Update Course Rewind: 2021 Top Ten Key Takeaways

Hi, my name is Ellen Ancisco, research resident at Cincinnati Children's Hospital. You might remember a few weeks ago we had the 2021 pediatric surgery update course. We wanted to go back and see what the top 10 key takeaways were from the update course, things that were significant or hopefully you can apply to your practice. OK, so let's start with number 10. Doctor Jose Campos from Hospital Sotero del Rio in Chile gave us the top 5 pediatric surgery articles in journals other than the Journal of Pediatric Surgery. One of the most intriguing articles was from Petcova et al. published in Annals of Surgery in 2020, and they were looking at children with uncomplicated appendicitis managed with either medical management with antibiotics, or with typical surgery. And so children were randomized to one of two arms. This was a 5-year follow-up. You might remember us discussing this article, uh, a few podcasts ago in a journal club, and here's what they found. That the group randomized to surgery had no complications, while in the group randomized to non-surgical management, 46% of patients required appendectomy in the follow-up time. So they concluded that medical management may be safe for children presenting with acute uncomplicated appendices. is but there is a high failure rate and a lot of children ultimately required a laparoscopic appendectomy. So key takeaway number 10 is that medical management of acute, uncomplicated appendicitis may be safe, but it is associated with a high failure rate. OK, number 9 comes from one of my partners at Cincinnati Children's Hospital, Doctor Roshni Dasgupta. She opens up a great discussion on the best surgical treatment for lung metastases in pediatric patients with osteosarcoma. We talked about some of the big questions like the surgical resection of lung mets actually improve survival? Do small nodules matter? And what is the best surgical approach for oligometastatic disease, thoracoscopy or open resection? So for the first two questions, the data tells us that yes, metastectomy does improve survival. You can make these patients long-term survivors. And yes, the tiny nodules can contain malignant disease. Even at the size of 1 millimeter, you can get about 60%. 10% of 1 millimeter nodules contained malignant disease, but the data does not definitively tell us yet which surgical approach is best for lung mets. Doctor Dasgupta shared with us that the Children's oncology group is actually starting a study to answer this very question, and they should be starting enrollment towards the end of this year or early next year. So if you're not already involved and are interested, contact Doctor Dasgupta. So the key takeaway for number 9 is that additional work is being done to help determine which is superior, thoracotomy or thoracoscopy for resection of pulmonary metastases in osteosarcoma. All right, so number 8 was a controversial topic. Doctor Bethany Slater from University of Chicago talked about the Flourish device. It's a catheter-based device that places magnets in the proximal and distal esophageal pouches. And then creates like a compression anastomosis to bring the two ends of the esophagus together. The compression anastomosis works by causing ischemia of the tissue between the two, and then that sloughs off and that creates the anastomosis. It's important to remember the inclusion criteria for the flourish device, which are the atretic gap must be less than 4 centimeters long. The fistula has to be repaired or just absent. And the G tube has to be able to accommodate an 18 French catheter. Doctor Steven Rothenberg from Rocky Mountain Hospital for Children in Colorado emphasized some key points to keep in mind about the flourish device. Know that it's associated with a high stricture rate and some known serious life-threatening complications. So, it should really only be used by centers that have the capabilities to treat the many issues associated with esophageal atresia. All in all, key takeaway Number 8, magnet therapy may be used as a non-surgical treatment for oesophageal atresia, but it should really only be considered carefully and by those institutions that have a lot of experience treating esophageal atresia because there are a lot of associated risks. All right, Ellen, back to you in the studio. OK, number 7 comes from Doctor Ciro Esposito, University of Naples in Italy, and he gave us a great presentation on the uses of endocyanin green, or ICG, which has become a big topic of interest in the last few years. Doctor Esposito reviewed applications of ICG in pediatric surgery, especially in mid. Minimally invasive procedures where it can be used to improve the visualization of structures. One of the most popular applications for ICG is in laparoscopic cholecystectomies because you can better see the biliary tree as Dr. Esposito is showing us here. You can see very well the biliary anatomy is absolutely. Amazing, as you can see, the main biliary tree, the gallbladder, and then the cystic duct. He told us that ICG has to be administered intravenously 12 to 18 hours prior to surgery so that it has time to accumulate in the extra hepatic ducts by the time of surgery. You could also inject it directly into the gallbladder during surgery. Other applications he reviewed include varicose seal repairs, partial nephrectomies, and tumor excisions. So key takeaway number 7 is that ICG has several possible applications in minimally invasive pediatric surgery, including in laparoscopic cholecystectomies. OK, here we are at number 6. Doctor Rebecca Rentia from Children's Mercy, Kansas City and Doctor Caitlin Smith from the Seattle Children's Hospital talk to us about. Clinical practice updates from the Pediatric Colorectal and Pelvic Learning Consortium, or the PCPLC. So they addressed a bunch of colorectal topics, but a few of them focused on timing of surgery and how early and delayed surgery for certain colorectal procedures made no difference, according to PCPLC studies. First, anorectal malformations with a rectal perineal or a rectal vestibular fistula had similar outcomes as it relates to. Complications, whether the procedure was done before 14 days or after 14 days of life. And so, the timing of pull-through for Hirschsprung disease. This is a consortium study. What this paper did was to look at the timing of endorectal pull-through less than 31 days or greater than 31 days was considered early pull-through or late. And what this study found was that preoperative entercolitis was the same between both groups. Post-operative enterocolitis. The same. Constipation and incontinence was the same, so basically a delayed pull through with irrigations is a safe alternative to an operation in the neonatal period. OK, so key takeaway number 6 is that primary endorectal pull-through for Hirschprung's disease and posterior sagittal anal rectoplasty for both a rectal perineal or a rectal vestibular fistula can be repaired either early or late with equivalent results. OK. So number 5, from a session on updates in pectus management, we had another lively discussion. We heard from a number of faculty, including Doctor Steven Lee from UCLA Mattel Children's Hospital, Doctor Sean Saint Peter from Children's Mercy, Kansas City, Doctor Victor Garcia from Cincinnati Children's Hospital, and Doctor Jason Wagner, also from UCLA. We first discussed a controversial topic, pain management for Pus patients. Cryoanalgesia has become very popular, as many participants expressed. It's probably pretty effective at improving post-operative pain and decreasing length of stay. The length of stay where we just couldn't get below 4 days, all of a sudden became 1. But Doctor Garcia cautioned, we really don't know all the long-term effects of this treatment. What I'm concerned about is, is that there are no long-term studies. Doctor Wagner talked about some other stuff like multimodal pain control plus non-pharmacologic management that might be just as good. There's more investigation to be done here. We discussed a lot more in this session. Talked about shorter bars. We talked about sternal elevators, subxiphoid incisions, you can get a better visualization. Whether surgeons like to go right to left or left to right with their bars. We talked about what if a patient presents with a spontaneous pneumothorax before their planned NUS procedure. It was super interesting, there was a lot going on, but our key takeaway for number 5 is that cryotherapy may be an effective treatment for post-operative pain management in patients undergoing a pectus repair, but, Studies on long-term outcomes are a must. All right, so number 4 comes from one of the updates from APSA's Professional Development Committee, or PDC. Doctor Marjorie Arca from the University of Rochester Medical Center and Golizano Children's Hospital gave us a lot of great updates, and one of them was about button battery ingestions in children. An important thing to remember, to recognize these ingestions is the double rim sign. Or a halo sign shown here on an X-ray, which will tell you that a child has swallowed a button battery rather than just a coin. This strikes fear at the heart of of uh ENT surgeons, gastroenterologists, and pediatric surgeons. Doctor Arca reviewed the guidelines for management of button battery ingestions from the poison control center. Remember that the main goal of treatment is to remove the button battery at least within 2 hours of its ingestion. But if you have to transfer the patient or make your way to the operating room, there are some temporizing measures like administering sucralfate and honey. What you need to do is cut down on the damage, the injury that this is doing. Sucralfate or honey can help. Reduce the damage from the battery on the child's esophagus, and so children less than 1 should not receive honey, as we know, due to the risk of botulism, so they should receive 10 mL of sucralfate every 10 minutes for up to 3 doses. Children over the age of 1 should receive honey, 10 mL again every 10 minutes for up to 6 doses, and again, you want to get to the operating room as quickly as possible. So here's key takeaway number 4. honey or sucralfate should be administered to children presenting with known or suspected button battery ingestion less than 12 hours prior to presentation. OK, number 3 are a few other PDC updates from Doctor Robert Ricca from Prisma Health in South Carolina. He gave us a few learning points, but one of them was about new ATLS updates for pediatric trauma patients that come in in hemorrhagic shock. The new recommendation is for earlier transfusion. So after 1 20 cc per kilogram bolus of crystalloid fluid, we're now supposed to give blood. Balanced transfusion protocol, typically 10 to 20 mLs per kilogram of pack red blood cells, and then inclusion of FFP and platelets. Earlier transfusion was associated with a shorter median time to transfusion and a decrease in the total fluid volume administered. We also talked about massive transfusion protocol and when you're supposed to call that. As well as increasing the use of whole blood in trauma patients as opposed to component therapy, the benefits of it, uh, you start to see that we have less volume required compared to component therapy. But overall, key takeaway number 3 is that updated ATLS guidelines support early transfusion in pediatric trauma patients presenting in hemorrhagic shock. We're almost at the end, so number 2. Doctor Ronnie Sullens, she opened up a great conversation about primary spontaneous pneumothorases. She talked about how the treatment of these has really changed over the last few years, which brings up the importance of this update course and how much we can learn. The latest research shows that observation of spontaneous pneumothorax in adults is non-inferior to immediate intervention with a tube thoracostomy. And the Midwest Pediatric Surgery Consortium study that looked at the management of spontaneous pneumothorasis with simple aspiration showed that 48% of those patients treated with simple aspiration were a success, but 44% of those patients in the simple aspiration group recurred. And then 83% of those who failed, ultimately ended up with a VATS or a blebectomy. So they they proposed changing the algorithm to proceed directly to VTS if the initial aspiration fails. The key takeaway for number 2, while observation can be attempted in those select patients with primary spontaneous pneumothorax, Initial aspiration can be performed, and if that fails, that should be considered. OK, so I know you've been sitting on the edge of your seat and we made it to number one. This comes from Doctor Mira Kotagal from Cincinnati Children's Hospital and Medical Center. And she gave us a really great and lively discussion about diversity, equity and inclusion, or DEI in pediatric surgery. She shared multiple sources of evidence of how implicit bias exists in medicine. One of them comes from Greenwood et al. and they showed that mortality amongst black newborns is 3 times. That of white newborns. But if black newborns are treated by black physicians, their mortality is reduced by 58% compared to black newborns treated by white physicians. So this study and others demonstrate that bias does exist within medicine and can change the outcomes. And representation matters and can make a difference. Doctor Koigal emphasized the importance of recognizing our own biases both on personal and systemic levels, and to combat those biases, our efforts need to be both personal and systemic as well, such as increasing representation, standard. care and thinking about how our biases affect what we do, recognizing that we all have biases and really trying to understand them for ourselves and not being defensive when someone says there's bias in that because we all have bias. We know that we all have bias. And so the question is, what are your biases and how do they affect what you do? So I would push everyone. To say, as you're thinking about this work, as you, as you live in this space, you know, what are you doing about it? So let's not just settle to talk about it, but let's figure out what the system level changes are that make a difference and change the outcome. So our number one key takeaway from the update course is that implicit bias is ubiquitous in medicine, and we should I'll be taking active efforts to both recognize and actively combat that bias in our day to day lives. Thank you so much for watching and listening, and we hope that you learned something from these key takeaways. Remember that we're always trying to keep you up to date on the app and our podcast and our videos, so keep tuning in. I am Ellen Ancisco, research resident at Cincinnati Children's Hospital, and remember, knowledge should be free.