Journal of Pediatric Surgery Article Review: September 2023

Published: 2024-03-07

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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 Jigena — host
E Goddy — host
Sahab Delaville — guest
Red Holcomb — guest
Jason Smithers — guest

Chapters

0:00Introduction and Pectus Arcuatum — Introduction to the September 2023 journal review covering four articles. Discussion of pectus arcuatum as a distinct chest wall deformity caused by premature sternal suture obliteration, requiring clinical and sometimes radiographic diagnosis, with 35% having associated malformations and treatment requiring sternotomy rather than bracing.
3:44CDH Repair Timing on ECMO — Review of Boston study on timing of CDH repair in ECMO patients. Early repair (within 48 hours) associated with lower bleeding risk (1% at 24 hours, 5-6% at 48 hours, 15% after 48 hours) and shorter ECMO duration, though survival rates were similar between early and delayed groups.
7:07ERAS Protocols in Pediatric Colorectal Surgery — Meta-analysis from China examining ERAS protocols in pediatric colorectal surgery across 10 studies with 1300 patients. Protocols showed reduced intraoperative fluids, decreased postoperative opioid use, faster time to oral intake and complete nutrition, and shorter hospitalization.
8:46Physician Suicide and Mental Health — Discussion of letter to editor by Dr. Angie Yellen regarding physician suicide following her husband's death. Emphasis on high suicide rates among physicians, contributing factors including stress and burnout, stigma preventing help-seeking, and need for open discussion and support systems.

Key claims

2:07Pectus arcuatum is a bony deformity caused by a premature obliteration of the sternal sutures, resulting in a short sternum bent on itself — Sahab Delaville
1:5647% of pectus arcuatum patients required X-ray or CT scan for diagnosis — Cecilia Jigena
2:4035% of pectus arcuatum cases had associated malformations like Noonan syndrome, scoliosis, or cardiopathy — Sahab Delaville
2:5525% of pectus arcuatum patients had skeletal malformation in their family — Sahab Delaville
3:02Bracing does not work for pectus arcuatum treatment — Sahab Delaville
3:07Pectus arcuatum treatment requires surgery that includes a sternotomy — Cecilia Jigena
3:13Patients diagnosed with pectus arcuatum need cardiac ultrasound to look for cardiac malformation and evaluation for scoliosis — Sahab Delaville
4:40Early CDH repair on ECMO was defined as during the first 48 hours after ECMO cannulation — Red Holcomb
4:58Bleeding risk for CDH repair on ECMO was approximately 1% if operated in less than 24 hours — Jason Smithers
5:08Bleeding risk for CDH repair on ECMO was 5-6% at 48 hours — Jason Smithers
5:11Bleeding risk for CDH repair on ECMO jumped to approximately 15% after 48 hours — Jason Smithers
5:17Duration of ECMO support was shorter in the early CDH repair group — E Goddy
5:17Survival was not statistically different between early and delayed CDH repair groups on ECMO — E Goddy
6:46Some patients who only get CDH repair off ECMO die because they never came off ECMO — Jason Smithers
6:53The key after CDH repair is to get lung growth in such a way that the contralateral lung grows the most and not the ipsilateral lung — Jason Smithers
7:41ERAS protocols significantly reduce intraoperative fluids needed by pediatric colorectal surgery patients — Cecilia Jigena
7:41ERAS protocols significantly reduce postoperative opiate use in pediatric colorectal surgery — Cecilia Jigena
7:55Time to first oral intake was less in pediatric colorectal surgery patients with ERAS protocols — Cecilia Jigena
7:55Time for complete nutrition was less in pediatric colorectal surgery patients with ERAS protocols — Cecilia Jigena
8:13ERAS protocols have a beneficial role in accelerating rehabilitation and shortening length of hospitalization — Red Holcomb
9:32Physician suicide is characterized by tragically high rates of suicide among doctors compared to the general population — E Goddy
9:47Every surgeon will have adversity in practice with patients where despite best efforts there is not a good result — Red Holcomb
10:17High levels of stress, emotional and physical burnout, demanding work schedules, and pressure to maintain successful careers contribute to physician suicide — E Goddy
10:33Stigma associated with mental health issues within the medical profession discourages physicians from seeking help, leading to untreated depression, anxiety, and other mental health disorders — E Goddy
11:30Physician mental health and suicide is discussed more now versus 10 years ago, but still should be discussed more openly — Red Holcomb

Open questions

What is the mechanism explaining why earlier CDH repair on ECMO results in lower bleeding risk?
What are the optimal strategies to promote contralateral versus ipsilateral lung growth after CDH repair?
How can the medical profession more effectively reduce stigma around mental health to encourage physicians to seek help?

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:

Pectus Arcuatum: Recognizing a Distinct Chest Wall Deformity That Requires Sternotomy

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 Exists as a Distinct Entity

Pectus deformities are common enough that most clinicians recognize pectus excavatum and pectus carinatum on sight. Pectus arcuatum exists as a separate diagnostic category because it mimics carinatum clinically but differs fundamentally in pathophysiology, associated conditions, and treatment 2:07. Misclassifying it as carinatum leads to failed bracing and delayed definitive repair 3:02 3:07. The condition arises from premature obliteration of the sternal sutures, producing a short sternum bent on itself rather than the simple anterior protrusion seen in carinatum 2:07.

The Core Clinical Problem

Pectus arcuatum presents as anterior chest wall prominence, but the underlying bony architecture is abnormal in a way that standard pectus carinatum is not 2:07. The premature fusion of sternal sutures arrests normal longitudinal growth, forcing the sternum to bend rather than extend 2:07. This is not a cosmetic variant—35% of patients have associated malformations including Noonan syndrome, scoliosis, or cardiac abnormalities 2:40. Another 25% have a family history of skeletal malformations 2:55. The clinical challenge is twofold: first, distinguishing arcuatum from carinatum when both present as anterior chest prominence 2:07; second, identifying the syndromic and structural associations that alter management 2:40 2:55.

How Recognition and Workup Proceed

Diagnosis is primarily clinical, but nearly half of patients require imaging for confirmation—47% needed X-ray or CT in one series 1:56. The key distinguishing feature is the short, bent sternum rather than a long, anteriorly displaced one 2:07. When arcuatum is suspected or confirmed, the workup expands beyond the chest wall itself 2:40 3:13. Cardiac ultrasound is mandatory to evaluate for structural heart disease 3:13. Scoliosis screening is similarly required 3:13. The family history should be explored for skeletal abnormalities 2:55. This is not a benign cosmetic condition that can be observed; it is a marker for potential multisystem involvement 2:40.

Why Standard Pectus Treatment Fails

Bracing, which can be effective in pectus carinatum, does not work for arcuatum 3:02. The pathology is not malleability of a normal-length sternum but rather a structurally short, fused bone 2:07. Compression cannot elongate a prematurely fused structure 2:07 3:02. Definitive treatment requires sternotomy 3:07—a fundamentally different operation than the minimally invasive or bracing approaches used for other pectus variants. This is why correct diagnosis matters: a patient with arcuatum sent for bracing will fail treatment and return months later, still symptomatic, having lost time and confidence in the care team 3:02.

When to Involve Pediatric Surgery

Any child with anterior chest wall prominence and a short sternum on examination should be referred to pediatric surgery with expertise in chest wall reconstruction 2:07 3:07. If imaging has already been obtained and shows premature sternal fusion, that strengthens the referral 2:07 1:56. The presence of syndromic features—Noonan phenotype, known cardiac disease, scoliosis—makes the referral urgent rather than routine 2:40. Even in the absence of those features, the 35% rate of associated malformations means that arcuatum is not a condition for observation alone 2:40. The surgical team will coordinate the cardiac and orthopedic evaluations if they have not already been completed 3:13.

Referring clinicians should know that this is not a cosmetic surgery discussion 3:07. The sternotomy required for repair is a major operation, and the decision to proceed is made in the context of the patient's overall skeletal and cardiac status 2:40 3:07 3:13. Families need to understand that bracing is not an option and that surgery, if pursued, is definitive but invasive 3:02 3:07.

What Remains Uncertain

The literature on pectus arcuatum is limited, and much of the clinical approach is extrapolated from small case series 1:56. The optimal timing of repair is not well defined 3:07. The natural history of untreated arcuatum—particularly whether the deformity progresses or stabilizes after skeletal maturity—is not clearly documented 2:07. The genetic basis for the premature suture fusion is not understood, though the familial clustering suggests a heritable component 2:55. These gaps mean that management is individualized, and families should expect shared decision-making rather than a single standard protocol 3:07.

Practical Takeaway

Pectus arcuatum is uncommon, but it is not rare enough to ignore 1:56. When you see anterior chest prominence in a child, consider whether the sternum is short and bent rather than simply prominent 2:07. If it is, think arcuatum, not carinatum 2:07 3:02. Do not send the patient for bracing 3:02. Refer to pediatric surgery, and ensure that cardiac and scoliosis evaluations are completed 3:07 3:13. The 35% rate of associated malformations means this is a diagnosis that demands a broader workup, not just a chest wall repair 2:40.

Takeaways from this story

Pectus arcuatum results from premature sternal suture fusion, creating a short bent sternum distinct from pectus carinatum.
35% of arcuatum patients have associated malformations; cardiac ultrasound and scoliosis evaluation are mandatory.
Bracing does not work for arcuatum—definitive treatment requires sternotomy, not the approaches used for carinatum.
Nearly half of patients require imaging for diagnosis; clinical suspicion should prompt referral to pediatric surgery.

Timing, Recognition, and Protocol-Driven Care in Pediatric Surgery

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 moves through four distinct clinical problems, each illustrating how pattern recognition and timing shape outcomes in pediatric surgery 2:07 4:40 7:41. The progression runs from diagnostic subtlety through time-dependent surgical risk to the value of standardization.

Distinguish pectus arcuatum from pectus carinatum by mechanism, not just appearance

Pectus arcuatum results from premature obliteration of the sternal sutures, producing a short sternum bent on itself 2:07. This is not simply a variant of pectus carinatum — the pathophysiology differs, and so does the treatment 2:07 3:02. Clinical diagnosis is primary, though 47% of patients required X-ray or CT scan for confirmation 1:56. The critical teaching point: bracing does not work for pectus arcuatum 3:02. Treatment requires surgery with sternotomy 3:07. Missing this distinction means offering an ineffective intervention 3:02 3:07.

Screen for associated malformations systematically

Once pectus arcuatum is diagnosed, the evaluation extends beyond the chest wall 2:40 3:13. Thirty-five percent of patients have associated malformations including Noonan syndrome, scoliosis, or cardiac abnormalities 2:40, and 25% have a family history of skeletal malformation 2:55. The workup is not optional: every patient needs cardiac ultrasound to evaluate for cardiac malformation and assessment for scoliosis 3:13. This is not defensive medicine — it is recognizing that pectus arcuatum is a marker for broader developmental patterns 2:40 2:55.

Bleeding risk in CDH repair on ECMO increases sharply with time

For congenital diaphragmatic hernia repair performed on ECMO, bleeding risk follows a steep time gradient 4:58 5:08 5:11. At less than 24 hours after ECMO cannulation, bleeding risk is approximately 1% 4:58. By 48 hours it rises to 5-6% 5:08. After 48 hours it jumps to approximately 15% 5:11. The mechanism is not fully clear, but the clinical implication is: early repair — defined as within the first 48 hours 4:40 — reduces bleeding risk and shortens ECMO duration 5:17 without compromising survival 5:17. The traditional approach of waiting to repair until after ECMO decannulation carries a hidden cost: some patients die because they never come off ECMO 6:46. Repairing early changes the denominator 4:40 5:17 6:46.

Optimize lung growth strategy after CDH repair

Post-repair management in CDH is not simply about keeping the patient alive until the lungs catch up 6:53. The goal is to promote contralateral lung growth preferentially over ipsilateral lung growth 6:53. This is a strategic choice, not an automatic outcome 6:53. The lung that was never compressed has greater growth potential than the hypoplastic lung that spent gestation compressed by abdominal contents 6:53. Directing resources toward the stronger lung yields better long-term function 6:53.

ERAS protocols deliver measurable benefits through standardization

In pediatric colorectal surgery, enhanced recovery after surgery (ERAS) protocols reduce intraoperative fluid requirements 7:41, decrease postoperative opioid use 7:41, shorten time to first oral intake 7:55 and complete nutrition 7:55, and accelerate rehabilitation while reducing length of stay 8:13. The mechanism is not a single magic intervention — it is the compounding effect of multiple small optimizations applied consistently 7:41 7:41 7:55 7:55 8:13. When everyone on the team knows the expectations and procedures, variance drops and outcomes improve 8:13. The value of the protocol is not that it contains secret knowledge, but that it ensures the knowledge gets applied every time 7:41 8:13.

The through-line across these topics is that good outcomes depend on knowing what to look for, when to act, and how to standardize the things that should not vary 2:07 4:40 7:41. Pectus arcuatum requires recognizing a pattern that looks similar to something more common but behaves differently 2:07 3:02. CDH repair on ECMO requires acting within a time window that closes faster than intuition suggests 4:40 4:58 5:08 5:11. ERAS protocols require building systems that make the right choice the default choice 7:41 8:13. In each case, the expert knows not just what to do, but when the answer changes 2:07 4:40 7:41.

Takeaways from this story

Pectus arcuatum requires sternotomy, not bracing — distinguish it from carinatum by the short, bent sternum from premature suture fusion
Screen all pectus arcuatum patients for cardiac malformations and scoliosis — 35% have associated conditions like Noonan syndrome
CDH repair bleeding risk on ECMO: 1% at <24h, 5-6% at 48h, 15% after 48h — early repair shortens ECMO duration without harming survival
After CDH repair, prioritize contralateral lung growth over ipsilateral — the uncompressed lung has greater growth potential
ERAS protocols in pediatric colorectal surgery reduce fluids, opioids, time to feeding, and length of stay through consistent application

Topic overview

A journal club discussion reviewing four articles from the September 2023 Journal of Pediatric Surgery. The discussion covers pectus arcuatum as a distinct chest wall deformity requiring sternotomy (not responsive to bracing), timing of CDH repair in ECMO patients (early repair within 48 hours associated with lower bleeding risk), benefits of ERAS protocols in pediatric colorectal surgery (reduced opioid use, faster recovery, shorter hospitalization), and a call to action regarding physician suicide and mental health support in the medical profession.

Key takeaways

Pectus arcuatum requires sternotomy, not bracing; 35% have associated malformations requiring cardiac and scoliosis screening. (2:07)
CDH repair on ECMO within 48h reduces bleeding risk (1% at <24h, 5-6% at 48h, 15% after 48h) without survival difference. (4:40)
ERAS protocols in pediatric colorectal surgery reduce opioid use, fluids, time to oral intake, and hospital length of stay. (7:41)
Physician suicide rates are tragically high; stigma around mental health in medicine prevents help-seeking for burnout and stress. (9:32)

Keywords

pectus arcuatum pectus carinatum congenital diaphragmatic hernia Noonan syndrome scoliosis cardiopathy depression anxiety burnout sternotomy ECMO CDH repair colorectal surgery X-ray CT scan

Hashtags

#PediatricSurgery #JournalClub #CDHRepair #ERASProtocols #PectusCare

Transcript

Click "Show Transcript" to view the full text (11019 characters)

Hello everyone, I'm Cecilia Jigena and I'm, I'm Gdy, 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. So, welcome back everyone to another episode of the HPS podcast. Today we have the September issue and for that we have Doctor Wit Holcom. The editor in chief of the Journal of Pediatric Surgery and the one who helped us choose the articles for today. I'm, uh, Red Holcomb. So for today, we have 4 articles. First, we are going to talk about actorsar quantum and how to differentiate it from pectus carinatum. Then we are going to talk about. About the repair of CD8 of patients that are on ECMO and when it is better to repair that we are going to talk about ER protocols for colorectal surgery and last we have uh a letter to the editor about physician suicide and how important it is to care about mental health in doctors. As always, we attach the papers in the description below, so, uh, click the links and read with us. OK, so the first paper for today is pectus or quantum, a pectus unlike any other, and this is a retrospective study done in France, and their aim was to better describe the pectus or quantum, and we talked to the first author of this paper. Hi, so I'm Sahab Delaville. I'm a resident at the Lyon Children's Hospital in France. So they review all the charts from the patients with pectussar quatum. They had 34 patients with a mean age of 10 years. The main diagnosis for them was done clinically, but 16 patients, meaning 47%, require an X-ray or. CT scan. pectus arcuatum is a bony deformity caused by a premature obliteration of the sternal sutures. So you have a patient with a thoracic deformation, which is a short sternum bent on itself. And I think that the picture, and I believe it's figure 3, is really good, the picture on the right, and you can see is how it's contrasted with a typical pectus carotum patient. And again, he was Doctor Holcomb, the editor in chief, who helped us choose these articles. What they found important is that 35% of the cases had a malformation associated like Noonan syndrome, scoliosis, or cardopathy, and we also found that 25% of our patients had a keletal malformation in their family, so, and for the treatment of this, if they want to do some treatment, the brace doesn't work. And it has to be with a surgery that includes an astronomy. So, if you have diagnosed a pectus archaeom, you have to think about associated malformation, so you need to look for a cardiac malformation with an ultrasound, and you need to see if the patient has a scoliosis. And here's what Doctor Holcomb had to say. It's not very commonly seen. But you need to recognize the patient that has this particular problem. Should we move to the second paper? Yeah, the second paper is the timing of congenital diaphragmatic hernia repair on extracorporeal membrane oxygenation impact surgical bleeding risk. This is a paper coming from Boston's, and we talked to the first author, Doctor Jason Smitters. I'm Jason Smithers. I'm a, a surgeon down at All Children's Hospital with uh Johns Hopkins in Florida. I spent the first, uh, almost 20 years at Boston Children's, and it, it was with the, the group in Boston that we, that we wrote this paper. So in this paper, they wanted to see what is the optimal timing for surgical repair in these patients. They did a retrospective review of 146 infants who underwent CDH repair uh while on ECMA support from 1995 to 2021. And they separated the patients in two groups, early repair and delayed repair. Their definition of early repair was during the 1st 48 hours after eggmocanulation, and then delayed repair was anything after that time. And that was Doctor Holcomb. He's the editor in chief and Journal of Pediatric Surgery. And the editor of the month to help us pick these articles to highlight. For reasons that might not be totally clear, that the earlier you do it, the, the less the bleeding risk was. I think it was in the ballpark of 1% if you operate in less than 24 hours. At 48 hours, it was 5 or 6%. And then after it jumped up to maybe 15%. And that was Doctor Smiters. He's the first author of this paper, and we can say that duration of ECMA support was shorter in the early repair group, but survival was not statistically different between the two groups. I think it is important to be switching into early repair, especially when they're on ECMO, cause knowing that we can repair them at the beginning of the ECMO run, that will decrease the surgical bleeding, I think it's beneficial cause usually before we only repair them after ECMO, yeah. And also, like they stated in their paper, there are some limitations for the study. First of all, it's retrospective and it's a single center uh patient population, and they mentioned that their center uh historically preferred early CDH repair for patients on ECMO. So the patients who had delayed repair in this paper may have clinical differences from early repair patients, so that might be the reason they got delayed repair. And I believe, as I mentioned earlier, that the pendulum has shifted in some people's minds towards an early repair, but I'm sure there's still a lot of pediatric surgeons who perform a delayed repair, and some even perform repair after the patient gets on ECMO, and that is. They won't repair the patient while on ECMO, and if, if the patient gets off ECMO, then they'll do the repair. If you only repair off ECMO, there's uh, there's a certain amount who died. Because they never came off ECMO. So, I think one of the keys is to grow, get the lung growth after you do the repair, and do it in such a way that the contralateral lung grows the most and not the ipsilateral lung. OK, so time for the 3rd paper. Meta-analysis of enhanced recovery after surgery or ERAS protocols for the perioperative management of pediatric colorectal surgery. And this paper comes from China, and they wanted to investigate the effects and safety of the ERAS protocols for pediatric colorectal surgery. Uh, these authors, uh, looked at several databases PubMed, M-Base, Cochrane Library, and so they found 10 studies involving 1300 patients. And comparing them, they found that ERAS protocols significantly reduce the intraoperative fluids needed by the patients and the postoperative opiate use. Also, what they found is that the first oral intake and the time for complete nutrition was less in those patients that were having ERRAS protocol versus those who weren't. Major finding was that there was a beneficial role for using these ERIS protocols in terms of accelerating rehabilitation, shortening the length of hospitalization. Uh, and this is just another paper affirming the benefits of ERIS protocols. Yeah, and clearly it's something that we see often, that having protocols improve patients' outcomes, whether it is an ERAS protocols or other type of protocols. The fact that everyone knows what to expect and how to proceed makes things better for the patients. In this last article, we discussed physician suicides, secondary to physicians stress, which has unfortunately become more common these days. At Global Custom, we are dedicated to disseminate comprehensive knowledge and we recognize the urgency of addressing this issue by engaging in meaningful discussions to explore potential solutions. Well, the last one is a letter to editor about physician suicide, a personal story and call to action. By Doctor Angie Yellen. She's an OBGYN at Johns Hopkins, and, and she is talking about her husband, which we lost to suicide two years ago, and she is. Calling all of us to action, physician suicide is a critical and deeply concerning issue within the medical community, which characterized by the tragically high rate of suicide among doctors compared to the general population. So I think this is a very important topic because every surgeon is going to have adversity in his or her practice. We're all gonna have patients and. Do everything to the best of your abilities, and yet there's not a good result, and I think it's important that we all know that there are support systems available to help those difficult situations. And fortunately we've been talking about these matters lately more and more. We know that various factors contribute to this alarming situation, including the high levels of stress, emotional and physical burnout, demanding work schedules. And the pressure to maintain a successful career. And there is a stigma which is associated with mental health issues within the medical profession, often discourages physicians from seeking help, which leads to untreated depression, anxiety, and other mental health disorders. I just think that the letter is, is a good reminder that there are support systems available for all of us when we have adversity and and conflicts that we just don't know how to get through, and we see people who are the kindest to their patients cannot show the same kindness to themselves, and unfortunately we lose them to these battles, and I wish we would. Speak more, make them feel comfortable and understood and let them know that everyone's struggling in their own way, that's. Doesn't mean that they're not brave enough. That doesn't mean they're not strong enough. This topic is not discussed openly nearly as much as it should be. It's, it's discussed more and more now versus 10 years ago, but it, it still should be discussed more openly. The important thing to put in words here is. Let's make mental health an issue to talk about and to be a thing that everyone can come forward so that we try to avoid people feeling ashamed or not in the need to seek for help. OK, so that was everything for today. We have really interesting papers. The first one was about pectus arquatum and how can we diagnose it, especially clinically looking at a short bended sternum. And how the treatment is based on erronomy, then we talk about the best time to operate a CDH patient who is on ECMO, knowing that it is better to operate them early on ECMO than late because of the surgical bleeding that is less. After that we talk about the ERAS protocols for colorectal surgery and how. This improve patients' outcomes, reducing the hospital length and the complications and opioid use and last we talk about the importance about mental health to make every pediatric surgeon and physician actually aware of this so we can help everyone who is in need out there. Thank you for listening to this episode. Please check the link in the description. below to read each paper and please follow State Cart MD on social media. Give us a rating and subscribe to the YouTube channel. And don't forget to download the Stay Current app on the App Store or Play Store for tons of content. I'm Cecilia Ganel and I'm E Goddy, and we are research fellows at Cincinnati Children's Hospital, and along with State Current, we are sharing knowledge to improve child health around the globe.

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