Update Course Rewind: 2024 Top Ten Key Takeaways

Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hi everyone, in August 2024, we held our 12th annual update course in pediatric surgery, and in this video, we are bringing you the top 10 key takeaways. Let's start with number 10, collaboration of surgery and interventional radiology in the OR. This topic falls into the blue category as a newer approach. Doctors Dan Von Allman, John Riccadio, Timothy Lautz, and interventional radiology technologist Amanda Wallingford showed us different use cases of image-guided surgery which uses real-time imaging, like CT, MRI, ultrasound, or fluoroscopy to improve precision during procedures. This session is really about combining the expertise of surgeons with the expertise of our interventional radiologists. There's cross-training at Cincinnati Children's, for example, interventional radiologists teaching pediatric surgery fellows how to use ultrasound guidance for vascular access. So it's important to understand that you don't have to have a hybrid OR to be able to do this type of collaboration. It can occur in your regular OR by bringing in an ultrasound machine. A hybrid operating room eliminates the need to transfer patients between imaging and surgical areas. It combines advanced imaging technology with a traditional surgical setup. One key component of a hybrid OR is the cone beam CT. So it's a CT scan that's performed on a C-arm fluoroscopy unit. Basically, it's positioned over the patient's point of interest and it rotates around the patient collecting multiple images which are then stacked together to create a CT. You can also use it for identifying and protecting critical structure during surgery. And then you can use it at the end of the case to confirm vessel patency. In conclusion, collaboration between surgeons and interventional radiologists enhances patient care by integrating ultrasound and cone beam CT. Innovative image guided techniques such as lymph node localization and pulmonary nodule marking further simplify complex surgeries. At number nine, we hear from Drs. Rami Shaban and Carlos Kulunga as they break down the top AI tools of 2024. Information from this session classifies as a blue square for promising newer practice. We are researching how ChatGPT can help us in the research process and I personally use ChatGPT in systematic review and meta-analysis and when you do systematic review you screen thousands of articles. This process is intimidating. We prompted ChatGPT with following. I'm conducting a systematic review on this specific topic. I need you to act as a data analyst. Please analyze the TASH Excel sheet and screen the included articles based on title and abstract. Because we don't trust ChatGPT a lot, I asked ChatGPT also to add a column to explain why they decided that decision so you have a better understanding about this data and we get an excellent result with that. Let's review our next tool. Jenny AI. Use AI to supercharge your research paper. Jenny AI is one of different academic models that has been with research papers and you literally put your prompt and the first thing that you'll get is a suggestion. You can start writing this. You, because you're the surgeon that has the hand on the wheel, can say, yeah, I like it. I want to modify it. You can also chat directly with its built-in chatbot and say something like, I want to research this topic. It will provide relevant answers, site-supporting papers, and even help format those citations according to your preferred style. If you want to have a personal trainer, we use also ChatGPT. Upload a guideline to ChatGPT and then ask ChatGPT to create a training session out of a guideline and then it creates a series of interactive questions where you can interact with ChatGPT and get trained on a specific thing. And Dr. Colonga summarizes in the best way. We have to have these thoughts. We have to learn how to use it because it's here to stay. We can't close our eyes and don't admit that everyone's using it to increase their efficiency and improve the way they manage their day-to-day lives. In number eight, pediatric surgeon Dr. John DeFiori discusses how he uses cryoanalgesia in pectus. This topic falls into the blue category as a newer approach. Cryoanalgesia is a minimally invasive procedure to alleviate pain during chest wall surgery by temporarily freezing the nerve. We use a double lumen tube in all patients. A double lumen endotracheal tube deflates the lung on the side of the cryoablation and the surgeon uses a thoracoscope to guide the cryoprobe through axillary incisions. We go from T3 to T8. After cryo, we do intercostal nerve blocks with subpleural injections. They start on the third rib with a two-minute free cycle and work their way down. After we do that, I do a subpleural injection with a quarter percent marcaine with epinephrine. This works immediately as opposed to the eight to ten hour delay with the cryo nerve block. It takes about 15 seconds per intraspace. The double lumen endotracheal tube also helps reduce the risk of pneumothorax. I've gotten multiple calls from other surgeons that say sometimes my blocks don't work and invariably it's a surgeon using a single lumen tube doing the block too far anteriorly. In summary, cryoanalgesia is an effective tool for pediatric pectus procedures controlling pain and decreasing hospital length stay with few short-term complications. Double lumen tubes enhance precision, especially for targeting lateral cutaneous nerves. Let's take a look at number seven. Pediatric surgeons Dr. Stephen Lee and Rebecca Stark discuss the techniques from performing ECMO in severe congenital diaphragmatic hernia, or CDH cases, as well as strategies for determining when and how to approach surgical repair. Information from this session classifies as a blue square for promising newer practice. So full-term neonate, known diagnosis of a left-sided very severe CDH, you delivered about an hour ago, intubated and resuscitated per your institutional protocols. Preductal sats are in the 70s, heart rate is 150, blood pressure is 35 over 25, pH is 6.8, PaCO2 is 130, and PaO2 is 28. What's your next move for this patient? Would you prefer vena arterial VA ECMO, vena venous VV ECMO, time to reassess, or opt for comfort care? There are lots of benefits to VV. There are lots of benefits to VA. The majority of centers, as I said, still do VA ECMO primarily for CDH babies. So both answers are totally reasonable. Sphere Protocol from Michigan used prenatal criteria to guide decisions on offering ECMO versus comfort care for severe unilateral CDH. And outcomes showed that survival was equivalent between groups, revealing we're often wrong about who will benefit from it. I do think that if you had good prenatal counseling with the parents, you should pursue ECMO for every unilateral isolated CDH. Same case, patient is on ECMO managed with bivaliridin. When do you proceed with surgical repair? There are many institutions that are lower volume, where neonatologists are very involved with the care. And switching to an early repair, if you're only putting one or two children on ECMO per year for CDH, is a challenge and you need a whole buy-in. If you use bival, you don't have to wait for the circuit to kind of equilibrate. It's very fast. You can operate after eight hours of putting them on bival as long as your levels are stable, which happens really soon. And it's a much easier surgical repair. In summary, in cases of very severe isolated unilateral CDH, you should consider the patient a survivor until proven otherwise. Additionally, early repair while on ECMO is safe and can offer physiological benefits with the optimal window open between eight to 24 hours. Let's review number six with Dr. Carlos Kalunga discussing how he uses the CO2 laser in surgical procedures. This topic falls into the black diamond unproven category. The laser emits infrared light and is highly absorbed by water and biological tissues. We're using it in the spectrum of 920 to 1,400, which is really well absorbed by water. It's very effective for precise cutting and ablation and reduces blood loss. We have great reduced pain and edema and shorter operative time. They used it in 56 circumcision cases using the sleeve technique with a dorsal slit and cyanoacrylate adhesive. The complication rate was only three percent. We've used it for phrenolectomy, 47 patients, low pain profile, no suture required. Other conditions that they've used the CO2 laser for include perianal fistulas, fistulotomy, and pyelonidal cysts. We do laser ablation and there's a sinus tract. We also ablated lower labia fusion and condylomatosis. Great for ablation. In summary, CO2 laser is an evidence-based option with promising outcomes, less bleeding, reduced pain, and shorter operating time. Barriers include high equipment costs, required training, and limited availability. For number five, pediatric surgeons Dr. Justin Huntington and Ben Ham will discuss the use of autofluorescence and ICG in geography for identifying parathyroid glands and assessing their perfusion. This session is classified as a black diamond for early adopter practices only. One of the things we think about in thyroid surgery is we want to preserve the parathyroids and decrease the risk of hypocalcemia and the need for calcium supplementation both initially and over a long period of time. It's demonstrated in a randomized control trial from France. Autofluorescence has shown to reduce rates of hyperparathyroidism and hypocalcemia following thyroidectomy. You don't inject anything. It's just the parathyroids naturally autofluorescence at that wavelength. So it's using that technology. And then in addition, you can inject ICG to look at the perfusion of the actual parathyroid glands. There's a fluobeam system in addition to the probe system, and they noted hypocalcemia rates that were about half with using it versus not using it. So this just shows an example where you can see the thyroid gland lifted and exposed. And then with autofluorescence, you can see the bright areas signifying the superior and inferior parathyroids to help identify them early and then be able to separate them from the thyroid and work to preserve both them and their blood supply. And then this is adding ICG. We have the flu optics machine and like the pictures that are sort of published in the studies, like I haven't found it as nice as those pictures. But I do think it's a helpful adjunct. In summary, autofluorescence and ICG and geography help identify parathyroid glands and assess perfusion, reducing the risk of hypocalcemia after thyroid surgery. In number four, Drs. David Vitale, Luke Neff, and Jeff Ponsky explain the surgery-first mindset in pediatric biliary stone cases. This video is classified as a green circle for established practice. You have a 15-year-old patient with colicky right upper quadrant pain for 24 hours. The ultrasound shows a dilated common bile duct and a stone is visualized. What's the next step? We've just recently published some work showing that a surgery-first pathway, or at least that mindset and embracing that concept really does reduce resource utilization, including MRCP. Before a gastroenterologist does an ERCP, often the patient has had an ultrasound and an MRCP. And we can utilize some of our predictive factors where we can go straight to doing a procedure if we need to, whether that be a combined procedure with a laparoscopic cholecystectomy and IOC and potentially call me into the room if an ERCP is needed. We know that as good as you are at ERCP, you're going to get pancreatitis 10% of the time. And if that kid gets pancreatitis and you could have gone straight to surgery, that was a mistake. In this paper published in the Journal of Pediatric Surgery, they demonstrated that with a surgery-first mindset, the stone clearance rate reflected by a negative intraoperative cholangiogram was 86%. If you just did flushing, if you just got that catheter a little bit more, just peek it in the common bile duct or maybe ream the sphincter, that success rate was in the 90s. So it doesn't take much. In summary, a surgery-first approach for pediatric choledical lefiasis can be highly effective with stone clearance rates as high as 86% and a reduced need for preoperative imaging like MRCP. On number three, we'll hear from pediatric surgeon Dr. Greg Tiao on the use of MMP7 as a diagnostic tool in biliary atresia. Information from this session classifies as a blue square for promising newer practice. The key to treating biliary atresia is making an early diagnosis. This is where this biomarker that really came out of Georgia Bezzara's lab, my research mentor. He identified MMP7 about 10 years ago as a diagnostic biomarker for biliary atresia. This all ties to this critical concept that I think we all know, but we don't necessarily integrate, which is you got to get your casais done as soon as possible. The sooner and sooner you get it done, the more likely you'll save the native liver. The key is to distinguish BA from other non-physiologic cholestatic jaundice conditions so that we can get our casais done at an earlier stage. Data from a recent Midwest study shows that every 10-day delay in treatment, outcomes worsen by 20%. It's one of those cases where the earlier we can intervene, the better the outcome. This urgency helped drive the research that led to the MMP study. So MMP7 is now a validated biomarker for biliary atresia. It's not perfect. Actually, if you just look on the table here, the sensitivity is pretty good, but the cutoffs that the different teams used vary because it's an assay that's still evolving in front of our eyes and depending on how you do it. But this all translates to the next question here, which is when are you going to do your casai procedure? Our commitment to the patients who come to our institution is within seven days of them showing up. If they have it, they're in the OR. In summary, timely diagnosis of biliary atresia is vital for native liver survival as early intervention through the casai procedure greatly improves outcomes. MMP7 has been validated as a biomarker to aid in earlier diagnosis, though its essay continues to evolve. We're so close to number one. Let's check out number two. Pediatric surgeon Dr. Regan Willams is here to discuss when to perform Reboa in pediatric patients. This topic falls into two categories, both black diamond and blue square, both uncroven and newer practices. A 16-year-old shoots herself in the abdomen while cleaning her rifle. She is hypotensive and near cardiac arrest despite massive transfusion. Reboa, resuscitative endovascular balloon aortic occlusion, can be used in children. We don't do a lot of this in a pediatric hospital, but you can do it if you have that at your center and you're good at it. Reboa is a procedure to control bleeding in traumatic shock or cardiac arrest. A catheter is inserted through the femoral artery into the aorta. Then a balloon is inflated to stop blood flow, which buys time for surgical intervention. So this would be the patient to do it if you could not get them to the operating room to actually control the source of bleeding. Reboa is often compared to resuscitative thoracotomy, which opens the chest surgically to control the source of bleeding since both techniques occlude the aorta. It seems to me reboa take longer than opening the abdomen or the chest if you're just needing to cross-clamp the aorta. In summary, reboa can be performed in pediatric patients but is rarely done with no clear survival advantage over laparotomy. Most surgeons favor laparotomy over reboa for quickly treating shock in a controlled environment. Here's what we have been waiting for. Our number one key takeaway. Pediatric surgeon Dr. Nelson Rosen is explaining the importance of patient education and non-surgical management of pilonidal disease. This one classified as a green circle for established practice. One thing that I can tell you that from our looking at our own data is that patients presenting with wounds as their initial presentation for pilonidal tend to not always get to the finish line fully healed with a minimally invasive probe. Joan Armstrong, while serving in the U.S. Army, ran a clinic with a captive patient population. They implemented a protocol where patients were shaved weekly and they observed a dramatic improvement, significantly reducing the need for surgical intervention. I think if you're not pushing hair removal and meticulous hygiene to do the best that you can, you're probably going to end up operating on some people that might not need an operation. But again, you have to talk to your patient. So what are the best techniques for hair removal and hygiene? Shaving, diploidal hair removal agents like Nair, or laser hair removal? A lot of our patients are teenagers or people going to college and sometimes they don't have anybody to help with them. If there's a parent or an active caregiver involved, we believe that clipping is probably the easiest and simplest approach and having someone do it once a week is recommended. In conclusion, pilonidal disease severity varies. And treatment options should be tailored to individual case. Non-surgical measures like regular shaving, hygiene, and even waxing can lead to significant improvement and should be considered before moving to surgery, especially in cases of mild to moderate severity. GlobalCastMD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health health around the globe.