One of the key decisions that pediatric surgeons have to make when they're in the trauma bay is whether or not you're gonna take that patient to the operating room or not. Because sometimes, it's really obvious, right? Like, uh, hemodynamically unstable patient with a penetrating abdominal or thoracic injury, yeah, you're probably gonna take that to the operating room. But what about a situation where it's not so clear-cut, like a blunt abdominal injury, or specifically, a splenic injury. You know, there are probably a bunch of scenarios that are running through your head right now, but I think there's at least a good enough consensus that when I texted my boss, Doctor Todd Ponsky, he's a pediatric surgeon at Cincinnati Children's. I said, hey, let's say hypothetically, I, I have a patient here, a trauma patient with a grade 1 or 2 splenic plaque, a little bit of blood on the abdominal CT but it's contained, but, you know, I'm an eager general surgery resident. I wanna take this patient to the operating room. I wanna take their spleen out. What do you think, boss? No way. This patient should absolutely not go to the operating room. Todd had some more colorful language for me, but The fact of the matter is that in the back of his mind was probably the recent atomic guidelines. Essentially, grade doesn't matter. That's Doctor Rich Falcone. He's the director of trauma services at Cincinnati Children's Hospital Medical Center. Your decision making on the clinical concern, regardless of grade, if human dynamically normal and stable, admit to the floor, right? Regular diet, out of bed is tolerated. And then if you get 2 more hemoglobins and it's stable, you could actually send that kid home. Now, for the modern-day surgical trainee, this probably isn't really earth-shattering groundbreaking news. I mean, non-operative management or, or non-invasive management for a lot of previously surgical pathologies, you know, it, it's all really in vogue right now. But I can tell you, it was definitely not always this way. If you had a little scratch on the spleen during a gastrectomy or a colon resection, you had to take it out because otherwise the patient would die. That's Doctor David Wesson. He's an absolute. Legend of pediatric surgery, and he's talking about a time that isn't very long ago. And in fact, he remembers it really well because a lot of the groundwork on how we take care of splenic injuries non-operatively, well, we have him to thank. This is the Stay Current Pediatric Surgery podcast. In the early 1900s, Doctor Coker, you know, one of the fathers of surgery, he wrote a little bit about the spleen. If the spleen is injured, it should be removed, and that was the only treatment for it. Doctor Weston goes on. Think about this scenario in 1909. There's no ICUs, there's no blood available, there's no way to maintain an IV, there's no monitored beds, there's no oxygen for delivery. The big thing for me is that they didn't have any imaging. You only had to go on clinical grounds. I mean, think about it, there were probably some trauma patients who had splenic injuries, but they were so mild that The surgeons never even noticed. Patients with splenic injuries that were actually recognized in practice for those that had massive hemorrhage and So the fathers of surgery, like Coker are saying the only way to take care of a bleeding spleen. Is to take it out. And that was again the prevailing wisdom up until um the papers that came from sick kids in the 1980s. That's right. Toronto in the 1980s. But to really understand this, Doctor Wesson wanted us to go back a little bit further to the 1940s. The late 1940s, Tim Wandsworth, that was the head of general surgery at Toronto Sick Kids. He had a patient who had an abdominal injury, recovered, went home, and then came back with another injury that subsequently caused their death. And at autopsy, they found the spleen was in two pieces that had healed, and this sort of gave them the notion that, you know, you don't necessarily have to take out the spleen and just because it's injured doesn't mean it's gonna, the patient's going to exsanguinate. So then in select patients, he wouldn't operate on splenic injuries. And that became sort of the practice among the general surgeons that sick kids throughout the 1950s and 1960s. But they didn't tell people about it. It was a secret. They didn't, nobody really talked about it too much because it went against the common wisdom of all of the other pediatric and general surgeons at the time. That carried on to fast forward about 1968. Doctor Jimmy Simpson. He was the slickest guy around. The slickest guy around, and he decided it's time for sick kids to publish his data. It was the first published series of non-operative management and panic injuries. It was in a good journal. It was in what we now know as the Journal of American College of Surgeons, but it was a case series. It was. Only 50 patients. There, of that, like only a small percentage of them ended up getting their non-operative management for their splenic injury. But, but the key thing is, at that time, in the 60s and 70s, there was no way to prove that they had a splenic injury, cause they didn't have the imaging that we have today. So there's something fishy about Doctor Simpson's experience, and we don't really believe it, so we're not gonna change what we do. Didn't change anybody's minds. Do you remember the first time when you were at Sick Kids, um, when some people started talking about not operatively managing kids with splenic injuries? That's Doctor Bindi Nai Mathura. She is a pediatric surgeon and associate professor of surgery at Baylor College of Medicine. And what you thought about that back, back then. And so then that brings us to 1980. Dr. Wesson presented another case series in Detroit at the American Academy of Pediatrics, pediatric surgical section. Um, it was called Ruptured Spleen, when to operate, and uh I had a little electric typewriter. I can just picture myself sitting there. Um, I think I've seen one of those at a museum once. But what was unique about this case was that all of the patients had some sort of diagnostic imaging. The majority of them were radionuclide spleen scans. OK, great. So now we have imaging to prove that it was the spleen that was injured, and then these non-op patients did fine, right? Surely that changed people's minds. The, the non-believers said, well, they, those were phony, you know, uh, those were just congenital anomalies. OK, so, Doctor Weston's like, fine, some of these images kind of look they could be congenital anomalies, so what does he do? What we had done was that we had done follow-up radionuclide scans and showed the healing. And so the resolution of the defect was, in my mind, proof. Yeah, it seems like proof, right? Like now you have the imaging to say, hey, these were definitely traumatic splenic injuries. Something like 70% of the patients in the study were managed not operatively and seemed to do OK. So now, surely, Doctor Weston's convincing people, right? Well, fast forward to, he goes to an American College of Surgeons meeting in Florida, and runs into some world-famous trauma surgeons like Doctor William Blaisdell. Blaisdell said, if you believe surgery aggravates bleeding, then you shouldn't be in surgery. We probably have more experience in managing kids than any pediatric surgeon will ever see, because they don't see that much. Were you a resident at that time, Doctor Westman, or I was, um, I had just finished my training and I was a fellow. I was doing a, doing a year of research at the Brigham and Women's Hospital. So Doctor Wesson is like fresh out of training, and his, his heroes are telling him, hey, you're wrong about how you're managing these splenic injury patients. So for, for most people, that would probably make them pause, right? Well, not Doctor Weston, he actually kept going. In 1989, we published a follow-up series. It was a 5-year follow-up on that case series, and this time, most of those kids, Almost all had CT scans, which documented the injury. And again, his team showed that, hey, look, you can have really good outcomes for these patients by not operating on them. Then, this K series plus the one from 1980 combined, made the first treatment algorithm for when to operate and when not to operate on a pediatric splenic injury. Doctor Weston, just a question, so that's Doctor Adam Vogel. He's a pediatric surgeon and pediatric intensivist at Texas Children's. This way of managing patients, you know, non-operatively is coming out there. What were those backroom conversations like? Pediatric surgeons and the general trauma surgeons responded differently. The trauma, the trauma surgeons thought it was complete baloney. But the pediatric surgeons. I think are probably a little bit more open-minded to a big practice change like this. I, I know I'm being biased. Here's Doctor Nick Maura. How long do you think it took to, for it to become accepted and implemented? In pediatric surgery, it wasn't very long at all. So, ABSA and JPS are basically teenagers at this time, right? And here they are pushing out. More data to say maybe we should take a more minimalistic approach to some of these blunt abdominal trauma patients. What's your perspective on that, that next, that next 10 years that, that, that rolled out as far as the management of blunt solid organ injuries? All the talk in the after the initial presentation in 1980 was about resource utilization and length of scale. And I think that's the hook is they, they hung their hat on the fact that these patients are gonna have better outcomes if we manage them non-operatively. And I think that's kind of what got the attention of the rest of the surgical world. The pediatric surgeons in the trauma world are sometimes are not considered as relevant or important just because we're, we contribute such a small percentage, but I think that this non-operative management of the spleen put us in the limelight, and, um, you know, even to this day I've heard adult trauma surgeon. At adult trauma meetings, credit pediatric surgeons for starting this, this trend that is now the norm. And how did we get there? Well, the evolution continued. So APSA then made standardized guidelines, and that's important because first of all, manage things in a similar way so that you could then Group outcomes across the country and say, OK, everyone's managing this the same way. Let's see what the outcomes are. They found some good outcomes. CT scans became more prevalent, so much so that we came up with a grading system for splenic injuries, then a treatment algorithm based on those gradings that we got from the CT imaging. But Then we decided, hey, maybe this isn't the right way to go. Doctor Vogel again. The last maybe, you know, 10 years or so where we've flipped the script on that, and now, yeah, the CT scan, sure, that's important, I guess, to know if we got it, but yeah, you know, their heart rate's fine, their blood pressure's fine, all is right with the universe, let's just send them home. Because what did we really get back to? We got back to the clinical assessment of the patient. I've always thought that when when you look back at the patients that need an operation. Needed an operation. It sounds really simple, but if you boil down the atomic guidelines, that's pretty much it. Here's Doctor Falcone again. If you're hemodynamically stable, you go to the floor and get a diet the next morning and, you know, a hemoglobin check and go home. If you're hemodynamically unstable, you're gonna get fluids, blood, decide whether or not you go to the OR, but it's not, I got a grade 4, I must. Get admitted to the ICU, right, you gotta use some clinical judgment as well as just the imaging, and that's really what this, what the atomic team found. That's how far we've come from Coker in the early 1900s to Toronto sick kids in the 1940s, and then Doctor Wesson in the 1980s. So, then we had the atomic guidelines that Doctor Falcone was talking about. Now, we have an update from ABSA. It's an update from their 1990 blunt liver spleen injury guidelines. It's on the ABSA website, but we're also gonna link it below if you want to read along with us. A is for admission, meaning when you're gonna admit to the ICU and then orders for the ICU or for the ward. P is for procedures, meaning when are you're gonna transfuse, when you're gonna angioembolize, when you're gonna go to the operating room to control this bleeding. S is for set free, or, you know, what is the boxes you need to check to say, OK, this patient's clinical. Condition is such that we can discharge them, are they eating, etc. A is for aftercare. So they still restrict the activity of the patient, you know, once you send them home, but then it also has some recommendations for follow-up imaging. Like I said, we're gonna link this below, but otherwise, you can, you know, go to the app's website and you can read the whole thing, look at the references and everything. What, what I've learned from this story, from Doctor Wesson is it's OK to have a novel idea to try to better the care for the pediatric surgical patient. And if you have the right data, You can convince a lot of people. You could even change the trajectory of how this diagnosis is managed. Doctor Nick Mathura and Doctor Vogel trained under Doctor Wesson, and they learned a lot more than I did. It's everything, right? It's how do you handle yourself in the trauma bay? How do you handle yourself in the clinic? How do you Work with young children, older children, adolescents. Probably the, I've learned so much from you, but probably the main thing I've learned from you, which I still carry to this day is just treat the patient, not the imaging. How to be the consummate pediatric surgeon, and I don't think that's something that is really definable, right? Like you know it when you see it, and that's, and that's Doctor Wesson. And I, I always say now that I, I wanna, I wanna pay that forward. I want to continue to do that for people because he did that for me, so. So, there you have it, the history of non-operative management for splenic injuries. If you like this episode, if you don't like it, either way, leave us a comment, whether you're watching us on YouTube or listening to us on Apple Podcasts, SoundCloud, Spotify, Stitcher, or the best way to listen, to stay current pediatric surgery app. It's in the Apple App Store, it's in the Google Play Store, download it today. But until then. I'm Rod Gerardo from Cincinnati Children's, and remember, Knowledge. Should be free.
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