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 fourth quarter of 2024 October, November, and December issues. In this episode, as always, we are joined by three JPS editors who helped us choose these articles. First, we'll talk about the growing role of locum tenants in pediatric surgery. What does the future hold for locum surgeons, and how can we enhance the safety and efficiency of this practice for both surgeons and patients? Our second article examines the challenges of tracheomalacia in children with esophageal atresia, exploring how pre-op bronchoscopy might predict long-term respiratory outcomes and whether it should be a standard part of surgical preparation. Finally, we will explore the rising trend of same day discharge following elective laparoscopic gastrostomy tube placements. Is this shift a safe and effective choice for patients, or is it an overambitious trend? If you're ready, let's start. Our first article is locum tenants in pediatric Surgery, a position statement and practice guidelines from the American Pediatric Surgical Association or APSA. In this article, our editor, Doctor Escobar is also the senior author. My name is Tony Escobar. I'm a pediatric surgeon at Mary Bridge Children's in Tacoma, Washington. I'm an assistant editor of the Journal of Pediatric Surgery. We also talked to the first author of this paper. My name is Adi Fahy. I'm one of the pediatric surgeons at Penn State Children's Hospital in Hershey, Pennsylvania. I would like to take a step back for our international audience. Let's learn what locum tenance is, why it's needed. And how the system works. The definition means to work in place of, and what that means in reality or in real terms is that if a practice doesn't have a full complement of the surgeons that they would need to provide the care that they want to provide, then they can hire somebody. On a temporary basis who can fill in those roles. And within the ABSA group, there are many surgeons who will do this occasionally for a variety of different reasons. Some people use it as a bridge to retirement when they're reaching the end of their career, but still want to be able to do some cases and contribute in some meaningful fashion, and they'll do occasional locums work at various practices. It seems like a Work system with flexibility and attractive qualities that draw some people to choose it as an alternative employment practice. My interest arose in locum Ten's coverage of pediatric surgery during my time as chair of the practice committee of the American Pediatric Surgical Association. That was Dr. Escobar. He's a senior author and editor who picked this article. They observed an increase in the use of locum tenants, the growth of the locum tenants companies, and its adoption by various stakeholders, including group practices and hospitals. However, there was no regulation, no recommendations for the practicing pediatric surgeon on how to engage with the locum tenants market. So. A committee led by our first author, Doctor Adi Fahi came together to research how other organizations and medical and surgical societies approach locum tenants and came up with a series of recommendations that were ultimately endorsed by the board of APSA. If a pediatric surgeon or medical provider is interested in trying locum tenants. Should they reach out directly to hospitals or work through an agency? There are several models that can be employed for a pediatric surgeon to engage with locum tenants' work. The classic, or I guess the most readily available model is the locum tenants agency. Many board certified pediatric surgeons who have a telephone number in the phone book basically will be called by many of these companies that are looking. To fill the spaces for their clients, a pediatric surgeon can then engage with that locum tenants agency to essentially be the mediator to facilitate the attainment of state medical license, start working on privileges and credentials of the hiring institution, and try to make it as seamless as possible. Additionally, this company will negotiate the price of the pediatric surgeon. That they will be paid and may include things such as travel and lodging, but that's not the only way to do it. We interviewed multiple active locum surgeons either who do locuming full time or do it occasionally, and even that was in itself interesting in the range of different practices. They gathered insights on what worked well and what didn't, consulting both committee members and broader EPSA members, as well as hosts. Institutions to identify key considerations, these insights were compiled into practice guidelines aimed at highlighting important features for pediatric surgeons, hospitals, and local agencies with the goal of making this practice as safe for patients and as effective for all parties as possible. We aimed to. Evaluate multiple different settings that people did locum tenants practice in and identify key highlights of what made that safe for the surgeon and for the patient in those settings and identified points or red flags that people might want to consider before engaging in a pediatric surgical locum's role. In different settings because I think that variety is part of what makes this so challenging. That was Dr. Fahi. She's the first author of this article. Let's hear from Dr. Escobar. Our goal was to be inclusive and to be as supportive as possible while still maintaining some level of benchmark of quality. That we wanted to endorse in terms of going forward or future steps, but we had a workshop at our most recent ABSA meeting, which was very well attended with a lot of interest in the whole kind of evolution of the locum's tenants pediatric surgeon and how to put some suggested Frameworks on that to to really help that practice offer the optimal care to our pediatric patients. We learned from the authors that ABSA is in the process of developing a breakout group that may provide ongoing support to pediatric surgeons working on locum tenants roles. Let's move to our second paper, The Valley of Preoperative rigid tracheal bronchoscopy for diagnosis of tracheomalacia and esophageal atresia patients. This is a paper from the Netherlands. The editor who helped us choose this article was Dr. Pakarinen. My name is Mikko Pakarinen. I'm a professor of pediatric surgery in Helsinki Children's Hospital, Finland, and we had a Chance to talk to the first author. My name is Anna Flirt van Gaal. I'm a PhD candidate at the Department of Pediatric Surgery in the Erasmus Medical Center Sofia Children's Hospital in Rotterdam, the Netherlands. Tricheomalacia can greatly affect the lives of children born with esophageal atresia, causing respiratory issues such as stridor, wheezing, a harsh barking cough, and lower respiratory infections. In up to a third of the cases, it can lead to recurrent respiratory insufficiency and severe respiratory events. And despite the broad impact of tracheomalacia, there's no consensus on the tracheal assessment during diagnosis. Therefore, we wanted to evaluate the presence of tracheomalacia during routine rigid tracheal bronchoscopy in our patients with oesophageal atresia. And compare this to the postoperative tracheal bronchoscopy when available or if otherwise with the clinical manifestations. Here's Dr. Pakarinen. He's the editor who helped us choose this article. And in this paper, Dutch colleagues studied close to 80 patients and they evaluated the reliability of preoperative bronchoscopy in predicting the development of clinically significant. Tracheomalacia. We have retrospectively compared the presence of tracheomalacia during preoperative tracheal bronchoscopy to the presence of the postoperative tracheal bronchoscopy in Dr. von Holt's Center. Patients undergo a preoperative tracheal bronchoscopy as standard of care. However, postoperative tracheal bronchoscopy for esophageal atrichia patients is. Confirmed only when clinically indicated. And secondly, we compared the pre-operative tracheomalacia to the post-operative clinical signs of tracheomalacia after at least 12 months. That was Dr. Ron Hall. They categorized patients as definite tracheomalacia and probable or suspected tracheomalacia. They defined definite tracheomalacia based on findings in trachea bronchoscopy, which basically means that there is almost a complete or complete collapse of the airway. And the suspected trachomalacia was based on symptoms usually confronted in patients with the trachealacia, such as barking cough and upper airway infections and so on. They found that the sensitivity and specificity of the preoperative tracheal bronchoscopy were around 50%, making it about as reliable as a coin flip. In predicting outcomes, the results were not very surprising, as we know that the assessment and diagnosis of the tracheomalacia is difficult and the approach varies. On the other hand, we did not expect the sensitivity to be as low as 50%, so this has proven and highlighted the need for a systematic approach with the right timing. How might these findings influence future approaches to pre-operative and post-operative care for patients with tracheomalacia? I think one of the main messages here is that even in this rather large European center, they couldn't identify the patients at the time of primary repair, which clearly indicates that it might be to avoid the primary therapeutic at the time of repair and only treat those patients who go on and develop symptoms. But of course we have to take into account that this was a retrospective study. And of course, has all the limitations related to that kind of study design. So to really clear this issue, we would need to have a prospective study. Here's Dr. von Hall. She's the first author of this paper. We would like to see. The next step to be further research in the assessment of tracheomalacia with distinguishing between the rigid and the flexible bronchoscopy and standardized severity measurements. So a prospective study with standardized assessments and a bigger patient group should help fill the gap. Let's review the third and the last paper of today. Same day discharge for elective pediatric laparoscopic gastrostomy tube insertion is safe and increasing in frequency. An Iquip pediatric retrospective review, 2017 to 2021. This paper is from Buffalo, New York. Doctor Lahe picked this article for us to highlight in this podcast. My name is Pablo Lache. I'm the editor in chief of the Journal of Pediatric Surgery case reports and the associate editor for the IPEC meeting for the Journal of Pediatric Surgery. For this one, we were able to talk to the first author. My name is John Woodward. I am the pediatric surgery research fellow at John RO Shi Hospital in Buffalo, New York, and the senior author. Of this paper, I'm Ben Hamm, one of the pediatric surgeons at John R. Oshai Children's Hospital in Buffalo, New York. Dr. Ham is the Nisquip surgeon champion for their hospital, so he's engaged in quality work associated with that. I decided to choose this manuscript because I thought it is something that is going to change in the near future, and I think it's something that we all. To learn about in order to make a significant change in our practice. Many centers typically keep children in the hospital for a day or two after elective laparoscopic gastrostomy tube placement in outpatients. This allows time for family education, setting up a feeding plan, administering feeds, providing necessary supplies and equipment, and ensuring the child tolerates the feeds. After the pandemic and during the pandemic, we. Found ourselves dealing with a full hospital and limited hospital beds for post-operative patients. That was Dr. Hamm. He's the senior author of this paper. They had to cancel some surgeries, so they began to wonder if there might be another way. And we wondered if same day discharge of these patients may optimize use of resources and help kids to get home and get back to being kids as soon as they and their family are ready. But did wonder if it might affect complications, readmissions, and that sort of thing. In this paper, authors use NSQWIPP registry data to assess the outcomes and national trends of same day discharge following elective pediatric laparoscopy gastrostomy. For our listeners who haven't heard of it yet, what is NSQWIP? NESQWIP is a registry that is handled by the. American College of Surgeons. The original one is obviously for data from adults, but we have the Net script for pediatrics. Let's hear from Dr. Lahey. He's the editor who helped us pick this article. There are more than 150 participating hospitals across 44 states and 7 countries. These registries and big databases are key, at least to start to understand. What what the trends are in what we do. Here's Dr. Woodward. He's the first author of this paper. Our methodology for this project was utilizing the Nisquip pediatric registry from 2017 to 2021 to identify pediatric patients who underwent elective gastrostomy tube placement, presenting from home and discharging home with a diagnosis of failure. Failure to thrive, feeding difficulty, or dysphagia. They created two cohorts to compare those who were discharged the same day as their surgery and those who were discharged 1 to 2 days postoperatively. Our primary outcomes were readmission and re-operation, both early and slightly delayed. They found a total of about 6000 patients, and of those, about 5% of them. Were discharged on the same day. When they analyzed the data year by year, they observed an increase in the trend from about 2.7% of the patients in 2017 to 6.3% of the patients in 2021. So the authors claim that there is, or there has been at least at that time. A trend towards discharging these patients more and more. Yeah, I thought it was fascinating that the rate of same day discharge had doubled from 2017 to 2021, and we could see a nice uptrend, although there was a little bit of a plateau in the middle. Yeah, and when we had discussed possibly doing same day discharge at our center, others had expressed concerns that Oh, they'll be more likely to have the tube pulled out inadvertently if they don't stay and see how it's handled, or they may have issues that require coming back to the emergency department, but, yeah, we didn't see those. So we can see for same-day discharge patients, were they coming back at the same day as they discharged 1 day, 2 days postoperatively. Which would be the window in comparing those two cohorts that a same day discharge or non-same day discharge may be impacted, and we found no differences between those two cohorts. Now it's very important to to clarify a few things again. The population were patients who came to the hospital electively compared to patients who. were in the hospital or were transferred to the hospital from different facilities or from the emergency room, so patients who were clearly sick to begin with were excluded from the study, as well as patients who remain in the hospital for more than 2 days because obviously you can remain in the hospital for a long time regardless of the details of the of the surgery. That was Dr. Lahey. We have worked to begin talks to implement earlier discharge. It does require major process changes to set up all the education of the family ahead of time. To partner with nutrition if needed, to determine the feeding plan ahead of time, to set up the pump and other supplies if needed. According to Dr. Hamm, it takes some getting used to both in terms of the system and working with other providers within it. While it can be done, it requires significant effort upfront to make it happen. From every single point of view, one less day in the hospital is a win for the patient, for the family. And even for the hospital, I think promoting these early discharges, early recovery plans is definitely something we need to encourage and we need to challenge ourselves to try to do, even if it goes against what we've been doing for the last 20 years, I think as evidence shows that things can be changed for better, we just do it. The last question is, what are the next steps looking into this paper? Do you plan to conduct a follow-up study or reach out to institutions to share the results, maybe help start a movement toward making same day discharge more accessible and easier to implement? With our process changes that we're doing at our institution, we hope to look at that and verify that what we're seeing nationally, we're seeing at our institution, but that will be an ongoing process and then it would be fantastic to. Utilize multi-institutional groups to be able to look at this and verify whatever our single institution data is, does it corroborate with other institutions? But that's going to be a, a many-year plan. Yeah, and I think we will continue conversations here in terms of implementing it and then open to other institutions who are also looking at implementing the same thing to potentially analyze it together. Great, we are almost at the end of today's episode, so let's recap what we covered. Our first paper highlighted the growing use of locum tennis in pediatric surgery and the need for clear practice guidelines to ensure safety and efficiency for both surgeons and patients. Next, we explored a study on preoperative bronchoscopy which showed its limited reliability in predicting tracheomalacia in children with esophageal atresia, underscoring the need for a more systemic approach. And finally, our last paper revealed that increasing same day discharge after elective laparoscopic gastrostomy tube placement has not shown negative outcomes while helping to optimize hospital resources. 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.
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