# Journal of Pediatric Surgery Article Review: November 2021 — GCMD Library

We're back with the November issue of JPS article highlights. This time we're talking to Dr. Pablo Laje and authors Dr. Frederick Rescorla and Dr. Niloufar Hafezi.

Hosts: Ellen Encisco & Rod Gerardo

Articles: Rubalcava NS, Overman RE, Hirschl RB, Thirumoorthi AS. Central Line Placement at ECMO Decannulation: A Missed Opportunity. Journal of Pediatric Surgery. https://www.jpedsurg.org/article/S0022-3468(21)00184-6/fulltext Hafezi N, Carpenter KL, Colgate CL, et al.

Partial splenectomy in children: Long-term reoperative outcomes☆. Journal of Pediatric Surgery. 2021 Jan 8. https://www.jpedsurg.org/article/S0022-3468(21)00018-X/fulltext Elhattab A, Elsaied A, Wafa T, et al.

Thoracoscopic surgery for congenital lung malformations: Does previous infection really matter?. Journal of Pediatric Surgery. 2021 Jan 27. https://www.jpedsurg.org/article/S0022-3468(21)00086-5/fulltext

100:00:04,320 --> 00:00:04,840Hello. 
200:00:04,920 --> 00:00:09,320We are back with our December issue.
300:00:09,520 --> 00:00:10,240Right November. 
400:00:10,240 --> 00:00:12,400November, November.
500:00:12,400 --> 00:00:14,080Sorry, I'm jumping ahead. 
600:00:14,080 --> 00:00:16,560Releasing December. Yeah.
700:00:16,880 --> 00:00:18,120I'm Rod Gerardo. 
800:00:18,120 --> 00:00:19,480I'm Ellen Encisco. 
900:00:19,480 --> 00:00:21,720We're research residents at Cincinnati Children's.
1000:00:22,240 --> 00:00:25,000Again, we have three articles that we're going to feature.
1100:00:25,000 --> 00:00:28,840But these are ones that may make me change what I do every day.
1200:00:28,840 --> 00:00:33,520So I thought it was those were the were the ones with these topics.
1300:00:33,520 --> 00:00:38,120Handpicked from one of the editors, one of everyone's favorite Editor.
1400:00:38,640 --> 00:00:39,440Hi, everybody. 
1500:00:39,440 --> 00:00:41,520My name is Pablo Laje i'm one of the attending surgeons
1600:00:41,520 --> 00:00:43,320at the Children's Hospital in Philadelphia. 
1700:00:43,320 --> 00:00:46,600So the first article is called Central Line Placement
1800:00:46,800 --> 00:00:49,680at ECMO decannulation a missed opportunity.
1900:00:50,160 --> 00:00:52,360And this is out of the University of Michigan.
2000:00:52,760 --> 00:00:56,280This was a single institution retrospective study.
2100:00:56,400 --> 00:01:00,440I think I think it's important to say the main question here is should we go
2200:01:00,440 --> 00:01:05,400ahead and place a central line at the time of ECMO decannulation?
2300:01:05,800 --> 00:01:09,720Because a lot of times I think I think common practice is not to do that.
2400:01:10,000 --> 00:01:12,72040% ultimately required a central
2500:01:13,320 --> 00:01:16,200venous line within 30 days after ECMO decannulation.
2600:01:16,640 --> 00:01:19,000Which is probably a lot.
2700:01:20,440 --> 00:01:21,480Here's what Todd thought. 
2800:01:21,480 --> 00:01:23,320Almost never. 
2900:01:24,400 --> 00:01:25,640That's what, that's what I suspected. 
3000:01:25,640 --> 00:01:26,560And that is why 
3100:01:26,560 --> 00:01:30,360I think this is a single institution experience, because that's just the way
3200:01:30,360 --> 00:01:31,600they do it there. 
3300:01:31,600 --> 00:01:35,600But I will tell you that and I've worked at multiple institutions.
3400:01:35,600 --> 00:01:38,480So, I've worked at five children's hospitals
3500:01:38,760 --> 00:01:42,240considering, you know, including where I trained. 
3600:01:42,240 --> 00:01:46,480And I think I've had to do that twice
3700:01:47,160 --> 00:01:49,400and I've never had to go back
3800:01:49,560 --> 00:01:52,880and reinsert a line afterwards.
3900:01:53,640 --> 00:01:56,160I mean, you can also kind of turn it around, say 60%
4000:01:57,000 --> 00:02:00,160didn't need it after a month.
4100:02:00,160 --> 00:02:02,400Or at least that's how Dr. Laje kind of saw it.
4200:02:02,400 --> 00:02:05,840The typical case of whether you want to see things
4300:02:05,840 --> 00:02:09,000on this side of the coin or the opposite side of the coin, you may say,
4400:02:09,720 --> 00:02:12,600Well, you know, if you have 40% of babies
4500:02:13,160 --> 00:02:16,040needing a center line sometime after the cannulation
4600:02:16,400 --> 00:02:19,920you should actually put it in all of them because, you know, 40% will need it.
4700:02:20,120 --> 00:02:23,000Or you can say the opposite only 40%, will need one.
4800:02:23,000 --> 00:02:26,880So why would you put a line in the other 60%, right?
4900:02:27,840 --> 00:02:32,160Perhaps it's not surprising to those listening in neonates,
5000:02:33,120 --> 00:02:35,520you know, babies less than 28 days. 
5100:02:35,520 --> 00:02:38,040They primarily needed it for access.
5200:02:38,760 --> 00:02:41,280A lot of them are CDH babies. 
5300:02:41,280 --> 00:02:44,880And then in the older children or babies, the primary reason
5400:02:44,880 --> 00:02:49,200for needing a line after medication was hemodialysis.
5500:02:49,680 --> 00:02:53,000If you just need access, then just use a picc line.
5600:02:53,280 --> 00:02:57,760So really, this is about a trend that in older patients
5700:02:58,520 --> 00:03:01,560leaving a central line, maybe reasonable
5800:03:01,560 --> 00:03:03,840because they'll need hemodialysis more often,
5900:03:04,640 --> 00:03:08,280maybe to pose yourselves the question at the time of the cannulation at least
6000:03:08,600 --> 00:03:10,960to make sure that the baby
6100:03:11,440 --> 00:03:14,360will not need a central line shortly after it.
6200:03:14,640 --> 00:03:18,480You know, if there is a borderline situation, maybe that's a good idea.
6300:03:18,880 --> 00:03:22,520Dr. Laje did point out that, you know, this may not change his practice,
6400:03:22,520 --> 00:03:26,360but it would make him kind of think more about.
6500:03:27,400 --> 00:03:28,800The possibility of 
6600:03:28,800 --> 00:03:32,760needing a central line later down the road at the time of decannulation.
6700:03:32,760 --> 00:03:35,040Yeah, I think that's fair to say.
6800:03:35,480 --> 00:03:38,720Not every kid needs a central line, but
6900:03:39,600 --> 00:03:42,840maybe we should consider it for those patients who maybe are
7000:03:42,960 --> 00:03:44,120a little bit more sick than others. 
7100:03:44,120 --> 00:03:48,720Now, now that I read this, I will take a closer look at every case
7200:03:48,720 --> 00:03:53,080and say, Well, the baby doesn't need it now, so I'm not going to put it for sure.
7300:03:53,480 --> 00:03:55,440But we are sure that 
7400:03:55,440 --> 00:03:58,840the baby is not going to benefit from it in that in the next two days.
7500:03:59,280 --> 00:04:03,360Oh, and if you want to read this article, scroll down to the video player.
7600:04:03,360 --> 00:04:05,320We're going to give you the link to it 
7700:04:05,320 --> 00:04:07,440so you could read along with us when we talk about them. 
7800:04:07,440 --> 00:04:12,440Yeah, so it's called thoracoscopic surgery for congenital lung malformations.
7900:04:12,600 --> 00:04:15,120Does previous infection really matter? 
8000:04:15,120 --> 00:04:17,440And this one is from Paris. 
8100:04:17,440 --> 00:04:18,320Excuse me. 
8200:04:18,320 --> 00:04:21,560It was her multiple places, mainly Paris, someone from Egypt.
8300:04:21,880 --> 00:04:25,280This one was pretty interesting, I think, for multiple reasons.
8400:04:25,320 --> 00:04:28,320one is, if the listener hasn't
8500:04:28,320 --> 00:04:33,120already heard our hour long podcast on CPAMS from a few months ago,
8600:04:33,120 --> 00:04:35,280definitely jump out here and listen to that.
8700:04:35,280 --> 00:04:38,160It's called the full story on CPAMS, and I think we kind of
8800:04:38,880 --> 00:04:40,320touched on this a little bit. 
8900:04:40,320 --> 00:04:43,280But now this is we get to do a deep dive on this specifically.
9000:04:43,760 --> 00:04:49,760Yeah, this was a retrospective study, and they're basically looking at patients
9100:04:50,040 --> 00:04:54,000over a nine year period who had congenital malformations
9200:04:54,160 --> 00:04:57,200Well I think their main question was like if they because they divided it by people
9300:04:57,200 --> 00:05:01,520who had a prior infection versus those who didn't before resection.
9400:05:02,000 --> 00:05:05,120These article supports the idea that, you know,
9500:05:05,520 --> 00:05:08,880a number of patients will will have a pneumonias,
9600:05:08,880 --> 00:05:12,720and when that happens, the indication for the surgery becomes obvious.
9700:05:12,720 --> 00:05:16,240And when that happens, the surgery is a lot more difficult.
9800:05:16,280 --> 00:05:18,840I mean, and they they really did a nice comparison.
9900:05:18,840 --> 00:05:21,240They had about 30 and 60.
10000:05:21,240 --> 00:05:24,28030 with infections before and 60 without infections before.
10100:05:24,840 --> 00:05:27,520And you know, every single parameter that you look at, you know,
10200:05:27,560 --> 00:05:30,800time of the operation needed, transfusions need for reoperations.
10300:05:31,000 --> 00:05:34,640More conversions the operative time was longer.
10400:05:34,880 --> 00:05:38,880All those things were worse within the group that had previous infections.
10500:05:38,920 --> 00:05:42,280But there weren't any differences with their complications.
10600:05:42,280 --> 00:05:43,080Complications. 
10700:05:43,080 --> 00:05:46,000I was so worried to hear what the conclusion was going to be.
10800:05:46,000 --> 00:05:48,320I'm so happy that they concluded this.
10900:05:48,400 --> 00:05:49,840Listen, here's a story. 
11000:05:49,840 --> 00:05:53,880In general, one of the fears that someone has on doing a thoracoscopic
11100:05:53,880 --> 00:05:58,200lobectomy to me is that in a small baby, it's going to be challenging.
11200:05:59,520 --> 00:06:00,240And so 
11300:06:00,240 --> 00:06:03,480the natural instinct is to wait to let them get bigger.
11400:06:03,920 --> 00:06:06,720So you have more room and more space to do the operation.
11500:06:07,240 --> 00:06:09,200And that is a fallacy. 
11600:06:09,200 --> 00:06:13,360A lung that was infected is going to be
11700:06:13,880 --> 00:06:16,960a more difficult lung to operate on.
11800:06:17,280 --> 00:06:21,760And the main reason to to do it early is not only is it easier,
11900:06:22,040 --> 00:06:25,520but you have a much less chance of having an infection beforehand.
12000:06:25,520 --> 00:06:28,960And so it's clean, pristine virgin planes.
12100:06:29,280 --> 00:06:32,960If having an infection before surgery makes it more difficult,
12200:06:33,720 --> 00:06:36,000then we should operate sooner in order
12300:06:36,000 --> 00:06:38,400to not give the baby time to have an infection.
12400:06:39,280 --> 00:06:41,760And sooner is a moving target.
12500:06:42,000 --> 00:06:45,280So I was trained at six to eight months.
12600:06:46,000 --> 00:06:48,000Now I'm down to three months. 
12700:06:48,000 --> 00:06:51,920Quite early, actually, our averaging in hundreds of these is about eight weeks.
12800:06:53,160 --> 00:06:54,600So, you 
12900:06:54,600 --> 00:06:57,120know, we're talking obviously asymptomatic lesions.
13000:06:57,800 --> 00:07:00,120You know, we let the babies go home, bond with the family.
13100:07:00,520 --> 00:07:03,000We get a follow up CAT scan around four weeks of age
13200:07:03,000 --> 00:07:06,000and sometime, you know, around eight, ten weeks.
13300:07:06,280 --> 00:07:07,880We do the elective lobectomy. 
13400:07:07,880 --> 00:07:11,080Does not necessarily change what you're already doing,
13500:07:11,120 --> 00:07:13,640do what you're already doing it and they suggest most,
13600:07:13,880 --> 00:07:18,080you know, doing it before, you know No it won't change what I what I do, but
13700:07:18,840 --> 00:07:22,200keep thinking that what we do is the right thing, which is to attack
13800:07:22,200 --> 00:07:25,240these lesions before we before they get complicated.
13900:07:25,360 --> 00:07:28,280Are you going to cut these out early when you're a big, bad pediatric surgeon?
14000:07:29,200 --> 00:07:30,200Probably. Probably. 
14100:07:30,960 --> 00:07:35,560Once I once I learned how to do the operation and feel confident doing it.
14200:07:35,560 --> 00:07:35,840Right. 
14300:07:35,840 --> 00:07:39,840Theres a lot of steps to get to that point.
14400:07:39,840 --> 00:07:40,520Yeah. 
14500:07:40,520 --> 00:07:42,400Perfect that's great. So then we can just move 
14600:07:42,400 --> 00:07:44,760on for the next one and You know, just keep doing these.
14700:07:45,080 --> 00:07:49,040Partial splenectomy in children long term re operative outcomes.
14800:07:49,280 --> 00:07:50,880And this one comes from. 
14900:07:50,880 --> 00:07:52,760I'm Frederick Rescorla I'm one of the pediatric surgeons 
15000:07:52,760 --> 00:07:55,160from Indianapolis at Riley Hospital for Children.
15100:07:55,320 --> 00:07:59,840I'm Nily Halfezi I'm a current PGY 3 at Baystate UMass,
15200:08:00,200 --> 00:08:04,000and I was the previous clinical research fellow at Indiana University.
15300:08:04,600 --> 00:08:05,760In this article. 
15400:08:05,760 --> 00:08:07,800It was a retrospective review. 
15500:08:07,800 --> 00:08:11,880We basically we chose to look at our long term outcomes
15600:08:11,880 --> 00:08:16,080and partial splenectomy to get a gauge for what happens
15700:08:16,160 --> 00:08:21,120after these kids continue to grow and continue to
15800:08:22,400 --> 00:08:24,800retain some of that splenic function. 
15900:08:24,800 --> 00:08:26,360When Nily kind of came up with this. 
16000:08:26,360 --> 00:08:28,400We thought It would be useful 
16100:08:28,400 --> 00:08:31,640if we could kind of like figure out what our numbers were saying, actually
16200:08:31,640 --> 00:08:33,200counsel families ahead of time and say. 
16300:08:33,200 --> 00:08:35,560Hey, this is the risk. 
16400:08:35,560 --> 00:08:38,720We reviewed all of the cases and all of the patients who underwent
16500:08:38,760 --> 00:08:40,160a partial splenectomy. 
16600:08:40,160 --> 00:08:42,68017 years from 2002 to 2019.
16700:08:42,720 --> 00:08:47,840From there, we were able to split up to basically to two groups
16800:08:47,840 --> 00:08:50,480those who underwent a partial splenectomy
16900:08:50,480 --> 00:08:53,920and did not require a subsequent operation.
17000:08:54,360 --> 00:08:59,080And those who did undergo the partial and then subsequently underwent
17100:08:59,080 --> 00:09:00,240a total splenectomy. 
17200:09:00,240 --> 00:09:02,480And how often they needed a cholecystectomy.
17300:09:02,800 --> 00:09:05,880And they really wanted to do this, which Nily described to, you know,
17400:09:05,960 --> 00:09:08,600kind of inform their discussion with families.
17500:09:08,920 --> 00:09:12,640And what we looked at then after we divided into the two groups,
17600:09:12,640 --> 00:09:15,920was we compared several metrics.
17700:09:15,960 --> 00:09:18,960Would there be anything that we can find that that could be
17800:09:18,960 --> 00:09:22,040a predictor for subsequent reoperation?
17900:09:22,600 --> 00:09:23,040I'm sorry. 
18000:09:23,040 --> 00:09:25,440What were the indications for these patients?
18100:09:26,560 --> 00:09:29,320They all had hemolytic anemia's of some sort like that.
18200:09:29,360 --> 00:09:31,720I think the most common was hereditary spherocytosis.
18300:09:32,480 --> 00:09:33,480Yeah. Yeah. 
18400:09:33,480 --> 00:09:35,360The other ones there were like three patients 
18500:09:35,360 --> 00:09:39,400who either had splenomegaly or hereditary hereditary pyropoikilocytosis.
18600:09:40,120 --> 00:09:43,360So as far as your results were you were you at all surprised.
18700:09:43,400 --> 00:09:47,640It sounds like the about 29% completion rate was similar
18800:09:47,640 --> 00:09:51,360to other results, but what did you think of that finding?
18900:09:51,680 --> 00:09:54,560The 30% is on the higher end of what's
19000:09:54,880 --> 00:09:58,000been recorded in the literature so far.
19100:09:58,000 --> 00:10:02,120These partial splenectomy are are not undergoing completions
19200:10:02,120 --> 00:10:05,560until years after the initial
19300:10:06,680 --> 00:10:08,600initial index precedure. 
19400:10:08,600 --> 00:10:11,080And from my perspective, it's really good to see this data
19500:10:11,080 --> 00:10:13,560because I feel like when I talk to my family, 
19600:10:13,560 --> 00:10:16,840I can really tell them this is the rate that your child will need
19700:10:16,840 --> 00:10:20,280a subsequent total splenectomy, and you have to make sure that your worth.
19800:10:20,800 --> 00:10:22,840You're happy accepting that risk.
19900:10:22,920 --> 00:10:26,000They can go through the rest of those years where they're
20000:10:26,000 --> 00:10:30,240fairly high risk for a post splenectomy sepsis, although it's a low risk,
20100:10:31,560 --> 00:10:32,760with the spleen intact. 
20200:10:32,760 --> 00:10:36,960And if you're willing to do it, then we do it, even though it says there,
20300:10:36,960 --> 00:10:41,280that partial splenectomy has gained acceptance among pediatric surgeons.
20400:10:41,640 --> 00:10:46,200I don't think that that represents everybody's practice.
20500:10:46,240 --> 00:10:49,200I mean, at least where I work
20600:10:49,600 --> 00:10:52,120is very uncommon to do a patial splenectomy.
20700:10:52,560 --> 00:10:56,160OK, so the conclusion of this paper is if you feel comfortable
20800:10:56,160 --> 00:11:00,000doing a partial splenectomy, it works 70% of the time.
20900:11:00,360 --> 00:11:03,280But then after reading these and having the good results,
21000:11:03,760 --> 00:11:08,000I thought that this is something that will seriously consider interesting study.
21100:11:08,080 --> 00:11:09,040It's good. 
21200:11:09,040 --> 00:11:10,920Anything by Rescorla I trust. 
21300:11:10,920 --> 00:11:13,040He seems pretty cool. 
21400:11:13,040 --> 00:11:16,800If you are listening to this and you are one of the authors for this
21500:11:16,960 --> 00:11:19,760These papers like reach out to us, we'd love to hear from you as well.
21600:11:20,160 --> 00:11:22,640Otherwise, get ready for next month.
21700:11:22,640 --> 00:11:26,040We're already gearing up to do our December
21800:11:26,640 --> 00:11:30,120Articles podcast, so keep an eye out for that.
21900:11:30,400 --> 00:11:33,400Can I add one thing you can put this back in if you want?
22000:11:33,560 --> 00:11:35,440I would just add, like 
22100:11:35,440 --> 00:11:38,160all of these articles are pretty practice based like Dr.
22200:11:38,160 --> 00:11:40,840Laje pointed out. Things that might actually change your practice.
22300:11:41,120 --> 00:11:44,320But until then, I'm Rod, I'm Ellen.
22400:11:44,560 --> 00:11:47,120And remember, knowledge should be free.
22500:11:47,800 --> 00:11:48,160Nice. Type: podcast · 11 min · posted 2022-01-25 Canonical: https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911 ## Chapters - [0:00](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=0) Central Line Placement at ECMO Decannulation - [4:07](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=247) Thoracoscopic Surgery for Congenital Lung Malformations - [7:45](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=465) Partial Splenectomy Long-term Outcomes ## Statements - "40% of patients ultimately required a central venous line within 30 days after ECMO decannulation" — Ellen Encisco (clinical) [1:09](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=69) - "In neonates (babies less than 28 days), the primary reason for needing a central line after ECMO decannulation was access, with many being CDH babies" — Ellen Encisco (clinical) [2:27](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=147) - "In older children or babies, the primary reason for needing a line after ECMO decannulation was hemodialysis" — Ellen Encisco (clinical) [2:41](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=161) - "If you just need access, then just use a PICC line" — Todd (opinion) [2:49](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=169) - "Leaving a central line at ECMO decannulation may be reasonable in older patients because they'll need hemodialysis more often" — Todd (opinion) [2:53](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=173) - "60% of patients did not need a central line within a month after ECMO decannulation" — Rod Gerardo (clinical) [1:53](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=113) - "In the congenital lung malformation study, approximately 30 patients had infections before surgery and 60 did not" — Pablo Laje (clinical) [5:16](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=316) - "Every parameter examined (time of operation, needed transfusions, need for re-operations, more conversions, operative time) was worse in the group that had previous infections" — Pablo Laje (clinical) [5:24](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=324) - "There were no differences in complications between patients with and without prior infection in congenital lung malformation surgery" — Pablo Laje (clinical) [5:34](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=334) - "A lung that was infected is going to be a more difficult lung to operate on" — Rod Gerardo (clinical) [6:09](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=369) - "The main reason to operate early on congenital lung malformations is not only that it's easier, but you have a much less chance of having an infection beforehand" — Todd (opinion) [6:17](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=377) - "Training for congenital lung malformation surgery timing has shifted from 6-8 months down to 3 months" — Todd (clinical) [6:42](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=402) - "At Children's Hospital of Philadelphia, the median age for elective lobectomy for asymptomatic congenital lung lesions is about 8 weeks" — Pablo Laje (clinical) [6:48](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=408) - "For asymptomatic congenital lung lesions, babies go home to bond with family, get a follow-up CT scan around 4 weeks of age, and undergo elective lobectomy around 8-10 weeks" — Pablo Laje (clinical) [6:57](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=417) - "The partial splenectomy study reviewed cases from 2002 to 2019, spanning 17 years" — Ellen Encisco (clinical) [8:35](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=515) - "Patients were divided into two groups: those who underwent partial splenectomy without subsequent re-operation and those who subsequently underwent total splenectomy" — Nellie Hafezy (clinical) [8:42](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=522) - "The most common indication for partial splenectomy was hereditary spherocytosis" — Rod Gerardo (clinical) [9:26](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=566) - "Other indications included splenomegaly or hereditary pyropoikilocytosis in about 3 patients" — Ellen Encisco (clinical) [9:33](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=573) - "The completion splenectomy rate was about 29%, which is on the higher end of what's been recorded in the literature" — Nellie Hafezy (clinical) [9:40](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=580) - "Partial splenectomies are not undergoing completions until years after the initial index procedure" — Nellie Hafezy (clinical) [9:58](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=598) - "Patients with retained spleen after partial splenectomy go through years where they're fairly high risk for post-splenectomy sepsis, although it's a low risk" — Frederick Scola (clinical) [10:22](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=622) - "Partial splenectomy works 70% of the time without requiring completion" — Todd (clinical) [10:52](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=652) - "Partial splenectomy is very uncommon practice at Children's Hospital of Philadelphia" — Pablo Laje (clinical) [10:35](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-november-2021-4911?t=635) ## Transcript 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. --- Not medical advice · citation policy: https://library.globalcastmd.com/ai