And now we're going to go out of order again. So from one virtual faculty to another, I'd like to introduce Dr. Ken Azaro. Dr. Azro is going to also do rapid fire discussions for us, and I think, Kenny, can you hear us OK? Yes, I'm with you. OK, we hear you now. Perfect. Dr. Ken Azaro, it comes to us from Portland, Oregon, and he's going to be talking to us about a few rapid fire topics. Kenny. All right, perfect. Uh now we're at the beginning. Good. Um, before I start on the case, um, let me just give my usual disclosure. Um, as as most of you know, uh, part of my job is to examine for a living. So, um, you know what I'm gonna present to you, you will not see in any other format in a hotel room or anything like that. And um it's really all about Judgment and we're going to try and present a few controversial cases today. I picked these cases because there's really no right or wrong. It really should describe how we've evolved over the years and and some of our rationale for doing things. So having said that, my first topic is going to be malrotation, and as you can see from this slide, probably the most controversial topic in malrotation. Is going to be what to do with uh with heterotaxy syndrome and the the rotational defect that goes along with that. There's really no controversy if someone has a volvulus. I mean you either operate or you get a new job. As far as what to do in this particular situation, uh, I'll be interested to see what all our Viewers would do. So this is a case that presented to us about six months ago. A 6-year-old female with a known history of heteroachy syndrome born outside of this country. You can see that the congenital cardiac history includes single ventricle anatomy, tricuspid atresia. Um, and a variety of other things I won't read to you. Um, she was, uh, our initial operation was at 2 weeks of age. Uh, she essentially, uh, was referred to our cardiac, uh, uh, service for a completion operation. Um, and, uh, upon pre-op evaluation, uh, was noted to be very low on her growth curve, uh, was classified as failure to thrive, uh, upon detailed questioning, really. No history of any bilious vomiting, no blood in the stool, and no significant abdominal pain per se, just some intermittent spitting up over the years and failure to thrive. So an upper GI was obtained given this history, and what you can see here is the stomach is on the wrong side and you get an impression that the duodenum and does not make a C loop and So we've got the sitis in versus and a suspicion of malrotation. Uh, they followed this through with the small bowel follow through, and, and this is pretty interesting. Um, so you can see everything is reversed. It's a, uh, it's a situ in versus uh uh in the abdomen. You can see the cecum is in the right lower quadrant, appendix is down there, uh, and the duodenum makes a straight shot down the left side with all the small bowel on the left side. So at this point in time, you're really stuck with um. You know, what are you going to do if you go in and do an operation in the past, most people would just wind up doing an appendectomy and that's it, because you really cannot widen the root of the mesentery any further than this. So I'd be to know what people would do at this point. Yes, let's go ahead, Mark. Does the child have right atrial isomerism or left atrial isomerism? Right. So in right atrial isomerism, at least in our data, it suggested that there's a higher incidence of malrotation. Going, you know, the other thing to weigh with this, this kid's gone 6 years without a problem. So I think there are some people that would just watch this. On the other hand, if she has any GI symptoms at all, you can always put a laparoscope in and assess how wide the mesentery is. And if it's a wide broad based mesentery, I don't think you can tell from this study, even if the cecum is on one side and the ligament trites is on the other. I think it can be very deceptive with everything floating around in there, but just look and see if it's a narrow base necessary because he's symptomatic now, because he's vomiting. If if there's a symptom, but I'll tell you, so in our, in our institution, based on our data, based on our paper, if there is a child with Right atrial isomerism. We will put a scope in and and look and see because those were the kids that got volvulus. Volvulus, we had only one patient that had any real issues that had left atrial isomerism and it wasn't a true volvulus. But I think you're also dealing with the problem that that may be confused by the cardiac issues, but the child is small and is not apparently not thriving. And I think you have to be able to sort out that there's not a component of some element of the lads' bands causing this as well, and I think that I would put a scope in for no other reason than to, you know, divide in the lad's bands. If anything could be causing that type of issue, take out the appendix. I think you have to do that when the child has some symptoms related to the GI tract, and those, to my mind, include failure to thrive. I agree. All right. So very, very interesting, um, all your opinions are of course correct because there are no right or wrong answers here. Um, there's been a lot of literature written over the past few years and I just thought that I would, uh, uh, put up, uh, the hottest one off the press, soon to be published. So Texas Children's, um, presented this at the CAPS meeting about 3 weeks ago. So 95 consecutive patients with heterotaxy malrotation, three quarters of them underwent a labs procedure, and long term follow-up revealed none of them volvulized post-op, but they had 11% small bowel obstruction rate requiring admission and in many cases surgery. 25% of that group got observed with no small bowel obstruction and no volvulus to date, and they're granted. They didn't follow these patients for 80 or 90 years, but we're talking about 10 or 15 year follow-up in many cases. So it's just interesting to note what people are doing out there. I don't think there's a right or wrong thing. Um, I think you do have to be sure of your assessment and and putting in a scope is, is what I have done in the past. I'm not sure if that's the right or wrong thing. I'll be interested to those of you who put in a scope, do you take the appendix out at that time? I do. So you know we all know that an appendectomy is not without its obstruction rate in the long term from adhesions. So it's just important to note that you are buying a slight complication with that. I don't take out the appendix. The appendix is in the correct location. If it wasn't the correct, if it's not in the correct location, I think it's Ken's part. The appendix is in the correct location and he's malrotated, so it's a double negative. So his appendix is in the correct location. So, Kenny, that secum is going to be floppy for this, for this, and I do an inversion appendectomy. OK, so Kenny, for the sake of time, because we wanted these rapid fires to be 5 minutes each. The high yield point for this is heterotax. What I think you're saying, I mean, situs inversus, basically if they're asymptomatic. It sounds like most people here would not do anything if they're symptomatic, put in a laparoscope. You only do that if they're right. Well, I would rephrase, Todd, let me just rephrase. I mean, if they're symptomatic, I don't think anybody would just observe and do nothing. And I mean by symptoms they're having significant pain, vomiting, maybe bilious, bloody stools. I mean that you have to operate on. We're talking about the patient with minimal symptoms, reflux, little spitting up, little reflux, failure to thrive, which is the most common patient we see with this actually, right? OK. All right, ready to move on. Next, next one. We're going to talk about one specific situation with Maconi Emilius. Kenny, I want to stop you. Sorry, before we go off Malro, before we go off Malro, rapid fire. You have a kid that you're working up for malrotation. They have a C loop that crosses midline, not heterotaxy, normal kid. They have a C loop that crosses midline, but it's a low lying ligament of trites. What do you do? I usually put a scope in and take a look. You put in a scope. What do you do? Scope, scope, scope, scope. I don't do anything, and now I'm going back and forth because we had a big discussion. I may start scoping again, but I did all my scopes have all been negative. Just keep in mind one thing on that case you just presented. Yes, it's the low lying ligamented traits that defines malrotation, not something crossing the midline, because something can be floppy when it crosses the midline, and that does not exclude a malrotation. How many patients have you seen that have had a great that crosses midline. I know everyone here is going to say they've seen one that crossed midline and had a low lying liga image rights and you went in and they were malrotated too. So I know Tony's, I know Tony's in your audience there in fellowship we saw half a dozen of those, so I've probably seen another 3 or 4 since then. Wow, I've always seen that. OK. Anyone do anything different than, so everyone would everyone here put in a scope. I wouldn't scope him. OK, I just watch. OK, we would just watch. Dan, you would watch. OK, so we're split here. So we had a baby a few years ago who had a low lying ligament trite. It didn't look like anything. We watched and the baby came back with a volvulus. We were trying to do a combined study. We wanted to do a multi-center. We talked to Sean about your, we know there was actually 22, yeah, so, um, but, so I may be convinced now. All right, sorry, go ahead, Ken. No problem. Let's, we'll move on to the next one. Yes. Again, I think you're probably going to be split with this one as well in the long run, but so we we have a newborn male, failure to pass meconium. Billy is vomiting. X-ray shows multiple dilated loops loops of bowel. So the the neonatologist instantly and correctly got a got a limited upper GI which showed normal rotation, followed that with a BE. Which showed a microcolon and small filling defects and a failure to get into the dilated bowel. Here's I'll show you what the what the gastrographic enema actually looks like. So you can see the residual contrast from the limited upper GI and you can see the The filling defects all along very consistent with Maconi Emilius. There there's a follow-up one. So this study is, I will tell you the rest of the history of this study was done about 2 o'clock in the morning by not a pediatric radiologist. However, some who does take take call in our hospital. And now the question is, what, what to do in the morning. You still got a baby with Billy's material coming out of an NG tube, very distended, and we've not fixed the situation. So at this point in time, who would, who would go to the operating room? And who would go back to radiology, I will tell you, other than the distention and the bilious material coming out of the NG tube, the baby is otherwise stable and doing fine. All right, let's start at this table over here. Witt, go first. What would you do? I'd just like to ask Ken a question because we no longer use gastrographic and so. I just wanted to make sure that this was a gastrograph and enema and are they still using it in Portland because our radiologists will not use gastrographic. What do you use? So it depends. It depends upon who's doing the study. Our pediatric radiologists will not use gastrographing. However, it's used occasionally. That's the best way to put it. Omnic or what is it that you? Yes, we use an isotonic, right, which defeats the purpose of the enema, at least in my opinion. Um, Right, it's not therapeutic, I see. So that's a great question. So should we for the for these distal things be using gastrographic, right? But it's a radio, at least in our hospital, it's a radiologists call and they worry about the hypertonicity of the gastrograph and, so they don't use it anymore. But that treats most of the cause of agreed. I mean, it used to be a great, you know, back in the day, a great. The great contrast medium to use. That's the reason we gave IV fluids ahead of time, right? Interesting, uh, David, how about acetylcysteine enema dilute that down and try to get a tube in as far as you can before you start injecting. So you do an enema, an acetocystine enema. Well, let me say this, I, I, I, well, you can do both. I think it would start from below. It's had to rally the neonatologists into because a lot of them are very hesitant. There's some reports of Nick. OK, Dan, pretty similar. We would, I would restudy. We have used cys. We've used an acetylcysteine from above and below, and we mix it in with our hypertonic hyper osmolar contrast to be very aggressive. Wow. And you stay on top of the baby. I, I'm down there with the baby in radiology doing this fluoroscopic study and making sure. Let me back you up though hydrated. All you have is a baby that has distention and a distal obstruction. You don't know what it is. So do you use, do you use, what do you do? Make your diagnostic. Your initial study. Initial study is gastrographin, gastrographin, or a similar hypertonic, hypertonic solution. My preference is gastrographin, and I would resttudy the kid. Yeah, same thing, I'd gastrographin and reststudy the kid. Would anyone operate? When everyone rest-study in this room. OK, everyone's gonna reststudy. All right, perfect. So now you go back, you're there. The pediatric radiologist who you think is the best one is there. You get down to the cecum, you get a little bit of reflux into the TI, but you don't get into the dilated loops. Child is still doing fine. Now what do you do? Had you started giving any an acetylcysteine from above? Not yet. That's what you would do, OK. Would anyone do anything different than I would go again, by the way, I would go another enema, 3rd enema, and go from above. Would anyone do something different? How about we'll do it this way? OK, go ahead. All right, so you guys are you guys are right on. I thought that'd be a little more controversial, but uh the point that that um if you look at the most Current literature last 5 years say our overall success rate is going, going down on first attempts, and this is kind of a reminder of what we've done in the past to achieve the success rate above 60%, almost 2/3, almost three quarters, you need to do multiple. enemas to achieve that success rate and I just pulled one study and really 63% of successful enemas require more than one attempt in radiology. So it's partially due to the experience of the radiologists, whether or not the surgeon attends it, but the bottom line is that you need to do multiple enemas in order to. Achieve your success rate. Now, I will tell you, if you think you've done a really good enema and pushed as hard as you can push from below, it's not wrong to put a scope in or operate. I mean, that part is never wrong, because certainly a perforation in this setting complicates things tremendously. But we, we all expect to have a success rate of this of simple meconium ileus. Certainly greater than 60% and pushing three quarters and in order to do that you need to do a multiple enemies and you obviously have a very senior panel right there Todd, but most people forget that and a lot of folks just called this old the contrast medium that was evaluated. OK, so contrast medium evaluated was changing, and they do talk about going because as you pointed out, many people are going to IOU using using an isotonic material, and it does point out going to a hypertonic solution in gastrograph and on 2nd or 3rd attempts has been a contrast of choice. OK. Any other questions? So Kenny, I know you don't know much about trauma, but uh why don't you talk to us about solid organ injuries. Well, it's good you have Wit there because I'm gonna be quoting Witt's Witt's institution quite a, quite a bit on this. So, um, so here we go, and this actually is a case of mine that came in about 4 months ago. Uh, the 15-year-old uh involved in a collision with a teammate during a baseball game. Uh, I think he was a second baseman, fly ball in between, right fielder coming in. And not only did they collide, but the right fielder landed on top of the second baseman, kind of knee to left upper quadrant, comes in, and I'll show you guys a CT scan in a second. It was read as a grade 5 injury with a blush, and the vital signs as they were read to me over the phone was 125/80. Well, you can read them there. Pulse of only 85, which was amazing to me. But this, this is the CT scan. And you can see it's a complete crush injury of the spleen involving down to the hilum. And uh the blush, while not overly impressive, you know, I put an arrow in there and this was read as a as a definite blush by the radiologist. You can also see there's blood around the liver. So so there's blood in the abdomen as well. So, the phone call I got was um Doctor Azov, we're on our way to the angio suite. OK, that was the phone call I got in the middle of the night. So My question to the panel is, What would you guys do? How many of you would meet the patient in the angio suite, stop that, do something else? Where would you go at this point in time? I'd say turn around. Treat the patient, not the, not the blush. I'm going to the angio suite to block the door. to the ICU. So you guys are right on target. That's exactly what I did. I actually went in the hospital and essentially grabbed the stretcher and got them en route and rerouted them. And so really there are a couple couple of papers you notice the 4th 1 down is from Wits Institution. Um, the, the one that I, I really like the title of the best is the top one by McVeigh. Basically throwing out the grade book in the management of isolated spleen and liver injuries. So, what we're really doing now is we're we're looking at the patients and we're, we're looking at the hemodynamics and we're treating based on hemodynamics. And the offshot of that is we are actually able to get these patients in and out of the hospital much quicker than we used to. Um, because you know we were all raised watching these patients, you know, several days in in. ICU several days in bed, several weeks at home, and you, you have children with just isolated spleen injuries, and it's all you can do and you, you tell them not to do anything. And, and the parents called you up saying these kids are driving them crazy. And so, really managing based on hemodynamics is the current trend across the country. Exactly how we do that is different in almost every institution. So what I'm going to show you is our is our current protocol. We just had our fellows draw this up this year and this is again for hemodynamically stable patients. So these are ones with no blood pressure changes and You can argue whether the tachycardia that we're going to discuss makes them hemodynamically unstable or not, but for the most part, normal blood pressure, normal respiratory rate, not, not an extremist at all. And then while we're trying to get away from looking at the CT scan, it does tell you how badly injured things are, and then you can just Follow it down. The hard part is determining whether your tachycardia is due to pain, uh, whether it's due to an overlying broken rib, or whether it's just due to blood in the abdomen and the splenic injury. So you really have to do give a little bit of pain control in order to make this work. And then if you have a tachycardia due to a low hematocrit. You know, that's a patient who's in the ICU that you're going to potentially need to transfuse, maybe not depending upon how low, but for the ones with normal vital signs and not tachycardic, we get them up to the ward fairly quickly, and for the ones that are not injured that severely, they are literally out of our hospital in 20 in less than 24 hours. For the ones like this particular child. This child was discharged within 48 hours from the hospital and given that degree of injury, that's something that never would have happened even last year at our place without an algorithm like this. Now the other caveat is we take patients from all over the state and we would not send somebody across the state with this. These are for folks who are who are local in the community. You know, parents are now, you know, educated by us and can get back fairly quickly if they need to, but you know you can follow this down and we get them up, we get them eating, and we get them home. Let me stop you, Ken. Let me go through here and see. We do the same protocol early discharge. Does anyone here still follow Stilanos' recommendations? I think we've tightened it up, but you still keep them long. Oh, you've shortened it, but not quite this short, right. Anyone here have a difference of opinion? Is there anyone here that's opposed to this early discharge protocol? a football injury in New Jersey and then the report was a splenic injury. Obviously we have no idea. So on the one hand, yes, it makes sense and I know our trauma team is very aggressive about moving patients through, but on the other side. You know, there is a consequence to these injuries. OK, Ken. So the question is, is, you know, I think most places around the country have aggressive discharge protocols, but the question I have for the panel and for the audience is is then what? So once they're home, how long do you keep them out of school? How long? Or they can go back to, you know, full activities. I think the literature is fairly clear. They don't need to be imaged any further, but I think we all do different things as to what you do when you send them home. So I'd be interested to hear what folks' opinions are with that. Um, I do for that part. I still follow the old rules because unlike the fact that we keep, I mean, I don't give any restrictions after surgery. I tell people that if it hurts, don't do it, they can do anything, but for this, I give restrictions because I've seen rebleeds. Uh, so I do, I think it's 2 plus the grade, grade plus 2, yeah, so I still do that. Does anyone have a longer or shorter time frame? No, it looks like we're all in agreement there on that, Ken. So, so my guess is, is what's going to happen in the future is the reason why we're all in agreement is because we really haven't started looking closely at what we do when we send them home. I think once this gets to be common practice with the early discharge, my guess is we're going to be looking more aggressively at getting folks back to at least doing maybe not playing contact football or wrestling practice, but at least getting them back to Some semblance of normal activity, um, because if this is like any other injury, you know, once you have a stable clot for about 3 weeks. That's probably more stable than the remaining spleen. So we'll, you know, we'll have to see what happens long term, but I think that's where we're moving in the future. This is just very interesting. This is one of those things that, as you all know, this has changed several times within our careers, and I think it's going to continue to change in the next, uh, in the next 10 years. So this was great, and I'll tell you, I think that today I'm getting kind of excited here because I think that each time we do one of these, there's like. Even each year, it's amazing to me how there's new trends that are coming out, and this is one that I'm glad you brought to the attention of everyone watching. This is definitely a new trend that is, is really taking, taking over everywhere, I think. What else you got? Is that it? That's it. That's all I got for you today, Todd. Ken, thank you, wish, wish you were here, but we'll take you virtually. Thank you for spending the time. If you can, as much as you could stay online and participate in the rest of the discussion, we'd love to have you, but if you've got to go, we understand, and we'll, we'll talk to you another time. All right, thanks for inviting me. Have a great day, everyone. You too. Thank you. All right, so can I ask you a question. Uh, Ken said, and we all know that there's good literature that says that these patients do not need to be reimaged after their solid organ injury. What do you all do if, if, for example, a child is reimaged and it's found to have a pseudoaneurysm? don't know. Pseudoaneurysm in the vessel. Yes, you could, I mean, if it's a big pseudoaneurysm you probably coil it, I guess pseudoaneurysms in this day and age, the interventional radiologists vascular. Interventional radiologists, vascular surgeons have a lot more alternatives. We have had to deal with some of these in some of our kids with massive spleens where they have aneurysmal weaknesses, and you can stent them, you can coil them. You can also, and so on occasion though, you still have to deal with it because if they start to grow, you're in a position you're going to have to deal with it. Would you ever consider just If it's small, following it and yeah, absolutely, absolutely start with following, but if they get bigger, and again, I don't know what the number is, clearly in adults, you know, 2 centimeters for a mesenteric vessel is the cutoff at which everybody's going to get nervous, but how does that factor in a 10-year-old or a 12-year-old? And we've had some of those kids, right. Agains to childbearing women, I mean, I think that may be a small subset of patients and many do have very, very active follow-up if you're not going to court, right? It's just interesting that we don't really know the denominator of how many of these kids do have pseudoaneurysms because they're not getting imaged. Well, a lot of them don't have hilar vessel injuries either, right? I mean you can see that on their initial scans.
