Pediatric Surgery Updates for the PCP - Full Show

Good morning and welcome to the Cincinnati Children's Division of Pediatric Surgery live event this morning. Uh, we're joined by Division Director Greg Tal, um, Dan Chuu, and, uh, Georgie Bezarra, uh, from their respective, uh, divisions today. Um, I'm Steve Warwick. I'll be moderating the event. I'm a community pediatrician at Pediatric Associates of Northern Kentucky. Um, just so you know, there will be CME and MOC offered. Links will be posted at various points throughout the webinar this morning, and I will try to call your attention to those when they come up. Um, for today's discussions, the community support tools which our colleagues at Children's have developed are sort of the basis for our discussions. Um, there will be some links at the right side of your screen for those today. They're also available on the Children's website, which I think most people are familiar with finding. Um, but they will also be sent to you after the broadcast if you're a registered, uh, participant today. Um, just a couple little pieces of info about the format this morning. There'll be a total of 6 speakers discussing 4 topics which include pectus, ingested foreign bodies, pulmonadal disease, and abdominal pain. The speakers will speak for just a few minutes, roughly 8 to 10 minutes. Uh, we will have some time for questions. Um, in order to ask a question of the presenters, um, uh, there will be a box at the top right of your screen that says send question. If you send that, I will then receive that and we'll ask those of the presenters as, uh, time allows. Um, it's OK to ask questions at any point throughout the, the session this morning. Um, all the participants will stay on the line until we are finished. Um, so if you have a question that comes up for, say, for a, a subsequent speaker or previous speaker, please go ahead and ask. If we're not able to get through all those questions, we will ask them to the speakers directly and have a, a response emailed to you, um, from the faculty. Um, I just wanna remind everyone these topics were selected by us as community pediatricians and sent through. Um, so we're very grateful to the faculty who've, uh, given us their time, um, to share, share their expertise in these areas. So, with that, I'm gonna turn it over to Doctor Tia to, to begin the introductions. Thanks, Steve. Uh, very much appreciate the opportunity to spend some time with our community pediatric teams. Um, the division of pediatric Surgery at Cincinnati Children's is one of the larger ones in the country. We actually have, uh, 19 partners in the group and we have partners within that group that focus on such, um, areas of, um, specialty. It's kind of an unusual nature of our group where many pediatric surgery groups are, um, really a broad-based. Approach to patient care. Our group is one in which we all have, um, um, participated in pediatric surgery, but then we subspecialized in areas. And that results in us, uh, bringing in patients from a wide range of, uh of, of areas. But one of our goals with this event is to make sure we stay connected with our community pediatric teams. Um, one of the challenges of being a subspecialty group is sometimes people think we don't do all the general pediatric surgery and they might be trying to reach specific individuals about different things. The reality is all of us are pediatric surgeons and this is a good form for us to be able to share that. We have a wide ranging faculty in terms of experience, and we have 2 senior partners on and we have 2 younger partners who are more recently joined to, to be able to share that experience with our community teams. In addition, we have the great privilege of having our ENT and um GI colleagues because our team is one in which we oftentimes participate in multidisciplinary care. And so again, it's nice to have Doctor Ishman and Doctor Mkata um here participating. Um, our commitment to the pediatric, um, community locally is significant. It's one of the things that is the hallmark of what our, our group is trying to do. Sometimes it does appear that we have this focus on subspecialty areas, but really, our commitment to the general pediatric population in Cincinnati and region is as high as it's ever been. And really that is the goal of today's presentation is to make sure we're connecting with the, with the teams. Um, some of the things that we're trying to do from an outreach standpoint include events like this, but also, you know, we continue to have the contact information, contact mechanisms through the PPL and also through, you know, through, uh, email. One of the things that we're piloting is an effort to reach our community in a more personalized fashion. Um, we're developing an effort and Doctor Koigal is going to pilot this first in northern Kentucky where she will be a contact person who knows what the schedule is for all the pediatric surgeons in the group so that we can facilitate, um, timely care for patients who have urgent needs. And so this process is something we'll pilot in Northern Kentucky and then we plan to take to the rest of the community in an effort to really connect with our pediatric groups in a way that is durable. With that, I'm going to turn the time over to Dan and Georgie to, to introduce his faculty. Um, go ahead, Dan. Thanks, Greg. And thanks to everybody who's logged on, and as well as the participants here. If there are any silver linings to coronavirus in this pandemic, it's the fact that, uh, it's compelled us to reach out to our colleagues a little bit more effectively. And these virtual forums, not quite the same as in person, but um I actually appreciate the fact that we can share information uh that everybody from the community has requested. This topic of foreign body ingestions is really typical. It's part of our day to day work, and it goes everything from mundane foreign bodies like toys to much more critical stuff like button battery ingestions, and Stacey and Vince and others are going to present on that today. Um, but thanks again for being receptive to this type of communication, and Stacey has been one of those champions who really has embraced this idea of how to connect with our, our community colleagues. Uh, so thanks again for signing on and hopefully you find this very informative. Georgie, Then I completely second your gratitude and thank you and Greg for always including GI in. Using a multidisciplinary approach to better care for children with digestive disease, uh. I want to, it's my privilege to introduce uh the GI speaker today is Doctor Vince Macada. He's a gastroenterologist and he's a member of the therapeutic endoscopy team. I also want to take just a couple of seconds to share with you 3 new initiatives. That we are undertaking to improve access to GI care for your patients. The first one for patients that need to be seen within 2 days, we have the so-called GO or GI of the week. Actually this is a similar to the model developed by this stigma group of pediatric surgical colleagues for the surgeon of the week or the south. So you have now the Gau. The process to uh reach the GI of the weak uh physician is called PPL, Physician Priority Link. The second is we have initiated an asynchronous access to the gastroenterologist. There'll be one of us always on call via EI direct messaging so that we can provide you answers to questions that you might have that do not need to be answered the same day, but we have an agreement to get back to you within 2 to 3 days via EPI. The third one is we have a new access to inpatient care for patients that do not require multidisciplinary care. This is uh via a GI inpatient service at Liberty. This is also another partnership with the surgical team at Liberty. The type of patients that we'll be seeing there will be patients with abdominal pain evaluation, failure to thrive, uncomplicated IBD, first episode of pancreatitis, and a few other, uh, uh, diagnosis. The way to access that type of, uh, inpatient service here at Liberty is via physician priority link. Thank you very much. Back to you, Greg. Thanks guys. And so uh we'll turn this over to Steve who will be kind of uh moderating the session. And again, we want to thank all of our pediatric colleagues who are joining this call. It's our privilege to um have some time with you guys this morning. Thanks, Greg. Uh, one thing I'll remind folks is the contact info for each division who's presenting today will also be on those community support tools that'll be sent out and available to you, um, throughout the session and online. So just a reminder that there's lots of various ways to contact folks. So, with that, first up, I'll introduce Doctor Brown who's gonna speak to us about Pus this morning. Hi, I'm, I'm Becky Brown and I'm the co-director of the uh Chestwall Center. I'm gonna talk about pectus. Uh, pectus is very common, occurs in about 1 in 300 to 400 people, and it occurs more commonly in males than females, about 80 to 20%, and it's Familial in about 40% of patients and associated with various connective tissue diseases like Ehlers-Danlos, Marfan's disease, Pott's disease, hypermobility syndrome in about 10 to 20% of patients and is also associated with scoliosis in about 30% of patients. It's a bimodal presentation where some patients are kind of born with it and then other patients, it doesn't even show up until they start to go through puberty. And what, what is it? Well, basically what it is, is it is an indentation of the sternum, um, where over here is the, uh, the bony portion of the ribs, but anteriorly is the cartilaginous portion of the ribs and those cartilages are deformed such that they're pushing the sternum in. And by pushing the sternum in, it causes compression on the heart and can also cause decreased uh thoracic volume and can affect the lungs as well. And so symptoms occur in about 75% of patients and those symptoms might include exercise intolerance. They just can't keep up with their peers. A lot of these kids are active in lots of different sports and things like that. Sometimes they can even have shortness of breath at rest or with different positions. Sometimes bending over, uh, they'll get kind of short of breath whenever they're bending over and when they stand up, they may get kind of uh dizzy or have syncopal episodes as well. Fatigue is another symptom that patients will many times, uh, complain of and then there are the psychosocial issues of just low self-esteem by just, uh, you know, the boys won't take off their shirts and they're just very self-conscious. And then there are some patients who really don't have any symptoms at all, and uh some of those patients may be the ones where they had uh pectus from the beginning of their life, so they don't know any different. They don't know what it's like to take a deep breath, and it's so rewarding whenever you fix that patient and they, they say to you, man, I took a deep breath for the first time in my entire life. It's like putting on a pair of glasses for the first time. Um, we think also that there may be, uh, sort of minimal symptoms because the chest wall during this time frame is very flexible. And so even though there is a pressure on the heart, it's flexible and there's some give to it. And also you have a young healthy person who has very good compensatory mechanisms for the heart and so a lot of the symptoms don't show up. Sometimes what we're finding is that those Symptoms will show up later on in life. I, I sometimes see people, uh, young adults in their 20s or 30s who didn't have symptoms early on, but now they're complaining of major symptoms like a 25-year-old girl that I saw who uh we didn't do anything when she was younger, but at 25, she has 2 or 3 kids, and she says, I can't keep up with them. I can't go up and down the stairs. I, I get short of breath just walking around. Uh, something needs to be done. And so those are some of the symptoms that you'll see in the office, uh, whenever you see these patients, uh, obviously pectus is a very easy diagnosis, and when you see these patients, I would think about referring them to the chest pulse center. Uh, other things that you wanna look for, you wanna look for those signs of connective tissue disease, you know, a lot of our kids are thin and morfenoid in appearance. Uh, you want to look for that arachnodactyly that sometimes can occur. You wanna see if they have like flat feet, are they hypermobile? Can they do the, you know, thumb to forearm sign? Uh, do they have the wrist sign? Do they have like a, a high ratio of their arm span to their height? Some of those things uh go along with pectus and those should be looked at on your physical examination. So once you've identified that they, that they have a PETI, we are happy to see any of those patients and we wanna see them. We wanna get them in the system early on cause we wanna follow them for long term. Now, the patients, uh, the determination of how we treat those patients is based on their age, it's based on the depth of their pectus, and it's also based on their symptoms. But typically, you know, when we see kids in the 0 to 6 year age range, uh, we're not gonna do a whole lot. We're gonna reassure those families, and I'll tell you on social media. Uh, there are families out there like, what do I do with this little baby and they'll, they'll do like videos of that patient, um, you know, showing their chest wall, and so we're there to reassure them, we'll follow them. In the six year to uh 10-year range, we've actually developed or not developed, but we're offering a newer modality, uh, Uh, for those patients when they're not quite ready for surgery, the ideal age is between 11 to 16, but yet we may want to do something that, to potentially correct that, and I've got a prop here and uh here's my prop. This is Henry and Henry, this is a vacuum valve that we're now offering. And uh this was developed back in 2005, uh, but it's uh ideal for those patients that are less than 11 years of age that have a, a milder defect and have a flexible chest wall and basically you can pump this up and it basically sucks the chest wall out. Um, it can't be used on patients that have like uh bleeding disorders or skin disorders or, or things like that. But it may be that nice uh non-operative management that can correct a pectus completely in about 25-40% of patients. So that is something we're offering during that time frame from 6 to 10 years of age. 11 to 16 will typically, depending on what we find on their workup, we'll offer a NUS procedure and as many of you know, that's the procedure where we make a couple of little incisions and we place some bars. We pass the bars like this and then when we flip them over, it pushes the chest out. The newer things that have happened over time is that now uh with better pain management, we're actually able to get those patients out of the hospital within 2 days uh using erector spinal catheters. I'm actually presenting that at our Chestwell International meeting coming up in just a few days and it's a novel approach to this and Pain management, we've been able to minimize our opioid use by like 13. So this is the procedure, we, they have some limitations for activity for like 3 months, but after that, they can go back to doing all of the things that they were doing before and better basketball, baseball, soccer, swimming, all of those type of things. Now, whenever they come to us, we just been trying to determine whether or not they're a surgical candidate. We typically get 3 tests. Uh, the first test that we'll get is a cardiac MRI and it gives us tons of information about the anatomy of the chest wall. It gives us information about depth. The most common measure of depth that we, you'll hear talked about is the Haller index. It's basically a ratio of how wide your chest is to the deepest portion between the sternum and the spine. A normal chest is about 2.5 to 2.7, greater than 3.25 may be a chest that may warrant a surgical correction. More importantly, the cardiac MRI is gonna tell us uh whether or not there's compression on the heart and where that compression is. The most common place that we see compression is the right ventricle. And uh we're able to look at anatomy, mitral valve prolapse can be associated with pectus as well as aortic dilatation, and then we look at function. It's interesting, we looked at 345 patients. This should be published in the Annals of Thoracic Surgery here shortly. Um, but, uh, we looked at 345 patients that underwent, uh, a cardiac MRI that had pectus and found that 16 to 22% of these young healthy patients already had, had abnormal cardiac function with right ventricular ejection fractions less than 50% and left ventricular ejection fractions less than 55%. That's just at rest and the remainder of them had low normal function, so we know that it's impacting the heart. We also want to see what happens when they exercise. So, uh, they do a cardiopulmonary exercise test and with that, we're able to see if they have a cardiac limitation to exercise or pulmonary limitation to exercise and 33% of our patients had abnormal cardiopulmonary exercise tests already and these are Young healthy people in their prime of their life. And finally, we'll get a pulmonary function test. Uh, there's decreased thoracic volume, the lungs don't have as much room to expand and many times there's a restrictive defect which can impair, uh, function as well. So I just wanna emphasize that pectus is not just a cosmetic, um, abnormality. Uh, but that there are significant cardiopulmonary issues associated with it that may progress over life, and we're here, we're happy to follow these patients and, uh, follow them throughout all of the stages, uh, whether or not we do surgery, don't do surgery, or just reassure them. But thank you for your referrals, uh, to the Chestwell Center. Excellent. Thanks, Becky. Um, I don't have any questions that have filtered over to my screen just yet, so if folks have questions for Doctor Brown, please feel free to send them through. Um, we'll move right along for time. Um, next up, we're gonna hear about foreign bodies, um, from, uh, Doctors Iman, Mkatta, and Milliudi. You guys go ahead. Thanks so much. Uh, we are all gonna be chiming in, so I'm gonna start. Um, I'm Stacey Ishman. I'm with the ENT division. And the reason there's 3 of us from 3 divisions is cause depending on where the foreign body is located, we all participate in the care of these kids. So foreign bodies, as you guys know, are very common. When we think about the assessment, there's some really key things we need to start off with. Um, the, these include things like whether or not it was a wit witnessed foreign body ingestion, what the timing was, um, and whether or not they're having significant symptoms. And so common symptoms include things like pain or drooling, and those are the kids who are a little bit more acute. They may just be acting fussy. Um, oftentimes they could be refusing oral intake. Um, may have difficulty with breathing or noisy breathing, or they may be asymptomatic, but the ingestion was witnessed, and then alternatively, there's a group who may have had an incidental finding on some kind of imaging that was done for another reason. Um, the key thing here is to decide if these kids need to be sent, um, for some kind of further evaluation, whether that's imaging or whether you think there's gonna need to be some kind of intervention. Um, and then there's a group who may be watched and, you know, observed, um, whether that's done with imaging that was done through the pediatrician's office or whether you think that's something that should be done in a more urgent setting. Um, and then, especially if it's a witness ingestion of something that's fairly benign, there may be a group where you observe and wait and see if they pass that or develop any symptoms, especially in those kids who are asymptomatic. We'll hear a little bit more of that as we hear my colleagues talk about management. Now, there are some red flags in the history and physical exam that would make you want to refer those kids and to be honest, most of these kids will be referred directly to the emergency room, not to one of our specialties specifically. Um, but those tend to be those who have the breathing difficulties I talked about, so difficulty breathing, um, kids who have intolerance, um, to either their own secretions or are unwilling to take any oral intake. If there's any blood or vomit, um, I'm sorry, any blood in the vomit or the stool? Anybody with a fever? Um, and then if you've witnessed ingestion of certain foreign bodies that we know are urgent, so this is including things like button batteries, which Dan mentioned earlier, that is an urgency, it needs to be taken care of right away, magnets, um, sharp objects like pins, um, or caustic gestion. And then those kids with severe abdominal or chest pain, in addition to kids with a history of oesophageal anomalies or those with a history of surgery, you should really have some increased suspicion of the risk of impaction. Of course, I'm getting a phone call, sorry. Um, and then once those symptoms are noted, um, a phone call and a referral are really indicated. Sorry. Um, and then the other key thing is to make sure that you instruct the family in those cases where there's red flags not to give anything to eat or drink. Um, I'm gonna pass this along to my colleagues to talk about management and treatment. Um, all right. So I will, I'll, I'll lead off here, um, from, I'm Vince McCado from GI, um, as Georgie said, I, I, I do some of the therapeutic endoscopy here as, as well as eosinophilic disease and, and inpatient care. So, um, I'm gonna start with talking about management and, and treatment options, um, and then I'll hand off to Vargava to also talk about where pediatric surgery gets involved and how the different specialties interact on, on management of these patients. So, Um, as, as Stacey said, um, the key thing in, in the assessment is figuring out, are, are you seeing any of the red flags that we saw? I mean, the, in, in all honesty, for most of, a lot of these cases, the, the, um, ultimate answer is referral into the, into the emergency room, um, for further evaluation. But Um, as we, we started to discuss, there are some, uh, few foreign bodies that can be managed conservatively and, and observed. So, uh, for instance, coins, um, single magnets, um, intestinal foreign bodies, so foreign bodies that are seen in the, in the intestine, um, incidentally, um, so, If, if a patient comes in and says they've had a single coin swallowed or they, they saw their child swallow a coin or a, a single magnet and they're asymptomatic, um, and We would typically refer them for imaging. If the, if the object is beyond the esophagus, um, it may be appropriate for them to be managed expectantly and, and they generally will pass. Um, but, but by and large, a lot of these things are, are things that we need to be involved with and, and, uh, potentially consider removal. Um, and so, it is, is, is in our decision aid, um, you'll see When to refer. And so, um, referring for the, to the Cincinnati Children's Emergency Room for management and treatment. Um, and really, we are talking about the base ER, um, at the moment. Uh, we can, we do do some of these at Liberty as well, but for emergent or urgent cases, it's, it is, uh, more appropriate for them to be sent to the, to the base. Um, in the ER then we'll, we'll see them, assess them, and, and then talk to us to, to make decisions about how to do this. Um, so, cases that we talked about that are requiring more urgent removal, so button batteries is, as we've referred to multiple times. So these, uh, small button batteries are true emergencies. They, they need to be evaluated and, and usually taken out, um, as soon as we possibly can. Um, unfortunately, they have caused, uh, really bad outcomes, including fatalities within 2 hours of ingestion. And so this is a true emergency. Um, magnets, especially if it is more than one magnet, um, or a magnet and another metallic object, um, and particularly rare earth magnets, which are the, what, what we're seeing are the, these, uh, desk sculptures, those type of very strong magnets. Um, because unfortunately, if they separate or they're ingested at separate times, uh, they can attract each other across the wall of the bowel, um, and actually cause perforation and, and, uh, fistulas, um, and they are not easy to remove for that reason, but they, they need to be, uh, need to be dealt with quickly. Um, coins, if they are still in the esophagus, or, or if, or if patients are having symptoms. So, um, if the, if the child is complaining of pain or not tolerating the secretions, those need to be removed urgently. Um, objects greater than 25 millimeters, um, may be difficult to get past the pylorus, and so they can kind of get stuck there and cause vomiting. Um, so we will typically go and get those. Um, long thin objects may also get stuck either transverse, uh, traversing the pylorus or as they make the turn in the duodenum, and so we tend to try to get those if we can in the stomach. Um, once, once things have reached to the intestine, by and large, we, we let them go, um, because it is difficult to get to them, and most of them will pass without difficulty, and, um, that, that can include some, some surprising things. So we, you will see us let sharp objects go sometimes, um, once they get past the stomach, they tend to, to pass without too much difficulty. Um, There may be, you know, this is, as the focus of this is on community care right now, um, a lot of this is focused on getting the patients to the emergency room and for evaluation. Um, there may be some coming changes as, as we talk about button batteries in terms of things that we might be able to do at home, but, uh, more to come on that. Um, and I was gonna hand it over to you to maybe discuss when surgery gets involved or how the, how the services interact. Yes. Um, I'm Bargaba Muliudi, I'm one of the pediatric surgeons and a transplant surgeon here at Cincinnati Children's. Um, so, most of what, uh, Stacy and Vincent do is try to avoid, uh, me or my group from getting involved, uh, but it do happen sometimes. The way we think about these is either a delayed presentation or an early presentation when surgery gets involved. Early, most of the time, the first question we ask when There's a foreign body is again, just to reiterate what they, um, what Stacy and Vincent said is, is it a button battery. Uh, it always comes back to that, trying to get that emergency out of the way first. Um, and also magnets, if magnets that are swallowed at different points of time, these are all high risk for perforation. sepsis and having really bad morbidity. So, our goal is to avoid that. Uh, most of the time, um, those either cause perforation and sepsis needing us to go in surgically, either sometimes laparoscopically, sometimes open depending on the degree of the injury. Um, and sometimes it could be very benign, such as there, there could be an esophageal kind of ischemic injury that can cause a stricture that we, we may need to address later on. Sometimes they can be uh further along in the small bowel. They're just, uh, uh, just like two different magnets at two different times. They can attract to each other in the small bowel and they can cause perforation. Uh, some of those things can be managed laparoscopically. So, again, our goal is to avoid needing surgery, um, but we're there whenever it is necessary. Excellent. Thank you guys for that. Um, while we're getting ready to make the transition, we did have a question come in for Becky, which I suspected it would take a couple of minutes for him to trickle through. Um, that question was, are there any concerns with pectus carinatum or is that simply a, a reassurance standpoint? So for the uh Pictus carinatum patients, we do wanna see those patients. We have a very, very, uh, well-developed, strong bracing program for those patients that uh we get great results and the earlier we see the patients, the better. If we see patients even as early as like 6 years old, um, we get great results. If they're compliant and wear the brace, uh, there is, there's great uh chance of the pectus carinatum getting completely corrected without surgery. Awesome. Thank you very much. All right. The next speaker is gonna be Doctor Rosen talking about pyelonidal disease. Yes, good morning. My name is Nelson Rosen, and I'm one of the colorectal surgeons here at Cincinnati Children's. Many of you may not know me as I've only been here for 2 years, but before that, I was in practice here in New York. And as a young pediatric surgeon, I became very frustrated with traditional approaches that I was taught to treat patients with pelonidal disease, and I had a specific patient, a 6'4 hockey player that I did a wide excision on and a primary midline closure, and my big, beautiful surgery ripped completely open, and I was faced with a very frustrated young man begging me to do something for him. And I did what many people do, and I went online and I found pylonital.org, and that led me to the patient forum, and I read the story about people talking. Uh, about all their suffering from open wounds for years and then finally getting their, their Bascom, and then all was fixed. And I had never heard of this Bascom, and I did additional searching and I came across John Bascombe, who was a surgeon in Eugene, Oregon, and he came up with what he called the cleft lift procedure. And so I called him up and we spoke for hours and my New York pyelloidal center was born. And uh when I came here, we structured a full pyloidal program with a very special cohort of surgeons who provide full spectrum pyloidal care and uh we, I, I think we have a good thing going to be able to support these patients and to support struggling people with pyelonidal in the area. Now, uh, very briefly, I'll take you through our approach. Real pyelonidal disease always presents in patients who have started puberty. You know, like, uh, in life, no always, no nevers. There are exceedingly rare exceptions, but overwhelmingly, if you have a patient who is much younger than puberty age with a sinus in the cleft, or pain in the cleft, it's probably not real pyelonidal disease. And if you have trouble distinguishing, just let us know, give us a call, uh, you know, we'll, we'll be happy to see the patient start with a physical exam and image as needed. Uh, Once patients get to puberile age, we really start seeing pyelonidal disease come in fast and furious. Pyonidal patients come in a variety of presentations, but usually split between acute and stable disease. Acute patients have active infections, pain, and swelling. Stable patients have either an acute infection that are already draining, and therefore they're usually not in much pain, or they just have like holes that drain a little bit of fluid that is either bloody or foul smelling. When we meet a new patient with uh ploidal, we get a full history, and specifically I ask about inflammatory bowel disease, uh, because you do see, uh, you see a combination of Crohn's and pyelonidal, not infrequently, and it can be sometimes hard to distinguish. Am I looking at a perianal fistula? Am I looking at a pyelloidal? Uh, so, uh, we can help with that. Uh, I also ask about other pile of idols in the family, and you often find, oh yeah, my, my father, my cousin, somebody, they're not that far out there. Uh, when we do a physical exam, the first thing I do is actually use a clipper and get all the hair out of the natal cleft. I find it like impossible to see what's going on without clipping and getting the hair out of there. So we actually, to make this easy, we have like a whole bunch of rechargeable clippers in the office with disposable clip heads. It's really, really helpful. Years ago we used to use single-use razors and like sometimes one patient, you'd go through 4 of those razors. It was terrible. Really, really help. Uh, and the other thing that, uh, that the clipping helps, like, you know, you, once you see down there, you can see the holes in the midline, uh, and Uh, pylo is a hair is the pylo and pyloidal, and when we see those holes, you often will see hair sticking out of the holes. And what we'll do is we'll take a tweezers and we'll slide that hair right out. That hair is no longer connected to the patients, and by getting it out, you're helping prevent infection and may help things heal. So for patients with acute infections, if there's a palpable fluctuance, we drain it. Small infections can be aspirated. If it looks large, uh, we'll make an opening into the abscess cavity and drain it completely. Uh, we try and avoid packing these wounds as packing, you know, the traditional stuffing, packing strips deep into the wounds, uh, really doesn't help infections drain. It can increase pain. It also makes challenges in home care. You need to coordinate. Packing removal. I prefer just to tuck the corner of a gauze gently into the opening of the wound, which is all you need to control hemostasis. If you do a little drainage, it usually bleeds a bit, and you don't want them sopping blood into their pants on the way home from the office. That is suboptimal. And then once I tuck the corner of a gauze in there, I just wad up a little dressing on top, and it's like really all on the outside, and I tell them to take a shower or bath twice a day. Wounds like water and these patients need to bathe. And if my initial dressing has stuck to the wound, when they get in the shower, it gets all wet and it falls off. Uh, you know, people often recommend baths. I find the compliance with baths to be fairly low, so I recommend showers and hand showers, but bath is quite good. All right, when we put acute infection patients on oral antibiotics and we use broad spectrum antibiotics like Augmentin, Clinda, or for recurrent infections or very significant infections, Cipro and Flagyl, a 5 to 7 day course is usually all that's necessary. The infection may have resolved with simple drainage and good hygiene measures, but they often have a lot of pain, and I think the antibiotics helps resolve it quicker. Now for patients without acute infections, they need to start on a regimen of good hygiene and regular hair removal. We counsel weekly clipping or the use of a debilatory like Nair. We recommend they have somebody inspect the pits or sinuses once a week and try to tease out air. We even give them the tweezers that we use in the office so that they'll have something and that won't be an excuse, but compliance is, is, is moderate on that one. And at this point now we think of our surgical options. So back when I started the pilonidal program in New York many years ago, the only option I offered was the cleft lift, which is an off midline closure, a primary closure operation, and it has a tremendous success rate. But in 2017, I started doing what's called the GIPS procedure. One of my younger partners actually contacted Gips and learned all about it. Moshe Gibbs is a surgeon in Israel. Who's really led the charge in the minimally invasive pyelonidal movement. What Gibbs does is he uses skin biopsy punches size to be just bigger than the holes. He punches out the holes. It can actually be done under local. I prefer to do it under sedation because once you punch out the holes, then you go into the cavity with a little scrapy tool, a curette, and scrape out the cavity and remove all the hair. And then we leave the holes open. Most heal within a couple weeks. They don't need packing. They don't need activity restriction. And about 75% of the patients, this will cure them, and they will not have issues. But 75% is not 100%. So for patients that it comes back, we might offer another GIPS or we might move it to the next level, to the cleft lift. One thing that we do differently here with the GIPS procedure is that we actually take a small scope. Once we've done cleaning out the cavity, we put the scope in the cavity and take a look and make sure we didn't miss anything. So it's a little bit of a hybrid approach. The Italian surgeons have pioneered the use of endoscopy and pilonidal, so we blend the two operations. For patients who present initially with wounds, there are patients who present with large wounds at the initial presentation. They're often the patients that don't have a lot of pain, which is how a wound could have developed without them really knowing about it. We usually spend several weeks to months of non-surgical care, good aggressive wound care to get things to heal, and then we'll usually offer a. Left lift. The cleft lift is still an ambulatory procedure like the GIPS procedure. It takes about 90 minutes of general anesthesia. They do have a lot more pain. So unlike the GIPs that just need Tylenol or ibuprofen, they will need Percocet. They do have a drain for about 5 days, but they are very happy with the procedure, and it has an over 95% success rate. So those are your surgical options. Our pilot program is here to support you and the patients in the area. I know many pediatricians and family doctors routinely drain abscesses. So if you don't, just give us a call. If you do, we're happy to see your patient and follow up at any time. You have an anxious family or suffering patient, we will see them that day or the following day. You just have to let us know. We'll take care of everything. And with that, I will hand it back off. Excellent. Thanks, Doctor Rosen. Good to hear about the new approaches to this as well. Um, we do have another question that came in, uh, regarding the, in, uh, foreign bodies related to magnets, and the question is, can, uh, gastroduodenal fistula caused by magnets be managed conservatively after taking out the magnets by endoscopy? I think the, uh, more commonly, the fistulas are enteroenteric fistulas. If they're there for a long time, you tend to have connections between the small bowel or sometimes small bowel and colon. Um, based on where the connection is, sometimes you can have a lot of diarrhea because a lot of bile is being shunted from the small bowel in directly into the colon and such. Gastroduodenal fistulas are kind of not that often, especially if they're magnets or, um, uh, button batteries and they Erode through the gastroduodenal area and most of the time they end up either perforating or causing some kind of ischemic injury, and especially if any of these ingestions present with a gross abdominal pain, that is um a concerning sign and something, an indication for an operation. Excellent. Thank you very much. All right. And our next speaker is gonna be Maraota Gall talking about abdominal pain, and I'll just put a plug in that she and I spoke on the phone a couple of weeks ago about this very sort of scenario, and I think the process she's gonna talk about um is very helpful to us as community pediatricians in, in contacting folks and, and getting our patient services. So Mara, go right ahead. Perfect. Thank you so much, Steve. Um, I have the very narrow topic of abdominal pain. Um, obviously, it's, there's a lot of complex diagnoses within the bucket of abdominal pain. We're gonna touch a little bit on the three most common, and then, um, particularly wanna touch on the topic of non-operative management of appendicitis, as I'm sure you'll get questions about that from patients and from families. Um, and then touch on the, uh, the process that Steve mentioned um that we recently used for an abdominal pain patient of his. Um, so, obviously, uh, in the, uh, the practice tool, this specific practice tool focuses mostly on acute abdominal pain. So obvious some patients can have chronic abdominal pain and there's a separate sort of workup and thought process to evaluating those patients. In patients who present with more acute abdominal pain, the three most common diagnoses that we think about for those patients in addition to gastroenteritis, which obviously is not necessarily a surgical diagnosis. Appendicitis, gallbladder pathologies which include symptomatic cholithiasis and and acute cholecystitis, and then ovarian pathologies including torsion and the rupture of an ovarian cyst. Um, those patients that really, as with most things in the surgical field and, and many of the things that you deal with every day, the most important steps are really thinking about history and physical exam. And, and by doing those pieces, you can learn a lot about how long has the pain been going on, what are the palliating and provoking symptoms for those patients, what are associated symptoms that may be um indicative of what kind of um driver there is for the pain. And so we start by doing the same thing that you do, understanding that history, and then looking at the physical exam. For patients with ovarian pathology, they may have a more sharp onset of pain, um, particularly related to either torsion or a rupture of a hemorrhagic cyst. Um, they may, you may actually on exam be able to feel a palpable or tender pelvic mass. Um, and those patients should be referred urgently. They'll get a workup including an ultrasound to evaluate allow us to evaluate whether or not there's some evidence of an ovarian mass that might be suggestive of torsion. An ultrasound itself does not always tell us whether or not a patient has a torsed ovary, and so we, we will sometimes take those patients to the operating room for laparoscopy either by ourselves or with our GI our gynecology colleagues to determine whether or not there's an ovary that needs to be detorced. And if so, if there's a cyst associated with it that could be removed while sparing the ovary in order to reduce the risk of a future repeat torsion. When we talk about gallbladder pathology, the most common things that we see are symptomatic cholelithiasis and acute cholecystitis. And those are obviously differentiated both a little bit by chronicity. Many times patients with symptomatic cholelithiasis have had more than one episode of pain, and acute cholecystitis tends to be more abrupt in onset. In both cases, um, ultrasound evaluation to allow us to determine whether or not the patient has stones. And then, um, looking to see whether or not there's wall thickening or elevations in their white count that might suggest a more acute infectious process. Cholecystitis is the most common gallstone related complication, um, but again, not super common in our patients. We more frequently see patients who have symptomatic gallstones and have had them for quite some time. And then the last kind of big bucket is thinking about appendicitis, and I, and I wanna touch on that, um, just to kind of give people the perspective of a couple of things that we're doing now and that you might hear about in the literature. Um, the first, you know, thing that we think about with appendicitis is really the nature of the pain, often starts perambilical and migrates to the right lower quadrant as they develop some localized perineal uh inflammation. They may have an elevated white count or left shift um with their leukocytosis, and often an ultrasound is the first diagnostic study that we use and it can often give us pretty good information if the if the appendix is able to be visualized, so that we can determine how thick it is, whether there are any secondary signs of inflammation, and whether or not there's any concern for an abscess or free fluid suggesting perforation um adjacent to the appendix. Within our practice over the last year, you may have seen more patients that come back to you with a single incision. Um, and so we have been, um, studying and, and using single incision laparoscopic surgery for appendicitis, where we actually make an incision just below the umbilicus or at the level of the umbilicus, um, and use a camera and a working scope that allows us to identify the appendix and actually mobilize, um, the cecum and the appendix enough that we can get the appendix out through the belly button. We then remove the appendix in the old fashioned open fashion through the belly button and then reduce the cecum back into the abdomen and close the, um, the umbilical site. Um, so many of us are doing that procedure when we're able to. Not all patients are able to have their, their appendix easily brought up through the belly button depending on the degree of inflammation or how stuck it is to things around it. So, in some instances, we'll start with a single incision and then add in two additional ports if we find that we need to in order to be able to safely remove the appendix. So just so that that's um something that you've heard about from us, um, as you may see patients who just have that single incision at their belly button after having an appendectomy. Um, and then the last thing I wanted to touch on, um, is really about non-operative management of appendicitis. Um, it may be something that you hear about from families or that they ask you questions about, and we definitely hear about it from families when we see them in the emergency room at times. Um, non-operative management has been sort of an ongoing debate over the course of many years, but there are two kind of recent studies that have really informed a lot of this discussion. Um, the first is actually a study that we were involved in as part of the Midwest Pediatric Surgical Consortium, which involves 11 hospitals around, um, the Midwest region and mostly children's hospitals, and those, um, hospitals focused, um, on asking a question about was antibiotic use for management or no. Operative management of appendicitis. How did that compare to surgery for two outcomes. One was the likelihood that those children needed their appendix then removed sometime within the next year, and the other was whether or not they had more disability days, days that they couldn't go to school or participate in in normal activities. And when they looked at that, they found that about 67% of kids who had non-operative management of appendicitis, meaning that they got treated with antibiotics and did not undergo a surgical procedure, were able to make it through the next year without requiring an appendectomy. So they had that single episode, they were treated with append with antibiotics and did not require a surgical intervention. And that they had a slightly decreased rate of disability days. This study done through the Midwest Pediatric Consortium was a choice. Families could come in and say, I wanna have surgery or I don't wanna have surgery, so it wasn't a randomized study. But it does give us some information that somewhere between 2/3 and 3/4 of patients who get treated with antibiotics may not need a surgical intervention. Um, but there is the, the ongoing risk that they could have a recurrent episode of appendicitis, or, um, That they could have complications um related to that. There's a second study that occurred in the adult world, which is actually a randomized study, and that's called the CODA study, and that was just published um in the New England Journal in the last month. And, and they looked at quality of life as well as um the likelihood that patients had appendicitis. And I bring it up just because they noticed something that we commonly see in our practice, which is patients who have an appendicolith. Or more likely to fail non-operative management. So they found that 40% of their patients who had an appendicolift went on to have surgery within the 1st 90 days. Um, so we often within our practice and every, every surgeon is a little bit different in how they discuss this, but we do offer this and discuss it with our parent patients. Some people feel more comfortable with it than others. Some families feel more comfortable than others, um. And it, but it is something that exists out there and that you may get questions about, and most of us sort of say that there's somewhere between a 2/3 and 3/4 chance that that will be successful in patients without an appendicolith, um, who have non-complicated, non-perforated appendicitis. Um, and I'll stop there. I I imagine there may be questions about abdominal pain because it's such a big topic, but those are just some basic things, um, that we're thinking about when we see patients with abdominal pain. Um, the last thing to mention. Um, that Steve sort of was talking about was this idea of how can we help when you have patients who have who have urgent abdominal pain. And I think the, the biggest thing there is we, we have sort of two things that we want you to be aware of. One is that Priority link is always available and we're always happy to talk to you about our patients. Um, Greg mentioned the idea of these sort of liaisons, that we're gonna try to create more contact for you with somebody from our group, so that you have someone you can touch base with when you have a question. But the last thing is that over the course of the last few months, we've developed the Liberty Sal model, which is just like we have a surgeon of the week at base, we now have one at Liberty. That person is up there all week, and they have clinic in the morning and OR cases uh in the afternoon, and a lot of flexibility to get patients in the same day or the following day as needed for intervention. So, as you call us, you may hear one of us say, let me stick, let me find out if I can get this patient in up at Liberty, and that's what Steve and I did. We had a patient came and saw me in clinic in Northern Kentucky. Doctor Chia was actually the Liberty Sal that week, and so he saw the patient and and got them in for surgery. That same week. So without adding an additional clinic visit, um, and a long time to a surgical intervention, we were able to do that pretty quickly. So we're always happy to help if you have questions or anything we can do to answer, um, about your patients and, um, thanks for being such great partners with us. Excellent. Thanks, Mira, and thanks to Greg as well. It was sort of a, I think it's funny we're all 3 on this call and had no idea it would fall out that way with our single patient, but it worked well. So, I don't have any other questions specifically that have come in right now, but um I do have one question of my own regarding the, the button battery ingestions and so, Um, just, I wanna clarify, I know Vince, you talked a little bit about it. It's my understanding that right now, the standard of care is still to go get those if, uh, if we know it's there. But I know there are a couple of centers around the US just based on some colleagues, um, that I have in other places that have called me and asked the question, well, what are people doing in Cincinnati? Uh, because they've had patients who swallowed it, but then for Some reason or something related to the specific cases, um, it was, it was allowed to let those pass actually rather than, than to go get them right away. And I was curious if you could speak a little bit to some of that, uh, that evolving sort of, of science right now cause it seems to be a little different, but everybody wants to know what we're doing here, which I think is a nice thing still. Yeah, so, I, uh, uh, excellent question. So, Um, in general, if the, if the button battery is in a location where we can get it, we are still going and getting it. Uh, we will let them pass if it's reached past the stomach, um, cause by that point, they usually, um, we, we're usually past the danger point. So in an asymptomatic patient where it is past the stomach, um, where it would require operative management to go get it, usually, it is fine to, to let them go. Um, but the one, the thing that has changed a little bit in the outpatient management of these, um, is just the preoperative management. Um, and we, as I sort of hinted at, we, we may change our guidelines here as well. Um, there's been a move towards, uh, having people give Honey in the outpatient, so if, if a family calls, um, they, on their way to the emergency room, um they can give honey and, and uh it's recommended to be 2 teaspoons every 10 minutes up to 6 doses. Um, and then in the emergency room setting, sometimes we, we can use Carafate, which does seem to, uh, from the evidence seems to reduce the, the damage that's done by these batteries. We haven't, I think our groups need to discuss this, um, whether we want to change how we suggest managing this. I've, I've done a couple of cases now where the patients have come from the outside like this. Um, I will say it, it did, you know, the outcomes were good. The, the patients did not have any significant damage to their esophagus or stomach. Um, it does make the removal challenging. It was actually quite difficult to find the battery in the midst of, of a massive honey and carafate that was at the, in the distal esophagus. So it's not, uh, it's not 100% trivial to, to deal with that, but I think if the, if the evidence is good enough, we might, we might make that change on the outpatient side, which might also change what, what you guys potentially could do, um, when you get phone calls, for instance. Um, But by and large, if it's in a spot where we can reach it, uh, we go and get it. I, there's, there's some discussion over stomach gastric foreign bodies. Um, I will say most of us tend to go get gastric foreign body, uh, I'm sorry, gastric button batteries. Um, unfortunately, I've had, uh, uh, one fatal outcome, uh, with a patient with a, with a gas gastric foreign body. So, um, I, or, sorry, I keep saying that gastric button battery. So I, if I can reach it, I, I will go get it. I would also say no matter what, I, all those kids should come urgently to children, so we may decide that we don't end up doing surgery, but they should all be evaluated if we thought that that's the most likely outcome. We had an interesting case. That was gonna be my follow-up question was, I feel like we should still send them all and then the decision could be made once the assessment is made. 100% correct. OK. And we had an unusual case earlier this year where a foreign body like that was passed, um, but never was, did not come out and it ended up stuck in the appendix and so we had to do an appendectomy to get the, the, the, the, the, the foreign body, so. These things are unusual and they find ways to get into strange spots and especially with the batteries and you know, with magnets also, if they kind of fistulize, it can be really problematic. So it is one of those, you know, you know, common issues that really have some morbidity if not optimally managed. All right. I have a few more questions that have come in, in the interest of time. The first two here are gonna go to Doctor Rosen. Um, the first question is, is there a video for the pylonato procedure you discussed that folks can find to watch? Great question. Actually, the best video, uh, I would love to say it was ours, but, uh, on the minimally invasive is actually Moshe Gibb's video, and, uh, I, I think it's pretty easy to find, you know, if you search Gipp's Island Idol, YouTube, I think that's how I found it the first time, uh, and you can find Moshe Gibbs doing the GIPS procedure. Um, but, uh, like we can make sure that we Uh, send that out. I think that should be easy enough. OK. And then the second question for you was, would you recommend referring all patients with pyelonidal disease to your division to discuss the importance of hygiene and, and future potential surgical options or just those patients that are having the recurrent pain and drainage issues that are not responding to the initial treatment? That's a great question. So, uh, I, I think it really is variable depending on, uh, the comfort level, uh, in your practice. So, you know, we have, uh, our island Ile offices are really set up for clipping and, uh, like, you know, picking in these little holes and really emphasizing the hygiene and doing the longitudinal follow-up. But All of those things, like just because I actually go and do surgery, doesn't mean I'm any better at talking about those things or doing those things as a pediatrician or uh uh an internist or a family doctor. So, if, if that's the kind of thing that You like to, well, like, I wanna hold on to the conservative management and manage the patient, absolutely. But it's like, you know, that's, uh, like a heavy lift and, uh, you know, why you have to move on to other things, by all means send the patient along. We're delighted to see. OK. All right. Mara, the next couple of questions are for you, uh, related to some of the appendicitis stuff. The first one is, do you consider enlargement of the mesenteric nodes in the lower right quadrant in a symptomatic patient, um, as appendicitis sign in the, in case the ultrasonographer did not find the appendix? So, I mean, we do consider adenopathy as part of the secondary sign pathology, but adenopathy can be there for lots of reasons, including gastroenteritis or mesenteric adenitis. So not necessarily. We have to think of that in the context of the whole clinical picture and do we see any other evidence? Are we able to identify the appendix any other way? Sometimes that means we observe those patients and do serial exams to see if they're getting better or worse or consider even doing a CT scan. Depending on our level of concern, um, with the patient. So adenopathy can go either way, um, uh, with regard to whether or not it's appendicitis. All right. And then the the next question was which symptoms and signs direct you to suspect ovarian pathology in those patients more? So, I mean, I think it's, it's hard, and that's part of why that whole clinical picture is really important. I, I think sometimes we see patients have a more acute onset of pain, right? They're, they were feeling fine and then they have a sharp onset of pain. Um, that tends not to be as commonly associated with appendicitis and may be suggestive of torsion or a ruptured hemorrhagic cyst. But again, it's the whole clinical picture and it can be difficult. We look at the, you know, where the patient is in terms of their, um, cycle, particularly with ruptured cysts, but you can have ovarian torsion in a premenarchal patient. Who happens to have a teratoma or something else associated with their ovaries. So we look at the imaging studies, including a pelvic ultrasound, as well as their clinical exam and their history to try to get some more information and put the pieces together. But sometimes that's why observation or even diagnostic laparoscopy becomes needed when we're not able to be really clear on the diagnosis because it is quite complex. Excellent. Thank you. Um, there was one other question that came in and I think Mira, I might just email you and ask you if you would do it cause I was asking for a little bit more of an explanation or something, and I know we're down to about one minute of time left. So I was gonna ask Greg Tia, do you have any parting words you'd like to say before I wrap up our group this morning? Uh, it's again, like I said, a privilege for our group to interact with our community and providers. Uh, we're here to provide service. Um, we're trying to improve, uh, the effectiveness and efficiency by which we can provide that service. Mary. Pointed out that important change that we made, which is our Libertyal really has improved our team's availability. We have a committed partner, a committed partner up there every week whose responsibility is to deal with urgent and new cases and urgent consults. And so again, our goal is to provide effective, efficient service for our outstanding community providers. So again, and we appreciate everybody's time in terms of jumping on this educational opportunity. All right. Thank you. I'd like to just wrap up by thanking everyone who's attended this morning as well as thanking all of our faculty who've taken out of their day to join us and help us, uh, be better able to meet our patients' needs. Um, uh, you know, we invite everyone, if you still have residual questions that maybe were not answered, to reach out to us. As I said, the contact info for each of the divisions that is presented today is located on the Community Practice support tools which will be emailed out and are also available on the website. Um, and And, uh, uh, know that for those questions that did not get answered, we will specifically ask the presenter and have those, uh, answers emailed out to the participants today. So thank everyone uh again for participating and uh if you have questions, please feel free to reach out and wish everyone a great day. And happy Veterans Day to any veterans out there today.