Top Ten Things to Remember from the 2017 Stay Current Annual Update Course...
hosted by Dr. Todd Ponsky · StayCurrentMD
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
Gastric stimulation for pediatric gastroparesis can be tested temporarily via endoscopic placement before permanent laparoscopic or open implantation
Reynaldo Garcia from Akron Children's Hospital presented gastric stimulation results showing significant symptom improvement in patients with persistent nausea and vomiting unresponsive to medical therapy
Cardiac sympathectomy for CPVT (catecholaminergic polymorphic ventricular tachycardia) and hypertrophic cardiomyopathy involves high thoracoscopic approach to the lower stellate ganglion to prevent fatal arrhythmias
Sophia Abdulhai and John Clark presented cardiac sympathectomy technique using clips and scissors for partial stellate ganglion resection, avoiding electrocautery to prevent Horner's syndrome
Sympathectomy provides 100% compliance for arrhythmia management as patients cannot skip the intervention once performed
Ray Anders from University Hospitals of Cleveland demonstrated diaphragm pacing for spinal cord injury, transverse myelitis, acute flaccid myelitis, and brain stem tumors, with youngest implant at one year of age
Diaphragm pacing requires intact phrenic nerve and motor neurons; diaphragm contraction with neurostimulation must be confirmed before implantation
Dave Carpata from Cleveland Clinic stated biologic mesh is not appropriate for bridging gaps in ventral hernia repair, only for temporary solution or reinforcement
The best mesh for ventral hernia repair is macroporous monofilament lightweight polypropylene synthetic mesh such as Marlex, which performs well in contaminated fields in retromuscular space
Retrorectus repair with mesh is superior to laparoscopic underlay for ventral hernia repair
Posterior component separation has less wound morbidity than anterior component separation while providing space for wide mesh overlap and minimal fixation
David Lanning from Virginia Commonwealth presented gastroesophageal disconnection (esophageal division with Roux-en-Y jejunal interposition) for severe reflux after failed Nissen fundoplication
Gastroesophageal disconnection may be appropriate as primary repair for high-risk patients predicted to fail fundoplication
Laparoscopic gastroesophageal disconnection can take 6 to 8 hours
Patients who took full feeds by mouth preoperatively can continue oral feeding after gastroesophageal disconnection
Chris Druck published a five-variable prediction rule identifying low-risk population for intra-abdominal injury after blunt trauma to guide CT scan decisions
Patients with only abdominal pain after trauma have approximately 5% risk of abdominal injury and nearly 0% chance of requiring intervention
Patients with abnormal physical exam findings such as handlebar injury have approximately 15% chance of abdominal injury
The low-risk group (55% of trauma population) has less than 5% risk of any injury and less than 0.3% risk of injury requiring acute intervention
Patients without abdominal wall trauma, tenderness or distention, with normal chest X-ray, no abdominal pain complaints, normal AST, and normal pancreatic enzymes probably do not need CT scan and can be sent home
The ATOMAC prospective multi-institutional solid organ injury protocol de-emphasizes injury grade in favor of clinical predictive factors
Patients with solid organ injury who do not respond to 20 cc/kg crystalloid bolus should receive 10-20 cc/kg blood bolus rather than second crystalloid bolus
Patients requiring 40 cc/kg blood (4 units) or with hemoglobin less than 7 after blood transfusion should go to the operating room as this indicates non-operative management failure
Stable solid organ injury patients can be admitted to the floor with vitals every 2-4 hours and hemoglobin at 6 hours, and discharged the next day if they never required blood transfusion
Sean Saint Peter's group demonstrated stable solid organ injury patients can be discharged much more quickly than traditional prolonged admissions based on injury grade
Mike Rubin from Akron Children's Hospital recommends chest CT for suspected airway foreign bodies in unclear cases, with nearly 100% sensitivity for detecting radiolucent and radiopaque foreign bodies
CT scan for suspected airway foreign body eliminates unnecessary bronchoscopies in children with respiratory virus symptoms
Oral contrast is unnecessary for suspected bowel obstruction CT scans as intraluminal fluid serves as adequate contrast
Eliminating oral contrast speeds up CT acquisition time and prevents nausea and vomiting in bowel obstruction patients
Unsuccessful intussusception reduction should be reattempted if there is movement to the ileocecal valve, with second attempts mostly successful
Modern pediatric hospital CT scans deliver 1-10 millisieverts of radiation, equivalent to one year of natural background radiation on Earth
Dalton's pyloric stenosis resuscitation protocol: chloride less than 85 requires 3 fluid boluses, chloride less than 97 requires 2 boluses, chloride greater than 97 with bicarbonate less than 33 requires 1 bolus
Richer's paper showed traumatic or non-traumatic pneumomediastinum requires only chest X-ray without further imaging
Vella's randomized trial of 42 patients with post-TEF repair leaks showed glycopyrrolate group had 124 mL chest tube output versus 370 mL in placebo group
Glycopyrrolate achieved leak resolution in 76% of treatment group versus 29% of placebo group after TEF repair
The Gips procedure for pilonidal disease involves trephine excision of pits, mosquito extraction of granulation tissue and hair, curettage with smaller trephine, and irrigation with saline then peroxide
Pilonidal disease Gips procedure takes 3-5 minutes with no packing, no sutures, no drains, and no activity restrictions except avoiding swimming for 2 weeks
Steven Rothenberg recommends thoracoscopic lobectomy scope placement anterior to scapula tip at mid-axillary line, not posterior, to avoid working in paradox during anterior fissure dissection
For thoracoscopic lobectomy vessel division, seal proximally and distally separately, make test incision between seals to confirm hemostasis, then complete division rather than using seal-and-divide device
Understanding segmental pulmonary anatomy allows prediction of vessel relationships to bronchus, such as superior segmental artery location above lower lobe bronchus
Incomplete fissure during thoracoscopic lobectomy should be managed by layer-by-layer sealing like finger fracture technique until structures are identified
Contralateral main stem intubation is the best and easiest technique for single lung ventilation during thoracoscopic lobectomy, superior to double lumen tube, bronchial blocker, or CO2 collapse