Journal of Pediatric Surgery Article Review: Q1 (Jan-Mar) 2024

Hello, everyone. Welcome back to another episode of the Stay Current podcast. I'm Cecilia Jigena and I'm Egodi. 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, and this time we are highlighting articles from the first quarter of 2024. And for that, we talked to each editor of the month. So for January, we talked to Doctor Romeo Ignacio. Uh, my name is Romeo Ignacio. I'm the trauma medical director at Brady Children's Hospital at the University of California, San Diego. And, uh, currently I serve as the ABSA Publications Chair. In February with Doctor Mark Davenport. This is Mark Davenport, uh, the UK editor of Journal of Pediatric Surgery. And in March with Doctor Pablo Laje. Hi, everyone. I'm Doctor Pablo Laje. I'm an attending surgeon at the Children's Hospital of Philadelphia. The three articles we are covering today, we are talking about the use of antibiotics in complicated appendicitis, lengthening procedures for esophageal atricia, and the sensory function in patients after cryoanalgesia for the repair of pectus excavatum. If you'd like to join and read the articles with us, check the links in the description below. So the first article of the day is cessation of antibiotics for complicated appendicitis at discharge does not increase risk of post-op infection. So this is a prospective study done in one center in Utah, and we talked to the senior and first author of this paper. Um, I'm Scott Short. I'm an associate professor in pediatric surgery at the University of Utah and Primary Children's Hospital. And I'm Katie Russell, also an associate professor at Primary Children's Hospital in the University of Utah. So this study wanted to analyze the effectiveness of antibiotic therapy for complicated appendicitis. So what they did is they compared two cohorts in their hospital. We really defined our two groups by time frame. And that was Doctor Short. He is the senior author of this paper. Before and after, um, near uniform implementation of, of. The change in protocol, which essentially was stopping antibiotics at discharge, but for either provider preference or for patient factors, they weren't followed 100% of the time. And they compare the outcomes. They looked at deep space organ infections, they looked at length of stay, readmissions, the use of CT scans afterwards. And that was Dr. Romeo Ignacio. He is the editor that chose this article. So they had 185 patients in the home antibiotic group. And 121 patients in the no home antibiotic group. And what they found is there were no significant difference in deep organ space infection that require intervention. And there was no difference in the length of stay. They also looked at secondary outcomes like C. diff infections, uh, superficial site infections, length of stay, post-operative CT imaging, and readmission. Again, no difference. And so this again challenges the tradition of what some surgeons are doing, which is giving antibiotics and maybe too much antibiotics after discharge. And again, that was Doctor Ignacio. So, what do you think about this? Like fortunately, the modern science shows us we might not have to keep doing what we're doing for the, the last couple of decades. So I think this is a good proof of concept for post-op surgical management. Yes, I found it really impressive that appendicitis is a thing that every pediatric surgeon has every day, and we're still discovering new things. Talking about next steps, you know, we have studied this now institutionally, but we think it's important to study it on a broader scale, and our plan now is to roll this out to the Western P Paediatric Surgery Research Consortium. Should we go to the second article? Yeah, so second article of the day is from February 2024, which is BP's issue of Journal of Pediatric Surgery. This paper is from the United Kingdom. And called what proportion of children with Complex oesophageal atresia require oesophageal lengthening procedures. And we talked to the senior author, Doctor Bruce Jeffrey. Hi, I'm Bruce Jeffrey. I'm one of the children's surgeons in Newcastle in the north of England. So this is a 25 year experience. Description of 220 consecutive infants with esophageresia in Newcastle. And that was Doctor Davenport. He's the editor that chose this article, and outcomes they looked at were the rate of retention of native esophagus, complications requiring thochotomy. And rates of anastomotic leaks, strictures from the application, and mortality. They had 215 esophageal atresia patients and 13% of them had complex esophageal atresia, and of them. Only 25 patients survived the repair. 14 patients were type A, 11 patients were type C esophageal atresia. Cecilia, I'm sure most of our, uh, audience know the differences between these types, but do you want to simply explain? Yeah, OK, so, uh, type A and C. The most common. Type C is the most common and means an esophageal atricia with a distal fistula, and type A means pure esophageal atricia, meaning there's no fistula to the trachea. Perfect. Uh, let's go back to our patient population. So we said 25 patients survived the repair and 18 of them had delayed primary anastomosis and 7 had esophageal replacement. And two of the replacements were salvage procedures following a failed traction, and only 4 patients who had es vigil atresia were potentially treatable by traction. Most often they can, if you mobilize both ends sufficiently. The esophagus has got a great intrinsic blood supply, and you can easily mobilize it right down to the diaphragm and right up to the thoracic inlet, and it will stay alive. And that was Dr. Jeffrey. He's the senior author of this paper. So I, I suspect many of the cases that are being put forward for lengthening are because surgeons get cold feet about attempting a primary anastomosis. The rest of the patients where traction techniques had not been attempted. The native oesophagus was retained in 80% of the cases, and the median time to esophageal continuity was 77 days. In conclusion, we can say, according to this paper, management of complex esophageal atresia without lengthening procedure can result with a similar rate of retention of the native esophagus, but with significantly less morbidity. And here's what Doctor Davenport said about this article. Nevertheless, this is definitely a pushback series which extols relatively conventional open surgery, of course. It really, it really does beg the question as to what role and they would say, if any, er lengthening procedures have in those with er with long gaps. So I think Unless you, you know, have an experienced surgeon who says after maximum mobilization, I genuinely can't get this together. I can't see that esophageal lengthening is required. If we were anastomosing esophaguuses with excess tension and the repairs were failing, you would expect us to have a very high incidence of oesophageal replacement, and we don't. So most of these cases, the vast majority are anastomosed without problems. And the 3rd paper of the day is Long-term sensory function, 3 years after Minimally Invasive repair of Vectus excavatum with cryoablation. For this, we talked to the editor, Doctor Pablo Laje. Hi, everyone. I'm Doctor Pablo Lache. I'm an attending surgeon at the Children's Hospital of Philadelphia. So, this study is a prospective cohort study from the Singles Center in Phoenix, and they aim to quantify the long-term hyperesthesia and neuropathic pain after the minimally invasive repair of pectus excavatum with cryoablation. So, what they did is they selected all the patients that were under 21 years of age. They presented for bar removal between November 2021 and May 2023. Basically, what they did was just before taking the barb out, they tested, you know, quite thoroughly for a cold and soft touch and pinprick. And in this study, they enrolled 47 patients. In these patients, the median bar dwell time, meaning the time the patients have the bars inside, was approximately 2.9 years. And they had placed a median of 2 bars. Almost 81% of them were secured with pericostal sutures. In paper, just about half of the patients had some degree of hyposthesia. T5 was the most common dermatome with this hypoesthesia. The area that was the problem was less than 5% of the entire surface that was treated with cryo. So in reality it was just a very small percentage of the chest wall that was having this hyposthesia. And again, that was Doctor Pablo Laje. Neuropathic symptoms were identified by 13% only of the patients, but none of them required treatment. So what they conclude is that in the long term, um, any minimally invasive repair of practice cavatum that had cryo, a lot of patients will experience some sort of chest wall hyesthesia, but it will be Limited to one or two dermatomes and chronic symptomatic neuropathic pain was very rare. So, what I have to say about this paper, patients were evaluated still with the bars. And so I would love to see this test done without the bars. And also, I think the Um, secure of the bars with pericostal sutures also can damage nerves. So, Oh, I'm hesitant that what we are seeing is only due to cryo and not to these other factors that are playing a role. I think just to say that this is a great start, but you're right. Before saying that that is a consequence of the cryo, I think it might be a good idea to repeat the study after the bar comes out. It is so fascinating to see how many studies are coming out about cryonalgesia and Pus management, and hopefully we'll have better and better results. And even though some people are still hesitant, we're trying new things. So it'll be interesting to see for me how we manage Pus patients 10 years from now. OK. So, time to summarize. We first talked about the cessation of antibiotics in complicated appendicitis, and we found out that it may not be necessary to give antibiotics after the in-hospital treatment. We know we still need more multi-center studies, but this paper looks promising. Secondly, we talked about the lengthening procedures for esophageal atresia, and we saw that it may be reserved for very specific cases, since many of the complicated esophageal attritions can be treated by a primary anastomosis either at the newborn period or with a delayed anas. Otomosis. Last, we talked about long-term effects of cryonalgesia in minimally invasive repair of pectus excipatum, and we identified that even half of the patients had some sort of hyposhesia that was circumscribed to one or two thermal tones. And also we have to keep studying if that could be related to still having the bars on or with the way that they were secure. So I hope you enjoyed this issue of the 1st quarter of the Journal of Pediatric Surgery Article Review podcast. 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.