2025 Pediatric Surgery Update Course - Nerve Monitoring and Stimulation in Pediatric Surgery

All right, so the next session is going to be nerve monitoring and nerve stimulation. So wanting to hit the nerve and not wanting to hit the nerve, two extremes by Ben Ham from Buffalo. Thank you. So we'll touch on recurrent nerve monitoring. I know it's already been mentioned for esophageal atregia and airway surgery some. So we'll focus on thyroid surgery, sacral nerve stimulation for children with medically refractory fecal incontinence or severe constipation as well as diaphragm pacing for respiratory failure. So we'll start with a case. A patient presents with a 1.1 centimeter right thyroid nodule that is tyraids 4 on ultrasound. Some fine needle aspiration is Bethesda 3 which is atypia of undetermined significance in addition to some other possibilities. Otherwise no pass medical history, negative work up normal labs. Have a few different options up there. So what would be your next step? What would you recommend? I'll open it up to the audience. Any comments from anyone here? Looks like it's all over the place. I think Bethesda 3 you can also repeat the FNA. So the adult guidelines mentioned that as a possibility. Using the FNA you wouldn't want to do it early in an adult because sometimes having a prior FNA can affect a future FNA if it's done more recently. Molecular testing, there's various different companies, a firm, etc. That's in the adult guidelines as well. And it's not currently in the 2015 pediatric guidelines other than being mentioned. The new guidelines are being written and possibly coming out within the next year or so. And so we'll see if they make it into those possibly in a different way than they currently are for adults. So for this nodule that would have an intermediate risk of cancer, probably 30% or so, would not recommend a thyroidectomy because they probably only need a hemothyroidectomy and then you avoid the additional risk associated with it. And so then the main question becomes are you going to do it or is somebody else going to do it and then are you going to do it with or without nerve monitoring? And so the 2015 pediatric guidelines do recommend... Do you recommend it being done by a high volume thyroid surgeon which with pediatric disease not being as common as adult diseases? There's not many centers that have, even if they only have one person doing it, 30 a year by a pediatric surgeon. So you can either have a high volume adult surgeon either do it or I will typically invite a higher volume adult surgeon to join me for the nerve and parathyroid identification portions. And so potentially a couple different answers and we'll touch on what tyraids is later. And so mentioned several of these things already. Low beck to me for pediatrics is recommended rather than molecular testing or repy effinate currently because there is a little bit higher rate of malignancy in those populations compared to adults. And then if it did come back as cancer then completion thyroidectomy would be recommended. So either of these two options C or E would be what the literature leans towards currently. And then one recent study published the rate of recurrent laryngel nerve injury decreasing from 8 to 1.5% with monitoring and there's various different monitoring options which will touch on a little bit. But in a recent survey about 80% of pediatric thyroid surgeons do use monitoring. There have been studies and adults that have shown that maybe it helps you identify the nerve more but maybe doesn't change injury rates. And we don't have studies that I've seen in pediatric showing a significant decrease in injury rates but there's several that do show absolute so it's probably open for a meta-analysis to be done. And so with a higher rate of nerve injury in children it's a smaller nerve maybe harder to identify. So the rate in children's 9% versus about 6% in combination of many studies that may suggest it may be more helpful to use it. And then the main thing is avoiding the risk of tracheotomy if you have bilateral injury. And that may lead you to stage it if you have injury on one side that you've seen with the nerve monitoring. You may want to wait and see if it's just a transient thing that can then recover later. Can I ask you what's the downside of the monitoring? Is there a downside to the monitoring? Because it seems like to me like a no-brainer but it might be a resource challenge but is that the only downside to it? Yeah, expense is one consideration and if it doesn't change the injury rates some of said we'll why use it if it doesn't change the outcomes. And others have said well maybe there's just not enough power in the studies to show that. And so those play into the common arguments. The other thing is that oftentimes in pediatric patients there may not have been devices small enough to monitor it. And you can see in this publication they've stratified it by ages where it has been tried up to age five or age four in others and in some other recent adhesive publications are intertricle tube electro publications even down to age zero. So we may be getting to where it's available for even the smallest patients now. I think one of the other downside is when we're not used to using the probe as much as for EMT people sometimes it just beats the whole surgery. So with several studies coming out intraoperative nerve monitoring can be considered for almost all pediatric thyroid surgeries now that adhesive electrodes can be put even on like a 3.0 ET tube now. It may be most beneficial when you're doing a total thyroidectomy where the contralateral cord is paralyzed to try to help decrease the risk of tracheotomy with bilateral paralysis may be helpful also in reoperative surgery. And so something to discuss with the patients when you're consenting if you are using it in the setting of doing both sides that if there were changes on one side that might lead you to delay and do the other side later. And so that's how it can impact surgical decision making. In terms of tyrads so this was developed for adults basically at risk stratifies nodules based on ultrasound imaging characteristics. Sure. So it has been caution to not use it for pediatrics in one paper and our radiologist always put this in our reports. But there was a recent paper with one of the authors here in attendance suggesting if you adjust the size criteria it actually performs better than the 2015 pediatric guidelines. Dr. Aldrin would you like to come? Yeah. I wanted to make one quick comment just about the electrodes too. If you don't have a tube or if a child is too small for the 5.0 tube you can they come the electrodes come separate too and you can just do a direct learning task to be and put them directly into the vocalis muscle and it can monitor that way. So just a hint if you have a you know MEN patient that you want to do that. So we did this. This is our smaller multi-center study and then we just finished through the pediatric surgical oncology research collaborative. We did a much larger multi-institutional study looking at tyreds and using the modified version or the PEDS tyreds which basically says for every tyreds three that's over a centimeter and a half we would recommend biopsy and using those restricted criteria based on size of the tyred relative to size of the patient and that modification we didn't miss any malignancy. So it does perform better in terms of sensitivity and mis-malignancy rate. Great. Thank you. If somebody's any kind of streaming the event, make sure you're following the test and you're going to be back. So we'll move on to next scenario. A 13-year-old male with a history of idiopathic functional constipation presents with daytime and nighttime fecal incontinence and has been unable to remain clean despite more than four years of enema and laxative therapy. PGI has referred him. Contrast enema showed an elongated sigmoid colon otherwise normal. Previous rectal biopsy was normal. So what would you recommend? Botox, ACE, sacostomy, sigmoid resection. Cycle nerve stimulator, Iliostomy, something else? I see one option that's not there. And the challenge that we find is that our often RGI colleagues are all over the place with how they manage these kits. And when we put them through formal enema bowel management, we get a lot of them clean. So like I would put that up there too. This scenario, the kid has had that. So one thing that could be considered, ACE of course, or sacostomy tube, is a sacral nerve stimulator trial. And in that trial, the rates of daytime incontinence decreased from, excuse me, the rate of wearing a diaper during the day, decreased from 19% to 2%. And then at nighttime, it decreased from 33% to 11%. It's not FDA approved in kids. There's a Cochrane Review and adults suggesting that it can help with fecal incontinence. And so it may help avoid an ACE or other options. And then there was a recent retrospective cohort study with 70 patients. Can we show our poll results? No? Okay. I would just keep going. All right. And so in this study, it showed improvement in the involuntary daytime and nighttime bowel movement rate. There were side effects of pain and neurological symptoms and about 40% did require re-operation within about three years for dead battery of the stimulator or replacement. So basically with these, the stimulator is placed through the third sacral form and it sends signals to the sacral nerves. And then you see how the kid does for a couple weeks. If it is helpful, then it can be implanted in a more long term fashion with a battery. And we have a couple authors of this paper in attendance too, if they want to come in. Well, yeah. The biggest challenge that I found having started doing sacral nerve stimulation when I got to Cincinnati about seven years ago was, who is it a good option for? So you describe your case, has some of those key points there. So tell me, what do you think? Use the patient that you're going to try this on and like the others, you probably wouldn't try it on. I think it's a conversation with the family to discuss the options and whether an ACE or sacostomy tube and the associated things with that would be the preferred approach. Or if it's not a patient who wants those things and they want to consider something else, then that's an option. Why don't we do just real quick? The only other thing I would add to that is that the kids with urinary incontinence tend to respond pretty well and learning from the adults, the urologists put these in a lot of times for urologic indications. So that's usually something that will lead me towards offering it if they have urinary incontinence as well. All right. We want to just give a quick summary of diaphragm just like that in a minute. Sure. So for kids who have hypovinelation, whether it be due to central hypovinelation, syndromes, spinal cord injury, ALS, metabolic disorders, diaphragm pacing is an option and has been able to avoid tracheostomy in some patients or help wean patients with a tracheostomy off of ventilation and get off the tracheostomy. It can be done in different ways. Right nerve stimulation or direct diaphragm stimulation. And so here's an image where you can see the leads implanted in the diaphragm. Did you have comments on that? Todd, since I know one of your papers was in the review. You guys should also learn to do it. Ray Anders invented it here in Cleveland and did Christopher Reeve and it gets incredible. It gets kids off ventilators. Everyone should, it's very easy. So everyone should learn how to do it. I just got a text from Yama yesterday that he's doing them now. He's done a lot. So, all right. This, you covered a ton in a very short amount of time. So thank you so much, man. That was awesome.