Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024

Hi everyone, I'm M. Goddy from Cincinnati Children's, and we are back with another episode of our Journal of Pediatric Surgery article review podcast. This time we have three publications from the second quarter of 2024 April, May, and June issues. In this episode, you'll hear from three editors who helped us select these articles. We'll explore how MMP 7 levels affectlitriure prognosis. Which is better for gastroschisis outcomes, breast milk or formula, and if we have enough resources for colorectal patients transitioning from pediatric to adult care, it is gonna be a very good episode, so let's start with our first paper. Clinical characteristics and prognosis of biliary atresia with low serum matrix metallourinase 7 levels. This is a retrospective cohort study from China, and Doctor Mary Brindle helped us choose this article. Let's hear from her. I'm a pediatric surgeon at Alberta Children's Hospital. I've also been the publication chair for the uh Pacific Association of Pediatric Surgeons. In this study, they investigated the clinical characteristics and prognosis of biliary atresia, with low serum MMP 7 or metric metalloprotease 7 levels. Metalloproteinases are basically proteolytic peptidases, so they break down peptide bonds for amino acid. They're part of tissue remodeling process. And they play an important role in things like tissue repair, arthritis, metastasis, and also cirrhosis. This has been used before to basically help with the determination of the diagnosis of biliaryresia, so MMP 7. Higher levels of this are associated with the diagnosis of biliary atresia. So they had biliarresia cases from July 2020 to December 2022. And divided these patients into low and high MMP 7 groups. Out of a total 329 cases, 40 were classified as low MMP7. This is a group that has an ability to access a very large number of patients in a very short period of time, which really puts them in a position where they can dive deeply into. To things that others couldn't even start thinking about, and they compared the perioperative clinical characteristics, the 3 month and 6 month jaundice clearance rate post Kasai procedure, and the native liver survival between the two groups. In this cohort, they looked at these patients that had biliotresia but actually had low levels of MMP 7. And those low levels of MMP7 are also associated with low levels of preoperative GGT and direct bilirubin. So, let's take a step back because these abbreviations change from country to country. So I wanna explain what GGT is. GGT stands for gamma glutamyl transpeptidase, and it is an enzyme found in high levels in liver, kidney, pancreas, heart, and brain. And looking for GGT levels in blood tests is used to detect diseases of the liver and the bile ducts. We know that biliotresia has a variable outcome depending on where you are, even in one particular center. We know that we can have patients that anatomically look like they should behave in a similar fashion. But they can have dramatically different outcomes. And so being able to hone in on where those differences are, I think allows us to both explore some of the ideology behind this because still biliaryresia has a lot of mysteries as to why it happens, but also potentially think of ways of targeting specific therapies for them. It is expected that high levels of MMP7 is typically associated with the diagnosis of biliary atresia. And we can imagine that these high levels of enzymes may end up degrading some of these structural proteins, leading to biliatresia. But why, which is I find fascinating and obviously so much more to look at, why is having a lower level within that cohort of patients with biliotresia, why are those patients worse? Doctor Brindle believes that this just shows how much there is to learn about the process. And one of the things I love about this paper is that it just brings us down to some of those really basic questions about when we deal with these conditions, what actually underlies it? What are these processes? How do we target them? So, this paper shows us that even though we know high MMP 7 levels points. Directly to the biliary resia diagnosis, we still do not know what might be the reason of low MMP7 levels equals the worst prognosis of biliaryresia, and that means biliaryresia is one of these areas where we have so much that we still need to learn. With that humble acknowledgement, I think we can move to the next paper. Here's the second paper of the day. Association of Exclusive Breast Milk Intake and Outcomes in Infants with uncomplicated gastroschisis, a national cohort study from Canada. In this paper, we will try and explain which is better for gastroschisis outcomes, breast milk or formula. So for this paper, we interviewed the senior author, Doctor Michael Livingston. My name is Mike Livingston. I'm a pediatric surgeon at McMaster Children's Hospital and assistant professor of surgery. We will also hear from Doctor Ilana Barris. She helped us choose this article from the JPS May 2024 issue. So my name is Ilana Barris, and I'm one of the pediatric surgeons at Saint Christopher's Hospital for Children in Philadelphia, and I am the current chair of the CAPS Publication Committee. In this study, they hypothesized that exclusive breast milk is associated with Improved neonatal outcomes. There's been lots of research looking at different types of closure techniques, looking at whether antibiotics are needed or not needed, but there's been less focus on how to actually feed these kids and what to feed them. We've seen a lot in our NICU here at my hospital of patients developing neck or other unfavorable outcomes when they're on formula feeds. So, I was really interested in seeing if there was some updated evidence on using. Breast milk exclusively. So they did a retrospective review of infants with uncomplicated gastroschisis, and their primary outcome was the time to full internal feeds. We use data from the Canadian Neonatal Network and the Canadian Pediatric Surgery Network. So they're both collaborative organizations where there's data that's always being pooled prospectively, and it's just a great opportunity to learn rather than from a single institution, but a broader consortium. They had 411 infants with gastroschisis treated at Capsnet centers from 2014 to 2022. 144 patients were excluded due to different reasons like gestational age, birth weight, or the existence of other congenital anomalies or having complicated gastroschisis. The listeners will know there are some patients with gastroschisis who have uncomplicated disease, meaning they don't have an atresia or obvious ischemia, necrosis, or perforation. And we decided to focus specifically on those patients because we thought there'd be less heterogeneity in the data. And that was Doctor Livingston. He's the senior author of this paper. With the remaining 267 participants, 78% of them received exclusive breast milk in the 1st 28 days of life, and 22% received supplemental or exclusive formula. There's so many variables that go into how these babies are fed. And the advancements of feeds, and I think it's really hard to confirm results of this and like really prove that it's breast milk that's beneficial. We just heard from Dr. Barris. She is the editor who helped us choose this article. Even those patients who had some exposure to formula in the 1st 28 days of life didn't seem to have increased risk of necrotizing enterocolitis or any major differences in reaching full enteral feeds. There were no significant differences between groups in time to reach full internal feeds, duration of parental nutrition, or length of stay. In fact, if anything, we saw that patients who were exposed to formula seemed to have a slightly faster time getting to full feeds. We realized that was probably more related to timing of closure and differences in that closure rate than it was probably relating to feeding. And they did find that patients who received exclusive breast milk and 1st 28 days of life were far more likely to transition to exclusive breastfeeding. In fact, the rate was as high as 73% compared to 11% in those who had some exposure to formula in the 1st 28 days. But most of the other outcomes were pretty similar. In general, as pediatric surgeons and, and with our NICU colleagues, we could do a much better job of trying to support moms who want to breastfeed. A lot of the time, the neonatal period is quite overwhelming, even if You have a baby that you get to take home from the hospital with you right away, and not a baby who's gonna spend a significant amount of time in the NICU. But, you know, the mom should still be able to, to hold and snuggle the baby, and I wonder if that will help if we're more breastfeeding friendly and involving lactation. Then we asked Doctor Livingston if he thinks maternal breast milk or donor milk would make a difference. That's a really good question, and we do have a follow-up study that we're hoping to present next year, looking at more of those just Descriptive questions. In that follow-up study, we are gonna have both patients with uncomplicated gastroschisis, as well as complicated gastroschisis, and we're gonna be looking at things like not just frequency of maternal breast milk, but frequency of donor milk and exposure to formula. So I don't want to spill the beans just yet, but uh I can promise that there will be results coming out very soon. Well, we will be looking forward to seeing Doctor Livingston and his group's upcoming study. Certainly this was an interesting paper, and I think we touched base on some important stuff as well. It was a surprising outcome to know that breast milk and formula had similar outcomes for uncomplicated gastroschisis patients when we look at time to fall internal feeds, and Doctor Barris mentioned that as a new mom, she was also able to look at this paper from a different perspective, and I think that is very valuable. It is also important to remember to build a connection between the parent and the patient, whether it's with breastfeeding or holding or snuggling. So let's move on to the last paper of the day. In this paper, we will try to answer the question, do we have enough resources to help colorectal patients transitioning from pediatric to adult settings. This paper is called Transition from Pediatric to Adult Healthcare for Colorectal Conditions, a systematic review, and it's from Australia. And after tackling some time zone issues, we were able to talk to the first author, Emma Moore. I'm a PhD student with the Colorectal and pelvic reconstruction Service at the Royal Children's Hospital, focusing largely around transition from pediatric to adult healthcare. And A mother of an ARM patient. We also talked to a third author, Dr. Sebastian King. I'm a pediatric surgeon at the Royal Children's Hospital in Melbourne and director of the Colorectal and pelvic reconstruction Service. And the editor of the June 2024 issue was Doctor With Holcomb. And as always, he was very helpful and supportive during this podcast and helped us choose this article. This is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery. I just wanted to highlight the importance of transitioning care because I thought this topic was important. So let's get on with the paper. My PhD project is all around transitional care. Whilst we knew there was sort of a small body of research out there, we didn't have a good feel for what it actually involved. And so this was a logical starting point for us. Because we know that there are a growing number of adults that were born with congenital colorectal conditions, and we don't know a whole lot about transitional care. So they did a systematic review to try to figure out what is known about transitioning these colorectal patients from pediatric to adult settings. They found 8 studies that included patient and parent responses and also clinician perspectives. The research included patients between ages of 10 to 30 years. It focused on patients with either an anorectal malformation or Hirschsprung disease, and it was transition or transfer specific. We found that there wasn't a lot of research, and despite that growing number of patients moving across, we really don't have a good feel for the transitional care need. We learned from the authors that they seem to have a group of patients that discharged from care in late childhood around the age of 10 years. And another group that seems to remain in pediatric care way beyond the normal age of transfer to adult care, which is around 25 years. And so what we don't really understand is the life course progression of anorectal malformation and Hirschsprung's disease. Here, Emma Moore, the first author of this paper, tells us about another takeaway from the paper. There was quite a level of agreement between what we found as barriers and enablers of successful transition for surgical patients and those medical patients that the guidelines, were based on I think that the patients felt that the clinicians didn't always understand the need for transitioning their child's care from pediatric to adult settings and what that entailed, what were the reasons for that, what were the processes behind that, and how to make those processes as smooth as possible. We also heard from Dr. Holcomb. He's the editor of this issue and helped us choose this article. This one sentence says it all. There was little evidence from patients that transfer happened in a timely or coordinated manner. And patients felt that the clinicians did not always understand the significance of transfer to an adult service. No models of transfer of care were identified. So what should be the next steps then? I think we've probably got to take a step back first and better understand just what the transition or the life course trajectory is of these patients and what portion of our birth cohort do need that transitional care. And then once we understand that, We'll be better able to tailor a program to those patients, but it's really important for us as clinicians to go back to the families and ask what was it that you felt was lacking, and they might not have even felt that until they were in the adult care and had their first or second interaction with an adult healthcare provider. That was Dr. King. He's one of the authors of this paper. We need to do a better job. Of structuring this transition, we're doing better with handoffs in the hospital with patient care. We need to do a better job with handing off the care for any pediatric patient who needs a transitioning to adult providers. So this paper shows us unfortunately we don't have a structured system to help colorectal patients transitioning from pediatric to adult healthcare. Well, that's a wrap. So we reviewed three papers today. First one was about biliary atresia, and it highlighted the complexities in prognosis and particularly for patients with low levels of serum MMP7 and emphasized the need for further exploration for the underlying mechanisms. In the second paper, we looked at the research on infants with uncomplicated gastroschisis, which showed that exclusive breast milk intake increases the likelihood of successful breastfeeding later on, though overall outcomes are similar to those fed with formula. In the last paper of the day, the systematic review from Australia revealed significant gaps in the transition from the pediatric to adult care for patients with congenital colorectal conditions, and we need to create better structured care models and support during this critical period. Thank you for listening. 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. Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.