QUAD #11 Pediatric Surgeon’s Perspective on Improving the Care of TEF/EA Patients Keynote With Dr. Dan von Allmen

Global Cast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hi, I'm M Gody from Cincinnati Children's Hospital Medical Center. And last year in October 2022, Cincinnati Children's hosted the quad conference, which was a combination of four conferences. The International Organization for Esophageal Atresia, the Aerodigestive Society conference, the Cincinnati Children's Airway course, and the Cincinnati Children's pediatric dysphagia series. And today we're going to hear from Dr. Dan von Allmen, a pediatric surgeon and surgeon in chief at Cincinnati Children's, on pediatric surgeons' perspective on improving care of tracheoesophageal fistula and esophageal atresia patients. First, we're starting with a little bit of history. Esophageal atresia was first described back in the 1600s, but it was really in 1939, Logan Levin of Minneapolis and William Meyer of Boston independently had the first long-term survivors of esophageal atresia with a series of operations to construct skin-line tubes on the anterior chest wall that connected an esophagostomy to a gastrostomy. It was actually in 1941 that Cameron Haight described the first primary repair of esophageal atresia. And this was really at the dawn of the evolution of the beginning of pediatric surgery as a subspecialty. Here's a classic Netter diagram on how you repair a type C esophageal atresia. Dr. Von Allmen says, if you have a Netter diagram, that means it's important. Many of these cases are complicated. We recognize that there are lots of associated anomalies. On the right there, you can see the relationship between the various anomalies. And it's very complex because there are lots of things that can impact these children. And pediatric surgeons, much as I'd like to say, wow, we can do everything. We can't do everything, we can't begin to do everything. Everybody has different skill sets and they cover different parts of this, but I would argue that nobody can do all of this. And so it really takes a team to take care of these kids. Here is a very large study with 207 patients. Airway abnormalities were found in 40% of these kids. Almost half of the kids have an airway anomaly, and not only did they have an airway issue, much more frequently required a trach and more importantly, had a much increased risk of death, 14% versus 4% in the patients without an airway issue. So that means you need to know how to deal with the airway issues in addition to just sewing the esophagus together. In very small patients who have major cardiac defects, the mortality is quite high. So we still have a long way to go to understand exactly how these patients are diagnosed. We're much better at diagnosing them in utero. Dr. Von Allmen adds that they're actually doing interventions in utero for cardiac defects now. But there's still lots of work left to go, and it requires a team approach with a lot more than just pediatric surgery. And we've made great strides. So here's the mortality curve for esophageal atresia, starting back in the 40s where virtually every child died. Now this is relatively uncommon unless your patient is 700 grams or a baby with a major cardiac defect. But for most patients, they will live, but there's so much more now that we have to look at. Now pediatric surgery has subspecialized, and I would argue in Cincinnati, we're the the poster child for subspecialization. At Cincinnati Children's, they have a colorectal team and an esophageal team, and a bariatric team, and a trauma service, and critical care, and all other sub specialties. The challenge with that is that you tend to know more and more about less and less. The challenge with it is the very, very real risk of causing fragmented care. It's not the patient-centric approach. The team is important, but it's also very important how the team is structured. The team is very broad. We talk about it includes pediatric surgery, ENT, pulmonary, GI, CT surgery when there's a case that might require bypass or has a complex vascular anomaly. Radiology and speech therapy is certainly key, and then intensive care, genetics and many others. You need to have various providers involved. Dr. Von Allmen mentions that they do have dedicated OR time and they take patients to the OR at the same time with all members of the team. When I go to the OR, I don't do anything there other than spend time watching what the other three services are doing, pulmonary GI and ENT. The challenge with that is that means I don't get to bill for anything. So that's a barrier for hospitals sometimes, especially with the system in the United States. But the great thing is, we go out and we talk to the families and we can give them a coordinated plan. And the great experience for me was to hear other people's perspective on how they would do stuff. From that practice, now they have a series of patients with complex recurrent tracheoesophageal fistulas where the team adapted the tracheal slide procedure to close the hole in the esophagus and the trachea by sliding the trachea and repairing over it with an interposition of sternal periosteum. And that's very effective. I never would have thought that and I would argue that many of my surgical colleagues in general pediatric surgery have never even considered this option and wouldn't know how to do it themselves even if they could think about it. Dr. Von Allmen has found tremendous value in the multidisciplinary team approach. Let's hear about a few things he finds particularly valuable. I don't do neck dissections very often and I'm not an expert at finding the recurrent laryngeal nerve. For me, I sleep much better at night when Mike Rudder or D Khan or Katherine Hart or one of the ENT folks dissects the neck out because A, they know where to look for it, they do it every day, and B, if there's a problem with it and many have pre-existing problems, they know how to fix it. It's incredibly liberating to let that go. It's also very efficient because they operate as two teams at the same time. So instead of taking 8 to 12 hours, these cases take 6 to 8 hours because they can make progress twice as fast. And that's a good thing for the patient. So again, if we focus on the patient, having somebody who knows the anatomy, knows the complications, knows how to avoid them is the best thing for the patient. So this is an important takeaway from this session. Everybody has to check their ego at the door when it comes to the different services working together, and that's not always easy. There are very well established cultures that sometimes are barriers to that. But if you can check your ego at the door, forget what the letters are after your name and have a collaborative meeting, then that will overcome this barrier. Like we mentioned before, there's a potential for financial losses when a surgeon attends a procedure but doesn't actually operate. While observation is an important learning tool and being present is more important in case they are needed, the surgeon is unable to bill for their time in the OR. We also have barriers from outside the center. We have trouble sometimes getting other states to pay anything close to what it costs for us to take care of these patients because the Medicaid reimbursement for an out of state referral can be sometimes four or five cents on the dollar. And that's very hard to do consistently because you just can't do that for everybody. Also, research is a huge opportunity and it's an obligation because that's how we, providers, get better. That's why that mortality curve came down in the first place. That's the kind of thing we have to continue to do and it's not just clinical research and we've seen several sessions here with some amazing basic science research that will contribute to that overall improvement. We all need to work together and put the patient at the center of what we do and we will achieve great things. In summary, from esophageal atresia's initial description in the 1600s to significant breakthroughs in its repair in the 20th century, the field has seen remarkable progress. Today, it's all about teamwork with specialists from various fields collaborating to provide comprehensive care. Challenges like financial and bureaucratic barriers and the need for ego-free patient-centric approaches still remain. But with continued research and a focus on teamwork, we're making great strides for these young patients. Thank you for watching this video. Don't forget to subscribe to the stay current MD YouTube channel. Follow our social media channels and download the stay current MD app for tons of content in pediatric surgery. Global Cast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.