Update Course Rewind: 2022 Top Ten Key Takeaways

Cincinnati Children's and State Current are sharing knowledge to improve child health around the globe. Hi everyone, I'm M. Tom Bash, a research fellow at Cincinnati Children's Hospital Medical Center. As you might know, we had our 10th annual Pediatric Surgery Update course back in August. In this video, we are bringing you the top 10 key takeaway points from that update course. Okay, starting with number 10. This is from our updates on gastrochesis feeding protocols. As we know, infants with gastrochesis often require prolonged hospitalization for surgical repair and then initiation and advancement of feeds. There isn't really much guidance as far as initiation of feeds and how to advance them. In this presentation, Doctors Beth Roweski, Jason Fraser and Stephen Lee discussed the initiation and advancement of feeds for a baby with uncomplicated gastrochesis. They asked attendees at the update course when they would start feeding a baby with uncomplicated gastrochesis after they'd undergone sutureless abdominal closure. Based on recently updated protocols from Cincinnati Children's Hospital and Children's Mercy, Kansas City, it's recommended that you can actually start feeds immediately after closure. Starting with 10 to 20 milliliters per kilogram per day and having advancements in 20 milliliters per kilogram per day if it's tolerated. This has been shown to be associated with shorter length and stay and faster attainment of goal feeds. From this presentation, we learned overall that it's safe to say that for babies with uncomplicated gastrochesis, it's safe to start feeding immediately after closure. And if they're tolerating for a few days and have even one bout of emesis, it's okay to continue with the feeding protocol. Number nine is next. This one comes from our session on updates in the management of congenital esophageal stenosis. We heard from Doctors Dan Von Allman and A. Jay Coal from Cincinnati Children's, as well as a pediatric surgeon from all the way across the world in Turkey, Dr. Seref Kilik. We heard about a case from Dr. Coal and discussed the workup for a pediatric patient with dysphagia. And we heard from Dr. Kilik about his institutions investigation into the management of congenital esophageal stenosis. At the conclusion of the session, we started to understand an algorithm for diagnosing and managing these patients. First, it's important to determine the diagnosis. High resolution esophageal monometry can help with this, as well as esophography and endoscopy. If we determine a diagnosis of congenital esophageal stenosis, then we may be able to manage with serial dilatations if there is no cartilage component suspected in the stenotic area. Surgical resection can be reserved for patients where this is unsuccessful or there is a concern for cartilagenous component. So, our key takeaway from this segment is that initial conservative management should be considered for patients with congenital esophageal stenosis, especially if a cartilagenous component is not suspected. Now, we have number eight, and we'll review outpatient management of intersusception, and who can be safely discharged from the ER. For this, we'll talk with three experts. Dr. Elizabeth Speck is a pediatric surgeon at Mott Children's Hospital, while Justin Huntington and Mark Wilken are pediatric surgeons at Akron Children's Hospital. As always, they brought us a case. A six-month-old healthy baby who underwent successful air enema reduction of an ileocolic intersusception. His abdominal exam is benign and he's tolerating a diet. Can we send him home from the emergency room? Management of intersusception after enema reduction varies in practice. Historically, inpatient observation was recommended. However, there is a lack of evidence-based guideline for this practice. In this study, a systematic review and meta-analysis evaluated outcomes between inpatient and outpatient management after enema reduction was performed. According to this study, evaluating overall recurrence rates, recurrences within 24 and 48 hours, well, they were similar between inpatient and outpatient groups. Also, there was no significant difference in the rate of return to the emergency department, and both groups had a similar rate of requiring operative intervention. In conclusion, it's safe to say that outpatient management of intersusception after air enema reduction results in a shorter hospital stay with no difference in the rate of returns to the emergency department, recurrence, need for an operation, or mortality. Okay, for number seven, we're looking at mechanical bowel preparation and if it helps reduce surgical site infections or SSIs. And this presentation was from Dr. Paul Y. Giorgiac from the Apse PDC or Professional Development Committee. So, mechanical bowel preparation in colorectal surgery has been increasingly used in an attempt to try to reduce surgical site infections. Unfortunately, there is really no compelling evidence in the pediatric or adult literature to support this. Recent adult studies have shown no benefit from mechanical bowel preparation in terms of reducing surgical site infections. In fact, some of the studies actually showed an increase in wound infections. These studies also suggest a possible benefit of oral and IV antibiotics to reduce SSIs. But in recent retrospective studies, the importance of oral antibiotics for pediatric colorectal operations has not been seen. Overall, we have seen no benefit of mechanical bowel preparations for reducing SSIs. However, case appropriate pre-operative IV antibiotics may reduce SSI incidents. Now we have number six. And here we'll review the importance of preventing pediatric gunshot injuries. This session was put together by some passionate advocates of gun violence prevention, Dr. Mirion Henry, Peter Masiakos, Bindi Nik Matoria, and Richard Pearl. At State Current, we previously highlighted some recently published articles about gun violence. So, most of us already know that firearms are now the leading cause of death in all children and adolescence in the United States, overtaking motor vehicle crashes in 2019. Unfortunately, there are controversies about whether pediatric surgeons should be involved in firearm violence prevention efforts and advocacy all across the country. We believe as pediatric surgeons that we need to advocate with protecting children's health and well-being, no matter what the topic is. There is a lot to do on different levels depending on how much we want to be involved in. For example, looking up our own state bills that support smart gun laws, discussing safe gun storage with our patients and families, and supporting promotion of background checks. Also, we can do research ourselves to further understand the complexities of the problem and the solutions that will have an impact. Finally, we can vote for officials who are actively advocating for gun violence prevention. In conclusion, as pediatric surgeons, we can play key roles for patients affected by firearms, including direct patient care and advocacy. This time, we have number five. In this session, we review the efficacy of CT evaluation of a suspected airway foreign body aspiration with Dr. Charles Schneider from the Apse Professional Development Committee. Dr. Schneider brought us a case of a nine-year-old child presenting with transient respiratory distress after a choking episode at home. She has a prior history of asthma, and in the emergency department, she's not in distress, but she does have an exploratory wheez on exam, and chest x-ray, well, it's normal. So, what should we do? Unwitnessed foreign body aspiration can be challenging to manage, and there's often a significant amount of stress surrounding the episode. Many items are not radio opaque, and so they can't be seen on plain x-ray. The gold standard for airway evaluation has been rigid or flexible bronchoscopy. However, there are risks of negative bronchoscopy with subsequent airway compromise. So, CT bronchoscopy has been proposed as an adjunct in cases of children without obvious respiratory distress. A low-dose non-contrast CT of the chest has a high sensitivity and specificity for identification of airway foreign bodies. This can also avoid the cost and resources of taking a child to the operating room for a non-therapeutic procedure. Okay, we're getting close to the end of the list. For number four, we're taking a look at laparotomy versus peritoneal drainage for necrotizing enterocolitis. This topic was actually discussed at two sessions at the update course. First, by Dr. Jose Campos in his presentation on the top publications from non-pediatric surgical journals, and second, from Dr. Paul Georgic, from his presentation as part of the Apse PDC updates. This was the largest study looking at initial laparotomy versus peritoneal drainage for patients with neck. At 20 US centers, they looked at combined death or neurodevelopmental impairment in patients at a corrected age of 18 to 22 months. According to the study, death or neurodevelopmental impairment occurred in 69% of patients with a preoperative diagnosis of neck who underwent initial laparotomy versus 85% of those who underwent initial peritoneal drainage. The prospective randomized cohort study from the National Institute of Child Health and Human Development showed no difference in overall survival, but did show improved long-term neurodevelopmental outcomes. Long story short, we can say that for infants with necrotizing enterocolitis, initial laparotomy may be associated with less neurodevelopmental impairment and improved outcomes for extremely low birth weight babies. Here we have number three. And this time we'll review the importance of implicit and explicit bias with Dr. Craig Lillahei from Apse Professional Development Committee. Dr. Lillahei brought us a case from this publication. In this case, a black intern was being identified by a parent as a custodian and Dr. Lillahei asked us what we should do? Say nothing to the parent, talk to the intern in private and apologize, speak up and correct the mistake. I know this is a tough conversation to have and it's nearly always out of our comfort zone. But, racism and sexism that manifest as microaggressions are commonly experienced by members of minority groups. Individuals from minoritized groups are often left in ary, weighing the potential benefits and risks of addressing the comments. Placing the burden to interrupt bias on our marginalized colleagues is unjust and such microaggressions can harm trainees's performance and sense of belonging. You may say that doing nothing or only speaking to the subject in private makes us a bystander and sort of part of the problem. Bystanders can and should make an effort to become upstanders, which means bystanders who respond with action. We should all learn how we can de-center ourselves and our discomfort and leverage our privilege to interrupt microaggressions. Here we are, so close to number one, but we have number two to discuss. In this session, we reviewed who can be safely discharged from the emergency room with three pediatric surgeons, Dr. Elizabeth Speck, Justin Huntington, and Mark Wilken. Blunt head trauma represents the majority of pediatric trauma admissions. However, you have very little evidence on how to best manage isolated skull fractures. So, our speakers brought up a case of a four-month-old baby who was accidentally dropped from their uncle's arms and sustained a linear parietal skull fracture. They cried immediately and appeared at her baseline. There's no intercranial injury. So, what should we do? Even though we may want to keep those patients for observation, this study determined that observing isolated skull fractures in the pediatric population is costly and unnecessary. They did a 10-year retrospective review of isolated traumatic skull fractures with normal neurologic exam findings. And while 77% of those patients admitted for observation, but it turned out none of them needed any neurosurgical intervention or additional imaging in the index admission. So, the authors concluded that pediatric isolated skull fractures are low risk conditions with a low likelihood of complications. Therefore, these patients can be discharged safely from the emergency department without inpatient observation. Okay, we made it to number one for the top key takeaways from the 10th annual Pediatric Surgery Update course. Thanks for sticking with us. Our number one key takeaway has to do with the antibiotic treatment for complicated appendicitis. This topic was also discussed at two sessions. The first one being Dr. Jose Campos's presentation and the second from the Apse PDC updates. The impact trial was a multi-institutional prospective randomized trial looking at the antibiotics for perforated appendicitis in children. They looked at monotherapy with piperacilin and tazobactam versus combined drug therapy with ceftriaxon and metronidazol. The primary outcome was 30-day post-operative intra-abdominal abscess rate. And the patients taking piperacilin and tazobactam had a lower incidence of intra-abdominal abscesses, lower usage of CT scans and fewer ED revisits. They also didn't have an increase in antibiotic usage or increase in antibiotic related complications. In conclusion, we can say that monotherapy with piperacilin and tazobactam has been shown to be associated with decreased incidence of intra-abdominal abscesses after surgery for patients with perforated appendicitis. Thank you for watching this video. Please follow us on social media, give us a rating and subscribe to our YouTube channel. And don't forget to download our State Current app on App Store or Play Store for more content. Cincinnati Children's and State Current are sharing knowledge to improve child health around the globe.