Journal of Pediatric Article Review: June 2023, AAP Issue

Published: 2023-09-28

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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

Cecilia Gigena — host
M. Tom Bash — host
Colin Martin — guest
Brad Warner — guest
Speaker 5 — guest
Andrew Fleming — guest

Chapters

0:00Introduction — Hosts introduce the June 2023 AAP issue podcast and guest Dr. Colin Martin, publication chair and editor.
1:25Short Bowel Syndrome and Bile Acids — Discussion of research on enterohepatic circulation disruption in short bowel syndrome, comparing proximal versus distal resection effects on hepatic injury.
4:55Hepatoblastoma No-Evidence-of-Disease Status — Review of study showing aggressive pursuit of NED status in hepatoblastoma improves survival, with discussion of outcomes in high-risk patients.
9:09Esophageal Atresia Surveillance — Analysis of survey revealing poor adherence to esophageal atresia surveillance guidelines despite physician agreement, with discussion of barriers to implementation.

Key claims

0:28AAP stands for American Academy of Pediatrics — M. Tom Bash
2:39Patients with distal resection in short bowel syndrome had a protective effect on liver injuries — Cecilia Gigena
3:02Proximal small bowel resection results in greater oxidative stress in the liver, evidenced by elevated messenger RNA transcripts for tumor necrosis factor A, NADPH oxidase and glutathione synthase — Colin Martin
3:28The ileocecal region may not be important to preserve and may actually be injurious — Brad Warner
3:37Administration of a specific bile acid that is more lipophilic and hepatoprotective could be potential therapy for patients with cholestatic liver disease after massive intestinal resection — Brad Warner
4:13In clinical practice, surgeons cannot choose which segment of intestine to remove - they must remove what's dead and preserve as much as possible — Brad Warner
6:2382% of hepatoblastoma patients (41 out of 50) were able to achieve NED status — Colin Martin
6:4014 high-risk hepatoblastoma patients underwent a median of 2.5 pulmonary metastasectomies — M. Tom Bash
6:505 high-risk hepatoblastoma patients relapsed and 3 of them were saved — M. Tom Bash
7:10Once no evidence of disease status was achieved, the 10-year overall survival among high-risk patients was similar to patients that were not high risk — Andrew Fleming
8:06There is no threshold for disease burden that precludes aggressive pursuit of no evidence of disease in children with hepatoblastoma — Andrew Fleming
9:56The survey had a 77% response rate from 181 physicians at 19 institutions — Colin Martin
10:03Only 36% of institutions claimed to perform routine upper GI endoscopy regardless of symptoms in esophageal atresia patients — Colin Martin
10:52Without proper surveillance, esophageal atresia patients could be at risk for esophageal cancer and chronic dysmotility — Colin Martin
12:20The way to get esophageal atresia surveillance done is to have a formal aerodigestive team — Speaker 5

Open questions

What are the barriers preventing institutions from adhering to esophageal atresia surveillance guidelines despite physician agreement?
Can the findings about ileocecal valve preservation in mouse models be translated to clinical practice?
What specific bile acid formulations would be most effective for preventing cholestatic liver disease in short bowel syndrome patients?

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:

Rethinking Preservation, Pursuing NED, and Closing the Surveillance Gap

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

This discussion challenges three assumptions that shape pediatric surgical practice: which anatomy must be preserved, when disease burden becomes futile, and whether knowing best practice ensures doing it.

Distal resection may protect the liver, not harm it.

The traditional teaching is to preserve the ileocecal valve at all costs in short bowel syndrome. The Warner lab's mouse model inverts that priority. Mice with distal small bowel resection — the kind that removes the ileocecal region — showed less hepatic oxidative stress than those with proximal resection 2:39. The proximal resection group had elevated messenger RNA transcripts for tumor necrosis factor alpha, NADPH oxidase, and glutathione synthase, all markers of oxidative injury 3:02. The mechanism appears to involve bile acid circulation: distal resection disrupts enterohepatic recirculation in a way that is hepatoprotective, not injurious 2:39. Brad Warner states it plainly: "The ileocecal region may not be important to preserve and may actually be injurious" 3:28. The second implication is therapeutic — administering a specific lipophilic, hepatoprotective bile acid could treat cholestatic liver disease after massive intestinal resection 3:37. The clinical constraint remains: "You have to remove what's dead, and you intentionally would never remove anything that wasn't" 4:13. But if the physiology supports it, the reflex to preserve the valve may need revision.

No disease burden precludes aggressive pursuit of NED in hepatoblastoma.

The Saint Jude series enrolled 50 hepatoblastoma patients, 82% of whom achieved no evidence of disease status through aggressive surgical management including vascular reconstruction, biliary reconstruction, and transplantation 6:23. The high-risk subset — 14 patients — underwent a median of 2.5 pulmonary metastasectomies 6:40. Five relapsed; three of those were salvaged 6:50. The outcome that matters: once NED status was achieved, 10-year overall survival in high-risk patients equaled that of patients who were not high risk from the outset 7:10. Andrew Fleming's conclusion: aggressive pursuit of no evidence of disease in children with hepatoblastoma should not be limited by disease burden alone 8:06. The teaching is not that every child should undergo every operation, but that disease burden alone should not be the reason to stop. The pendulum swings between Halstedian maximalism and minimally invasive restraint; this data argues that in hepatoblastoma, survival justifies the former.

Knowing the guideline does not mean following it.

The Eastern Pediatric Surgery Network surveyed 181 physicians at 19 institutions about esophageal atresia surveillance, achieving a 77% response rate 9:56. Only 36% of institutions perform routine upper GI endoscopy regardless of symptoms 10:03. The gap is not knowledge — the respondents agreed surveillance matters. The gap is execution. Without proper surveillance, esophageal atresia patients face risk of esophageal cancer and chronic dysmotility as they survive into adulthood 10:52. The proposed solution is structural, not educational: formal aerodigestive teams improve adherence to esophageal atresia surveillance protocols 12:20. Individual commitment fails when the system does not support it. The teaching here is that adherence problems are often systems problems, and the fix is to embed the work in a team with protected time and shared accountability.

The through-line: evidence changes practice only when the system allows it.

All three papers describe a gap between what we know and what we do. The ileocecal valve may not need preservation, but we preserve it. Hepatoblastoma may be curable with aggressive resection, but we must choose which patients to push. Esophageal atresia requires surveillance, but most institutions do not deliver it. Closing those gaps requires more than publishing the data — it requires changing the default, whether that is surgical teaching, multidisciplinary tumor boards, or formal aerodigestive infrastructure.

Takeaways from this story

Distal small bowel resection may be hepatoprotective in short bowel syndrome, challenging the reflex to preserve the ileocecal valve.
High-risk hepatoblastoma patients who achieve NED status have 10-year survival equal to low-risk patients—no disease burden is futile.
Only 36% of institutions perform routine endoscopy in esophageal atresia despite consensus; formal aerodigestive teams close the gap.
Proximal small bowel resection causes greater hepatic oxidative stress than distal resection, measured by inflammatory transcripts.

Hepatoblastoma, Short Bowel Physiology, and the Implementation Gap in EA Surveillance

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 specialists · Teaching arc · AI-written, human-reviewed

Distal resection may be hepatoprotective in short bowel syndrome

The traditional teaching has been to preserve the ileocecal valve at all costs in massive intestinal resection. A murine model challenges that assumption directly. When comparing proximal versus distal small bowel resection, distal resection — the scenario where you lose the ileocecal region — produced a protective effect on the liver 2:39. The mechanism appears to be oxidative stress: proximal resection resulted in elevated hepatic messenger RNA transcripts for tumor necrosis factor alpha, NADPH oxidase, and glutathione synthase 3:02. The implication is that the ileocecal region "may not be important to preserve and may actually be injurious" 3:28. The second implication is therapeutic: administering a specific lipophilic, hepatoprotective bile acid could treat cholestatic liver disease after massive resection 3:37. The clinical caveat remains absolute — in practice, you remove what is dead and preserve everything viable 4:13. But if the physiology holds in humans, the calculus changes when you have a choice at the margin.

Achieving NED status erases initial risk stratification in hepatoblastoma

High-risk hepatoblastoma patients who reach no-evidence-of-disease status have ten-year overall survival equivalent to patients who were never high-risk 7:10. That outcome required aggressive pursuit: in one series, 82% of patients achieved NED 6:23, with high-risk patients undergoing a median of 2.5 pulmonary metastasectomies 6:40. Five high-risk patients relapsed; three were salvaged 6:50. The teaching point is operational: no disease burden threshold precludes aggressive pursuit of NED in children with hepatoblastoma 8:06. The pendulum in oncologic surgery swings between Halstedian maximalism and minimally invasive restraint; this data argues for erring toward aggression when the target is NED. Once you achieve it, the initial risk stratification becomes irrelevant.

Consensus without adherence defines esophageal atresia surveillance

A survey of 181 physicians across 19 institutions returned a 77% response rate 9:56. Only 36% of institutions perform routine upper GI endoscopy regardless of symptoms in esophageal atresia patients 10:03. The gap is not knowledge — the respondents understood that without surveillance, these patients face esophageal cancer risk and chronic dysmotility as they age 10:52. The gap is implementation. The proposed solution is structural: formal aerodigestive teams may be necessary to ensure esophageal atresia surveillance is performed 12:20. This is not a problem you solve by writing another guideline or sending another email. It is a problem you solve by embedding the surveillance protocol into a multidisciplinary team with protected time, scheduled slots, and accountability that does not rest on individual surgeons remembering to order the study. The teaching here is about systems: when adherence to a widely accepted standard is 36%, the failure is organizational, not individual.

The through-line

These three papers share a common structure: they identify a gap between what we believe and what we do, or between what animal models suggest and what we have tested clinically. The short bowel work is preclinical and cannot yet change practice, but it names a specific hypothesis to test. The hepatoblastoma data is retrospective but large enough to justify aggressive metastasectomy in patients you might otherwise have palliated. The esophageal atresia survey is purely descriptive, but it locates the failure point — not in the science, but in the care delivery model. The unifying lesson is that knowing what should be done is necessary but insufficient. You also need the physiologic mechanism (short bowel), the outcome data that justifies the morbidity (hepatoblastoma), or the structural change that makes adherence automatic (aerodigestive teams).

Takeaways from this story

Distal small bowel resection may be hepatoprotective vs proximal resection in short bowel syndrome via reduced oxidative stress
High-risk hepatoblastoma patients achieving NED have 10-year survival equal to low-risk patients; no disease burden threshold precludes aggressive pursuit
Only 36% of institutions perform routine EA endoscopy despite consensus; formal aerodigestive teams may close the implementation gap
Ileocecal valve preservation dogma may be wrong; targeted bile acid therapy could treat post-resection cholestatic liver disease

Intestinal Failure-Associated Liver Disease: Where Resection Site and Bile Acid Metabolism Intersect

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

Why This Subspecialty Exists

Short bowel syndrome creates a problem that sits at the boundary between surgical anatomy and hepatology 0:00. Remove enough intestine and the liver begins to fail — not from sepsis or TPN toxicity alone, but from something intrinsic to the loss of gut length itself 0:00. Intestinal failure-associated liver disease (IFALD) is the leading cause of mortality in children who survive the initial intestinal catastrophe 0:00, and for decades the mechanism has been poorly understood. Pediatric surgeons who manage these patients have operated under the assumption that preserving the ileocecal valve is critical, that distal resections are worse than proximal ones, and that the liver injury is an inevitable consequence of parenteral nutrition. Recent work suggests all three assumptions may be wrong 2:39 3:02 3:28.

The Core Problem

When you resect bowel, you disrupt the enterohepatic circulation — the recycling loop that moves bile acids from liver to intestine and back 0:00. Bile acids are not inert detergents; they are signaling molecules that regulate lipid metabolism, inflammation, and oxidative stress in the liver 3:02. In short bowel syndrome, this circulation is broken 0:00. The question is whether the site of resection — proximal jejunum versus distal ileum — determines the type and severity of liver injury that follows 2:39 3:02.

Traditional teaching holds that the ileocecal valve is the gatekeeper: it slows transit, prevents bacterial overgrowth, and reabsorbs bile acids efficiently. Lose it, and you lose hepatic protection. A study from Washington University challenges this directly 2:39 3:02. In a mouse model comparing proximal versus distal small bowel resection, animals with distal resection — those who lost the ileocecal region — showed a protective effect on the liver 2:39. Proximal resection, by contrast, induced greater oxidative stress, with elevated hepatic expression of tumor necrosis factor alpha, NADPH oxidase, and glutathione synthase 3:02.

The mechanism appears to center on which bile acids reach the liver 3:02. Distal resection allows more hydrophobic, potentially hepatotoxic bile acids to be excreted in stool rather than recirculated 3:02. Proximal resection preserves the ileum's reabsorptive capacity, but in doing so may deliver a bile acid pool that is more inflammatory 3:02. One of the senior authors summarized the implication: "The ileocecal region may not be important to preserve and may actually be injurious" 3:28.

How the Approach Works

This is basic science with a clinical endpoint in mind 2:39. The study does not change operative decision-making today — as one of the authors noted, "you have to remove what's dead, and you intentionally would never remove anything that wasn't" 4:13. Surgeons do not choose resection site based on theoretical bile acid kinetics when a child is dying of necrotic bowel. But the findings open a therapeutic avenue: if the problem is the composition of the recirculated bile acid pool, then administering a specific, more lipophilic and hepatoprotective bile acid could mitigate cholestatic liver disease after massive resection 3:37.

This would represent a shift from supportive care — managing TPN, treating sepsis, waiting for the gut to adapt — to targeted biochemical intervention 3:37. The liver injury in IFALD is not simply a consequence of lost bowel length but of altered bile acid signaling 3:02, and that is a problem you can potentially treat with the right molecule 3:37.

Where Practice Remains Uncertain

This is mouse work 2:39. The next step is clinical validation, and that will be difficult. You cannot randomize children to proximal versus distal resection. You cannot ethically withhold standard care to test a bile acid supplement in a small, heterogeneous population. The study also does not address the role of sepsis, TPN lipid composition, or gut microbiome shifts — all of which contribute to IFALD in ways that may dwarf the bile acid effect.

The claim that the ileocecal valve is expendable will meet resistance 3:28. Decades of surgical teaching and observational data support its preservation, even if the mechanism was never clear. Overturning that doctrine will require more than one animal study, however elegant 2:39.

When to Involve This Team

If you are managing a child with short bowel syndrome and rising conjugated bilirubin, the intestinal rehabilitation team needs to be involved early — ideally before the liver injury is established. These are multidisciplinary programs that include pediatric surgery, gastroenterology, nutrition, and transplant hepatology. Referral triggers include dependence on parenteral nutrition beyond six months, progressive cholestasis, thrombocytopenia suggesting portal hypertension, or recurrent line sepsis.

The discussion in this podcast did not address specific referral criteria, but the implication is clear: IFALD is not an inevitable endpoint to be managed palliatively 3:37. It is a targetable process 3:37, and the earlier you engage the team that understands both the surgical anatomy and the metabolic consequences, the better the chance of preserving liver function long enough for the gut to adapt — or for transplant candidacy to be optimized.

Takeaways from this story

Distal bowel resection may protect the liver in short bowel syndrome, contrary to traditional emphasis on preserving the ileocecal valve.
Proximal resection increases hepatic oxidative stress via elevated TNF-alpha, NADPH oxidase, and glutathione synthase expression.
Administering hepatoprotective bile acids could become a targeted therapy for cholestatic liver disease after massive intestinal resection.

Topic overview

A podcast reviewing three articles from the June 2023 American Academy of Pediatrics issue of the Journal of Pediatric Surgery. The discussion covers research on bile acid circulation in short bowel syndrome showing that distal resection may be hepatoprotective, a study demonstrating that aggressive pursuit of no-evidence-of-disease status in hepatoblastoma improves survival even in high-risk patients, and a survey revealing poor adherence to esophageal atresia surveillance guidelines despite physician agreement with their importance.

Key takeaways

Distal bowel resection in short bowel syndrome may be hepatoprotective vs proximal resection which increases oxidative stress (2:39)
Aggressive pursuit of NED in hepatoblastoma yields 10-yr survival similar to low-risk patients, even after multiple metastasectomies (6:23)
Only 36% of institutions perform routine endoscopy for esophageal atresia despite 77% survey response and cancer/dysmotility risk (9:56)
Formal aerodigestive teams improve adherence to esophageal atresia surveillance protocols (12:20)

Keywords

short bowel syndrome hepatic injury cholestatic liver disease hepatoblastoma esophageal atresia esophageal cancer chronic dysmotility proximal resection distal resection pulmonary metastasectomy total hepatic vascular exclusion vascular reconstruction biliary reconstruction total hepatectomy with transplantation upper GI endoscopy

Hashtags

#PediatricSurgery #ShortBowelSyndrome #Hepatoblastoma #JournalClub

Transcript

Click "Show Transcript" to view the full text (11604 characters)

Welcome back, everyone. We are back with another episode of the Stay Current podcast. I'm Cecilia Gigena and I'm M. Tom Bash. And we are research fellows from Cincinnati Children's Hospital, and along with Stay Current, we are sharing knowledge to improve child health around the globe. And so today we have another episode of the JPS podcast. We have June episode this week, and this is the AAP issue. AAP stands for American Academy of Pediatrics. Great. And for this issue, we talked to Dr. Colin Martin. He is the publication chair and the editor of this issue. Hello, my name is Colin Martin. I'm a pediatric surgeon and the division chief of pediatric Surgery at Washington University in St. Louis, and I'm also the chair of the Publications Committee for the AAP. And he selected 3 articles. The first one is about the disruption of the enterohepatic circulation in patients with short bowel. For the second one, we have the pursuit of no evidenced disease status in hepatoblastoma, and last but not least, the surveillance in esophageal atricia patients. As always, you can find the articles in the description below so you can follow along with us. So, let's get started. This first article for today is one from Basic Clinical, so it's a little bit more complicated of what we are used to, but let's give it a try. This paper is disruption of enterohepatic circulation of bile acids ameliorates small bowel receptor. associated hepatic injury, and this is from Barneshus Hospital from Saint Louis, Missouri. In this paper, they wanted to elucidate the driving force behind the hepatic injury in patients with short bowel syndrome. And for this, we talked with Doctor Brad Warner. He's the senior author of this paper. Yeah, I'm Brad Warner. Uh, I'm the chief of pediatric surgery at Saint Louis Children's Hospital. And professor of surgery at Washington University School of Medicine in St. Louis. They wanted to see what happened with the entire hepatic circulation and the bile acids in different short bowel resections. In looking for mechanisms as to how this occurs, we sought to determine whether bile acids or the site of intestinal resection would really make a difference in terms of the liver injury. And so for that they study a group of mice. Half of them had a proximal resection, half of them had a distal resection, and what they realized actually is that patients that had a distal resection that we thought was. Super prejudicial and bad for the patients, actually had a kind of protective effect on the liver injuries. In the latest study, they revealed that proximal small bowel resection results in a greater oxidative stress in the liver, as evidenced by elevated messenger RNA transcripts for tumor necrosis factor A. Additing denucleotide phosphate oxidase and glutathione synthase with a greater compensatory antioxidant response. And that was Doctor Colin Martin, the editor that helped us choose these articles. Two takeaways here, one of which is the ileocecal region. May not be important to preserve and may actually be injurious. And the second point is that administration of a specific bile acid that is more um uh lipophilic and, uh, and more hepatic, uh, I guess, uh, protective could be potential therapy for patients that have cholestatic liver disease after a massive intestinal resection. And here's what Todd had to say. This is a great study, but this is just in mice. So, obviously, the next thing that needs to be done is a, a clinical assessment. There are a lot of factors that are obviously in play here. Uh, we can choose which segment of intestine to remove. In patients, you can't choose that. You have to remove what's dead, and you intentionally would never remove anything that wasn't. You want to preserve as much and And I think that's really important to highlight. So, I think what we learned from here though, is what's the absolute physiology that occurs when you remove the ileocecal valve. If the preservation of the ileocecal region is not as beneficial as we thought, this is a really groundbreaking discovery. Like, it changed every pediatric surgery mindset. So now we're ready for the next paper, so kill it, um. The next paper is aggressive pursuit of no Evidence of Disease status and hepatoblastoma Improved Survival, and Observational Study. This study is from Saint Jude Children's Hospital in Memphis, Tennessee. And for this paper, we talked to the first author. My name is Andrew Fleming, and I'm a surgery resident with the University of Tennessee Health Science Center in Memphis, Tennessee. Um, I'm currently completing a two-year postdoctoral research fellowship at Saint Jude Children's Research Hospital, uh, under the mentorship of Doctor Andrew Murphy. This project, I was also fortunate enough to be mentored by the senior author, uh on this paper, Doctor Max Langham. So in this paper, authors examined the effect of aggressive pursuit of no evidence of disease status on like event-free and overall survivor in hepatoblastoma. They put together the records of patients with hepatoblastoma from 2005 to 2021. Their primary outcomes were, Overall survivor and event-free status and no evidence of disease status. There were 50 patients that were enrolled from 2005 to 2021. 46 of the 50 underwent resection with the use of adjuvant techniques including total hepatic vascular exclusion, vascular reconstruction. Biliary reconstruction or end-block resection and total hepatectomy with transplantation, and the remarkable thing is that of these patients, 82%, 41 out of 50, were able to achieve NED status. And he's Doctor Martin. He helped us to pick these articles for this issue. According to their data, 14 high-risk patients underwent a median of 2.5 pulmonary metastatectomies, 7 for unilateral disease. 7 for bilateral disease with a median of 4.5 nodules resected and 5 high risk patients in total relapsed and 3 of them were saved and this this natives of disease or NED status were inversely correlated with 5 year mortality. Once no evidence of disease status was achieved, the 10 year overall survival. Among patients that were high risk from the get-go was actually similar to patients that were not high risk, which I think again kind of emphasizes that if you are able to get children to that point, they can have long-term survival despite being stratified into a very high-risk group from the beginning. How hard to reach that no evidence of disease status? Because you need to get chemotherapy, radiotherapy, so it's not easy to get that disease status, but once you get them, it seems like it affects the long-term survival in a very like positive way, right? So, I think that the outcome of high-risk patients to have a better long-term survival and also the status, like event-free status. It's really important. I think again, just kind of the biggest takeaway is there is no threshold for disease burden that precludes you from aggressively trying to achieve no evidence of disease uh in children with hepatblastoma. And that was Doctor Fleming. He's the first author of this paper. Yes, again, I found it super interesting cause it's really hard when you're doing like super aggressive surgeries to Young children to decide whether that it's worth it or not, and seeing that this is worth it, I think it's huge. We always try to balance aggressiveness with With outcomes, and cause the, the pendulum keeps swinging. We, Halstead was incredibly aggressive, and, and the Halsteadian approach was go big, and then we got minimally invasive, and now we're trying to find this balance of aggressiveness and survival, and sometimes you unfortunately do have to be aggressive. So, it's an important paper. Are you ready for the 3rd paper? Yeah, let's jump. So for the last paper of the day, we have esophageal surveillance practices in esophageal attricia patients, a survey by the Eastern Pediatric Surgery Network. This paper coming out of the Eastern Pediatric Surgery Network. First author is Malcolm Hamilton Hall, the 3rd, senior author is Doctor J. Leslie Nodd, and that was Doctor. Colin Martin, and what they did is they wanted to see the guidelines after Nestofael Patricia repair and how the the experts did it. So they did a survey, a 23 question survey for 181 physicians at 19 institutions. There was a 77% response rate, and the interesting thing is that many institutions, um. Um, although they had air digestive teams, um, only 36% claimed to perform routine upper GI endoscopy regardless of symptoms, so a small number, despite the evidence showing that these patients should be surveilled. And in many institutions, the digestive clinic was the one who followed them. And we, we can see in this paper that physicians agreed with the current guidelines, and they believe that yes, we should do this. But how many of them are actually doing it? And so the paper just kind of points to lack of either lack of consensus or lack of adherence to a consensus guideline about these patients, and these patients, because of our advanced techniques, they're surviving, but now these patients are growing into adulthood. And without proper surveillance, they could be a risk for other problems, esophageal cancer, chronic dys motility, etc. This survey actually brought us a like a main problem and every pediatric surgeon probably knows that um we need to follow up. be more strict with the guidelines, but we're not, and I don't know if the survey can tell us what is the reason with that weak adherence or a weak commitment to the guideline, maybe. What do you think is the problem with this like lack of commitment to a guideline with the surveillance? I think that maybe not having something that's really proved to be working and more like Like as if they're not evidence-based. And they are more like. Institutional guidelines, maybe that's why they don't follow it as much. Um, I mean, I'm just guessing, it's not a real thing. But I think that, that maybe if we have some well-designed guidelines, they will follow it more. Let's not think about just pediatric surgeons who are not like uh committing enough to it like a protocol, but like how hospital is supporting them to commit that protocol because it's all, at the end of the day, it's all like a system problem, sounds like it. And here's what Todd had to say. I think this is great. So, the, the surgeons believe it should be done. But they're not doing it, and the way to get it done is to have a formal aerodigestive team. OK. So, that was our June JPS podcast. We talked about first, the disruption of the enterohepatic circulation in patients with short bowel, and we actually discovered that keeping the ocecal valve may be not as beneficial as we thought. And then we talk about the pursuit of no evidence disease in hepatoblastoma and we realized that actually in this, it's really important to achieve that for the long survival. In these patients. And last, we talked about the surveillance in esophageal attricia patients and how we really need an evidence-based guidelines to be more Aware of it and, and to follow the guidelines that we have. So, I think it was an awesome issue. If you like this episode, give us a rating on wherever you listen to your podcasts. Don't forget to subscribe to our YouTube channel, follow us on social media, and download the Stay Current app for hundreds of pieces of content. I'm I'm Tom Bash and I'm Cecilia Jigena, and we are research fellows at Cincinnati Children's Hospital, and along with Stay Current, we are sharing knowledge to improve child health around the globe.

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