From
StayCurrentMD
Journal of Pediatric Surgery quarterly review: tracheobronchopexy outcomes, surgical outreach access, and gastrostomy practice variation
With Dr. George W. Holcomb III & Dr. Sean Kunisaki · hosted by Dr. Em Gootee
Chapter 1 of 3
Tracheobronchopexy series
Tracheobronchopexy outcomes for severe airway collapse after esophageal atresia repair
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Host summaries · secondary, not cited in answers
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Most pediatric surgeons won't see 10 patients with postoperative airway collapse spells in their career, and many wouldn't see 5
Dynamic bronchoscopy showed complete airway collapse in 90% of patients
Three-quarters of procedures used a posterior approach
Tracheobronchopexy was performed on thoracic trachea alone in over half the patients but had to extend onto the bronchi in 40%
94% of patients avoided tracheostomy with a mortality rate of 5%
The procedure significantly reduced pressure ventilation and ventilator dependence
Canada is the second largest country in the world geographically but population-wise smaller than California
The majority of Canada's population lives within 200 kilometers of the US border
The study did not address surgical care provided to children in remote communities by non-pediatric surgical specialists
In most places in Canada, no one would transfer a 16 or 17 year old with appendicitis to a children's hospital for surgery as they are physiologically adult and do not need pediatric surgeon expertise
Access to surgical care for children in Canada has been in need of improvement for decades
It is a misconception that the Canadian healthcare system ensures timely care; children wait for surgery beyond their wait time target
Newfoundland and Labrador's population is really rural and spread out, and weather can make accessing care impossible or financially devastating
The study used RGIS geospatial mapping to identify distribution of outreach sites nationally across Canada
There are measurable costs of living remote to accessible high quality care in terms of time required to be seen and clinical outcomes
Gastrostomy tube insertion is one of the most common operations performed in pediatric surgery
Until now there wasn't a great national clinical sample of data capturing both care processes and outcomes specific to G tubes
The study used 71 NSQIP pediatric hospitals that participated in the G-tube pilot starting in 2023
In the NSQIP database, 5% of all pediatric procedures were G tube
77% of G tube cases were first-time G tubes as opposed to redos
The heterogeneity in use of preoperative upper GIs was extremely broad with no clear reason, indicating a potential teaching moment
An additional 5.5% of G tubes were dislodged in the 31 to 60 day period
Dislodgement rates are higher than readmissions or IR interventions, making them a great QI target
If you can get dislodgements down, ED visits go down; when early dislodgements happen patients are told to come back to the ED
Esophageal atresia repair patients can experience severe airway collapse leaving them ventilator dependent or suffering repeated cyanotic spells
The series included 80 children who underwent tracheobronchopexy from two high volume centers, most with type C esophageal atresia
These results reflect expertise of centers who have done numerous or hundreds of these type procedures
In the Canadian context, outreach is defined as pediatric surgery service provided outside the main pediatric surgery tertiary center, not necessarily tied to geographic distance
Outreach services were present in only 7 out of 10 provinces and only 8 out of 18 children's hospitals (44%) provided outreach services
A significant number of outreach services are located within 50 kilometers of a children's hospital, leaving vast regions without access
Many families must travel hundreds or even thousands of kilometers for basic procedures
Newfoundland and Labrador has the best outreach setup with only two pediatric surgeons but outreach clinics all over the province, serving as a model
The children's surgery team within the American College of Surgeons started collecting G tube specific variables through NSQIP
The study analyzed 4,612 G tube placements from one year of data in 2023
Upper GI studies were obtained in 45% of first-time G tube cases with interhospital variability from 0 to 99%
14% of G tube cases resulted in an ED visit within 0 to 30 days
5.2% of G tube cases involved dislodgement within 0 to 30 days
Quality improvement interventions include mechanical barriers to dislodgement, education, standardizing care preoperatively/intraoperatively/postoperatively, and ensuring language concordant care
Quality improvement is possible in the G tube space and these variables are good targets because you can actually do something about them