What's New in Pediatric Surgery 2020 - FULL SHOW

Well, thanks everyone for coming. Uh, we'll get started now. Um, this is not gonna be a lecture. This is an interactive, uh, open forum. So, I wanna hear how everyone practices different things in different parts of the world. Um, we will do this as, as frequent or, uh, as often as, um, people want. Um, we, uh, tried to pick. Some topics that we thought were relevant and new. I see some of you, uh, who have come to see this talk before. Um, so you'll know a lot of these, so it won't be new. Uh, we've added a few more new ones to it, but, uh, I had to pick and choose. So, um, let me know if you think there's, uh, other, uh, points to discuss that you think should be highlighted. So, let me, um, introduce myself. So I'm Todd Ponsky, pediatric surgeon in Cincinnati. Uh, uh, and, uh, we, uh, I'm also work with the Journal of Pediatric Surgery. So part of what we try to do is identify articles that, um, are, uh, critical and new and things that people should know about, um, because there's so many new articles out there that it's always hard to know which ones are important. So, what we did is we developed a group called the Idea Team, and I see some people here are part of it, and we all want to invite as many people who want to join to help, help identify what we think are the best articles and, and, and highlight those through fun, engaging social media, uh, videos or podcasts or whatever. So, all we're trying to do is spread knowledge to get people to know about what's out there, what's new. And, uh, so, uh, We're gonna get going on these, and I, I really do want to encourage people to get involved by unmuting your cam unmuting your mics or opening your cameras and giving us your thoughts. Um, or you can just, if you're shy and you just want to answer the polls, that's fine. But I think what'll make this more fun is to hear what people do in all the different parts of the world. Uh, so I'm gonna go ahead and, uh, start with the presentation. Um, and, uh, let me explain. So these are all cases that have been presented through the state current app or through social media. So if you follow us, you've seen these. Uh, but we figured this is a good time to sort of share ideas and talk about it. If you don't have the app, uh, you should get it. It's, uh, uh, free and, and provides all sorts of new content every day. Uh, we have, uh, uh, the pediatric surgery fellows at Cincinnati Children's, uh, Rod Gerardo and Robbie Shaban. Uh, who have been helping this year, uh, produce all the content. All right, here we go. So how do you manage a spontaneous pneumothorax? So, 16 year old comes in, no prior history of trauma, and they have a pneumothorax. Uh, hemodynamically stable, uh, breathing OK, uh, a little, maybe a little bit of short of breath. Um, How do you manage it at your institution? Do you place a chest tube? Do you admit them for observation? I know, uh, you're gonna ask me right now, so I'll tell you. Let's say it's um a 50% um pneumothorax or maybe let's say a couple of centimeters off the chest wall, uh, collapse. So, uh, how, how do you manage it? Do you observe them with, with, with or without oxygen? Do you aspirate it, or do you just take them straight to the operating room for thoracoscopy? So, so far, It looks like 67% of you, uh, place a chest tube, um, 33% do observation, and nobody does aspiration or thoracoscopy. So, please feel free to chime in, give us your thoughts on this question before I give you the answer. Uh, there's no answer, but I wanna talk about the data. So feel free to either raise your hand or just go ahead and open up your camera or your mic and tell us how you manage it at your place. If no one says anything, I'm gonna just keep going. OK. So, let's see what the latest, uh, literature, uh, shows here. Here's an article you should know about. The Journal of Pediatric Surgery published a study from the Midwest Pediatric Surgery Consortium looking at the optimal management of spontaneous pneumothorax. In this prospective trial, patients were initially treated with simple air aspiration from the pleural space with a pigtail catheter in the emergency department, followed by 6 hours of observation. If the pneumothorax did not recur, they were sent home, and if it recurred, they were admitted to the hospital. They found that 83% of those who failed the aspiration eventually required a VATS procedure. The recurrence rate of those who were sent home was 44%, with no episodes of tension pneumothorax. The authors recommend performing this aspiration protocol, and all patients that fail should go straight to the operating room, since the need for the OR is so high in these patients. So, holy cow, the answer might be what 0 people answered now. Uh, as I said, uh, you know, this could get, uh, I'm gonna keep doing this, which is gonna drive Jay crazy, but I'm gonna stop sharing for a second. So, it looks like, um, uh, it looks like what they did in this study, this is the Midwest Pediatric Surgery Consortium, is they're trying to get to the bottom of what's the best management? Should they go straight for vats? Do we really need chest tubes? It was really what they were trying to figure out. And the only thing I can conclude from this, and, and how you interpret the data, I'm curious what others think, is that we should never do chest tubes. Is that crazy? So, there's two choices. Basically, it showed that those that First of all, it showed a few things. Most patients, by the time they come in, the hole is already sealed. OK? So, you, you, you aspirate and it doesn't recur, that means it's already sealed. So, you theoretically could send them home. And so in those patients, you wouldn't need a chest tube cause it's already sealed. The other group that it didn't already seal, so that, they did the aspiration, they waited 6 hours and the recur pneumothorax came back, so the hole was still open. 83% of those who got a chest tube, they all got a chest tube, and 83% ended up getting a vats. So, You either go home or you get a vat. There should be really no reason to put a chest tube in these patients. It's an extra cause of pain that didn't really get us anywhere. That's the big, now, there's a lot of other discussion points about this. Uh, we're looking to see that the, the risk of sending a patient home with spontaneous pneumothorax is probably really low because those patients don't seem to get tensions. Does anyone have any comments on this? Questions? Do you disagree with this? Uh, let's see if anyone has anything to say. If not, we'll keep going. It's a quiet crowd. OK. So everyone kind of agrees with this big point. So I will tell you at our institution, we now do this aspiration trial. We aspirate, we wait 6 hours, we check an X-ray, and if their pneumothorax is not recurrent, we send them home. And if their pneumothorax is there, they go straight for vats. We do not do chest tubes. So, uh, and we're gonna keep going. All right. Following the removal of a mature ovarian teratoma, how frequently should you follow the patient? Every 6 months, every year, every 2 years, or only follow up as necessary. How do people follow up these patients after they take out a mature ovarian teratoma? So what do you, what were the results? OK. So, uh, here we go. Let's see what the study showed. Here's an article you should know about. In the August 2019 issue of JPS, Braungaretal looked at the recurrence rate of benign ovarian tumors in children. They performed a retrospective review of 12 pediatric centers in the UK. Among mature and immature teratomas and serous cys adenomas, the recurrence rate was 8%. Their conclusion is that these patients need robust follow-up, and they recommend every six month ultrasounds, but don't conclude on the duration of follow-up. Check out the links below. So, you know, these conclusions were just based on the author's recommendations, but the big point here is it's not a small thing that almost 10% of patients will get a recurrence. So you just can't let them go. So, I follow their recommendations. I do every 6 months, uh, ultrasound. Um, and I do actually, uh, contact them after the ultrasound. So you don't need to necessarily have them in your clinic, probably, but you need to at least touch base with them every 6 months. Does anyone do anything different? Just curious. I saw a lot of things all over the place. If anyone has an opinion, um, or if they'll change their practice based on this. OK, let's keep going. So, following an uncomplicated appendectomy, Rod, this is gonna be your, your video here. Following uncomplicated appendectomy, what percentage of patients do fine without opioids? So, Jay, let's open up that poll. And so Rod, go ahead and uh tell us your thoughts. If you, you don't have to, if you don't wanna open your cam, you don't have to. But what, what do you think is the answer here, Rod? Yeah, I was kind of surprised to read from JPS that a lot of these kiddos really don't need. Opioids after uh an uncomplicated appendectomy. I'm thinking it's probably more closer to 95, probably almost 100%. All right, let's take a look. It depends on the day. There you go. Here, I'll play it again for you. So yesterday, um, after seeing this beautiful TikTok, I, uh, I decided to, we had a big discussion in the operating room. I always get afraid of sending someone home without narcotics because if they need them, they have to come back to the hospital. You can't call it in. So the, the resident asked, should we send them home with just a few narcotics? Well, according to this, this paper, um, uh, about 85% or 84%, um, get by without narcotics on the first post-operative day. That means that about 15% will need it. Now, if you don't send them home on any, they might be uncomfortable. But I wonder if that number, like how many would actually call, come back to the hospital, or they would just deal with it. Um, but by post-op day two, it's 95%, and post-op day three, it's 100%. So, uh, we, I stopped sending home my narcotics. I think it would be a really interesting study to see if you send them home, nobody gets narcotics, how many would actually come back to the emergency room. Now, I send them home from the recovery room. So, that means they don't get their first day in the hospital. So they're going home right from the recovery room. So, it's a bit of a different question. If you do send them home, not giving any narcotics. Any comments from anybody? Questions, comments? Anybody do it different at their institution? OK. After a pyloomyotomy, which feeding protocol leads to the fastest time to full feeds and discharge? Uh, A, start with a clear liquid, then go to half-strength feeds, then full-strength feeds. B, start with 1 ounce of feeds, then go to 2 ounces, then go to 3 ounces, then ad-lib, or just let the baby take as much formula or breast milk as they want. So, start with clears, then go to half, then full, or do like a volume, incremental approach, 12, and 3, or ad lib. Jay, how's the poll looking? OK. So if anyone chatted and they wanna make a comment, just open your mic and tell us. But, um, you know, it's a tough call, and I, I really think I'm curious how many people would come back to the emergency room or be really unhappy if we just didn't send them home without any narcotics. All right, well, let's see about this is the pylo pylomyotomy. How do you advance feeds? Here is an article you should know about. It was published in the Journal of Pediatric Surgery in 2016. Doctor Markle and his team at the Riley Hospital for Children performed a randomized controlled trial to assess feeding after surgery for pyloric stenosis. They compared a relaxed feeding strategy that was mostly ad lib. To their standard incremental feeding protocol of scheduled Pedialyte half and full strength feeds, they found that a relaxed feeding strategy decreased the time to goal feeds and overall length of stay without significant differences in post-operative vomiting or readmissions. Those with serum chloride less than 100 on admission took significantly longer to reach their feeding goal. Check out the link below. So, uh, for those who, you know, there's been a lot published on this. And, uh, uh, different studies showing different things. I think ad-lib is starting to come out as the winning horse here that, uh, it ultimately is easier on nursing, easier on the patient, easier on the parents. Uh, and so, um, I, I have slowly started to switch to the ad-lib. I think I'm curious, uh, it sounds like, uh, it's all over the place. I'm curious if anyone disagrees with this study or has a question about it. Uh, but it does look like ad-lib feeds may be the way to go. So you're preparing for a stoma takedown, and your resident and your resident asks about preoperative antibiotics. What do you tell her? Do you say preoperative antibiotics have not been shown to actually decrease infections for stoma closure? Do you tell her that, oh, cefoxitin is the best antibiotic choice, or do you say, oh no, it's Unison is the best antibiotic choice? What do you tell your resident? About preoperative antibiotics for stoma takedown. So, let me just tell you that I like tricking everyone. So, my hope is that the lowest answer is the correct answer, and it looks like it succeeded this time. Uh, these are, we picked these because they're surprising articles that have good data. We chose these by good study design, high-powered studies, uh, and that answer a question that is very new and very different than the way we used to do things. So, um, Um, let's, uh, let's see what the video shows. Hey, Pediatric Surgery. Here's an article you should know about. In 2017, Nordenital out of Columbus published that by implementing a perioperative bundle for stoma takedown, they were able to reduce the wound infection rate from 21% to 8%. But in their most recent article in the October 2019 issue of JPS they published that they could reduce the infection rate even further, down to 2% by changing the antibiotics from cefoxitin to Unison. Check out the links. It's crazy, right? So, basically, um, it shows that, number one, and this was done out of Nationwide Children's Hospital, they basically showed that, uh, switching first to a bundle, um, and the bundle is a, I, I can show you the bundle. Uh, this is the bundle. Uh, I, I was talking to Levitt this morning and I asked him, what was it about the bundle that you think makes The biggest change, and he said, changing gloves and changing instruments when you do fascial and skin closures. So, changing out all the operative stuff, and then they thought out of all the bundle things, that was the one he guesses is probably the one that made the biggest difference. So, check out, change your gloves, change your instruments, but then they showed a big drastic decrease. When they kept everything exactly the same and then just changed the antibiotics from cefoxitin to Unison. And the reason they chose Unison is what they did was they looked at all the infections that happened after stoma takedown and it was enterococcus. And Unison is much better at enterococcus than cefoxitin. So that's why they switched to Unison and they were correct. It went down to 2.something% after switching from cefoxitin to Unison. So that is a very helpful study for me. It was a well-done study, uh, and it's gonna change my practice. Curious if anyone has any comments or questions about that. Yeah, a question came in, and I'm definitely about to butcher this, but no metronidaz metronidazole. No, uh, they did not use Flagyl or metronidazole. They, they just use unison, um. And uh it's an, it's a great question cause that is what we usually use, cefoxitin and Flagyl, which probably would be, you know, could be argued to be the same as unison. Good question. Any other comments? Just, uh, some other people kind of chiming in saying that they think that, uh, that previous drugs probably a good idea. Oh, Unison. OK. Cool. All right. Let me just show you a couple of other slides from this study. Um, so, Levitt sent me this slide this morning. So you can see that's the infection like at 22%. They did the GI bundle and it dropped down to 10% and then they switched to Unison and it dropped down to a very low percent. It was like 2, 2%. So, uh, 2.2%, which is the best, which is the age that you should be doing umbilical hernia repairs if you want the lowest recurrence rate. Lowest recurrence rate, OK? 1 year, 2 years, 3 years, or 4 years. What age should we be doing umbilical hernia repairs to get the lowest recurrence rate? What do we got, Jay? Wow, you guys are smart. Here we go. This is an article you should know about published in the Journal of Pediatrics in 2019. Umbilical hernia repair is one of the most common operations performed in children. Although it has a high chance of spontaneous resolution with almost zero complications while waiting, many children are having it repaired at an early age. The main results of this multi-state retrospective cohort study show that umbilical hernia repair before the age of 4 have doubled the recurrence rate and doubled the readmission rate. We should probably wait until at least the age of 4 to operate if you're not already doing so. Couple of comments here. So, first of all, I wanna talk about Jose Campos, who was just on that video. He's part of the idea team. Again, I see a lot of you are part of the idea team, but anyone who wants to send us a note either in this chat box with your email or email me at Tonsky@gmail.com, uh, and we can write that down in the chat and let me know if you wanna be a part of the idea team. Um, the, uh, Jose has taught me a good, his Jose's point is when we're trying to find important articles, we have to look beyond the pediatric surgery journals, and he's been looking at all the other journals, all the other non-pediatric surgery journals like Pediatrics or New England Journal or wherever, and he tries to find the best articles there. So it's great. He's been finding non-sur surgery journals, and, and he helps us find these important articles. So thank you to Jose for that one. Any comments or questions so far? I never knew that pediatric surgeons were so shy. Uh, would love to hear what everyone's doing at their different, uh, locations. It looks like in the chats people are um commenting about they want some some uh want the email to be a part of the idea team so we can definitely get some of that info. No, the email is my email here. I'll, I'll type it right now. There you go. What else, Rod? Yeah, and it looks like, uh, some folks saying that they're gonna have to change to the 4 years mark after looking at that, after you shared that literature with them. OK. Yeah, I, I look back, there's a lot of comments I see um in the chat. Um, so Rod, if you could do me a favor as we keep going, just, it sounds like people wanna prefer to chat, which is totally fine. So if you could just do what you do best. Uh, and then you don't have to turn on your camera. You can just open your microphone if you're in your pajamas. So, uh, feel free to, to, to chime in. OK. Yeah, no shame. I'm hanging out here in a hoodie and basketball shorts. All right. OK, this one, this one is so cool. I think this is my favorite one. It's just so out there and, and this, this article was brought to you by my partner at Akron Children's, Justin Huntington, pointed this article out to me, and it just blew my mind. And then I, I, I, uh, so I wanna present it. So, does the appendix have any effect on ulcerative colitis? A, yes. It may actually help to improve ulcerative colitis. So it should be left in when possible because the appendix may offer beneficial effects to ulcerative colitis. B, yes, but it worsens ulcerative colitis, so you should remove the appendix to help treat ulcerative colitis. Or C, it has absolutely no effect on ulcerative colitis. Jay, what do we got? OK. So all over the place. Let's see the answer. Hey pediatric surgery, here's an article you should probably know about. In the February 2019 issue of the Journal of Crohn's and Colitis, a prospective multicenter study found that removal of the appendix in patients with refractory ulcerative colitis resulted in sustained symptomatic improvement in 30% of patients. There was actually pathologic improvement in 50% of the patients, and 17% had complete endoscopic remission. Check out the link below. How crazy is that? So, who knew that? I mean, I had no idea that uh the appendix was actually could worsen ulcerative colitis. So if you remove the appendix, there's substantial improvement in, in their symptomatology and even pathologic um visualization uh uh on endoscopy. So, any comments about that? Yeah, there's uh some interesting ones. So, uh, we have someone asking, what about preserving the appendix in a lab's procedure? So, uh, I love it. So let me, this brings up a good point. If you have a question or a topic that's not necessarily what I'm talking about, but something to bring up, bring it up. So, uh, so, so I guess a lot of, again, this show, the appendix was harmful for ulcerative colitis. So for UC, no. The question I think that's being asked is, um, is, you know, is there, do we really always need to be taking out the appendix and is there some Benefit. Now, obviously, there's benefits to keeping an appendix, right? If you need to see Costomy, uh, or a Malone, uh, you can keep the appendix. I don't know, Mitul, if that's what you're referring to, uh, but, um, but you can comment more if you want to. Um. I see. Go ahead, Rod. I was just gonna say, just to backtrack on the umbilical hernias, uh, there's some questions about whether or not the 2 centimeter thing, which I think is interesting how we standardize. If you think about the size of these umbilical defects in the size of the patient, and you're looking at a 1 year old to a 4-year-old, that range that we're talking about. You know, is it worthwhile to look at defects that are greater than 2 centimeters, and are they gonna closed spontaneously? How does that apply to the previous article? So let me, let me, um, let me answer that. So, We, there was a study done in the 1960s that looked at only African-American children in the United States, and they found that the size of the ring did actually matter. That in very large defects, their chance of spontaneous closure was less. That was uh, a study that if anyone, any study anyone wants, let me know and I can find the study for you. Um, but that study, um, was published in the 1960s or 1950s, I think, that showed that large defects, uh, had a lower chance of closure. So, some people argue that if it's really big, they do it at a young age. My argument against that is, so what? Um, uh, even if it's not gonna close, why not just wait till they're older? Because some may close. The incarceration rate is incredibly low, and the recurrence rate is lower if you wait, not to mention anesthetic risks of a baby undergoing surgery. So unless someone, cause You know, for those who know me, I love a challenge. So please challenge me. I'm not the, the most knowledgeable person here by far. I'm probably the least. So, I'm just presenting the data, so please argue with me. I mean, I, wait, is there anyone that would argue that you should do an umbilical hernia repair in a 2 year old if it's a big defect? And if so, why? Um, while we're waiting, I see Salim asks about Crohn's disease. No, it does not reference Crohn's disease. That's a, that was my question. Um, you know, we're always taught to avoid doing appendectomies in patients that have Crohn's disease at the base of the appendix cause it can cause a fistula. So, they do not talk about Crohn's. This is ulcerative colitis, which is not a transmural disease, uh, that taking out the appendix helps. It's very interesting if they would, uh, study that. Um, Let's see, umbilical hernias mostly get better. Exactly. So 80% of all comers, um, do, do get, uh, do go away. All right. Any other comments or questions before we move on? Uh, Todd, Leslie not here. I was just going to mention that with the appendectomy and ulcerative colitis, I don't know if the paper went into it, but I suspect that affects the microbiome of the, uh, the flora of the gut, and that's probably the etiology for the negative outcome. So, Leslie, thank you so much. Uh, I totally agree with you. You know, the question is, Leslie, is it Laura or is it, is the appendix acting as an immunogenic organ? I don't know. Um, I will, if I can, if you email me, I can send you the link to the article. Um, I took a screenshot so I can find it on PubMed. And, and all of these are available on our Facebook or Twitter. Um, the Journal of Pediatric Surgery or stay current and also the app. So, um, they should all be there, but anyone should always know my email. If you want an article or thing, uh, feel free to call me out because I need to be called out because I'm not always right. So, um, Let me know if I'm, if I said something wrong. But thanks, Leslie, I appreciate it. What were you gonna say something? Yeah. Thanks, Leslie. All right. Let me go back. Which technique has the highest association with penile necrosis after circumcision? Now, I actually have to admit, I haven't seen this a lot, but again, in the United States, we have urologists and gynecologists that do most of the circs. So, I just don't see huge numbers, but I've never seen penile necrosis. Apparently, whoa, uh, whoa. Ah. We forgot about that feature. OK. So, uh, Faith says electrocautery. So, is it using a gumko clamp, using a plastic ball, or using electrocautery? Let's see. The answer. Has anyone, I'm just curious, people can answer in the chat, have they seen penile necrosis? But let's look at the video. And this is a great submission by our idea team. By the way, if you're on our idea team, uh, we would ask you to make these videos for us as well. Here is an article you should know about that was published in Pediatric Surgery International Journal, Retrospective Study of 24 Patients with penign Necrosis after circumcision surgery. Mentioned 5 predictive factors. The first one was monopolar cutie use. Second, post circumcision infection. Third, compartment syndrome. Fourth, local anesthetic agent use. Fifth, methemoglob anemia. And the main approaches to necrosis treatment were surgical intervention and hyperbaric oxygen treatment. Penal necrosis is a preventable complication that requires early intervention. Check out the link below. And we are actually joined by the star of that video. Bartizan is here in this meeting. Bartizan, any comments about this? Hello. Actually, uh, I, we. We came across about 2 penile necrosis. Uh, uh, that it was actually elect electro. Uh You got muted there, Bartizan. OK. It was the electrogram what caused the penile necrosis in the two situations, in the two cases. Interesting. So the electrocautery actually in your two cases confirmed what that article said that you shouldn't be using electrocautery. Yes, I see that Mitul. Uses never have experienced so Maul, you use cautery too then, huh? Yeah, Todd, uh, I've been using core. In fact, bipolars are not even available in my place, so we are using monopolars. But what we do, wrap the base of the penis with a saline soak gauze and try to keep the penis attached with the body as much as possible so that those problems with electric electrocautery do not happen. So, uh, we have never seen because, um, I feel, and we feel that uh penis is frankly a very, very much a vascular organ, uh, although there is an end artery is there, but unless you, we, um, damage that artery, we, we, where we, we are not supposed to do that. And actually, uh, in recent times we are um doing this funeral artery preserving surgery. So that's how if we take precautions, we can preserve, uh, we can avoid the complications, I think. So, I have a question. So I use, uh, I, I do, um, I use cautery also for exactly the reason you said. Um, I, I will tell you what I do see. Um, and I'm curious if, if either you or Bartizan have seen this. I, um, I see swelling. I do see that the, the glands swells a little bit if I use cautery versus if I use a knife. I is that not the case that you're seeing? OK, I, I, I, I always use knife. Cauteries are only to, uh, for, to, for hemostasis purposes. No cautery, yeah, exactly, exactly. I always use a knife, yeah, and that is the section method of, uh, exactly, exactly. So you're saying I should use a knife and then go back. I was pot cautery, yeah, OK, we still use just. We just, uh, we also use the knife and the bipolar just to to uh to coagulate the some points. Got it. And then Florencia brings up the question, I knew it was coming, why are we doing circumcisions? So, should we stop doing circumcisions? What are people's comments on that? In my opinion, yes. You have to stop. Is there anyone that disagrees with that? Well, Todd, I think I should stop making a comment on that, but I think nature has given something to us for over for an experience that is almost a million years old. So whatever nature has given us that is valuable for us. So you're saying that you think the foreskin is valuable? Uh, yeah. It's interesting. It's a, this is a, a discussion we'll never get to the bottom of, uh, always controversial, uh, but it's, it's always fascinating to hear, uh, great, and Florencia, I hope that, that shows you that, uh, you're not alone in your question. Uh, so So, uh, and, and, and that, and that is, that does fall on our lap, that, um, if somebody asks me, I, I do tell them that there's, this is a cultural thing. There's no medical reason to do the circumcision. OK, absolutely, absolutely, yeah, it's completely, I see that, uh, beta, it's a culture, very cultural, and it's very regionally different, um, and, and it's a, it's a great, a great point. And I always discourage neonatal circumcisions. Absolutely. I've never performed for the last 20 years, I've never performed a neonatal circumcision. 567 years is good. OK. OK, very good. Um. Uh, let's go. So that was a good discussion. There we go. Finally. Uh, now, the ones I just showed you were from this past year, mostly. Now, we're getting into things from previous years that I just felt were important enough to make sure that everyone's aware of these new changes. So, how do you manage a poonidal cyst? Observation alone. Uh, hair removal, and I, I take it back. Let's say this is the 2nd recurrence of an abscess. I, I didn't make that easy. So, the 2nd recurrence of an abscess you've drained, do you continue to observe? Do you remove hair and that's it? Wide local excision and do wet to dry dressing changes until it heals, a vac, uh, do a wide local incision and close it and just leave a drain. Different flaps. Um, marsupialization, pit picking, or something else. What do we got, Jay? OK, hold on a second. So before I show this video, is that true, or are people being shy? Is there really no one else here that does anything else other than these choices? We got a couple people in the chat saying GIP's procedure. Ah, so that's, I'm saying more. Gipps is popping up and someone is asking if we can see the pic again before we move on to the video. OK, hold on. OK. All right. So, you know, not too much has changed. Um, you know, E is definitely just, uh, top contender with 7 votes, but, uh, D is not far behind with 4. OK, here we go. We have narrowed down the top 10 points that you missed if you didn't catch the annual pediatric surgery update course. And finally, coming in at number 1, which I think was probably the biggest change this year. in pediatric surgery was a concept presented by Dr. Aaron Lipscar on a new way to treat pyelonidal disease. This is something we all struggle with. Our results are not very good. There have been many flaps described, and Doctor Lipscar actually talked about a procedure that was described by Dr. Gibbs in Israel, and this procedure is very simple, minimally invasive, and has great results. The idea here is for a patient that has pyelonidal disease, you take them to the operating room. And core out with a trophine or a punch biopsy, you core out the pits and then you take a mosquito underneath the area underneath the skin and pull out all the granulation tissue, all the hair, and then you use the trophines as a curette, a smaller trophine than what the hole is to go in through those holes and sort of curate out the cavity and pull out more and then flush the cavity, the cavity first with with saline and then with. So the bleeding is usually minimal. All the punch openings are left unpacked and unsutured. Drains are not required. A dressing is placed. They're told to shower once a day, put a new dressing. There's no activity restrictions except I tell them not to swim for 2 weeks. You know, injecting the local, you know, take these little punch biopsies, go right in. I've done this where it's only been 2 holes. I've done this where there's been 8 pits I excised. Um, it's really a very simple procedure. It really takes about 3 to 5 minutes. Then go into these cavities and pull out. I then take a trophine and go in. It's a smaller size than what the hole is, and, uh, just go pour it out, but it's a, you know, a cheap, quick procedure. Like I said, I'm the cleft lifts, I'm worried about padding and pressure, and with this they're, they're lying down, they're awake. On behalf of Cincinnati Children's Hospital, Children's Health Care of Atlanta, Women and Children's Hospital of Buffalo, Children's Mercy of Kansas City, Akron Children's Hospital, and the Journal of Pediatric Surgery, we want to thank you for tuning in and watching this top 10 list from last year's annual pediatric surgery update course. We hope to see you next year on August 9th when we do this course again. So I would say this, when this was first presented, uh, it was a, a big breakthrough in that a lot of people switched just because our traditional methods were so poor in outcomes. And this is so minimally invasive and has the same, if not better outcomes with almost no pain after surgery. So it's a, a really impressive uh change in my practice. I'm curious if there's comments. Rod, any comments before I go on? Uh, we had a comment, um, Mitt saying that pollinalal disease is rare, uh, in my place. Reasons unknown, maybe adult surgeons are taking care of them. So maybe there are some geographic regional differences in the presentation of this. Um, but maybe if anyone else has different regional, uh, uh, differences, if you guys notice something different about what you guys see when this is, this presents or anything like that, let us know. All right. So let's go on here. This one has been a big change in our hospital. So, 2-year-old male with a history of reactive airway disease, uh, has been coughing for 12 hours, some expiratory wheezing. Mom says he choked with when eating a carrot and hasn't stopped coughing since. What do you do? Uh, the chest X-rays are normal, and there's no air trapping on the chest X-rays. So do you observe? Do you do a bronch? Do you get a CAT scan or something else? So most people say bronchoscopy. Now, that's the traditional answer. I'm gonna show you why we don't do that anymore. We have narrowed down the top 10 points that you missed if you didn't catch the annual pediatric surgery update course. And now we're getting to the top 3. What were the top 3 key points made this year at the annual pediatric surgery update course? Doctor Mike Rubin, a radiologist at Akron Children's Hospital, presented some really new and interesting ideas in radiology. Number 1, The idea of using a chest CT for suspected airway foreign bodies. Traditionally, any child that has a history which is suspected for airwayform body, we take to the operating room for bronchoscopy. This unfortunately takes a lot of children who probably just have a respiratory virus going to the operating room, getting general anesthesia, and getting a bronchoscopy, which probably will worsen the situation, and a lot of these are negative. So what he recommends is getting a CAT scan in these patients that are unclear. And that has an incredibly high, almost 100% sensitivity for airway foreign body. And then if they have a foreign body, whether it's radiolucent or not, you can still pick it up on a CAT scan. And if they have a foreign body, then you can do a bronchoscopy. This will eliminate a lot of unnecessary bronchoscopies. This is a child, 4 days, 4 year old with 2 days of wheezing and may have choked on a peanut tube of your chest. Was normal. The cubes were normal and then gets a foreign body and you can see there in the bronchus intermedius, let's see, you can see the peanut in the main stem or in the bronchus intermedius. You can see the air trapping which actually we commonly see here's the the the other view. Here's the foreign body sitting in there with the with the air trapping. And then this is a 16 month old who may have choked on a hot dog yesterday. Uh, the chest view, a little streakiness on the right side. On the decubitus views, uh, there was no volume loss or on the, on the decubitu view, you can see the right, there really isn't volume loss. It actually looks like the right lung. There might be some air trapping. Uh, he got a volumetric CT that was completely normal, uh, was diagnosed with bronchiolitis, went home the next day, and, and hasn't been back since the CT. And so far, you know, we've had, uh, about 12 to 15 patients, um. That we've done volumetric CT for foreign body. Um, most of them are positive. We've had 4 or 5 negatives. Those haven't gone on to, to, to bronking. Um, so we've had a 100% concordance, you know, we'll, we'll get a false positive because there'll be some mucus plugging, there'll be some atelectasis. Um. Another interesting point he made was we really don't need oral contrast. Suspected bowel obstructions probably do not need oral contrast. He believes that. You can read the CT scan just as well without oral contrast, and this will really help speed up the time of how long it takes to get a CAT scan and will also prevent a lot of unnecessary nausea and vomiting on these patients that have bowel obstructions. I think it should almost never be given for anything. This is a nice example. This is a nine year old male. He had this film that's a little concerning for obstruction, but, but everybody had gastroenteritis. That's who gets a CT scan and, um, you know, you can see here in these kids, you, you've got, especially the ones that are for partial bowel obstruction or bowel obstruction, you've got so, you know, fluid is, is your, is your contrast agent. This patient had a Meckel as you can see right here. Um, it's hard to see that over here is the, the more distal loop of ileum coming out of it. It was actually twisted around the Meckle there was an ophthal mesenteric cyst, but you know, this patient came in after the X-ray. He gets the CT scan. Literally within minutes and you have an answer. This is a patient, and this happens to us all the time for rule out abscess, and this is the history. This kid got contrast 32, and 1 hours before. It's all sitting in the stomach. When you read the note, he was throwing it up, poop down, you know, these loops of all are pacified. None of these distal loops are. Here's actually the abscess sitting in the low pelvis, nowhere near where the contrast is. He also talked about that patients that have An unsuccessful reduction of intussusception should get a repeat attempt. As long as there's some movement, you know, we always try, we'll always try a second attempt. And again, if you get movement all the way to the ileocecal valve, then usually the second attempt I found are mostly positive. Lastly, he talked about that he thinks that in the modern era we shouldn't be as afraid of cats. that the radiation that one receives from today's CAT scan in a children's hospital is equivalent to living on the Earth for 1 year. The average range of a normal CT scan in a pediatric hospital is about 1 to 10 millisieverts. So a lot of times it's easy if you're getting a chest CT that may be 1 or 2 or 3 millisievers. It's basically the same amount of radiation you get from being on the Earth for 1 year. So, uh, that's pretty impressive that. Basically, we, we just went ahead and published and we now have 133 patients. 84 were treated with bronch. Um, if the CT showed a foreign body, findings were confirmed on BronC 94% of the time. If they only had a bronch, only 61% had a foreign body. The CT excluded foreign body in 30% of patients. So, uh, the point there is, if they're in extremists, you go to the OR and do a bronch, but if they're stable, Um, we can, you can avoid doing an unnecessary bronchoscopy in someone who has a reactive airway. That's the worst thing you could do in someone if they don't have a foreign body. So it's better to figure out if they really need it first and then go do the bronchoscopy. Any comments or questions on that before we go on? Yeah, I see a couple of good ones here. One is obviously considering, as we always do, the unnecessary exposure to radiation. Uh, so that's one thing. Another great question that came up is, you know, kids are gonna be kids. What if a kid needs anesthesia to get their CT? So they're gonna get anesthesia either way, and then do you still prefer it in that situation? Let me answer both of those. Uh, the risk of radiation, we have a whole another lecture on that with new CAT scans is so, so low. It's not much different than being on a cross-continental airplane flight. Um, it's very, very low with modern-day CTs. They're very efficient and in my opinion, the risk profile of doing. An airway instrumentation on a patient with reactive airway disease is a higher real risk to me than the negligible amount of radiation in a, um, in a very specific CAT scan. So, uh, I think our radiologists agree that the risk profile of an airway instrumentation is higher than the risk profile of radiation. Um, and so for that reason, we go for CAT scan first. Regarding needing a CT for, um, uh, needing an intubation for CT. Remember, most, most of the kids that are airway aspirators are older kids. They're not gonna be newborns cause they're not eating yet. So you usually do not need Uh, anesthesia for a CAT scan of a child that's old enough to be eating. Uh, so, for that reason, that just hasn't come up yet. If they do need, um, you know, uh, uh, uh, uh, an airway or anesthesia, then you could probably argue to, you know, to, to just look in the airway then. But, uh, you can take them as they come. Any other comments? OK. This one, let's just fly through cause we only have a few minutes left. Um, this is basically if you, we can put the question up there, 18 month old is into susception, contrast enema, reached the cecum but couldn't fully reduce. I'm just curious what people do here. Uh, do they, Do you, would you go to the OR for laparotomy if you can't reduce it? Uh, do you do a laparoscopy or do you repeat the contrast enema? What do we got, Jay? So, just to save time, we'll skip through this. The answer is correct. You should absolutely repeat the enema if the patient is stable, doesn't have peritoneal signs. That the enema will in, in a, almost 80% of the time, you, if you've made it all the way to the cecum, uh, the inflammation will resolve by the second enema and you can get it completely reduced at that, at that point. So, most places I know now has switched to, uh, moving towards, um, uh, the, um, the repeat enema. So I'm gonna skip this. He also talked about that patient, OK, um, there you go. Oh, so there, then I lied again. See, I told you I lie sometimes, 64%, uh, from 50% to 64% of success with the second reduction. So, Let's go to this one. a fifteen-year-old male who's injured in a motor vehicle crash, has abdominal pain, his heart rate's 130, blood pressure is 90/60. And you give him a bolus of saline. He gets better, but then gets tachycardic again. So what do you do? So this is a trauma. They, you gave them one bolus of saline. Uh, they got better but then got worse again. Do you give a second bolus of saline, or do you give blood? Do you get a CAT scan or do you go to the OR? What do we got, Jay? OK. So I probably would not go to the CAT scan in someone who's not quite stable yet. I'd make sure they're stable first. Uh, however, the, the big change here, and I'm gonna skip the video for the sake of time, is that the big change in the teaching in ATLS has been to give two boluss of saline before giving blood. That the atomic data, which was a, a cohort of about 8 children's hospitals over a large period of time with a lot of data, showed that actually, uh, you do not, you do better if you get blood earlier. So, only 1 bolus of saline, if it doesn't work, then go to blood. So one bolus, one blood. Do not give two boluss of saline as we were originally taught. We have narrowed down the top 10 points that you missed if you didn't catch the annual pediatric surgery update course. Coming in at number 4 was Doctor Norica's presentation about the atomic data. What he showed here was a very impressive result of many institutions that came together and did a prospective solid organ injury protocol to better determine how we should be treating these patients. Here are the big things. Number one, this idea of looking at the grade of the injury is really falling by the wayside. We're now using more clinical predictive factors. Failure is can't, can't be guided by the, by an algorithm. You basically, you, you fail when the surgeon says you fail. For example, he presented a very impressive algorithm for patients that have solid organ injury. We will post this algorithm with the video or the podcast so that you can refer to it later. Here are the key points that he made from this new revised algorithm based on this very large prospective study. Number one, we used to talk about giving 2 20 cc per kilo boluss of saline before you give blood. This protocol is suggesting earlier blood. Patients that get 20 ccs per kg and don't respond should probably at that point get a 10 cc to 20 cc per kg bolus of blood. If they respond to the blood, then they can go ahead and get a CAT scan or go to the pediatric intensive care unit. But if they drop and their hemoglobin is less than 7, And they need further blood which would ultimately total 40 ccs per kilo, they probably need to go to the operating room. The big magic number that David mentioned was 4 units of blood or 40 ccs per kilo. If a patient is transfused with 40 ccs per kilo of blood or 4 units of blood, that is probably an indication of failure in someone who can probably not be managed non-operatively and should go to the operating room. In patients that are unstable. Um, if you don't respond to Paxels and, and fluids, you need to go to the OR, and if you do respond, um, then you get the chance to go to the PICU and see if you'll stop bleeding in the PICU. That was probably the biggest takeaway point. He briefly talked about what to do with those patients that aren't unstable, the patients that are doing quite well, no real suspected bleeding. Those patients used to get a very prolonged admission to the hospital based on their grade, no longer. This is a big change in how we should be managing solid organ injuries in the future. If you could look at his protocol, you can see that it's a revised abbreviated protocol. Basically, patients are admitted to the floor. They get vitals every 2 hours and every 4 hours, and they get hemoglobin at 6 hours. If they are symptomatic or their hemoglobin drops below 7, then they can get blood. And then another hemoglobin test in 6 hours. If, however, they never needed blood, they can probably go home the next day. For stable patients, you really don't need to be in the hospital for a long time. The, uh, you can, you can basically transfuse them so their hemoglobin is greater than 7, and when they stop bleeding they can go home and then, uh, Sean Saint Peter and his group really said patients can go home much more quickly if they're stable from the get-go. This is a total new change from the traditional way of managing solid organ injury. All right. Let's, this one just says, if you have a line that gets stuck, uh, what do you do for a line that gets stuck? Uh, and the answer is, you leave it. Um, you don't have to, to, to go, uh, oh no, sorry, this is the wrong one. This is, I apologize. This is after placing a line. Just let's see what people say here. Do you get an X-ray for all central lines? Um, do you get only X-rays for percutaneous lines? Do you get a chest X-ray for only for all subclavian lines. Um, do you get X-ray only if you have to make multiple sticks, or you only get an X-ray if you have symptoms? Do we have any answers yet, Jay? So, uh, I'll just tell you the answers. We only have a few minutes, is that Sean Saint Peter and his group at Kansas City showed that if you just get X-rays for symptomatology, you're gonna do fine. That, um, the number of interventions, uh, Uh, in patients that, you know, nobody got critically ill. Uh, people did get symptoms and only one needed an intervention. Uh, the rest were just managed, uh, with observation. So they have moved to only getting, uh, X-rays in those who are symptomatic. Um, again, you can email me if you want any access to any of these articles. This is, uh, our summary. They had 622 catheters in the study, um. All right. Uh, this is just an interesting thing. Um, what do you do if you have a TEF leak? Uh, persistent leak? What do you do? Do you continue to observe after a week? Do you explore after a week, or do you give IV glycopyrolate? What do we got, Jay? So, observation, which is exactly what I did until I saw this study. Today he reviewed a great paper. The title of today's article is Role of Glycopyrolate in Healing of Anastomotic dehiscence after Primary repair of esophageal atresia in a low resource setting, a randomized control study. The first author on this paper was Doctor Vela. This was a prospective randomized control trial studying the effect of glycopyrolate on patients that had leak after esophageal atresia repair. There were 297 patients over a 10 year period that underwent esophageal atresia repair. Of the 297, there were 42 leaks. That's about 14%. They then prospectively randomized the 42 patients into two groups, 21 each, the one group receiving glycopyrrolate and the other group receiving placebo, which was saline. The observer was blinded to which treatment group the patient was in. And Raouf, what were the results? So the main explored variables were chest tube output, which was 124 mL in the treatment group, compared to 370 mL in the placebo group. Second variable was the leak resolution, which was accomplished in 76% of the treatment group compared to 29% of the placebo group. And oral feeding, which was achieved in 71% of treatment group compared to only 14% of the placebo group. OK, so the results are pretty astounding, the Robinol or the glycopyrolate group. So final slide, what type of hat do you wear in the operating room? Disposable bouffant, disposable skull cap, cloth bouffant, or cloth skull cap? All right, let's see it. This is Todd Ponskey with the Journal of Pediatric Surgery, and today we're gonna address a hot topic of debate in the operating room, which is the safest headgear to wear in the operating room? Is it this? Is it this or is it this? Well, this question was just answered in a recent study called Hats Off, a study of different operating room headgear assessed by environmental quality indicators. The first author was Doctor Troy Markel and the senior author Doctor Jennifer Wagner. This was done out of Riley Children's Hospital in Indianapolis. This was a really cool study. What they did is they compared 3 types of hats to wear in the operating room and they did a head to head to head trial. They looked at cloth skullcaps, they looked at disposable bouffant caps, and they looked at disposable skull caps. And what they found. Was that the disposable, uh, the cloth skullcaps had the lowest rate of infection. So cloth skull caps had the lowest rate of infection. The disposable bouffant cap had the most permeability and the most porous out of all three hats. This, the disposable skull cap or the cloth skullcap. When they looked at contamination or particle shedding, they found that when they used that vacuum to assess active sampling in the air, there was really no difference. But when they looked at the field, they found a big difference between what was shed on the field that the disposable bouffant caps had the highest shedding of all three. These caps, there was the most microbial and particle shedding on the field. The gist is that the cloth skull cap had the lowest permeability and the lowest porous material and had very low shedding compared to the disposable bouffant cap. There we go. So. Any comments or questions? We're at our time limit. We time is up. Uh, I hope this was helpful. Uh, we kind of did some rapid-fire here. Uh, Rod has been really helping finding us some critical articles. So hopefully, when we do this again, we'll have some new articles for you. Uh, let us know if you want to be a part of our idea team. Let us also know if there's articles that are out there that we didn't hit on or areas of interest that you have. Uh, if we have, you know, maybe 30 seconds if there's any comments or questions. Perfect. All right. Well, thank you, everybody. Have a good day, good evening, good morning. We'll see you next time. Thank you.