Top Ten Things to Remember: Update Course 2017

This is Todd Ponsky, and for those of you who may have missed it, about two weeks ago we had the 2017 annual pediatric surgery update course. What we did is we took the entire course, full day course, and we have narrowed down the top 10 points that you missed if you didn't catch the annual pediatric surgery update course. So coming in at number 10. Gastric stimulation. This has been very popular in adults and now finding its way in children, where kids that have persistent gastroparesis may actually be a candidate for surgery. This is the insertion of a gastric stimulator into the stomach that will reduce the symptoms of gastroparesis and actually for patients that have persistent nausea and vomiting that doesn't respond to medical therapy, they can get a temporary gastric stimulating test. Endoscopically, see how they do. If they improve with their symptoms, they can go ahead and have a laparoscopic or an open permanent gastric stimulator placed, and the results are pretty staggering. This was presented by Doctor Reynaldo Garcia from Akron Children's Hospital. Coming in at number 9, cardiac sympathectomy. Most of us do sympathectomies for hyperhydrosis, but Doctor Sophia Abdulha and Doctor John Clark presented a unique indication for sympathectomy. These are patients that have a diagnosis called CPVT, which is catechomonnergic polymorphic ventricular tachycardia, and also hypertrophic cardiomyopathy. These are patients that have a cardiac disease that requires an ICD. That fires whenever they have a potentially fatal arrhythmia, and some of these patients may actually benefit from having a very high thoracoscopic sympathectomy that goes all the way up to the lower part of the stella ganglion and actually can shut off these arrhythmias for the most part. And it's pretty spectacular the results that they were presented. We now perform the partial resection of the stellate ganglion using clips and scissors. It is important to avoid the use of electric cautery on the steellate ganglion as it may damage the remaining portion of it and result in Honner's syndrome. The benefits of sympathectomy is there is 100% compliance. Once they've had it, they can't not take their sympathectomy that day and hopefully can potentially attenuate the effects of adrenaline if there is an inappropriate shock or any other adrenaline surge for any reason. Coming in at number 8, diaphragm pacing, not a common thing that we see in pediatrics, but Doctor Ray Anders from the University Hospitals of Cleveland, who described diaphragm pacing and actually paced Christopher Reeve, he actually showed that this is a very reasonable option in kids that have spinal cord injury that. Have transverse myelitis, acute flaccid myelitis, or brain stem tumors. The youngest patient that he's ever implanted was one year of age, and these patients can get off of a ventilator because you implant the diaphragm pacings directly into the diaphragm, and they can breathe on their own. He did note that diaphragm pacing can only be used if the patient has an intact system, so the phrenic nerve and the phrenic motor neurons must be intact. So prior to implantation, you need to check that the diaphragm contracts with neurostimulation. OK, coming in at number 7, abdominal wall reconstruction. We don't see too much of this, and I know that I have fallen behind the what is the standard of care of how we should be treating ventral hernias. When I was trained in residency, we did the lap ventral hernia repair. No, that is not the current way now. Doctor Dave Crapata from the Cleveland Clinic Foundation talked to us about some of the new things that have happened in the last 5 or 10 years with abdominal wall reconstruction, and actually he pointed out a few key points. Number one, the best mesh to use for a, for bridging a gap is not a biologic mesh. Biologic mesh is Not good for bridging a gap. It is only a temporary solution or a reinforcement, but not meant to bridge a gap. He did say that the best mesh to use is probably a macroporous monofilament, lightweight polypropylene synthetic mesh such as Marlex, and that that actually has been shown to do well in contaminated fields in a retromuscular space. So what he told us was that the best repair these days is not the way we learned with the laparoscopic underlay, but actually doing a retro rectus repair with mesh such as Marlex, a macroporous monofilament mesh. He said that posterior component separation has less wound morbidity than an anterior component separation, while also providing a space for wide mesh overlap and minimal fixation. All right. Coming in at number 6, gastroesophageal disconnection. This was presented by Doctor David Lanning from Virginia Commonwealth. The idea here is that in patients that have severe reflux, that have failed a niss and fundoplication. You can actually do essentially a gastric bypass, divide the esophagus from the stomach, and bring up a ruli of jejunum to the esophagus, and it actually has really good results, and a lot of people have been reporting this. The points that he made were that this operation is good for children that have had a failed fundoplication and may be good for patients even as a primary upfront repair if you think they're a high risk for failure. He did note that it can be a long and difficult operation if it's done laparoscopically, up to 6 hours and even 8 hours in one of his cases. It was interesting. He noted that these patients can still take full feeds by mouth if they were doing so preoperatively. There is an ongoing prospective study comparing the laparoscopic GE dissociation with a redo Nissen fundoplication, so we're eagerly awaiting those results. All right, coming in at #5, Doctor Chris Dreck talked about who needs a CAT scan for blunt abdominal trauma. And really what he did is he showed us a prediction rule consisting of 5 variables that identified a population who were really at low risk for intraabdominal injury, and he used these to help determine if they need an abdominal CT scan. Doctor Streck's presentation was based on an article he recently published that helped to address the issue that too many children are probably getting unnecessary CAT scans after abdominal trauma. So what he did is he stratified the risk based on finding. So for example, if a patient only has abdominal pain, they really have only about a 5% risk of having an abdominal injury and almost a 0% chance of them needing any intervention. Compare that to if a child had actually an abnormal finding on physical exams such as a handlebar injury, and they have about a 15% chance of abdominal injury. We reordered the five variables in the order of information that you obtain as the physician, so the patient complaining of abdominal pain. If it's no or you can't assess based on being intubated or sedated, uh, the next was the physical exam of the abdomen, chest X-ray, AST, and abnormal enzyme, uh, if you wanted to look at a group that you might be able to observe, uh, or, uh, send home with, um, careful instructions, uh, what we found, uh, was a low risk, uh, group. Um, that, uh, made up 55% of the population with a less than 5% risk of any injury, uh, and a less than 0.3% risk of an injury requiring acute intervention. So back to our example of a patient who only has abdominal pain, the fact that he has almost a 0% chance of requiring intervention, this patient may not need a CAT scan and may simply be observed or sent home with close follow-up. If they don't have any of these things listed, their AST is normal, they have no abdominal wall trauma, tenderness, or distention, a normal chest X-ray, no complaints of abdominal pain, and no abnormal pancreatic enzymes, they probably don't need any CT scan, no further imaging, and can probably be sent home. Coming in at #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. Uh, failure is, uh, can't be, can't be guided by the, by an algorithm. You basically, you, um, 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 bolus 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 injuries 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 airway foreign 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, 44 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, 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, the, 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 decubous views, uh, there was no volume loss 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 9 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 through was omphal 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, 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 attempts I found are mostly positive. Lastly, he talked about that he thinks that in the modern era we shouldn't be as afraid of CAT scans, 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 millisiever, which is basically the same amount of radiation you get from being on the Earth for 1 year. Coming in at number 2, Doctor Holcomb presented what he thought were the top 3 papers this year in the Journal of Pediatric Surgery. Number 1, he presented a paper by Doctor Dalton which showed a really nice way of resuscitating patients with pyloric stenosis. The purpose is to try to avoid the problem of randomly guessing how much fluid to give, rechecking electrolytes, and then giving more fluid. Essentially they showed that if the chloride is less than 85, you should give 3 boluss of fluid. If the chloride is less than 97, you should give 2 boluss of fluid. And if the chloride is greater than 97, but the bicarb is less than 33, you should give 1 bolus of fluid. The next paper he talked about was a paper by Dr. Richer which showed that patients that present with either traumatic or non-traumatic pneumonia stinum probably do not need any further imaging other than just the chest X-ray. The debate still exists on whether or not these patients need to be observed or not, but it seemed that most of the people in the audience would observe them in the emergency room for a few hours and send them home. A 12 year old girl comes to the ER with chest pain and an X-ray that shows a pneumo mediastinum. Uh, what should be done next? Mike, do you have any thoughts about this? You know, for, for kind of unexplained pneumo media sign that comes in, you know, if there's not a history of trauma or a foreign body, um, I, I guess in my experience, anything else you do is typically not very helpful. Rapid fire. David, what do you do? An inhaler and go home, inhaler and go home. And go home. No imaging, Chris. Typically these patients get an esophagram without good data to support esophagram. David, no imaging. Nothing. Mark, nothing. Witt, you can't answer. Dan. Nothing. OK. Anyone here have a disagreement on nothing? So everyone here says either esophagram or nothing. Spoiling the fun here. All right. Finally, there was a paper by Doctor Vella which showed there was a great benefit of using Robinol in patients that have a leak after a tracheoesophageal fistula repair. They found a very dramatic improvement in closure rates in these patients. After one week, there's a persistent leak. The patient is stable and the leak is well controlled and, um, coming out the chest tube. Question is what would you do next? Uh, A is continue observation. B is explore the baby. C is start uh intravenous uh glycopyrrolate. And D is something else. 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, the 42 patients into two groups, 21 each. The one group receiving glycopyrrolate and the other group receiving placebo, which was saline. The main explored variables were chest tube output, which was 124 mL in the treatment group, compared to 370 mL in the placebo group. The Second variable was the leak resolution, which was accomplished in 76% of the treatment group compared to 29% of the placebo group. Robinal or the glycopyrolate group really had impressive results compared to the placebo group. And finally coming in at number one, which I think was probably the biggest change this year in pediatric surgery, was a concept presented by Doctor Aaron Lipscar on a new way to treat pyelonidal disease. This is something we. 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 a 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. oxide, um, so the, the bleeding is usually minimal. All the punch openings are left unpacked and unsutured. Um, 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 two weeks, you know, injecting, uh, 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, uh, it's. But wait, there's more. So we took you through the new ideas in pediatric surgery, but we also invited a special guest, Doctor Steven Rothenberg, to take us step by step through the. Thoracoscopic lobectomy and teach us about the pearls and pitfalls, the key points we need to know about that procedure. We hope you enjoy. Steven Rothenberg presented a technique video about thoracoscopic lobectomy, and during his technique video, he spent time showing us what were the key points that we need to know about how to do a thoracoscopic lobectomy. Number one, the scope should be anterior. He describes putting the scope anterior to the tip of the scapula and not just slightly anterior but almost at the mid axillary line and that the operating ports are actually at the anterior axillary line. He believes this will give you the best view and you want the scope to be right over the major fissure. And this is probably the biggest mistake that I see surgeons make when they're doing these procedures is they put their scope port. Um, posterior to the tip of the scapula, which is where we want to be if we're doing something like a thochoscopic TEF or other posterior mediastinal structure. But what happens if you have a scope behind the tip of the scapula is you end up looking back on yourself as you work in the anterior part of the fissure, and most of the complex work, um, in these cases, whether you're doing an upper lobe or a lower lobe is going to be. In the major fissure or anterior, and if your scope is too far posteriorly, then you find yourself working in a paradox. Number 2, he emphasized the importance that when sealing a blood vessel when doing a thoracoscopic lobectomy. That one should use a sealer, not a sealer divider, but just a sealer, seal in proximal and seal and distal, and then make a little nick between the two seals to make sure it's truly sealed, and then you can complete the cut of the vessel rather than using a device that seals and divides at the same time. And we make one seal and then we seal distally. It's like having two ligatures and then we cut partway between the seals, makes you see an open lumen, and when we see that and there's no blading, then I know it's safe to complete. Uh, the vision of the vessel and we cut it the rest of the way. He talked about the importance of really knowing the anatomy, trying to predict where the vessels are going to be and how they're going to be related to the bronchus, for example, where the superior segmental artery will be coming off the lower lobe and that the bronchus will be right below it. If you understand the anatomy and you understand the segmental anatomy, you can use these relationships to help you identify the vessels and also dissect. So often in a lower lobectomy, as you can see here when we're dissecting out the main pulmonary artery trunk to the lower lobe, I can palpate the bronchus behind it, and I can use that to help me safely dissect around the vessel and gain control. Number 4, he talked about how to approach an incomplete fissure and that one should use a sealing device to go layer by layer, sealing the tissue until you identify the structures. And what I do is I simply dissect uh kind of like your finger fracturing across the lung, um, like you were in the liver and, and then sealing the tissue layer at a time. And then what we do once we've opened the fissures, we expose the um the pulmonary artery. And finally, he talked about the importance of doing single lung ventilation by doing a contralateral main stem intubation. What are the best techniques for single lung ventilation? Um, should you use a double lumin endotracheal tube, a bronchial blocker? Uh, tracheal intubation with CO2 collapse or a main stem innovation on the contralateral side. I think a main stem innovation on the contralateral side is by far the best and easiest thing to do. 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.