Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 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 third quarter of the 2024 July, August, and September issues. In this episode, you'll hear from 3 editors who helped us select these articles. In the first paper, we'll explore if delayed diagnosis of Hirschsprung disease impacts postoperative and functional outcomes. The second paper will look into when is the best time for delivery, how long you should use antibiotics, and what is the best type of closure in gastroschisis patients. And the final paper will explain how to grade unexpected events in pediatric surgery with a brand new classification system. If you're ready, let's start. Here's our first article. Does delayed diagnosis of Hirstprung disease impact postoperative and functional outcomes? A multi-center review from the pediatric Colorectal and Pelvic Learning Consortium. Dr. Colin Martin helped us choose this article. Let's hear from him. This is Colin Martin. I'm a pediatric surgeon at Washington University in St. Louis. I'm the division chief here. And at the time of this article being processed and being published, I was the chair of the publications Committee for the American Academy of Pediatrics section on surgery. We also talked to the first and the senior authors of this paper. My name is Sarah Ulrich. I'm a pediatric colorectal surgery fellow at Cincinnati Children. My name's Jason F Fisher. I'm a pediatric surgeon and director of the Colorectal Center at Cincinnati Children's, and I also happen to be. The lead of the subcommittee for Hirschprung's disease for the PCPLC or Pediatric Colorectal and Pelvic Learning Consortium. The PCPLC has a multi-institutional registry that includes a number of institutions throughout the United States. The PCPLC is an organization that can really harness the strengths of many clinicians and researchers. And being able to put our data together in a granular way that can be shared in effect clinical care. So I came up with the idea of trying to get more information. And data regarding delayed diagnosis Hirschprung's disease. We wanted to understand if the age of diagnosis of Hirschsprung's disease impacted the surgical and the functional outcomes for these children. We thought that patients who were operated on later and diagnosed later in life had poorer outcomes. Particularly, I wanted to know if the. The strategy of diversion prior to pull through or at the time of pull through affects outcomes. And here's Dr. Martin. He's the editor who helped us choose this article. What stood out to me is that it's a relatively large cohort of patients. There were 679 patients that were diagnosed with Hirschrung's disease. We divided children into different age groups. Neonatal, that was less. Than um 1 month old at diagnosis, infant less than 1 year old at diagnosis, toddler, 1 year to 5 years old, and children older than 5 years old at the time of diagnosis. 85% of those were diagnosed at less than 1 year of age, and we did a retrospective review of the PCPLC database to better understand this. And that was Doctor Ulrich. She's the first author of this paper. This may be an easy question for some in our audience, but as someone without surgical training, I wanted to learn more about why there's a delay in diagnosis for some patients. We found that kids with a shorter segment of disease, so rectosigmoid or a very small portion of the bowel that was a ganglionated or not working, were more likely to be diagnosed at a later age. And for children with a long segment of disease where a significant portion of their colon wasn't functioning, The condition was often evident at birth and typically presented with classic symptoms such as failure to pass meconium. Since we cleared that, let's review the results. Delayed diagnosis of Hirschbaum's disease does not impact postoperative outcomes nor the need for revision surgery of the pull-through, but it is associated with the increased need for fecal diversion after pull through. Our outcomes demonstrated that approximately 1/3 of the neonates and 50% of the infants, toddlers, and children had diverting ostomies performed prior to pull-through. The significance of that slightly unknown. Some of it could be that some centers are doing leveling ostomies. In some cases, as patients grow older and concerns arise about the size mismatch and the outcomes of the anastomosis, a diversion is performed to decompress the bowel in preparation for the technical aspects of the later anastomosis, and that was actually statistically significant in our findings when they analyzed the. Rates of pull-through revisions. They found no difference in the overall rates of redo pull-throughs. However, older children were more likely to need a redo due to an anastomotic leak. So we suspect that the higher rates of diverting ostomy post pull-through were actually a treatment for a post pull-through leak or an anastomotic leak. Let's hear from Dr. Fisher. The only outcome. That was different that we saw was nighttime soiling or incontinence in the older patient population and that might be because of a selection bias in that the older patients probably report that more than the younger patients, but unknown. One takeaway is that children with delayed diagnosis may be more prone to anastomatic leaks and complications with pull-through procedures. This should be considered when operating. And preoperative diversion may be necessary. And I think another key takeaway is that kids that are diagnosed in a delayed fashion or diagnosed later are still have similar functional outcomes, so they might be more likely to need to enter a bowel management program, but I agree. Congratulations to the authors and the PC PLC for putting this together. We're getting away from single center, single surgeon experiences, and the more collaborative approach will be a thing in the future, and we're looking forward to more work from this group and similar research consortiums. So it's safe to say that delayed diagnosis of Hirschsprung's disease does not impact 30 day post-op outcomes or need for revision surgery. But delayed diagnosis is associated with increased need for fecal diversion after pull through. Let's move on to the next paper. Our second paper of the day, Management of gastroschisis, timing of Delivery, antibiotic usage, and closure considerations, a systematic review from the American Pediatric Surgical Association Outcomes and Evidence-based Practice Committee. Doctor Casey Culkins is the editor who helped us choose this article. My name is Casey Culkins. I'm a general and thoracic pediatric surgeon at the Medical College of Wisconsin and my. Primary practices at Children's Wisconsin and Milwaukee. I'm the fellowship program director and I am on the editorial board of the Journal of Pediatric Surgery. Again, for this paper, we were lucky enough to talk to both first and the senior authors. My name is Dr. Mark Slidell. I'm a pediatric surgeon at Johns Hopkins Children's Center in Baltimore, Maryland, where I'm an associate professor of surgery and associate chief for health services research, and I'm Dr. Joanne Berg. I am a pediatric surgeon. Uh, in the division of pediatric Surgery with Presbyterian Healthcare Services in Albuquerque, New Mexico, neonates with gastroschisis consume a disproportionate amount of resources compared to other children in the NICU. There were a lot of unanswered questions and perhaps some variability in how people were managing gastroschisis, and that's part of the reason we were interested in studying this group. There were 28 high quality manuscripts that they ended up reviewing for this paper. And two randomized control trials that had been started, but both ended prematurely and were underpowered. So in this systematic review, authors tried to answer three main questions. The first question we looked at was whether there was evidence regarding outcomes for children with gastroschisis based on their gestational age. At which they were delivered. The second question was what recommendations can be made regarding antibiotic use during treatment of infants with gastroschisis. The third question addressed the outcomes of different closure strategies which were further divided into subquestions, including the timing of repair, fascial closure versus siloplacement, and sutureless versus sutured closure. This Paper adhered to PRISMA guidelines. PRISMA stands for Preferred Reporting Items for Systematic Reviews and meta-analysis. PRISMA is a 27 item checklist used to improve transparency in systematic reviews. These items cover all aspects of the manuscript, and the authors in this paper use this guideline to review studies for this paper. Let's hear the results from the authors. We definitely noticed. Significant practice variation regarding the optimal timing of delivery for infants with gastroschisis. While some centers recommended allowing for spontaneous vaginal delivery after 38 weeks gestational age, others seemed to favor early induction of labor. This paper highlighted the fact that currently there's no evidence to suggest that earlier delivery prior to 37 weeks is justified, which, based on the current evidence, I would say. Is the right answer as you look on the recommendation. And that was Dr. Caulkins. A planned delivery before 37 weeks gestational age is probably not beneficial and may in fact be harmful, and that early delivery. May promote some of the complications of prematurity, whereas delivery of infants with gastrosthesis after 37 weeks post-conception seems to be preferable. To address the second question, the authors examined recommendations for antibiotic use in the treatment of infants with gastroschisis. We found there was the practice regarding. infants with gastroschisis and the use of antibiotics seem to really just reflect the neonatologist's practice in various NICUs, and that was Dr. Berg. She's the senior author of this paper. Clinical practice suggests that skin organisms are most commonly identified in infections among infants with gastroschisis. Gastroschisis. Infants do have a fairly high rate of wound infection. Silo closures have a higher rate of infection, and a sutureless closure has the lowest rate of infection. So their recommendation was to provide coverage for skin flora until the defect was closed and potentially for an additional 24 hours thereafter. Which they concluded would be adequate if the infant was otherwise clinically stable. I don't think there's a lot that will change practice unless people really embrace antibiotic stewardship, but I think what the Austro suggested is that Once the defect is closed, that you can safely stop antibiotics, and, and I think that's a reasonable recommendation that everybody ought to follow unless there's some other reason to do so. But the exact duration of antibiotics to minimize risk of infection is still really unknown and definitely would be an area of future study to develop more firm conclusions. Final question focused on the outcomes of the various closure strategies. I would say the theme running through this question is really the idea of the abdominal visceral disproportion of the infant, and that was Dr. Berg. She's the senior author of this paper. So the question is the abdominal cavity have enough capacity for us to put the intestines back into the abdomen? Is there enough room in the abdomen, and it's up to the surgeon to determine what closure technique can we best fit to what we see when we make our clinical evaluation of the infant. They found that stable infants with sufficient abdominal capacity for sutureless closure tend to have the best outcomes. Additionally, minimizing fluids and paralytics in these infants further improves their results. They will have a shorter length of stay. They will achieve feeding sooner, but ultimately there are many infant determined factors that reflect outcomes. As surgeons, the best approach is to evaluate the available space in the abdomen for the intestine and the infant's overall condition. And the status of the intestine itself. And a surgeon should certainly evaluate for sutureless closure when first going to see an infant with gastroschisis. Let's hear from Dr. Caulkins one more time. I think there is fairly clear evidence, as noted by this group, sutureless repair is safe and effective and associated with a clear decrease in the need for use for mechanical ventilation, which is, I think, a big deal. When it comes to neonate that you're thinking about putting to sleep within the 1st 24 hours of life, the literature on gastroschisis really suffers from a lack of level 1 randomized controlled trials or really high level comparative studies, which makes it challenging to formulate practice recommendations. That was Dr. Slidell. I believe the key takeaway from this paper, as Dr. Slidell mentioned, is the wide variation in gastroschisis management. Despite the large number of studies on this topic, the quality of data remains poor, so we need high quality randomized controlled trials to provide an evidence-based approach when caring for these infants. Let's review the last paper of the day. Validation of the Clavian Madadi classification for unexpected events in pediatric surgery, a collaborative Ernica project. And Dr. Holcomb, the superstar editor, was the one who helped us pick this article. This is Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery. We also talked to the first author. My name is Omid Madarianjani. I'm a pediatric and general surgeon working at the University Medical Center Hamburg-Eppendorf in. The Department of visceral Transplantation. We didn't really have a classification system that was unique to pediatric surgery, so that's why we have used the Clavian dindo classification, although that was validated in the adult world. We tested different severity grading systems, validated in adult surgery. And what we saw is that the benefits reported from the added surgical literature were not transferrable into pediatric surgeries, so we contacted the initial team designing and validating the Caddo classification, and we reported them the drawbacks that we observed in pediatric surgery for the classification. These classification systems are used to rank the severity of a surgical complication. It is based on the type of therapy needed to correct the complication. The scale consists of several grades from 1 to 5. This is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article. That was Doctor Beth Holcomb. He helped us to choose this article. So on the first step, In a multi-stage process, we started to modify it in a team of 5 to 6 surgeons, including the initial general surgical team for the Clavian Dino classification and Professor Pierre La Clavian himself. When they established the system, they circulated up to 20 case scenarios of unexpected events within the Ernica Network, the European Reference Network for inherited and congenital anomalies. Now let's hear the author's definition of unexpected. Events we said that an unexpected event includes any event with a subsequent deviation from the planned pre-intra and post-operative course of children. We learned from Dr. Madari S Sanjani that several issues remain unaddressed when relying solely on a surgical classification system, because in children we face a lot of problems not associated with surgery, probably associated with. Management problems, organizational problems still leading to a prolonged recovery for the patients. 59 surgeons from 12 European countries completed the questionnaire. Based on the ratings of the various case scenarios, the Clavian Madati classification showed improved agreement rates of the respondents, 85% versus 76%. And it was less frequently considered inaccurate for rating in the pediatric population when compared to the lavian dindo classification. More pediatric surgeons preferred the Clavian-Mdadi classification for the case scenarios, which is 43% to 12%, and advantages of the Clavian-Mdadi classification were. Affirmed by nearly 82% of the surgeons. I think the main problem that we faced when we encouraged all the centers to use the system, we need the cultural change of the perspective assessment of unexpected events. Here's Dr. Madari S Sanjani. He's the first author of this paper. Not only involving serious adverse events, but any event that leads to Any deviation from pre-intra and post-operative course that you and your institution were planning for the patient. This was a good first attempt at trying to find a reliable instrument for pediatric surgeons, and I think that we'll figure out by using it whether it's good or bad or appropriate for pediatric surgeons, but right now we don't have anything, and so obviously a first step is better than no step at all. Wow, this was a long episode. So let's recap. In the first paper, the authors examined the impact of delayed diagnosis of Hirschsprung disease and found no effect on 30 day post-op outcomes, but showed that delayed cases have an increased need for fecal diversion after pull through. The second. Paper focused on gastroschisis management concluding that early delivery before 37 weeks offers no benefit and may cause harm. Sutureless closure methods resulted in better outcomes, including shorter hospital stays and faster feeding times, and targeted antibiotic use based on skin flora being crucial until the defect is closed. Lastly, we reviewed the new Clavian Madari classification system, the first tailored one for pediatric surgery, which demonstrated greater accuracy compared to the adult-based Clavian dindo classification. 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.