# Update Course 2021: UPDATE COURSE 2020: REVIEW OF LAST YEAR'S IMPORTANT T OPICS — GCMD Library

General surgery residentRodrigo Gerardo, MD reviews the highlights from the 2020 Update Course including MMP7 for diagnosing biliary atresia, complex gastroschisis, and so much more.

Type: video · 23 min · posted 2022-05-19 Canonical: https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405 ## Chapters - [0:00](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=0) Course Introduction and Format - [3:47](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=227) Biliary Atresia Management Review - [7:45](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=465) Blunt Abdominal Trauma Resuscitation and Rectal Prolapse - [10:35](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=635) Gastroschisis Closure and ERAS Introduction - [15:12](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=912) ERAS Implementation Discussion - [21:18](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=1278) Thoracoscopic Hemostasis and Social Determinants ## Statements - "The Update Course has approximately 2000 people signed up" (epidemiological) [0:00](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=0) - "MMP7 could be used to distinguish biliary atresia from other cholestatic diseases" — Rod Gerardo (clinical) [3:47](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=227) - "Intraoperative ICG can be used to determine biliary flow or identify a transaction" — Rod Gerardo (clinical) [3:47](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=227) - "26% of respondents use ICG to visualize the biliary tree, 23% use it in select patients, and 51% do not use it" (epidemiological) [4:45](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=285) - "MMP7 testing is often a send-out test at non-freestanding children's hospitals" — Rod Gerardo (clinical) [5:48](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=348) - "Children with biliary atresia presenting at five weeks have limited time to achieve best outcomes" — Rod Gerardo (clinical) [5:48](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=348) - "For pediatric trauma patients, early blood therapy and massive transfusion protocol are where ATLS and literature are leading" — Rod Gerardo (guideline) [8:30](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=510) - "There is currently no great definition of what constitutes massive transfusion protocol in pediatric patients" — Rod Gerardo (clinical) [8:30](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=510) - "Balanced resuscitation should be initiated when approaching 40 cc per kg blood transfusion" — Rod Gerardo (clinical) [8:30](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=510) - "Hypertonic saline is the most common sclerotherapy choice at 46%, with phenol, ethyl alcohol, and dextrose in water at 10-16% each" — Rod Gerardo (epidemiological) [10:35](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=635) - "Getting phenol into the operating room for sclerotherapy is not always easy due to institutional and pharmacy restrictions" (clinical) [10:50](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=650) - "There are case reports showing mucosal sloughing with phenol use" (clinical) [10:50](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=650) - "Deflux, used by urology for vesicoureteral reflux, has been reported in case reports for rectal prolapse" (clinical) [10:50](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=650) - "3% sotradecol is used as an alternative sclerotherapy agent" — Rod Gerardo (clinical) [11:48](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=708) - "D50 from the code cart is easier to acquire than 3% saline in some operating rooms" — Rod Gerardo (clinical) [11:56](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=716) - "50% of respondents always use sutureless closure for large abdominal wall defects, 39% use it in select patients, and only 11% do not use it" (epidemiological) [12:23](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=743) - "ERAS is a bundle of interventions to help patients get through the hospital faster with less pain and less narcotics" — Rod Gerardo (clinical) [16:14](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=974) - "ERAS includes a carbohydrate drink two hours before surgery, changing from traditional NPO protocols" — Rod Gerardo (clinical) [16:14](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=974) - "ERAS implementation requires anesthesiologist buy-in because it represents a big change from traditional practice" — Rod Gerardo (opinion) [16:42](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=1002) - "ERAS protocols are difficult to implement because they require the whole hospital to adopt a different culture and philosophy" — Rod Gerardo (opinion) [17:55](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=1075) - "Surgical pathways created for ERAS are used more by hospitalists and pediatric residents than any other pathways" — Rod Gerardo (clinical) [19:09](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=1149) - "Surgical pathways have led to decreased cost, antibiotic utilization, and decreased length of stay" — Rod Gerardo (clinical) [19:09](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=1149) - "Starting with one component like decreasing opioid use intraoperatively and perioperatively can be an entry point for larger ERAS implementation" — Rod Gerardo (opinion) [19:42](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=1182) - "For pulmonary vessel bleeding during thoracoscopic lobectomy, energy sources work well as initial hemostasis because it is a low-pressure system" — Rod Gerardo (clinical) [21:18](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=1278) - "Multiple hemostasis options including energy, clips, and sutures should be available for thoracoscopic vessel bleeding" — Rod Gerardo (clinical) [21:38](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=1298) - "Most institutions are either addressing social determinants of health or working on it, with few saying no" (epidemiological) [21:50](https://library.globalcastmd.com/watch/update-course-2021-update-course-2020-review-of-last-year-s-important-t-opics-5405?t=1310) ## Transcript We are, we all live in our own little country and we do our own little thing. And it's only when we talk to each other from all over that we do true learning. And it's still incredible that after all these years, we have so many people, we have 2000 people signed up almost. And it's very exciting. And to answer questions, yes, this is all recorded. And Ellen and Cisco and Rod Gerardo, the fellows at Cincinnati Children's and Akron, they're going to be chopping this up and pushing this out all year round. So you'll be able to see this on social media and the State Current app. To remind everyone what this is about, this is about rapid fire. We're not doing in-depth stuff here. This is rapid fire, important topics that we feel and that a lot, that's why we bring new faculty in every year, that the faculty feel are kind of the real important points that we need to be highlighting all over the world that came up over the last year or so. So we're going to ask a question, see what you do, and then kind of give a new slant on what we think is maybe a new way of doing things in pediatric surgery. But we're wrong half the time. So argue with us. Tell us we don't know what we're talking about. This is interactive. We're not always right. So say, with all due respect, I totally disagree with you. Fine. We love it. Bring it on. We're going to have fully interactive. You're going to, this is, if you want to say something, chat it. Put it, we'll give you poll results. I promise you, I'm making this promise every year, something will glitch. Okay? I've been saying this for nine years. Even a few years ago, the whole power went out in the city and we had to drive to my living room. Something will glitch. Bear with us. We'll communicate with you through email, through chat, whatever we can. Let us know if you're having any difficulties with anything. And we'll try our best to get this fixed. But do not worry. It's all being recorded. In fact, let's make it a point this time to make sure, Garrett, just wanted to highlight, is this being recorded? Want to make sure it's all being recorded. And let's make sure I'll even record this room, just in case. Yes, this is being recorded. Okay, cool. So now, this only, as you know, this is free. This is free because, and we've been trying to keep this free as long as we can. We try to believe that knowledge should be free as long as we can do it, as best we can do it. It's not really free. It's free to us to watch because of the very generous contributions from the sponsoring institutions. And that is Akron Children's Hospital, Children's Mercy of Kansas City, Cincinnati Children's. We've got UCLA. We've got O'Shea Children's Buffalo Children's Hospital. We have APSA sponsoring this and the Journal of Pediatric Surgery. All of these. Did I forget anyone? I think I got everyone there. This would not happen without those hospitals. Every year, they keep contributing to make this happen. So thank you very much. What else can I say? I think we're going to get going. And you're going to meet tons of faculty. You're going to hear us disagreeing a lot. And hopefully, we'll learn a lot today. So Rod Girardos is the first talk. He is in mid-flight because his flight got canceled. So I'm going to try to give Rod's talk. Fortunately, I don't, it's all, you know, mostly Rod's talk. Rod shows. So I don't have to say much. But this is what it's going to be. What we're doing is at the start of every update course, we review what the main points were from last year. So Rod's going to go through. We're going to show you a clip. And then we're going to see if you were here last year, did this change your management? So Garrett, Sam, go ahead and roll the first presentation. Rod Girardos. Hi, I'm Rod Girardos. Research resident at Cincinnati Children's Hospital Medical Center. And last year's update course was awesome. In case you missed it, here's some highlights. We started off strong with a session about biliary atresia. New research suggests that MMP7 could be used to distinguish biliary atresia from other cholestatic diseases. We talked about considering antiretrovirals and steroids in the postoperative period. And then we discussed a revised algorithm for biliary atresia. But one of the most interesting topics is the use of intraoperative ICG to determine biliary flow or identify a transaction. So I got to ask, how many of you out there in the audience utilize intraoperative ICG to visualize the biliary tree? Most people are saying no. Yeah, most people are saying no. So it's changing quite a bit. It's moving a lot. But it looks like 26% say yes, 23% say no, select patients, and 51% say no. That's probably a big jump from last year where it was probably almost nobody. So I think that's great. So, Garrett, go ahead and play the talk. And if you could broadcast the live sound with us, that would be great in this room. If not. And next, we have a second question, and it's already up. People are answering that, too. Whether or not you use MMP7 to differentiate biliary atresia from other pathology. Looks like, again, most people are saying no. So this one was the big one for me. I'm curious what everyone else in the faculty said here. This is what I learned last year, the MMP7. It's not really available, Todd. But after the course last year, I wasn't a speaker, but I actually watched. It was something that we implemented here at the University of Rochester. Unfortunately, as you know, some of these children present at five weeks, and we have a limited time to get the best possible outcomes for them. And for, I believe, many of not freestanding children's hospitals, MMP7 is a send out. And so what happens is, you know, we're using it almost as a study, but I don't wait for it, especially if the child is already quite advanced. And, you know, we want to get biliary, the diagnosis and biliary flow as soon as possible. That's, so is that true without others are finding that it's, it's a send out, it's not going to be sort of there readily available enough for it to make a clinical difference? Okay. Okay. Let's keep going then to the, we'll keep playing the PowerPoint. Then we had APSA jump in with the PDC or Professional Development Committee. They brought up a whole lot of new topics that were popular in the NAT or not a textbook. We talked about everything from CDH to sleep apnea. They covered so many topics. But one of my favorites, I gotta ask you, if you had a blunt abdominal trauma patient who was hypotensive and tachycardic in the trauma bay, injuries listed here, and they already received a 20 cc per kg bolus of crystalloid, what's your next step? So, so we have the next poll question up for everyone. All right. So the poll question here is, so this is a question that really changed my management. The first time I heard about this was really when David Notrica presented this. So you have a 10-year-old hit by a truck. Upon arrival is unconscious. Heart rate's 140. Systolic blood pressure is 80. Closed head injury. Suspected abdominal injury. Pelvic femur fracture. The choices are going to be a second bolus of crystalloid. Transfuse blood, type-specific blood. Initiate massive transfusion protocol. Administer TXA or implement permissive hypotension with a systolic blood pressure of greater than 70. What does everyone here think? Todd, I think we're going to discuss this a little bit later on again. I'm glad this keeps coming up because I think it's an important topic to discuss. And I think you have two potential answers in there discussing, you know, initiation of blood. We want early blood therapy of these patients as well as potential for massive transfusion protocol. And I think currently we don't have a great definition of what an MTP is in pediatric patients. There's still a lot of debate about what constitutes that. I think 40, you know, per kilo blood once we start going there. We need to start doing a balanced resuscitation. So I think those that are starting early blood as well as that massive transfusion protocol and a balanced resuscitation are the ones that are where ATLS and where the literature is leading us to go. All right. So, Rob, you're going to talk to us about that, which is awesome. But let me tell you this. What is the tiny percentages are not that many people want to give a second bolus of fluid, which is good. And the administer TXA was the smallest option and permissive hypotension was also really, really low. So it was about either massive transfusion protocol. And I can't wait to hear now because I'm curious exactly how I know when to do that. So we'll get to that. All right. I'm going to go to the next video here. Then we had a session about colorectal surgery. And we talked about treating predisposing factors medically first. We talked about rectal prolapse, but a controversial topic that we also discussed. I got to ask you, which one of the following is your sclerotherapy of choice? Okay. So here are the choices. We've got ethyl alcohol, phenol, hypertonic saline, dextrose in water, or cow's milk. What would people use? What is their sclerotherapy of choice? Okay. And it looks like hypertonic saline is waiting. Ellen, what are you showing? What are we seeing here? Yeah. Hypertonic saline, 46% are saying that. And then the other options, phenol, ethyl alcohol, or dextrose in water are about 10% to 16%. Okay. I'd just add, you know, fortunately we have a colorectal group, so they see these patients, not me. But I think hypertonic saline is what I have traditionally used. And in some institutions, including ours, getting phenol into the operating room to be able to use that for sclerotherapy is not always an easy thing. So, you know, I don't think that that's always possible just based on restrictions from the institution and the pharmacy. Great point. I think there's also case reports that show mucosal sloughing with phenol. Now, interestingly, there's a couple of case reports that use deflux, which is a compound that is used by our urology colleagues to help with vesicle ureteral reflux. Does anyone in this panel use that at all? Okay. I haven't used that, Marge, but I do use 3% sotradecal is what our pharmacy carries. Okay. And how about D50? Because it's also hypertonic. That's what we use, Marge. The D50 out of, you know, out of the code cart. Right. That's, for us, that's actually easier to acquire than the 3% saline in the operating room. Those two. Okay. So, what we're going to, why don't we keep going and we'll get as many as we can. We only have about eight minutes left, so we'll see as many as we can get to here. Then we had a session about gastroschisis and omphalocele. We talked about complex gastroschisis and how that's like a totally separate thing altogether. We talked about the management for gastroschisis. We talked about different methods of closure, including silo. But I got to ask you, how many of you out there utilize suture-less abdominal closure for large abdominal wall defects? This is the common question. So, suture-less abdominal wall closure. We've hit this topic a bunch. So, choices are, do you utilize suture-less closure for large abdominal wall defects? Yes or no, or only in select patients? I'm going to go ahead and do my answer, which is yes, I do it. And it looks like... You're in the majority. Tell me, Ellen, what are you finding? Yeah, most people are saying yes. Okay. And then the next one is only in select patients. And then you run back to Cincinnati and leave us to take care of it. Yeah, that's all I have to do is get it closed and hand it off. But, you know, would you guys... I think this, maybe not, but over the last nine years, I know we did this early on, almost eight or nine years ago. And the numbers were not this high. I mean, I love how we see changes in practice happening over time. So, it's good that we're reviewing this. 50% of people do it. But I would say that I probably would change my answer to only... How about this? Only 11% don't do it. So, 90% do it always or in select patients. This is clearly a big change in management. And probably this deserves more time for another session. But that's a good review from last year. All right, here we go. Next slide. Another hot topic we talked about was ERAS, or Enhanced Recovery After Surgery. We talked about how to build a team. How multidisciplinary that team could be. We talked about perioperative pain control and how it really takes a village. And then we reviewed some different guidelines. So, I gotta ask. How many of you out there utilize ERAS for your pediatric surgical patients? So, this is the question. Do we use ERAS at your institution? Yes, for several procedures. Yes, but only for a few procedures. No, but in the process of developing it. Or absolutely not. We do not use ERAS. While we're waiting for the polls, let's hear you guys. What do you think? Dan? Yeah, Todd. This is definitely something that is in evolution, I would say, here. Started with our colorectal group pushing this. Now we're actually studying oncology patients and using it for oncology patients. So, I would say our answer is yes in selected cases. But we're trying to do it in a way where we can actually get some data from it and expand the populations. Our urology group uses it very aggressively for their patients. So, it is one of these things where practice has very much changed in our institution. And I think getting patients out of the hospital sooner is a huge advantage as we get pushed for volumes. And it's a lot nicer for the patients to be at home. So, this is one of those great changes in care. Okay. So, that was a perfect, and I bet you that represents most. By the way, everyone, you will see the person who knows the least about most of these things is me. So, do not be shy asking something if you don't know. There was a question asked, what is ERAS? Mark Wilkin, have you ever heard of that term, ERAS? Never heard of it before. Tell us what it is. Enhanced recovery after surgery. For those that don't know, it's actually, it's a bundle. Just like we have central line bundles to prevent infection, this is a bundle to help the patient get through the hospital faster with less pain, less narcotics, up and moving around. And it includes things like a carbohydrate drink two hours before surgery. I mean, that was- Let me stop you. Let me stop you. That's a huge, that's one example of a big change. Because it used to be NPO, NPO, and now you drink two hours before. Drink two hours. That's why it requires the team. You got to have your anesthesiologist on board with that because that's a big change. Yep. Yeah. You know, I'll tell you that, you know, Kurt Heiss started doing this in Atlanta sort of subversively. And then all of a sudden, he showed us our data, much like NUST did. And then we started doing it in many more procedures and implementing it. When I came up here to Akron, I mean, I was just blown away by it. I'd say almost all of our patients that undergo major surgery are having some form of ERS. But that's because it's actually not driven by, it is driven by the surgeons, but it's really driven by anesthesia. And they just totally bought into this. So they are just making sure that we do regional blocks where we can do regional blocks and doing all these. Again, like I said, it's a bundle. It's a whole bunch of different little things that you do that add up to getting the patient out of the hospital faster. Yeah. Great point. Yeah. Go ahead. Can I say that, like, they're really difficult to implement, I must say, because the benefit, it's true, it's out there. But comparing to the previous slide that you showed, I think it's much easier to say, let's do suture-less gastro-schesis. Something that you only do when it's really easy to bring in. But this involves, like, I don't know, the whole hospital to be in a different culture, in a different philosophy. So I found this very difficult to implement. I have an idea. It's a good point, Jose. Here's what I want to do. I want to do an event later in the year, not a course where there's lectures. It's fully interactive where if anyone is interested in starting this at their institution, we get those on here who have done it where we can say, okay, almost like a little full-day thing about how to get your teams to come, your anesthesia, everyone. And we go through the steps and answer questions so we can see that more and more people are starting to do this over time. I think this has been, you know, it's scary to tell your patient to drink when you're not 100% sure that anesthesia is not going to cancel your case. And, Mark, your point was it was no ERAS and then all of a sudden tons of ERAS because two specific people came, anesthesia and head of surgery, head of anesthesia, and that's what it takes. So this was an amazing – yeah, Steve. Can I add, you can start small with surgeons by having pathways, and that standardizes care. And what we've done is created some pathways, and interestingly enough, it's the surgical pathways that our hospitalists and our pediatric residents use more than any other pathways because they like that standardization and communication, and that has led to decreased cost, antibiotic utilization, as well as decrease length of states. Yeah, I would agree with that too, Steve. I think, and to Jose's comment, it is difficult, but if you chip away at these things, right, decreasing opioid intraoperatively and perioperatively is a pathway that you can start as part of a larger ERAS protocol and as part of a larger ERAS system at your hospital. So take one thing and start to work on it and get by-in from your anesthesia, your nursing staff, and everybody around you because that's really what it's going to take. And I think you chip away at these things before you know it, you find that you have a larger ERAS protocol ahead that really is making a difference. This is a great discussion. Clearly, this is something that's a hot topic again. And by the way, you'll notice with the update course, we hit on a lot of the topics every few years, and it's okay. And it's okay that it's discussed more than one time a year at different meetings because we want to hammer these ideas home. Hopefully, you'll learn soon about the PDC and how that's their whole purpose. So we'll get to that. All right, next one. Lastly, we had a lively debate about what to do when complications arise. We talked about all sorts of stuff from how tight to make a curl closure, different techniques for mesh use, challenges with diagnosing lung lesions. But another piece that was kind of interesting, let's say you're doing a loracid case and you see some bleeding from a pulmonary vessel. How do you secure that hemostasis? So you're doing a thoracoscopic lobectomy. You notice a bleeding pulmonary vessel. How do you get hemostasis? Clips, ties, energy, stapler, or a combination of multiple? Mark Wolkin, I'm going to go to you, and then I'm going to go to Mac. I'll start with an energy source. You know, one of the sealing devices I think usually work pretty well. Remember, it's a low-pressure system. And then if you need to, then if that's not working, you can go to a clip, and you can even suture if you have to. All right, Mac? I hate to agree with Mark, but I think I agree completely with this technique. The answer is multiple. You need to have multiple options. But I think the energy sources that we have these days are a good start. All right, so here's what I think. We're over time. I'm going to fly through and see what we got here. I think, I don't know how many more he has, but let's just play the video. One more. Here we go. Then we had a really interesting conversation about social disparities in health care. We talked about racial biases, economic distress, the toxicity of poverty, and hopefully brought awareness to a lot of surgeons who were at the update course last year. So I have to ask, is your institution taking steps to address social determinants of health? All right, so this is a huge topic last year. Did this make a difference? Did other hospitals do this on their own? How much is your institution? And I'm curious how this works. Obviously, this is a very international audience. So the social determinants of health strategy should be the same, but the results may be different. So let's see here. Alan, what are we finding? Yeah, most people are saying either yes or they're working on it. Not many people are saying no, which is good. Okay. That's great. That's really, really a huge step because this was something that just was not discussed enough before, and I'm glad we keep addressing it as many meetings as possible. This was in a great session last year. By the way, you can get all of these sessions on the Stay Current app or the website. Go there and watch any of these sessions in completion at any point in time. --- Not medical advice · citation policy: https://library.globalcastmd.com/ai