Update Course Rewind: 2021 Top Ten Key Takeaways

Hi, my name is Ellen and Cisco, 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. Okay, so let's start with number 10. Dr. Jose Campos, from Hospital Sotero del Rio in Chile, gave us the top five pediatric surgery articles from journals other than the Journal of Pediatric Surgery. One of the most intriguing articles was from Petkova 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 five-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. The group randomized to surgery have 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 appendicitis, 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. Okay, number nine comes from one of my partners at Cincinnati Children's Hospital, Dr. 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, does 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, metastatectomy 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% of 1 millimeter nodules contained malignant disease. But, the data does not definitively tell us yet which surgical approach is best for lung mets. Dr. 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 Dr. Dasgupta. So, the key takeaway for number nine 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 eight was a controversial topic. Dr. 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. Dr. 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 for number eight, magnet therapy may be used as a non-surgical treatment for esophageal 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. Okay, number seven comes from Dr. Ciro Esposito, University of Naples in Italy. And he gave us a great presentation on the uses of Indocyanine Green or ICG, which has become a big topic of interest in the last few years. Dr. Esposito reviewed applications of ICG in pediatric surgery, especially in minimally invasive procedures, uh where it can be used to improve the visual visualization of structures. One of the most popular applications for ICG is in laparoscopic cholecystectomies, uh because you can better see the biliary tree, as Dr. Esposito is showing us here. You can see very well the biliary anatomy. It's 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 extrahepatic ducts by the time of surgery. You could also inject it directly into the gallbladder during surgery. Other applications he reviewed include varicocele repairs, partial nephrectomies and tumor excisions. So key takeaway number seven is that ICG has several possible applications in minimally invasive pediatric surgery, including in laparoscopic cholecystectomies. Okay, here we are at number six. Dr. Rebecca Rentia from Children's Mercy Kansas City and Dr. Caitlyn Smith from the Seattle Children's Hospital talked 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 rectoperineal or a rectovestibular 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's 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 the study found was that preoperative enterocolitis was the same between both groups. Postoperative enterocolitis was the same, constipation and incontinent was the same. So basically a delayed pull through with irrigations is a safe alternative to an operation in the neonatal period. Okay, so key takeaway number six is that primary endorectal pull through for Hirschsprung's disease and posterior sagittal anorectoplasty for both a rectoperineal or a rectovestibular fistula can be repaired either early or late with equivalent results. Okay, so number five from a session on updates in pectus management, we had another lively discussion. We heard from a number of faculty, including Dr. Stephen Lee from UCLA Mattel Children's Hospital, Dr. Sean Saint Peter from Children's Mercy Kansas City, Dr. Victor Garcia from Cincinnati Children's Hospital and Dr. Jason Wagner, also from UCLA. We first discussed a controversial topic, pain management for pectus patients. Cryoanalgesia has become very popular as many participants expressed. It's probably pretty effective at improving postoperative pain and decreasing length of stay. The length of stay where we just couldn't get below four days all of a sudden became one. But, Dr. 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. Dr. 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, subzyphoid 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 Nuss procedure. It was super interesting, there was a lot going on, but our key takeaway for number five is that cryotherapy may be an effective treatment for postoperative pain management in patients undergoing a pectus repair, but studies on long-term outcomes are a must. All right, so number four comes from one of the updates from APAS's Professional Development Committee or PDC. Dr. Marjorie Arga from the University of Rochester Medical Center and Gozanno 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 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. Dr. Arga 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 one should not receive honey as we know due to the risk of botulism. So they should receive 10 milliliters of sucralfate every 10 minutes for up to three doses. Children over the age of one should receive honey, 10 milliliters again, every 10 minutes for up to six doses. And again, you want to get to the operating room as quickly as possible. So here's key takeaway number four. Honey or sucralfate should be administered to children presenting with known or suspected button battery ingestion less than 12 hours prior to presentation. Okay, number three are a few other PDC updates from Dr. Robert Rica 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 20cc per kilogram bolus of crystalloid fluid, we're now supposed to give blood. Balance transfusion protocol, typically uh 10 to 20 MLS per kilogram of packed 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 three is that updated ATLS guidelines support early transfusion in pediatric trauma patients presenting in hemorrhagic shock. We're almost at the end. So number two, Dr. Ronnie Sullen, she opened up a great conversation about primary spontaneous pneumothoracies. She talked about how the treatments 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 pneumothoracies 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 blectomy. So they they proposed changing the algorithm to proceed directly to Vats if the initial aspiration fails. The key takeaway for number two, 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. Okay, so I know you've been sitting on the edge of your seat and we made it to number one. This comes from Dr. Mira Kotagal from Cincinnati Children's Hospital 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 three 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. Dr. Kotagal 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, standardizing care, and thinking about how our bias affect what we do. Recognizing that we all have biases and and really trying to understand them for ourselves and 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 all 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. Uh 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'm Ellen and Cisco, research resident at Cincinnati Children's Hospital. And remember, knowledge should be free.