Hello, everyone. Welcome back to another episode of the JPS podcast. I'm Cecilia Gienna and I'm Mgodi. And we are research fellows at Cincinnati Children's Hospital, and along with Stay Current, we are sharing knowledge to improve childhood around the globe. So today we have the November issue of JPS and for that, we talked to the editor, Doctor Miko Picard. Hi, everyone. My name is Mik Papakaren. I'm a professor of pediatric surgery from Children's Hospital, Helsinki and the University of Helsinki. And I'm also editor for Europe in JPS. For today, we have 3 articles. The first one is about the quality improvement campaign of utilization of MRI for the diagnosis of pediatric appendicitis. Then we have a paper that talks about the economic burden and the high frequency of complications after uh adhesive small bowel obstruction in pediatric patients. And last, we have a paper that talks about the repair of esophageal atricia and compares thoracoscopic versus open procedures. If you'd like to join and read articles with us, check the links in the description below. Awesome. So let's go with the first one. This is a quality improvement campaign, improved utilization of rapid sequence MRI for diagnosis of pediatric appendicitis. This is a paper that came from Colorado and we talked to the first author, Doctor Bailey Little. Hi, my name is Bailey Little. I'm a PGY 4 at the University of Colorado and I'm currently in my 2nd year of research, and I work over at the Children's Hospital of Colorado at my during my lab time. So this paper is about a quality improvement campaign that they included to try to reduce the use of CT scans for the diagnosis of pediatric appendicitis and change it by the use of a rapid sequence MRI. So to do this study, we first performed a series of stakeholder interviews so that we could figure out exactly where we were missing our target in terms of getting people to use MRI. We additionally performed a midway feedback survey during our study period, and then finally we performed a retrospective cohort study to see what our utilization. was of CT scans and MRI to see how that changed over time. We know that sometimes MRI is hard to always use it, so they came up to a protocol to facilitate everyone to ask for it. So the MRI was only needed to ask in normal MRI technologist hours. It was only for patients that were 7 years or older. And if the patient had a perforated appendicitis and an abscess was suspected. Then MRI was not the indication and CT should be because it's better for abscess evaluation. Yeah, they, yeah, in summary, they order a CT and CT tech calls the MRI, see if they're available. If they're available, they do the MRI. If not, they go with the CT. And following this quality improvement campaign, The rate of MRI increased almost by tenfold while the use of CT decreased markedly at the same time. And that was Doctor Pakarinen. He is the editor that helped us choose these articles. And let's hear what Doctor Little had to say. She is the first author of this paper. So, for the results of our midway feedback survey, we found that the majority of providers preferred to use MRI over CT scan. However, we did identify some persistent barriers, and that included lack of availability of MRI overnight, challenges with scheduling, and the additional time required to obtain the imaging compared to CT scan. I think it's a good paper to start less use of CT, like to be aware about the Ionizing radiation that patients receive and they may receive a lot of times and so to start putting this out there to reduce this um radiation, I think it would be helpful for patients, especially pediatric patients, right? Yeah, it's, it's definitely favorable to use less radiation, especially in the pediatric population. So, our second paper is pediatric adhesive small bowel obstruction is associated with a substantial economic burden and high frequency of post-op complications. And this one is a registry-based study from Sweden. And that was Mikko Pekarinen. He's the editor of the Month and he helped us choose these articles. And we know that intraabdominal. Adhesions can lead to adhesive small bowel obstructions. The incidence is higher in pediatric surgery, but there isn't much data on related complications, economic burden, and clear management guidelines in the treatment of these obstructions. And they addressed currents of adhesive bowel obstruction in pediatric surgical patient population. This was an observational retrospective study, included children from 0 to 15 years hospitalized for adhesive small bowel obstructions during 2000 to 2020, and 101 patients experienced 137 episodes of adhesive small bowel obstructions. And what they found out was that most of the obstructions occurred within the 1st 5 years of the index surgery and. And around 90% of these obstructions required surgery. The most frequent initial surgeries leading to these obstructions were necrotizing enterocolitis, duodenal obstruction, and primary adhesive small bowel obstructions, and 50% of these obstructions had significant complications, clavian dindo grade 2 or higher. And obviously the costs related to these obstructions and their surgical treatment were high. The median cost of managing one episode was approximately $36,000 and we just mentioned there were 137 episodes in 20 years in one center, which makes nearly $50 million. What is your experience with these obstruction? Instructions and the management. Is it as expensive as in Argentina compared to the US? I think it is actually, cause you have a lot of in-hospital days, and that includes ICU which is really expensive to stay a couple of days there. And we have to take into consideration that if you have a small bowel obstruction, you'll need central lines, parental nutrition. And those things are really expensive and also increase the risk of infections and other complications that the patient may have. Still, a lack of evidence regarding effect of laparoscopic surgery and, and lack of comparative studies to find out whether laparoscopic surgery. In fact, reduces uh long-term post-operative adhesive obstructions in pediatric patients. And that was Doctor Pakernan. He's editor of the Month, who helped us choose the articles. But I think it is important when we are talking to the patients, the family, and To the team that's taking care of these patients to address this percentage of patients that have this complication, so that we can recognize the early signs of this happening. OK. Moving to the 3rd 1 of the day. It is thoracoscopic versus open repair for esophageal atricia, a retrospective cohort study of 359 patients at a single center. So this is a single center retrospective study than in Changsha, China, and they wanted to compare the effectiveness of thoracoscopic versus open repair for oesophageal attricia. I selected this paper because basically what it describes is a Experience on how one center transformed from open to thoracoscopic repair of esophageal atresia. So, they did a retrospective study between January of 2010 till December of 2021. And all the esophageal attritions that they compare were type C, meaning with the distal fistula. They had 359 patients, 152 were done. via open operation and 217 were done via thoracoscopic approach. And what they found is that surgical time is longer in the thoracoscopic group, and they had no significant difference in complications such as leak or strictures. So thoracoscopic repair of esophageal atricia is a safe procedure. That has a little bit more time to complete the surgery but has similar outcomes than open surgery. But also, we know that with open surgery, you highly likely have scoliosis, shoulder girdle weakness, which with teroscopic repair, you can prevent 100%. I do think that it is important to concentrate this type of patients, these complex patients to achieve better results, like you said, but unfortunately, I don't think it's easy. They were able to change their practice in, in about 10 years, but it, like I said, it requires a lot of patience and, and concentration. And like you said, most of the centers don't see 20 esophageal treats of patients or 30 per year. Yes, maybe if we start concentrating the patients, like having not only a surgeon within a, a hospital, but a hospital within a city or a country or states, um, that could help concentrate the patients and get more expertise in the matter. OK. So, those were the three papers for today. And so, first, we talk about the quality improvement campaign for the utilization of rapid sequence MRI in pediatric appendicitis, and we discovered that it is important to have a protocol to start using more MRI and reduce the ionizing radiation that CT can give to our pediatric patients. Secondly, we talked about Adhesive small bowel obstruction in pediatric patients, which comes with a lot of economic burden and has a lot of complications, specifically, discovering patients that had neonatal surgery. So it is important to assess these patients and to know that they are in high risk of having adhesive small bowel obstruction diagnosis. And last but not least, we talked about the esophageal. repair and comparing thoracoscopic versus open procedures. And what we've seen in this paper is that they actually didn't present any significant difference in complications like anastomotic leak or strictures. But from previous work that we've done, we've seen that thoracoscopic repairs avoid some complications such as a scoliosis. And so it is better. In our point of view, to try to do the theracoscopic repair, even if it means transfer of the patient. 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. I'm Cecilia Jigena 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.
Comments