Complications and Beyond

Um just to let you know, so the journal of pediatric surgery has been very kind in letting us share um um key charts from articles through both social media through um through the uh stay current app. And so uh we we really appreciate their involvement in in education. And um those as you noticed that video made by the fellows was was was put on and in part with the journal of pediatric surgery to highlights what they have felt have been the high the key articles. Um and uh let's see, I don't know if if I see Wit, but um is he yeah there's Wit. Wit, do you want to make a comment about the JPS? Yeah, the JPS has been very fortunate to team uh with stay current Global Cast. And um, I'm glad to do that and and really uh JPS is trying to improve the care of our patients uh through peer-review articles. So we're we're glad to be part of this process. Uh, I congratulate you Todd uh, and um the others for uh another wonderful um uh webinar and uh we're just glad to be part of it. Thanks. Thank you Wit and uh we'll continue to work together and and help provide people the most uh important information. Um so we're going to move on to then the final session and hopefully get this uh closed out on time because I know we we always try to end this on time. And this final session is a complication session, always the hardest thing to discuss. Uh and so we've uh asked uh Dr. Jason Fraser and and Dr. Miguel Gilfond to take all these faculty and you know what's fun. Now we've got a a lot of faculty in here now in this zoom room and also in the chat. So uh Jason, why don't you start off? Take us through some of these cases and I know by the way, um if we have time, which that that has never happened in history, but if we actually have time at the end, then feel free to present your own complication on here. You don't need slides. I know Sean, you have a complication you may present that doesn't have slides. So uh Jason, you and and Miguel go and then um we'll we'll we'll let uh anyone talk open forum. Sounds great. Thanks Todd giving us this opportunity here. I'm gonna share my screen. All right, well hopefully this will at least start uh somewhat interactive here. Um our first case uh is a newborn baby. Uh did have a prenatally diagnosed lung lesion uh and was born uh and brought to your NICU asymptomatic. Um you of course calls you uh and says, hey what uh imaging do you want to do for this asymptomatic baby with a prenatally diagnosed uh congenital lung lesion. So I pose that to the group and then ask our experts uh what what is your practice at your facility to do? All right, who wants to start? You want me to start calling on people or does someone want to go? There Mac. Chest X-ray. Chest X-ray. I agree. Chest X-ray. Chest X-ray. Does anybody do nothing? Does anybody just follow these symptomatically and uh wait till they're older? I'm curious if there's anyone here from Canada. Uh, let's see, Eric, is Eric still on here? Um, Mary Brindle. I don't know if they're still on here because I know it's not always the same in the US or let's see if anyone from another country has a different thing, but I think most people in the US would get a chest X-ray. Oh, Tara says nothing. Uh so I'm curious. Okay, so there are some people that say nothing, but let's keep going. All right. So, uh of course, basically that chest X-ray. Uh I can see a little lucency there. Um so then comes in uh a couple months later. Uh sees sees sees me in clinic uh and gets this CT scan. So I can see acy here. I'm sorry. So the the CT scan was done uh just after birth? So the CT scan um I in my practice and if you're usually, we don't that do not necessarily routinely CT scan patients uh in the NICU. I'll usually have them come back at three to six months in clinic uh for a CT scan at that time with the CTO. and that's what happened with this patient. Um I think symptomatic patients is a different uh a little different work up and algorithm. I think that's where you probably recommend CT at least I would in the NICU. Um but in this case an asymptomatic baby, I would usually see them back in clinic at three to six months with the CTO. All right, let me stop you. So, uh Tara, by the way, correct me if I I'm calling you Tara Lou. I I'm assuming that's how I'm pronouncing your last name correctly. Um, but Tara just provoked an interesting question that I'm sure someone here has studied and I'm just not knowledgeable of it. So you get a chest x-ray and I agree with you, I would get a CT scan prior to surgery should be around three months. Um, but Tara's Tara says she would get nothing and just go ahead and get a CT at three months. So the question is, how many babies with a prenatally diagnosed lesion end up having a negative chest x-ray that never end up getting a cat scan. Because if 99% of them end up getting a CT, then maybe you don't need a chest x-ray. Sean, do you have data on that? You have data on everything. No data on that. But um I think it would be more heroic to keep neology from getting a chest x-ray than it was for Kurt Heist to get them to to get anesthesia to back off from their NPO rules. Which I have to just say Kurt, is the most amazing thing I've heard of a pediatric surgeon accomplish ever. But having said that, you make a good point. If if you're going if you're going to get a CT before you operate, the chest x-ray is going to offer nothing in the asymptomatic patient. The only thing it may do is give you a baseline if the kid comes in with a potential respiratory issue and you get a chest x-ray and they have in they have a consolidation or something. You you don't have any baseline to compare that to. That's the only reason I would get. So so I have a question for everybody if uh you get a chest X-ray and it's normal, which does happen, do you then still get a CT scan at three months or I I followed chest x-ray in three months. Always. Absolutely get a CT scan at some point. Always. But but I'm saying some of these kids totally like say they're born, totally normal. Three months X-ray. Yeah, you can get another X-ray and it's still totally normal. Yeah I'm not. But that doesn't mean it's a real normal baby. The X-ray is normal. No, but so it I guess that goes to Dan vonman's point that maybe it's a baseline, but if you're using it if you're going to get a cat scan on everyone anyways, it supports Tara's point that unless you're using an X-ray for some other reason like a baseline, you just go ahead and get your cat scan at three months. I I think to Dan's point you there's no way that theologist would not get a. Yeah, most of the time they're going to they're going to call you and say, hey the baby's here and it's already had a chest x-ray. So that's going to happen before you even probably know about the baby, so. We're not going to change this. We're not going to change this. Keep going. Yeah. So the another great question which I don't know if we're going to have an answer to and it's probably very personal preferences. What when are you going to operate on this baby? Mark, when do you operate on these kids? Around three months. Okay. Yeah, I think I think you wait longer the start you know, I've had some kids that have been further out for one reason or another and there's a little it's it's always a little bit more inflamed, it's always a little bit harder. I think three months is the sweet spot. Todd, I can't see the chat, but is there anybody out there going to say they're not going to operate on these babies? Uh, well, that's that's what I was actually there's a million responses about different ways that they work them up when they're born. Like. No one's saying that they're not going to operate yet. I think they just they're just now getting that question again because of our lag. But there are some people like we were talking about before, there's a lot of discussion about do you even get this CT? Do we want to wait till they get symptoms? Does if the chest x-ray is negative, you know, are you going to go with the CT anyway, so why not just go for it? A lot of the discussion we had previously. But as these results are coming in now, it looks like the the poll results at least, it looks like a lot of people are saying operate somewhere around three to six months. Todd, a few years ago, we had a entire Ipeg session on whether it should be less than six months or over six months. Yeah. So I think I think uh I don't know, do you want to get into that now because I I I I I can give you my opinion. I think a lot of us on this panel agree, but um we have uh Marion says six months. Uh, we got three months. We got three and six. I don't see anyone, let's see Rod, you said no one answered never. Um and it's changing but most are three to six months. I think that's probably pretty standard for most people. Hey Todd, I think you ought to get a CT at three months and act on it accordingly. Wait, so that means if there's something there, you take it out at around three to three a little over three months. Yeah, yeah. But you don't get it just you don't get another CT at six months. I mean you you know. Okay. Well, it's all been great discussion. It's nice to hear that everyone's got you know, similar but different interactions with their ideas with this, so. All right, so I guess this I would probably know the answer to this mostly, but uh is there anybody that would approach these open. I guess might be the easier option from this, your question from this. Well, while we're waiting for the faculty to answer, there's a uh from Nigeria, um, Dr. Aji says in a facility without laparoscopic capacity, when do you do open? And so obviously not everyone has laparoscopic capacity. Um, Well, if you don't have a laparoscopic capacity, would that more force you to wait until the patient are older or just observe these? That's what he's wondering or orcopic because these are hard to get through the abdomen. Yes. It's doable but you need the long instruments. Maybe you can do that, Sean. All right. There's a lot of people answering that they do openthortomies for this, so that is an issue. I I don't think that whether you do it open or scopic would change when you go after it because I think the reason for the timing has nothing to do with the scope or the technique. has to do with the lesion and whether there's going to be inflammation or infection there. Yeah, because I know the ones that I've done that have been either later diagnosed or diagnosed after pneumonia, those are can be pretty darn difficult and kind of hair raising what what little hair I have. But Mark. Mark. Yeah. Yeah, definitely if you're going to do a three month old baby, it's much easier doingcopically that open in terms of visibility. Definitely. I I think it's better to do itcopically in terms of visibility and everything else at any age. I know, but but if you don't the question is if you don't have laparoscopic have to do it on all the I would do it in all the child rather than a three months. That's the question, right. Okay, I I would do the same. I would do I would still do it at three months. All right. All right. So this kind of gets into the crux of the uh next complication section here. Um so you're doing aectomy,copically. What how do you secure vessels? Are you going to use clips, ties, energy devices, staplers, combination thereof? I know then US we have multiple different uh technological uh pieces of machinery that we can use. Uh and obviously different things like that but uh does anyone have anything that they would or would not for sure use for taking doing loectomy. So I would argue you should be able to you should at least know how to use all of these. Um, you know, but in general we use an energy device. Uh, you know, and and in the small babies it works really well. But even in the bigger kids you can use the bigger energy devices. Yeah, I would say to use whatever you use best. That's a very good point. Um Go ahead Mark. Yeah, I was just going to say I mean I I don't know maybe some of the younger people haven't seen it, but everyone's seen my uh, you know, my worst nightmare session from Ipeg where I had a stapler fail on one of these older kids that had a uh that had a low back to me for uh a CPAM that wasn't diagnosed until they were eight or nine and was having recurrent. But you know, staplers do fail and they're not and I think you need to be really careful with that and uh there's ways to do it so you have control. I think that leads us into a good segue into into this complication here. Uh, thank you Dr. Wilkin. It's a good plant. So, So you you're doing your section here, you just have the pretty much the vein left and you fire a stapler across and then you can see bleeding kind of slowly starting here um and then it becomes a little bit more rapid and a little more bleeding here. So now what do you do? So the question that we'll beg is not what do you do now and then why do we get there? So you're gonna open, you're gonna clip, we're gonna tie, we're gonna staple. Right now you just see you you can't tell what what's happening where it's coming from. No Take a look at the 11 o'clock position. No, this have this have three. Oh right. Yeah, yeah, yeah. It's coming. It's coming stream of blood coming from the polar area vein there. Yeah, so I mean I'm assuming you tried to grab it with a grasp or something, were you able to just grasp it and control it in there? Again, good good good good thinking Dr. Wilkin. Always good to have that ready. Yeah. Yeah, unfortunately, I'm uh I I my knowledge is all from experience. So that little that little bleed actually that wasn't ferocious yet but significant, gives you a few a minute or at least 10, 20 seconds to get your stuff together, get the right instruments together, get suction before going after it. I mean if it's really going, but sometimes going after it, it can make it substantially worse. So I would get my suction ready, be prepared and then go and and do the grab and try to maintain it. get get your prolene ready if you need it or whatever. Yeah, and I think that's that's the the very valuable point of this is now that you have a little bit of time to catch, you can talk to your anesthesia, you can talk to your circulating team. You can get what you need to get to be able to have the multiple next steps ready and available for when and if you do have problems that if you, you know, you let this go and uh, you know, the the whole thing opens up, you can be ready. Put in another Trocar. Yes. And that's the part of the next video that I just cut out is walking around the other side of the table, putting another tro car in and then thankfully, um thankfully being able to put a five tro car in and taking that can that Maryland off and just putting a clip on that. But having that extra step, extra extra equipment there ready, ready and ready to go is the is the important thing. But I think the most one of the most important things is realizing how how you get to this place, how you get to this place of having having here, but then also how you get out of it. So um the tips for using energy devices and everyone please uh interject as we go. Um and obviously this was an issue with the stapler which we'll get to next. But uh I know Dr. Rothenberg uh has talked talks extensively about this uh in all of his talks that he gives too. But um, you know, you want to be able to leave yourself with enough of a remnant that if you do have an issue with that energy device, it doesn't suck back. You're able to get a good purchase on um on the vessel that you're sealing. you get proximal control so that or you partially cut across. So when you have if you do have an issue there, you know about it before you go ahead and and fire completely. And the same thing with the stapler, uh, you want to make sure that you see the end of your staple. you use appropriate size of your staple and appropriate size staple load for your tissue. and then uh if you need to leave an extra little pieces of tissue around the the edge of the stapler uh so that you do have appropriate tissue cotation. And then of course with all these things uh like Dr. Wolken alluded to is be ready for the next and and Mac alluded to to Dr. Harmon alluded to is be ready for the next two things that could happen. Uh if your device or your stapler or whatever fails. those are very important things. And that's something to think about before you fire the stapler every time. Yeah, or or the sure and before you deploy any of these technologies, um, it's why I become a fan of placing a silk suture before doing that. I on the vein once you get the dissection complete, lay a silk suture down and tie it right against the mediastinum, so now whatever happens, um, you're you got the electricity off and you may lose visibility but the patient's not going to die. And then likewise the the main branch of the artery on a lower lobe, let's say, um passing a tie on that and in one case we put the tie on there and then took all the distal branches with sure. But you know that posterior superior branch um comes off before you have that that that main trunk. And so we fired the share on that and it opened up, but because we had the silk in place, we had something that we could grab, roll it over and get easy visibility and put the clip on there. Um also gives you the ability to manipulate the vessel a little bit better. And I think too, understanding the device for the stapler that you're using, understanding the mechanics of it, you know, what button sequence you need to do to push. Uh what comes next? Does your device fire on the way out or on the way back? Things like that that you know, when you know you know the instrument before you're cutting across a pulmonary artery. I think it's an important thing too. Yeah, and like like was pointed out in your case Jason, um at Ipeg that you had dissected the vessel so cleanly that it was no longer probably a a staplable um vessel as opposed to had there still been some adventiti on it. Yep. Okay. Well that's it for this one. Does anyone else have anything else if not we'll move on to our next case? Uh just want to bring up some comments here. So um the question that uh Dr. Shika brought up back to the very beginning of this discussion that we've had debates on here is that until we know the real risk of malignancy, we we really won't have a good answer on the Canadian versus US debate of leaving these versus taking these out. Um, and so, you know, it's just it's an interesting point. I don't know if the data is any better now than it was a few years ago. Um, so that's that's one point and yeah, I I agree that when you have that I I've always been hoping for creating a great trick for when you have a now a flat surface with bleeding, nothing to really on but it's a flat surface and there's blood coming out from a flat surface, how do you best get control? And all I know reliably is a stitch. Um, because a clip won't really work, it can make it worse, a stapler won't really work, it can make it worse. Um, and so you just have to I think if you're going to be doing athoracoscopic low but it's back to what Mark's point is, that's something you should go in the in the models and really make sure that you can quickly throw in at least even a basic tie. Uh, and this is not one you want to have tension while you're pulling up to tie it. I mean, this would be a good one for a controlled um, a controlled tie either corporeal or but this is exactly the reason why you need to know how to suture and tie before you do athoracoscopic lobe. Agree. All right, next case. Jason, you go Okay, so this is the second case. I'm sure Mark has a couple of those and never had one so we need Mark, you know, uh thoughts. This a young patient had ansan from a couple of years ago as a child and now present as a later and found aal hernia that is completely asymptomatic. Next one. So what do you do? How's your approach? Just observation, primary repair, repair with patch, other like medication, some thoughts, Sean, Mark, Whit, Mac, the others. What's your first approach on this? You said completely symptomatic. Yeah. So somebody's got to do something. Meaning also observation is not a good choice. Okay, medication is some doing something or just go straight to surgery? Well you can start in. Go ahead Mark. I was going to say I probably say the same thing. I'd do a trial of medication. Uh unfortunately, I don't think it's going to work, but it may give you a month or so of reprieve before you got to go in there and fix this. So will you do a month of trial of medication and see how it goes first? Yeah. Sean, with? I'll let Whit talk about this. I think he's probably seen as many of these as anybody on the phone. Not not his fault just the era. Wait. And what do you do, Sean? So if if they've got a substantial herniation, um that they're going to need a repair at some point. And so they're currently symptomatic, even if you suppress the acid, that's not going to be a lifelong answer for somebody who's got a hial hernia and we've had the small ones that we've followed back in the dissection era when we took down the frale membrane during a fundocation and invariably, they just continue to progress. They continue to go further up into the chest and create a bigger defect. Is there any difference between uh sorry, who's going to say something? This is definitely a maximal mobilization