It's all when we're picking the agenda for the update course, we always debate, do we do things that not everybody does? And we feel strongly about putting things in even if most people don't do that operation for exactly that reason to make sure that people may want to start doing that and sort of getting acquainted with it. Um, but we certainly would love to hear feedback on, um, other topics like this for next year. We've already had one hidradenitis Tim gave us. All right, um. So this is the highly anticipated part of the event every year. Um, I was a conference where we at IPEG or something, and Jose Campos walked out to me and he said, hey, you're Todd, you, you guys do that, uh, update course. I was like, yeah, thinking he was going to tell me a big compliment. He's like, yeah, it's not very good. No, he, he. He, he said, you know, you're, you're, you're great at talking about pediatric JPS articles. What about all of the other journals out there that are publishing really high yield important articles that we should know about? So for the past how many years? 10 years? I don't know how long you've been helping us, but he's been pointing us out, pointing out, and if you get all the social media stuff, all the, uh, infographics come from Jose Campos and his team. In Chile that point out all the key articles that we may not see every day in our core journals. So, uh, we're gonna bring you guys in. We have Sean Saint Peter and, uh, Jose Campos, otherwise known as Nano, uh, to present this year's updated literature review. Do we have a, uh, a thing for them too? OK, we'll see what score you get. We'll see if you're. Um, is this mic working? No. Test it. There there is thank you very much Todd for that kind introduction. We need to come up with a better anecdote because we've been repeating that one the same one I'm very happy to be here within uh among friends. Thank you for the opportunity to standing to be standing next to Doctor and Peter and I know we're running out of time, but can we get the slides please? I just need to take a minute. To thank, uh, some people I wouldn't be here by myself. I, we, I lead a group of 30 volunteers, so last year we were 25, now we're 30, we're slowly growing. And this is a group we call Journal Hive nested within the Surgical Society of Chile. So what we do 3S we screen 1200 articles, each month, uh, then we select based on different criteria, methodology, journal specially we also included voting so you all can vote, you all can collaborate, and then we spread the word every month with new newsletter, podcast, and infographic. So all the links are gonna be in the last slide. So let's just get on with it. So we picked that's the whole group sorry I wish we could name everybody but they're all there. Let's get on. So we brought 4 articles this time uh we tried to make it still a subjective selection, but we try to bring like uh bread and butter to surgery like the most common surgeries we do, uh, so we're gonna talk about inguinal hernia trauma, we're gonna talk about ovarian sparing surgery, and we're gonna repeat a little bit about the CBD stone discussion with um an algorithm to predict CBD. So our first question is you are asked to evaluate a former 29 weeker. A baby with an uncomplicated inguinal hernia unilateral. The referring pediatrician mentions that the baby is likely to be discharged within 2 weeks. What would you recommend? Perform inguinal hernia repair before discharge? This is very common to all of us, I think. Or discharge the baby and settle an elective outpatient surgery. So while we get the poll results, I would like to ask Carlos, dear friend from Mexico, what would you do in this scenario and why? So we would do a, uh, especially with the, our population where you don't really know if the patient will come back if you if you schedule for another surgery, so we guarantee that the surgery is done by not letting them leave without the surgery. OK, cool. Anyone else? Anyone else? Does, does anyone, is there anyone that would send them home? Oh, you guys are crazy. Just that's all I can say. Just like anything, it depends, right? How big is this hernia, you know, is it something that's always out and then, you know, it's gonna be a rock fight for 1.5 or 2 hours in the operating room, and they're otherwise fine, you know, send them home. Easy to reduce, uncomplicated hernia. Don't make it more complicated than that. I mean, that matters. So I think the, the, uh, thought of them incarcerating before coming back is much lower than we think. Um, I practiced in the system when I first came out of fellowship where we were regional and there were 12 other NICUs that all sent them home before we even knew they existed. They came back and followed us in clinic, and none of them had incarcerated when we waited their time and that was over 80 patients. So I think, I don't know the exact rate, but I think it is, um, pretty low. Great point. The other thing, you may have a child that just weaned off of oxygen or is on like, you know, 1 L nasal cannula, and all of a sudden you're resetting the clock big time. And that's, that's really kind of a, a demoralizing thing for the family, for the team, because you took them to the operating room because you felt obligated to repair. I understand in certain contexts where you may not get those patients back, of course, but again, it depends on the, the environment and. In the economy that you're sending these patients out to, if they have good follow-up, then let them go. Yeah, I think there's a lot of complexities to this that can be. But the study that that is going to be reviewed. Not working? No, no, it's working. Um, the study that's gonna be reviewed is data that puts a nudge in one factor toward, toward one direction, which would be the delayed repair. So we have, uh, a bunch of nurseries in the area that don't have pediatric surgeons, so they come to our clinic. So by definition they get the delayed report repair simultaneously, we were frequently doing repairs in our nursery, so we were doing a dichotomous practice within ourselves. And to make it clear for the fellows and the neonatologists, we just recently went to the plan is for coming back with a delayed repair. And what you just alluded to, those kids that are just kind of coming off oxygen and just starting to find their feet, those are the ones that ended up making the big difference in that study that, that Marty led, because those kids that are kind of fragile, it wasn't about the hernia repair, it was about their pulmonary status. All great points and shows how nuanced this discussion is and how difficult it must have been to put this trial together I think why don't we have a look at the we have a short one minute video that is explaining the article and then we can see if someone got convinced to change over the practice. We did not comment on the on the results. It was quite how much was it was like 60 and 40, 50/50, yeah, OK, let's go. in preterm infants, but the optimal timing for surgical repair is still debated due to the associated risks. A recent European study demonstrated an important variation in practice patterns, with 56% of surgeons recommending surgery before discharge. This article entitled Effect of Early versus Late Inguinal Hernia Repair on Serious Adverse Event Rates in Preterm Infants, A Randomized clinical Trial was published in JAMA 2024. The authors assessed if the timing of inguinal hernia repair influenced the likelihood of serious adverse events in preterm infants. This study involved 338 pre-term infants diagnosed with inguinal hernias before their initial hospital stay. They were randomly assigned to either early repair before NICU discharge or late repair after NICU discharge. The primary outcome measured was the occurrence of any of the predefined serious adverse events over a 10 month period, including death, hernia complications, and respiratory and cardiovascular morbidity. The study found that late repair significantly reduced the rate of serious adverse events, with only 18% in the late repair group compared to 28% in the early repair group. The late repair group also experienced a 3 day reduction in length of stay. Applying these results, delaying inguinal hernia repair until after NICU discharge might be safer for preterm infants, potentially reducing the risk of serious complications. What? Can we go to the next slide, please? So, OK, so you're not convinced by it. So there's a well done randomized controlled trial that showed that there's a 10% benefit. You're not convinced. Tell me why you're not convinced. No, no, you always change my practice more than almost anyone else, so I, I just am surprised by the results. It's not that I'm not convinced. I just, it's not what I would have expected from this paper. OK, but I, I, I saw a lot of hands up when on the early repair. So are those people convinced or not? I mean, I think it was said right earlier. This is an important data point. It adds to the nuance of this discussion, and I think for many patients waiting is the right answer, but I, I don't think that this data says that early repair is wrong. If you look at that table, it's mostly apnea requiring intervention. That's what the difference is, right? And so you have some kids, you have some kids with apnea who need some oxygen. Uh, or who need a little, you know, extra time of close monitoring. And so it's not like these are, you know, they call them serious complications, but how serious is apnea in a, in a premature neonate. Yeah, so that's a great point that this table doesn't fit in our short video, but you know, you can see clearly that there's two profile of complications here. Like there's different complications as you did with early and different complications as you did with late, and I just wanna bring back Steve's comment where he said like we, we thought inguinal hernia recurrence was such a high thing, and you know it's in this study at least it's uh 4% in late rebirth groups, so it might not be such an important point. This, uh, I think highlights one of the things I know Todd's passionate about, which is laparoscopic inguinal hernia repair. If you're putting a G tube in and you see, like, look at the rings, I mean, hopefully if you're facile with it, it's an extra 5 or 10 minutes to get those things repaired. And then, yeah, yeah, yeah, it's a big, I mean, but if you're, if you're there anyway, and you've got to be there because that is the next thing that that child needs to ultimately be discharged, then yeah, early repair, go for it. Don't, don't spend 5 hours doing it, but you, you also bring up a very good point is that this was designed in the open era. So part, part of what we talked about, and this started with a conversation we had at Pabst in 2011 when Marty had this passion to start the hour later. That's how long it takes to get this kind of work done. So congratulations to that group for having done it, but. It started around the auspice of how difficult that is in the hospital with an open operation. And then within 2 years, we had gone completely over to laparoscopy. So we were thinking, well, that question really doesn't need to be answered anymore because it's a different one than what we were asking in the first place, which is how difficult the open operation is. It ended up turning out that it didn't matter if it was open or lab because it was all driven by respiratory complications and that was the difference. So now the, the point is just, just let them grow up a little bit unless there's any other mitigating factor that would say, let's just do it now, like a lap G tube, like they're 3 hours away, like Carlos said, they're not going to come back. Interesting discussion. Should we just keep going, or I think we're, we're running late, isn't it? So second audience, um, second audience poll, you are the trauma surgeon on call. The emergency department has just received a 70-year-old boy involved in a car collision at 100 kilometers per hour or 60 MPH. With a rollover, the boy is currently clinically stable with a normal physical exam. What would you recommend? A admit for observation, discharged from ED, or C perform a CT scan. Can I get Reagan Williams' opinion, who just gave us a beautiful article on ABSA recommendations for she gonna give the answer though? I just want her opinion. There's no answer. There's no answer. To Talk kind of slow so you don't give it away. So I think there are a lot of options depending on where you are, um, but our current data would say for a patient like this, you probably don't need to get a CT scan. Um, you can observe them and maybe even discharge them from the ED if your situation allows that. Going back to what you said about hernias. Can I get some hands raised? Who would have CT this patient? No, no, no, OK, so I have a bigger question. There are many trauma guidelines that make something a level 1 or a level 2. There are historical elements. In the, meaning the history of the patient and the trauma, how many things should we be reevaluating that the actual history of what happened should be impacting how we take care of those patients? The mechanism of injury, all those things. We, we've done studies. There's a Nexus trial and others that have looked at speed of the, you know, were there deaths in the car? Were there are all these things that help should guide us on how we take care of the trauma patient. And as we're getting better, I wonder at some point we should relook. Maybe that's what you're gonna talk about. No, I, I wanna know what the nexus trial is, Todd. Oh shit, just tossing that one out there. That's the C-spine trial, right? That's the one that said in adults, oh, and it doesn't apply to kids because I've been using it. There's a new, actually, we'll put that on the list for next year. There's a really good new pecar study for the cervical spine, but that was the at that time was the largest clinical trial, at least for trauma. That that's where it looked at mechanism of injury and all those things that talked about indications on when to get a C-spine, and that was the first big large, why are you laughing at me? What did I say wrong? I loved it. I loved you. You know how insecure I am with trauma data. Why are you making? No, it's awesome. You're so right. You're so right. I was curious if Doctor Williams would get labs on that patient because that wasn't an option. I would absolutely get labs before I made a decision about getting a CT scan. My question is, do you think that the imaging or workup is different if it's this patient presents at an adult trauma hospital with pediatric accommodations versus a, a true pediatric trauma center? Great questions. I do not know the answer to that. Can we see some poll results, or Dan Dan wants to answer that question in the chat about. As a non-FAST advocate, I just would be curious as to what's your answer on that. Great question. So again, I'm not a trauma expert. I would rely on on Reagan's opinion on this, but I think FAST is an algorithm based on adult experience and actually in children has a lot of negative, um, uh, false positives and false negatives. So if you're using ultrasound as a scope to make you better assessment and get more info and to make a clinical assessment. I would say yes, but using F as kind of the uh streamlined algorithm that it is in adults, I would not apply that to children personally. You are exactly correct. Boom, amen. OK, uh, did we get some poll results or not? So. Most would admit for observation and 40% would do a CT scan just like I would. Uh, can we see the video? So I'm happy that Katie you brought the Pay current group because that's exactly what we're highlighting today the Pay Pay current group. CT scans are frequently used in pediatric abdominal and head trauma, and many times overused exposing children to an unnecessary risk of radiation-induced malignancies. The article titled Precurrent Prediction Rules of CT Imaging of Children presented to the emergency department with blunt abdominal or minor head trauma. A multi-center perspective validation study was published in The Lancet Child and Adolescent Health in May 2024. The authors asked themselves whether the Picard prediction rules accurately identify children at very low risk for serious injuries, thus reducing unnecessary CT scans in pediatric emergency departments. This prospective multicenter study enrolled 27,541 children under 18 years old who presented with blunt abdominal or minor head trauma across 6 US pediatric centers. The study evaluated the preclinical prediction tool before the decision of obtaining a CT admission or any other intervention. The primary outcomes measured were intraabdominal injuries requiring acute intervention and clinically important traumatic brain injuries. The precurrent prediction rules demonstrated a sensitivity of 100% and a negative predictive value of 100% for identifying both. One limitation of the study is that the precurrent rules were already known by the physicians applying them by previous retrospective studies, so they could have been already applying them. Implementing the current prediction rules in prediatic emergency departments could help clinicians avoid up to 25% of abdominal CT scans and 15% of brain CT scans, thereby reducing radiation exposure and improving the overall quality of care for children with blunt abdominal or minor head trauma. OK, so we're not saying of course that CT or imaging doesn't have a role in trauma. I apologize for this super busy slide. I hate sites like this, but it just, uh, mentions the inclusion criteria for, for, for the Pecan and the Pecan rule, and actually it's been in shortened because the head part of it, uh, it's diff slightly different under the two year and above the 2 year mark. I think the bottom line is that in most cases you don't need a CT, but the high quality of this article just brings the reassurance for the clinician in which cases you have a 0% chance of having an intraabdominal injury requiring intervention and therefore no need for a CT. Doctor Peter. No symptoms and no physical findings. The chances of three dimensional imaging changing your management is pretty slim. I mean, it doesn't surprise, we keep finding that more and more now that, that, the, the history and the, and the mechanism are not, should not be considered as much as we thought historically. Yeah, I know we say here like, yeah, I don't find it surprising. I am very happy for this uh audience, this present audience just to, to be so, um, on the top of their game that they're not gonna scan, but you know the poll audience, the, the 3000 people at home, 40% of them would seeT in this case. So I think these articles, it, it, it is relevant worldwide I think. Or at least for me, I did learn, I, I learned a lot from it. Anyway, let's go to the scenario number 3, or does anyone want to comment on anything else? Let's roll. So you are a patient for a cholecystectomy after an ultrasound diagnosis. Do you routinely order any of the follow-up tests pre-op to assess the risk of a common bile duct stone so this overlaps like a little bit with Luke's neff and team presentation. Um, who can give me their opinion, um, while we wait for the poll results, Doc, uh, oh, Miguel, you wanna, you wanna say, OK, you do know I rely on clinical factors and ultrasound and. Can you elaborate on that, please? Like how if the patient has just, you know, came to the ED with, you know, colic pain and had an ultrasound and everything was perfectly well, just, just, just, you know, stones in the the gallbladder, no other previously, you know, history. The labs were normal at that time. I shouldn't do anything else than just go to, uh, you know, surgery at all. And how many times have you been surprised by performing the lab coli and finding dilated bile duct, finding a stone, not knowing what to do, or maybe not in your case, sorry, but, but being challenged by the situation to do no I called out. You call Todd. OK, let's go. So how many times have you been in this situation in which you just rely on clinical factors and ultrasound and then boom, uh, I'm in a difficult situation. I don't have, not talking about you, Todd, but don't have the skills or the equipment to resolve how many times? Sleek, slim, very, very rarely. OK, can we get some poll results? OK, please. Yeah. But wait, is the, is the question that the patient had an ultrasound and normal labs or had an ultrasound with no labs? No, you have patient ultrasound, nothing else. OK, what, what's, that's a Miguel said that the labs from the emergency room were normal, so those are two different situations. No, no, it says C. Yes, I ordered liver function tests. Do you order liver function tests before? So symptomatic, you wouldn't clinical factors ultrasound, what would be your choice? I, I did see you did see, yeah, so I, I think, I think going into this without any preoperative risk factors, uh, you need, you need to know, you need to know, you have to have an ultrasound, you have to have labs. I think that's in, those are straightforward things to do. You can put a patient in a Very, very low risk category if they have a normal ultrasound, normal labs. In fact, most guidelines would suggest then you don't even need to do an intraoperative angiogram. You can just take the gallbladder out and those by themselves, just getting that preoperatively is going to help you risk stratify the patient. I think that's a segue to the prediction model. Why don't we talk about the prediction model and then we'll give the upshot of the last one, Jose, I lied to you. They want us to wrap up. OK, these are so critical. So, um, just the high yield points. Yeah, let's go to the video then. Pediatric cholelithiasis is becoming increasingly common due to the rising obesity rates among children and adolescents. Unobstructed common bile duct stone can be found in up to 30% of pediatric patients with cholelithiasis during surgery. Making a timely diagnosis of common bile duct stone can be critical for improving patient outcome. The article titled Machine Learning to Predict Pediatric Cholerocholithiasis, a Western Pediatric Surgery Research Consortium Retrospective Study was published in surgery in 2023. The authors evaluated if a machine learning model could accurately predict pediatric choledolitisis using clinical and laboratory data. This retrospective cohort study included 1,597 pediatric patients who underwent cholecystectomy across 10 institutions between 2016 and 2019. An extra 3 machine learning algorithm was used to evaluate nine clinical features, including age, BMI, and specific lab values, to predict the presence of choleoglitiasis. The machine learning model demonstrated high accuracy with an area under the receiver operating characteristic curve out of 0.95 and a negative predictive value of 98%, significantly outperforming previous prediction models. A limitation of the study is the reliance on the retrospective data, which could introduce bias and affect generalizability of the model. Also, machine learning is a novel technology for the medical field. Implementing this machine learning model in clinical practice could improve the accuracy of diagnosing cholelithsis preoperatively in children and improving patient selection and resource organization and use. It could also reduce the need for invasive procedures and unnecessary imaging. Cool. The key point is that you can actually uh reststratify patients with a lot of certainty, and I think comparing this to other models, this is the best we got. This is awesome. Give me, what's the high yield point of the last one? Point of the last one is, um, it's about ovarian sparing surgery uh in benign tumors and by actually getting together with your team with radiologist, oncologist, um, adolescent OBGYN you can actually develop an algorithm to reduce your uh unnecessary oophorectomy rate from. You can have it in this scenario from 16 to 8% and. You pointed out a really good point about this article. Can you share it with the audience about the Hawthorne effect and stuff? Oh, I, I was saying that some of this was the Hawthorne effect because this was put into place and then we measured it going forward. So places who were already having multidisciplinary conversations we're still gonna have those, but you had to basically check the box once you had a consultation that you talked to the gynecologist and then once you had a chance to have that mutual conversation, you always had a game plan that very rarely led to oophorectomy. So I learned about the Hawthorne effect after Doctor Saint Peter's commentary. I had no idea, but anyway, if it's the Hawthorne effect, it's not kind of a real surgical difference. It's still replicable. So even if it's the Hawthorne effect, someone published it, and you could do it too. That's it. Just get your gynecologist on the phone, yeah, any final comments? We're gonna break for a little bit. I know we're about 10 minutes behind. We'll make it up during the break, so that means everybody here has to eat fast. Any comments or questions on all the stuff you just heard? Yeah. I, I have one regarding the machine learning model. I, I think there's gonna be, uh, we have to be prepared for these machine learning models because there's gonna be a huge, uh, slew or a huge wave of these models are that work in a great manner but we as pediatric surgeons have to define how we'll approach it and how we'll use it because we know these machine learning models work with the population that they were trained at but how will we, uh, apply them to our population. Yeah, we were just talking about that yesterday. Uh, Katie Russell is one of the co-authors of that, is it? Yeah, and they're they're moving forward to do a prospective validation and also Luke Neff, I think it's involved in that and they're looking to broaden the validation population so I think that's an excellent point you've made. Thank you. Any other comments, questions? That was a lot. You guys can see why we value your team so much because it opened our eyes to studies we normally would not see because we, we keep reading the same journal. So thank you for continuing to do this and doing it all year round. Um, your work's incredible. Thank you so much. So, uh, congrats to you for doing that. Thank you.
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