, or kind of a mix of basic science with clinical, and these are all very clinical, which is, which is nice. We are like, and I feel like in our podcast, we We love clinical-based things. Um, so we talked about laparoscopic versus open appendicectomy, and it sounds like probably it won't change the management for a lot of people. A lot of us are, a lot of people are already doing laparoscopic appendectomies even for complicated appendicitis. The second one is about congenital esophageal stenosis and how to manage that. It sounds like maybe there's more discussion here. Um, and maybe we'll change practice for some people. And then the last one was protocol after appendicostomies, and that 1 may or may not change your practice depending on what kind of postoperative protocol or standards say your patients have. But also we have, if you If you like what you heard, make sure you leave us a comment on our social media on our YouTube channel. Make sure you download the Stay Current and pediatric surgery app. Until next time, I'm Ellen. I'm Brittany, and I'm Em. And remember, knowledge should be free.
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