Top 4 Key Takeaways from the Best of the Best in Pediatric Surgery 2024

Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hi everyone. In February 2024 we held our third best of the best in pediatric surgery live event, and we are bringing you the top four 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 morphine equivalents are represented on the Y axis, and the time is represented on the X axis, beginning in the January 2011 through January 2021. Our intervention occurred in January 2016 and is denoted by the blue vertical line. This figure re-establishes that the intervention itself was successful in reducing post-operative 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, while 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 Yurchek. 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 not significant increase in individuals with congenital surgical anomalies. In a. 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 be 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 atrophy vary based on colon length. Cloal atrophy 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 edge 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 pull-through procedure. Early studies resulted in a great deal of popularity of the colonic pull-through. However, it's unclear whether pullthro remains heavily utilized today. We 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 Stomach 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 group. 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 cloacal atrophy, but Then it may be selectively offered to children with an adequate column length. We're ready for the most anticipated video of the day. 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 is 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 the block 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, and 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 atrasa 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.