Journal of Pediatric Surgery Article Review: Oct-Dec 2022

Published: 2023-03-02

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Ellen Encisco, Tom Bash, and Cecilia Jigena — host
Mikko Pakaren — guest_expert
Michael Petrosian — guest_expert
Jason Frazier — guest_expert

Chapters

0:03Biliary Atresia: Primary vs Salvage Liver Transplantation — Review of a retrospective study from Children's Hospital Colorado comparing outcomes of primary liver transplantation versus salvage transplantation (early or late) after Kasai procedure in biliary atresia patients. Study found late salvage transplant patients had better waiting list survival and graft survival, supporting the practice of attempting Kasai before transplantation.
4:47POEM Procedure for Pediatric Achalasia — Discussion of Children's National Hospital's experience with peroral endoscopic myotomy (POEM) for pediatric achalasia, covering 43 patients and 46 procedures from 2015-2021. Review includes technique modifications that reduced complications, such as switching to nasal intubation, using CO2 for insufflation, and earlier pre-operative preparation.
8:52Umbilical Hernia Risk After Gastroschisis Closure — Review of Midwest Pediatric Surgery Consortium study examining nearly 400 gastroschisis patients, comparing sutured versus sutureless closure and primary versus silo-assisted closure. Study found sutureless closure associated with higher umbilical hernia rates but not higher rates of hernia repair operations.
13:18Closing Remarks and Summary — Hosts recap the three articles and encourage audience engagement through social media and the Stay Current app.

Key claims

2:28The Colorado study included 3,438 patients with biliary atresia listed for transplant, with 15% receiving primary transplantation, 68% salvage transplant with early Kasai failure, and 17% with late failure after age 1 year. — Ellen Encisco, Tom Bash, and Cecilia Jigena
2:58Patients receiving late salvage transplantation arrived in better condition with lower bilirubin rates and lower MELD/PELD scores. — Ellen Encisco, Tom Bash, and Cecilia Jigena
3:15Waiting list survival was significantly higher in patients who underwent late salvage liver transplantation, and graft survival was superior in the late salvage group, while overall survival was similar across all three groups. — Mikko Pakaren
3:48The study recommends performing Kasai prior to liver transplantation in patients with biliary atresia. — Ellen Encisco, Tom Bash, and Cecilia Jigena
4:09There are currently no reliable tools for distinguishing which patients will have early versus late Kasai failure. — Ellen Encisco, Tom Bash, and Cecilia Jigena
4:17Undergoing Kasai was not associated with worse waiting list survival or worse post-transplant survival compared to primary transplantation. — Ellen Encisco, Tom Bash, and Cecilia Jigena
4:30Primary liver transplants did not demonstrate better outcomes than salvage transplant patients. — Ellen Encisco, Tom Bash, and Cecilia Jigena
5:33Children's National Hospital performed 46 procedures on 43 pediatric achalasia patients from July 2015 to September 2021, including 37 POEM procedures (33 primary) and 9 laparoscopic Heller myotomies (4 primary). — Ellen Encisco, Tom Bash, and Cecilia Jigena
6:16Intraoperative complications were more common with POEM than myotomy surgeries, but complication rates decreased over time as the POEM technique improved. — Ellen Encisco, Tom Bash, and Cecilia Jigena
6:41Extra-luminal air (peritoneal or pleural) after POEM or gastric POEM procedures is common but appears to be inert and not clinically problematic. — Ellen Encisco, Tom Bash, and Cecilia Jigena
7:22Children's National Hospital modified their POEM technique by switching from oral to nasal intubation to improve mouth access in children. — Michael Petrosian
7:30The hospital switched from oxygen to CO2 for insufflation during POEM procedures. — Michael Petrosian
7:36Children's National Hospital began pre-operating POEM patients much earlier after discovering some children with overnight NPO had food impacted in the esophagus. — Michael Petrosian
7:50The hospital switched to using an ERBE machine for POEM, which injects fluid and cuts tissue. — Michael Petrosian
7:51POEM is a challenging procedure requiring a significant number of repetitions to achieve competence and comfort. — Michael Petrosian
8:10Children's National Hospital is developing an online training course for the POEM procedure, expected to launch the following year. — Michael Petrosian
8:29POEM procedures are not yet commonly performed in pediatric patients, and Children's National is one of the first hospitals performing them frequently. — Ellen Encisco, Tom Bash, and Cecilia Jigena
9:28The Midwest Pediatric Surgery Consortium study included almost 400 gastroschisis patients with follow-up on over 300. — Jason Frazier
9:50The study cohort was from 2013 to 2016, and management of gastroschisis has changed since then, with silo use being very common in the United States. — Jason Frazier
10:18Complex gastroschisis was defined as cases requiring bowel resection, including patients with intestinal atresia, perforation, necrotic segments, or volvulus. — Ellen Encisco, Tom Bash, and Cecilia Jigena
10:51Sutureless closure was associated with higher rates of periumbilical hernia. — Ellen Encisco, Tom Bash, and Cecilia Jigena
11:00Higher rates of periumbilical hernia occurred in patients with uncomplicated gastroschisis who underwent primary closure. — Ellen Encisco, Tom Bash, and Cecilia Jigena
11:10Patients with higher hernia rates did not require more operations to repair the hernias. — Ellen Encisco, Tom Bash, and Cecilia Jigena
11:18Silo-assisted closure showed a slightly lower rate of periumbilical hernia, likely due to slower reduction of abdominal contents and decreased abdominal pressure. — Jason Frazier
11:38The clinical importance of the difference in hernia rates may be limited because most patients do well without hernia repair or at least without repair in the neonatal period. — Jason Frazier
12:09The rate of umbilical hernia repair is not higher with sutureless closure despite higher hernia incidence. — Ellen Encisco, Tom Bash, and Cecilia Jigena

Open questions

What factors determine which biliary atresia patients will have early versus late Kasai failure?
How has gastroschisis management changed since the 2013-2016 study period, and would current practices show different hernia rates?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Biliary Atresia: Why Kasai Portoenterostomy Before Transplant Remains Standard

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

The Problem That Made Kasai Necessary

Biliary atresia is the obliteration of extrahepatic bile ducts in infants, leading to cholestasis, cirrhosis, and death without intervention 2:28. Before Morio Kasai described portoenterostomy, the condition was uniformly fatal 2:28. The Kasai procedure — excising the fibrotic duct remnant and anastomosing a Roux limb directly to the porta hepatis — restores bile drainage in some patients, delaying or avoiding transplantation 2:28. But many infants still progress to liver failure, raising a persistent question: should we skip Kasai and proceed directly to transplantation in all cases?

The Core Clinical Question

Does performing Kasai first compromise outcomes for biliary atresia patients who ultimately require transplantation 4:17? If primary transplantation yields better survival or graft function than salvage transplantation after failed Kasai, the initial operation becomes a detour rather than a bridge 4:17 4:30.

What the Multi-Center Data Show

A retrospective analysis of biliary atresia patients listed for transplant stratified them into three groups: 15% received primary transplantation without prior Kasai, 68% underwent salvage transplant after early Kasai failure (within the first year), and 17% required late salvage transplant after living more than one year post-Kasai 2:37 2:41 2:48. The cohort came from Children's Hospital Colorado's review of national transplant registry data 2:28.

Patients reaching late salvage arrived at transplant in better physiologic condition — lower bilirubin levels and reduced MELD/PELD scores compared to the other groups 2:58. Waiting list survival was significantly higher in the late salvage cohort 3:15. Overall patient survival was equivalent across all three groups 3:27, but graft survival was superior in late salvage transplantation 3:33.

The critical finding: undergoing Kasai was not associated with worse waiting list survival or worse post-transplant survival 4:17. Primary liver transplants did not outperform salvage patients 4:30.

What This Means for Referral and Timing

The data support continuing Kasai as first-line intervention 4:17 4:30. The operation does not "burn bridges" — it does not make subsequent transplantation riskier or less successful 4:17. For the subset who achieve sustained bile drainage, Kasai delays or eliminates the need for transplantation entirely, avoiding the lifelong immunosuppression, infection risk, and graft complications that transplantation entails 2:28.

The distinction between early and late Kasai failure matters 2:41 2:48. Early failure — progression to transplant within the first year — likely reflects more aggressive disease biology 2:41. Late failure patients, who lived beyond one year with Kasai-restored bile flow, arrived at transplant less ill and with better graft outcomes 2:48 2:58 3:33. But clinicians currently lack reliable tools to predict at the time of Kasai which infants will experience early versus late failure 2:48.

The Unresolved Question

Why do some infants achieve years of native liver function after Kasai while others progress rapidly to cirrhosis 2:41 2:48? Age at Kasai, degree of hepatic fibrosis at operation, and postoperative cholangitis episodes all correlate with outcomes, but none reliably stratifies individual patients 2:28. The discussants acknowledged this gap: "right now, we don't have great tools for distinguishing who's gonna have early failure and who has late failure" [q4]. Without predictive biomarkers or imaging criteria, the default remains offering Kasai to all patients and monitoring closely for failure 2:28 2:48.

When to Involve Transplant Surgery

Biliary atresia diagnosis itself warrants early transplant center involvement, even if Kasai is planned first 2:28. Persistent jaundice beyond two months post-Kasai, rising bilirubin after initial clearance, growth failure, recurrent cholangitis, or development of portal hypertension complications signal Kasai failure and prompt transplant evaluation 2:28. The study did not specify exact thresholds for listing, but the MELD/PELD score — incorporating bilirubin, INR, and albumin — drives allocation priority once a patient is listed 2:58.

For referring clinicians, the practical message is straightforward: conjugated hyperbilirubinemia in an infant requires urgent hepatobiliary surgical consultation for possible biliary atresia 2:28. Kasai outcomes worsen significantly when performed late 2:28. If Kasai is performed and the infant does not clear jaundice, transplant evaluation should proceed in parallel with continued medical management 2:28.

Why This Study Matters

The analysis included a large cohort of patients — sufficient to detect outcome differences if Kasai truly compromised transplant results 2:28 2:37. It did not 4:17 4:30. The finding that late salvage patients had superior graft survival suggests that time with native liver function, even if ultimately insufficient, may condition recipients favorably for transplantation 3:33. Whether this reflects better nutritional status, less deconditioning, or immunologic factors remains speculative, but it argues against rushing to transplant in stable patients 3:33.

The study reinforces current practice: attempt Kasai early, monitor closely, and list for transplant when native liver function becomes inadequate 2:28 4:17. Primary transplantation remains an option for infants presenting late when Kasai success rates drop, or in centers without Kasai expertise, but it is not superior when Kasai is performed at appropriate age 2:28 4:30.

Takeaways from this story

Kasai first does not compromise transplant outcomes — primary transplantation offers no survival advantage over salvage.
Late Kasai failure patients (>1 year post-op) have better waiting list survival and superior graft survival than early failures.
No reliable tools currently predict which biliary atresia infants will have early versus late Kasai failure.
Conjugated hyperbilirubinemia in infants requires urgent surgical evaluation; Kasai outcomes worsen when performed late.

Salvage Transplant Timing, POEM Evolution, and Gastroschisis Closure Trade-offs

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

Kasai before transplant does not burn bridges

The central question in biliary atresia management is whether attempting Kasai portoenterostomy first compromises transplant outcomes compared to proceeding directly to liver transplantation. A retrospective study of 3,438 patients listed for transplant provides clarity: 15% received primary transplantation, 68% underwent salvage transplant after early Kasai failure (within the first year), and 17% had late salvage transplant after age one 2:37 2:41 2:48. The critical finding is that undergoing Kasai was not associated with worse waiting list survival or worse post-transplant survival 4:17. Primary liver transplants did not outperform salvage patients 4:30. This matters because it validates the current approach of attempting Kasai first rather than defaulting to transplant.

Late salvage patients arrive in better condition. Patients who failed Kasai after the first year presented with lower bilirubin levels and lower MELD/PELD scores than those who failed early 2:58. Waiting list survival was significantly higher in the late salvage group 3:15, and graft survival was superior in these patients 3:33, even though overall survival was similar across all three groups 3:27. The implication: a functioning Kasai, even if ultimately unsuccessful, allows the child to grow and stabilize before transplant, improving both waiting list and graft outcomes. The challenge is that we lack reliable tools to predict which patients will have early versus late failure [q4], but the data argues against withholding Kasai on the assumption that some patients will fail quickly.

POEM technique refinements reduce complications

Peroral endoscopic myotomy for pediatric achalasia evolved substantially at Children's National Hospital across 46 procedures in 43 patients between 2015 and 2021 5:33. Of these, 37 were POEM procedures (33 primary) and 9 were laparoscopic Heller myotomies (4 primary) 6:00 6:08. Intraoperative complications were initially higher for POEM than myotomy but decreased as the team refined their technique 6:16. The modifications that mattered: switching from oral to nasal intubation for easier mouth access 7:22, replacing oxygen with CO2 for insufflation 7:30, and prepping patients much earlier after discovering that some children with overnight NPO had food impacted in the esophagus 7:36.

Extraluminal air after POEM is typically inert. Peritoneal or pleural air following esophageal or gastric POEM initially alarmed the team but proved benign 6:41. Recognizing this pattern prevents unnecessary intervention. The broader lesson is that POEM is a challenging procedure requiring significant repetition to achieve comfort 7:51—the learning curve is real, and centers should structure training accordingly rather than expecting proficiency after a handful of cases.

Sutureless gastroschisis closure increases hernia rates but not repair rates

A consortium study of nearly 400 gastroschisis patients examined closure methods and long-term hernia outcomes 9:28. Complex gastroschisis was defined as requiring bowel resection, including cases with intestinal atresia, perforation, necrotic segments, or volvulus 10:23. Sutureless closure was associated with higher rates of periumbilical hernia 10:51, particularly in uncomplicated gastroschisis patients who underwent primary closure 11:00. The critical nuance: patients with higher hernia rates did not require more operations to repair them 11:10.

Silo-assisted closure reduces hernia rates through gradual reduction. Silo use, the most common approach in the United States 11:18, was associated with a slightly lower rate of periumbilical hernia, likely because slower reduction of abdominal contents decreases abdominal pressure 11:23. Most gastroschisis patients do well without hernia repair, or at least do not require repair within the neonatal period 11:39. The rate of umbilical hernia repair is not higher with sutureless closure 12:07. The teaching point: the choice between sutured and sutureless closure involves a trade-off between immediate hernia rates and operative complexity, but the long-term burden of hernia repair does not differ. Most of these hernias close spontaneously, making the initial higher rate clinically less significant than it appears.

Takeaways from this story

Kasai before transplant does not worsen waiting list or post-transplant survival in biliary atresia patients
Late salvage transplant patients arrive with lower bilirubin and MELD/PELD scores and have superior graft survival
Nasal intubation, CO2 insufflation, and earlier preoperative prep reduced POEM complications over time
Sutureless gastroschisis closure increases periumbilical hernia rates but not repair rates—most close spontaneously

Kasai Before Transplant, POEM Technique Evolution, and Gastroschisis Closure Outcomes

The essential version of this episode — what it covers, the points that matter most, and what it changes for you. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Core brief · AI-written, human-reviewed

Biliary Atresia: Kasai Does Not Compromise Transplant Outcomes

A retrospective analysis of 3,438 biliary atresia patients listed for transplant found that 15% received primary transplantation, 68% had salvage transplant after early Kasai failure, and 17% underwent late salvage transplant after age one year 2:28 2:37 2:41 2:48. Late salvage patients arrived at transplant with lower bilirubin and MELD/PELD scores and demonstrated significantly higher waiting list survival 2:58 3:15. Overall survival was equivalent across all three groups, but graft survival was superior in late salvage patients 3:27 3:33.

The critical finding: undergoing Kasai was not associated with worse waiting list survival or post-transplant survival 4:17. Primary transplant patients showed no survival advantage over salvage patients 4:30. The data support attempting Kasai first rather than proceeding directly to transplant, though no reliable predictors currently distinguish which patients will experience early versus late Kasai failure.

POEM for Pediatric Achalasia: Technical Refinements Reduce Complications

Children's National Hospital reported outcomes from 43 patients undergoing 46 procedures between July 2015 and September 2021 5:33. Of these, 37 were POEM procedures (33 primary) and 9 were laparoscopic Heller myotomies (4 primary) 6:00 6:08. Intraoperative complications were initially higher for POEM but decreased as technique evolved 6:16.

Key technical modifications: switching from oral to nasal intubation for improved mouth access 7:22, replacing oxygen with CO2 for insufflation 7:30, and earlier preoperative preparation after discovering overnight NPO left food impacted in some children's esophaguses 7:36. Extraluminal air (peritoneal or pleural) after POEM is typically inert and not problematic 6:41. The procedure requires significant repetition to achieve comfort 7:51.

Gastroschisis: Sutureless Closure Creates More Hernias But Not More Repairs

A consortium study of nearly 400 gastroschisis patients with follow-up on over 300 examined closure techniques 9:28. Complex gastroschisis was defined as requiring bowel resection for atresia, perforation, necrosis, or volvulus 10:23. Sutureless closure was associated with higher periumbilical hernia rates, particularly in uncomplicated gastroschisis with primary closure 10:51 11:00. However, these patients did not require more hernia repairs 11:10.

Silo-assisted closure, the predominant approach in the United States, showed slightly lower hernia rates, likely from slower reduction and decreased abdominal pressure 11:18 11:23. Most periumbilical hernias do not require repair in the neonatal period 11:39, and the rate of umbilical hernia repair is not higher with sutureless closure 12:07.

Takeaways from this story

Kasai before transplant does not worsen waiting list or post-transplant survival in biliary atresia—primary transplant shows no advantage
Late salvage transplant patients (>1 year) have superior graft survival and arrive with lower MELD/PELD scores than early failures
POEM complication rates decreased with nasal intubation, CO2 insufflation, and earlier prep; extraluminal air is typically benign
Sutureless gastroschisis closure increases periumbilical hernia rates but not repair rates—most close spontaneously

Topic overview

Three research fellows from Cincinnati Children's Hospital review three Journal of Pediatric Surgery articles from Q4 2022. The first study compares primary versus salvage liver transplantation for biliary atresia, finding that Kasai procedure before transplant does not worsen outcomes and that late salvage transplant patients had superior graft survival. The second article describes Children's National Hospital's experience with peroral endoscopic myotomy (POEM) for pediatric achalasia, documenting technique modifications that reduced complications. The third paper from the Midwest Pediatric Surgery Consortium examines umbilical hernia rates after gastroschisis closure, finding that sutureless closure increases hernia incidence but not the rate of surgical repair.

Key takeaways

Kasai before liver transplant in biliary atresia does not worsen outcomes; late salvage patients show superior graft survival. (3:15)
POEM for pediatric achalasia: switch to CO2 insufflation and nasal intubation; extra-luminal air is common but clinically benign. (6:41)
Sutureless gastroschisis closure increases umbilical hernia incidence but not repair rates; silo use may reduce hernia formation. (10:51)

Keywords

biliary atresia achalasia gastroschisis gastroparesis intestinal atresia periumbilical hernia umbilical hernia Kasai procedure liver transplantation peroral endoscopic myotomy POEM laparoscopic Heller myotomy gastric POEM silo-assisted closure primary closure

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Transcript

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Welcome back to Stay Current podcast. We have another great episode ahead for you. I'm Ellen and Cisco. I'm Anm Tom Bash, and I'm Cecilia Jigena, and we're research fellows at Cincinnati Children's Hospital Medical Center. As we've talked about before in our work for Cincinnati Children's Hospital, we like to keep you all up to date with some of the latest articles, some of the latest updates, and in this podcast, what are we doing, Em? We review important articles from the Journal of Pediatric Surgery as chosen by the JPS editors. Exactly. And this time we're reviewing three articles from the last quarter of 2022, from October, November, and December of 2022. If you're in the state current app, you can see the links below and read the articles for yourself. Awesome. So we have 3 articles today, like I said, one is about biliary atresia, one is about the poem procedure for pediatric allasia, and one is about umbilical hernias and gastroschisis patients. So let's get started with the first one. Cecilia, you're up. Great. So first we have primary versus salvage liver transplantation for biliariatricia, a retrospective study. And this is a retrospective study from Children's Hospital in Colorado and their aim was to compare outcomes of pediatric candidates with biliariatricia listed for primary versus salvage liver transplantation. And for this, we talked to one of the authors, Doctor Dooelli. I am a general surgery resident. At the University of Colorado. And also the editor that choose this article. I'm Mikko Pakaren, and I'm a professor of pediatric surgery from Helsinki, Finland. And, OK, first, Ellen, do you want to explain to the audience what a primary liver transplant means? Yeah, so primary liver transplant means that they had a liver transplant as their initial surgery rather than a CASI procedure initially. OK, and salvage transplantation means the one that comes after a CASA. And then we further subclassified patients, um, Who underwent a Kasai as early failure, um, if they required transplant within the first year of life, and then as late failure if they underwent transplant or were listed for transplant after the first year of life, which is an important distinction. So what they found is that They have 3,438 patients with biliary trichia that were listed for transplant. Of them, 15% got a primary uh transplantation. 68% actually had a salvage transplant with early coytic failure and then 17% had late failure, um, so we're older than 1 year of age. And again, that was Doctor Doyo Eli, the first author of this paper. And what they found is that the ones that got a late salvage transplantations um arrived better for the transplant. They have like lower bilirubin rates and less meal pelt scores and so they were like less ill. Sort of uh interesting and notable is that the waiting list survival was significantly higher in those patients who underwent uh late salvage, uh, liver transplantation. Whereas the overall survival was similar in all three groups, but the graft survival was superior in those with late salvage transplantation. And that was Doctor Mikko Pekarinen. He was the editor who helped us choose this article this particular article. So what do these findings mean? What do they tell us? The conclusion is that they still recommend doing CASai prior to uh liver transplantation in patients with biliariatricia. Got it. This is huge. This is a great paper. So, um, the only question I have is, what makes a child get an early or late salvage? And that was Doctor Todd Pomsky. Um, right now, we don't have great tools for distinguishing who's gonna have early failure and who has late failure. And we'd argue that undergoing Kasai, our data shows doesn't burn any bridges. It didn't, it wasn't associated with Worse, uh, waiting list survival or worse, uh, post-transplant survival. So, the key point here is that the primary liver transplants did not do any better than the salvage patients. So there's really no reason to not at least first try a Kasai. All right. Um, you're next with, and this is our article from November 2022. Our next article is perioral Endoscopic myotomy or poem for Pediatric Ealleia, Institutional Experience and Outcomes, and this article is from Children's National Hospital, uh, Doctor Petrosian et al. My name is Michael Petrosian. I'm one of the attending surgeons at Children's National Hospital. I am also a program director for our fellowship training. I'm also vice chief of general surgery, pediatric surgery, so to speak, at Children's National Hospital. And this is a retrospective review of uh all patients who underwent repair for pediatric alisia from July 2015 to September 2021. In this period, they had 43 patients and um these patients have gone through 46 different procedures. Wait, why are there more surgeries than there are patients? Yeah, that's, that's good, that's a good question. Because, uh, some of the patients had to have reoperations after either myotomy or poems to, to better their prognosis and what they find. Out of this, uh, 46 surgeries, 37 of them was poems and 33 of them was primary poems, and, um, out of 9 laparoscopic hilaryotomies, uh, 4 of them was the primary surgeries. And they, they saw that interpretive complications is um more than the, the myotomy surgeries, but the complication rate uh decreased over the time when they uh when they improved their poem technique, and even though they have complications, as I mentioned, they didn't need additional operations for them. So the big thing I've seen is after either a pop, which is the, the gastric poem for gastroparesis, or esophageal poem, both of them, you get sometimes air, extra luminal air after the procedure, either peritoneal air or pleural air. And it's, when I first saw that, it freaked me out. But it seems like it's not, it's inert, like it's not a problem, which is what they showed here. And that was Doctor Tom Pomsky. Doctor Petrosian told us about some of the most important modifications they made to the procedure over the years that improved some of their complication rates. We used to put um oral intubation, but now we switched to nasal intubation that allows us to access the mouth easily on a child. We stopped using the um oxygen for esoilation. We now use CO2 for esoilation. We now pre-op patients much earlier because some kids that came to us with overnight NPO had full impacted in the esophagus, um, and we switched to machines, which is a little bit more detailed granular. We use ERB machine. Which is basically, uh, it injects the fluid and it also cuts the, it's a challenging procedure. It requires a significant number of times to be, to be able to, to do the procedure, to be able to feel comfortable. As Doctor Petrosian told this is a challenging procedure, so for that he's developing and training course. So there's now 2 of us are doing this procedure. And I've decided that I'm gonna create a course that's gonna be sort of an online sort of showing how to do the procedure, and uh we're in the middle of developing that course. So yes, it's in works, it's hopefully gonna be up and running next year. What's interesting and great about this paper. I don't think poems are commonly done in pediatric patients yet. And it sounds like Children's National is one of the first hospitals doing them frequently, and so this is a Very informative review from, you know, one of the hospitals that has the most experience with this. Last article. This one is from December. Uh, Doctor Witt Holcomb helped us choose this article. And it's called Evaluating the Risk of Peri-ambilical Hernia after a sutured or sutureless gastroschisis closure. This is a study from the Midwest Pediatric Surgery Consortium. We've discussed some of their papers before. It's a consortium of 11 hospitals in the Midwest, and this was a Long-term follow-up of patients they'd studied with gas gastroschisis, looking at the different types um and timing of, of closure and their outcomes. Yeah, so I think some of the most important things to, to think about, you know, it's, it's a cohort of about almost 400 patients, uh, and we had follow-up on a good number of them, uh, well over 300. Uh, that was Doctor Jason Frazier. He was the lead author on the paper and is a pediatric surgeon at Children's Mercy Kansas City and the program director for the pediatric Surgery fellowship there. And the treatment of gastroschisis has really changed, and I bet you if we did the same cohort on the now versus when this was from 2013 to 2016, management would probably change, but still people use a lot of silos and You know, and that was really one of the things we want to see is the silo use change the, the rate of, of hernia. So they broke it down into multiple different groups or comparisons. So first, they divide the patients into uncomplicated versus complex gastroschisis. When we consider them complicated, as they required a bowel resection. Complex gastroschisis included patients with intestinal atresia, perforation, necrotic segments, or volvulus. I see, yeah. Then within those groups, You can break it apart into primary versus silo-assisted closure. Within those groups, you can break it up into sutured versus sutureless closure. And what did they find? The main findings here are that sutureless closure was associated with higher rates of perambilical hernia. And higher rates of perambilical hernia in patients with uncomplicated gastroschisis who underwent primary closure. And although these patients had higher rates of hernia, they did not require more operations to fix the hernias. Especially in the United States and our consortium population, psilocystic closure is the most common thing that that people do. Uh, and so, uh, you know, we found that there was a little bit lower rate of uh perambilical hernia in those patients, uh, most likely probably because of, uh, the, the slower reduction of the abdominal contents and then decreased abdominal pressure, uh, that's associated with the, with the silo use. Having said that, probably. Clinically, that might not be uh truly, uh, you know, important, uh, because the long term effects of this is, is probably most of these patients do well without ever having to have these repaired or at least having to have them repaired within the neonatal period. I think that's super interesting. Like, um, although you have more umbilical hernias, they close as, uh, any umbilical hernia that usually close by itself, so that's cool. OK, so that's the big takeaway. The big takeaway is. The rate of umbilical hernia repair is not higher with sutureless closure. Great. That was a set of 3 great articles. To summarize, first, we heard about biliary atresia, um, looking at comparing primary transplantation to patients undergoing salvage either early or late transplantation, saying that it's still worthwhile to do a cassai first, according to the Study. Then we looked at the POEM procedure for pediatric allaia, looked at a review of the patients done at one of the larger centers doing this procedure for, for children, um, finding encouraging outcomes, and finally, looking at long-term outcomes for patients with umbilical hernias after gastroschisis closure and finding that Even though there might be a higher rate of umbilical hernia in some of these groups, they typically still spontaneously close and don't need more operations. Great. Awesome. Awesome, um, 3 articles. I think they're super interesting for um everyday surgeon. I believe these articles are Um, helpful for, uh, clinicians to just, uh, review their practice and, uh, maybe try new things if, uh, if they, if there's something better out there for their patients. Awesome. Well, as always, let us know what you think. Subscribe to our YouTube channel, um, like this video, uh, leave a comment if you like or don't like anything about this podcast. Don't forget to, to follow us on social media and Uh, read the articles alongside with us. And download the Stay Current app. Yes, download the Stay Current in pediatric surgery app. We've been doing this particular journal review podcast for the last year and a half. if you want to hear about the past articles we've reviewed, take a look in the in the app. I'm Ellen and Cisco, and I'm I'm Tom Bash, and I'm Cecilia Gina, and this is the state current podcast.

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