It's just for, yeah, but it's fun. I so people can watch it later, but you, you don't have to do anything with any of that, you know, down there and um in Utah County and uh yeah and it's just kind of fun to work at a different hospital, um, at some point I need to get, we need to have a different flow than the ER, you know, it's so refreshing yeah like have really beautiful. Right now, over a time or for like more than a half hour this time of year, I uh, I'm I will have some kind of a, not a. OK, yeah, I have a few hours. Well, yeah, yeah. So are you still working and. So I'm I won't be scheduled for this, but I'll probably pick them. I'm good. How are you? You've been out and about. So yeah, you. your fingertips the gel's still there, yeah, and, uh, there's actually a lot that's still happening. There's me and Miguel, you know. Chambers that's right. I'm talking to. Do you, do you, um, I bet there's a lot of variety, but Oh. like all of that chambers are, are DOP, right? So I don't are you all part of, um, uh, Glasgow OK, so you see what happens to that is that is that. Is because he had another x. rex that's a study. And the criteria, let's see I'm sure we can, yeah, that would be good to make it so that it makes more sense to stay sure, sure, it's, that's actually probably good for us for likesciated with that work and stuff. Yeah, we all know that it works, you know, with and at and in some cases for and now you know that so that that is. Like all the traumatic stuff like there was always barriers they're not a, you know, but it's, um, you know. Yeah, I I've always enjoyed. It's so nice. Yeah, yeah, yeah, that's why what happens, um, I don't know the realistic works in primary care. It's like I don't know you working on me. I hope somebody around here or what he's gonna do with it. in your mouth and it's I can't get it that it was, oh, the computer thing. I don't know, the computer thing, yeah, it was showing and I was showing it so you were just putting it and I was like. OK, so you're attached. Oh, you know what, it's going from the Oh, that's really interesting. I, I know that what would you guys start to look at you like, oh, both of these guys go on. That's why like I don't, I don't like it. It's a really good thing that I also think like. Oh, I know, but that looks like that's fine that's not. there's a I would say 60,000. So, so as long as you know the right and then you all that stuff it's much better, I think so. I like. So yeah, I'm gonna drop me off. I'll get this in your ear and this is a microphone so. It's been so bad. That's unusual. It's not. You can keep your stuff there. It's just I'm, when I talk about you to check out that I have not, should I get started? Yeah, yeah. You ready? Yeah. I think it's all working. So for those who don't know me, I'm Carrie Page. I'm one of the nurse practitioners on the Johnson Street trauma team. I've been at primaries for 20 years and on the team for 12, you know, I'm aging myself. And then I brought Alicia Donaldson as well. I'm also a nurse practitioner on the team. I've been at primaries for 14 years and I'm the general general trauma service for 7. And then there's a couple other APPs that are gonna be joining us in just a little bit. So, um, no financial relationships to disclose. So I was asked to talk about surgery drains and tubes and some post-op complications. Luckily, we don't actually send patients home with a lot of drains and tubes, and we don't have a lot of complications, but still there's tons to get through. So we're gonna talk kinda fast and hopefully this isn't too basic. If you guys have questions, please, please ask questions as we go. I wanted to start just by introducing our team. Um, we have, we will have 11 surgeons starting in October. Robert Swenneman just finished his fellowship. He joined us as a permanent member of our team, and then Laurie Bowman's our new attending coming in October. She just finished her fellowship at Children's Hospital Los Angeles, so she'll be coming. And then we have a new fellow, Michael Traynor. I don't know if you've met him yet, but he started this month and he'll be there for a couple of years. He came with his Beautiful wife, a couple of kids. They're from North Dakota. I think you'll really like him. Um, our surgeons, they cover uh primaries Maine, obviously, and also Billings, Montana, Utah Valley, and they have clinic at Riverton. And all the surgeons, they kinda have a specialty they're involved in. Our newest one, Zach Kasberg, he's gonna start training at INC for liver transplants. He's gonna be an official liver transplant surgeon coming up, which will be awesome. And then our APP team. So we have a big team. The roster up there, that's our most current one, although we also have two more that need to be added. So Carly, she does her job, um, jump her APP at Utah Valley. She's joining our big group, and then Dan Hill Crane is our newest one, and we have 7 more. Yes, what is your staffing in Billings? Like, how often are you there? Are you 24/7, 365 there? Yeah, I think there might be a day lab over the weekend where there's, there might be a day lab over the weekend where they're switching. So pretty much they have a surgeon 24/7 and they have clinic like Monday through Friday. And what do they do in? Are they doing everything? Everything that the facility allows. They don't do trauma. No, just general surgery, yeah. They can follow some trauma patients up there in clinic, but not doing like inpatient trauma. Um, we just hired, we have 4 more starting in the next couple of months and we are hiring 3 more currently. So we have a big team. We, um, obviously cover 24/7. We usually average about 40 patients on our list that we're primary on our consulting, and we do, we respond and run all the NTPs. We do telehealth, or first assistant or at night. We cover liver transplant at night, so we, we're a busy team. But with this, Yes, can we get that picture printed in the ER? Of course. Like do you wanna send it to me, and I'd be happy to print it. Yeah, sure. Yeah, it'll it's went, it went out to after it changes. It went out to most teams, but yes, I'll definitely make sure the ER has it. Uh, with this, you can see that we are new, that we're fairly new teams. So with that this will come some patience hopefully on your end and hopefully we can continue to collaborate well and just might take some extra time, um. To get back to on plans since the new people are navigating like what's best for patients and staffing with the tennis. And then I wanted to talk about outpatient clinics because we do, I think, a fairly good job routing patients through clinic instead of through the ER with problems. We, I talked about general surgery clinic. We also have specialty clinics. So colorectal, we have an esophageal airway clinic, IBD, and a pulmonary hyperplasia. They're busy clinics, um, but we get patients through, you know, we can see patients same day. So it's usually not an issue like some clinics to get in to see us. Preparing for this, I wanted to look at what our most common procedures are and numbers, um, which is kind of what I expected. So we do a lot of appendectomies. We do about 500 a year. G tubes for about 250. We open abdomens about 200 times a year. Central line is about 250. It means we dilate a lot of esophagus. Cholecystectomies, hernias, masses, burpectis, excavatum, we do pylo pylootomies and foreign bodies. So those are kind of our top 10 procedures we do. And then I looked at patients that come back within 3 months of having a surgery. The number one thing was G tubes, so about 7% of G tubes come back through the ER in that 3-month period. About 6% of our ex-pats, Abby, even though we do do a ton of those, less than 2% come back, and then we have a lot of central lines. But for the majority, it's kinda nice to see that we don't have a lot of patients coming back in that first 3-month period, which is nice. So I know you guys are probably really familiar with appendicitis. I just wanted to hit on a couple of things with this. It's extremely rare for us to see complications with non-ruptured. I've seen a couple of kids in the ER. Usually, they come in with viral symptoms or something not related to the surgery. So extremely rare to have problems if it's not ruptured. But about 50 to 70% of kids less than 5 are ruptured coming in 30% of older kids. With ruptured appendicitis, we've seen an intraabdominal abscess about 20% of the time after. And usually these kids are still in the hospital when this happens cause they just haven't. Like, done well and haven't been ready to go home, but they present the same way as coming in initially with appendicitis or fever, abdominal pain, emesis. And we wait 7 days to scan this patient. So coming in from the ER, most of these patients, if they went home first and come back, when we pass the 7-day mark, but we wait 7 days just to make sure they have a well-defined abscess that we can actually intervene and drain. And those CT scans, we use IV and PO contrast. We occasionally see some wound infections, although that's rare. Prolonged ileus is rare, and appendiceal something, I've seen that once in 12 years. So really rare. Um, before coming in initially to the ER, if patients have symptoms more than 5 days, we ask that you a CT scan so we can look to see if there's an abscess that we can intervene on. Um. Most of our surgeons support draining those and initial non-op management. So we look for an abscess. They'll go to, we'll admit, they'll go to IR, yes. Sorry, did you say IV contrast? Do you want IV and oral contrast after 5 days or just IV? Just IV, yeah. We used to torture patients with rectal contrast, but now it's just IV contrast. We don't need oral, so we don't need oral contrast on the initial workup. Yeah, well, when they come, if so if they're post-op and come back with symptoms, then we do oral and IV if we're looking for an abscess post-op. Um, So with uh interval Apis, we'll admit they go to IR for drainage. Most of those kids are in the hospital 2 to 5 days. You almost always get the drain out before they go home, so it's rare that you would see those drains in the ER, but they're just pigtail catheters to, to a bag just like to down drain. And most of the time, we do a lot of education on um when those should come out if they do go home with them and they just come to our clinic. So I don't think I've even seen one in the ER, but um most of the drains come out before they go home and then we have a discussion with family outpatient on whether they should have the, the appendectomy or not. There's kind of controversy in the controversy in this, um, 5 to 30%, they say reoccur, the appendicitis of 5 years if they don't remove it. It's higher if they have a fecalli, so. We usually talk to parents about that, and most parents, I think, agree to have the surgery. It's just outpatient. It's quick, so. With interval appendectomies, the number one complication we see with that is small bowel obstruction, even though that, that's so rare, but we've actually seen a couple of those just in the last month. And so if kids come in, in between that period of having a drain and not have their appendix out yet, then, um, an X-ray to look for small bowel obstruction. We'll talk about whether a CT scan is needed. And then we occasionally have kids readmit with recurrent appendicitis, and we talk about whether we just wanna continue antibiotics or, or take the appendix out at that time. Um, just kind of highlighting the reason why we, we push to keep kids in the ER longer. If there's a high suspicion it's not ruptured, then those patients can go home from PACU and not have an inpatient stay. And so that's why we're like, can they stay, you know, a couple of hours until they go cause they can just discharge, get out of the hospital quicker and not have that inpatient charge. And then we often will like Spy on your ED board and see that there're, you've accepted patients to come with, with ultra with imaging-positive appendicitis. So just putting that out there that we're happy to take these kids direct. You don't need them to come from, through the ER just give us a call. And one caveat to that is we take a lot of outside calls about this. We really only wanna do that if they have a CT scan read by a pediatric radiologist or we can get the imaging habit read or looked at, or if the ultrasounds read by a pediatric radiologist. We've been told a lot to admit kids and, honestly, most of the time they come and they don't actually have appendicitis if it's read by an outside radiologist. And then G tubes. Oh my goodness, we see a lot of G tubes. We, we get called a lot about G tubes from the ER. So just quickly, and I have, I brought the little G tube baby that you can actually play with, um, deflating the balloon, putting it in and out, and there's some different G tubes and measuring device if you kinda wanna look at that while we're talking. I'm not gonna go through how to use the measuring device right now, but if you're interested, I can teach you after how to measure it to get the appropriate length of the G tube. But we primarily place ENT mini one buttons. If it's an older patient, like a teenager, they have a lot of subcutaneous tissue, then we sometimes have to do it percutaneous, and it's actual G tube, a PEG tube, and then we go back 6 weeks later, measure the length, and order the appropriate G tube button size at that time. On the button itself, it will tell you how much water needs to go in the balloon. We use water, not um saline. And then it will have the diameter and the length on there as well. So the tube itself will tell you most what you need to know. It takes 6 weeks for that tract to fully heal and mature. And so if that comes out in 6 weeks, general surgery, like we wanna be the ones to put it back in, so we're responsible if it's not in the correct place. So less than 6 weeks post-op, definitely call us. If it's after 6 weeks, anyone should um be able to put that back in, and we teach the loon team, not we, the loon team teaches parents to put those in at 6 weeks, how to take them out, put them in. So most parents like have that education by the time you see them and know how to put it back in. Oftentimes, like the balloon broke or they don't have an extra G tube to put it in themselves, but a lot of parents should be able to do it. I don't know if some of you remember Doctor Downey, one of my favorite surgeons who retired, but his quote was, there's no G tube with no problems, and it's so true. A lot of them have issues, and 6% of all G tubes need to be revised. The most common thing we see is granulation tissue. I don't know how often you see this in the ER, like, parents shouldn't be coming to the ER with this, but they probably do. So, um, with that, it's like beefy, moist, friable tissue. We treat that initially with triamcinolone cream for a week. We send every patient home after G2 with a prescription for that Ninra. So, wound team, usually they're able to call wound team. Wound team can tell them to start it, they can fill it, but you're welcome to prescribe that. If you see this, we would give that a good try first before silver nitrate. If it's extensive or causing issues, doesn't work, then we can use silver nitrate on this. A couple of things that may pull you on the bottom, this mucosal tissue. Sometimes you can have some of the gastric mucosa prolapse out of it. It looks similar sometimes. The difference with this is you can actually pull up on the edges of the mucosa tissue pull away from the skin. Um, and then we see occasionally some excessive scar tissue, which is more dry, smooth, and we don't typically do anything with that unless it's causing problems, and then we would revise it. With cellulitis, you know, you see a lot of cellulitis in G tubes in the ER. Sometimes, um, depending on what it looks like and other symptoms of the patient, if it's been leaking a lot, it can just be really inflamed, irritated skin. So we just treat that by fixing the problem of trying to decide, trying to discover why it's leaking or You know, just try to do a better job of protecting the skin. But if we think it's cellulitis, we treat that with antibiotics. Um, we, uh, you're happy, we're happy if you call us to come see this, but honestly, you guys can treat this without us. Often, we'll just say, great, yeah, start antibiotics. Um, and then they can come see us in clinic if it's not getting better, it's getting worse. Leaking G tubes look like they almost all leak. The first thing to do if it's leaking is to check and see how much water is in the balloon. Um, sometimes after time, it loses water, it deflates a little bit, and that's often a problem, or you can just refill the water in the balloon. Um, one thing to point out is if the strama has actually stretched out bigger, please don't put, put a bigger size diameter of G tube. It just makes it worse, makes it get bigger and bigger. We actually just had a patient that an outside hospital kept upsizing it because of This and he had like a 30, 30 French YouTube. I didn't even know they had those and was still causing problems and the kid was gonna gonna pick you from electrolyte disturbances. So the, the fix is not to keep upsizing the diameter. We see a lot of kids with, um, viral infections that that's why they just have a little bit of ius and they leak so. Dislodgement. So often we see kids where they pulled it out at night. The parents don't know, you know, it's been out for a long time. They can't get it back in or can't get the appropriate size. I think that's very typical of why they come to the ER. Um, the goal is to get something in there to keep the tract open, so they go home with an emergency kit, which is also in that little thing passing around where they have the same size buy and one smaller. Like usually they can get smaller size in. Again, we replace it if it's been out less than or been in less than 6 weeks. Um, you are welcome to dilate. I think some of you feel comfortable dilating, some of you don't. The easiest way I found to dilate is just to use the silicone foleys. So you start with the size that fits, you leave it in for a while, you upsize it, and you just keep going till you get to the size of the Foley. Usually, it's well tolerated by patients and it's quite easy. So feel free to do that. There's only a couple on the wound team that will do that. Um, But you're welcome to try that. And then the biggest key, honestly, is to use a little blue stylette which is also in that, but a lot of patients don't come with that, but you almost always have to have that blue stylette in the G tube to get it in place. So that's a big help and lots of lubrication. And then sometimes you have to measure to get the correct size. If they don't come with a button or if it's like way too tight, way too long, there's a measuring device that you can get for materials that makes it easy to kind of guess the length you need. And G tube studies. If it's been in less than 6 weeks or it's fairly fresh, or if you have to dilate it or it's really difficult to get in, then we recommend the G tube studies just to make sure everything looks OK. GJ's GJ tube, so IR is the one that converts the G tube to a GJ. They have to be 6 weeks out. They have to be over 8 kg, um, and that's you call if the GJ comes out and they come in for that problem. We don't do, but it's before 5 p.m. if it's before 5 p.m., well, it's the same hours as the week. That's funny too. I know. I was gonna say sadly the routine isn't available on weekends anymore, but they're here weekdays and they can come to the ER too. So with any, you know, G2. General questions. They are so good, and they will come to the ER so you can always call them first to to have them come help you out. We rarely do primary J tubes, but if they have a J tube that was surgically placed, it's essentially like a G tube just into the JG unum. that. Awesome. I'm sure you guys see a lot of central lines come back. We place them, but we're not necessarily the team that manages these patients. As a question, do you guys prefer water or distilled water in the tap tap water, yeah. So yes, we play slides. We say we're the mechanics and then we put the lines in for usually it's GI for like TPN use or for oncology for therapy, of course. Uh, so there's a couple of different types. Uh, but if they come in with an issue that it's, uh, not working or anything, then you can do the, it's kind of like a two-d study but through The line itself to make sure that it's not broken in the wrong place. Uh, if the cuff is out, which did you find the cup picture, it's just a white, um, the white part. OK, perfect. So if you can see the little white part, that's what we say you call us and say the central line was dislodged a little bit, doesn't need to be replaced, we'll say, well, is the cuff out. So you really want to look for that little white part that comes out of the skin. These are bracs. They are stitched in. Uh, if the cuff's out though, we do have to replace it. And if it's a simple, if it's during the day type of thing, we can just hopefully rewire it in the operating room and send them home. But if they have to be admitted, usually they'll go to their primary team of what problem they have underlying, and then replace it while they're patient. What is the cuff? Cuff helps hold it in place, really. It kind of creates a thing for, uh, the kind of scar over it holds it in place for. Yes, there are some lines that the IV team actually can fix. So we'll also ask you what the, what can they fix. So IV team, they are here 24/7 in the hospital. They, it has to be a silicone lines. They say the white robex, uh, they cannot. Help with the polyurethane or the purple robiac. So it's kind of good to know that color. You can try them first always if you're unsure and see if they can fix it. But they'll probably ask you what type it is and just look at the line and see if you can give them any descriptors, and they can usually tell you if they can fix it or not. And if they can't, you guys can call us. Is there an an easy place in my sister to find the type of line that's that's operative in the, yeah, which the surgeon should say very specifically what kind of line it is and they usually label their operative note what the line is like we're gonna take it and then you can find it what we do that way. But you don't know when it was placed though, like if they're not like a. Central place where it's operative now in the old system you used to there was a very specific central line database we'd have to enter that in, but that's kind of gone away with the central, I think, isn't there in the line there's like a they're working on, yeah, because I remember there used to be it was great because yeah, I think they're working on trying to create a central line to. Something somewhere that we can look it would be really nice, but that's also in the operative note if you wanna dig a little if you have to have it set up on mine that I can search just operative notes and then it only pulls up those, it makes it a lot easier. So if you can figure out how to do that, that's awesome, um, or if they know when it was placed, you can always scroll a couple pages until you can make it, but most often, oh you can't touch it just give it a second, OK. Uh, I'm sure the most common thing they come in for is, uh, central line infection. They come in ill, fevers, those type of things. Again, they would go to their, their primary service through the GI or oncology or replace one of the line in the first place, uh, and they talk to infectious disease. They try to treat through it, save those lines if they can, and then if they need it replaced while they're a patient, call us. We'll take it out for 72 hours until cultures are negative for 72 hours, and we'll place it back in. And just reminder that picks are not placed by us. That's the pick I need to prepare. I said this is just a quick clarification about the cuff. And when you're saying externalized, essentially the, the cuff should be entirely in the skin, right? So if you can see the cuff at all, that's externalized that, and when do we need to replace it? Just if the dressing was pulled off, or because I've had that happen a couple of times where the dressing got pulled off by the kid in the night and then parents come in and we end up, you know, replacing the line. Is that more of a judgment call? Yeah, I haven't seen that as much. Replace the light of the dressing. Uh, sometimes I've had a Like a proper place the line, but most of the time, right, it sounds like you would not change the line if the top isn't externalized. You just replace the dressing, yeah, and I think he is more than happy to come do dressing change, yeah. OK, sorry, can you go back to that last picture? Can you just touch the cuff just to make sure I, I, I think it's the white part, but it's like a white little cushion like underneath. Yeah, you should never see the white turtle. And then they sew where the little holes are. Yeah. So usually if the suture is still intact, the cuff should be under the skin, but OK. Small bowel obstructions. I feel like we get these a lot recently. So most of these are the kid has had surgery in the past and they come in with adhesions, but the majority of them, 75% are from adhesions or prior surgeries. Um, a third of those occur within the first year after an ex-lab or it also can be from laparoscopic surgery, but we're coming from X labs. Um, 18% of those require reoperationss just for lysense adhesions, just to, uh, free up that scar tissue and things. So We do medically manage the majority of these with bowel rest, um, and we do gastrographic challenges if you get the first that, uh, where we're gonna just do NG for decompression, um, and then do the gastrographic study while they're inpatient to see if just rest and time will help with that. So when they first come into you guys, uh, first to the abdominal X-ray, you can see a beautiful picture example of a skull bowel obstruction here, uh, place that into you tube to get those labs listed there, of course, food bowls them because they've probably been vomiting or or dehydrated. And then, uh, all these kids come to us primarily. Occasionally, we have to replace the ending on the floor. So just we want like the biggest tube that will fit in the patients. So, I think the nurses just trying to be nice and they put in two little tubes, but they really need to be like a large, huge. What's the smallest, um, uh, tube size that's like an Anderson that has all the multiple ports, you know, like if the kid is small and the biggest you can get in is a tube that just has a single hole on the end, right? Like, is that OK, or no, are there like, are there ones that are fairly small that have all the multiple Anderson like ports? Early in the NICU, so you, they would do an OG. If, if you needed that bigger size. The smallest sandwich. Oh, should be able to get that in 99% but or or you can just drink. You have to be pretty young to tolerate that. That's great. OK, uh, surgical site infections. This is a fun picture of a Nesbar placement. So hopefully, you guys do not see a lot of these come back to the ER, but if they do, we take, um, an infection of a mesbar very seriously because they have internal hardware that we try to save at all costs. Um, so usually they come in and get infectious disease, they wash out to get them back, they get antibiotics. Uh, we try to save that for all costs and try to prevent removal. Every once in a while you have to get removal, so they'll have an incision like this on both sides, uh, and this is an example of an infection on one. so definitely call us if an SR comes in for infection. Usually they're seen in clinic or by video, and then we directly admit them. So we try to save most of them in your visit, but if you see them. It's important, uh, would be hisance. I'm not sure if you guys have seen that, but of course the moon comes apart, um, definitely give us a call. Sometimes we have to do moon back type of thing and their fascia is intact, they just get like a skin back or something like that. So Anasmatics, anastomotic leaks, uh, usually happen while they're inpatient. We do a bowel resection. Uh, they're usually still inpatient at this time. It's usually about 5 to 7 days after surgery and they just have a slow and they start getting sicker and then they have a leak. But if for some reason, they're really doing awesome and they go home early, they come in pretty sick, febrile, uh, septic, and they usually have the next amount of leak if they have a res left in. IBD. We have a wonderful IBD clinic. Um, Doctor Scott Shore is our IBD surgeon that is kind of specialized in that. Um, and he has brought with him these wonderful three-stage procedures, uh, for, it usually ulcerative colitis kids that have failed medical medical management. So these are all GI patients primarily that start consulting us and they just are not doing well with medical management. So we do a three-stage procedure. Uh, I'll kind of briefly go over this just for anatomy-wise so you can understand when they come in and what the possibilities of complications could be. Uh, so the first step, take out their colon and give them an ileostomy. Uh, you can see they preserved the rectal stump down there. Um, for the second one, they do. Uh, a J pouch. So if you look at the bottom, that's what we say that they could have pouchitis or something like that. That's the J shape at the very bottom, that's the ileum that they put back together. And then they leave, they do a new type of ileostomy to also just really let that site heal for a while, and that's the point of that, but they still have a stoma at the second stage. Uh, and then in a few months if they're doing really well they'll take down the stoma, so they'll just be ileostomy essentially no colon, um, have a J pouch just to help collect waste before it comes out. Otherwise, you can imagine how small an ileum is to stool. It doesn't hold very much, so that gives them extra space. So usually we deal with this really soon postoperatively. They don't have ileostomy output for a few days and then they start dumping liters of school and they just get really dehydrated. So most often, we're able to help with this before they go home, uh, but there's a possibility when they go that they become dehydrated. Hopefully we're able to again get those in the clinic and directly admit them, but generally, if there's some outputs over 1500 mL, we add thickening agents like psyllium, Imodium, Marco, um, as well as just really promote hydration, drinking a lot. So we teach patients about this before they go home. I think bowel obstructions again, they can get bowel obstructions, they get stricture or sometimes it's just kind of the fashion with the way the ileostom made. Uh, so sometimes it just takes a red rubber catheter, putting it right through, uh, and it just opens it and sometimes we even leave the red rubber catheter in and it drains through that until it's, uh, a little bigger and lifts it up a little bit. There's such fun pictures. Here I found some beautiful pictures. So, ostomy complications. Um, so we talked a little bit about pouchitis, so they can come in really ill, uh, kind of signs of ulcerative colitis flare, uh, just with fevers, diarrhea, abdominal pain, um, and it's usually treated and it's fine with just antibiotics. And again, it's usually GI or, uh, doctor clinic, but if they come in sick and they have that J pouch, you can see that up or no or history, it could be pouchitis. So just treat it with antibiotics and then they go home. Uh, prolapse, if you guys have ever seen the sugar packet thing, sometimes that helps. Just get the packets ready and we can dump it on it and try to manually reduce it. Um, every once in a while, we'll have to surgically revise it. Uh, it's been out for a long time. We had a recent releases that kid in the ICU that prolapsed and we were told that for a while, actually got a chronic and he got very sick and. I'm gonna play name that picture. Does anyone know what the left picture is? I guess it. sausage like what the, what's the problem? What's the problem with it? Have a problem with finance. Sorry. I can't hear you anymore, but you can see that the, the actual stomach is like pulled away from the skin, actually the skin, so it's just coming off the side and getting infected. What about that top corner? What's in the the ileostomy bag. It has collapsed. Yes, a lot of them. So that is, that's not valve, that's omentum, which this, this was just last week, which I haven't actually seen this before, but out the side of the stoma, a bunch of omentum came out into the ostomy bag. So that right upper picture, that's momentum and bowel in the bag or just momentum momentum momentum and stool looks like a yellow is that the kid's leg coming out to the left? OK, all right. It's like So like left lower quadrant ostomy side leg patient and that's the knee, yeah, it was like an infant, but I, I honestly haven't seen that much momentum come out before and we would normally, you know, we would need to go excise that and um when we took off the ostomy bag, it actually just fell away. It was so weird. But anyways, it's kind of a, so was, was the omentum coming out in a like hole between the ileum and the skin right here? Oh, this is the same patient. No, no, no, not the same patient. I'm just showing like it was coming from between the skin and the, the stoma, yeah. What is the yellow? Is that stool or is that that's stool. It's or like um. Like sweat, like foul sweat. And then the bottom one, that's a picture of a prolapse. Kind of hard to tell from there. And this actually, this was the same patient that had a narcotic belt in the PICU and he, a week later, he collapsed and then this got pretty dark and nasty looking by the time we got to that one, so. So much. OK. Um, Deb is our wonderful liver transplant NP. She can't be here today, but she shared her slides. Uh, so PTC, that's like you guys see at least fairly regularly, these come back to the ER now. They come in with fevers type of thing. Uh, let's just explain what they are and what it looks like. PTC, percutaneous transplantic cholangiography catheter. Uh, these are post-liver transplant kids. They're placed in IR, uh, so they'll be admitted to go to IR to have it replaced if needed. Uh, it talks about how to be internal or external depending on, uh, where it is, uh, in the biliary system. And then they are instructed when they go home if they start to get fevers or sick, uh, that they unclamp it and open it. So the main thing is if they come to the ER sick with fevers, parents should know already how to clamp it. Uh, but if not, make sure it's not clamped. Also, Next slide, there's a lot of information on here. But, uh, yes, so for signs of sickness, open the catheter. You guys can flush it. We can flush it. Uh, don't be scared of flushing the PTs with the catheter. Uh, sometimes they can get breakdown around it if it's leaking. And I think that they wanted to emphasize that there's issues with PTC catheters. So it's actually the liver, like GI liver fellow that you'll call, um, call them first of all, we, but we admit these patients primarily if they're less than 45 days after the transplant. So we will consult too if they're 45 days after surgery. Where does it go? it's. So the internal lens goes through the biliary system into the GI tract, so digitum orduata. It's external, it's biliary system to drainage back. Not telling you why they know which one or the other. And so after transplant they do this just to kind of keep that track open or only if they're having complications. Which most of our patients have a lot happening. And so most of our transplant patients have these currently. So that's why you're seeing more of these in here. But any questions, just call. Well, we, our liver transplanters practitioners are here during the day, every day. And then it's us or GI at night. So what, what determines whether a patient has one internal versus external? I don't wanna say now fairly, you know, I, I think it just depends on where the The blockages in the biliary system. Yeah, which is external if they're unable to get it into the biliary system at least on a slide. So I'm not sure just mechanically they're unable to get over. Do they have the same kind of risks, uh, like of, not of the catheter per se or the drain, but of the underlying physiology like infection and sepsis and all that, or, OK. We just think about it the same pretty much. All right, that's kind of brief. That could have been a whole another like, but those are drains that you're seeing in the ER frequently. So just kinda wanted to wait. So next, Carol Lee, she is over our esophageal airway clinic, and so she came to talk about those that patient population. And then after her Katherine Gaddis, she's over IVD and Colorectal clinic, so she is gonna talk about those patients. Yeah. So, um, most of you probably know me from surgery and trauma, but about 4.5 years ago, we started the esophageal Airway Center, which is a multidisciplinary clinic for, um, patients that have an abnormality, um, either born with an abnormality or an obtained abnormality of their esophagus or airway that has required surgical intervention. So the majority of our patients are gonna be oesophageal atresia with tracheoesophageal fistula. We also Also are seeing the button batteries after they've been ingested and have strictures. We do see a lot of kids with reflux strictures as well, or kids with rolasia. So it's a multidisciplinary clinic where when they come to see us, they see a general surgeon, GI, pulmonary, ENT, speech, and nutrition all in one visit. So instead of in the old days when they had to make all these multiple different, um, appointments after they left the hospital, now they come and see us. I also have a clinic. Clinic where it's kind of like the HP clinic but it's for kids who have esophageal atresia, um, that is just feeding, swallowing, and myself, um, so it's a speech therapist, nutritionist, and myself. And then we have a clinic, um, the second Wednesday, which is GI, Doctor Barnhardt and myself for the kids with obtained strictures. So that would be the button batteries, the phallasia, the reflux strictures, OK? So we're gonna talk a little bit about some of the most common things you're gonna see in the population. Of esophageal resia. So just to refresh, esophageal resia with her without a tracheoesophageal fissa is a really common thing that we see at primary children's. So most centers will see about 5 a year. Um, we, our average is about 18. So last year we only saw 13. The year before we saw 23. Most pediatric, uh, surgical fellows will do maybe 10 TEFs in their in their 2-year training. Um, I think Rob's women did 45, so. We draw from a big region. Is it the water? Is it because we have so many kids? I don't know. But so far this year we've already had 11 patients born with esophageal resia and or treated esophageal fistula. Um, so there's 5 variations of esophageal resia. Most common is gonna be that incomplete formation of the esophagus, um, and then a fistula between the trachea and the distal esophagus. That's the most, that's about 85% of what we see. Next most common is pure esophageal atresia, so it's incomplete formation. of the esophagus without a fistula. So, um, here you'll see type A. We see that about 7.5%. That's our second most common. Uh, this first one is just a proximal, uh, fistula. Um, we have seen that in three patients this year. Um. And then again, C is the most common thing we see, so the distal fistula, D, um, we've got, we've got two fistulas. We've had two patients like that last year, and then the H-type fistula is interesting. The H-type fistula, um, the esophagus is together, but the. It, there's a fistula. And these are the babies that cough and choke when you first feed them, um, with those first feedings. Oftentimes we think, oh, maybe they just are having issues with swallowing. But if you get an esophogram, you'll see that, that fistula. Yeah, you see this because we have Sort of an outlier in resident of this, uh, do you see this across demographics or is it in in like one particular racial ethnic, you know, we, I have a lot of that. A couple of years ago, but now it's just every, it's Salt Lake Provo. It's, I can't focus in one. I can't, no, no, I, I've looked at ages of parents. I've looked at where it comes in the family, if it's the first baby, if it's the 7th. There's, there just doesn't seem to be any correlation that we can come up with. It usually occurs about um 89 weeks of, uh, gestation where the, um, uh. I should say the airway and the esophagus become two tubes, for some reason there's that connection. We just don't, we can't figure out why. Um, yeah, so the HTC fistula, oftentimes we don't see those babies till they're about 2 or 3 months. They've just been bad feeders. They've been getting NG feeds at home. Um, but any baby that comes into the ER that's coughing and choking with feedings should get. And so the complications that we see are esophageal strictures, oh my goodness. Um, and then esophageal perforations, not as common, thank goodness. And then we'll talk about. So esophageal strictures occur in about 18 to 60% of all our patients. Some of the common factors are they initially have a really long gap, and so we have to groan and groan. And when we put it together, there's some tension on it. Um, so tension on repair, and then if they have an anastomotic leak, so when we put it together, we get an esophagram in 7 days. If there's any leaking from the anastomosis, those patients that are higher risk. But again, um, we see it in kids who have a very uncomplicated, um, Of course. Um, and actually, we have two surgeons that, um, are doing it thoroscopically. Um, our other surgeons are doing an open repair. I'm actually seeing in our population, we're actually seeing an increase in strictures in the thoracoscopic population. I don't have a paper to do, it's just kind of what I'm seeing as we're doing more of the thoracoscopic. Uh, so, the most common time is about, uh, 3, I'd say 2 to 3 months after their repair. So usually they've gone home and they start having some more choking, gagging, and they're unable to swallow their secretions. Um, or what the parents say when we're feeding them, they just sound really wet. They sound like a washing machine, um, because they've developed a stricture and things just can't get through, so they back up. So the diagnosis is an esophagram. Um, and then we will go down and with an and do an EGD and actually look at the stricture and dilate it. So here's a couple of examples. You can see where the anastomosis is. You can see that top part of the esophagus. It's just a little out pouching, and then a stricture here, and then going down to the stomach. This is pretty minimal. This patient will probably do OK on formula, but once they start eating solids, then it's gonna be a problem. This was a horrible, this is actually one of our patients. Um, so you can see stricture at the top and then stricture below and a very uncoordinated, a very dilated esophageal, uh, pouch above because it's pushing trying to get through. This was a patient that we, uh, actually got from Idaho. Um, they came down and they were having some increased choking, and that's as far as we could get the contrast to go. We could not get it to go. So they had a complete esophageal. I mean, we couldn't get anything through. We took him to the operating room. We couldn't even get a feeding tube in. So we ended up doing an esophageal resection of that stricture. And then this was just uh interesting. This is a a little guy, actually he's about 15, he's from Mexico and he comes here once a year to have his um follow up, um, and you, and when he came in this year, mom and grandma, they're Spanish said, yeah, he's choking. More on foods. So we got this esophagram, and you can see why he was choking. Um, that just still, I mean, that proximal pouch is very dilated, trying to push things through that stricture. We were able to take him to the operating room and dilate that, and he's doing much better. So when you have to take out for the esophagus, is it stretchy enough to like, well, that, right. So when we have to do that resection, usually there's enough esophagus so that we, cause usually the stricture is not very, it's maybe 1 centimeter or two. Um, but the problem is when you take that out, it's gonna restrict. So we have a patient that's commonly coming to the operating room or coming to the emergency room now because he had, uh, he had his esophagus put back together, but then later on when you start eating solids, we found that lower down, he had a second stricture, which was not from an operative, it's just an anomaly that we see in about 2% of kids with TEF. Um, so that stricture was actually, so you couldn't stretch it. We went down, um, Doctor Patel has what he does at endo flip, and he can actually measure the compliancy of the esophagus. It was just like a cartilageist ring. So we ended up resecting that, but now, he's got a stricture there. So we're struggling with We're trying to dilate the stricture. So sometimes taking out the stricture is great, and sometimes it just causes another one. Yeah, we do, we see a lot of kids with dysphagia and RTU like evaluating. There's a lot like very small studies. Mhm. Can they pick up on that H type that with the typical swallow study? Yes, you can. You can actually, oftentimes you can. If you go back and look at a swallow study if someone, you can actually see the HIV. You have to look really closely at the esophagrams, but the esophagram is gonna be better. Are most of these diagnosed prenatally? No, I would say, I, I would actually say that about maybe 5% are prenatal. Um, oftentimes they're diagnosed prenatal if they have natural, so they have other cardiac issues or renal issues. Um, the only sign that most moms will have is polyhydramus. So usually, you know, this is a baby that is born. Everything is great. They start coughing and choking. They try to put an NG tube in, and it doesn't go. So it's, it's usually diagnosed within a few days. It's usually diagnosed, um, usually in the delivery room. Yeah. Um, but if the baby's coughing and choking or, um, in the nursery is when the baby goes back. But I did have a baby that came in at, was born at home and came in at day like 4. So, which is incredibly scary. I'm not sure how they survived for 4 days, but, but they did. So, there are a lot of our patients that get stucky, OK? So, and the reason being is that food goes in and they don't necessarily have a stricture, but you have to remember where we put that esophagus back together, it never works the same. It doesn't have the same peristalsis uh as the rest of the esophagus. So it's always gonna have a little bit Medicinal fertility. So food gets stuck there. So it's most common in things that are, um, when you combine it with water, are sticky. French fries, pancakes, um, uh, pizza, and then, of course, meat, right? Unless it's not cut up very well. And, um. The kids usually, well, we, we teach them to eat and drink, eat and drink, eat and drink. But sometimes they just take too big of a bite and they can't get it out. Um, pickles, olives, what else have we had in there recent, oh, clementines, Clementines are terrible. But even some kids, you would think bananas would be OK, but we have a A lot of bananas and scrambled eggs get stuck for a reason, I don't know. But it's just because they, the esophagus just can't squeeze it through, not necessarily a stricture. Um, so we have to do lots of liquids, carbonated beverages, pineapple juice. We have a parent that swears on. You know, I want that, that, that crazy icky drink that, yeah, she swears by that and then we just give them time. So oftentimes parents are concerned that it's actually they get confused. They think it's in their airway and it's not right. It's in their esophagus. So oftentimes with some time it. Oftentimes will pass, but the parents are afraid that they're gonna vomit and then aspirate. So we try and tell them that just give them a little time, give about 24 hours, is what we say. But obviously, if they're unable to take liquids, um, or unable to clear in 24 hours, then most likely will have to go in and get it out. Um, so we do an EGG with the removal of the foreign body. Um, we can also do a dilation at that time. We found there's, um, a paper where they've been injecting some steroids and triamcinolone into the esophagus, and they're having luck with strictures with that. I don't know. I, I'm not seeing a huge difference whether or not we use the. Triamcinolone or not. Um, Doctor Fidel also has this EndoKnife, um, where he's actually able to make tiny little microscopic cuts in that scar tissue of the stricture, and that seems to be helping some patients. And then ultimately, sometimes we just have to resect that part of the esophagus, but not great because Oftentimes it's been restriction. OK. Um, so esophageal perforation is most commonly gonna happen after oesophageal dilation, OK? So usually, we, we dilate them, they go home, they seem to be doing OK. Um, but because we always do an esophagram in the operating room after, but it's fooled us 2 or 3 times. We thought the esophagram looked great, and they got home and they started to get really sick, and they came back in and we did another esophogram, and they had a perforation. So symptoms, fever, difficulty swallowing, vomiting, and they're sick. So again, we're gonna get an esophagram. Oftentimes, if you do a chest X-ray, you're gonna see some uh pneumoediostinum. We're gonna start antibiotics. We like to start Zosyn. I learned from Doctor Meyers that we also start fluconazole. Some of our neurosurgeons are I don't know. Doctor Barnhart, Doctor Sca you do fluconazole, some of the other surgeons think that Zosyn will cover it. And then we just usually use time to let the esophagus heal. Um, if it's a horrible perforation, we'll talk about the stent. But oftentimes if we can just keep the kids' NPO, we can put an NG or NJ down and just let the esophagus heal. It's pretty good at healing. Now, again, when it heals, it probably will have what we call a contained perforation that we'll watch. And then oftentimes that will stricture afterwards. But if you, if there's a horrible um perforation, then oftentimes we have to put in an esophageal stent. These are not tolerated well by kids. Um, yeah. Do you also use like Protonix antacids and stuff? Yes, yes. So we would use antacids as well. That's good for you. Um, but the stents are just not tolerated. You can see if you have that in your esophagus, um. It's not comfortable. Some of the older kids will do OK, but the younger kids just can't tolerate that. We don't have a, a pediatric esophageal stent. And so it goes down so near the GE junction and the kids just vomit and vomit. So oftentimes we keep them, if we have to put a stent in just for a couple of days, uh, we'll just keep them in the hospital and keep them, um, hydrated. Um, but we don't have a great solution for Those perforations except just time and waiting. Questions about strictures or preparations? OK. So I'm gonna talk about fruit. And the reason being is, um, most TEF patients will have a barky cough. I mean, you've guys have all seen that, right? That barky, barky cough. And the reason is, is they all, almost all will have tracheomalacia. And it's where the fistula goes to the trachea. Um, It's just because it's a little bit weak where that attachment was. But also, in utero, the esophagus got very distended with amniotic fluid and it would push against the trachea. And so it also caused some weakening there. So those are the two reasons why they get tracheomalacia. This will usually get better with time, as long as they don't Don't have like an adherrant artery that's pushing um on the trachea. Oftentimes, some of our kids have these weird errant vessels that will push. But it's just tracheomalacia from TEI um it does get better with time, but they will always have that barky cough. So when they come into the emergency department, they've got croup, right? Cause they sound like they have croup. We actually, amongst the population, we have stickers that says my cough is not contagious because they all, when they cough just on a regular day, they sound like they have croup. Um, so the good thing is that really most of the respiratory infections that we see, um, RSV, adenovirus, all these usually will respond. Um, to the croup, right, to steroids. But the one thing with kids, um, with TEF is albuterol oftentimes makes the tracheomalacia worse because it relaxes the, the airway, right? And so that trachea is already a little bit floppy and relaxed. The albuterol sometimes can actually make it worse. So if that, if you're not seeing response, try Flovent. And see if that helps. OK? We also talk a lot about airway clearance with our patients, um, using saline. Some actually have some compass to help them because, again, just like the esophagus, that part of the trachea just doesn't clear secretions as well. And so when kids get sick, they get that mucus that gets stuck in the airway. So we talk a lot about families how to do airway clearance. OK. OK. And I think you all know my, one of my favorite TEF patients. I don't know if you know Millie Mall. Um, she was a very complex patient. She's had many surgeries. She ended up actually, um, having her esophagus replaced with a piece of colon. Unfortunately, that piece of colon died. So we ended up having to pull her stomach out. To her esophagus. Um, so she's Jafed, but she's eating. She also has some heart issues. Um, but she's a trooper and she's in first grade and she's doing great. So, um, you know, that's the, the great part about my job is actually seeing these kids now grow up to, to be little billies. Sorry, it's like we have a minute to do colorectal really quick. Is that OK? I just don't wanna oh sorry skip and go to the device. How much time do you focus on devices. OK, yeah, so thank you. Yeah, we can do that. Yeah. So I'm Catherine Gaddis. I'm one of the nurse practitioners, um, in the colorectal clinic. Yeah, such good surgical pictures. All right. So most of the tubes that are related to colorectal that you're gonna see is the appendicostomy. So there's a lot of names that these get called. They're not really the same thing. So the appendicostomy is an opening into the appendix for a colon flush. It's commonly called the base or the mace. Um, the C-costomy is an opening into the. Gum for a colon flesh. The Mitrofenac, those are really owned by urology, but that's a catheterizedzable stoma into the bladder using the appendix. Nemonte is very similar, it just uses a small bowel. So those are gonna look like the same. But they're, they use different pieces of the bowel to make the conduit. Um, commonly called mace, ace, chape, blush, Malone. So the appendicostomy is just another way to give the enema. Um, it's for children with people incontinence or chronic constipation. Um, and it's a surgical procedure using the appendix to create the conduit into the colon. Typically, the opening isn't the umbilicus or the right lower quadrant. So this is a picture of the Malone appendocost. This is the one that you typically see that you access every day with a straight catheter. Um, so the surgeon will wrap the stitches around the base of the cecum here around the appendix to create a one.
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