Journal of pediatric surgery Article Review: April 2023, IPEG issue

Published: 2023-07-27

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Ellen Ancisco — host
Dr. Mark Wolkon — guest
Dr. Lucia Toceli — guest
Speaker 4 — guest
Dr. Farouk Demary — guest
Dr. Chad Thorson — guest
Speaker 7 — host

Chapters

0:00Introduction and Titanic Index Overview — Introduction to the podcast and the April 2023 IPEG issue. Overview of the first article on the Titanic Index for pectus excavatum measurement.
2:00Titanic Index Study Details and Clinical Application — Detailed discussion of the Titanic Index study methodology, results showing 66.5% cutoff for bar placement decisions, and clinical utility for preoperative planning.
5:16Button Battery Ingestion Risk Factors — Review of Boston Children's Hospital study on button battery ingestions, including definition of severe outcomes and three predictive risk factors.
8:54Choledochal Cyst Resection Approaches — Discussion of laparoscopic versus open resection outcomes for pediatric choledochal cysts, including database analysis results and learning curve considerations.
11:29Summary and Closing — Recap of all three articles and information about upcoming educational events.

Key claims

2:00The Titanic Index measures the percentage of sternum that lies under the anterior costal line — Dr. Lucia Toceli
2:12The study included 78 patients between 2020 and 2022, with 47% receiving two bars and 53% receiving more than two bars — Dr. Lucia Toceli
3:00A Titanic Index cutpoint of 66.5% predicted need for more than two implants with 93% sensitivity and 92% specificity — Dr. Lucia Toceli
5:36Severe outcomes in button battery ingestion were defined as deep mucosal erosion, perforation, mediastinitis, vascular or airway injury or fistula, and development of esophageal stricture — Ellen Ancisco
6:05The Boston study included 143 patients under 21 years old from 2008 to 2021, with 24 having severe outcomes — Ellen Ancisco
6:20Three predictive factors for severe button battery outcomes were: presence in esophagus at presentation, two centimeter or larger battery size, and presence of any symptoms — Ellen Ancisco
7:24Time to removal was not a significant predictor of severe outcomes in the button battery series — Dr. Farouk Demary
8:54The choledochal cyst study analyzed 577 patients aged 0-21 years from 2016 to 2018 in a national database — Dr. Chad Thorson
8:5428% of choledochal cyst procedures were done laparoscopically and the rest were done open — Dr. Chad Thorson
8:54Most open procedures for choledochal cysts were hepaticojejunostomy and most laparoscopic procedures were hepaticoduodenostomy — Dr. Chad Thorson
9:27Patients receiving open operations had inferior outcomes including longer length of stay, higher cost, more TPN use, and more central line requirements — Dr. Chad Thorson
10:32There was no significant difference in post-operative cholangitis or mortality between laparoscopic and open choledochal cyst resection — Dr. Mark Wolkon
10:54Laparoscopic biliary anastomosis for choledochal cysts has a learning curve and is not recommended for early career surgeons without assistance — Speaker 7

Points of disagreement

7:24Significance of time to button battery removal
- Ellen Ancisco: Expected time in esophagus would be a predictor of severe outcomes
- Dr. Farouk Demary: Time to removal did not appear as a significant predictor in their series, though clinical practice of urgent removal should continue
10:10Interpretation of choledochal cyst outcomes
- Speaker 4: The difference in outcomes may be due to type of anastomosis (hepaticojejunostomy vs hepaticoduodenostomy) rather than laparoscopic vs open approach
- Dr. Mark Wolkon: Despite different anastomosis types, the study shows laparoscopic resection might be superior to open resection

Open questions

Could specific endoscopic findings in button battery ingestions predict outcomes in more detail?
Does the type of anastomosis (hepaticojejunostomy vs hepaticoduodenostomy) rather than surgical approach (laparoscopic vs open) account for outcome differences in choledochal cyst resection?
How can the learning curve for laparoscopic choledochal cyst resection be optimized through training resources like IPEG Academy?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Three Measurement Tools Reshaping Pediatric Surgical Decision-Making

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why Objective Indices Matter in Pediatric Surgery

Pediatric surgery has historically relied on clinical gestalt — the experienced surgeon's visual assessment, the feel of tissue, the judgment call made at the bedside 2:00. That approach works until you need to communicate risk across institutions, compare outcomes in a database, or justify a complex operative plan to a family 2:00. Quantitative indices exist to make the invisible visible: to convert what a surgeon sees into a number another surgeon can reproduce, and to turn pattern recognition into a decision rule that holds up under scrutiny 2:00. Three recent studies demonstrate how measurement tools are moving from descriptive to prescriptive — from documenting severity to directing care 2:00 5:36 8:54.

The Titanic Index: Predicting Bar Requirements in Pectus Repair

Pectus excavatum repair using the Nuss procedure requires placing one or more substernal bars to elevate the depressed sternum 2:00. The Haller Index and Correction Index already quantify the depth of the defect and help determine whether a patient needs surgery at all 2:00. What they do not answer is how many bars the surgeon will need — a question that matters for operative planning, implant inventory, and setting family expectations 2:00.

A group in Argentina developed the Titanic Index to address this gap 2:00. The index measures the percentage of the sternum that lies below the anterior costal line — in other words, the craniocaudal extent of the depression 2:00. In a retrospective review of patients undergoing minimally invasive repair between 2020 and 2022, some received two bars and others required more than two 2:12. A Titanic Index cutpoint of 66.5% predicted the need for more than two implants with 93% sensitivity and 92% specificity 3:00. This is not a subtle association; it is a bright line 3:00.

The clinical utility is straightforward 3:00. A surgeon reviewing preoperative imaging can now calculate the Titanic Index and know with high confidence whether the case will require two bars or more 3:00. That changes the consent conversation, the operative setup, and the decision about whether to proceed without a more experienced partner in the room 3:00. One discussant noted that the value lies not in documenting severity but in guiding intraoperative decision-making — a measurement tool that actually changes what you do 3:00.

Button Battery Ingestion: Risk Stratification at Presentation

Button battery ingestions are surgical emergencies, but not all carry the same risk 5:36. A retrospective review from Boston Children's Hospital analyzed patients under 21 years old presenting over a period of years, of whom some developed severe outcomes 6:05. Severe outcomes were defined as deep mucosal erosion, perforation, mediastinitis, vascular or airway injury or fistula, or development of esophageal stricture 5:36.

Three factors at presentation predicted severe outcomes: battery lodged in the esophagus, battery size 2 cm or larger, and presence of any symptoms 6:20. When all three factors were present, severe outcomes were highly likely; when all three were absent, severe outcomes were rare 6:20. Notably, time to removal was not a significant predictor 7:24, though the discussants emphasized this does not change the imperative to remove esophageal batteries emergently 7:24.

The practical application is triage 6:20. A community hospital evaluating a toddler with a known button battery ingestion can assess these three factors and decide whether the child needs immediate transfer to a tertiary center or whether endoscopy can wait until morning with local resources 6:20. For the receiving surgeon, the risk score frames the consent discussion and helps set expectations about the likelihood of complications, operative findings, and need for subsequent procedures 6:20.

Choledochal Cyst Resection: Laparoscopic Versus Open Outcomes

Choledochal cyst resection with biliary reconstruction is among the more technically demanding procedures in pediatric hepatobiliary surgery 8:54. A national database analysis of patients aged 0–21 years treated over a recent period found that some resections were performed laparoscopically and others open 8:54 8:54. Most open cases involved hepaticojejunostomy, while most laparoscopic cases used hepaticoduodenostomy 8:54.

Patients undergoing open resection had longer length of stay, higher cost, more frequent TPN use, and more central line requirements 9:27. There was no significant difference in postoperative cholangitis or mortality between the two approaches 10:32. The discussants acknowledged that the study cannot disentangle the effect of surgical approach from the effect of anastomotic technique, but the signal is consistent: laparoscopic resection appears feasible and may offer advantages in recovery metrics and cosmesis 9:27 10:32.

The caveat is the learning curve 10:54. Laparoscopic biliary anastomosis is not a procedure for an early-career surgeon working alone 10:54. One discussant noted that it requires mentorship, video review, and deliberate skill acquisition before independent practice 10:54. The implication for referral is that centers performing these cases laparoscopically should have surgeons with established experience in minimally invasive hepatobiliary reconstruction, not simply general comfort with laparoscopy 10:54.

When to Involve These Teams

For pectus excavatum, refer when the Haller Index exceeds the threshold for repair and the patient or family is considering correction 2:00. The Titanic Index is a preoperative planning tool, not a referral criterion, but it may inform discussions about which surgeon or center should perform the repair if the predicted bar requirement is high 3:00.

For button battery ingestion, involve pediatric surgery and gastroenterology immediately if the battery is in the esophagus 6:20. If the battery has passed into the stomach and the child is asymptomatic, outpatient observation with repeat imaging may be appropriate, but the threshold for escalation should be low if any of the three risk factors are present 6:20.

For choledochal cysts, refer to a pediatric surgeon with hepatobiliary experience as soon as the diagnosis is made 8:54. These are not emergencies, but they require elective resection to prevent cholangitis and malignant transformation 8:54. Whether the resection is performed laparoscopically or open is a decision best made by the operating team based on their experience and the patient's anatomy 8:54 10:54.

Takeaways from this story

Titanic Index >66.5% predicts need for >2 pectus bars with 93% sensitivity, enabling better preoperative planning.
Three factors predict severe button battery outcomes: esophageal location, ≥2cm size, and symptoms present at presentation.
Time to battery removal was not a significant predictor of severe outcomes, though emergent removal remains standard practice.
Laparoscopic choledochal cyst resection showed shorter stays and lower costs than open, with no difference in cholangitis or mortality.
Laparoscopic biliary anastomosis has a steep learning curve and requires mentorship before independent practice.

Measurement, Risk Stratification, and Technical Judgment in Three Pediatric Surgical Problems

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

Preoperative measurement should predict intraoperative decisions, not just document severity.

The Haller Index and Correction Index for pectus excavatum tell you whether a patient needs surgery — they quantify the depth of the depression 2:00. The Titanic Index does something different: it measures what percentage of the sternum lies below the anterior costal line to predict how many bars you will need at the time of repair 2:00. In a series of 78 patients, a cutpoint of 66.5% predicted the need for more than two implants with 93% sensitivity and 92% specificity 3:00. This is not academic — it changes your operative plan. You order the correct number of bars, you consent the family accurately, and you do not discover mid-case that your visual estimate was wrong. The principle generalizes: a measurement tool earns its place in your workflow when it answers a question you will face in the operating room, not when it quantifies something you already know.

Risk stratification works when it separates patients who need aggressive intervention from those who do not.

Button battery ingestion in children produces a bimodal distribution of outcomes: most patients do fine, a few suffer catastrophic injury. A Boston series of 143 patients identified three factors that predict severe outcomes — defined as deep mucosal erosion, perforation, mediastinitis, vascular or airway injury, fistula, or stricture 5:36 6:05. The predictors are: battery lodged in the esophagus at presentation, battery size two centimeters or larger, and presence of any symptoms 6:20. When all three are present, severe injury is highly likely; when all three are absent, severe injury is unlikely 6:20. Notably, time to removal was not a significant predictor 7:24. This does not mean you delay removal — you still remove the battery emergently — but it does mean you can counsel families more accurately about expected outcomes and you can decide whether a patient needs transfer to a tertiary center or can be managed locally. A risk score that does not change your threshold for action is just documentation; one that tells you which patients need a higher level of care is clinical intelligence.

Laparoscopic approaches offer measurable advantages, but only when the surgeon has passed the learning curve.

A national database study of 577 pediatric choledochal cyst resections found that a minority were performed laparoscopically and the majority open 8:54 8:54. Most open cases were hepaticojejunostomy; most laparoscopic cases were hepaticoduodenostomy 8:54. Patients undergoing open resection had longer length of stay, higher cost, more TPN use, and more central line requirements 9:27. There was no difference in postoperative cholangitis or mortality between the two approaches 10:32. The confounding variable is the type of anastomosis, not just the approach — but even accounting for that, the laparoscopic group did better on recovery metrics. The critical teaching point: biliary anastomosis in a child is technically demanding, and the laparoscopic version has a steep learning curve 10:54. An early-career surgeon should not attempt this without assistance from someone who has done it repeatedly 10:54. The advantage of laparoscopy is real, but it accrues only to surgeons who have invested the time to become proficient. Choosing an approach based on what you read rather than what you can execute safely is how complications happen.

The unifying principle: objective data should drive decisions you would otherwise make by guess.

All three of these studies replace clinical guesswork with measurement. The Titanic Index replaces eyeballing bar number. The button battery risk score replaces vague worry. The choledochal cyst outcomes data replace assumptions about laparoscopy being "too hard" in children. In each case, the data do not tell you what to do — they tell you what to expect and what to prepare for. That is the difference between evidence and protocol. You still exercise judgment; you just do it with better information.

Takeaways from this story

The Titanic Index predicts bar number needs for pectus repair with 93% sensitivity at a 66.5% cutpoint, enabling accurate preoperative planning.
Three factors predict severe button battery injury: esophageal location, ≥2cm size, and symptoms present. Time to removal was not predictive.
Laparoscopic choledochal cyst resection reduces length of stay and cost versus open, but requires mentorship for early-career surgeons.
Measurement tools earn clinical value when they answer intraoperative questions, not when they only document severity you already assessed.

Objective Measurement Tools That Change Intraoperative and Triage Decisions

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Teaching arc · AI-written, human-reviewed

Quantifying cephalocaudal extent determines bar number before incision

The Haller and Correction indices already guide the decision to operate on pectus excavatum, but they measure depth of depression, not longitudinal extent. The Titanic Index fills that gap by calculating the percentage of sternum lying beneath the anterior costal line 2:00. In a series of 78 patients, a cutpoint of 66.5% predicted the need for more than two bars with 93% sensitivity and 92% specificity 3:00. This matters because guessing bar number by visual assessment or age alone leads to intraoperative surprises — discovering mid-case that you need a third bar costs time and requires additional stabilization planning. The index converts a subjective judgment into a preoperative measurement that shapes your operative plan and your implant inventory before the patient is draped.

Risk stratification in button battery ingestion separates observation from urgent intervention

Three factors predict severe outcomes in button battery ingestion: battery lodged in the esophagus at presentation, battery diameter ≥2 cm, and presence of any symptoms 6:20. Severe outcomes were defined as deep mucosal erosion, perforation, mediastinitis, vascular or airway injury or fistula, or subsequent stricture development 5:36. In a series of 143 patients with 24 severe outcomes, the presence of all three factors was highly predictive of severe injury; absence of all three was highly predictive of benign course 6:05. This stratification does not change the mandate to remove an esophageal battery urgently, but it does two things: it identifies which patients can be managed at community hospitals versus requiring transfer to a tertiary center, and it frames the preoperative discussion with families about expected severity. Notably, time to removal was not a significant predictor 7:24 — the injury mechanism is electrochemical and begins immediately, so the battery's location, size, and the patient's symptoms matter more than whether removal happens at two hours versus four.

Laparoscopic choledochal cyst resection offers measurable advantages but demands technical fluency

A national database analysis of 577 pediatric choledochal cyst resections found that 28% were performed laparoscopically, with the remainder open 8:54 8:54. Open cases were predominantly hepaticojejunostomy; laparoscopic cases were predominantly hepaticoduodenostomy 8:54. Patients undergoing open resection had longer length of stay, higher cost, greater TPN use, and more frequent central line requirements 9:27, yet there was no significant difference in postoperative cholangitis or mortality between approaches 10:32. The biliary anastomosis is the technical crux — it is not a procedure for an early-career surgeon working alone 10:54. The learning curve is real, and the consequences of a leak or stricture are severe. But for surgeons with laparoscopic biliary experience or access to mentorship, the data suggest that the laparoscopic approach delivers equivalent safety with measurably better recovery metrics. The choice of anastomosis type (jejunal Roux-en-Y versus duodenal) may confound the comparison, but the absence of a cholangitis or mortality difference argues that laparoscopic resection is not inherently riskier — it simply requires the technical skill to execute it well.

The unifying principle: measurement tools earn their place by changing decisions

The Titanic Index is useful because it tells you how many bars to bring to the OR. The button battery risk score is useful because it tells you whether to transfer the patient. The choledochal cyst outcomes data are useful because they tell you that laparoscopy is not a compromise if you can do the anastomosis safely. Measurement tools that only describe severity without altering management are academic exercises. These three studies offer tools that change what you do.

Takeaways from this story

Titanic Index ≥66.5% predicts need for >2 pectus bars with 93% sensitivity, enabling preoperative planning rather than intraoperative guessing.
Button battery in esophagus + ≥2cm size + symptoms predicts severe injury; absence of all three predicts benign course, guiding triage decisions.
Time to battery removal was not a significant predictor of severe outcomes, though urgent removal remains standard practice.
Laparoscopic choledochal cyst resection matched open surgery for cholangitis and mortality but reduced LOS, cost, and TPN use.
Laparoscopic biliary anastomosis has a learning curve and is not recommended for early-career surgeons without experienced assistance.

Topic overview

Three research fellows from Cincinnati Children's Hospital review articles from the April 2023 Journal of Pediatric Surgery IPEG issue. The discussion covers a novel Titanic Index for measuring cephalocaudal extent in pectus excavatum to guide bar placement, risk factors predicting severe outcomes in pediatric button battery ingestions, and outcomes comparing laparoscopic versus open resection of pediatric choledochal cysts. Each article is contextualized with commentary from the journal editor Dr. Mark Wolkon and other pediatric surgery experts.

Key takeaways

Titanic Index ≥66.5% predicts need for >2 pectus bars with 93% sensitivity, 92% specificity—aids preoperative planning. (2:00)
Button battery in esophagus, ≥2cm size, or any symptoms predict severe injury; time to removal was not significant. (6:20)
Laparoscopic choledochal cyst resection yields shorter stay, lower cost vs open; no difference in cholangitis or mortality. (9:27)
Laparoscopic biliary anastomosis has a learning curve; not recommended for early-career surgeons without assistance. (10:54)

Keywords

pectus excavatum button battery ingestion choledochal cyst deep mucosal erosion perforation mediastinitis vascular injury airway injury fistula esophageal stricture cholangitis laparoscopic surgery hepaticojejunostomy hepaticoduodenostomy biliary anastomosis

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Transcript

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Hello, everyone. Welcome back to the Stay Current podcast. I'm Ellen Ancisco. I'm Emton Bash. And I'm Cecilia Kikena. We're research fellows at Cincinnati Children's. And along with Stay Current, we're sharing knowledge to improve child health around the globe. We have another installment in our series in the Journal of Pediatric Surgery article reviews. This is coming from the April 2023 issue. This was the IPEG issue. So it's from articles and presentations from last year's IPEG conference. IPEG is the International Pediatric Endosurgery Group. There are pediatric surgeons from all over the world doing endoscopic surgery. And the editor who has to choose these articles this time is Dr. Mark Wolkon. I'm Mark Wolkon. I'm the chair of Surgery at Akron Children's Hospital and the CEO of IPEG. The articles are listed and linked in the description below. Follow along and read with us. Okay, so we have three articles to share today. We're going to share one about a new index for measuring patients with hectus excavatum. Then we'll talk about some predictive factors for severe outcomes and pediatric button battery ingestions. And finally, we'll talk about laparoscopic versus open resection of pediatric cholodocal cysts. It's called Novel Index to Estimate the Cephalocaudal Extent of the Excavation in Pectus Excavatum, the Titanic Index. And this is coming from Argentina. And so here the authors took a look at a new index that they created for Pectus Excavatum. So we know about the Haller Index and the Correction Index. They calculate the severity of the depression and help us decide when patients need surgery. So what we did actually was determine the percentage of sternum that lies under the anterior costar line. And that was Dr. Lucia Toceli. She's an author on the article. We call that the Titanic Index. Dr. Marcelo Martinez-Ferro came up with that name. And these authors wanted to find an index that would help us determine the extent of cephalocaudal to see how many bars we might need. We use lateral bridges to stabilize the implants. So we always use at least two implants. But the question remains whether we needed two or three implants for complete remodulation of the thorax. And so you can take a look in the article to see exactly what the calculation is. And they previously reported it. But in this article, we took a look at a retrospective review of patients at their institution between 2020 and 2022. They looked at 78 patients. And they looked at how many bars the patients had placed at the time of their correction. And so 47% of the patients or 37 patients had two bars placed. And the other 53% or 41 patients had more than two bars placed. And we correlated it to the Titanic Index that we were measuring. And we found that cut point of 66.5, in which if we have more than 66.5% of Titanic Index, we were putting usually more than two implants. And if we had a Titanic Index under that value, then probably we were introducing two implants. And that had a sensitivity of 93% and a specificity of 92%. So it sounds like this index would be useful for preoperative planning to see how many bars we'll need. So I think this article is really worth highlighting because it provides a novel way to measure the pectus defect. And that was Dr. Wolkon. Again, he's the editor who helped us choose these articles. The reason that this is important and the reason that I think that we should highlight it is that looking at the Titanic Index can actually give you an idea of whether you're going to need one, two, or three bars. You know, currently we, you know, have to sort of guess based on eyeballing it. Some people do it by age, but this is an objective way to determine how many bars you might need. I think this was really important because we always do preoperative planning. We have them pre-eventing and doing with a software. And so when they came with this, it was really useful because we have an orientation on what to do and how many bars we need. So it's useful in a clinical practice. And here's what Todd had to say. I love it. And I think it's great to have a measurement tool that actually has use for clinical decision-making rather than just noting the severity is actually will help guide you in surgery. So I like it. Our second paper of the day is pediatric bottom battery ingestion, a single center experience and risk score to predict severe outcomes. This paper is coming from Boston Children's Hospital. And we talked to senior author. I'm Farouk Demary. I'm a pediatric surgeon at Boston Children's Hospital. In this study, as a single high volume center, they wanted to look at the management and outcomes of the primary bottom battery ingestions. What they were doing is trying to look at a regression analysis to figure out which factors predicted severe outcomes. And that was Dr. Mark Wilken. So here's how they defined a severe outcome. The patient need to have at least one of the following, deep mucosal erosion, perforation, mediastinitis, vascular or airway injury or fistula, and development of esophageal structure. They looked at the patient under 21 years old from 2008 to 2021. They had 143 patients and 24 of them had a severe outcome. They had three predictive factors of a severe outcome according to their analysis. The presence of the button battery in the esophagus at presentation, the two centimeter size battery or larger, and the presence of any symptoms. And so basically, if those three things were present, very highly predictive of a severe outcome. If all three were absent, very highly predictive of not having a severe outcome. And here's what Dr. Wilken said about this. Dr. So one of the advantages of this article and perhaps how it could change management is if you're at a center that can evaluate these risk factors, you might avoid a transfer. Flip side is that if a patient does have risk factors, then you certainly should send the patient to a hospital or a facility that has the capability to take care of a patient that has a significant button battery ingestion. I guess one thing you could say is that if they have symptoms, but there's no button battery on the chest x-ray, then that doesn't mean that there couldn't be a injury in the esophagus, even if you don't see it in the esophagus on the x-ray. By the way, interesting that the time it was in the esophagus was not something that they listed because I would have thought that would be a predictor. Actually, in our series, it did not appear that time to removal was a significant predictor. Does that mean that I'm not going to rush a child to the operating room to remove a button battery as soon as I can? No. I think we all will continue to practice the same way we are. We just get it out as soon as we can, especially if you have one that is in the esophagus still. But I think what it does is it does help us kind of think to ourselves as surgeons and to counsel the family about how worried we really are. And here's what Todd taught about this. This is more of just something to give expectations to the parents prior to surgery so that they have some idea. I think the next interesting thing to do would be to look at, in a more detailed way, specific endoscopic findings and trying to predict, okay, what the outcomes could be. So you have to remember, a lot of these patients, patients, nothing happens. And some of these patients have devastating consequences. So being able to sort that out is very important. Okay. So for the last paper, we have outcomes of laparoscopic versus open resection of pediatric colatical cysts. This was a retrospective study done in Miami, where they looked at the national database for surgery done in clinical cysts in pediatric patients from zero to 21 years from 2016 to 2018. And we talked to the senior author, Dr. Chad Thorson. Hi, my name is Chad Thorson. I'm an associate professor at the University of Miami. And they got our 577 patients. 28% were done laparoscopic and the rest were done open. And most of the open procedures were hepatic adenostomy. And most of the laparoscopic procedures were hepatic adenostomy. And so we looked and saw that the patients who were receiving open operations had inferior outcomes for some measures such as length of stay, cost, use of TPN requirement for central lines during their recovery. Whereas those with laparoscopic surgeries, as you would expect, have shorter length of stays, shorter costs, better cosmesis, of course. Well, they're saying like laparoscopic resection for these patients can be feasible and can lead to less complications on length of stay and it can be safer. It's possible that this study is just showing us that it has nothing to do with laparoscopy or open. It just has to do with hepatic adenostomy versus jejunostomy. That was taught. What would have been helpful is to control for the type of anastomosis to see if there was really a difference between lap versus open? Yeah, it makes sense what Todd was saying that the fact that they're using two different anastomosis between the surgeries is kind of a confounding factor for the outcomes. And here's what Dr. Wilkins said. Despite the different types of anastomosis, there really wasn't any significant difference in post-operative cholangitis or mortality. While this is not a prospective randomized trial, it's from a large nationwide database, it does really show that laparoscopic resection very well might be superior to open resection. It's so interesting. I know we're doing even more laparoscopic than we used to. Yeah, this is a complicated surgery to do the biliary anastomosis. So there's a learning curve, right? So this is not something that a first year grad or early career person who's never seen one might do by themselves, but with assistance from a partner or somebody that's been trained, doing videos, IPEG Academy, things like that, looking at the different techniques. It is possible, but it's something that there is a learning curve in the beginning until you get there to become efficient to be able to do it safely and effectively. Awesome. Three great articles from IPEG. We talked about a novel index, a titanic index for measuring the cephalocodal extent of pectus excavatum and how that might help us determine how many bars we need to do the repair. We talked about pediatric button battery ingestions and some risk factors for severe outcomes, like of course, the button battery in the esophagus, the size of the button battery, and any symptoms that the patient may be experiencing. And finally, we talked about pediatric chaldocal sits and open versus laparoscopic resection and how laparoscopic resection may be safe for these patients, even though a lot of them historically have been done open. If you liked this episode, don't forget to follow us on social media, subscribe to our YouTube channel, listen to previous episodes of this podcast or other podcasts, wherever you get your podcast from, and don't forget to download the State Current app on App Store or Play Store. What do we have coming up at the end of August, Cecilia? At the end of August, we have the update course in pediatric surgery. 2023 is the 29th of August. Don't forget to register and join us. Yeah, there's a link below in the description where you can register. It's all for free. We'll be in Cleveland for the update course, but anyone around the world can watch for free. So just register below and check it out. It's always really useful learning to stay up to date in pediatric surgery. Thanks for listening. I'm Ellen Ncisco. I'm Emta Mbash. And I'm Cecilia Kikena. We're research fellows at Cincinnati Children's Hospital. And along with State Current, we are sharing knowledge to improve child health around the globe.

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