Update Course Rewind: 2023 Top Ten Key Takeaways

GlobalCastMD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hi everyone. As you may know, in August, 2023, we held our 11th annual update course in pediatric surgery. And today we are bringing you the top 10 key takeaways from that day. We are starting our video with number 10.

Our first key takeaway is poem procedure for ecclesiastreatment. In this session, Dr. Mikhail Petrosyan and Timothy Kane went through different cases and presented us the types of ecclesia and how we can manage them. As we know, the gold standard for ecclesiastreatment is the laparoscopic heller myotomy. But there is one new technique, peroral endoscopic myotomy, or poem procedure, that is becoming more and more popular, and our experts showed us the benefits of poem amongst these patients.

So tell us why you feel this is the best way to go, or what are the advantages of poem over the laparoscopic esophageal myotomy? Yeah, I think you have 360 degrees of options to do a myotomy. Whereas with a heller, you're kind of more anterior. So you've got maybe 180. You don't even, you got the vagus there that you've got to worry about. And a re-op for a heller, you have all those issues.

So you can do a, you read your poem after a heller or a poem, and you can choose a different side to do your dissection once you get in a clean spot. So you don't burn any bridges. You don't dissect the hiatus, so you're not worried about reflux. In conclusion, poem is a safe procedure for ecclesia and has an advantage since it has a larger surface to perform the myotomy.

Poem comes with very few to zero chances of damaging the vagus nerve, less reflex rates, and it's useful when there is a lot of scarring tissue.

In number nine, we will explain the importance of blunt cerebrovascular trauma, or BCVI screening, in head trauma patients, and see when is it necessary. BCVI occurs in 1.3% of the all head trauma in pediatric population, and nearly one third of them will have a stroke, increasing their mortality up to 20%. So it is really important that pediatric surgeons start screening patients for it. Let's hear from Dr. Zmeera Kodakal and Katie Russell, who originally gave this presentation.

We had a couple of patients, one with a delayed diagnosis stroke from a BCVI that was missed, that really prompted us last year to make a routine protocol for BCVI and to determine all of these patients should get CTA head and neck because of concern. Also in this session, we reviewed various scoring systems that can help us determine which patients are at risk of having a BCVI, and for which ones we should order a CT and geography of head and neck.

In this atomic paper, the Memphis score is what they use, and it is the most sensitive score. To summarize, we learned that performing a BCVI screening in head trauma patients is crucial. And even though there are many tools and scoring systems that can help us determine whom to screen, the most sensitive score for this population showed to be the Memphis score.

For number eight, we picked a topic from one of our most popular sessions, who to send home from the OR. This time, Dr. Philip Benham presented different cases of pilaromyotomy. Two patients, one over and one under 37 weeks of gestational age, looking for an answer to see who can be discharged early after pilaric stenosis surgery. I say that if they're full term and more than four weeks old, then they don't have to be observed for 12 hours, but it will be institution specific.

They each have to come up with their own. Dr. Hem and our audience both agreed that patients under 37 weeks of gestation require overnight monitoring following anesthesia, even if they're tolerating full feeds shortly after surgery. However, a full term baby over four weeks old may be eligible for discharge from the PACU. Looking at NISQIP data, only 1.5% of pilarics were discharged on the day of surgery, and there was no difference in the odds of readmission.

So there's a little data, Todd, and then no difference in complications for them. So it is safe to say that patients under 37 weeks of gestational age or younger than four weeks old should be monitored overnight post procedure. Meanwhile, those over 37 weeks of gestational age or older than four weeks can be discharged for living successful feeding tolerance. Coming up number seven, we will review the ICG application

for identification of sentinel nodes. This topic was presented by Dr. Seth Goldstein. As we know, ICG, efflorescent dye, has become increasingly integrated into biliary-related surgeries, such as cholecystectomies, due to its hepatic excretion. The sentinel node, defined as the initial lymph node, where cancer cells are most likely to spread from a primary tumor, often necessitates a biopsy to classify and treat tumors effectively.

Historically, technetium-99 served as the primary marker for identifying the sentinel nodes. And even though it works, it requires a special machine to detect it, and it's hard to control the injection. In the operating room, you can take charge because the ICG technique is real-time in the operating room. With equipment, you either have or are about to have standard in all your laparoscopic towers.

The main point is to find the node that is your first sentinel drainage, and that's ever so important, and ICG can do that. So here, Dr. Goldstein will demonstrate how ICG can enhance our ability to locate these crucial structures, aiding in surgical procedures. So, indocyanin injection into the tumor, and then look at that right below it with the lights off contrast. You can just watch over the course of 45, 60, 75 seconds, the ICG head to the sentinel node.

In conclusion, ICG can be used to detect sentinel nodes in many types of cancer, allowing the surgeon to control the time and place of the injection, and avoiding the issues that may occur with technetium-99.

This time, we have number six, anal dilation following a PSARF. This was a part of Dr. Caitlin Smith and Julia Grabowski's presentation. Anal dilations were traditionally a common practice following PSARF to mitigate or prevent stricture formation post-procedure. However, recent studies have challenged this approach, revealing a lack of firm correlation between anal dilations and stricture development.

Twice a day dilations for however many weeks and months might be able to be teased down a little bit so that the family's stress, which does seem to be a stress, but that we can sort of mitigate that a little bit by just modifying the dilation plan. One other interesting fact is that many of these patients have a colostomy, so they are going to have another procedure for colostomy closure, which is a perfect moment to perform a strictureplasty if needed.

I personally see them anywhere from, I see them about two to four weeks after the operation, whenever I can get them into clinic in that kind of timeframe, and then I size the anoplasty in the office, and when I size it, I'm like, okay, like here's the time where we can talk about what dilations look like, we can do them or not, this is what might happen, you might need to get a strictureplasty.

I've talked to the family before the surgery about dilations as an option, so they're not surprised, but if it looks really good, I will skip it. In summary, dilations following PSARP are not recommended for every patient. This procedure can be distressing for families and may be unnecessary, particularly if the patient requires a colostomy closure. In the event of a stricture, it can be addressed through a strictureplasty at that time.

We're halfway through our list, and number five brings us to the updates in fertility preservation session. Here, Dr. Erin Rowell will discuss the process of removing ovarian tissue for cryopreservation. Dr. Rowell shared a case involving a six-year-old female diagnosed with hemophagocytic lymphohistiocytosis, or HLH, requiring chemotherapy, and thus ovarian tissue preservation for future fertility.

It is very important to note the emphasis placed by every society on fertility preservation counseling, even when surgery isn't planned. So how does the counseling process work? When we have a patient who's got a new diagnosis of cancer or is gonna come up to stem cell transplant, they activate our counseling service through an order set in Epic. It's easily available to anyone, and then that triggers a consult by, we have an advanced practice nurse practitioner. I do some of the counseling.

We also have somebody from oncology. So we have multiple different people who could be available to talk to the family about that risk assessment. Another important factor is deciding what is the best procedure for preserving ovarian tissue. It's really important to recognize this is a prepuberty child. The size of this child's ovary is about two centimeters. It's about the size of a grape. And that really what you ought to do is a laparoscopic oophorectomy.

That would be our best recommendation. So laparoscopic oophorectomy is recommended to reduce the risk of hemorrhage and ensure that any remaining ovarian tissue is preserved for the future fertility. So in conclusion, fertility preservation is very important for children undergoing chemotherapy. Counseling must be included in their multidisciplinary approach. And in females, the best way to do it is with a laparoscopic oophorectomy. Getting closer to the top three, and we have number four.

To talk about the massive transfusion protocol, we'll tune into Dr. Dmyro Kodogal and Katie Russell. Massive transfusion protocol, or MTP, is a multidisciplinary process whereby blood and blood products can be rapidly obtained for severely bleeding patients. Effective communication is crucial due to the urgent nature of the situation, and having a protocol simplifies the process, ensuring timely access to essential blood products. But when should we activate MTP?

And what kind of blood products should we give? If you're in the trauma bay and you're giving blood, you need to activate it. Like, it's go time. So blood equals MTP. Yes. That's its phrase to remember. So if you give blood, call MTP. Another important thing we learned is the ratio we should give the blood products, which is one to one to one, meaning for every bag of blood, you pass a blood of plasma and one of platelets.

When do you give something other than packed red blood cells, and what do you give? If it's a bad trauma, bad trauma coming in, not stable or not normal at all. Whole blood. Yeah, whole blood would be the best, I think. So we have not been able to get our blood bank to make whole blood for kids because it needs to be open. We want to aim for one to one to one, for sure. And definitely FFP should be what you give after you give blood.

Most of the time, an original trauma cooler that comes to the bay in most hospitals does not have platelets. So the MTP helps you get platelets or you can call for platelets, but they usually don't come in your trauma cooler. In summary, the massive transfusion protocol should be activated in the trauma bay after administering 20 milliliters per kilogram of blood. Following activation, the protocol dictates providing the patient with blood products in a ratio of one to one to one.

We're finally in the top three. For number three, we will review the management of ovarian torsion with Dr. Lizzie Breach, a pediatric gynecologist. Dr. Breach started this session by presenting a case of a pre-puberty girl with a right ovarian torsion. Comes to the emergency department, gets an ultrasound, large cystic mass, no blood flow to the right ovary, and you decide to take this patient to the operating room, you find right ovarian torsion, and you can see this sort of dark purple ovary.

The key thing to watch out for is the presence of a cystic area on the ultrasound. Often, this is less visible in the operating room. And although many surgeons may wanna go in and attempt to remove the cyst, Dr. Breach advises against it unless the edema makes it clearly visible. Now, there's more question about the fallopian tube, how to manage a blue-black fallopian tube. Take a look at the tube. If the tube is black, it's edematous, you have detourst it, you've given it plenty of time.

I would say a consideration about what to do about that tube. Therefore, it's best to avoid removing the ovary because it may still regain some of its functionality, even if it appears to be black. Dr. Breach also advises against pixying the ovary. Instead, she recommends just detorsion and subsequent monitoring. In conclusion, ovarian torsion does not always involve cyst. Therefore, unless it is clearly visible, do not attempt to remove it.

To preserve as much ovarian tissue as possible, avoid performing an oophorectomy and ensure the patient is followed up. And for number two, we'll review total pancreatectomy

with islet ototransplantation, or TPIAT, from updates in pancreatitis management session. This time, Dr. Juan Guria will help us understand the topic. Chronic pancreatitis is a condition that causes pancreatic insufficiency and damage to the islet cells. One treatment option is TPIAT. This procedure involves a complete removal of the pancreas along with the spleen, followed by extraction of islet cells in a specialized lab. These cells are then injected into the portal vein.

In the acute post-op period, you have to manage their glucose for them. If you put them under stress, the cells die. Everybody's on insulin in the ICU. I want the cells to be like just chilling, not doing any work until they implant and find new vessels from the liver to survive. It is important to understand that many patients with chronic pancreatitis have a gene mutation that triggers recurrent attacks, causing the gland to replace normal cells with fibrosis.

This is why performing any surgical resection procedure without extracting the islet cells may result in continued pancreatitis attacks and an increased risk of diabetes after TPIAT due to the reduced pancreatic parenchyma. In conclusion, TPIAT is a surgery for chronic pancreatitis that helps the pain and the recurrent attacks with the idea of preserving as many islet cells as possible to avoid endocrine insufficiency.

And we made it to the number one. I know everyone's been waiting for this. Let's hear from Drs. Mira Kodigal and Katie Russell on management of blunt trauma to the liver and spleen. Blunt trauma is a significant concern in the pediatric population, primarily due to the potential severity and complications associated with such injuries, and its management has been evolving for many years now.

Last year, the American Pediatric Surgical Association, or APSA in short, released a guideline, including new updates. So the APSA guidelines are relatively new-ish that came out with revised guidelines around management of patients, and it includes four basic categories, thinking about where they should be admitted, procedures, when you would discharge them, and then what you might think about doing after discharge, and particularly in this instance, talking about patients not going to the ICU.

For grades one and two blunt trauma to the liver and spleen, we can monitor patients who are hemodynamically stable and consider discharging them from the emergency department. Regarding lab results, should we repeat them? And if so, how frequently? They're gonna get one. I practice out in Utah, and 80% of our kids are transfers. Most likely, they've already had a CBC at the other hospital, but we do not repeat it.

If it's a hemodynamically normal child, they will go to the floor and not get a repeat crit. Perfect, that's what we're doing, too, and there's actually data to support that, that we know there is some degree of hemodilution. The data suggests that the patients who are more likely to fail non-operative management have an initial hemoglobin less than 9.25.

Therefore, for patients who are hemodynamically stable and have normal hemoglobin levels in their initial lab tests, there's no need to repeat the tests unless there are changes in their condition. In conclusion, for blunt liver and spleen trauma, there is increasing evidence that supports treating the patient based on signs and symptoms rather than solely on the injury grade. GlobalCast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.