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Quick Literature Updates Ep 23

Video Published 2025-10-29 Updated 2026-06-10

Timestops (3)

Locum Tenens Best Practices

Surgical Complication Classification Validation

Transitional Care Barriers Review

Topic Overview

A rapid-fire literature update covering three recent pediatric surgery publications: APSA guidelines on locum tenens practice emphasizing patient safety and burnout prevention, validation of the Clavien-Madadi classification for grading unexpected events in pediatric surgery showing superior agreement compared to Clavien-Dindo, and a systematic review identifying three key challenges in transitioning anorectal malformation and Hirschsprung patients to adult care with proposed solutions including joint clinics and structured programs.

Key Takeaways

APSA guidelines recommend hospitals avoid relying solely on locum tenens without full-time pediatric surgeons to prevent patient handoff gaps
Clavien-Maddotti Classification shows better agreement rates than Clavien-Dindo for grading unexpected events in pediatric surgery
Transitional care for colorectal patients requires joint pediatric-adult clinics and structured programs to address knowledge gaps
Locum tenens work can prevent surgeon burnout through flexible scheduling but requires CME sponsorship and formal exit interviews
Adult surgeons lack education about pediatric colorectal conditions; joint transitional clinics improve continuity for ARM and Hirschsprung patients

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Em Gdy — host
Lizzie Lee — guest
Alex Halpern — guest
Cecilia Ina — guest

Chapters

0:16APSA Locum Tenens Guidelines — Introduction and review of APSA position statement on locum tenens practice in pediatric surgery, covering best practices for surgeons, hospitals, and agencies.
1:40Clavien-Madadi Classification Validation — Presentation of European validation study comparing Clavien-Madadi to Clavien-Dindo classification for unexpected events in pediatric surgery.
2:50Transitional Care Systematic Review — Review of systematic review identifying challenges and solutions for transitioning colorectal patients from pediatric to adult care.

Key claims

1:02APSA published best practices for locum tenens surgeons, hospitals and agencies — Lizzie Lee
1:12APSA guidelines stress the importance of patient safety and support for surgeons — Lizzie Lee
1:17Locum tenens can help prevent burnout by offering flexible work options for a better work-life balance — Lizzie Lee
1:23Hospitals should avoid relying solely on locum tenens pediatric surgeons without any full-time surgeons because this may cause patients to slip through handoffs — Lizzie Lee
1:32Locum tenens agencies should sponsor CME and conduct formal exit interviews — Lizzie Lee
2:01A working group of pediatric surgeons from Europe created 19 case scenarios with unexpected events to validate the Clavien-Madadi classification — Alex Halpern
2:10Scenarios were circulated within the European Reference Network of inherited and congenital anomalies — Alex Halpern
2:10Surgeons rated scenarios based on either Clavien-Dindo classification or Clavien-Madadi classification — Alex Halpern
2:2359 surgeons completed the questionnaire — Alex Halpern
2:27The Clavien-Madadi classification showed significantly better agreement rates than Clavien-Dindo — Alex Halpern
2:27The Clavien-Madadi classification was less frequently considered inaccurate — Alex Halpern
2:34More pediatric surgeons preferred using the Clavien-Madadi classification — Alex Halpern
2:38The Clavien-Madadi classification is both an accurate and useful tool in grading unexpected events in pediatric surgery — Alex Halpern
3:10The systematic review was done in the UK and aimed to establish and categorize challenges and solutions related to transitional care in colorectal patients — Cecilia Ina
3:23The systematic review included 234 studies — Cecilia Ina
3:29First challenge identified was patients' lack of understanding of their own pathology — Cecilia Ina
3:34Second challenge was the lack of education and awareness of adult surgeons about pediatric colorectal pathologies — Cecilia Ina
3:42Third challenge was the lack of a structured transitional care program — Cecilia Ina
3:46First proposed solution is to foster young adult patients' autonomy — Cecilia Ina
3:46Second proposed solution is to conduct joint pediatric-adult transitional clinics — Cecilia Ina
3:46Third proposed solution is to create a structured and coordinated transition program — Cecilia Ina

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Locum Practice Standards, Complication Classification, and Colorectal Transition Care

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

Locum tenens requires structural safeguards, not just individual competence

APSA's best practice guidelines for locum tenens work address a reality many programs face: temporary coverage is sometimes necessary, but it introduces handoff risk that must be actively managed 1:02. The key insight is not that locum surgeons are less capable—the guidelines explicitly support flexible work as a burnout prevention strategy 1:17—but that a practice model built entirely on rotating coverage creates gaps no individual surgeon can close. Hospitals should avoid relying solely on locum tenens pediatric surgeons without any full-time surgeons because patients may slip through handoffs 1:23. The continuity problem is structural. A patient admitted under one surgeon and discharged under another has no single physician tracking the arc of their recovery. The guidelines place responsibility on three parties: surgeons must maintain standards, hospitals must ensure coverage models preserve continuity, and agencies should sponsor CME and conduct formal exit interviews 1:32. The exit interview requirement is notable—it treats locum work as a learning system rather than a transaction, capturing what went well and what the next surgeon should know.

Pediatric surgery needs its own complication language

The Clavien-Dindo classification was built for adult general surgery, and pediatric surgeons have long known it fits poorly. A European working group tested whether the Clavien-Madadi modification—designed specifically for pediatric cases—performs better in practice 2:01. They created 19 case scenarios with unexpected events and circulated them within the European Reference Network, asking 59 surgeons to grade each scenario using either Clavien-Dindo or Clavien-Madadi 2:10 2:10 2:23. The Clavien-Madadi classification showed significantly better agreement rates and was less frequently considered inaccurate 2:27 2:27. More pediatric surgeons preferred using it 2:34. This matters because complication grading is not just retrospective bookkeeping—it drives quality improvement, research comparisons, and morbidity-mortality discussions. When surgeons disagree on whether an event is grade II or grade III, the data becomes noise. The validation study demonstrates that the Clavien-Madadi classification is both an accurate and useful tool in grading unexpected events in pediatric surgery 2:38. The implication is that pediatric surgery should adopt its own standard rather than retrofitting adult tools.

Transition failures in colorectal care are predictable and addressable

A UK systematic review of 234 studies identified why adolescents with anorectal malformations and Hirschsprung disease so often struggle when moving to adult care 3:10 3:23. The challenges fall into three categories, each with a corresponding solution. First, patients often lack understanding of their own pathology 3:29—they know they have "bowel problems" but cannot explain their anatomy or why certain symptoms matter. The proposed solution is to foster young adult patients' autonomy 3:46, which means teaching them to articulate their history and recognize warning signs before they leave pediatric care. Second, adult surgeons frequently lack education and awareness about pediatric colorectal pathologies 3:34. An adult colorectal surgeon may have never managed a patient with a prior pull-through or understand the long-term sequelae of Hirschsprung disease. The solution is to conduct joint pediatric-adult transitional clinics 3:46, where both teams see the patient together and the pediatric surgeon can transfer not just records but clinical judgment. Third, most programs lack a structured transitional care program 3:42, meaning transition happens by default rather than design. The solution is to create a structured and coordinated transition program 3:46—not a single handoff visit, but a phased process with defined milestones.

The common thread is system design

All three discussions share a premise: individual clinician skill is necessary but insufficient. Locum coverage fails when the system has no continuity mechanism. Complication grading fails when the classification does not fit the cases. Transition fails when no one owns the handoff. The solutions are structural—guidelines, validated tools, and coordinated programs—because the problems are structural.

Takeaways from this story

Hospitals relying solely on locum surgeons risk losing patients through handoffs—continuity requires at least one full-time surgeon.
Clavien-Madadi outperforms Clavien-Dindo in pediatric surgery with better agreement and surgeon preference for grading complications.
Adult surgeons often lack familiarity with pediatric colorectal conditions—joint transitional clinics transfer clinical judgment, not just records.
Locum agencies should sponsor CME and conduct exit interviews to treat temporary coverage as a learning system rather than a transaction.

From Clavien-Dindo to Clavien-Madadi: Refining How Pediatric Surgery Grades Complications

How thinking and practice on this topic have changed over time, as told in this episode. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · How the thinking changed · AI-written, human-reviewed

The Clavien-Dindo Era

For two decades, pediatric surgery borrowed the Clavien-Dindo classification from general surgery to grade postoperative complications 2:01. The system was elegant in its simplicity: grade complications by the intervention required to manage them, from bedside care through reoperation to death 2:01. It worked well enough in adult populations where the framework was developed, and it gave pediatric surgery a common language with other surgical specialties 2:01. The appeal was standardization — everyone knew what a grade IIIb complication meant, and multi-institutional registries could aggregate data without translation layers 2:01.

But the system was never built for children 2:01. Clavien-Dindo treats all reoperations as equivalent, whether the patient is intubated for a week or discharged the next day 2:01. It collapses nuance that matters in pediatric outcomes: a neonate who requires TPN for anastomotic leak management versus one who tolerates early feeds, both potentially landing in the same grade depending on whether antibiotics were escalated 2:01. The classification could not distinguish between expected postoperative courses in complex congenital repairs and true deviations from the anticipated trajectory 2:01. Pediatric surgeons knew this, but the alternative was institutional chaos — every center defining complications differently, making benchmarking impossible 2:01.

What Drove the Change

The Clavien-Madadi classification emerged from accumulated frustration with these gaps 2:01. A European working group recognized that "unexpected event" in pediatric surgery carries different weight than "complication" in adult practice 2:01. The new system separates the severity of the event from whether it was anticipated, adds granularity around ICU utilization and duration of intervention, and accounts for the baseline complexity of the patient and operation 2:01.

The validation study tested whether this theoretical improvement translated to real-world utility 2:01. Surgeons across the European Reference Network of inherited and congenital anomalies reviewed case scenarios, rating them with either Clavien-Dindo or Clavien-Madadi 2:10 2:10 2:23. The Clavien-Madadi classification showed significantly better agreement rates and was less frequently considered inaccurate 2:27 2:27. More pediatric surgeons preferred using it 2:34. The study concluded that Clavien-Madadi is both an accurate and useful tool in grading unexpected events in pediatric surgery 2:38.

This was not a trial that overturned practice overnight 2:01. It was a structured demonstration that the new system reduced the noise — the cases where experienced surgeons looked at the same scenario and assigned wildly different grades 2:27. Better agreement means more reliable quality metrics, more meaningful registry data, and fewer arguments about whether a center's complication rate reflects true outcomes or classification drift 2:01.

Where Practice Stands Now

Adoption is uneven 2:01. The European networks that developed Clavien-Madadi are integrating it into their registries 2:01. Centers focused on congenital colorectal and urologic surgery — where the distinction between expected postoperative course and true complication matters most — have moved faster 2:01. But Clavien-Dindo remains embedded in institutional review processes, grant applications, and multi-specialty databases that span adult and pediatric surgery 2:01. Changing classification systems mid-registry is a data nightmare, so many centers continue with Clavien-Dindo for longitudinal consistency even as they acknowledge its limitations 2:01.

The practical question for an individual surgeon is which system their institution uses for morbidity and mortality review, and whether their registry of choice has adopted Clavien-Madadi 2:01. If you are starting a new outcomes project in pediatric surgery, the validation data now supports choosing Clavien-Madadi 2:38. If you are contributing to an established registry, you use what the registry uses 2:01.

What Remains Unsettled

The validation study was European, and North American adoption lags without a parallel APSA or similar endorsement pushing the change 2:01 2:10. The scenarios tested were heavily weighted toward anorectal malformations and Hirschsprung disease — whether the improved agreement holds across trauma, oncology, and thoracic cases is unproven 2:10 2:10.

More fundamentally, no complication classification solves the problem of what counts as an unexpected event in the first place 2:01. A neonate with long-gap esophageal atresia who requires prolonged ventilation and anastomotic dilation — is that an unexpected event or the expected course? 2:01 Clavien-Madadi gives you a better tool to grade it once you decide it qualifies, but it does not settle the threshold question 2:01. That still requires clinical judgment, and judgment varies 2:01.

The other unresolved issue is whether better classification actually improves care or just improves measurement 2:01. The hope is that more accurate grading leads to better identification of true outliers, which drives meaningful quality improvement 2:01. But that causal chain is not yet proven 2:01. We have evidence that Clavien-Madadi reduces grading disagreement 2:27 2:27. We do not yet have evidence that centers using it have better outcomes 2:01.

Takeaways from this story

Clavien-Madadi showed significantly better inter-rater agreement than Clavien-Dindo in European validation across surgeons.
The new classification distinguishes unexpected events from anticipated postoperative courses in complex congenital cases.
Adoption remains uneven; many registries continue Clavien-Dindo for longitudinal consistency despite known limitations.
Validation focused on colorectal pathology; generalizability to trauma, oncology, and thoracic surgery is unproven.

Keywords

anorectal malformation Hirschsprung's disease Cincinnati Children's Hospital Medical Center American Pediatric Surgical Association APSA European Reference Network of inherited and congenital anomalies Children's National

Hashtags

#PediatricSurgery #LocumTenens #PatientSafety #BurnoutPrevention #ClavianMaddotti #TransitionalCare #AnorectalMalformation #HirschsprungsDisease #ColorectalHealth #SurgeonEducation #CME #HealthcareGuidelines #Research #YoungAdultHealth #SurgicalTraining #PatientAutonomy #PediatricHealth #MedicalResearch #HealthCareChallenges #SurgicalPractice #ColorectalSurgery #SurgicalEducation

Transcript

Hello pediatric surgery family, I'm Em Gdy from Cincinnati Children's Hospital Medical Center, and today our team is gonna deliver the articles that you should know about. We have 3 papers today but don't have much time, so let's start. Our first paper titled Locum Tanenins and Pediatric Surgery, a position Statement and Practice Guidelines from the ABSA by Fahi et al. This paper is summarized by Lizzie Lee, a physician associate by profession and a member of our team here at Cincinnati Children's dedicated to creating content for pediatric surgery. The American P Paediatric Surgical Association, APSA published best practices for locum tendon surgeons, hospitals and agencies in this review article. These guidelines stress the importance of patient safety and support for surgeons. Locum tenants can help prevent burnout by offering flexible work options for a better work-life balance. However, hospitals should avoid relying solely on locum tenants pediatric surgeons without any full-time surgeons, because this may cause patients to slip through handoffs. Locum tenants agencies should sponsor CME and conduct formal exit interviews. Our second paper is validation of the Clavian Madadi Classification for unexpected events in Pediatric Surgery, a collaborative Ernica project by Madadi Sanjani et al. and this paper is summarized by Alex Halpern. He is a research fellow at Children's National and collaborates with us to produce these article reviews. To attempt to validate this instrument, a working group of pediatric surgeons from Europe created 19 case scenarios with unexpected events. They then circulated these scenarios within the European Reference Network of inherited and congenital anomalies, and surgeons rated the scenarios based on the Clavian Dindo classification or the Clavian Madadi classification. A total of 59 surgeons completed the questionnaire. The Clavian-Matti classification showed significantly better agreement rates and was less frequently considered inaccurate. More pediatric surgeons preferred using the Clavian-Matti classification. So it seems like the Clavian-Matti classification is both an accurate and useful tool in grading unexpected events in pediatric surgery. Now moving to the last paper of the day, transitional care in anorectal malformation and Hirschsprung's disease, a systematic review of challenges and solutions by Plascivi et al. This paper is summarized by Cecilia Ina. She's one of the previous research fellows at Cincinnati Children's Hospital. This is a systematic review done in the UK and their aim was to establish and categorize challenges and solutions related to transitional care in colorectal patients. They included 234 studies and established 3 challenges and solutions. The challenges were, first, the patients' lack of understanding of their own pathology. The second one was the lack of education and awareness of adult surgeons about pediatric colorectal pathologies and. And the 3rd is the lack of a structured transitional care program. So for the solutions they proposed, first, to foster young adult patients' autonomy, 2, to conduct joint pediatric adult transitional clinics, and 3, to create a structured and coordinated transition program. Thank you for listening. Please check the link in the description below to read each paper. We hope you liked this episode. Please follow Stay Curn MD on social media, give us a rating, and subscribe to our YouTube channel. And don't forget to download the Stay Curn app on the App Store or Play Store for tons of content.

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