Journal of Pediatric Surgery Article Review: September 2022, Part 3

Hello, everyone. We're back with another episode of the JPS podcast. Today we have part 3 of September issue. As you know, here at Cincinnati Children's Hospital, we like to highlight what's new out there. So, we are doing this JPS podcast, and we have one of the editors that help us choose the articles for every month. And this month, we had Doctor. Holcomb. So today, we're going to talk about two articles. One is about the surgeon's experience in thyroidectomies for pediatric patients. And we also have an infographic for this. If you are in the state current app, you can see the infographic link below. And the second one is about the same day discharge for Fus excavatum patients after the minimally invasive repair. So I'm Cecilia Genna. I'm Ellen Ancisco. I'm, I'm Tom Bash, and we are research fellows from Cincinnati Children's Hospital Medical Center. Also, as always, these articles are linked below the media player that you can, so you can read them for yourselves. OK, so let's start. For the first article, we have effect of surgeon volume on pediatric thyroid surgery outcomes, a systematic review. This is a paper from Luy Children's Hospital in Chicago. Their aim was to address the definition of a high volume surgeon for thyroidectomies and to examine the outcomes related to this high volume surgeon. So they found 10 articles that had 6430 patients. 5 of them were. Single center retrospective studies only on high volume surgeons. One was a retrospective study done at single center with low volume surgeons, and 4, well, national database studies that reported both high volume and low volume. And we talked to one of the authors, Doctor Raval. Uh, so my name is Mehul Ravel. I'm one of the pediatric surgeons at Laurie Children's Hospital. Um, I'm a health services researcher and uh Also serve as our vice chair for quality and safety. And what they found is that the definition of a high volume surgeon is very wide. They have papers that describe them as surgeons that do over 200 annual thyroidectomies, with 30 of them being in pediatric cases, and other defined with over 9 annual pediatric thyroidectomies. But the important thing about it. The patients that were operated in high volume centers, they have better outcomes, less complications like less bleeding, less injury to the laryngeal nerves, and less uh hyperglycemia rates. I'm a big proponent of, of concentrating relatively uh low volume cases to a uh a cohort of surgeons. Like we did the same thing for our biliary retrieve you. I, I just think concentrating cases like this to a small group, uh, within a group is a good idea. And that was Doctor Wit Hawke, the editor that helped us choose these articles. Defining what a high volume thyroid surgeon is, is actually really challenging. You see in the papers that we included the very, the, the definition was indeed very variable. Um, and so we don't have an answer and, and I don't know that this study necessarily provides a discrete answer for what should define high volume for pediatric, um, but rather I think it just gives us an idea that, um, it's, it's, it's some, it's not single digit, right? It's, it's probably not, you're doing one of these a year and therefore you can consider yourself to be a high volume surgeon. That was Doctor Raval, one of the authors of this paper. Like Doctor Raval said, it's kind of clear that at least in this review, like you said, patients Operated by high volume surgeons had fewer complications, so. This is very controversial. We debated this this weekend about whether or not this, this is a fallacy that high volume surgeons have better outcomes. And this is, this is just one of those papers that helps to support the fact that there might be certain operations that high volume surgeons do better at. And if the, and so the question becomes, when do you send it away? I do have some concern that it's a slippery slope and that we actually may be potentially causing some uh access to care challenges for patients if we are too stringent or too aggressive with these volume thresholds. But nonetheless, I think that clinically balancing what's right for patients and thinking of creative ways to collaborate, bring in higher volume surgeons, think about team approaches to to patient care or ways that we could still deliver high-quality, safe care to patients that need our, our, our help day in and day out. The next one is same day discharge for pectus excavatum. Is it possible? This is a paper from Kaiser Permanente, Los Angeles Medical Center, and we talked with the senior author, Dr. Syra. Sure, I'm Romanyak in Los Angeles at Kaiser. This paper looks at the intercostal nerve cryoablation and intercostal nerve block on effects of pectus excavatum patients' length of stay after the procedures, and their goal was to see if we can discharge these patients from the hospital the same day. This is a prospective study. They had 15 patients had nos repair and intercostal nerve cryoablation or intercostal nerve block, which followed by ERAS protocol, and length of the stay among those patients was average 12 hours. 10 of those patients went home the very same day, and 5 of them was discharged the next day. The main reason we actually kept The few patients in the hospital overnight was not pain. It was anxiety or a little bit of nausea or a few other reasons, but it was very rarely pain control. That was Doctor Syarak. He's a senior author in this paper. Among those 15 patients, 10 of them did not use any opioids after the discharge, and only 1 patient had bar migration requiring return to the OR for revision. You know, I remember the days we did a prospect a randomized trial, a trial maybe 10 years ago, and uh as I recall, I think we had a meeting. Discharge day of 4.5 or something. But anyway, that's just, uh, that's yesterday's news. And so, uh, so this is today's news, and today's news says that we can even drop everything down to maybe uh same day discharge. That's Dr. Wit Holcomb. He helped us choose these articles from the September issue of JPS. I like the surgery, but I used to hate how the patients were after because they were so much in pain. But now with this, I think that's, it's, it's amazing because they are feeling good and they want to do things and they can do exercises for like what they need for the practice, so I really like that. I agree that cryoablation plays a pivotal role or may play a pivotal role, but I would just say in general, we've gotten better with pain control. We have other modalities that we use. We've optimized pain control, and we're seeing the effect of that by getting probably the most painful operation we do home the same day. So it's a, it's a, it's a good testament to the improvements we've made. In pectus surgery. That's Doctor Todd Ponsky. And I know this isn't within the scope of the paper, I know, but I'm just curious if, um, now that you've been doing it for a few years, have you seen any patients come back with any issues like kind of down, you know, 2 years later or The only thing I sometimes see with cryo, like I said, is probably 1 out of 10 will have some degree of neuropathy, either early on or a couple of months later when sort of nerve regeneration is occurring. So for those patients, I tend to put them, like I said, on some Neurontin, and it usually resolves within a month or two. I've had no long-term, uh, you know, sequelae of using the cryo, and now I've done, I think, almost 200 patients. So I think it's a technology that's here to stay. OK, so, that was the part 3 of the JPS September issue podcast, and we have two articles. The first one was about the high volume surgeons in thyroidectomies for pediatric patients. I think we can all agree that being a surgeon of high volume is better for patients. And the same day discharge impacted cabaum after a Minimal invasive repair with cryo analgesia. So, I hope you like it. If you like it, leave us a rating and a review wherever you're listening in Spotify or Apple Podcast. Don't forget to follow us in the YouTube channel and also to download the Stay Quarantine Pediatric Surgery app. But until then, I'm Cecilia Jigena. I'm, I'm Tom Bash. And I'm Ellen Ancisco. And this is the Stay Current podcast.