Journal of Pediatric Surgery Article Review: November 2021

Hello, we are back with our December issue. Wait, November. November. Sorry, I'm jumping ahead of myself releasing in December. Yeah, I'm Rod Gerardo. I'm Ellen and Cisco. We're research residents at Cincinnati Children's. Uh, again, we have 3 articles that we're going to feature, but these are ones that may make me change what I do every day. So I, I thought that this was, those were the, the, the were the ones for, for these talks. Handpicked from one of the editors, one of everyone's favorite editors. Uh, hi, everybody. Uh, my name is Pablo Lache. I'm one of the attending surgeons at the Children's Hospital of Philadelphia. So, the first article is called Central Line Placement at ECMO decanulation, a missed Opportunity, and this is out of the University of Michigan. This It was a single institution retrospective study. I think, I think it's important to say the main question here is, should we go ahead and place a central line at the time of emodecannulation, because a lot of times I think, I think common practice is not to do that. 40% ultimately required a central venous line within 30 days after emodecannulation, which is probably a lot. Um, here's what Todd thought. Almost never. That's what I, that's what I suspected. And that is why I think this is a single institution experience because that's just the way they do it there. But I will tell you that it, I've worked at multiple institutions, so I've worked at 5 children's hospitals, considering, you know, including where I trained, um, and I think I've had to do that twice, and I've never had to go back and reinsert a line afterwards. I mean you could also kind of turn it around, say 60% didn't need it after a month, or at least that's how Doctor Lahe kind of saw it. The typical case of whether you wanna see things on this side of the coin or the opposite side of the coin, you may say, Well, you know, if, if you have 40% of babies needing a central line sometime after the de cannulation, you should actually put it in all of them because you know, 40% will need it, or you can say the opposite, only 40% will need one. So why would you, you know, put a line in the other 60%, right? Perhaps it's not surprising to those listening and, and neonates, uh, you know, babies less than 28 days, they primarily needed it for access. A lot of them are CDH babies. And then in the older children or babies, the primary reason for needing a line after emodecannulation was hemodialysis. If you just need access, then just use a PICC line. So really, this is about a trend that in older patients, leaving a central line may be reasonable because they'll need hemodialysis more often. Maybe to pose yourselves the question at the time of the decanulation, and at least to make sure that the baby will not need a central line shortly after it, you know, if there is a borderline situation, maybe that's a good idea. Doctor Lahe did point out that, you know, this may not change his practice, but it would make him kind of think more about. The possibility of needing a central line later down the road at the time of the accumulation. Yeah, I think that's fair to say. Not every kid needs a central line, but maybe we should consider it for those patients who maybe are a little bit more sick than others. Now, now that I read this, I will take a closer look at every case and say, well, the baby doesn't need it now, so I'm not gonna put it for sure. But are we all sure that, you know, the baby is not going to benefit from it in the, in the next few days? Oh, and if you want to read this article. Scroll down under the media player, we're gonna give you the link to it, uh, so you could read along with us while we talk about them. Yeah. Uh, so this one's called thoracoscopic surgery for congenital lung malformations. Does previous infection really matter? And this one is from Paris. Excuse me, it was from multiple places, mainly Paris, but someone's from Egypt. This one was, uh, pretty interesting, I think for multiple reasons. One is, if the listener hasn't already heard our hour-long podcast on CPAs from a few months ago, definitely jump out of here and listen to that. It's called The Full Story on CPAs, and I think we kind of Touched on this a little bit, but now this is, we get to do a deep dive on this specifically. But yeah, this was a retrospective study, and they are basically looking at uh patients over a nine-year period who had congenital lung malformations. I think their main question was like, if they, cause they divided it by people who had a prior infection versus those who didn't before the resection. This article supports the idea that, you know, a number of patients will will have pneumonias and when that happens, the indication for the surgery becomes obvious. And when that happens, you know, the surgery is a lot more difficult. I mean, and they, they really did a nice comparison. They had like about 30 and 60, you know, 30 with infections before and 60 without infections before. And you know every single parameter that you look at, you know, time of the operation, needed transfusions, need for re-operations, more conversions, the operative time was longer. All those things were worse within the group that had previous infections, but there weren't any differences with their. Complications complications. Um, I was so worried to hear what the conclusion was gonna be. I'm so happy that they concluded this. Listen, here's the story. In general, one of the fears that someone has on doing a thoracoscopic lobectomy is that in a small baby, it's gonna be challenging. And so the, the natural instinct is to wait to let them get bigger. So you have more room and more space to do the operation. And that is a fallacy. A lung that was infected is gonna be a more difficult lung to operate on. And the main reason to, to do it early. not only is it easier, but you have a much less chance of having an infection beforehand, and so it's clean, pristine virgin plains. If having an infection before surgery makes it more difficult, then we should operate sooner in order to not give the baby time to have an infection. And sooner is a moving target. So I was trained at 6 to 8 months. Now I'm down to 3 months. Quite early actually. Our a in, in, in hundreds of these is about 8 weeks. Um, so, you know, this, we're talking obviously asymptomatic lesions. Um, you know, we let the babies go home, bond with the family. We get a, a follow-up CAT scan around 4 weeks of age and sometime, you know, around 8, 10 weeks, uh, we do the elective lobectomy. Got it. So this wouldn't necessarily change what you're already doing. You would, you're already doing it, and they suggest it, you know, doing it before a year. No, it, it won't change what I, what I do, but, um, keep thinking that what we do is, is the right thing, which is to, you know, attack these lesions before we, before they, they get complicated. Are you going to cut these out early when you're a big bad pediatric surgeon? Probably. Probably. Once I, once I learned how to do the operation. And feel confident doing it. Right. There's a lot of steps for us to get to that point. Yeah. Perfect. That's great. So then we can just move on for the next, next one and, you know, just keep doing this. Partial splenectomy in children, long-term reoperative outcomes, and this one comes from. I'm Frederick Scola, one of the pediatric surgeons from Indianapolis at Riley Hospital for Children. I'm Nellie Hafezy. I'm a current PGY 3 at Bay State UMass, um, and I was the previous uh clinical research fellow at Indiana University. In this article, it was a retrospective review. We basically, we chose to look at our long term outcomes and partial splenectomy, uh, to get a gauge for, uh, what happens after these kids, uh, continue to grow and, uh, continue to, um, retain some of that splenic function. When Neilly kind of came up with this, we thought, well, you know, it'd be useful. If we could kind of like figure out what our numbers were so we could actually counsel families ahead of time and say, hey, this is the risk. Uh, we reviewed all of the cases and all of the patients who underwent a partial splenectomy. 17 years from 2002 to 2019. From there, we were able to, uh, split up to basically 22 groups, those who underwent a partial splenectomy and did not require a subsequent re-operation and those who. did undergo the partial and then subsequently underwent a total splenectomy. And how often they needed a cholecystectomy. And they really wanted to do this, which nearly described to, you know, kind of inform their discussion with families. And what we looked at then after we divided into the two groups was we compared, um, several metrics, would there be anything that we can find that, that could be a predictor for subsequent re-operation. I'm sorry, what were the indications for these patients? They all had hemolytic anemias of some sort like that. I think the most common was hereditary spherocytosis. Yeah. The other ones, they're like 3 patients who had either splenomegaly or hereditary pyropoikilocytosis. So, as far as your results, were you, were you at all surprised that it sounds like the, about 29% completion rate was similar to other report results, or what, what did you all think of what you ended up finding? The 30% is on the higher end of what's been recorded in the literature, um, so far. These partial splenectomies are, are not undergoing completions until years after the initial. Uh, initial index procedure and, and from my perspective, it's really good to see this data cause I feel like when I talk to a family, I can really tell them this is the rate that your child will need a subsequent total splenectomy, and you have to make sure that you're worth, you're, you're happy accepting that risk. They can go through the rest of those years where they're fairly high risk for post splenectomy sepsis, although it's, it's a low risk. Um, with the spleen intact, and if they're willing to do it, then we do it. Even though it says there that partial splenectomy has gained acceptance, you know, among pediatric surgeons, I don't think that, that represents everybody's practice. I mean, um, at least where, where I work, um, it's very uncommon to do a partial splenectomy. OK, so the conclusion of this paper is, if you feel comfortable doing a partial splenectomy. It works 70% of the time. But, but then after reading these and, and, and having the good results, uh, I, I thought that this is something that we'll seriously consider. Interesting study, it's good. Anything by Roscola, I trust. He seems pretty cool. If you are listening to this and you are one of the authors for this, these papers, like reach out to us, we'd love to hear from you as well. Otherwise, get ready for next month. We're already gearing up to do our December. Articles, uh, podcast, so keep an eye out for that. Can I add one thing? You can put this back in if you want. I would just add like all of these articles are pretty practice-based, like Doctor Lahe pointed out, things that might actually change your practice. But until then, I'm Rod. I'm Ellen, and remember, knowledge should be free. Nice.