Journal of Pediatric Surgery Article Review: February 2023, BAPS issue

Published: 2023-04-20

3 Views

0 Likes

0 Shares

0 Comments

StayCurrentMD

View profile →

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 Ancisco — host
Speaker 2 — host
Mark Davenport — guest
Speaker 4 — guest
Govind Murti — guest
Beth Rmey — guest

Chapters

0:04Introduction and Episode Overview — Hosts introduce themselves as research fellows at Cincinnati Children's Hospital and outline the February 2023 BAPS issue review with guest editor Dr. Mark Davenport from the UK.
1:07Thoracoscopic Esophageal Atresia Repair — Discussion of Dr. Patkowski's Karl Stortz lecture on thoracoscopic EA repair, covering his Polish center's exclusive use of the technique since 2005, surgical tips, centralization of care, and expert commentary on outcomes and feasibility.
4:55Stoma Management in Hirschsprung Disease — Review of Sheffield study on stoma use in Hirschsprung disease showing 47% of patients required stomas before primary pull-through, with discussion of practice variations between UK and US approaches.
8:40Preoperative Soap Bathing for SSI Prevention — Presentation of Tanzanian randomized controlled trial demonstrating that preoperative soap bathing reduced surgical site infections from 40.6% to 11.4% and decreased length of stay from 22 to 12 days.
11:31Closing and Summary — Recap of the three articles discussed and information about upcoming Stay Current events and resources.

Key claims

1:38Dr. Patkowski's center in Poland has been performing thoracoscopic esophageal atresia repair exclusively since 2005 — Ellen Ancisco
1:54The first thoracoscopic EA procedure took almost 4 hours, but the procedure now takes 1 hour — Ellen Ancisco
1:59The Polish center has had no conversions from thoracoscopic to open approach since beginning the technique — Ellen Ancisco
2:06All thoracoscopic EA cases at the Polish center have been managed by one team using only the thoracoscopic approach — Ellen Ancisco
2:25Experience in endoscopic surgery and endoscopic suturing is required for thoracoscopic EA repair — Ellen Ancisco
2:58Centralization of EA care is important even if transportation costs are higher, because complication costs are much higher — Ellen Ancisco
3:06The Polish center handles 15 to 20 EA cases per year, which provides sufficient volume for good experience — Ellen Ancisco
3:38The center in Rocklaw has become the referral center for esophageal atresia and long gap esophageal atresia for all of Poland — Mark Davenport
4:13Centers of excellence for EA repair are showing better outcomes — Speaker 4
4:26Centralization of EA care would be difficult to implement in the United States healthcare system — Speaker 4
5:25The Sheffield study included 95 Hirschsprung disease patients from January 2004 to August 2021 — Ellen Ancisco
5:3547% of the Sheffield cohort needed a stoma before primary pull-through — Govind Murti
5:41In the stoma cohort, 38 patients had ileostomies and the remainder had colostomies — Ellen Ancisco
5:46The most common indication for initial stoma was washout failure in nearly 40% of cases — Ellen Ancisco
6:19Of 20 patients needing post-pull-through stoma formation, 7 occurred within 30 days and 13 after 30 days — Govind Murti
6:28Most post-pull-through stomas after 30 days were needed because of constipation or soiling — Govind Murti
6:35The Sheffield data represents real life surgical reporting and reflects overall Hirschsprung management within the UK — Mark Davenport
7:20US practice typically involves neonatal pull-through or home irrigations with pull-through in first months of life — Beth Rmey
7:39In US practice, pre-pull-through diversion is typically only done for delayed presentation with perforation or complicated cardiac cases — Beth Rmey
8:10Sheffield primarily performs Duhamel pull-throughs while Cincinnati primarily performs Swenson procedures — Ellen Ancisco
8:52The Tanzania study was conducted at Mahambile National Hospital and included 252 patients — Speaker 2
9:26114 patients received preoperative soap bathing and 11.4% developed surgical site infections — Speaker 2
9:26In the control group without soap bathing, 40.6% of patients developed surgical site infections — Speaker 2
9:43Preoperative soap bathing reduced the odds of surgical site infections by 80% — Speaker 2
9:53Length of stay was reduced from 22 days in the non-interventional group to 12 days in the soap bathing group — Mark Davenport
10:04Preoperative bathing was not common practice in Tanzania before this study — Speaker 2
10:41A Cincinnati Children's team working in Tanzania had almost every patient develop wound infections in their first year, but near-zero infections after implementing preoperative baths — Beth Rmey

Points of disagreement

7:01Appropriateness of stoma use in Hirschsprung disease management
- Govind Murti: Stoma is sometimes a necessity and not always a failure, with 47% of Sheffield patients requiring pre-pull-through stomas
- Beth Rmey: US practice typically avoids pre-pull-through stomas except for perforations or complicated cardiac cases, preferring home irrigations

Open questions

How can centralization of esophageal atresia care be implemented in healthcare systems like the United States where geographic distances are much larger than in European countries?
What is the optimal approach to teaching parents rectal washout techniques to reduce the need for stomas in Hirschsprung disease?
Why is there such wide practice variation between UK and US centers regarding stoma use in Hirschsprung disease management?
Can the simple preoperative soap bathing intervention be successfully implemented in other low-resource settings beyond Tanzania?

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.

Stoma Use in Hirschsprung Disease: Necessity Versus Avoidance

The points where the speakers disagreed, with each position presented side by side. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Points of disagreement · AI-written, human-reviewed

The Question

Should stoma formation be a routine part of Hirschsprung disease management, or should it be reserved only for specific complications? A Sheffield series reporting 47% pre-pull-through stoma rates 5:35 stands in sharp contrast to contemporary US practice, where most patients proceed directly to pull-through without diversion.

The Case for Selective Stoma Use

The Sheffield approach reflects what one discussant characterized as "real life surgical reporting" representing overall Hirschsprung management within the UK 6:35. In their cohort of 95 patients from 2004 to 2021 5:25, 47% required stoma before primary pull-through 5:35, with washout failure accounting for nearly 40% of initial stoma indications 5:46. Of the 38 ileostomies and remaining colostomies placed in this group 5:41, the distribution suggests a pragmatic response to clinical circumstances rather than protocol-driven decision-making.

The post-pull-through stoma data adds nuance: of 20 patients requiring stoma formation after their pull-through, 7 occurred within 30 days and 13 after 30 days 6:19. Most of the late stomas addressed constipation or soiling 6:28 — functional outcomes that a pre-emptive stoma might not prevent. As one discussant stated: "Stomma doesn't mean always a failure. Sometimes it's a necessity. Comes with the nature of the disease" [q5].

The Case for Primary Pull-Through

US practice typically involves neonatal pull-through or home irrigations with pull-through in the first months of life 7:20. Pre-pull-through diversion is typically reserved for delayed presentation with perforation or complicated cardiac cases 7:39. One discussant noted that the Sheffield data "does not seem reflective at all of the type of things that that we see in our practice here, and I think that would be seen in a lot of practices in the United States" [q6].

This approach prioritizes avoiding the morbidity of stoma creation and closure — two additional operations with their own complication profiles. When families can manage home irrigations, the infant proceeds to definitive repair without the intermediate step of diversion. The technical approach differs as well: Sheffield primarily performs Duhamel pull-throughs while Cincinnati primarily performs Swenson procedures 8:10, though both can achieve good outcomes.

Where They Agree

Neither position advocates for universal stoma use or universal avoidance. The Sheffield series demonstrates that just over half of patients proceeded directly to pull-through. The US approach acknowledges specific indications — perforation, cardiac complexity — where diversion is appropriate. Both recognize that some patients will require post-pull-through stoma for functional problems that the initial operation did not resolve.

The disagreement is not about whether stomas have a role, but about the threshold for using them. Sheffield's 40% washout failure rate as a stoma indication 5:46 suggests a lower threshold for abandoning medical management, while the US approach extends the trial of home irrigations further before proceeding to either pull-through or diversion.

What Would Resolve It

One discussant observed: "I think this paper just demonstrates the wide variability in practice around the world. I mean, I guess it depends a lot on the healthcare system, uh, on the individual practices, and, and also just traditional approaches" [q7]. The healthcare system variable is not trivial — home irrigations require family capacity, reliable follow-up, and geographic proximity to the treating center. A family living hours from the hospital may not be a candidate for the same management as one living nearby.

What remains unresolved is whether the functional outcomes — the constipation and soiling that drove 13 late stomas in the Sheffield series 6:19 6:28 — differ between the two approaches. If primary pull-through patients ultimately require the same rate of diversion for functional problems, then avoiding the initial stoma only delays the inevitable. If they do not, then the US approach spares a subset of patients two additional operations. The Sheffield data cannot answer this because it does not report functional outcomes in the non-diverted group, and the US practice pattern is not captured in a comparable series.

Takeaways from this story

Sheffield's 47% pre-pull-through stoma rate contrasts sharply with US practice, where diversion is reserved for perforation or cardiac complexity.
Washout failure drove 40% of Sheffield's initial stomas, suggesting a lower threshold for abandoning medical management than typical US practice.
Most post-pull-through stomas occurred after 30 days for constipation or soiling, functional problems a pre-emptive stoma might not prevent.
Healthcare system differences — family capacity for home irrigations, distance from hospital — may drive practice variation more than evidence.

Topic overview

Three research fellows from Cincinnati Children's Hospital review articles from the February 2023 Journal of Pediatric Surgery BAPS (British Association of Pediatric Surgery) issue. The discussion covers thoracoscopic esophageal atresia repair techniques from a Polish center performing exclusively minimally invasive repairs since 2005, stoma utilization patterns in Hirschsprung disease management at a UK center where 47% of patients required stomas before primary pull-through, and a randomized controlled trial from Tanzania demonstrating that preoperative soap bathing reduced surgical site infection rates from 40.6% to 11.4% and decreased hospital length of stay from 22 to 12 days.

Key takeaways

Thoracoscopic EA repair is feasible as exclusive approach; Polish center achieved 1-hour operative times with zero conversions since 2005. (1:38)
47% of UK Hirschsprung patients required pre-pull-through stoma, most commonly for washout failure—higher than typical US practice. (5:35)
Preoperative soap bathing reduced SSI from 40.6% to 11.4% and cut hospital stay from 22 to 12 days in Tanzania RCT. (9:26)
Centralization improves EA outcomes; Polish center handles 15-20 cases/year as national referral site for complex cases. (3:06)

Keywords

esophageal atresia Hirschsprung disease surgical site infections constipation soiling long gap esophageal atresia thoracoscopic repair thoracoscopic esophageal atresia repair ileostomy colostomy pull-through Duhamel pull-through Swenson procedure rectal washouts rectal irrigations

Hashtags

#PediatricSurgery #EsophagealAtresia #HirschsprungDisease #ThoracoscopicSurgery #BAPS

Transcript

Click "Show Transcript" to view the full text (11024 characters)

Hi, welcome back to Stay Current in Pediatric Surgery. I'm Ellen Ancisco. I'm I'm Tom Bash, and I'm Cecilia Gena. We're research fellows at Cincinnati Children's Hospital, and along with Stay Current, we're sharing knowledge to improve child health around the globe. And for this week, we are highlighting some more articles from the Journal of Pediatric Surgery. The articles are listed and linked in the description below. Follow along and read with us. The issue we're highlighting this week is from February 2023 and this is the BAPS issue. BAS? Is the British Association of Pediatric Surgery, and these are highlighted papers that were presented in the last year's conference. And Doctor Mark Davenport from the UK is the editor who helped us choose these articles for this podcast. Hello, I'm Mark Davenport, uh, the UK editor for the Journal of Pediatric Surgery. Awesome, so let's get started with the first one. The first article we're highlighting is called Thoracoscopic Approach for Esophageal atresia, a Real Game Changer. This was the Karl Stortz lecture at G at Babs last year. It was given by Doctor Patkowski. My name is Derek Potkowski. I am a pediatric surgeon. and also pediatric neurologist. I'm working at the Department of Pediatric Surgery of Rosslav Medical University. And he highlighted his experience in doing thoracoscopic repair for oesophageal atresia. He notes that in Poland, where he comes from, they've been doing thoracoscopic esophageal atresia repair since 2005 exclusively. We were happy that our first procedure was successful. When we did another one, it was much easier. Of course, at the beginning, the first procedure took us almost 4 hours. Right now it's a 1 hour procedure, but of course it's very difficult, but we are very happy to have no conversion. And since the beginning when we started with the thoracoscopic approach, all cases were managed by one team and only by thorachoscopic approach. He gives us some tips for things that he's learned along the way that will help make us better at doing thoracoscopic esophageal atresia repair. The first, you need experience in endoscopic surgery. And then just you need time, and you must be very experienced in endoscopic suturing. You must be very slow. If you do it slowly, you will do it fast. And what do you think, Cecilia? I mean, he's one of the best pediatric surgeons in the world, and I think that he perfected this thoracoscopic technique. Also, one thing that he mentioned is the importance to centralize the care of these patients. Even if this is a higher cost, but probably the costs of complications are much, much more higher than transportation. At my center we have about 15 to 20 cases a year. It depends on the year, and it shows that with such a number of cases you can get a good experience. Because it's not an easy operation, so it's better to have them made by experts that know how to do this theracoscopically because he thinks it's not the same to do it that way than open. And indeed this is probably the key factor. Distinguish him from many of his peers, and that was Doctor Davenport again, the editor who helped us choose these articles. The Centre in Rocklaw has become the center to refer cases of esophageal atresia and certainly the long gap esophageal atresia to from the whole of Poland, and with that experience and with his technology and technique, he has shown that you can give outstanding results for it. Here's what Todd had to say. First of all, It's great that Babs had Darius as their Stewart's lecturer, because I actually think he's probably gonna go down as one of the most brilliant pediatric surgical minds of our era. So regarding this particular paper though, I think we're starting to understand that these centers of excellence are probably a smart thing to do, and we are seeing better outcomes. And a lot of countries will have a very hard time doing that. It depends on your health care system. That won't happen in the United States very easily. And it's a shame because it probably should. And also if you look at most of the European countries, it's 4 or 6 hours drive from one side to the other side of the country, but that's the side of a basically a state in the United States. So, the centralization part could be done maybe in the state base. Next, we have M's article. The next article is from Sheffield, England, the role of stoma in the initial and long-term management of Hirschsprung Disease. We talked to the senior author for this paper. Hi, I'm Govind Murti. I'm a consultant pediatric surgeon in Sheffield Children's Hospital in the UK and I specialize in lower GI surgery. We were interested in is to see what the role of stoma in the management of Apring's disease in modern or current practices. They retrospectively look into the data from January 2004 to August 2021, and they had 95 patients in their cohort. If nearly 50 to 47% of our cohort. needed a stoma before the primary. In the stoma cohort, 38 of them had ileostomies and the remaining has colostomies. The most common indications for initial stoma was for nearly 40% washout failure. In case you're used to the term rectal irrigations, that's the same thing as rectal washouts in this paper. And he mentioned that for the last 40 years when we moved from three-stage surgical management to primary pull-through, started feeling like stoma is a failure. Stomma doesn't mean always a failure. Sometimes it's a necessity. Comes with the nature of the disease. Of the 20 patients that needed post pull through stoma formation, 7 of them happened within 30 days and 13 happened after 30 days. So there was a larger number of them needed it after 30 days, and most usually because of constipation, because of soiling. Well, it's just about the same, so I think this does represent real life surgical reporting from a representative group, Sheffield. Reflecting the overall management of Hirschprung's disease within the UK. That was Doctor Mark Devenport. As you're reading the article and as we were talking to Todd, we were realizing that this, sequence seemed a little bit different than what we usually hear about in the US. And so we talked to one of the colorectal experts at Cincinnati Children's, Doctor Beth Rmey. That it does not seem reflective at all of the type of things that that we see in our practice here, and I think that would be seen in a lot of practices in the United States. She pointed out that, you know, typically we see Many primary pull-throughs these days, as I said. So either a neonatal pull-through or, uh, you know, if the scheduling prohibits or if the baby is small, putting them home on irrigations and having them come back for a pull through in the first couple of months of life. The only patients that we would divert pre-poll through are if it is a delayed presentation, misdiagnosis, and they perforate. And then the other group. For the complicated cardiac babies. I think it's OK to manage patients by doing washouts at their houses and only use the stoma if they need it, but I think that what they can improve and even Doctor Murthy said it himself, it's to teach the parents how to do the washouts. The last thing I think Doctor Ray Maski pointed out is that it sounds like In Sheffield they're doing mostly do Hamel pull-throughs, whereas in Cincinnati, at least, they primarily do more Swenson's. Both can be just as good, but as far as technique goes, that is one difference. I think this paper just demonstrates the wide variability in practice around the world. I mean, I guess it depends a lot on the healthcare system, uh, on the individual practices, and, and also just traditional approaches. Cecilia is the last one. OK, so for the last paper of today we have a randomized control trial using soap for the prevention of surgical site infections in Tanzania. This is a randomized trial conducted in Mahambile National Hospital in Tanzania, and what they did is they had two groups. One received a bath. With plain soap prior to the surgery and the other one didn't. There was uh actual intervention by trained carers to direct the sort of method of of cleansing uh concentrating on areas known to harbor commensal and pathogenic bacteria. And again that was Dr. Mark Davenport. And they gathered 252 patients. 114 had a bath prior to surgery, and of them only 11.4% developed an SSI or surgical site infections, whereas in the other group, 40.6% of the patients develop NSSI. So analyzing that they have that with clean soap they reduced the odds of having surgical site infections by 80%. Uh, not only that, uh, they looked at length of stay, and in the interventional arm that was reduced from, it was 12 days, uh, compared to the non-interventional group which was 22 days. That's super important and one of the things I think it's cool about this is that it seems that in Tanzania it wasn't that common to give the patients a bath prior to. Surgery and just by implementing it, they definitely improved the patients' outcomes. Doctor Amski, who we discussed the last paper with, happened to recently have traveled to Tanzania with a group from Cincinnati Children's, and she mentioned that before implementing preoperative washing in their patients, um, they had, they similarly had higher SSI rates and afterwards, they decreased the rate of SSI as this paper shows. Yeah, I mean, the first year that we operated there, almost every kid got a wound infection, and then we started the next year we had the nurses do pre-op baths up on the floor the day before, and that year we had like 0 wound infections. So I do think that pre-op bathing is not sort of on the standard thing of things that people think about. Uh, I think this is an important trial. It was well designed, analyzed really in quite substantial detail. And I think the results seem fair and unambiguous and would have implications for that particular surgical environment, this is Tanzania, low to middle income country, clearly surgical site infections are a major problem. Awesome. We had 3 articles from the BAPS issue. One about thoracoscopic esophageal atresia repair and some tips from Dr. Patkowski. Then we talked about stomas and Hirschsprung disease and the experience in a hospital in the UK. And finally, a randomized control trial for preventing SS. in pediatric surgery patients in Tanzania with pre-operative soap washing. If you liked this episode, don't forget to follow us on social media, subscribe to our YouTube channel. Listen to previous episodes of this podcast or other podcasts, wherever you get your podcast from, and don't forget to download the Steak or an app or an App Store or Play Store. OK, so keep an eye and don't miss our update course 2023 that's going to be on August, so stay tuned for more information. Awesome. I'm Ellen and Cisco. I'm I'm Tom Bash, and I'm Cecilia Geno. We're research fellows at Cincinnati Children's and along with Stay Current, we're sharing knowledge to improve child health around the globe.

Comments

Loading comments...