2025 Pediatric Surgery Update Course - Updates in Colorectal: Debunking Dogma

All right appropriately so color rectals our last session before lunch. So, oh hey everybody. Yeah so we're the only thing standing between you and lunch. But don't worry we haven't liked about an hour and a half of material so it'll be fine. Hey let's next slide. Where's the little magic ring here? All right. Backwards forwards. Make sure you're virtual. Let's hear the R here. All right. All right so hey Nelson Rosen from Cincinnati Children's with Aaron Garrison and Annie Ludanwin with me here. We got Elizabeth Speck, Jamie Harris online and we're excited to give you guys an update. And our intention is to talk about some things. These are roughly the topics that we're going to hit. And this was a real challenge. And I heard earlier if you want to go into the real innovative you have to look into adult literature too. And we do. Now ever there isn't a ton of earth shattering stuff that's occurred in the literature in the past couple years that is really game changing that we could put out there. So but I did think that it would be a really good exercise to hit these points because some of these articles are still quite fresh. Not all of you may know about where things have gone. And now that things have been out like a year or two when people started doing them back in their home places you can see like maybe it's not exactly the way they talked about. So hopefully some of that will come out the conversation. And I think with that we'll move into a clinical scenario. And Jamie Harris take it away if you're online. Hi. Good morning. Everybody hear me okay? Excellent. So thanks so much for the opportunity to present the Colorectal update. Our first case is one of my favorite calls to get from the NICU actually. It's a term female infant. She weighs three kilos and she's got a rectivestipular fistula. We've done the work up in the NICU and besides her inner rectal malformation her bacterial work up is completely negative. So that brings us to our first clinical question that we're going to pose to the group here. Which is what is your next step? You can do dilations only, dilations in elective surgery after discharge, a diverting stoma or neonatal piece art. I think we can hopefully do our poll everywhere. All right. What do we got there? On the poll it looks like dilations and then delayed piece art is leading by a substantial margin over a neonatal piece art making a little comeback there. All right. I think as we go through the answers we can agree that doing dilations alone is probably not the correct management of this for a number of different reasons but certainly dilations initially will allow for decompression. And I would recommend only dilating to a seven-hagard. It decreases the potential scarring along the track for future pea-serves. Along those lines of the fishulas you compressing a diverting stoma off and not necessary. And those are two other answers that it seemed like the group kind of felt similarly with which is dilations in a later surgery after discharge or a neonatal period piece art. And a little bit of controversy in these but there is data to support either of the next steps. So kind of the next question is you've calibrated the fishula. You're able to get your seven-hagard dilator and the babies decompressing well via the stochasticula. And so it brings us to the next question. What are you going to do your piece art? Are you doing an ASAP before the baby leaves the NICU at one month of age, three month of age? Do you have a weight requirement? Are you going to do it later because you're on vacation? What does our panel think? I think. I think. Yeah. Definitely. You start talking. I guess so. This is a three kilogram baby, a term baby. I would rather do it one month of age just because you do the if the patient can be decompressed with the rectal dilation, the fishula dilation and then just so the baby can grow a little bit bigger. I would be more comfortable at one month of age. I think Nelson and I disagree a little bit on this. He likes doing them up front. I hope I'm not putting words in your mouth. But I like also getting them a little bit older, let the babies go home and then so somewhere between B and C I think makes makes sense to me. I guess I'm old school on this. I like to you know I'm fine maintaining patency and I think Jamie brought up a really important point about that if you're going to just try to keep it open you just have to keep it open enough for like little soft, musterty poop to be able to make it through there. So there's no reason to drive that dilation like up big. But I like to do this operation like when I can you doesn't have to be the next day that day after you know you can get it done but I like to get it done on the NADL admission. Provided that there's no comorbidities or that the kids not like in a 1.2 kilos or something. Yeah. And I think that's kind of our sort of gestals in the group is you know I think both are safe and understanding kind of the surgical principles of the peace harp and this operation can be performed both safely in the neonatal period or after the patient's discharged. There were two kind of important studies that both came out in 2021 sort of looking at this. If you're at all looked at female perinatal or rectivist of your fistulas this was a nisklet study and it defined early repairs less than seven days delayed six to eight, a six weeks to eight months. And again they found no difference in those groups between wound complications, re-operations and readmissions. And again there was another...