I hope you're enjoying everything so far. We're going to move on to our next session, which is the APSA PDC, and I will let them explain what that is. And with us, we have four presenters. You only see three, but you're about to see four. We have Craig Lillehei. We have Paul Yejjorczyk, and we have Chuck Snyder, and we have Dr. Mary Edwards, who's coming in virtually. So Craig, take it away. Thank you, Todd. One of our challenges at the PDC each year is to identify those knowledge or practice gaps that our specialty we have. I must say, it's difficult to narrow those down, and in order to do that, we really need input from all of the APSA communities. But what you're going to see here today is a slice of some of those 10 topics that we thought as pediatric surgeons we need to address. Clicker here. Oh, clicker. Do you have it? My name is Craig Lillehei. I'm from Boston Children's Hospital. I've got two of the topics that I'm going to represent today. The first is implicit or explicit bias. If anything, these last two years, we've all struggled and challenged to try to understand our own explicit and implicit biases. I actually grew up in Minnesota, so George Floyd hit home to what I thought was a very liberal community. That's a leadership that's challenged us as an institution, but specifically as pediatric surgeons to address some of that. So let me jump to the first question. Let me jump to the first question. Here it is. Pediatric surgeon's internal. Leads her team to a patient room on Rappos. She identifies as black and is the only person of color on the team. She begins to introduce herself, but is interrupted by a white parent who says, finally, someone has come to take away the meal tray. The white pediatric surgery attending looks uncomfortable, opens his mouth as if to say something, and then closes it again. As a pediatric surgeon with a duty of compassionate care to patients and a mentor committed to diversity, inclusion, and protection of trainees, the pediatric surgeon should. The answers are before you. What do we do in that circumstance? Say nothing to avoid damaging the therapeutic relationship with the parent. Say nothing in the moment, but speak to the intern later to stress that what the parent said was wrong. Speak up, correcting the parent's mistake and encouraging to avoid role assumptions. Or D, speak up, using humor to diffuse the uncomfortable situation. What would you do? Comments? The poles? The poles? I'd like to hear that. And yet in the same breath, I wonder how often we're exposed to that and we come up with any number of excuses. Well, it's a very stressful situation. Or I don't want to undermine that relationship with the parent. Or I'll talk to them later and sort of set this right. Well, speak up and use the opportunity to correct the patient's mistake. Here what we said to describe in our discussion of this is that surgical intern has been victimized by racialized stereotype that could be characterized as microaggression. Now, microaggression, verbal, nonverbal, environmental slights, snubs, invalidations, or insults that send hostile, derogatory, or negative messages to individuals based solely on their marginalized group membership. Now, the next paragraph I think is particularly important. Micro. It's anything but micro. So, these sort of, they're referred to as small, repeatedly, that the individuals are repeatedly experiencing them, but they have a cumulative impact. Isolation. Self-doubt. That's the kind of behavior that we've got to turn around. And by not speaking up, the bystander is compounding that harm, even if later on you come. So, what's the personal practice change? Well, what we're asking is that for us to be upstanders, bystanders who respond with action to these microaggressive behaviors. That's the only way we're going to change it professionally for our hospitals, for our institutions, for our patients. I'm delighted that in the audience, one of the references that we alluded to was Mira's report. It was for pediatrics, I believe, their ethics rounds. But it really honed in on what a problem microaggression is. You know, I think that we talk about explicit bias. We talk about implicit bias. And then we hone it down and say, oh, boy, these microaggressions are happening. Mira, comments? Comments? I think one of the things that makes people uncomfortable in those moments about being an upstander is exactly what you're talking about. How do I not alienate the family, right? How do I not create differences or make, and particularly thinking about that intern and how you not avoid making that intern uncomfortable, too. And I think one of the biggest things to think about in those moments is intent versus impact. So, very often families, what they're doing, those implicit biases are not intentional, right? They don't necessarily recognize that that's what they're doing in that moment. And if we separate intent from impact, it's easier to respond to understanding the impact and talking about what the impact is and not worrying so much about what the intent is. Because the intent is sort of irrelevant. The impact already exists. And so I think that helps alleviate us from that anxiety about how the family, you approach it as like, hey, you maybe didn't intend this. But let me help you understand how that impacted the person who was standing there. Well, thank you, Mira. And I hope that that insight about intent will get rid of all those excuses that sort of come to mind in my own. I'm going to make a comment. Please. Take the mic. Hold it right up to your mouth. All right. All right. Let's move on to the next question. Here, you're seeing a mother carrying a fetus diagnosed with left-sided CDH, congenital diaphragmatic hernia. You knew we were going to get to that topic. The ODE observed the expected LHR using a tracing measure at 24 weeks is 28%. Follow-up measurement at 26 weeks is 32%. The parents conceived this baby after significant difficulty and are asking about the outcomes of fetal tracheal occlusion or fetotherapy for their baby. I get a lot of that. Okay. Okay, everybody refresh. All right. Keep going. Everything? Yes. Okay, good. Keep going. Great resources. I must say I was a little worried when Jose was going through the articles. I thought he was going to pull mine. I'm sorry. Okay. Let's come to the poll. There's a... Do we have the results of the poll? Okay. Now, I heard in the background here that there are two right answers. Give me the two right answers. Do we have the results of the poll? Embellish on that, Rick? Well, I mean, you could argue that some folks might opt for B. I would go for D. But there are people that I think would opt for B. I would agree with that. I think that there is data to suggest that fetal is an effective procedure in a very select population of patients. Thank you. I think that's sort of where we are right now. Now, this slide, I've tried to put all the results of the total trial. 2021 lead articles in the New England Journal of Medicine. The first and second article. The first was severe CDH. The second article was moderate CDH. And interestingly, they came to somewhat different conclusions. In the severe group, okay, that fetal was, in fact, significantly improved survival. In the moderate group, moderate CDH, what happened was, yes, there was some improvement in survival, but it didn't approach significance. So that's where some of the debate comes. Now, some of those online might be able to have read that slide, but thanks to the Educations Committee, Practicing Surgeons Subcommittee, I've got a visual abstract that I stole from them to really describe things for you, but tells us a little about the FETO trial, the total trial. And in the moderate group, their conclusion was that FETO was not yet beneficial, and in the severe CDH, it was. I will tell you that there was some editorial response from none other than Charlie Stoller and some others commenting that, please understand that this was in the setting, well, there's a few problems with this. Number one, it was a study that was done over an 11-year period where these patients were accumulated. Number two, it was at a lot of different centers. Some, you know, there was a protocol for how you manage a CDH, but it varied considerably from place to place, undoubtedly. And lastly, if you're going to apply this, maybe these were very experienced FETO centers. So I think the answer for us as pediatric surgeons right now is FETO is certainly an emergent therapy, which is very appealing, particularly in our most severe CDH, but it's got some problems. Prematurity is a big one. Premature rupture of membranes. What's the price of that that these kids pay for later on down the line? And that's still something that needs to be worked out. Comments, please. You have to really know your own center's numbers, especially for the moderate. Like for the severe, it's impressive. And for those of us who have seen babies who have had a FETO, it's a different scenario. Even when they're born prematurely, they often don't go on ECMO, which is just, it's crazy. But for the moderate, I think you have to know your numbers. And if your center's survival is better than, you know, what they're producing in this trial, then maybe you don't need to do FETO for those moderate babies. I think it's just, it's highly variable. You know, I think it's a theme that we've been hearing a lot already today is that keep your eyes wide open. It often isn't just a binary, I think was your word, Sean, a binary answer to some of these questions. Okay, with that, let's move on, cognizant of the time. Our next speaker is actually going to come to you virtually, Mary Edwards. And Mary, I think you're going to magically appear, and I'll show your slides. Can everyone hear me? Hello? Can anyone hear me? Yes. We can hear you. Okay. Hi, everyone. Well, or hello from upstate New York. I'm so sorry I can't be there in person. Can everyone see my slides? Okay. So just, just FYI, I'm having a really hard time hearing the discussion in the room, Todd, but I can hear you perfectly. So if someone has a question or wants to stop, just use them to me and I'll... We're working on... Okay. All right. So what I'm going to talk about briefly is intraoperative radiation safety and pre-op fasting. So we will jump right in with the first question. And so you are called at midnight from a community hospital with a level two NICU regarding your patient, who is a 28-week preemie, who is scheduled for a hernia repair at seven in the morning. He's otherwise well, and he's actually ready to go home. But the NICU has attempted to get an IV in him 10 times without success, and they've had it, and the kid has had it, and they call you, and they want to know what you want to do. So do you tell them, put an IO line in and give them maintenance fluids and make them NPO? Do you just tell them to allow them to continue to feed and just postpone the procedure, send them home, I'll deal with them in the office later on? Or do you allow feeds of Pedialyte until 5 or 6 in the morning and just tell them to stop with the IV attempts? Or D, do you transfer them to another hospital? So I... Thank you for the poll to come up. Any comments? No one? Mark? Mark Wilkong. You might say you should transfer that patient. But, you know, again, I think that the evidence, I know our anesthesiologists allow Pedialyte up to even an hour or two hours before the procedure, so there's no reason you can't continue with oral hydration with a baby like this prior to surgery. All right, what do the polls say, Owen? Most people are saying C, to allow feeds until 5 or 6 a.m. and then stop the IV attempts. Okay, Mary. Gosh, smart group. So yes, that is the correct answer. So, you know, this subject is, it's evolving. And if I'm right, Todd, we have a huge international audience here today, right? Correct. Mostly international. So it is amazing to me how variable practices are around the world. But I can briefly say, you know, NPO guidelines for children are in general based on very poor evidence. And if you do even a Google search, you'll find that from institution to institution, they vary a lot. The problem is, is that pulmonary aspiration is very scary, but it's also very rare. And it usually happens in emergency surgeries in children that are at high risk for aspiration. It just is very rare in elective procedures. So, and the other thing is studies suggest that clear liquids containing carbohydrates empty the stomach very quickly. And that really doesn't vary based on age. One of the more recent consensus statements came out of Britain and Ireland. And in their consensus statement, they essentially recommend one hour of NPO to clear liquids, four hours for breast milk, and six hours for solid foods in children under 17. And the United States, actually, the ASA, the American Society of Anesthesiologists is updating their policy or their consensus statement on NPO guidelines. And it is open for public comment, if any of you want to comment. But currently, what they recommend is two hours for clear liquids, four hours for breast milk, six hours for non-human milk and light meals, and eight hours for a heavy meal. The European Society of Anesthesia and Intensive Care actually is much more liberal. And what they recommend is one hour for clear liquids, three hours for breast milk, four hours for formula, and six hours for everything else. And our Australian and New Zealand colleagues, if they're on the line, they concur with those recommendations. The pediatric anesthesia societies in Britain, Ireland, and Canada go along with the ASA guidelines, except they essentially say one hour for clear liquids. So things are moving in the direction of being more liberal. But I can tell you one thing about all these consensus statements is that there's now language in there that essentially says you need to make every effort not to keep these children NPO for long periods of time prior to surgery. It's bad. It generates ketone bodies, causes hypoglycemia. It makes them just very irritable in the pre-op sort of area. Any questions or discussion on that? Comments on that? It's interesting. I mean, it's kind of aggravating that everyone does it different because it's confusing. But on the other hand, now maybe we can look at the differences and study that and see who does it better. All right. Let's keep going. Okay. We can probably move right along here. Okay. Okay. So now you're in the operating room. You're putting in a metaport in a one-year-old for chemotherapy. You get the port in. Everything goes well. You take out the introducer sheet, though. And the tip of the catheter is in the cardiac silhouette. And you just are having a really hard time seeing exactly where it is. So you've got the C-arm there. And the question is, to aid visualization while minimizing radiation to the patient and the staff in the room, you should, A, utilize the magnification setting on the C-arm, B, utilize continuous fluoroscopy to determine the position of the tip, C, reposition the patient closer to the x-ray source, or D, collimate the beam. And the C-arac, I do. E. Inject dye. E. There's a national shortage of ice of you. You can't use it. It's actually a true statement, but... E. Okay. Well, it was funny anyways. Okay. Let's see the poll results. What is it, Ellen? E. Majority are saying D, collimate the beam. E. All right. E. And that would be correct. So, minimizing exposure of children to ionizing radiation should be standard, but you have to get an adequate image. You want to minimize exposure not only to the patients, but also to yourself and the OR team. So, utilizing as low as reasonably achievable or ALARA best practice guidelines for fluoroscopy, which at least in the United States is not routinely taught to surgeons, includes positioning the patient as close as possible to the image intensifier or the flat plate detector, which usually means in the standard configuration of the C-arm, raising the bed as far as possible close to that eye eye. You obviously want to shield appropriately. You want to use pulse mode as opposed to continuous, which is actually very feasible in most of the applications in pediatric surgery, including the one described in this scenario. You just don't need the temporal resolution of continuous fluoroscopy. You just don't need the pulse should be fine. Collimation is key. And you want to avoid use of mag, if at all possible. Every time you hit the mag setting on the fluoromachine, it significantly increases the radiation dose, not only to the patient, but also to the room. What collimation does is it focuses the x-ray beam to a specific area. And because you're getting more radiation to that specific area, it tends to increase the detail and the clarity of the image. But because it limits the field, it decreases the total dose of the patient because the surface area getting irradiated is smaller. And it also decreases the dose to the room. So just by way of, I guess, demonstrating this. So these are two esophagrams that I did. And hopefully you can appreciate that the one where collimation was used, it's just much more clear. You can kind of see the mucosal detail of the esophagus better. And this is really entirely a function of collimation. It's very easy to do in modern machines that tech can sort of, you know, give you a little preview of what you'll see with collimation. I will say that you have to be careful when you collimate in a very small patient, because you can overexpose the image. So you don't want to get too carried away with it. But in general, collimation will allow you to see more detail with less radiation. A overview room, a view of the room for one second or is that going to complicate things? A wide shot of the room. So I want to ask, raise your hands if you knew all this. Raise your hand. You can be honest. It's not arrogant. Cocky. Okay, fine. All right. So it looks like half the room. For me, there were two modes of fluoroscopy, on or off. I didn't know all these other things. So, Mary, do we just tell, or if we're doing it ourselves, do we tell the technician, can you help me collimate? Is that, I mean, how do you, Chuck, you do it? So, I only know my own experience. I've done, you know, I've worked in like three different hospital systems in my career, but I just tell the tech, collimate down on the media steinum. And they have a little preview button. And so whatever the last image is up there, they'll sort of, they have a little frame that'll kind of zoom down. And you know that's where they're going to focus on. And then you get another image there. But you just tell the tech to do it. And they can collimate down in a uniform circle. They can collimate down in a stripe, like, which is what they did here. But you just tell them to do it. And it's the same with pulse mode. I just tell them, go to pulse mode, four frames a second, two frames a second. And they know how to do it. But they know way more about fluoroscopy than we do, obviously. But, yeah, it's really pretty simple. Oh, I'm just curious. The people here from Kansas City know we have a person named Nuclear Nancy. I don't really know what her full name is. But she makes us take a little quiz every year on radiation safety. And I wonder how many people have to do that to be able to use fluoroscopy at their institution. Raise your hand. Who does that? I do it, guys. Okay. So, Todd, why don't you radiology? Particularly if you're having trouble visualizing the image. I mean, shouldn't that be? Isn't that their area of expertise? That's a great question. Right. But it should be. Maybe that's what we work on is having better communication and proactive suggestions by the technicians. Yeah, Jose. I mean, like the esophagogram you showed was, was it done with a C-arm? Or was it done in a full fluoroscopy suit? Because I've seen collimation in the big room with everything. But I'm not sure about being able to use collimation with the C-arm? Everyone's nodding their head. You can. Okay. You can. Okay. All right. Mary, I don't know if you were able to hear that or not. But, okay. Okay. I think we'll move on. Just the summary points there were collimate, pulse, shield. And there was one more I forgot. But it's. No mag. No mag. Colimate, shield, pulse, avoid mag. No mag. No mag. And position the patient close to the eye eye. Got it. Okay. Perfect. We'll hopefully come back next year and find we've all had, we need almost like a timeout for that to make sure. All right. Next page. Okay. So the next question is kind of similar. So a nine-year-old girl is undergoing an elective colidocal cyst resection and you plan to start with an intraoperative cholangiogram. In order to obtain the best image with the least radiation exposure to the patient and the room, you plan to do all of the following except. I'm sorry, Craig. I know I'm not supposed to write questions this way, but I just, I had to. So all of the following except. A. Position the patient as close as possible to the image intensifier during fluoroscopy. B. Utilize the pulse mode during fluoroscopy. C. Drape lead aprons over the patient's pelvis and neck. D. Collimate the beam in the right upper quadrant. All right. Thoughts on this. Who's got the microphone? All right. Miguel, wit or Jose, since you have the microphone, pick A, B, C, or D. You guys don't know, so now you're on the spot. Your heart's a racing because I just called on you. I picked Jose. All right. Alan, what did the polls show? Aprons over the pelvis and neck. I would, I would. You can't take credit for his answer. Okay. All right. Microphone. All right. Microphone. All right. Mary, uh, Ellen, what do the polls say? Um, a few of the people are saying colomate and then the next person is draping and then the next person is draping and then the next person is draping and then the next person is draping and then the next person is draping. All right. Mary, what's the answer? What do the polls say? Can I know or no? Oh, oh, she didn't, sorry. We keep forgetting about microphones. Um, it's a pretty close between draping. Actually, it's more people are saying call me now. It keeps changing, but currently 47% are saying call me. Okay. Okay. This is the reason why I got into this is because, um, and I know this is probably TMI, but I used to be involved in general surgery education and I went into a room and I saw one of my former residents actually putting a drape over a patient who was pregnant during a IOC. So you need to appreciate that by convention, the x-ray source in the C-arm is placed below the table. It's below the table and it doesn't have to be that way, but the tech is always going to put it that way because the patient and the table protect you and everyone else in the room from the radiation. But if you put a drape on top of a patient, you're doing absolutely nothing to protect them from radiation because it's coming from below the table. Now, the other thing you need to understand is the way these machines work is they utilize this thing called automatic brightness control. So if there's something in the field that is preventing that beam from, from reaching the image intensifier and giving you an image, the computer will automatically tell the x-ray source to increase the energy. So if that shield is in the field, you're actually increasing exposure to the patient. So if you're going to shield, if it's a conventional sort of way, the C-arm is set up with the I above and the source below, you need to put those drapes below the patient. And the problem is, you know, the techs know this, but the techs don't come in the room until all the drapes are on and they don't know where the shields are. So it is a commonly made mistake and it's a bad mistake. So everything in that, and that I said, all those choices were correct, except the draping. And it has to do, or excuse me, the shielding. And it has to do with where the shield is placed. You want it to go beneath the patient. All right. Who knew that? Raise your hand if you knew. Gosh, this is the smarter side. Okay. Let's keep going. All right. Yeah. Oh, my question to you and Mary is if you put the shielding below the patient, does that mean you keep the shielding there throughout the case and the patient's lying on the shielding? And does that cause problems with sores and pressure issues and whatnot or? So you can put the shielding underneath, you know, the gel pad or whatever it is that you have. But, you know, the other thing you need to remember is a good collimation is your friend here too. You know, the collimator is a lead plate. It's sort of an, you probably can't see my pointer. It's on top of the tube. And so the collimation actually will help shield as well. But yeah, to answer your question, I think it was Whit, you can put your x-ray shield below your gel pad and it will still work. Well, I must tell you, I don't think I've ever seen that done in my career. So I think this is important and interesting information. I'll clarify, Mary. So what I'm hearing you say is that not that we should be shielding underneath the patient, but that we should be doing all those other things that you were talking about. Because I think shielding underneath the patient is probably problematic for a lot of reasons, including the potential for increased exposure if you're not getting the right image to the beam. I hear an opportunity for innovation here. So I'll be honest with you. The only time I, I collimate a lot, this is just my practice. I'm not saying this is the gospel truth. I collimate a lot, but the only time I really make it a point to shield is if the patient's pregnant. Um, you know, again, that's just my practice. Okay. Awesome. Thank you, Mary. Let's go to the next case. Oh, that's it, Mary, you're done. I think. Awesome. Yeah. That's. This is one of those things that I, Mac loves, I knew nothing about. I, I, I, again, I was on or off. So this was huge for me. And that actually paid attention, which is even a bigger plus. That was really good. All right. Let's see. I can not trip over the cord. What's, what else am I supposed to do? Um, how do I get my slides up? Just advance this? Okay. Okay. There we go. Okay. I have, uh, three topics. And the first one is straight from Dr. Ponski himself. CT evaluation of suspected airway foreign body. So here's the question. A nine year old child presents after choking episode at home associated with transient respiratory distress. She has a prior history of asthma in the emergency department. She appears in no distress with an expiratory wheeze on exam. Chest x-ray is normal. The parents are concerned about the risk of negative bronchoscopy given her history of asthma. So the most appropriate management and all of mine I think are somewhat controversial answers. Uh, MRI of the chest. CT scan of the chest. Uh, C admit and observe. Or D contrast enhanced ultrasound. Operating room. Yes. Maybe that got, maybe that got cut off. That was one of the, so, um, okay. I don't know how anyone can, you can type in your answer if you would go straight for bronch. I know. Well, okay. But also this was presented in a previous one from that rate from the radiologist. So it's interesting that this is back on the agenda again. Any, uh, all right. What's, what does the poll say? Oh, one. Oh, they haven't done it yet. All right. Why don't we, uh, just go straight. It will go straight. Looks like the poll came up. Um, most are saying CT, but you introduced it as the topic of CT for airway foreign bodies. So, okay. All right. Let's, let's go to the next slide. Okay. So the answer yes is CT scan. Uh, and this just highlights a report in the journal of pediatric surgery that Dr. Ponsky was the author on. Uh, it's just a, uh, issue of, uh, using a CT scan and patients who you otherwise would have a low threshold of suspicion in, and in their report, uh, they divide the patients into a couple of groups. One went straight to bronchoscopy. The other got CT scan. If the CT scan was negative, then they got sent home. And if the CT scan, uh, was positive, they went to the operating room and 94% of the time, they actually found a foreign body. And then, uh, there've been a couple of other reports of this. Uh, and they're just different suggestions for when that might be useful. One obviously being the patient you have a low threshold of suspicion in, uh, another example is a institution where there's no ENT or pediatric surgery, uh, expertise available. And they have a child with that. They could sometimes, uh, avoid intervention or avoid transferring them to some other institution in that circumstance. Uh, at least as far as I know at our institution, we haven't done this very often. We've shifted over time to where the ENT service now manages the airway forms of bodies far more than we do, although we used to do it quite a bit. Um, so I don't know what other institutions experience with this is, or how many people utilize this. It'd be interesting to pull the... Yeah. Well, I just one comment. The reason that we switched to this, um, is that there are, if it's clearly if airway aspiration, you go to the operating room. It's the ones you don't know. And what we found is the ones you don't know, it's a suspicious story. They were coughing after eating. Um, more often than not, it's reactive airway and it's not a foreign body. So you're instrumenting the airway of kids that already have a reactive airway. It made no sense. We were having a lot of negative broncs because we were so worried. CAT scan pretty much almost a hundred percent will direct you to go to the OR or not. So it's very low radiation and it eliminates those that are equivocal of getting an unnecessary instrumentation of their airway in the face of reactive airway disease. Um, any concerns, comments, or questions from the audience? Whit? What are the reasons for the false negatives on the CT scans? So we can alert folks who are using that technology. So I have to ask, I don't remember, the number of false negatives was either zero or close to zero. I don't remember. It was zero. It was zero. No false negatives. It was just telephone follow up and the follow up was incomplete. So there's unknowns maybe. Yeah. But there were no, right. So the only way to know if it's a false negative is did something happen to them afterwards? You would never know, right? And of all the patients that were called, there were, there was not any scenarios where anyone had any, so there's no way to ever know, right? But the false positives are, were very unusual, like 6% or something like that. So 94% were completely accurate and that was like mucus or something like that. You'd go in and it was a false positive, but it's incredibly surprisingly accurate and they do not need to be radio opaque. It can be plastic. It can be anything. So, all right. Comments, questions, or should we move on to the next? All right. Next. Oh, I miss the suspected one body aspiration common scenario. I'm going to throw this already. I don't think I need to read it again. Okay. Just a less invasive alternative to the traditional binary decision of operator observed. Okay. So the next one. A six month old boy had a chest x-ray due to chronic cough and right lower lobe. Cystic lung mass was seen. Subsequent chest CT scan demonstrated a macrocystic four centimeter lesion in right lower lobe with a question of a feeding vessel. The doctor had serial prenatal ultrasounds for placental position and no lesion was ever seen. Which factor is most concerning for possible malignancy in this child? And the choices are the size of the lesion, the location of the lesion, the absence of the lesion on prenatal ultrasound or presence of a systemic feeding vessel. Most concerning factor for possible malignancy. Most people on the polls are saying C, the absence of the lesion on prenatal ultrasound. Yeah. The poll worked fairly quickly. Wait. If you have comments, talk in the mic. Raise your hand if you have a comment. Okay. So, this is just based on a recent Midwest pediatric surgery consortium paper from 2021 that Dr. Kumasaki was the lead author on and some of the other authors here where they reviewed 521 primary lung lesions from 11 different children's hospitals and tried to identify factors that were associated with malignancy in those patients. And so, in that series, none of the, overall I guess, none of the prenatally diagnosed lesions were malignant. 10% of them that were diagnosed postnatally were malignant. Roughly 10%, I think it was more around 8.5 or so. And then about half of the malignant lesions were associated with the DICER1 mutation. There was no malignant lesion that had a systemic feeding vessel. And then the other factor that was notable was that the CT scan wasn't terribly useful. And there was a subsequent follow-up paper published later just looking at the CT scan accuracy and diagnosing PPB and it was not very good. They used the same data. They had nine different radiologists look at the lesions and the inter-rater reliability between the various radiologists was pretty poor. And then overall the sensitivity and specificity of the CT scan, even at picking up malignancy, was pretty poor as well. In this paper they mentioned that increased suspicion of malignancy by CT and bilateral disease were predictors. But as I said, they looked at the CT issue a little bit more thoroughly later on with another publication. So, I think that's a good thing. I think that's a good thing. I think that's a good thing. I think that's a good thing. Most of us are presented with our patients who've had a prenatal diagnosis of a lesion. And does that, the fact that we've seen it on, does that reassure you that it's not malignant? That was sort of the implication that none of these were, that if it was not seen in prenatal ultrasound, they were all, that was it? I'm not the world expert in this, but certainly I think overall the studies that have looked at the PPDs, there are some that are present on prenatal ultrasound. It's a small fraction, I mean 5 to 10 percent. So, I don't think you can definitively say, no, it was only seen postnatally, it wasn't there prenatally, so there's 100 percent guarantee that it's not. Thank you. And that's actually what Sean had said after his talk. I came up to him and said, you've got to be careful about this message. We'll see. Yeah. We looked at the same article. Actually, this series has like, I think 400 cystic lesions and there was not a single patient who had antenatal diagnosis who was found to have a PPD. There's another Canadian CEDU is, so if you sum it up, it's like 600 patients. If you have prenatal diagnosis, the chances of it being PPB, it's close to zero. Actually, there's like four or five case reports with PPB with antenatal lesions, misdiagnosis, CPAN. So, it's extremely rare. Instead of calling it, is this wrong, Chuck or Craig or whoever, is this wrong to say this statement? Yes, it's prenatal versus postnatal and we're seeing those as the two groups. Prenatal don't have cancer, postnatal can. Is another way of saying it is symptomatic and asymptomatic? That if they're presenting postnatally, it's because they're symptomatic. So, the symptomatic patients have a risk of cancer, the asymptomatic patients are very low. And my second half of the question is, and I'm curious what Wilken and Sean and everyone else here says, is Jack Langer right? Should we not be taking these things out now? If I recall correctly, 57% of the PPBs were asymptomatic. So, one sort of whole thing is, oh, it's not symptomatic, but there's a large percent. So, you're saying the same thing, prenatal ones are not symptomatic. What I'm saying, so the question from Rick Pearl was, am I saying that some of the prenatal ones are not, are all of them not symptomatic? And the answer is two separate things. I'm saying that prenatal, as a prenatal diagnosis is before you know if they're symptomatic or not. They're prenatal. So, some would say, and now I take them all out. But some would argue, some would argue that, look, if you diagnose these prenatally, and they don't ever get symptoms, you don't have to take these out. I think that's the argument because the numbers are so low. And we've had this debate on these events so many times, and this is the first time my needle went from always take them out. I'm like, maybe there's some validity to what they're saying, although we're not talking about infection. We've never gotten to that part. Other comments? Raise your hand. Yeah, Miguel. Mike. So the question was what, Rick? Right. The question is timing of taking them out. I think if you decide to take it out. Oh, because to see if they get symptomatic or not? No, no, no, I don't be, if you're a receptor, resect it early. If you're not a receptor, do what you want. But yeah, that's my opinion. But PB could be near zero, but it's not zero. That's the thing. I mean, asymptomatic or not asymptomatic, it's not zero. So at the end of the day, at some point you have a patient with a malignant tumor undiagnosed that you're keeping the thing inside forever. Is there anyone in this room that leaves an asymptomatic prenatally diagnosed lesion? Sorry, it's not zero, but I think you'd have to take 600 resections just to treat one PBV. So numbers matter in this case. I'm talking about asymptomatic, so prenatally diagnosed, asymptomatic. Because ultrasound technology is so good. And then these moms then get a fetal MRI, and then they get all these consultations, and then we see them, and they get a CT scan after birth. And a lot of these turn out to be nothing. Either it's not there, it's some sort of mucus plug that's gone away. So everything gets lumped into this garbage basket of CPAM in the fetal diagnosis world, you know, with a hybrid lesion, with all these different variations. But some of them aren't anything. So I do think that the management is changing, because we have to change with the technology and what we're finding. We have to change with the patient at six months old and have a CT that clearly show a malformation. That's what we're talking about. Mark? I worry less about cancer than, you know, I've had a few of these kids that have been referred to me when they're four, five, six, seven, eight, nine years old that have had recurrent pneumonias. And it's, I mean, all of us have probably been there. It is a mess and the chances of them having a successful thoracoscopic resection or, you know, at least in my hands are much lower in that age group than they are in the perinatal period or in that first year of life. So, I mean, I think my reason for taking them out is to prevent that. Yeah. Then I'm less worried. You know, when I, when I counsel parents, even before, you know, I say that the risk of, you know, they'll read about it and they'll come in all nervous about cancer, but it's, it's not the cancer. I worry about these recurrent pneumonias and real problems with bronchiectasis. Yeah. I agree with that. Just one last thing, but remembering the range of anomalies. Sometimes you, you, these are trivial little cysts and, and probably don't make much different one way or the other. Other times they are actually multi-lobar. And, and what it's going to mean if you're going to take them out is that you're going to do a pneumonectomy. And that doesn't seem sensible either. So I think as pediatric surgeons, we're all, we've got to tailor ours to, to what that actual pathology is. I think it's opening our eyes that we don't know it yet. Every year we're learning a little more. We're tailoring. I think that's the best phrase. This probably doesn't solidify any new practice plan for anyone, but I think it's, we're getting more information with each year. So it was a good discussion. Chuck. Summary here. Primary reasons to resect the lesions are the possibility of infection and risk of malignancy. And the risk of malignancy may be a smaller reason actually for most people. Systemic feeding vessels of prenatal diagnosis in this study were the two factors that were associated with significant lower risk. So I'll go on to our next question. About six months ago, Craig and I FaceTimed Jose. He, I think was at some sort of winery in Chile. And we said, is there any way in the interest of space learning that you can just present many of the same exact questions that we're going to present right before we do it? And he said, absolutely. No problem. I've got you guys covered. So this one's about a 13 year old girl who has been ill for six days. She undergoes a laparoscopic appendectomy for perforate appendicitis. Which of the following antibiotic choices was recently shown in 2021 to have a significant lower postoperative abscess rate, ER visit, and rate of postoperative CT scans compared to ceftriaxone and metronigazole? I can go pretty quickly through this. The answer, Zosin, Pipercilin, and Tazobactam. And this just cites the impact study. Since it's already been discussed a little bit, there was a study that Sean allude to by Sean Rangel of 654 patients in a NISQIP study across multiple institutions that showed kind of opposite results of this, suggesting that ceftriaxone and metronigazole were preferred over the Pipercilin, Tazobactam. And so I wouldn't say that this impact study was necessarily a clear cut study. It's multi-institutional, but 75% of the patients were at one institution, 25% were at another. So it's bi-institutional, I guess. But we have this issue with a lot of things in the PDC where it's nice to make questions where there's absolutely a clear cut answer. On the other hand, if you do that, then you're probably not trying to keep people up to date very well by picking topics that are worth discussion and worth knowing about. So this is one of those where, you know, there's a recent well-done, good, randomized study suggesting one thing, but there are other studies that are also not bad studies suggesting another. So I think the jury's probably still out on this one. I don't know how much time we've already kind of covered it. Yeah, I would keep going, but there's already two people that have presented this data and then Sean and Ray have been operating. But we were... Yeah. Yeah. Okay. That's it. Wow. All right. Last set. Paul Yzotrak from Peoria. So again, six-month-old, undergoing a colostomy closure after his PSARP. Following statement is correct about mechanical bowel prep. Decreases leaks, decreases hospital stay, promotes early feeding, has no effect on SSI. And I think what's fascinating in my career, I read a lot about this, different faculty, especially adult colorectal surgeons. If you read some of the early papers, it said things like a vigorous mechanical bowel preparation as if we're shaking or doing jumping jacks after the thing. So what do people think here while we're waiting for the polls? A, B, C, or D? No effect, effect, D? Miguel says D. Anyone disagree with Miguel? What is the audience there? Not up yet. All right. Not up. It is D, really no effect. There is some data that says it actually increases surgical site infections. The things that people are looking at in a lot of the studies, the issue is it doesn't look at just one thing. It adds things like oral antibiotics plus the mechanical bowel prep. We know of the strong data. It's appropriate timing over preoperative intravenous antibiotics. Really no strong data to support any of the other things. And some smaller case series on the use of oral antibiotics, flagyl, things like that. But really nothing strong to change too much on as far as that goes. So NEC again. Jose, thankfully prepped everybody so we should do this well. Five day old. Again, questions of PPD or laparotomy discussed with the family. This highlights a little bit of a different aspect. So the benefits of the laparotomy. A, mortality. B, stricture rate. C, neurodevelopmental outcome. D, postoperative intra-abdominal abscess. I guess the question for me and maybe in the room is how small is too small to do a laparotomy? The NEC trial and the papers from this, the cutoff was about a kilogram. Everybody feels sort of safe with that. But how small have people done laparotomies safely? 500 grams, 450. So. Stay here. An aesthetic as well. Not on the surgical point. I mean, it's a joint effort basically. Thoughts to you guys have agreed upon standards in your practice? Because I know we had a case like this recently and there was a lot of debate. No? Okay. So, again, I think we're going to talk about the question. So, again, Herculean effort to get the trial done. It does show that neurodevelopmental outcomes are improved compared to peritoneal drainage. And I think sometimes a challenge for me, so this, one of my patients, clearly very sick, sort of clearly NEC. Sometimes there's that gray area where people argue, well, it's just a sip. A drain will do fine. You don't need to operate. Sometimes it's hard to say unless you're looking at the bowel. That is necrotizing enterocolitis in the first place. And, you know, that's this definitive, you know, as Dr. Perlade said in the previous session, drain is a definitive thing. And, you know, if there's just a little perforation, the child does great. You sort of quote unquote get away with it. Maybe deal with the stricture down the side. And so I'm glad, you know, we have, you know, thankfully Dr. Lakeley and the team have given us at least a little bit more data, which is still a challenging, you know, thing with decades of information. Because you don't know exactly what is going on in traptomy in terms of the patient has a pneumoperitone and that's it. You know, it's a small segment, it's a whole bowel. How sick is the patient? It's different between every other patient. So regarding the question, what you do, A or B, like a binary, as Sean said, is very difficult. It's a case by case basis, basically. You need to decide on the spot, on the patient, and regarding what you're looking at. It's very difficult to decide A or B and that's it. And, Todd, let me ask you that. Patient you just had, was there a size issue? How small? It's about the size and an age issue. You know, at what age, I think this baby was 23 weeks in one day. And I think our hospital was 23 weeks, so because it was one day older than that, we decided to survive the baby. And I wanted to place a drain. And the neonatology unit wanted me to do an exploratory laparotomy because their bias is towards that. And then the whole discussion came up, why are we doing anything? And so it was just a debate. I think everyone had a different opinion. The thing is, again, you say a patient that you put a drain and the patient cured itself, you know, within seven days. And you didn't have to do any laparotomy. And the patient had put a drain and died in the next six hours. But if you decide the patient deserves a treatment, just saying a treatment, the baby deserves a treatment based on their size, their weight. I mean, the baby needs a treatment anyway, whatever you do. Well, is that true? No, no. I'm saying. I'm not sure I agree. You're trained because I have a huge, you know, distension of the abdomen and it's difficult to have that respiratory, you know. But Miguel, if the baby was 22 weeks, do you feel that the baby should get a treatment? I need to discuss with the team. Well, this is the question, right? And so we're getting lower and lower every year. Sure. So now it's, I don't know, ours, at least in Akron, is 23. I don't know what it is in Cincinnati. Yeah. So, you know, that's the first debate. If you decide that the baby meets your ethical or whatever criteria, hold on, to do anything. Then the second question is, if you think they need treatment, is their size and age enough of a reason for you to decide which treatment based on their age and weight? I completely agree with you. That's why I'm saying it's dependent on each patient. It's not about A, B, or C questions. The patient will tell you what to do exactly, basically. Mark? I guess the real question is, is a drain a definitive treatment? Occasionally. For survival. Yeah. No. So occasionally it is. But I guess the question is, for the next 24 hours, is there a survival advantage or disadvantage for drain versus laparotomy? You don't know until you do it. Right. No. I know. And that's the challenge. And that's the thing we don't know. You know, I think some of us feel that, you know, if the baby's going to die, they'll die with a laparotomy or a drain. If the baby's going to survive, they'll survive to at least 24, 48 hours with a laparotomy or a drain. Maybe. I don't know. You know, and I think when I, the way I interpret the NEST trial and everything else that's going on is that, well, for that survival piece, it's not, it's still not, 100% clear. Neurodevelopmental outcomes, different story. Yeah. And that's, and we can argue whether that's clear or not. But I don't know. So a patient like this, Todd, to me is the perfect patient. You put a drain in and see if they get better. And at least you can buy a little bit of time to have more discussions and decide what to do and then go on to a laparotomy if you need to. I don't think there's, but that being said, to your point, I don't think there's a lower limit to when you can do a laparotomy or not do a laparotomy or any of that on a basis. Really? Yeah. To go back to, to go back to your comment, I kind of got bothered every time a neonatologist told me how to operate. My response often is, did you go to surgical school? You know, I didn't go to neonatology school. And so I won't explain to you how to use a ventilator. I prefer you not explain to me how to, how to do an operation. I mean, you know, that's, this is our business to a certain degree to make a, who should go to an operating room, who not. And, you know, this is a very tricky business. To go back to what Craig said, you're draining an abscess. And sometimes you might go to the operating room six hours later after you put the drain in, or 12 hours later, or not at all. The patient's going to let you know. But sometimes the drain is just a temporizing measure. Sometimes it's a definitive measure. And you find out by following the patient. Not to open up a can of worms, but who agrees with that statement that, I mean, I. I mean, I, the ultimate decision is ours, but I do believe that working with the neonatology team on the decision to operate is actually prudent. I know you were, but a lot of people get upset about that. And I do have that discussion now. Ultimately, the decision is mine. But oftentimes they do sway me. And they're, so I get your point. And that's what happens frequently. So it's not something to just poo poo. That comp. Yeah. Okay. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. So just to add, I agree with the joint management and I know you're joking. The other question comes for those who cover outside community hospitals. Does that change your management when you have a drain versus a laparotomy? So say that again. So if you're covering a community hospitals, Nick you, and they have free air, does that change your management versus a drain versus laparotomy? I think if it's a hospital set up for neonatal surgery, it would not. Because the baby could eventually be transferred even after your treatment, whether it was a laparotomy or a drain if it need be. But I think a laparotomy or a drain, yeah, it's a bigger operation, but not that much bigger. I mean, it's still relatively. Yeah. Mark, you clip and drop. Or put a silo on. Go ahead. Go ahead. I was going to say, so I mean, in my previous institution, this is again, 10 years ago, I don't know what I do now. There were times we'd go out to an outside NICU. It wasn't that far away. We couldn't do a laparotomy there. You have a little baby, you kind of act like that, like that sip, you know, and we all know. You pop and drain it and see how they do over the years. Watch them in the outside hospitals, not at the children's hospital for a couple days to see if they get better. I'm a very smart person. Some of those kids never need a laparotomy to stay. They don't need to transport. Others, you know, they don't get better. You train them to be a big house and you do an operation. I was just going to comment that I think the other thing that we have to think about in these situations is families. And what do families want? And what do parents want? And how, you know, if they have a 22-weeker debate, there's a possibility that an operation or what they want for their child at that age. I think that's an important part of consideration when we're making decisions. Speak. Mac, can I call on you? Sorry. I just feel like we've evolved it. All of these stories are local M&M conferences. Case conferences where we're all talking about how we feel and we're not talking about any evidence right now. And it may be better use of our time to move on. Okay. All right. The only final thing I'll say is this is becoming more and more in our face because neonatology is surviving younger and younger and younger. And the separation between surgery and neonatology, that chasm is starting to widen because what they can survive is different than what we should be doing. And so that's a new problem for us. Yep. PJ. Okay. Last question. 16-month-old, right adrenal mass, measures 8 centimeters, biopsy of the mass, favorable with cell geneuroblastoma, biology, no mechanapification, but has segmental chromosomal abnormalities. What is the best next course? Observe as a low risk, return for complete resection, treat as intermediate risk, or treat as high risk. And so this is a recent update paper from the children's oncology folks. You know, that neuroblastoma tree is constantly changing as we're adding new info. Anything from the poll? Digging in. I think people are still working on answering. Yes, you see. Sounds good. Comment before the poll? All right. Just wait a second. I'm sorry. I'm sorry. Some people are saying, see, treat as an intermediate risk tumor. It's like 62%. This is good. So this would actually be a high risk tumor based on the 2020-21 COG data and the review from the most recent set looking at specifically those chromosomal aberrations, loss of game portions. You know, we're really getting very sensitive and our colleagues doing this research. Again, this is that arm that highlights that change in the schemata making it high risk as we're looking for the non-amplification. And now that next arm or next branch of the tree where we're looking at those segments of chromosomal abnormalities. And it's great. You know, I mean, we've evolved and we're getting a lot more data a lot more rapidly on some of the, what the genetics are and what the tumor biology is and how these kids will respond and how they should be treated. And that's it for us. All right. Oh, my gosh. We are, this is a first. We're so ahead of schedule. It's because you guys don't have mics in your hands. And so everyone's quieter. We'll try to do a better job getting everyone a microphone. All right. We are scheduled now for a 20 minute break. 20 minute break, Ellen tells me, as you guys can see, I completely rely on Ellen here. We're going to take a 20 minute break. We're 10 minutes ahead of schedule. So we're going to not, we're not going to stay on schedule. We're going to move ahead. So 20 minute break and we'll start the next session 10 minutes earlier than it's listed on the agenda. Does that sound about right, Ellen? Did I say that? Five minutes. What? We'll be five minutes early. Okay. I see a 10 here. Sorry. Okay. Got it. So let's take a break and we'll see you guys soon. Thanks.
