Hello, everyone. Welcome back to another episode of the Stay Current podcast. I'm Cecilia Gienna. I'm Egody. 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. Today we have the August episode of the Sha. PS podcast. And for this issue, we have Doctor Wit Holcomb as the editor that helped us choose these articles. I'm, uh, Witt Holcomb. I'm the, uh, editor in chief of the Journal of Pediatric Surgery, and I'm uh glad to discuss a few of the articles that came out recently. So for today, we have 4 articles. We are going to talk first about cryoablation in NAS procedures and how it affects the hospital length of stay and the opioid use, then about the management of primary spontaneous pneumothorax. Third, we are going to talk about the updated ABSA. Guidelines for the management of solid organ injuries, and last but not least, we're going to talk about cryoablation for the sleeping rib syndrome, which is something new. So let's jump right in. The articles are listed and linked in the description below. Follow along and read with us. So the first article for today is cryoablation and 350 NAS procedure, Evolution of Hospital length of Stay and opiate Use. And we talked to the first author, Doctor Crystal Lai. My name is Crystal Lai, and I was the research fellow at Phoenix Children's Hospital from 2021 to 2022, and currently I'm the clinical pediatric surgery fellow at the IWK Hospital in Halifax, Nova Scotia, Canada. So, this is a paper coming from Phoenix, they did a retrospective single chart review between December 2017 to August 2021. So we reviewed their charts for the basic demographics, hospital course and post-operative complications, and very specifically, two main outcomes, their amount of opioids used in oral morphine equivalents and their hospital length of stay. And essentially what they do is compare the early experience uh to their most recent experience and how those have changed. They did that by uh separating patients into the first quarter, so essentially the first year versus the last quarter of the study, the last year. And he was Doctor DeFore, an expert peo surgeon from Cleveland. So, overall, we found that from the 1st quarter compared to the 4th quarter, there was 74% less opioid use and 80% of patients achieved early discharge home by postoperative day number 2. So, the experience that the doctors gain by operating multiple times lead to shorter length of stay and opioid use. And this was primarily related to uh discontinuing use of IVPCA or uh intravenous patient-controlled analgesia during the study. The way they did that was base it on the fact that in the, as the study progressed, they just noticed that people weren't using the IVPCA. So eventually, they discontinued it. So, IVPCA really does not seem to be necessary and can be eliminated fairly early. In someone's experience as they're using cryoablation, the take-home message, at least to me, is that cryoablation can be a very useful and advantageous adjunct for the management of these patients and results in a significantly decreased length of stay. He was Doctor Holcomb, the editor that helped us choose these articles. It seems like with this technique, the children are pain-free for a longer period of time and I think this would help for the patients' families who are maybe scared about the further effects of using opioids for a surgery like this. It is really game-changing. To have cryo for the patient's outcomes. But more importantly, as in any surgery, we still have a learning curve. It is really not a learning curve in terms of technique. Uh, it's really more of a learning curve in terms of the pain protocols that you use around the time of surgery. The, the earlier differences were not really due to poor technique of how the cryo nerve blocks were done, but really that. Uh, they became more comfortable with discontinuing the PCA and switching to oral pain medication. In case you forgot, that was Doctor Di Fiore. Yeah, I certainly think that cryoablation in and of itself may not lead to the same results as if you were to implement cryoablation within a, almost like a protocol or a regimen. So, for us, the pain team would follow these patients and see them preoperatively and postoperatively, and they'd be started on, um, other adjuncts such as gabapentin. And that was Doctor Lai, the first author of this paper. OK, so I think we're ready for the 2nd paper. Our second paper of the day is Management of Primary Spontaneous pneumothorax in Children, a Single Institution protocol analysis. This paper is from Kansas City, Missouri, and we talked to the senior author, Doctor Sean Saint Peter. All right, I'm Sean Saint Peter. I'm a pediatric surgeon in Kansas City. I'm surgeon in Chief and department surgery chair. This is a retrospective analysis of patients between 12 and 18 years old who were diagnosed with primary spontaneous pneumothorax from 2016 to 2021. Initial management involved only aspiration. And because we're talking about children, what that morphed into was a prospective observational study where you put in a, a small catheter. And then clamp it, so you're mimicking aspiration. And then you check a chest X-ray in 6 hours. If it looks fine, then you can pull that and send them home. And success was defined as equal or lower than 2 centimeter distance. Distance between chest wall and lung at the apex and no air leak when the clamp was released. So we agreed as an institution, if they have a normal looking chest X-ray, then they get to go home. If they don't, they get booked for next case like a nappy. Then we just take the clamp off, let it drain. And they get booked for the next available OR. There were 59 patients and aspiration was successful in 33% of it, while 66% of the patients still required rats. And the median length of stay with successful aspiration was 20 hours, it's less than a day, while median length of stay after rats was 3 days. So in conclusion, we can say that simple aspiration is safe and effective initial management for children with primary spontaneous pneumothorax. But most still will require baths. However, early vats reduces length of stay and morbidity. I like this because they are trying to make the patients stay less. So what they found is that for the patients that go to vats immediately after a fatal aspiration, the median length of stay was 3.1 days, compared to patients from the Midwest Pediatric Surgery Consortium that have 6 days of median length of stay. And let's hear what Doctor Hawkin will say. So the idea of the protocol is early thoracoscopic assisted surgery if that is needed. And I think it's very good. It cuts the delay from presentation to operation significantly. And let's hear from Doctor Sam Peter. He's the senior author of this paper. And so that, that makes you realize that when you have a spontaneous pneumothorax, the entire treatment algorithm is split upon the question, did you leak or are you leaking? So, did you have a bleb that popped, and that's why you have some air there, in which case the aspiration is the only treatment you needed? Or did you pop a bleb and now your lung is leaking, in which case, an aspiration will not be adequate. And so, going straight to operation. And in case you wanna know more about the treatment for spontaneous pneumothorax, we had a podcast on that and we're going to leave the link in the description below, so, check it out. OK. So, 3rd paper for today is Updated ABSA Guidelines for the Management of lung, Liver, and Spleen Injuries. So these come from all over the US. And we talked to the first doctor, Doctor Regan Williams. Hi, I'm Regan Williams. I'm a pediatric surgeon at La Bonner Children's Hospital and the trauma medical director here. So in this paper, they wanted to update the guidelines for the management of solid organ injury, and for that, they did a literature review in the trauma obstruction. Committee and what they found is that the treatment was mostly focused on rate of injury and was very conservative, so they came up with this guideline. And interestingly, it comes from the ABSA trauma Committee and so the management's called APSA, A for admission, P for procedures, S for set free, that is discharged, and A for aftercare. He was Doctor Holcomb, the editor that helped us choose these articles. And so the new guidelines, what they say is in the admission, you have to identify the risk factors to go for an ICU admission. We added a section on um procedures, really focusing on angiography and when to operate, when to transfuse, and when to take to the angio suite. Then, they talked about set free, meaning the discharge, when to discharge the patient, and the most important change was done here. Because the discharge of a patient is not related to the severity of the injury. But to the clinical condition of the patient. And then, it's the aftercare, it's how many restrictions do we have. So that keeps pretty much the same. You have to restrict the activity for two weeks at first, and then you have to add the level of injury. And here's what Doctor Witt Holcomb had to say. And so interestingly enough, you know, over the next 20 years, 22, 23 years. We have uh refined those guidelines and we realized that the patients don't need to be in the hospital as long, they don't need to be on bed rest as long, and we're generally managing them now based on their hemodynamic status as opposed to their grade of injury. And let's hear what Doctor Williams said. I think the important thing is really to make decisions based on uh clinical symptoms and signs of ongoing bleeding. I think that's the most important thing. Now, grade of injury certainly gives us an idea of if people are bleeding or not based on how severe the injury is. So it's not about throwing out grade of injury, it's just that your decision making is not gonna be solely based on that imaging. It's really gonna be on the clinical course of the patient. Are we ready for the last one? Yes. The last paper of the day is initial Outcomes using cryoablation and surgical Management of slipping rib syndrome. We talked to the first and the senior authors. I'm Lisa McMahon. I'm a pediatric surgeon at Phoenix Children's. Obviously in Phoenix. I am the director. Of the chest wall clinic and I'm the surgical director of our IBD clinic. My name is Crystal Lai, and I was the research fellow at Phoenix Children's Hospital from 2021 to 2022, and currently I'm the clinical pediatric surgery fellow at the IWK Hospital in Halifax, Nova Scotia, Canada. And in this paper, authors are describing their experience with cryoablation and cartilaginous rib excision for slipping rib syndrome. And this is a retrospective chart review for all patients underwent cartilaginous rib excision between 2018 and 2022. There were a total of 98 patients. 68 patients had a rib resection without cryoablation, and those patients did, did receive other types of blocks, rectorspina, paravertebral blocks, or intercostal nerve blocks. And there were 22 patients that Had cryoablation, which was extrathoracic cryoablation. Now, those patients also received the other nerve blocks and uh there were 8 patients that, that had slipping ribs resected as part of their NUS procedure. And he was Doctor Di Fiore. The pecto surgeon from Cleveland. Now, let's hear Dr. May Mahon explaining us the technique. So, through the little incision that I make on the side where I'm taking the slipping ribs out, I just put the probe a little bit more lateral to where, um, usually I plate. So where the plates are kind of just a little bit more laterally on the ribs and cryo there externally. 91% of the cryo patients had cryoablation of T9 and T10 intercostal nerves with no documented abdominal wall laxity, with the immediate follow-up of 16 days. Patients who underwent rib excision with cryo used significantly less opioids in hospital compared to rib excision without cryo. And the medianl length of stay was 1 day with patients who had rib excision with cryo compared to 2 days, patients had rib excision without cryo. This is no surprise that we can say that intercostal nerve cryoablation reduces opioid use and length of stay in patients undergoing cartilaginous rib excision for slipping rib. Syndrome. And here's Dr. Lai. She's the first author in this paper. Something that I think was a bit surprising in our studies, we also looked at their visual analog scale scores for pain, and it was similar across all groups. However, their opioid requirement was different across groups with the slipping rib plus cryo group being significantly less than the slipping rib without cryogroup. So, I think that kind of shows that to the goal of cryoablation decreasing opioid use, it was successful to that end. The other thing that surprised me is that we didn't have this abdominal wall laxity, so I assumed that that would happen, and I've only seen it once, and the patient that I saw it with was not a slipping rib patient, it was a pectus patient. And that was Doctor McMahon. She's the senior author in this paper. I was very pleased to see that. Because there are some patients that have very low pectus deformities. Some of those patients will have more discomfort in the lower costal margin area, because I think that gets out of the field of T7 and T8, where most cryoablation is performed. So I think that was a major contribution of this paper. I really like this because with pectus explatum repair, we usually do the thoracoscopic cryo, and this is a different way of doing it externally. As you alluded to, Cecilia, cryoablation can be used extrathoracically uh with success, and I think this is uh one of the major contributions of the paper because there's not a lot of data on this quite yet. And he was Doctor Defierri, an expert pecto surgeon from Cleveland. And she actually invited us to the 2024 course. So we are also hosting the Fellows Pus course here in February, February 1st through 2nd in Phoenix, also with a cadaver lab. It's going to be focused to people who are currently in fellowship, either in pediatric or thoracic surgery, as well as for people who are fresh out of fellowship and just starting their practice. Perfect. So that was the August episode of the JPS podcast. And to summarize, first we talk about cryoablation for the NAS procedure and how the physician's learning curve with this technique lead to less opioid use and shorter length of stay of patients operated in the last quarter of their experience. Then, we talk about the management. Of primary spontaneous pneumothorax and how going straight to bats after a failed simple aspiration can lead to shorter length of stay there we talked about solid organ injury management and how can we distort patients considering their clinical signs and symptoms instead of just the grade of injury. And last, we talked about again, the cryoablation, that now for this new implementation, that is for the surgical management of the sleeping reed syndrome and the cartilaginous reb excision. So, great purpose for today, and we expect More for September, also with Doctor Wit Holcom. 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 in pediatric surgery. I'm Em Goddy. I'm Ceciliaukena, 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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