We’re featuring Journal of Pediatric surgery articles to bring you some of the latest news!
This week we are discussing three articles from the April 2023 issue, the IPEG issue with editor Dr. Mark Wulkan and authors Drs. Luzia Toselli, Chad Thorson and Farokh Demeri
Hope you enjoy!
Hosts: Em Tombash, Ellen Encisco and Cecilia Gigena
Articles:
"Novel index to estimate the cephalocaudal extent of the excavation in pectus excavatum: The Titanic index" Gaston Bellía-Munzon et.al.
https://www.jpedsurg.org/article/S0022-3468(22)00783-7/fulltext
"Pediatric button battery ingestion: A single center experience and risk score to predict severe outcomes" P. Nina Scalise et.al.
https://www.jpedsurg.org/article/S0022-3468(22)00790-4/fulltext
"Outcomes of laparoscopic versus open resection of pediatric choledochal cyst" Walter A. Ramsey et.al.
https://www.jpedsurg.org/article/S0022-3468(22)00799-0/fulltext
Type: podcast · 13 min · posted 2023-07-27 Canonical: https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959 ## Chapters - [0:00](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959?t=0) Introduction and Titanic Index Overview - [2:00](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959?t=120) Titanic Index Study Details and Clinical Application - [5:16](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959?t=316) Button Battery Ingestion Risk Factors - [8:54](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959?t=534) Choledochal Cyst Resection Approaches - [11:29](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959?t=689) Summary and Closing ## Statements - "The Titanic Index measures the percentage of sternum that lies under the anterior costal line" — Luzia Toselli (clinical) [2:00](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959?t=120) - "The study included 78 patients between 2020 and 2022, with 47% receiving two bars and 53% receiving more than two bars" — Luzia Toselli (clinical) [2:12](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959?t=132) - "A Titanic Index cutpoint of 66.5% predicted need for more than two implants with 93% sensitivity and 92% specificity" — Luzia Toselli (clinical) [3:00](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959?t=180) - "Severe 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 Encisco (clinical) [5:36](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959?t=336) - "The Boston study included 143 patients under 21 years old from 2008 to 2021, with 24 having severe outcomes" — Ellen Encisco (epidemiological) [6:05](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959?t=365) - "Three 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 Encisco (clinical) [6:20](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959?t=380) - "Time to removal was not a significant predictor of severe outcomes in the button battery series" — Farokh Demeri (clinical) [7:24](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959?t=444) - "The choledochal cyst study analyzed 577 patients aged 0-21 years from 2016 to 2018 in a national database" — Chad Thorson (epidemiological) [8:54](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959?t=534) - "28% of choledochal cyst procedures were done laparoscopically and the rest were done open" — Chad Thorson (epidemiological) [8:54](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959?t=534) - "Most open procedures for choledochal cysts were hepaticojejunostomy and most laparoscopic procedures were hepaticoduodenostomy" — Chad Thorson (clinical) [8:54](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959?t=534) - "Patients receiving open operations had inferior outcomes including longer length of stay, higher cost, more TPN use, and more central line requirements" — Chad Thorson (clinical) [9:27](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959?t=567) - "There was no significant difference in post-operative cholangitis or mortality between laparoscopic and open choledochal cyst resection" — Mark Wulkan (clinical) [10:32](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959?t=632) - "Laparoscopic biliary anastomosis for choledochal cysts has a learning curve and is not recommended for early career surgeons without assistance" (opinion) [10:54](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-april-2023-ipeg-issue-6959?t=654) ## Transcript 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. --- Not medical advice · citation policy: https://library.globalcastmd.com/ai