All right, awesome, we are back. Awesome session, that's the first time in the history of the update course we've ever finished a session early. That's going to move us right into, first of all, I want to remark on the last from Children's Mercy Kansas City, who has been, actually Whit Holcomb and I started this idea together, it was mostly Whit's idea to even do this. So thank you to Kansas City, as everyone knows I'm a massive fan of this hospital, I think it's probably one of the best in the world, so thank you for sponsoring this and always being a loyal supporter. All right, we heard about the hot topics from last year. What you're about to see, we talked about last year and it's incredibly exciting to me. I met Jose Campos at, I think, an IPEG meeting or something and he came up to me and he says, I said, hi, how are you? He goes, yeah, the stuff you're doing is a problem. I was like, nice to meet you too. He said, you're only looking at pediatric surgical journals and pediatric surgical societies, you're missing all of the incredible publications that come out in articles we don't read. New England Journal, Annals of Surgery, we don't look at those and those are probably some of the best, no offense, but they may be some of the best articles out there and we don't see them. Jose can give us a little explanation on what his team does in Chile to try to find the most important non-pediatric surgical articles to make sure we're all aware of those. So Jose. Thank you, Doug. Hi, good morning. Good afternoon and everyone. All the world. Special greetings for my fellows in Chile who are connecting. I think Todd already explained what we're doing. We share the spirit of this course. We want to stay updated in pediatric surgery and we take a different approach. We just want to look at the non-pediatric surgical journals. So when something is getting published in New England Journal of Medicine, Annals of Surgery, Journal of Pediatrics, we think that's really good methodology, really high yield information that we should not miss. But it's really difficult because only 3% of all those publications are relevant to pediatric surgery. So we want to do that work for you. In the Chilean Society of Pediatric Surgery, we've developed a method. We screen 1,200 articles each month and we want to get the best to you. So where can you find this content? We're glad to be here for the second time in this beautiful course that's celebrating its 10th anniversary. But actually we do it month by month. You don't have to wait an entire year just to get this content. So you can have it through the State Current in Pediatric Surgery app and also through their social media, through our societal website which is there. I'll make sure to write it down on the chat later on. And also through our social media. And we actually have a newsletter subscription that you can just click on in there, drop us your email and you'll get this content monthly. Actually you can get it as a subscription. If you want to get only oncology articles, you'll get those. If you want to get only hepatobiliary, you'll get those. So without further introduction, I just want to acknowledge that this is not my work. It's the work of State Current, My Society and also these 24 people that I don't have time to name them but they know they're all there. There's 24 volunteers working in this. So without further introductions, let's get to it. So first, we have a 10-year-old complicated with appendicular diffuse pyritonitis. What would be your preferred post-operative antibiotic? So I'm just going to repeat what Todd said once. We're finally getting good data. Like appendicitis is the bread and butter of surgery, general surgery and also opiate surgery. And during residency years, it was always a local preference. You change hospital, it was a different management or even a personal preference. And it still amazes me how we're not kind of on top of this. How we don't have really, really good data. And we're finally, I think, finally getting there. And it's not a matter now of personal choice. It's a matter of evidence. Do we have the poll results so far or not? Let's see. Go ahead. Yeah. . 46, 7%. . . Okay. So let me take you through a one-minute video about an article. Oh, this has audio, guys. Is that okay or no? . . In order to reduce intra-abdominal abscess formation after perforated appendicitis, intravenous antibiotics are given. This is a multi-institutional prospective randomized trial that compare the incidence of intra-abdominal abscess formation between pideracilient azodactam and ceftriaxone plus metronidus. Patients under 18 years old were recruited, all of them with perforated appendicitis. At 75% enrollment, the interim analysis favored the interventional group. Therefore, the study was stopped. Intra-abdominal abscess formation was significantly lower in the piperacilient azodactam group, with an odds ratio of 4.8. The number needed to treat with the peracilient azodactam to prevent an intra-abdominal abscess was 5.7. This would be interesting in order to define the possibility of changing our practice. . Dan and I were at the DC course. In Washington DC there was a fellows course. This was two days, three days ago. We presented this and everyone was writing down and I know that at that time Washington DC at that time officially changed. Those are huge results. Yes, I know. Massive. Go ahead. This was I think a huge change. Yeah. I just want to ask Miguel, let's start locally. Miguel Gelfand, a fellow from Chile. What do you do at your hospital and will this article change your management? Please let us know. . Anyone else in the audience wants to share? Sean is one of the authors of this. There was 162 in the study. I would be remiss not to mention that we were one of the two hospitals that were in this trial and we did not see a difference in abscess rate in our cohort. So the overall group was swayed entirely by Phoenix's experience. We didn't see the difference. And that is also consistent with what Sean Rangel finds at the national level, which looking across all of the NISQIP-P data, you're not seeing a difference in abscess rates between Roceph and Flagyl and Zosin. And that's much bigger numbers. So I do think that this data needs to be replicated by other centers. And we're currently pulling all of the patients who we treated in the study. Plus, we went through that period when we had a Flagyl shortage. So we were using Zosin like I think a lot of centers were. So I think we can use that period of time to get more data to compare the two. But we're... What are you doing here on the study? Would you use Zosin or...? We currently use Roceph and Flagyl. We haven't changed yet. Whoa. Wow. Because we didn't see a difference in our abscess rates. Okay. But we're currently pulling the data that we have of all of our cohort to see if there is some... So this is a classic situation where I get super excited about a study and then you bring me back down to... Okay. It takes a lot of patience to turn the period of time to... It takes an awful lot of patience, like what you're saying, to change what you do with appendicitis. I don't think there's enough patience yet. Maybe Whit, you want to comment on that? No? I mean, I read a lot of abscess papers thanks to Whit, appendicitis papers, and I don't think there's enough data here to actually change what you practice. I agree with what was just said. So Rick probably has reviewed more appendicitis papers, if not more papers in general for the Journal of Pediatric Surgery. So he's well read in this topic. Having said that, I'll go with what Sean says. Okay. Well, we'll keep going with the next article. I know there's a lot of comments in the chat and also within this room, but we don't have that much time. For some reason I can't see. Okay. So next poll. 20-week, all week preterm, 3-week-old, 980 grams at birth, acutely unwell and septic. An abdominal x-ray shows pneumatosis and pneumoperitoneum. What your suspicion is necrotitis and enterocolitis. What would be your preferred management? A, medical management. B, laparotomy. C, laparoscopy. D, periodontal drain. So while we were selecting the articles, my thoughts were, people in the audience are going to say, oh, not this again. Why are we still talking about laparotomy and drain? Why do we get this in every conference? I do laparotomy. I'm not going to change my mind. Or I do drains. I'm not going to change my mind. But you know, there's people doing incredible efforts to pull these extremely difficult trials. And I think it's worth listening to this. So that's why we brought it up. And do we have enough poll results or should I keep talking? . Oh, what a shocker. Half and half. Okay. So we need good data to answer these questions. And here it is for you. . . And when treated surgically, it's associated with high mortality rates and poor neurodevelopment outcomes. There have been two previous randomized controlled trials comparing surgical techniques, but both failed to enroll enough patients to answer this clinical question. These authors have conducted a 20-center randomized controlled trial comparing initial laparotomy versus peritoneal drainage. 310 premature newborns were randomized. At 18 to 22 months of corrected age, the composite of death and neurodevelopment impairment was similar in both groups in frequentist analysis. The Bayesian analysis showed a high probability of laparotomy being superior to peritoneal drainage. This huge and challenging study brings the best quality evidence to a long-standing question. With these results, you can change your initial surgical approach to necrotizing enterocolitis. Okay. So I want to ask the audience, and also please comment in the chat. I want to ask Sean St. Peter, do you think this settles the question finally, or do we still have to ask ourselves this question again and again? So first I would just comment, as you said, this was a Herculean effort by Marty Blakely to get this study done, so he deserves to be commended. I don't think it's binary, so I don't think it's going to be something that we're going to be able to answer as a yes or no. And I like the way that this was presented, that you look at frequentist data to see that there is the suggestion that over time with enough patients, laparotomy may be superior. In the study, there was a lot of surgeon intention to treat, and so that really kind of limited the effect size that you see here, even though there was a large number of patients. It ends up sort of answering the question in that putting in a drain and leaving a drain, sometimes you get away with it, and that leads to more of that behavior. But most of these patients went to laparotomy shortly after drain placement, so that also kind of convolutes it. So I don't think it's a black and white answer, and I don't think we're going to be able to get it with a study that's going to be able to fairly compare the two. But all of the data just continues to suggest have a low threshold for laparotomy, even if you placed a drain. And I don't think we can do a bigger study than this one, don't you think? I don't, and it would be so difficult to have criteria around converting to laparotomy after the drain's placed that would be able to truly fairly answer the question. So there's a role for drain, but I think it's going to remain an adjunct and not a definitive therapy. So Sean, are you thinking that some surgeons are using a drain as a temporizing measure to, quote, stabilize the patient and get them ready for the operating room or? Yeah. As opposed to a permanent therapy? Yeah. If you go back and read the original papers by Ziggy Hein, you know, a third of the patients died, a third of the patients got a laparotomy, and, you know, that's the way it works. You know, so it is a temporizing. For most kids, it's a temporizing. They're septic. They're crashing. You put the drain in. They stabilize, and they go ahead and get a laparotomy. Yeah. This is an example of a therapy that started out as a temporizing measure and then morphed into, you know, a definitive measure in maybe half the people's minds, 40% of the people's, surgeons' minds, where it really wasn't intended to be a definitive management. You know, I think it's fair to recognize that we all see a situation in which there's an abdominal compartment syndrome, and for that, an acute drain can relieve things for some measure of time. But again, temporizing maneuver and not definitive therapy. All right. I'm going to move us forward because we still have, like, four more papers in eight minutes. So, yeah. It's all right if we don't get through all of them. Okay. Third poll. So, 12-month-old baby with swallowing dysfunction due to cerebral palsy fed via a nasogastric tube last three months, and you are requested to do a gastrostomy, a very common scenario for all of us. What would you do in this case? An open gastrostomy, a laparoscopic gastrostomy. There's different techniques, but just overall, percutaneous endoscopic gastrostomy, or PEG, or interventional radiology gastrostomy. So, again, while I was choosing these articles, I felt a bit challenging because I don't know if you're aware, but the original description for a percutaneous endoscopic gastrostomy was done by Mr. Todd Ponsky Sr. So, I wasn't sure if it was going to bring controversy to the endoscopic gastrostomy after being invited to this course, but here we are, so… and Todd agreed to do it. So, do we have any poll results yet? Any poll results yet? Most dual laparoscopic. Most dual laparoscopic. Which one is the green there? PEG. PEG. Okay. So, can I ask Mira Kotragal what's your opinion on this? Sure. I mean, I think it is a lot of difference in practice and practice patterns based on institution. At our institution, we tend to do a lot of laparoscopic gastrostomy tubes, and so that is sort of our practice pattern. I think in little kids, you can easily put in stam sutures, and I think that saves you when the tube dislodges. You don't have it dislodge, you know, in the stomach drop away as you might with the PEG, but that's just a personal practice. Good. Can I make a quick comment? All right. So, was invented before there was widespread laparoscopy. It came first. Then laparoscopic. Because of that order, a lot of people favor PEG, but it's blind. I mean, you're putting something right through the belly without looking, so it makes no sense to me. What? What does that mean? We're mixing both. We're doing PEGs by a random view. Yeah, that's different. I agree. Yeah. In our institution, we have a pathway, and we choose PEG because our gastroenterologists don't use the general anesthetic for the PEGs, so we avoid the general anesthetic. I have a part to the F. to the W. to the W. to the W. to the W. to the W. by Todd's dad Jeff and Mike Goddard remains the most cited article in the history of the Journal of Pediatric Surgery by far by like three times the number two article so it's a real landmark paper and we owe dr. Sponsky and Goddard a tip the cap for coming up with this technique when it really was the first minimally invasive way to insert a gastrostomy tube outside of you okay let's look at this great article published in pediatrics the most common procedures in pediatric patients nevertheless there is significant variability in technique across institutions this is the metric review examinate for clinical questions including the optimal technique for gastrostomy insertions 900 publications were reviewed with 58 being used to for final recommendations 12 studies directly compare outcome between the laparoscopic and percutaneous endoscopic gastrostomy major complication rates were significantly less common with laparoscopic placement the number need to treat to prevent one major complication from PEP is calculated to be 24 this is a very useful article to discuss in your team regarding the optimal technique for gastrostomy insertion and other interesting gastrostomy challenge such as indication and workup okay I think we heard a lot of comments and I think what what I remember from the comments is there's a lot of variability inter institutions but you know there's strong evidence here saying that it's just not a preference there might be a risk associated with percutaneous it's not a definitive evidence this is done via a systematic review and all those are summarizing single institution series so I I think maybe at the 20th update course will see a randomized trial who knows but but there that's there and I think we should pay attention to to this anyone else has a comment or should we just keep going I was just gonna ask a quick question I think one of the issues also with peg is the difficulty in changing it then over to a button tube and the trauma of doing that to a child in the office and so I don't know what other institutions practices are but at ours children actually get a second anesthetic if they get a peg because they go back to the OR with the GI folks to get the peg removed under endoscopic and then they change it to a to a button so that to me is another sort of contraindication for peg in a patient who's small enough to safely do a lap G2 but I don't know if other people have Right I mean I've taken out a few pegs in the office but it's not it's not pretty and the complication rate for pegs is higher I mean and I think we've all seen you know we actually had a peg tube that was cut and eroded through the esophagus into the aorta so that the kid retched and got stuck but again I you know I do think that this is something that we probably you know Sean I'd look to you to see what we can do to really study this and answer this definitively the other question I have is we're starting to experiment you know do some work with laparoscopy under local regional blocks and so you know the question is as well you may be you may have your pathway to do a peg with without general anesthetic you know a lap G tube so quick or depending on what lap G tube maybe it's just putting the scope in and looking because I don't know if everybody remembers when laparoscopy started it was actually started by some gastroenterologists that were using nitrous oxide to look some hepatologists look at the liver there were a couple guys in Miami that did it like a long long long long time ago and that was all under local anesthetic okay we have only two more minutes so we'll just skip the last one and we'll do this final one this is an obese adolescent with hypertension who has failed to reduce weight after three month program you're asked about surgical management what would you advise this family a continue medical management b sleeve gastrectomy see ruin why gastric bypass or an intra gastric balloon I think again we finally having good data about this maybe 10 years ago I don't know if you guys here in the US but at least in Chile you would bring up bariatric surgery in a pediatric conference and you would be kind of shut down why would you do that to a child or adolescent and nowadays we even have an American pediatric academy statement saying that we should recommend this we should recommend this more often and that we should be treating patients with bariatric surgery do we have poll results oh Jason yeah so there's a lot of data and a lot of long-term data on the safety and efficacy of bariatric surgery and adolescence and obviously sleeve gastrectomy is a very safe operation and it's really exciting to see the results in these kids with resolution and the resolution of their co-morbidities that come with it especially in these pre-diabetic and diabetic kids so it's a really really safe thing and it's really it's an operation that we've done so or something like we've done so with some of our patients with bariatric surgery so there's a lot of data that we've done so with our patients with bariatric surgery so there's a lot of data on the safety and efficacy of bariatric surgery in adolescence It's really exciting to see the results in these kids with the resolution of their comorbidities that come with it, especially in these pre-diabetic and diabetic kids. So it's a really, really safe thing, and it's an operation that does an amazing thing for these kids, both now and for 60 years from now. Anyone else have the extra mic? James, if you could find us the other mic. Yes, thank you. I think the United States does have substantial data. The Teen Labs Consortium has been doing a prospective trial since 2007, NIH-funded, and it published lots of papers. I've been doing bariatrics since 2004 in teenagers, and so I do think the U.S. has lots of good, strong data that this is important and follows what you've said, so thank you. One of the reasons I brought this article is because most of the data in adolescence is analyzing Ruin-Y gastric bypass, and this is actually quite long-term good evidence about sleeve gastrectomy in keeping with what Jason said. So I think we're running out of time. We'll skip the... How much more do we have? One more? One more. Sorry. There you go. How? How do we... We're going to have to do this. Maybe we just... Can we go back to the slide that day? There we go. Yeah. Mike, we need... Can someone help us? We're seeing in our program, the average time that the kids are with us is actually a bit longer. It's usually around nine months or so before they end up going for surgery and everybody feels they're ready. And I do think that that's a very important piece, and that distinguishes, to a large degree, pediatric-focused programs from adult programs, some of which do adolescents. So the last one is challenging very strong guideline suggestions of doing total thyroidectomy for differentiated popular thyroid cancer. So it's a database comparison of 3,000 patients, and they're analyzing the survival of patients who had total thyroidectomy versus thyroid lobectomy, and actually find no difference at all. And it's really interesting. I don't think it answers the question. There's a lot of questions on recurrence, hypogalcemia, nerve lesions, but it opens the gate. Maybe we should do better for these children and avoid them the long-term hormone replacement therapy with... There's room for improvement there. And this is the final poll, so we're on a little bit longer than I wanted to, but just tell us. So far, I haven't learned anything new today. I've seen some interesting stuff. I'm not ready to change my practice. I will definitely look deeper into this topic, or I've already changed my mind. I will think different in any of these situations presented. Thank you very much, Todd, for this invitation. Great. Thank you very much. I can put this here. All right. So we are going to go to break, and the next session is going to be APSA PDC, which has been an incredible highlight over the last, I don't know, five? I don't know how many more years you guys have been doing this. But again, same sort of thing as rapid summaries of important new things that APSA believes are the most important topics. Going to break, you're going to watch a commercial here, which is announcing the fact that APSA is now officially in the Stay Current app. It's the latest society to join the network. It's not live yet. It's going to be coming soon. We're doing a soft launch this week, and it will be coming soon ASAP. So we'll roll that, and we'll set up for the APSA PDC session. Thank you.
