Top Ten Things to Remember: Update Course 2017
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.
Podcast
Top Ten Things to Remember from the 2017 Stay Current Annual Update Course...
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Gastric Neurostimulators: Update Course 2017
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Gastroesophageal Reflux: Contemporary Management Pediatric Surgery Update...
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Laxative for Bowel Management: Pediatric Bowel Management 2013
Dr. Todd Ponsky · 26 min · Published May 2013
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Pediatric Surgical Oncology Research Collaborative (PSORC): Studying Rare Pediatric Tumors
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Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
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Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
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Pooling Patients to Study Rare Pediatric Tumors: An Introduction to PSORC
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The fetal frontier: A review of current and emerging fetal therapies for genetic diseases
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Indocyanine green assists with sentinel lymph node mapping in pediatric and adolescent patients
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What the experts said
Gastric stimulation is now being used in children with persistent gastroparesis who do not respond to medical therapy.
Patients can receive a temporary endoscopic gastric stimulating test, and if symptoms improve, they can proceed to permanent laparoscopic or open gastric stimulator placement.
Thoracoscopic sympathectomy extending to the lower stellate ganglion can reduce arrhythmias in patients with CPVT (catecholaminergic polymorphic ventricular tachycardia) and hypertrophic cardiomyopathy who have ICDs.
Partial resection of the stellate ganglion should be performed using clips and scissors; electric cautery should be avoided as it may damage the remaining ganglion and cause Horner's syndrome.
Sympathectomy provides 100% compliance as an intervention because once performed, the effect cannot be reversed or skipped like medication.
Diaphragm pacing is a reasonable option for children with spinal cord injury, transverse myelitis, acute flaccid myelitis, or brain stem tumors, with the youngest implant performed at one year of age.
Diaphragm pacing requires an intact phrenic nerve and phrenic motor neurons; diaphragm contraction with neurostimulation must be verified prior to implantation.
Biologic mesh is not appropriate for bridging gaps in abdominal wall reconstruction; it is only a temporary solution or reinforcement.
The best mesh for abdominal wall reconstruction is macroporous monofilament, lightweight polypropylene synthetic mesh such as Marlex, which performs well even in contaminated fields when placed in the retromuscular space.
Posterior component separation has less wound morbidity than anterior component separation while providing space for wide mesh overlap and minimal fixation.
The current best repair for ventral hernias is retro-rectus repair with mesh, not laparoscopic underlay.
Gastroesophageal disconnection with Roux-en-Y esophagojejunostomy is effective for children with severe reflux who have failed Nissen fundoplication.
Gastroesophageal disconnection may be considered as a primary repair in patients thought to be at high risk for fundoplication failure.
Laparoscopic gastroesophageal disconnection can be a long and difficult operation, taking 6 to 8 hours.
Patients who were taking full feeds by mouth preoperatively can continue to do so after gastroesophageal disconnection.
A five-variable prediction rule can identify children at low risk for intra-abdominal injury after blunt trauma: abdominal pain, physical exam findings, chest X-ray, AST level, and pancreatic enzymes.
Children with only abdominal pain after trauma have approximately 5% risk of abdominal injury and almost 0% chance of needing intervention.
Children with abnormal physical exam findings such as handlebar injury have about 15% chance of abdominal injury.
A low-risk group comprising 55% of trauma patients has less than 5% risk of any injury and less than 0.3% risk of injury requiring acute intervention.
Children with no abdominal wall trauma, tenderness or distention, 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.
In the ATOMAC solid organ injury protocol, injury grade is de-emphasized in favor of clinical predictive factors.
Patients who do not respond to initial 20cc/kg crystalloid bolus should receive 10-20cc/kg blood bolus rather than additional crystalloid.
Patients requiring 40cc/kg total blood transfusion (4 units) likely cannot be managed non-operatively and should go to the operating room.
Stable solid organ injury patients who never required blood transfusion can be discharged the next day.
Chest CT has nearly 100% sensitivity for airway foreign bodies, including radiolucent objects.
Using chest CT to screen for airway foreign bodies can eliminate many unnecessary bronchoscopies in children with unclear history.
Oral contrast is not needed for suspected bowel obstruction; luminal fluid serves as adequate contrast material.
Eliminating oral contrast speeds up CT acquisition time and prevents nausea and vomiting in patients with bowel obstruction.
Repeat attempts at intussusception reduction are worthwhile if there is movement all the way to the ileocecal valve.
Modern pediatric hospital CT scans deliver 1-10 millisieverts of radiation, equivalent to one year of background radiation exposure on Earth.
For pyloric stenosis resuscitation, if chloride is less than 85, give 3 fluid boluses; if less than 97, give 2 boluses; if greater than 97 but bicarbonate less than 33, give 1 bolus.
Pneumomediastinum (traumatic or non-traumatic) requires only chest X-ray for imaging; further imaging is not necessary.
Intravenous glycopyrrolate (Robinol) significantly improves leak closure rates after tracheoesophageal fistula repair: 76% resolution in treatment group versus 29% in placebo group.
Glycopyrrolate reduces chest tube output in TEF leak patients from 370mL (placebo) to 124mL (treatment).
The Gips procedure for pilonidal disease involves coring out pits with trephine, extracting granulation tissue and hair, curettage with smaller trephine, and flushing with saline then hydrogen peroxide, leaving wounds open and unpacked.
The Gips procedure for pilonidal disease is minimally invasive, takes 3-5 minutes, requires no activity restrictions except avoiding swimming for two weeks, and has superior results to traditional approaches.
For thoracoscopic lobectomy, the scope should be positioned anterior to the scapula tip, nearly at the mid-axillary line, directly over the major fissure, not posterior to the scapula.
Placing the thoracoscope posterior to the scapula tip causes the surgeon to look back on themselves when working in the anterior fissure, creating a paradoxical working angle.
When dividing vessels during thoracoscopic lobectomy, use a sealing device (not seal-divider) to seal proximally and distally, make a small nick between seals to verify hemostasis, then complete the division.
Understanding segmental pulmonary anatomy allows prediction of vessel locations and their relationship to bronchi during thoracoscopic lobectomy.
Incomplete fissures during thoracoscopic lobectomy should be approached layer-by-layer with a sealing device until structures are identified.
Contralateral mainstem intubation is the best and easiest technique for single-lung ventilation during thoracoscopic lobectomy.