Top Ten Things to Remember from the 2017 Stay Current Annual Update Course (Audio Only)

Pediatric Surgery
This podcast recording highlights the things to remember from the recent Stay Current Annual Pediatric Surgery Update Course 2017 (also available in video format), with top ten topics including: gastric stimulation, cardiac sympathectomy, diaphragmatic pacing, abdominal wall reconstruction, gastroesophageal disconnection, blunt abdominal trauma, solid organ injury management, airway foreign bodies, glycopyrrolate after TEF repair, pilonidal disease and thoracoscopic lobectomy.

Additional Content

This is Todd Ponsky and for those of you may have missed it about two weeks ago, we had the 2017 annual pediatric surgery update course. We took the entire full day course and narrowed down the top 10 points

Chapter 1  - Gastric stimulation:

Coming in at number 10 - gastric stimulation is very popular in adults are now finding its way in children. Kids that have persistent gastroparesis may actually be a candidate for surgery. This is the insertion of a gastric stimulator into the stomach that will reduce the symptoms of gastroparesis and patients that have persistent nausea and vomiting the doesn't respond to medical therapy can get a temporary gastric stimulating test endoscopically and see how they do. If their symptoms improve they can go ahead and have a laparoscopic or open permanent gastric stimulator placed and the results are pretty staggering. This was presented by Dr. Ronaldo Garcia from Akron Children's Hospital.


Chapter 2 – Cardiac sympathectomy:

Coming in at number nine - cardiac sympathectomy. Most of us use sympathectomy to treat poorly controlled hyperhidrosis. Dr. Sophia Abdulhai and Dr. John Clark presented a unique indication – a percentage of patients having hyperhidrosis have CPVT which is catecholaminergic polymorphic ventricular tachycardia and also hypertrophic cardiomyopathy. These are patients that have a cardiac disease that requires an ICD that fires whenever they have a potentially fatal arrhythmia and some of these patients may actually benefit from having a very high thoracosocopic sympathectomy that goes all the way up to the lower part of the stellate ganglion and actually can shut off these arrhythmias for the most part and the results are spectacular. It is important to avoid the use of electrocautery during resection of the stellate ganglion as damage to the remaining portion of it may result in Horner’s syndrome. Benefits of sympathectomy is that there is 100% compliance once they've had it which is not seen with medication use.


Chapter 3 – Diaphragmatic pacing:

Coming in at number eight diaphragm pacing - not a common thing that we see in pediatric surgery but Dr. Onders from the University hospitals of Cleveland described diaphragm pacing as a very reasonable option in cases that have spinal injury or that have transverse myelitis and acute flaccid paralysis or brainstem tumors. The youngest patient that he's ever implanted was one year of age. These patients can get off of the ventilator because you implant this diaphragm pacing device directly into the diaphragm. He did note the diaphragmatic pacer can only be used if the patient has an intact phrenic nerve and the phrenic motor neurons must be attached, so prior to implantation you need to check that the diaphragm contracts with neural stimulation.


Chapter 4 – Abdominal wall reconstruction

Coming in at number seven abdominal wall reconstruction. We don't see too much of this and I know that I have fallen behind the standard of care of how we should be treating conventional hernias. Dr. Dave Krapata from the Cleveland clinic foundation talks to us about some of the new things that have happened in the last five or 10 years of abdominal wall reconstruction and actually he pointed out a few key points. Number one the best mesh to use for a for bridging the gap is not a biologic mesh. He did say that the best method to use is probably a monofilament light weight polypropylene synthetic mesh such as marlex that actually has been shown to do well in contaminated fields in a retro muscular space. What he told us was that the best repair these days is not what we relearned with the laparoscopic underlay but actually doing a retro rectus repair with mesh such as Marlex and macro porous monofilament mesh. He said the posterior component separation has less wound morbidity than an anterior component separation while also providing a space for wide mesh overlap and minimal fixation.


Chapter 5 - Gastroesophageal disconnection:

Coming in at number six - gastroesophageal disconnection. This was presented by Dr. David Lanning from Virginia Commonwealth. The idea here is that in patients that have had severe reflux and that have failed fundoplication you can actually do essentially a gastric bypass divide the esophagus from the stomach and bring up a limb of the jejunum to the esophagus and this actually has really good results. The points that he made were that this operation is good for children who had a failed fundoplication and may be good for patient even as a primary upfront repair if you think there a high risk for failure. It can be a long and difficult operation if it's done laparoscopically - up to 6-8 hours. He noted that these patients can still take food by mouth if they were doing so preoperatively. There is an ongoing prospective study comparing the laparoscopic GE dissociation with the redo fundoplication.


Chapter 6 – Blunt abdominal trauma:

Coming in at number five Dr. Chris Streck talked about who needs a CAT scan for blunt abdominal trauma. He showed us a prediction model consisting of five variables that identified a population who were really at low risk for intra-abdominal injury and he use these to help determine if they need an abdominal CT scan. Dr. Streck's presentation was based on an article he recently published that help to address the issue that too many children are probably getting unnecessary CAT scans after abdominal trauma. He stratified the risk based on finding so for example if the patient only has abdominal pain they really have only about a 5% risk of having an abdominal injury and almost a 0% chance of them needing any intervention compared that to of a child who had actually had an abnormal finding on physical exam such as a handlebar injury when they have about a 15% chance of injury. We reordered the five variables in the order of information that you obtain as a physician – the first was the complaint of abdominal pain, which may not be obtainable if the patient is obtunded or intubated, next was the physical exam of the abdomen, chest x-ray and then abnormal (pancreatic and liver) enzymes. If all of these are negative you should be able to observe or send home with careful instructions. These formed 55% of the population with a less than 5% risk of any injury and a less than 0.3% risk of an injury requiring acute intervention.


Chapter 7 – Solid Organ Injury management:

Coming in at number four was Dr. Notrica’s presentation about the ATOMIC data. He showed a very impressive result of many institutions that came together and did a prospective solid organ injury protocol to better determine how we should be treating these patients. This idea of looking at the grade of the injury is really falling by the wayside – we are now using more clinical predictive factors. Failure currently can't be can be guided by the predictive factors - you fail when the surgeon says you fail. He presented a very impressive algorithm for patients that have solid organ injury- we will post this algorithm with the video or the podcast so that you can refer to it later. Here are the key points that he made from this new revised algorithm based on this very large prospective study - number one we used to talk about giving two 20 cc/kg two boluses of saline before you give blood - this protocol suggest 10-20cc/kg of blood if patient does not respond to the first bolus. The patient can then get a CAT scan or go to the pediatric intensive care unit but if they drop their hemoglobin to < 7g and they need further blood which would ultimately total 40 mL per kilo they probably need to go to the OR - the magic number that David mentioned was with four units of blood or 40 mL per kilo. Admission to the hospital based on the grade is no longer necessary - this is a big change in how we should be managing solid organ injuries. It is a revised abbreviated protocol where patients are admitted to the floor to get vitals every two hours and then every four hours and they get hemoglobin in six hours - if they are symptomatic or their hemoglobin drops below seven then they can get blood and then another hemoglobin test in six hours; if however they never needed blood they can probably go home the next day.


Chapter 8 – Airway foreign bodies:

Now were getting to the top three key points made this year at the annual pediatric surgery update course Dr. Mike Rubin a radiologist at Akron Children's Hospital presented some really new and interesting ideas in radiology – One, the idea of using a chest CT for suspected airway foreign bodies; traditionally any child that has a history of foreign body ingestion / inhalation we take the opportunity for bronchoscopy. This unfortunately takes a lot of children who probably just have a respiratory virus going to the operating room getting general anesthesia and getting a bronchoscopy which probably will worsen the situation. So, he recommend getting a CAT scan in these patients that are unclear and that has an incredibly high almost 100% sensitivity for airway foreign body and then if they have a foreign body whether it's radiolucent or not you can still pick it up on a CAT scan and if they have a foreign body then you can do a bronchoscopy  - this will eliminate a lot of unnecessary bronchoscopy We have had about 12 to 15 patients that had CT performed with four or five negatives - those haven't gone on to the bronchoscopy had 100% conformity. We will get some false positives with a mucus plug when there will be some atelectasis. Another interesting point he made was we really don't need oral contrast for suspected bowel obstructions that one can read the CT scan just as well without oral contrast and this will really help speed up the time it takes to get a CAT scan and also prevent a lot of unnecessary nausea and vomiting in these patients. He also talked about the patients that have unsuccessful reduction of intussusception should get a repeat as long as there are some movements. He also thinks that in the modern era we should be aware that the radiation that one receives from today's CAT scan at Children's Hospital is equivalent to living on the earth for one year and this should be factored into the decision-making process.


Chapter 9: Glycopyrrolate after TEF repair

Number two - Dr. Holcomb presented what he felt were the top three papers to share in the Journal of Pediatric Surgery. Number one he presented a paper by Dr. Dalton which showed a really nice way of resuscitating patients with pyloric stenosis - the purpose is to try to avoid the problem of randomly guessing how much fluid to give - if the chloride is less than 85 you should give three boluses of fluid if the chloride is less than 97 you give two boluses of fluid and if records greater than 97 but the bicarb is lesson 33 you should give one bolus of fluid. The next paper he talked about was a paper by Dr. Richter which showed that patients present with either traumatic or nontraumatic pneumomediastinum probably do not need any further imaging other than just a chest x-ray. The debate still exists and whether or not these patients need to be observed or not but it seemed that most people in the audience would observe them in the emergency room for a few hours. A 12-year-old girl called to the ER with chest pain and an x-ray shows a pneumomediastinum; so what should be done – most people voted for no further imaging.

Finally, there was a paper by Dr. McCalla which showed there was a great benefit of using IV glycopyrrolate in patients that have a leak after TEF repair and they found a very dramatic improvement in closure rates in these patients. There were 297 patients over a 10 year period that underwent esophageal atresia repair; of the 297 there were 42 leaks; that's about 14%; they then prospectively randomized the 42 patients into two groups 21 each, one group receiving glycopyrrolate and the other group receiving placebo. The main explored variables were chest-tube output which was 124ml in the treatment group compared to 370ml in the placebo group; 2nd variable was the leak resolution which was accomplished in 76% of the treatment group compared to 29% of the placebo group and all of the glycopyrrolate group really had impressive results compared to the placebo group.


Chapter 10: Pilonidal Disease

And finally coming in at number one which I think was probably the biggest change this year in pediatric surgery was a concept presented by Dr. Aaron Lipscar on a new way to treat pilonidal disease. This is something we all struggle with; our results are not very good. Dr. Lipscar actually talked about a procedure that was described by a Dr. Gips in Israel. This is a very simple minimally invasive procedure and has great results. The procedure involves coring out the pits with a core biopsy after injecting local anesthesia and then you take a mosquito underneath the area and pull out all the granulation tissue /  hair and then curette out the cavity and flush with saline and then with peroxide. All the openings are minimal (2 - sometimes 8 in number) and are left unpacked /  un-sutured. Drains are not required and patients are told to shower once a day put a new dressing. There are no activity restrictions except for avoiding swimming for two weeks.

Chapter 11: Thoracoscopic lobectomy:

We invited a special guest Dr. Steven Rothenberg to take a step-by-step through the thorascopic lobectomy and teach us about the pearls and pitfalls - the key points we need to know about that procedure. Number one - scope should be anterior; he described putting the scope anterior to the tip of the scapula almost at at the anterior axillary line- this, he believes this will give you the best view and you want the scope to be right over the major fissure. This is probably the biggest mistake that I see surgeons make when they're doing these procedures as they put their scope or posterior to the tip of the scapula which is where we want to be for doing something like a thoracoscopic TF or other posterior mediastinal structures – otherwise, you will be working against the camera in a paradoxical manner which will make most of the work difficult. Number two, we emphasize the importance that one should use a sealer (not a sealer divider but just a sealer) and after sealing proximally and distally the vessel is divided. It is also important to really knowing the anatomy - trying to predict where the vessels are going to be and how they're going to be related to the process. Number three, we talk about how to approach in an incomplete fissure and that one should use a sealing device with layer by layer sealing (almost like finger fracturing the lungs) of the tissue until you identify structures. Finally, he talks about the importance of doing single lung ventilation by doing a contralateral mainstem intubation. One should use a double lumen endotracheal tube or a bronchial blocker or tracheal intubation with CO2 collapse or mainstem intubation on the contralateral side - the last is by far the best and the easiest thing to do.


On behalf of Cincinnati Children's Hospital, Children's Healthcare of Atlanta, Women and Children's Hospital Buffalo, Children’s Mercy Kansas City, Akron Children's Hospital and the Journal of pediatric surgery, we want to thank you for tuning in and watching this top 10 list from last year's Annual Update course. We hope to see you next year in August.