We held our 3rd best of the best in pediatric surgery live event and we are bringing you the top 4 key takeaways from that day. We're starting with number 4. Our first key takeaway is about post-op opiate prescription and racial disparity. Here, Doctor David Grabsky, a pediatric surgery fellow, presented their study to us. We implemented a multimodal intervention to reduce postoperative opiate use in children at our institution based on IV Tylenol, directed postoperative pain education seminars for related faculty and staff, and standardized post-surgical sign out. The purpose of the investigation was to determine if a difference in opiate prescribing patterns existed by race in their historical cohort and whether our intervention and more specifically the standardization of care. Had an effect on any potential racial disparity that was identified. The investigation included children under one year old who underwent non-emergent abdominal surgery in either the NICU or the acute care floor across the study period. We used a historical and retrospective pre-intervention coworker to compare the effect of our intervention on postoperative opiate prescribing patterns, pain scores, and secondary outcomes, including clinical safety profiles. The primary analysis was process control charts post-op. In equivalents are represented on the y axis, and the time is represented on the x axis beginning in January 2011 through January 2021. Our intervention occurred in January 2016 and is denoted by the blue vertical line. This figure reestablishes that the intervention itself was successful in reducing postoperative opiate use by 98% in our study population. This is the exact same data, but now plotted by race. White children are denoted in blue, black children in orange, and Hispanic children are represented in gray. Concentrating on the pre-intervention cohort to the left of the blue vertical line, it is clear that black children were prescribed significantly higher postoperative opiates than their peers. For numerical comparison, the median post-op morphine equivalent for black children was 13 mg per kilogram, while for white children it was 2 and Hispanic children it was 3.5. This represents a sixfold increase in post-operative opiate use in black children compared to their white peers. Let's look at the post-intervention. Cohort, it is clear that the intervention successfully reduced post-op opiate use in all racial groups. Specifically, the median postoperative morphine equivalence in black children reduced to just above 0 mg per kilogram, but for white children it was 0.05 and Hispanic children, it was 0.1. These findings in the post-intervention cohort were statistically equivalent. In summary, the data is consistent with a racial disparity specifically highlighted in black children in the pre-intervention cohort. Which was eliminated following the implementation of a clinical protocol and standardization of care. In 3, we'll review the new findings assessing a possible link between congenital surgical anomalies and mental health disorders, including anxiety, mood disorders such as depression, and substance use disorders with Matt Uchek. He's a 3rd-year medical student at the University of Manitoba. Congenital surgical anomalies are major anomalies requiring neonatal surgical correction for survival. They require prolonged hospital stays, exposure to general anesthetic, and increased exposure to the healthcare system throughout childhood. While there's substantial research completed on early clinical courses of these children, there is substantially less on their long-term mental health outcomes. We collected data on every child born with a congenital surgical anomaly in Manitoba, Canada between 1991 and 2022. They analyzed 818 children born with congenital surgical anomalies, and they had nearly 8200. Controls. Here we're looking at a table that will show the hazard ratios controlling for the child's sex and their socioeconomic status. Values above one indicate higher likelihood of diagnosis in children with a congenital surgical anomaly compared to the control group. Statistical significance is denoted by an asterisk and will be highlighted in yellow. In the diagnosis of all mental health disorders, there's a descriptive but Significant increase in individuals with congenital surgical anomalies. In anomaly-specific analyses, only anorectal malformation saw an increase in risk, being about twice as likely to be diagnosed with a mental health disorder. For anxiety and mood disorders, there is no significant increase in children with congenital surgical anomalies. Only patients with anorectal malformation were found to be at an increased risk, being about twice as likely to. Diagnosed with anxiety disorders, but not significantly more likely to be diagnosed with mood disorders. And next, we have substance use disorders. Pooled analysis indicated a significant 86% increase in diagnosis of substance use disorders across all anomalies. This was largely driven by patients with anorectal malformation and esophageal atresia, who are 4 times as likely to be diagnosed with this disorder. In conclusion, children with congenital surgical anomalies are likely not an increased risk of mental health disorders, including anxiety or mood disorders. However, these individuals are at an increased risk of substance use disorders as they grow up, and parents should be aware of possible signs of substance misuse in their children to ensure that early intervention and care can be given to those who need it. And we believe that adequate support and screening should be implemented to ensure these individuals receive the necessary care to optimize their long-term health and well-being. For 2, we have a study from the multi-institutional Pediatric Colorectal and Pelvic Learning Consortium. Doctor Srinivas will share their findings on how outcomes from clonic pull through for cloacal trophy vary based on colon length. Cloalotropy is a rare congenital abnormality involving a grouping of anatomical variations. It affects approximately 1 in 200,000 pregnancies and occurs along the spectrum of severity. Over time, the management of cloacal trophy has evolved and survival has improved. However, the initial surgical management remains the same and is focused on drainage, with an end colostomy or ileostomy and drainage of the bladder. As children grow, the opportunity for reconstruction emerges. From a colorectal standpoint, the main question has been whether or not a patient should have an endostoma, or if they're a candidate for a Coulter procedure. Early studies resulted in a great deal of popularity of the colonic pullul throat. However, it's unclear whether Pulthro remains heavily utilized today. He utilized a multi-institutional collaborative across the United States from 11 major pediatric hospitals over a 10-year time period. They performed a retrospective cohort study of 98 patients with a diagnosis of cloacal atrophy. We collected data on their demographics, operative course, and cleanliness, which was defined per standard terminology as one or fewer accidents per week. All patients underwent an initial stoma creation at a median age of 2 days. For those that underwent pull-through, the median age of pull-through was 1.3 years. Of the 98 patients in the cohort, only about 29% received a pull-through. There were 5 patients that were required to redo stoma for various reasons. This leaves 24% of the initial cohort who continue to use their pull-through. Of these, the majority of patients are not clean. In this cohort, only one patient is continent or not having accidents without the use of bowel management. This represents an overall successful pull through rate of 7%. Roughly 21% of the population has an unsuccessful pull through, meaning they're not clean or they went back to an ostomy. We then compared these two subgroups to one another. The group with successful pull through had over double the preoperative colon length compared to the unsuccessful pull through. This demonstrates the first association between a longer colon length and a greater chance of success following pull-through. In summary, in a multi-institutional sample, research has demonstrated that most children with cloacal atrophy will keep their stoma indefinitely. Of the children that undergo a pull-through, only a small percentage are able to be cleaned for stool postoperatively. A longer colon length correlates with higher success post pull-through. Overall, this suggests that colonic pull-through can remain effective for children with cloal atrophy, but. Then it may be selectively offered to children with an adequate column length. We're ready for the most anticipated video of today. Number one key takeaway, and the champion of the best of the best 2024. In this video, we'll learn from Doctor Derek Petkowski, a legendary pediatric surgeon from Poland, about internal traction technique to bridge the gap between the oesophageal pouches of long gap oesophageal atresia using stage tchoscopic approach. All 27 cases of long gap were operated. Both ends of the esophagus are brought together under tension with internal traction suture. This is static, not active tension. The preoperative rigid bronchoscopy is a standard procedure to check for upper fistula and any tracheal malformation. The patient lies in a prone position on the edge of the operating table. The right scapula is the anatomical reference point for trochar placement. The distal esophagus is usually located at the level of the diaphragm. It is dissected bluntly from surrounding tissues. The upper esophageal pouch and if present, the fistula are dissected in a similar manner. Dr. Petkowski mentions that there is no need to use electrosurgery here. The fistula is ligated on both sides and cut. Instead of a ligature, you can use clips or a 5 millimeter stapler. Placing the internal traction suture requires. thickness of tissue, including the mucosa layer. For internal traction, we use a 20 non-absorbable braided suture. According to Dr. Petkowski, the technique of tying a sliding knot in a small space requires a lot of skill and experience. It is one of the bases for success. Two sliding knots are made on both arms of the suture. The clips are placed to cover the entire thickness of the tissue and part of the suture. This method prevents leaks and allows for greater force to be used for traction. If necessary, both sliding knots can be converted to move in both directions. There is no need to rush. Time is needed for the tissue to stretch. Wait a moment. Be careful when applying traction force so as not to damage the tissues. Finally, the sliding knots must be blocked. We'll learn a few more tips on the process of this technique. Subsequent stages are performed every 1 to 5 days. There's no need for a gastrostomy. The patient remains intubated in the intensive care unit on parenteral nutrition. We don't use chest drainage. I am personally against suction with repro tube as it drives the mucosa in my opinion. I prefer intermittent suction on demand. Anastomosis is possible if both ends overlap, but care must be taken when deciding. There is no way back. Any failure will result in the loss of part of the esophagus. After pouches opening, the 8 French nasogastric tube is passed down into the stomach. Traction must be maintained until the first sutures are placed, because both esophageal pouches can easily retract, making anastomosis very difficult. The basis of the perfect anastomosis is a sliding knot. Typically, you need to place 2 or more sliding knots, and then gradually close them. It doesn't matter whether the anastomosis begins from the anterior or posterior wall, as the anastomosis can be rotated freely around. If anastomosis is not possible, the sliding knots can be reopened and used again to bring pouches together. We used the thoracoscopic internal traction technique in 25 cases of long gap esophageal a trachea and completed with anastomosis in 23 cases. Most cases were completed in 2 stages. Initially, the time between stages was about 4 weeks, but this was reduced to a few days now. In conclusion, Doctor Patkowski demonstrated that the torchoscopic approach using internal traction technique has the potential to change the way we manage the long gap esophageal atresia cases. Thank you for watching this video. All right, um, phenomenal video, and Carolyn, we're gonna play another one, but before we do, I just want to point out something. The, the lab that we have had now for many years focuses on looking at how we can best disseminate information. It's really hard to get important information seen by everybody, um, and so the lab is constantly pushing the limits on how we can do it. What you saw there. Just looked like a regular video. M and Carolyn Roberts and Cecilia and many others, um, have found that by taking something, cutting it down into a fraction of the time and narrating it is more appealing to the general public and it is much higher viewed. Then we figure out ways to disseminate it, but what's really cool. And I don't know if that video showed it, but we're now using AI and we can cut down the time to make massive amounts of videos that we believe or that others believe are the most critical ones and to get it out to the world, we're using AI tools that allow us to do it in literally in a couple hours instead of a couple weeks. So a lot of that, the, the stock footage and stuff is AI generated and it adds flavor to the video, um. So I don't know if the next video has the same kind of things, but the, the second video is now an update on, um, the update course that was best of the best. This is what the hot things were for the update course and by the way, the voting on the last one was public voting. There were brackets. The audience voted. Personally, I thought the. Uh, opioid thing was one of the most startling studies I've ever seen, and it came down. But, uh, I also think Darius is probably a world genius. So, uh, I thought those were great. Why don't we roll the update course highlights from last year? Thanks, E. And number 5 brings us to the updates in fertility preservation session. Here Doctor Erin Rawell will discuss the process of removing ovarian tissue for cryopreservation. Doctor Raul shared a case involving a six year old female diagnosed with hemophagocytic lymphohistiocytosis, or HLH requiring chemotherapy and thus ovarian tissue preservation for future fertility. It is very important to note the emphasis placed by every society on fertility preservation counseling, even when surgery isn't planned. So how does the counseling process work? When we have a patient who's got a new diagnosis of cancer or is gonna come up to stem cell. Transplant they activate our counseling service through an order set in Epic. It's easily available to anyone and then that triggers a consult by we have an advanced practice nurse practitioner. We, I do some of the counseling. We also have somebody from oncology, so we have multiple different people who could be available to talk to the family about that risk assessment. Another important factor is deciding what is the best procedure for preserving ovarian tissue. It's really important to recognize this is a prepubertal child. The size of this child's ovary is about 2. Centimeters. It's about the size of a grape, and that really what you ought to do is a laparoscopic oophorectomy. That would be our best recommendation. So, laparoscopic oophorectomy is recommended to reduce the risk of hemorrhage and ensure that any remaining ovarian tissue is preserved for the future fertility. So in conclusion, fertility preservation is very important for children undergoing chemotherapy. Counseling must be included in their multidisciplinary approach, and in females, the best way to do it is with a laparoscopic oophorectomy. Getting closer to the top 3, and we have number 4. To talk about the massive transfusion protocol, we'll tune into Doctors Mira Kotagal and Katie Russell. Massive transfusion protocol or MTP is a multidisciplinary process whereby blood and blood products can be rapidly obtained for severely bleeding patients. Effective communication is crucial due to the urgent nature of the situation and having a protocol simplifies the process, ensuring timely access to essential blood products. But when should we activate MTP and what kind of blood products should we give? If you're in the trauma bay and you're giving blood. You need to activate it. Like, it's blood equals MTP. Yes, that's a phrase to remember. So if you give blood, call MTP. Another important thing we learned is the ratio we should give the blood products, which is 1 to 1 to 1, meaning for every bag of blood you pass a blood of plasma and one of platelets. When do you give something other than packed red blood cells, and what do you give if it's a bad trauma, bad trauma coming in, not stable or not normal at all, blood, yeah, whole blood would be the best. I think so. We have not been able to get our blood bank to to make whole blood for kids because it needs to be open. We wanna aim for 1 to 1 to 1 for sure and definitely FFP should be what you give after you give blood. Most of the time an original trauma cooler that comes to the bay in most hospitals does not have platelets, so you have to, the MTP helps you get platelets or you can call for platelets, but they usually don't come in your trauma cooler. In summary, the massive transfusion protocol should be activated in the trauma bay after administering 20 mL per kilogram of blood. Following activation, the protocol dictates providing the patient with blood products in a ratio of 1:1:1. We're finally in the top 3. For number 3, we will review the management of ovarian torsion with Doctor Leslie Breach, a pediatric gynecologist. Doctor Bridge started this session by presenting a case of a pre-pubertal girl with a right ovarian torsion. Come to the emergency department, gets an ultrasound, large cystic mass, no blood flow to the right ovary, and you decide to take this patient to the operating room, you find right ovarian torsion, and you can see this sort of dark purple ovary. The key thing to watch out for is the presence of a cystic area on the ultrasound. Often this is less visible in the operating room, and although many surgeons may wanna go in and attempt to remove the cyst, Doctor Breech advises against it unless the edema makes it clearly visible. Now there's more question about the fallopian tube, how to manage a blue-black fallopian tube. Take a look at the tube. If the tube is black, it's edematous, you have detoursed it, you've given it plenty of time, and I would say a consideration about what to do about that tube. Therefore, it's best to avoid removing the ovary, because it may still regain some of its functionality, even if it appears to be black. Doctor Bree also advises against Pixing the ovary. Instead, she recommends just distortion and subsequent monitoring. In conclusion, ovarian torsion does not always involve a cyst. Therefore, unless it is clearly visible, do not attempt to remove it. To preserve as much ovarian tissue as possible, avoid performing an oophorectomy and ensure the patient is followed up. And for number 2, we'll review total pancreatectomy with eyelet or transplantation or TPIAT from updates in pancreatitis management session. This time, Doctor Juan Gurria will help us understand the topic. Chronic pancreatitis is a condition that causes pancreatic insufficiency. And damage to the islet cells. One treatment option is TPIAT. This procedure involves a complete removal of the pancreas along with the spleen, followed by extraction of islet cells in a specialized lab. These cells are then injected into the portal vein. In the acute post-op period, you have to manage their glucose for them. If you put them under stress. The cells die, everybody's on insulin in the ICU I want the cells to be like just chilling, not doing any work until they implant and find new vessels from the liver to survive. It is important to understand that many patients with chronic pancreatitis have a gene mutation that triggers recurrent. Attacks, causing the gland to replace normal cells with fibrosis. This is why performing any surgical resection procedure without extracting the islet cells may result in continued pancreatitis attacks and an increased risk of diabetes after TPIAT due to the reduced pancreatic parenchyma. In conclusion, TPIAT is a surgery for chronic pancreatitis that helps the pain and the recurrent attacks with the idea of preserving as many islet cells as possible to avoid endocrine insufficiency. And we made it to the number one. I know everyone's been waiting for us. Let's hear from doctors Mira Koral and Katie Russell on management of blunt trauma to the liver and spleen. Blunt trauma is a significant concern in the pediatric population, primarily due to the potential severity and complications associated with such injuries, and its management has been evolving for many years now. Last year, the American Pediatric Surgical Association, or ABSA in short, released a guideline including new updates. So the ABSA guidelines are relatively new-ish that came out with revised guidelines around management of patients, and it includes 4 basic categories thinking about where they should be admitted, procedures, when you would discharge them, and then what you might think about doing after discharge, and particularly in this instance, talking about patients. Not going to the ICU for grades 1 and 2 blunt trauma to the liver and spleen, we can monitor patients who are hemodynamically stable and consider discharging them from the emergency department. Regarding lab results, should we repeat them? And if so, how frequently? They're gonna get one. I practice out in Utah and 80% of our kids are transfers. Most likely they've already had a CBC at the other hospital, but we do not repeat it. If it's a. hemodynamically normal child, they will go to the floor and not get a repeat crit. Perfect. That's what we're doing too, and there's actually data to support that, that we know there is some degree of hemodilution. The data suggests that the patients who are more likely to fail non-operative management have an initial hemoglobin less than 9.25. Therefore, for patients who are hemodynamically stable and have normal hemoglobin levels in their initial lab tests, there's no need to repeat the tests unless there are changes in their condition. In conclusion, for blunt liver and spleen trauma, there is increasing evidence that supports treating the patient based on signs and symptoms rather than solely on the injury grade. GlobalC MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Awesome, um, phenomenal video and thank you for putting that together. Um, always blown away by the AI tools there as well.
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