Intussusception - Soft Tissue Abscess - Pilonidal Cyst - Bleeding Meckel's...

All right, all right, we're gonna move on to my, uh, two, research fellows to finish it off. They're, I know these, they're very fast cause these are just questions. We don't have any informational slides. So, uh, who's going first? I am. I love how they're sitting over there together. Just remember these faces, uh, Nick Bruns and Ian Glenn, who will be coming through the match, uh, in a few years. OK, Nick. OK. Well, I'd like to thank all the faculty for coming here today and thank you to Globalcast for putting on an awesome event. I will keep this short. So I'm talking about Intussusception. Um, so there's a 2 year old boy, he's hemodynamically stable, diagnosed on ultrasound. He has successfully reduced in radiology. How do you manage this afterwards? So do you admit them for observation? And if so, what, what diet do you like to do? Or does anyone discharge them home from the ED? Anyone discharge, observe for 4 hours and send them home. Wow, we changed our practice in Cincinnati half a year ago, 68 months ago, 8 months ago, and we've discharged home from the ER. I think there's a 4 hour observational period. Make sure they tolerate. in the emergency room, not admitted. Wow, David, same thing. We took a reluctant ED group, I think with very little push, got him, but the confusing thing was an intern sent my pyloric home 4 hours after the operation. I was confused and it worked out OK, but that wasn't the intent. In a deception, Pyloris, whatever, they're all the same. Wow, OK, so, so Aaron, we're behind the times here. Are you going to change your management? Sure. Have you guys had anyone come back? Uh, no, the bigger issue that we've, since implementing this protocol, the biggest challenge we've had is that if the ED is really busy, they don't want the patient to sit there for 4 hours and occupy a bed, so they come up briefly and then go home the same day. Um, OK, so it's a, it's a logistical give antibiotics before you do the reduction. I personally don't. OK. And do you have to have a surgical resident there when there's no, OK, good. about that. OK, um, so there's a paper that looked at this, and 48 patients were sent home from the ED and only one recurred in 48 hours, and that patient did not even need an operation. They just got reduced again. So they came up with the protocol and the patient is tolerating just oral hydration, hemodynamically stable, afebrile. They send them home. OK, so, uh, next question, um, Patients in radiology, uh, the radiologist feels like they reduced it but can't get the contrast to reflux into the small bowel. It does fill the appendix. Um, what do you do with this? Bring it back and do it again in a few hours. A few hours. Everyone, OK, we can skip to the next one. We all agree. OK, well, well, my preference would have been to, uh, observe there was a study about 20 years ago in which, uh, they, they attribute it to ileocecal edema that it won't reflux. We'll keep going. Wait, you wouldn't have gotten a repeat study. Um, no, in my vast clinical experience, uh, when are you going through the batch, just to clarify, the repeat study is just to prove what you said was absolutely true. The repeat study doesn't now reduce it. They reduced it the first time. The repeat study is just proving it because now it's less edematous. Is the. Just an ultrasound or a contrast? Typically it's an air enema again, contrast, I think, I think an ultrasound after that point, as we saw yesterday in one of our patients, is a difficult thing to interpret because it's so much inflammation afterwards. So, uh, I think you have to get a contrast, uh, some sort of enema. OK. All right, next, so for the patient that needed reduction in the OR, no bowel resection, um, does anyone take out the appendix? I used to, not anymore. What do you guys do? I take it out, whatever it is, yeah, no. He's a colorectal. No, no, now I love the appendix. Please leave the appendix in. I left it for you. Thank you. I get concerned if you have to go back again about bursting open your, uh, appendiceal stump, so that's the reason I leave it now. Plus I don't think it makes a difference. I used to take it out. All right, we have no answer again. Next, yeah, and then, um, finally, do you have a cutoff, um, that makes you concerned about a pathologic lead point that would lead you straight to the OR? No attempted radiologic reduction. Just go straight to the OR. Any age or factor 6 year old, yeah, if it's a 6 year old, I would go straight to the OR. Uh, I might do a contrast study for diagnosis. Several things. If it's not ileocholic, then I worry about it. If it's ileocholic in an older child, then I might do a contrast study for diagnosis. And, uh, although if you diagnose it on ultrasound, then that's usually right. So it's diagnosed on ultrasound. So I would do laparoscopic. I would don't try to reduce it maybe. I've done that before. I don't know. So I think in this situation I'd try to reduce it. I think after age 5 or so I'd be highly suspicious of a lead point. And then in an elective fashion, non-inflamed bowel, do, do a contrast study or whatever you need to diagnose, make a diagnosis and do your resection in a, I think, a better set of circumstances. OK, fair enough. Interesting. So you would reduce it, yeah, and then go back. You're definitively going to go back and go to. I'm going to definitively work the patient up to find out what the lead point is, OK, and then do that operation, OK. Any other comments? The data seems like the inflection point for having a lead point is about over 5 years old, where depending on the series, it's about 30 to 60% have a pathologic lead point if they're over 5. So that, that's probably the cutoff I would use it were up to me. So now we want to talk very quickly about uh soft tissue abscess. We deal with this a lot before we get there. Is anybody, is anybody doing an ultrasound guided enema reductions? Instead of X-ray guided heard the Chinese, yeah, certainly heard about it, but we have not done that. Chinese radiologists in the states or no, so, so, but it's definitely in the literature. I'm just wondering if, if you asked. Uh, no, uh, there, I mean, there's literature on it. I'm just wondering if that's going to be adopted because it's trying to reduce radiation and all that. It's a great, the original interceptions were reduced truly in China with a bellows. So I mean, the air, they use the idea of using air contrast, and now they use an ultrasound too, but those patients didn't get re-studied or anything, right? What's next? OK, we're going to the hottest topic, abscess. So for the, uh, the standard butt abscess, uh, in your hospital, where do you do an incision and drainage in the ED in the butt. In the in the OR, where do you do it in the butt? Where do you do it? Um, we're just many more often than not, many of these are drained in the emergency by the ER or by frequently by the ED, if not combination than a combination, but with sedation, with sedation, are drained in the ED by ED with sedation, our help occasionally. That would put us out of business. We, we, um, we, uh, have, I think you found a substantial reduction in, or we didn't think. Did you find a reduction in cost between we, we haven't looked at that. We wanted to look at that. Because we do them in the OR and my guess is it's a big cost savings to do these, yeah, but you do need some conscious sedation, otherwise it's just families are right, pretty unhappy and they don't drain well, right? They get scared. They go real quick and they don't pack it or who packed, who are you getting into that? Does anyone pack or use vessel loop or nothing? Pack, pack, use a wick, yeah, wick, there's something in there vessel loop if I'm if I'm at that level, it's a vessel loop. That's, it's changed game changer for me. Oh, I see, because most of them are drained by the ED. So there was that study at ABSA that showed that didn't make a difference, yet none of us follow it. OK, OK. And um, is there any criteria that makes you admit these kids to the hospital for intravenous antibiotics after, after they're drained? Yes, cellulitis. Yeah, I think if they have cellulitis, fever, and leukocytosis, I would admit that kid. All of those together or any of those? Some combination. Some, yeah, if the child's sick, I would admit them because you don't want them to get sicker. You want to make sure they're getting better before you, uh, cut them loose. So you reported your literature, right? Yeah, we'll, we'll get to that. Oh sorry. Uh, one last question, um, do you, do your patients go home with antibiotics? If they have cellulitis. If not, send him home with nothing. OK, great. So we looked at our own data and um did a retrospective review of all the kids that we did incision and drainage. So in the OR and then sent home the same day, usually about 2 or 3 hours after the procedure. And the rate of treatment failure, which we defined as readmission or needing another I&D within two weeks was minimal, so 0.9% of all patients had a treatment failure, and of the patients that had leukocytosis, only 2 out of 138 did, and only one that was febrile during their time in the hospital had a treatment failure as well. So, you know, there are some patients with white counts of 35 that got sent home and did fine, um, which would make me almost not want to know what the white count is. But um They are cost cutting on the antibiotics and. Spending more money on the OR. That's how we like to do things. All right, are you done, Nick? Yep, good job. All right, reading. All right, Ian Glenn. These guys are general surgery residents at the Cleveland Clinic right now, spending 2 years doing research. So continuing our trend of gross skin and soft tissue infections. You see a 12-year-old patient following up with you in clinic. One week previously, you did an I&D for an acutely infected cyst, which are acutely infected pyelonidal cysts, and this patient has no other medical comorbidities. So at what point are you going to attempt a more definitive treatment other than just performing an I&D on these patients? When do you operate? When it comes back, Erin, when do you operate? After 2. After 2 or 3 I transferred to David. I usually tell them after 1, but I stretch it out as long as possible. After 1, well, after the 2nd, 2nd 1, the next one comes back, but I discourage what it looks like does not make you go to the opera moon on the 1st 1. It's a big thing. You still wait for a second episode. OK, so I've bought hook, line and sinker into the best cum technique. This is a group of not organ, uh, taking, taking out pits and then only operating if they have bigger draining sinuses, doing a layered off center clo off, off center midline closure. OK, I know we're way over time, but I tell me how you do this. So you excise out the pits under local. Just take an 11 blade and cut out their 1 millimeter pits just at skin level subcu tissue and let them heal by secondary intent and that by their data 70% are never come back and that they might not come back anyway. They don't have a control group. So and then if there's a large after the first episode, after 10 days after incision and drainage, after it's subsided, you bring them back and take out the pits, right? OK. And then what were you saying about and then if that, if they recur or if they have larger draining sinuses, then they go to the OR for a formal. Excision of the entire affected area off midline layered closure with a drain. Sorry, adaptation of it, yeah, and it's a um it takes a miserable operation uh. Situation makes it a lot less miserable. It's still miserable. Are we jumping ahead on your a little bit? That's sorry. So are there, we're trying to save time. Yeah, I don't know. I've been tempted to try it. Let's see what, what do you got? So, uh, along those lines, are there any factors that would manage or that would affect your management, either timing and treatment or what type of operation? Any of those things change what you just told us, or no? Their age, their body habitus. Recurrence. That's what I waited for recurrence, but there are some patients who just have, you know, such high risk factors. They look, you know, they have a deep gluteal fold, lots of a ton of hair. Those patients, it's, it's a miserable process. So potentially physical exam findings, potentially, yeah. So you guys touched on this a little bit earlier, which operation would you perform for definitive management? Would anyone open it and leave it open? If it's really nasty, you would, if it was really nasty with wet to dry dressing change or a wound back, OK. OK, and then you guys talked about some other off midline closures, right? Anyone do a rhomboid flap? We just tried one. Sort of, OK, so looking at the literature, I was gonna say just briefly looking at the literature, the Kradaki flap was superior to excision only and pretty comparable to this modified Lindbergh flap, and then the less data on the modified elliptical rotation flap, but in the short term it has been shown to have comparable results to the Lindbergh and the Kraakis. What's the nuclear weapon? So when they keep coming back, you've had 3 recurrences. What's the nuclear weapon? Is it marsupialization? Is it a skin graft? Is it a, I think it's post-op management. You put them on a bed prone for until the wound heals. It's a wound healing problem. And when I think that typically is the biggest, it's them sitting on it afterwards, yeah, and you can do some sort of flap to get good tissue over it, but unless you get them off of it. Post-op and that's what our plastics guys will do, you know, when it finally comes to the I can't do this anymore, send them to plastics, they do a flap, leave them on their belly, um, for that's my laser hair removal, my completely undata substantiated feeling, OK. So yeah, like you said, has anybody used or recommended laser hair removal for any of their patients? I have. and the patient came back to me and said it was the most painful thing they had ever had, and he got through like one half a session and said he would never go back again. So having not had it done myself, I was willing to take his word for it, and I have not recommended it since. I haven't had that experience. I've sent a few and they haven't really complained. It's been decent. I've had to almost draw out for the laser hair removal list. Um, where to go because I don't think they're going wide enough or extensive enough, um, and I've even encouraged to try to submit for insurance, um, reimbursement, but have not been successful in that part yet because it is expensive. What's next? All right, so 3-year-old male has been admitted to the hospital with hematochezia. You're consulted. When you see the patient, he's stable with no other medical conditions. So you order a MECel scan and that's negative. So what would you do next? What do you do after a negative Meckels for a bleeding, bright red blood per rectum? Negative meals, bright red blood. Do you do a colonoscopy? Do you do a laparoscopy? Was it done with or wherever, yeah, it was done the right way. So depending on your GI. I guess depending on your GI folks, I probably would do colonoscopy with the intent to do a laparoscopy if the colonoscopy is negative, but at the same setting, same anesthetic, if, if you could, I'm not, I, I would like to do it. I would like that's OK. So you have them suction out as you go. OK. All right. I like the idea. I just don't you not have GI fellows where they're playing around for an hour or two and filling the abdomen with air. Herman can answer that question. All right. Does anyone do something different? I start a PPI. Why? Because if it's a Meckel's, it will stop bleeding and then bleed again. Well, but I'm, I'm not saying that's the end of the therapy. Oh, but that's what I would do next. I would just say do PPIs work that far down. Yes, it will stop the bleeding. It should never be an emergency operation. Wow, I did not know that. I didn't know it stopped it. OK, now I know. Another thing I've learned today. Change my practice. 4:42. 1 hour and 2 minutes over. Every hour I'll learn something new. OK, we'll just keep going. Keep going with it. So you do laparoscopy. You encounter this, you. Determine that's the source of the bleeding. What would be your next step in the operation? Find the Eccles. How do you take it out? Laparoscopically. What do you do? I didn't see the base. If I get staple across the base, if it's a bleeding meckles and you have an ulcer on the bottom, I may do a small bowel resection. Well, if it's bleeding, if it's bleeding meckles, I'll do a small bowel resection. Small bowel resection. I was so hoping you stop the bleeding with the PPI and you take out the meckles with the then you don't do a bowel resection, OK. Go ahead, staple across it if it's, if it's the right, yeah, yeah, yeah, it looks beautiful. Depends on small base, yeah, we staple staple staple. Bill Gazetta taught me at the fellows course this year. That the ulcers are in the meckles. I always thought it was in the small bowel. It doesn't matter if you take out the meckles. It doesn't matter where they are because you're going to fix the ulcer anyway. What people say, unless you use Mac PPI thing, is that you staple it off. You've taken away the source, but that bleeding ulcer is still there. So for the next day they're going to be bleeding still. Yeah, but you've taken away the source of the acid that's causing the ulcer, so you're bleeding. It's like doing a vagotomy for a gastric ulcer, but you take care of the ulcer or duodenal ulcer. Have, OK, have you proven you got point is I don't think you need to do a bowel cells out. I don't, and it's been a while since you did a vagotomy. Yeah. How do you know you got a do them all the time when I take out the esophagus because it's almost always at the tip of the meckles. OK. Next, who does it laparoscopically versus pulling the mechles out of the umbilicus? So do I. What do you do? I haven't actually had to do one yet, believe it or not. Oh, I don't know. I just do it like an appy, probably. Yeah, it's exactly singley my way or an appy your way. My way, of course. You have two choices. Both are single site, either inside single site or outside single site. Let me tell you why I would push for open, and I have good pictures, but I can't show them on the air here technologically. I think that when you do it laparoscopically and you're pulling it up to staple, there's a tendency to, to go a little bit onto the bowel. So what I do is I pull it out through the umbilicus and I let it relax. I'm not pulling on it and I draw with a marker. So I see where the edge of the bowel is without pulling on it, because once you pull it distorts everything. But if it's a linear staple line, who cares because the bowel's going to dilate out anyway. So you're not worried about impinging it a little, not unless you made a huge stricture there. Can't rethink. We should teach you how to do a laparoscopic appendectomy. I know that. I don't know, yeah, OK. What's next? Wow, we are finished an hour and a half over, but we have finished. So, uh, for the people who have survived and are still here, uh, this has been great. I thank you guys very much. This has been, uh, uh, I've changed my management on a lot of different things. I thank you all for staying the entire day, and, uh, again, this will all be available for watching afterwards, and we'll hopefully have this on podcast so you can listen to it. And hopefully we'll be able to do this again next year. So, good morning, good night, and good afternoon, wherever you are.