Journal of Pediatric Surgery Article Review: October 2023

Hello everyone. Welcome back to another episode of the Stay Current podcast. I'm Cecilia Jigena and I'm I'm Gori. 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 today we have another episode of the JPS podcast. Today we have the October issue, and for that, we spoke to the editor. Hi, everybody. I am Pablo Laje, pediatric surgeon at the Children's Hospital in Philadelphia. Thank you so much for inviting me for this podcast. So for today, we have 3 articles. The first one is about the prophylactic acid suppression after an esophageal atricia repair. Then we are going to talk about the management and evaluation of the primary spontaneous pneumothorax in adolescents and young adults. And finally, we are going to talk about how the clinical symptoms affect the treatment of congenital pulmonary airway malformations. If you'd like to join and read the articles with us, check the links in the description below. The first article of today is prophylactic acid suppression medication to prevent anastomatic strictures after esophageal surgery, a systematic review and meta-analysis. This study came from Cardiff, UK and we spoke to the first and senior authors. Hi, my name is Tom Wiley. I'm a specialist pharmacist. I specialize in neonates and metabolic disease. I'm Doctor Madina Chakraborty. I'm a neonatologist, and I've been a consultant in neonatal medicine for about 10 years now. So in this article, they wanted to see how the prophylactic acid suppression affects the production of strictures after the esophageal atricia repair. Acid suppression medicines, so particularly proton pump inhibitors or PPIs, have got potential harms, and I noted that we were using these. Routinely and I, and I couldn't see uh very much information on, on what the benefits were for them. So that's why we then looked into this. As a reminder, that was Doctor Wiley, the first author of this paper. So they did a systematic review, looking into different databases. Very early on, what we found out is that there isn't. Any randomized controlled trials on this topic. But they found 12 observational studies that they showed that within 1,395 patients, they found that 753 received acid suppression medication but didn't increase the odds of having. And esophageal stricture. So in this meta-analysis they found that there was no evidence to associate the prophylactic acid suppression and the formation or protection for stricture formation after an esophageal atrial repair also. This meth analysis looked at secondary outcomes such as the incidence of gastroesophageal reflux disease, anastomotic leak, and esophagitis, and they found no significant differences in these outcomes between infants receiving prophylactic acid suppression medication and those who did not. And the conclusion is that. Not only there is currently no evidence that anti-acid medication will reduce the risk of a stricture, but in fact, there was a tendency to a higher incidence of strictures. And that was Doctor Pablo Laje. He's the editor that helped us choose this article. This systematic review also addresses concerns related to the routine use of acid suppression therapy, especially in infants. And they mentioned that the potential risks associated with long term treatment such as dysbiosis or necrotizing enterocolitis, maybe increased neonatal infection rates which are particularly relevant in the context of preterm and low birth rate in infants. I, I think the, you know, the information that came out is, is important. I think it's important to say there is no strong evidence towards the use of anti-acid medication to reduce the incidence of stricture, and it's important to say because, you know, the use of anti-acid medication is not for free and it's not as innocent as we once thought. Let's kick it with the 2nd 1. OK. The 2nd paper of the day coming from ABSA Outcomes and Evidence-based Practice Committee, and it's a systematic review, evaluation and Management of primary spontaneous pneumothorax in adolescents and young adults. For this paper, we talked to the first author, Doctor Elizabeth Speck. Hi, I'm Elizabeth Speck, one of the pediatric surgeons at the University of Michigan. In this paper they used deferral databases for literature related to spontaneous pneumothorax between 1990 and 2020, and in this research they wanted to have information about initial management, advanced imaging, timing of surgery, operative technique, management of the contralateral side, and management of regrets. Basically, the author's tried to answer 6 basic questions. And that was Doctor Lahey. He's the editor of this Month. The first question should be, do we need to do anything at all? But it's not just the 1 centimeter pneumothorax that most pediatric surgeons wouldn't. Put a tube in, right? What about the big pneumothoraces? And I would tell you that large prospective study demonstrated that you can safely observe even children with even a sizable pneumothorax. And that was Doctor Speck. She's the first author of this paper. An alternative to that would be uh to aspirate a pneumothorax. Not everybody with a pneumothorax has an active leak. Repeat a film a few hours later and see what happens. If there's no recurrence, patients can go home. Second question is, what is the role of cross-sectional imaging in these patients? This one is really clear. Don't do cross-sectional imaging on children to help you make clinical decision about these patients. The data are supportive that conclusion. And the third question was, what is the right time to operate on patients, whether you buy into the observation period or not. If they're reaccumulate air, well then, you have your answer. They have an ongoing air link and that patient warrants an operation. What is the best initial surgical approach? Now, that's tricky. Don't just do a stable lobectomy. The data does support that, to do some pleural-based management. But, you know, how much of the pleuris should you take out? Is it 25%? Is it just the apex? Is it 50%? Do you really need to strip the entire chest wall? Who knows? And actually, as Dr. Samuel Pania showed us in the eta course a few years ago, some randomized trials showed that doing something to the pleura don't actually reduce recurrences of spontaneous pneumothorax. Just as a reminder, if you want to check these articles, go and find a link to the articles in the description below. Studies just aren't there to really demonstrate one pleural based procedure is better than. Another, what is the optimal approach to the asymptomatic contralateral side in children? So that's the question. Don't do anything unless it develops symptoms. Yeah, exactly. So question two and question 5, I think nicely piggyback on each other. And the last one, what would you do with a recurrent case? This, I would say, has the least data in the literature to support really any conclusive suggestion. The gist is, and the way we worded it in the manuscript is whatever you did before, do something more. What, what do you think, Cecilia? I think this study gave us a nice sort of guideline to treat spontaneous pneumothorasis. And even though there are some things that are not fully resolved or need more hard data, this is a nice paper to base our practice on. OK, so last paper for the day is clinical symptoms affect treatment and prognosis in pediatric patients with congenital pulmonary airway malformations or CAA, a propensity score matching retrospective cohort study. So, this is a paper that comes from China. This particular study reviewed 110 patients operated over about 5 years, and they looked at the perioperative outcomes among patients who had symptoms at the time of the surgery versus patients who did not have symptoms. And again, that was Dr. Pablo Lage. And so what they found is that the asymptomatic group had better peroperative. Results and this divides into shorter operating times, shorter post-operative mechanical ventilation, shorter chest tube durations, and hospital stays. Yeah, and I think we can add that there are several factors that are particularly associated with Symptomatic CPA lesions, which was age older than 4 years old postnatally diagnosed and a maximum cyst diameter is bigger than 39.9 millimeters. So what they concluded is that it appears to be a better perioperative outcomes in those without symptoms. And there are some limitations in the study. First one was the study did not enroll patients who accepted conservative treatment compared to the, the asymptomatic patients. And secondly, their sample size was insufficient, and all were from a single center. One of the things that was not explained very well was why did they do the operation in asymptomatic patients. And the question I bring is, when you look at the age group of the asymptomatic patients, it includes patients from 5 months to 120 months, so they operated on patients that were several years old. So some of the methodology is not all the way explained. And the last thing is that they excluded patients who underwent thoracotomy. So this was only patients who underwent thoracoscopic resection. I think it's, it would have been important to include the patients that underwent a thoracotomy as well. Do you have any comments on this, Cecilia? Like it would it change your practice or um, I think it's, it is not a definite paper to change one's practice. I think that in the end swinging the pendulum. In those that are not sure about only observing CPAP. I remember from our previous podcast we did with Dr. Jose Campos from Chile. We reviewed CPAM management using new articles and it's called Case-based Journal CPAM 2023, I believe, and you can find that in the description below if you want to have a further listen about the topic. OK, so that was everything for today. And, and first we talk about the prophylactic acid suppression to prevent strictures after esophageal attrition. And in this meta-analysis, we realized that we do not have any hard evidence to show that prophylactic acid suppression prevents strictures, so we may need to do some controlled randomized trials to prove or disprove this theory. Second, we talked about the evaluation and management of spontaneous pneumothorax in children, and we had a lot of questions that were addressed, but mainly we need to know that we can start by being less aggressive with these patients and then If they need it, we can evolve rapidly to surgery. And last, we talk about the clinical symptoms in patients with congenital pulmonary air malformations and what we saw in this single institution paper is that patients that were treated minimally invasive before the onset of symptoms resulted in a better perioperative results than those who were operated after the onset of symptoms. Thank you for listening to this episode. Don't forget to follow us on social media, subscribe to our YouTube channel, and download the Stay Current app for tons of pediatric surgery content. Awesome. I'm Cecilia Gena and I'm Em Goddy, 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.