the way we interpreted this study really is that you can do either way. It's surgeon preference. If you prefer to go ahead and operate on the patients and accept the potential complications from a difficult operation, that's fine. If you'd rather treat the patient initially non-operatively with drainage and antibiotics and come back for a Uh, interval appendectomy, then that's fine as well.
Based on the ratings of the various case scenarios, the Clavian Madati classification showed improved agreement rates of the respondents, 85% versus 76%. And it was less frequently considered inaccurate for rating in the pediatric population when compared to the lavian dindo classification.
there was no difference between the use of irrigation and the use of suction without irrigation. I think, I think it's also an interesting way to look at it is there was no detriment to using irrigation as well if folks wanted to continue to use irrigation.
we had to come up with a definition of perforation. And again, we have chosen stool in the appendix, meaning a fecal lith in the, uh, excuse me, stool in the abdomen, meaning a fecal lith in the abdominal cavity or a visible hole in the appendix.
we have been sending our non-perforated appendix patients home the same day. Now that's assuming that it's not 1 in the morning or something like that, but as a general statement, we do not do appendectomies past 7 or 8 o'clock at night.
I think it's very important to use a locking grasper when you're bringing the appendix out through the abdominal cavity because If not, I've had several occasions where the appendix has slipped off the, the uh non-locking grasper
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
▶Ep 35 · 12:05
quoteThis is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.↗
▶Ep 35 · 12:09
quoteI just wanted to highlight the importance of transitioning care because I thought this topic was important.↗
▶Ep 35 · 14:22
clinicalThere was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner↗
▶Ep 35 · 14:22
quoteThis one sentence says it all. There was little evidence from patients that transfer happened in a timely or coordinated manner. And patients felt that the clinicians did not always understand the significance of transfer to an adult service. No models of transfer of care were identified.↗
▶Ep 35 · 14:38
clinicalNo models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review↗
▶Ep 35 · 15:21
quoteWe need to do a better job. Of structuring this transition, we're doing better with handoffs in the hospital with patient care. We need to do a better job with handing off the care for any pediatric patient who needs a transitioning to adult providers.↗
Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
▶Ep 36 · 14:30
clinicalThe Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.↗
▶Ep 36 · 14:30
quoteWe didn't really have a classification system that was unique to pediatric surgery, so that's why we have used the Clavian dindo classification, although that was validated in the adult world.↗
▶Ep 36 · 14:30
clinicalThere was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.↗
▶Ep 36 · 15:19
quoteThis is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.↗
▶Ep 36 · 16:39
clinicalThe Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.↗
▶Ep 36 · 16:39
quoteBased on the ratings of the various case scenarios, the Clavian Madati classification showed improved agreement rates of the respondents, 85% versus 76%. And it was less frequently considered inaccurate for rating in the pediatric population when compared to the lavian dindo classification.↗
▶Ep 36 · 16:53
clinicalThe Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.↗
▶Ep 36 · 17:46
quoteThis was a good first attempt at trying to find a reliable instrument for pediatric surgeons, and I think that we'll figure out by using it whether it's good or bad or appropriate for pediatric surgeons, but right now we don't have anything, and so obviously a first step is better than no step at all.↗
Update Course 2023 - Updates in Pediatric Achalasia Management
▶Ep 3 · 22:45
epidemiologicalOnly approximately 10% of pediatric surgeons perform thoracoscopic tracheoesophageal fistula repair, illustrating the challenge of disseminating advanced techniques↗
▶Ep 3 · 24:03
quoteA lot of times when patients come in, moms and parents want the poem procedure. We don't even talk about Heller. They don't, we don't, we get an email that they tell us we wanna have a poem because they've done the research. They don't wanna hear about Heller, period, period.↗
▶Ep 3 · 24:03
opinionMany patients are now specifically requesting POEM after doing their own research, rather than considering Heller myotomy↗
Update Course Rewind: Updates in Achalasia 2023
▶Ep 4 · 2:45
quoteThe lap Heller is going to be the number one, which, which is probably standard of care in pediatrics.↗
▶Ep 4 · 2:45
opinionLaparoscopic Heller myotomy is probably standard of care in pediatrics and is the tried and true approach for achalasia.↗
▶Ep 4 · 3:05
epidemiologicalThere is a large and increasing experience in POEM in the world.↗
▶Ep 4 · 4:19
epidemiological50% of pediatric achalasia patients had some intervention before Heller myotomy, whether Botox or dilatations.↗
▶Ep 4 · 4:30
quoteBotox anymore because people are learning it's it causes a lot of scar tissue.↗
▶Ep 4 · 4:30
clinicalBotox is not used as commonly anymore because people are learning it causes a lot of scar tissue.↗
▶Ep 4 · 4:38
clinicalMany patients have had dilatations before Heller myotomy and the fibrosis is pretty minimal, so it is not recognized too much during surgery.↗
▶Ep 4 · 4:48
clinicalIn kids who have had Hellers or POEMs before, you have to get into a different plane because it's pretty scarred.↗
▶Ep 4 · 7:35
clinicalManometry will sometimes show achalasia that never goes away, with the same manometry findings, so kids are not routinely sent for manometry unless confirming achalasia from a different institution or if readings are equivocal.↗
▶Ep 4 · 8:00
clinicalEndoFLIP is a machine with a soft balloon that measures esophageal distensibility and diameter, used through endoscopy to determine if the myotomy was long enough.↗
Whit's statements about Aerodigestive / ENT32 statements
quoteI don't believe that the surgeons should be the ones doing the workup of these children.↗
▶Ep 1 · 13:36
quoteI don't believe that the surgeons should be the ones doing the workup of these children.↗
▶Ep 1 · 22:32
clinicalAn upper GI is really not a good study for reflux; it doesn't document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 1 · 22:32
quoteAn upper GI is really not a good study for reflux.↗
▶Ep 1 · 22:32
clinicalAn upper GI is really not a good study for reflux; it doesn't document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 1 · 22:32
quoteAn upper GI is really not a good study for reflux.↗
▶Ep 1 · 23:19
epidemiologicalIn a study of patients who had upper GI and pH studies, the upper GI did not help with diagnosing reflux, but it did help identify an anatomical problem in about 4% of patients.↗
▶Ep 1 · 23:19
epidemiologicalIn a study of patients who had upper GI and pH studies, the upper GI did not help with diagnosing reflux, but it did help identify an anatomical problem in about 4% of patients.↗
▶Ep 1 · 36:08
quoteI would like to thank Rachel for not sending that child who's retching preoperatively to the surgeons.↗
▶Ep 1 · 36:08
quoteI would like to thank Rachel for not sending that child who's retching preoperatively to the surgeons.↗
▶Ep 1 · 46:40
epidemiologicalIn Kansas City's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap; the primary reason for redo historically was transmigration of the wrap into the chest.↗
▶Ep 1 · 46:40
epidemiologicalIn Kansas City's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap; the primary reason for redo historically was transmigration of the wrap into the chest.↗
▶Ep 1 · 57:32
epidemiologicalBy doing minimal mobilization and not disrupting the phrenoesophageal membrane, we were able to drop our transmigration rate from 12% to 5%, and in our final study there was zero recurrence and zero redo fundoplication rate in both groups.↗
▶Ep 1 · 57:32
epidemiologicalBy doing minimal mobilization and not disrupting the phrenoesophageal membrane, we were able to drop our transmigration rate from 12% to 5%, and in our final study there was zero recurrence and zero redo fundoplication rate in both groups.↗
▶Ep 1 · 59:22
quoteThe surgical message that we should impart is that we need to do less rather than more dissection around the GE junction.↗
▶Ep 1 · 59:22
quoteThe surgical message that we should impart is that we need to do less rather than more dissection around the GE junction.↗
▶Ep 1 · 59:22
clinicalThe surgical message is that we need to do less rather than more dissection around the GE junction to prevent wrap transmigration.↗
▶Ep 1 · 59:22
clinicalThe surgical message is that we need to do less rather than more dissection around the GE junction to prevent wrap transmigration.↗
▶Ep 1 · 1:00:49
clinicalYou've got to know where the left gastric artery is, and you've got to be sure that you are cephalad to that to ensure the wrap is at the level of the lower esophagus, not the stomach.↗
▶Ep 1 · 1:00:49
clinicalYou've got to know where the left gastric artery is, and you've got to be sure that you are cephalad to that to ensure the wrap is at the level of the lower esophagus, not the stomach.↗
▶Ep 1 · 1:03:46
epidemiologicalUsing an esophageal bougie at the time of fundoplication has resulted in very little need for postoperative dilation; in all our prospective studies, we've dilated one or two patients.↗
▶Ep 1 · 1:03:46
epidemiologicalUsing an esophageal bougie at the time of fundoplication has resulted in very little need for postoperative dilation; in all our prospective studies, we've dilated one or two patients.↗
Gastroesophageal Reflux Disease
▶Ep 8 · 13:36
quoteI don't think that the surgeons should be the ones doing the workup of these children.↗
▶Ep 8 · 22:38
clinicalAn upper GI study does not document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 8 · 23:17
epidemiologicalIn a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients.↗
▶Ep 8 · 36:08
quoteI would like to thank Rachel for not sending that child who's wretching preoperatively to the surgeons.↗
▶Ep 8 · 46:40
clinicalIn Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique.↗
▶Ep 8 · 46:43
clinicalThe primary reason for redo fundoplication is transmigration of the wrap into the chest.↗
▶Ep 8 · 47:09
quoteWe spent 15 years or so trying to investigate this issue surgically and we feel like we've come up with, you know, what we call, you know, jokingly the perfect Nissen.↗
▶Ep 8 · 57:23
epidemiologicalBefore adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change.↗
▶Ep 8 · 1:00:49
clinicalThe key technical point is that the fundoplication wrap must be cephalad to the left gastric artery to ensure it's at the level of the lower esophagus rather than the stomach.↗
▶Ep 8 · 1:03:42
clinicalUsing an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation.↗
Whit's statements about Appendicitis132 statements
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 5 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 5 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 5 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 5 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 5 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 5 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 5 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 5 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 5 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 5 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 5 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 5 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Appendicitis with Dr. Whit Holcomb
▶Ep 6 · 1:53
quoteI would like to acknowledge that much of this work has been done and certainly has been spearheaded by Dr. Sean St. Peter, who directs our Center for Prospective Clinical Trials, and it is through his efforts and his leadership that much of the information that we'll discuss today has come about.↗
▶Ep 6 · 3:25
quoteif that case came in and the emergency physicians had not already performed an imaging study, which would be ultrasound usually initially at least today, then we would take that patient to the operating room. And perform a laparoscopic appendectomy.↗
▶Ep 6 · 3:25
clinicalClassic appendicitis presentation (umbilical pain migrating to right lower quadrant, nausea, vomiting, WBC 14, low-grade fever, McBurney's point tenderness) can be taken directly to OR without imaging study↗
▶Ep 6 · 5:11
clinicalSymptom duration of 24-36 hours generally does not indicate perforation, but duration longer than 36 hours likely indicates perforation if appendicitis is present↗
▶Ep 6 · 6:25
clinicalUltrasound may not be completely accurate for appendicitis diagnosis; if any concern on ultrasound, proceed to CT scan↗
▶Ep 6 · 7:28
clinicalNon-visualization of appendix on CT at 4 days should show secondary signs of appendicitis and perforation; if neither present, likelihood of appendicitis is low but not zero↗
▶Ep 6 · 8:40
clinicalChildren's Mercy uses IV contrast and limited CT scan focused on appendicitis to minimize radiation exposure↗
▶Ep 6 · 11:17
clinicalCeftriaxone (50 mg/kg) and metronidazole (30 mg/kg) once-daily dosing is the most cost-effective antibiotic combination for appendicitis and has similar efficacy to triple-antibiotic regimens↗
▶Ep 6 · 13:20
clinicalNon-perforated appendicitis patients receive only single preoperative dose of antibiotics; no postoperative antibiotics needed↗
▶Ep 6 · 14:18
clinicalProspective randomized trial (Journal of Pediatric Surgery 2008, 100 patients) found no difference in abscess rate or wound infections between ceftriaxone/metronidazole and ampicillin/gentamicin/clindamycin, with lower antibiotic charges for ceftriaxone/metronidazole↗
▶Ep 6 · 16:35
clinicalSingle-incision or double-incision laparoscopic approach used for thin patients with non-perforated appendicitis; three-port approach used for perforated cases↗
▶Ep 6 · 20:13
clinicalLocking grasper is important when exteriorizing appendix to prevent dropping it; non-locking graspers have resulted in several instances of appendix slipping off↗
▶Ep 6 · 20:13
quoteI think it's very important to use a locking grasper when you're bringing the appendix out through the abdominal cavity because If not, I've had several occasions where the appendix has slipped off the, the uh non-locking grasper↗
▶Ep 6 · 22:00
clinicalPerforation is strictly defined as stool in the abdomen (fecalith in peritoneal cavity) or a visible hole in the appendix↗
▶Ep 6 · 22:00
quotewe had to come up with a definition of perforation. And again, we have chosen stool in the appendix, meaning a fecal lith in the, uh, excuse me, stool in the abdomen, meaning a fecal lith in the abdominal cavity or a visible hole in the appendix.↗
▶Ep 6 · 24:45
quotewe have been sending our non-perforated appendix patients home the same day. Now that's assuming that it's not 1 in the morning or something like that, but as a general statement, we do not do appendectomies past 7 or 8 o'clock at night.↗
▶Ep 6 · 24:45
clinicalNon-perforated appendicitis patients are discharged home same day (within 6 hours) if surgery completed by 7-8 PM; over 100 patients managed this way with minimal returns↗
▶Ep 6 · 28:37
clinicalSingle-incision laparoscopic appendectomy had 5 minutes longer operative time than three-port (statistically significant but not clinically relevant), higher surgical difficulty scores, and greater hospital charges↗
▶Ep 6 · 28:37
clinicalAnnals of Surgery 2011 randomized trial (360 patients, non-perforated appendicitis): no difference in wound infection rate (3.3% single-incision vs 1.7% three-port, p=0.5), time to regular diet, length of stay, or return to activity between single-incision and three-port laparoscopy↗
▶Ep 6 · 30:23
quotein this study, There was no difference in wound infection rate, which we were concerned about because the appendix is being exteriorized through the umbilicus↗
▶Ep 6 · 33:00
clinicalProspective study comparing irrigation plus suctioning versus suctioning alone in perforated appendicitis found no difference in abscess rate (both approximately 20%) or abscess location↗
▶Ep 6 · 34:28
quotethere was no difference between the use of irrigation and the use of suction without irrigation. I think, I think it's also an interesting way to look at it is there was no detriment to using irrigation as well if folks wanted to continue to use irrigation.↗
▶Ep 6 · 34:42
opinionSurgeons who report lower abscess rates for perforation may be including gangrenous or necrotic appendicitis (not truly perforated) in their perforated group, which lowers the abscess rate↗
▶Ep 6 · 34:42
epidemiologicalAbscess rate for perforated appendicitis has been consistently 15-20% across 6-7 prospective studies at Children's Mercy↗
▶Ep 6 · 34:42
quotein every study for perforated disease. And so I tell families 20%, uh, and I think that's a pretty good ballpark for the, the, um Development of an abscess.↗
▶Ep 6 · 37:03
clinicalAt Children's Mercy, staplers are cost-effective for appendectomy when OR billing is $225/minute; if stapler costs $600 and saves 3 minutes, it is cost-effective↗
▶Ep 6 · 42:05
clinicalStandard protocol for perforated appendicitis: 5 days IV antibiotics (ceftriaxone and metronidazole once daily); discharge criteria are afebrile, normal WBC on day 5, tolerating regular diet↗
▶Ep 6 · 42:05
clinicalAlmost all postoperative abscesses in perforated appendicitis develop in-hospital, not after discharge↗
▶Ep 6 · 42:05
quoteIn our experience, almost all, not all, but almost all of the patients who develop an abscess postoperatively develop it in the hospital. So we have not, we've had very few patients actually go home and come back with the development of a, uh, of an abscess.↗
▶Ep 6 · 45:34
clinicalRandomized trial comparing 5 days IV antibiotics versus early discharge with oral Augmentin (to complete 7 total days) found no difference in abscess rates; 40% of early-discharge group went home before day 5↗
▶Ep 6 · 45:34
quotemy take-home message is about 40% of patients can go home before that 5-day period with those criteria that I, um, that I just discussed being uh afebrile. And um a normal white count and um tolerating a regular diet.↗
▶Ep 6 · 49:23
clinicalJournal of Pediatric Surgery 2010 study (40 patients): immediate laparoscopic appendectomy versus initial non-operative management with interval appendectomy for well-defined abscess showed no difference in total hospitalization, recurrent abscess rates, or overall charges↗
▶Ep 6 · 49:23
clinicalImmediate appendectomy for abscess takes longer than interval appendectomy (61 minutes vs 42 minutes)↗
▶Ep 6 · 49:23
opinionFor well-defined abscess at 5-7 days, prefer initial non-operative management with interval appendectomy at 8-10 weeks; for 3-4 day presentations, still operate acutely↗
▶Ep 6 · 49:23
quotethe way we interpreted this study really is that you can do either way. It's surgeon preference. If you prefer to go ahead and operate on the patients and accept the potential complications from a difficult operation, that's fine. If you'd rather treat the patient initially non-operatively with drainage and antibiotics and come back for a Uh, interval appendectomy, then that's fine as well.↗
▶Ep 6 · 54:50
opinionCurrent data on non-operative appendicitis management is not mature enough to change practice; same-day surgery remains standard until more data available in 5 years↗
▶Ep 6 · 57:28
clinicalCurrent practice at Children's Mercy: proceed with interval laparoscopic appendectomy at 8-10 weeks after non-operative management of perforated appendicitis; families prefer this to avoid future appendicitis episodes↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 10 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 10 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 10 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 10 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 10 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 10 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 10 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 10 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 10 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 10 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 10 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 10 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Evidence-based diagnosis and management of pediatric appendicitis with Dr. Whit Holcomb
▶Ep 12 · 1:53
quotemuch of this work has been done and certainly has been spearheaded by Dr. Sean St. Peter, who directs our Center for Prospective Clinical Trials, and it is through his efforts and his leadership that much of the information that we'll discuss today has come about↗
▶Ep 12 · 3:25
clinicalClassic acute appendicitis presentation (pain migration to right lower quadrant, McBurney's point tenderness, elevated WBC and CRP, low-grade fever in thin patient with short symptom duration) can proceed directly to laparoscopic appendectomy without imaging↗
▶Ep 12 · 3:25
quoteif that case came in and the emergency physicians had not already performed an imaging study, which would be ultrasound usually initially at least today, then we would take that patient to the operating room↗
▶Ep 12 · 4:00
clinicalAt Children's Mercy Hospital, emergency department physicians often perform imaging studies before surgical consultation, though this is at their discretion not surgeon direction↗
▶Ep 12 · 5:11
clinicalSymptom duration over 24-36 hours raises concern for perforation and warrants imaging starting with ultrasound↗
▶Ep 12 · 6:25
clinicalIf ultrasound is not diagnostic but raises concern, proceed to CT scan; if ultrasound is diagnostic of appendicitis, CT is not needed↗
▶Ep 12 · 7:28
clinicalNon-visualization of appendix on CT at 4 days should show secondary signs of appendicitis and likely perforation; absence of both findings makes appendicitis unlikely though not zero↗
▶Ep 12 · 8:40
clinicalChildren's Mercy uses IV contrast for CT and performs limited/focused CT scans to minimize radiation exposure; rectal contrast protocol was attempted but not adopted by ED physicians↗
▶Ep 12 · 11:11
clinicalCeftriaxone and metronidazole is the most cost-effective antibiotic combination for appendicitis and has similar efficacy to triple antibiotic regimens↗
▶Ep 12 · 12:58
clinicalNon-perforated appendicitis receives only single preoperative antibiotic dose with no postoperative antibiotics↗
▶Ep 12 · 13:29
clinicalOnce-daily ceftriaxone/metronidazole dosing facilitates home health care transition if needed, does not require serum levels like gentamicin, and avoids gentamicin toxicities↗
▶Ep 12 · 14:18
clinicalIn 2008 Journal of Pediatric Surgery randomized trial of 100 patients, daily ceftriaxone/metronidazole showed no difference in abscess rate or wound infections versus ampicillin/gentamicin/clindamycin but resulted in lower antibiotic charges↗
▶Ep 12 · 15:11
clinicalCeftriaxone dosing is 50 mg/kg once daily and metronidazole is 30 mg/kg once daily for appendicitis↗
▶Ep 12 · 16:35
clinicalSingle-incision or double-incision laparoscopic approaches are used only for thin patients with non-perforated appendicitis↗
▶Ep 12 · 17:51
clinicalIn double-incision approach, 5mm umbilical port is placed with 5mm suprapubic port for mobilization, then appendix is exteriorized through umbilicus for extracorporeal appendectomy↗
▶Ep 12 · 19:40
quoteI think it's very important to use a locking grasper when you're bringing the appendix out through the abdominal cavity because If not, I've had several occasions where the appendix has slipped off the, the uh non-locking grasper↗
▶Ep 12 · 19:40
clinicalLocking grasper is essential when exteriorizing appendix to prevent dropping it back into abdomen↗
▶Ep 12 · 20:53
clinicalFascial incision of 10-12mm is needed to safely exteriorize appendix because grasper creates U-shaped configuration rather than end-on grasp↗
▶Ep 12 · 21:58
clinicalPerforation is strictly defined as stool in the abdomen (fecalith in abdominal cavity) or a visible hole in the appendix; without these findings the patient does not have perforation↗
▶Ep 12 · 21:58
clinicalThis strict perforation definition was necessary because literature uses terms like gangrenous, necrotic, and perforated inconsistently, all meaning different things to different surgeons↗
▶Ep 12 · 24:45
quotewe're trying to send the non-perforated patients home within around 6 hours of having their appendectomy↗
▶Ep 12 · 25:46
clinicalSame-day discharge for non-perforated appendicitis uses local anesthesia in incisions, pain medications at home, and no postoperative antibiotics↗
▶Ep 12 · 25:46
clinicalChildren's Mercy has been sending non-perforated appendicitis patients home the same day (within 6 hours of surgery) for over a year with over 100 patients managed this way↗
▶Ep 12 · 27:33
quoteI can see down the line. A nice randomized trial of antibiotics versus day surgery appendicitis, if you will, for acute appendicitis↗
▶Ep 12 · 27:33
opinionRationale for same-day discharge includes patient satisfaction, opening hospital beds for patients who need them, and preparing for potential future trials of antibiotics versus day-surgery appendectomy↗
▶Ep 12 · 28:30
clinicalSingle-incision approach had longer operative time (5 minutes, statistically significant but not clinically relevant), more narcotic doses, greater surgical difficulty, and higher hospital charges than three-port↗
▶Ep 12 · 28:30
clinicalSingle-incision appendectomy showed no difference versus three-port in wound infection rate, time to regular diet, length of hospitalization, or time to return to full activity↗
▶Ep 12 · 28:30
clinicalOctober 2011 Annals of Surgery study randomized 360 patients (August 2009-November 2010) comparing single-incision to three-port laparoscopy for non-perforated appendicitis↗
▶Ep 12 · 31:32
clinicalFor single-incision approach, umbilical fascia is closed and interrupted plain sutures placed in umbilical skin; for three-port, umbilical incision closed similarly and 5mm port sites closed with 5-0 Vicryl in U-fashion↗
▶Ep 12 · 32:09
clinicalInterrupted plain sutures allow wound infection drainage while not requiring removal due to short half-life; wounds dressed with rolled gauze and Tegaderm↗
▶Ep 12 · 33:00
clinicalStudy used strict perforation definition (hole in appendix or fecalith in abdomen), not just distended, angry, necrotic, or gangrenous appendix↗
▶Ep 12 · 33:00
clinicalSt. Peter study compared irrigation plus suction versus suction-only for perforated appendicitis and found no difference in abscess rate or location; both groups had approximately 20% postoperative abscess rate↗
▶Ep 12 · 34:28
quotein every study for perforated disease. And so I tell families 20%, uh, and I think that's a pretty good ballpark for the, the, um Development of an abscess↗
▶Ep 12 · 34:28
opinionSurgeons reporting lower abscess rates for perforation likely include gangrenous/necrotic non-perforated cases in their perforated group, lowering the rate↗
▶Ep 12 · 34:28
clinicalAcross 6-7 appendectomy studies for perforated disease at Children's Mercy, abscess rate has consistently been 15-20%; Holcomb counsels families on 20% abscess risk↗
▶Ep 12 · 38:21
clinicalWhen using cautery for appendectomy, must carefully watch entire field to prevent electrical arc to adjacent small bowel loops↗
▶Ep 12 · 38:21
clinicalStandard stapler load is used for appendix and vascular load for mesoappendix, which is another reason not to staple both simultaneously↗
▶Ep 12 · 38:21
clinicalChildren's Mercy surgeons use stapler for both mesoappendix and appendix because it can be justified as cost-effective under their per-minute billing model↗
▶Ep 12 · 38:21
clinicalAt Children's Mercy, OR billing is $225 per minute; a $600 stapler is cost-effective if it saves 3 minutes of OR time↗
▶Ep 12 · 38:21
clinicalIn early 1990s at Vanderbilt, three children who had cautery used for appendectomy developed adjacent small bowel injuries requiring reoperation due to electrical arc↗
▶Ep 12 · 38:21
quoteif you do use cautery, I think it's important to be sure to watch everything that's going on↗
▶Ep 12 · 39:48
clinicalMurky fluid throughout abdomen in non-perforated appendicitis is very unusual and would prompt placement of additional port for better visualization and investigation of source↗
▶Ep 12 · 39:48
clinicalIn single-incision approach, pelvic fluid should be suctioned before incising the bridge between ports because it becomes difficult to suction after appendix removal↗
▶Ep 12 · 41:15
clinicalFor normal appendix found at surgery, if imaging study was done preoperatively, full small bowel run is often not performed; without prior imaging, full small bowel examination is done↗
▶Ep 12 · 42:05
clinicalIf WBC elevated on day 5, patient receives 2 additional days of antibiotics and repeat WBC; if still elevated, receives 3 more days and CT scan to look for abscess↗
▶Ep 12 · 42:05
clinicalInitial perforated appendicitis protocol at Children's Mercy was 5 days of IV antibiotics postoperatively, developed when beginning prospective randomized trials↗
▶Ep 12 · 42:05
clinicalDischarge criteria for perforated appendicitis: normal WBC on day 5, afebrile, tolerating regular diet; then discharged without oral antibiotics↗
▶Ep 12 · 42:05
clinicalEarly discharge study found no difference in postoperative abscess rate between groups; 40% of patients in early discharge group went home before day 5↗
▶Ep 12 · 42:05
clinicalFollow-up study randomized 100 patients (50 per group) comparing mandatory 5 days IV antibiotics versus early discharge with oral Augmentin to complete 7 total days if discharge criteria met↗
▶Ep 12 · 42:05
clinicalAlmost all postoperative abscesses in perforated appendicitis develop while patient is in hospital, very few develop after discharge↗
▶Ep 12 · 42:05
quotealmost all, not all, but almost all of the patients who develop an abscess postoperatively develop it in the hospital↗
▶Ep 12 · 46:12
clinical2010 Journal of Pediatric Surgery study of 40 patients compared initial appendectomy versus initial non-operative management with interval appendectomy for well-defined abscess from perforated appendicitis↗
▶Ep 12 · 46:12
clinicalInterval appendectomy is performed 8-10 weeks after non-operative abscess management and is becoming a day surgery procedure↗
▶Ep 12 · 46:12
opinionHolcomb prefers initial non-operative management with interval appendectomy because immediate operations can be difficult, patients have prolonged hospitalization, bad ileus, sometimes need NG tube, and risk recurrent abscess complications↗
▶Ep 12 · 46:12
clinicalInitial appendectomy took longer (61 minutes) versus interval appendectomy (42 minutes)↗
▶Ep 12 · 46:12
clinicalStudy found no difference between immediate versus interval appendectomy in total length of hospitalization, recurrent abscess rates, or overall charges↗
▶Ep 12 · 46:12
quoteit's easier on the patient and it's easier on the surgeon. To treat them non-operatively and then allow the inflammation to quiet down and return 8 to 10 weeks later for an interval laparoscopic appendectomy↗
▶Ep 12 · 46:12
clinicalFor well-defined abscess at 5-6 days symptom duration, two options exist: immediate appendectomy or non-operative management with interval appendectomy↗
▶Ep 12 · 50:23
clinicalAt 3-4 days symptom duration, would operate; at 6-7 days with well-defined abscess, would treat non-operatively; 5 days is transition zone requiring clinical judgment↗
▶Ep 12 · 51:01
opinionEven if abscess can be managed for 2 weeks non-operatively, that operation is much easier than going in early through dense inflammation and purulent material↗
▶Ep 12 · 52:18
opinionCurrent data is not mature enough to justify non-operative management, especially when patients can have surgery and go home same day returning to routine activities↗
▶Ep 12 · 52:18
clinicalCurrent data suggests 50-60% of patients could likely be managed non-operatively with antibiotics↗
▶Ep 12 · 52:18
opinionHigh-quality studies on non-operative appendicitis management will emerge in next 5 years showing good percentage can be treated without operation↗
▶Ep 12 · 52:18
opinionLong-term follow-up of 25-30 years will be needed to determine if non-operatively treated patients develop recurrent appendicitis years later↗
▶Ep 12 · 52:18
opinionInflammation and infection may cause appendiceal scarring leading to closed-loop obstruction and recurrent appendicitis, but this won't be known for 25-30 years↗
▶Ep 12 · 56:15
opinionLonger-term data (5, 10, 20 years) is needed to determine true recurrence rate after non-operative management; if patients return years later, this justifies interval appendectomy when young↗
▶Ep 12 · 57:28
clinicalChildren's Mercy currently proceeds with interval laparoscopic appendectomy after non-operative abscess management because families do not want child at risk for recurrent appendicitis↗
quoteSo I'm gonna present on the uh mundane topic of perforated appendicitis.↗
▶Ep 13 · 8:11
quoteYeah, so I would say that's because of the definition that we used.↗
▶Ep 13 · 10:51
opinionThe best quality study on irrigation showed no difference in outcomes, while a more recent but less well-designed study showed a difference favoring standardized large-volume irrigation.↗
▶Ep 13 · 10:51
quoteUh, the answer is we don't have an answer. The, the best quality study said no difference. The more recent study that was, uh, Uh, not as a well-designed study did show a difference. I, I do think it's, it really would behoove all of us if we came up with some standardized definitions. So we're all talking about the, the same disease process.↗
Whit's statements about Appendicitis128 statements
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 4 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 4 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 4 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 4 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 4 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 4 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 4 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 4 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 4 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 4 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 4 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 4 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Appendicitis with Dr. Whit Holcomb
▶Ep 5 · 1:53
quoteI would like to acknowledge that much of this work has been done and certainly has been spearheaded by Dr. Sean St. Peter, who directs our Center for Prospective Clinical Trials, and it is through his efforts and his leadership that much of the information that we'll discuss today has come about.↗
▶Ep 5 · 3:25
clinicalClassic appendicitis presentation (umbilical pain migrating to right lower quadrant, nausea, vomiting, WBC 14, low-grade fever, McBurney's point tenderness) can be taken directly to OR without imaging study↗
▶Ep 5 · 3:25
quoteif that case came in and the emergency physicians had not already performed an imaging study, which would be ultrasound usually initially at least today, then we would take that patient to the operating room. And perform a laparoscopic appendectomy.↗
▶Ep 5 · 5:11
clinicalSymptom duration of 24-36 hours generally does not indicate perforation, but duration longer than 36 hours likely indicates perforation if appendicitis is present↗
▶Ep 5 · 6:25
clinicalUltrasound may not be completely accurate for appendicitis diagnosis; if any concern on ultrasound, proceed to CT scan↗
▶Ep 5 · 7:28
clinicalNon-visualization of appendix on CT at 4 days should show secondary signs of appendicitis and perforation; if neither present, likelihood of appendicitis is low but not zero↗
▶Ep 5 · 8:40
clinicalChildren's Mercy uses IV contrast and limited CT scan focused on appendicitis to minimize radiation exposure↗
▶Ep 5 · 11:17
clinicalCeftriaxone (50 mg/kg) and metronidazole (30 mg/kg) once-daily dosing is the most cost-effective antibiotic combination for appendicitis and has similar efficacy to triple-antibiotic regimens↗
▶Ep 5 · 13:20
clinicalNon-perforated appendicitis patients receive only single preoperative dose of antibiotics; no postoperative antibiotics needed↗
▶Ep 5 · 14:18
clinicalProspective randomized trial (Journal of Pediatric Surgery 2008, 100 patients) found no difference in abscess rate or wound infections between ceftriaxone/metronidazole and ampicillin/gentamicin/clindamycin, with lower antibiotic charges for ceftriaxone/metronidazole↗
▶Ep 5 · 16:35
clinicalSingle-incision or double-incision laparoscopic approach used for thin patients with non-perforated appendicitis; three-port approach used for perforated cases↗
▶Ep 5 · 20:13
clinicalLocking grasper is important when exteriorizing appendix to prevent dropping it; non-locking graspers have resulted in several instances of appendix slipping off↗
▶Ep 5 · 20:13
quoteI think it's very important to use a locking grasper when you're bringing the appendix out through the abdominal cavity because If not, I've had several occasions where the appendix has slipped off the, the uh non-locking grasper↗
▶Ep 5 · 22:00
quotewe had to come up with a definition of perforation. And again, we have chosen stool in the appendix, meaning a fecal lith in the, uh, excuse me, stool in the abdomen, meaning a fecal lith in the abdominal cavity or a visible hole in the appendix.↗
▶Ep 5 · 22:00
clinicalPerforation is strictly defined as stool in the abdomen (fecalith in peritoneal cavity) or a visible hole in the appendix↗
▶Ep 5 · 24:45
quotewe have been sending our non-perforated appendix patients home the same day. Now that's assuming that it's not 1 in the morning or something like that, but as a general statement, we do not do appendectomies past 7 or 8 o'clock at night.↗
▶Ep 5 · 24:45
clinicalNon-perforated appendicitis patients are discharged home same day (within 6 hours) if surgery completed by 7-8 PM; over 100 patients managed this way with minimal returns↗
▶Ep 5 · 28:37
clinicalAnnals of Surgery 2011 randomized trial (360 patients, non-perforated appendicitis): no difference in wound infection rate (3.3% single-incision vs 1.7% three-port, p=0.5), time to regular diet, length of stay, or return to activity between single-incision and three-port laparoscopy↗
▶Ep 5 · 28:37
clinicalSingle-incision laparoscopic appendectomy had 5 minutes longer operative time than three-port (statistically significant but not clinically relevant), higher surgical difficulty scores, and greater hospital charges↗
▶Ep 5 · 30:23
quotein this study, There was no difference in wound infection rate, which we were concerned about because the appendix is being exteriorized through the umbilicus↗
▶Ep 5 · 33:00
clinicalProspective study comparing irrigation plus suctioning versus suctioning alone in perforated appendicitis found no difference in abscess rate (both approximately 20%) or abscess location↗
▶Ep 5 · 34:28
quotethere was no difference between the use of irrigation and the use of suction without irrigation. I think, I think it's also an interesting way to look at it is there was no detriment to using irrigation as well if folks wanted to continue to use irrigation.↗
▶Ep 5 · 34:42
quotein every study for perforated disease. And so I tell families 20%, uh, and I think that's a pretty good ballpark for the, the, um Development of an abscess.↗
▶Ep 5 · 34:42
opinionSurgeons who report lower abscess rates for perforation may be including gangrenous or necrotic appendicitis (not truly perforated) in their perforated group, which lowers the abscess rate↗
▶Ep 5 · 34:42
epidemiologicalAbscess rate for perforated appendicitis has been consistently 15-20% across 6-7 prospective studies at Children's Mercy↗
▶Ep 5 · 37:03
clinicalAt Children's Mercy, staplers are cost-effective for appendectomy when OR billing is $225/minute; if stapler costs $600 and saves 3 minutes, it is cost-effective↗
▶Ep 5 · 42:05
clinicalStandard protocol for perforated appendicitis: 5 days IV antibiotics (ceftriaxone and metronidazole once daily); discharge criteria are afebrile, normal WBC on day 5, tolerating regular diet↗
▶Ep 5 · 42:05
clinicalAlmost all postoperative abscesses in perforated appendicitis develop in-hospital, not after discharge↗
▶Ep 5 · 42:05
quoteIn our experience, almost all, not all, but almost all of the patients who develop an abscess postoperatively develop it in the hospital. So we have not, we've had very few patients actually go home and come back with the development of a, uh, of an abscess.↗
▶Ep 5 · 45:34
clinicalRandomized trial comparing 5 days IV antibiotics versus early discharge with oral Augmentin (to complete 7 total days) found no difference in abscess rates; 40% of early-discharge group went home before day 5↗
▶Ep 5 · 45:34
quotemy take-home message is about 40% of patients can go home before that 5-day period with those criteria that I, um, that I just discussed being uh afebrile. And um a normal white count and um tolerating a regular diet.↗
▶Ep 5 · 49:23
opinionFor well-defined abscess at 5-7 days, prefer initial non-operative management with interval appendectomy at 8-10 weeks; for 3-4 day presentations, still operate acutely↗
▶Ep 5 · 49:23
clinicalJournal of Pediatric Surgery 2010 study (40 patients): immediate laparoscopic appendectomy versus initial non-operative management with interval appendectomy for well-defined abscess showed no difference in total hospitalization, recurrent abscess rates, or overall charges↗
▶Ep 5 · 49:23
clinicalImmediate appendectomy for abscess takes longer than interval appendectomy (61 minutes vs 42 minutes)↗
▶Ep 5 · 49:23
quotethe way we interpreted this study really is that you can do either way. It's surgeon preference. If you prefer to go ahead and operate on the patients and accept the potential complications from a difficult operation, that's fine. If you'd rather treat the patient initially non-operatively with drainage and antibiotics and come back for a Uh, interval appendectomy, then that's fine as well.↗
▶Ep 5 · 54:50
opinionCurrent data on non-operative appendicitis management is not mature enough to change practice; same-day surgery remains standard until more data available in 5 years↗
▶Ep 5 · 57:28
clinicalCurrent practice at Children's Mercy: proceed with interval laparoscopic appendectomy at 8-10 weeks after non-operative management of perforated appendicitis; families prefer this to avoid future appendicitis episodes↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 7 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 7 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 7 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 7 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 7 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 7 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 7 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 7 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 7 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 7 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 7 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 7 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Evidence-based diagnosis and management of pediatric appendicitis with Dr. Whit Holcomb
▶Ep 9 · 1:53
quotemuch of this work has been done and certainly has been spearheaded by Dr. Sean St. Peter, who directs our Center for Prospective Clinical Trials, and it is through his efforts and his leadership that much of the information that we'll discuss today has come about↗
▶Ep 9 · 3:25
quoteif that case came in and the emergency physicians had not already performed an imaging study, which would be ultrasound usually initially at least today, then we would take that patient to the operating room↗
▶Ep 9 · 3:25
clinicalClassic acute appendicitis presentation (pain migration to right lower quadrant, McBurney's point tenderness, elevated WBC and CRP, low-grade fever in thin patient with short symptom duration) can proceed directly to laparoscopic appendectomy without imaging↗
▶Ep 9 · 4:00
clinicalAt Children's Mercy Hospital, emergency department physicians often perform imaging studies before surgical consultation, though this is at their discretion not surgeon direction↗
▶Ep 9 · 5:11
clinicalSymptom duration over 24-36 hours raises concern for perforation and warrants imaging starting with ultrasound↗
▶Ep 9 · 6:25
clinicalIf ultrasound is not diagnostic but raises concern, proceed to CT scan; if ultrasound is diagnostic of appendicitis, CT is not needed↗
▶Ep 9 · 7:28
clinicalNon-visualization of appendix on CT at 4 days should show secondary signs of appendicitis and likely perforation; absence of both findings makes appendicitis unlikely though not zero↗
▶Ep 9 · 8:40
clinicalChildren's Mercy uses IV contrast for CT and performs limited/focused CT scans to minimize radiation exposure; rectal contrast protocol was attempted but not adopted by ED physicians↗
▶Ep 9 · 11:11
clinicalCeftriaxone and metronidazole is the most cost-effective antibiotic combination for appendicitis and has similar efficacy to triple antibiotic regimens↗
▶Ep 9 · 12:58
clinicalNon-perforated appendicitis receives only single preoperative antibiotic dose with no postoperative antibiotics↗
▶Ep 9 · 13:29
clinicalOnce-daily ceftriaxone/metronidazole dosing facilitates home health care transition if needed, does not require serum levels like gentamicin, and avoids gentamicin toxicities↗
▶Ep 9 · 14:18
clinicalIn 2008 Journal of Pediatric Surgery randomized trial of 100 patients, daily ceftriaxone/metronidazole showed no difference in abscess rate or wound infections versus ampicillin/gentamicin/clindamycin but resulted in lower antibiotic charges↗
▶Ep 9 · 15:11
clinicalCeftriaxone dosing is 50 mg/kg once daily and metronidazole is 30 mg/kg once daily for appendicitis↗
▶Ep 9 · 16:35
clinicalSingle-incision or double-incision laparoscopic approaches are used only for thin patients with non-perforated appendicitis↗
▶Ep 9 · 17:51
clinicalIn double-incision approach, 5mm umbilical port is placed with 5mm suprapubic port for mobilization, then appendix is exteriorized through umbilicus for extracorporeal appendectomy↗
▶Ep 9 · 19:40
clinicalLocking grasper is essential when exteriorizing appendix to prevent dropping it back into abdomen↗
▶Ep 9 · 19:40
quoteI think it's very important to use a locking grasper when you're bringing the appendix out through the abdominal cavity because If not, I've had several occasions where the appendix has slipped off the, the uh non-locking grasper↗
▶Ep 9 · 20:53
clinicalFascial incision of 10-12mm is needed to safely exteriorize appendix because grasper creates U-shaped configuration rather than end-on grasp↗
▶Ep 9 · 21:58
clinicalPerforation is strictly defined as stool in the abdomen (fecalith in abdominal cavity) or a visible hole in the appendix; without these findings the patient does not have perforation↗
▶Ep 9 · 21:58
clinicalThis strict perforation definition was necessary because literature uses terms like gangrenous, necrotic, and perforated inconsistently, all meaning different things to different surgeons↗
▶Ep 9 · 24:45
quotewe're trying to send the non-perforated patients home within around 6 hours of having their appendectomy↗
▶Ep 9 · 25:46
clinicalChildren's Mercy has been sending non-perforated appendicitis patients home the same day (within 6 hours of surgery) for over a year with over 100 patients managed this way↗
▶Ep 9 · 25:46
clinicalSame-day discharge for non-perforated appendicitis uses local anesthesia in incisions, pain medications at home, and no postoperative antibiotics↗
▶Ep 9 · 27:33
opinionRationale for same-day discharge includes patient satisfaction, opening hospital beds for patients who need them, and preparing for potential future trials of antibiotics versus day-surgery appendectomy↗
▶Ep 9 · 27:33
quoteI can see down the line. A nice randomized trial of antibiotics versus day surgery appendicitis, if you will, for acute appendicitis↗
▶Ep 9 · 28:30
clinicalSingle-incision approach had longer operative time (5 minutes, statistically significant but not clinically relevant), more narcotic doses, greater surgical difficulty, and higher hospital charges than three-port↗
▶Ep 9 · 28:30
clinicalSingle-incision appendectomy showed no difference versus three-port in wound infection rate, time to regular diet, length of hospitalization, or time to return to full activity↗
▶Ep 9 · 28:30
clinicalOctober 2011 Annals of Surgery study randomized 360 patients (August 2009-November 2010) comparing single-incision to three-port laparoscopy for non-perforated appendicitis↗
▶Ep 9 · 31:32
clinicalFor single-incision approach, umbilical fascia is closed and interrupted plain sutures placed in umbilical skin; for three-port, umbilical incision closed similarly and 5mm port sites closed with 5-0 Vicryl in U-fashion↗
▶Ep 9 · 32:09
clinicalInterrupted plain sutures allow wound infection drainage while not requiring removal due to short half-life; wounds dressed with rolled gauze and Tegaderm↗
▶Ep 9 · 33:00
clinicalSt. Peter study compared irrigation plus suction versus suction-only for perforated appendicitis and found no difference in abscess rate or location; both groups had approximately 20% postoperative abscess rate↗
▶Ep 9 · 33:00
clinicalStudy used strict perforation definition (hole in appendix or fecalith in abdomen), not just distended, angry, necrotic, or gangrenous appendix↗
▶Ep 9 · 34:28
quotein every study for perforated disease. And so I tell families 20%, uh, and I think that's a pretty good ballpark for the, the, um Development of an abscess↗
▶Ep 9 · 34:28
opinionSurgeons reporting lower abscess rates for perforation likely include gangrenous/necrotic non-perforated cases in their perforated group, lowering the rate↗
▶Ep 9 · 34:28
clinicalAcross 6-7 appendectomy studies for perforated disease at Children's Mercy, abscess rate has consistently been 15-20%; Holcomb counsels families on 20% abscess risk↗
▶Ep 9 · 38:21
quoteif you do use cautery, I think it's important to be sure to watch everything that's going on↗
▶Ep 9 · 38:21
clinicalIn early 1990s at Vanderbilt, three children who had cautery used for appendectomy developed adjacent small bowel injuries requiring reoperation due to electrical arc↗
▶Ep 9 · 38:21
clinicalWhen using cautery for appendectomy, must carefully watch entire field to prevent electrical arc to adjacent small bowel loops↗
▶Ep 9 · 38:21
clinicalStandard stapler load is used for appendix and vascular load for mesoappendix, which is another reason not to staple both simultaneously↗
▶Ep 9 · 38:21
clinicalChildren's Mercy surgeons use stapler for both mesoappendix and appendix because it can be justified as cost-effective under their per-minute billing model↗
▶Ep 9 · 38:21
clinicalAt Children's Mercy, OR billing is $225 per minute; a $600 stapler is cost-effective if it saves 3 minutes of OR time↗
▶Ep 9 · 39:48
clinicalMurky fluid throughout abdomen in non-perforated appendicitis is very unusual and would prompt placement of additional port for better visualization and investigation of source↗
▶Ep 9 · 39:48
clinicalIn single-incision approach, pelvic fluid should be suctioned before incising the bridge between ports because it becomes difficult to suction after appendix removal↗
▶Ep 9 · 41:15
clinicalFor normal appendix found at surgery, if imaging study was done preoperatively, full small bowel run is often not performed; without prior imaging, full small bowel examination is done↗
▶Ep 9 · 42:05
clinicalAlmost all postoperative abscesses in perforated appendicitis develop while patient is in hospital, very few develop after discharge↗
▶Ep 9 · 42:05
clinicalFollow-up study randomized 100 patients (50 per group) comparing mandatory 5 days IV antibiotics versus early discharge with oral Augmentin to complete 7 total days if discharge criteria met↗
▶Ep 9 · 42:05
clinicalInitial perforated appendicitis protocol at Children's Mercy was 5 days of IV antibiotics postoperatively, developed when beginning prospective randomized trials↗
▶Ep 9 · 42:05
clinicalDischarge criteria for perforated appendicitis: normal WBC on day 5, afebrile, tolerating regular diet; then discharged without oral antibiotics↗
▶Ep 9 · 42:05
clinicalIf WBC elevated on day 5, patient receives 2 additional days of antibiotics and repeat WBC; if still elevated, receives 3 more days and CT scan to look for abscess↗
▶Ep 9 · 42:05
clinicalEarly discharge study found no difference in postoperative abscess rate between groups; 40% of patients in early discharge group went home before day 5↗
▶Ep 9 · 42:05
quotealmost all, not all, but almost all of the patients who develop an abscess postoperatively develop it in the hospital↗
▶Ep 9 · 46:12
clinicalFor well-defined abscess at 5-6 days symptom duration, two options exist: immediate appendectomy or non-operative management with interval appendectomy↗
▶Ep 9 · 46:12
clinical2010 Journal of Pediatric Surgery study of 40 patients compared initial appendectomy versus initial non-operative management with interval appendectomy for well-defined abscess from perforated appendicitis↗
▶Ep 9 · 46:12
clinicalStudy found no difference between immediate versus interval appendectomy in total length of hospitalization, recurrent abscess rates, or overall charges↗
▶Ep 9 · 46:12
clinicalInitial appendectomy took longer (61 minutes) versus interval appendectomy (42 minutes)↗
▶Ep 9 · 46:12
opinionHolcomb prefers initial non-operative management with interval appendectomy because immediate operations can be difficult, patients have prolonged hospitalization, bad ileus, sometimes need NG tube, and risk recurrent abscess complications↗
▶Ep 9 · 46:12
clinicalInterval appendectomy is performed 8-10 weeks after non-operative abscess management and is becoming a day surgery procedure↗
▶Ep 9 · 46:12
quoteit's easier on the patient and it's easier on the surgeon. To treat them non-operatively and then allow the inflammation to quiet down and return 8 to 10 weeks later for an interval laparoscopic appendectomy↗
▶Ep 9 · 50:23
clinicalAt 3-4 days symptom duration, would operate; at 6-7 days with well-defined abscess, would treat non-operatively; 5 days is transition zone requiring clinical judgment↗
▶Ep 9 · 51:01
opinionEven if abscess can be managed for 2 weeks non-operatively, that operation is much easier than going in early through dense inflammation and purulent material↗
▶Ep 9 · 52:18
opinionCurrent data is not mature enough to justify non-operative management, especially when patients can have surgery and go home same day returning to routine activities↗
▶Ep 9 · 52:18
opinionInflammation and infection may cause appendiceal scarring leading to closed-loop obstruction and recurrent appendicitis, but this won't be known for 25-30 years↗
▶Ep 9 · 52:18
opinionLong-term follow-up of 25-30 years will be needed to determine if non-operatively treated patients develop recurrent appendicitis years later↗
▶Ep 9 · 52:18
opinionHigh-quality studies on non-operative appendicitis management will emerge in next 5 years showing good percentage can be treated without operation↗
▶Ep 9 · 52:18
clinicalCurrent data suggests 50-60% of patients could likely be managed non-operatively with antibiotics↗
▶Ep 9 · 56:15
opinionLonger-term data (5, 10, 20 years) is needed to determine true recurrence rate after non-operative management; if patients return years later, this justifies interval appendectomy when young↗
▶Ep 9 · 57:28
clinicalChildren's Mercy currently proceeds with interval laparoscopic appendectomy after non-operative abscess management because families do not want child at risk for recurrent appendicitis↗
Evidence-based diagnosis and management of pediatric appendicitis with Dr. Whit Holcomb
▶Ep 7 · 1:53
quotemuch of this work has been done and certainly has been spearheaded by Dr. Sean St. Peter, who directs our Center for Prospective Clinical Trials, and it is through his efforts and his leadership that much of the information that we'll discuss today has come about↗
▶Ep 7 · 3:25
quoteif that case came in and the emergency physicians had not already performed an imaging study, which would be ultrasound usually initially at least today, then we would take that patient to the operating room↗
▶Ep 7 · 3:25
clinicalClassic acute appendicitis presentation (pain migration to right lower quadrant, McBurney's point tenderness, elevated WBC and CRP, low-grade fever in thin patient with short symptom duration) can proceed directly to laparoscopic appendectomy without imaging↗
▶Ep 7 · 4:00
clinicalAt Children's Mercy Hospital, emergency department physicians often perform imaging studies before surgical consultation, though this is at their discretion not surgeon direction↗
▶Ep 7 · 5:11
clinicalSymptom duration over 24-36 hours raises concern for perforation and warrants imaging starting with ultrasound↗
▶Ep 7 · 6:25
clinicalIf ultrasound is not diagnostic but raises concern, proceed to CT scan; if ultrasound is diagnostic of appendicitis, CT is not needed↗
▶Ep 7 · 7:28
clinicalNon-visualization of appendix on CT at 4 days should show secondary signs of appendicitis and likely perforation; absence of both findings makes appendicitis unlikely though not zero↗
▶Ep 7 · 8:40
clinicalChildren's Mercy uses IV contrast for CT and performs limited/focused CT scans to minimize radiation exposure; rectal contrast protocol was attempted but not adopted by ED physicians↗
▶Ep 7 · 11:11
clinicalCeftriaxone and metronidazole is the most cost-effective antibiotic combination for appendicitis and has similar efficacy to triple antibiotic regimens↗
▶Ep 7 · 12:58
clinicalNon-perforated appendicitis receives only single preoperative antibiotic dose with no postoperative antibiotics↗
▶Ep 7 · 13:29
clinicalOnce-daily ceftriaxone/metronidazole dosing facilitates home health care transition if needed, does not require serum levels like gentamicin, and avoids gentamicin toxicities↗
▶Ep 7 · 14:18
clinicalIn 2008 Journal of Pediatric Surgery randomized trial of 100 patients, daily ceftriaxone/metronidazole showed no difference in abscess rate or wound infections versus ampicillin/gentamicin/clindamycin but resulted in lower antibiotic charges↗
▶Ep 7 · 15:11
clinicalCeftriaxone dosing is 50 mg/kg once daily and metronidazole is 30 mg/kg once daily for appendicitis↗
▶Ep 7 · 16:35
clinicalSingle-incision or double-incision laparoscopic approaches are used only for thin patients with non-perforated appendicitis↗
▶Ep 7 · 17:51
clinicalIn double-incision approach, 5mm umbilical port is placed with 5mm suprapubic port for mobilization, then appendix is exteriorized through umbilicus for extracorporeal appendectomy↗
▶Ep 7 · 19:40
clinicalLocking grasper is essential when exteriorizing appendix to prevent dropping it back into abdomen↗
▶Ep 7 · 19:40
quoteI think it's very important to use a locking grasper when you're bringing the appendix out through the abdominal cavity because If not, I've had several occasions where the appendix has slipped off the, the uh non-locking grasper↗
▶Ep 7 · 20:53
clinicalFascial incision of 10-12mm is needed to safely exteriorize appendix because grasper creates U-shaped configuration rather than end-on grasp↗
▶Ep 7 · 21:58
clinicalThis strict perforation definition was necessary because literature uses terms like gangrenous, necrotic, and perforated inconsistently, all meaning different things to different surgeons↗
▶Ep 7 · 21:58
clinicalPerforation is strictly defined as stool in the abdomen (fecalith in abdominal cavity) or a visible hole in the appendix; without these findings the patient does not have perforation↗
▶Ep 7 · 24:45
quotewe're trying to send the non-perforated patients home within around 6 hours of having their appendectomy↗
▶Ep 7 · 25:46
clinicalChildren's Mercy has been sending non-perforated appendicitis patients home the same day (within 6 hours of surgery) for over a year with over 100 patients managed this way↗
▶Ep 7 · 25:46
clinicalSame-day discharge for non-perforated appendicitis uses local anesthesia in incisions, pain medications at home, and no postoperative antibiotics↗
▶Ep 7 · 27:33
quoteI can see down the line. A nice randomized trial of antibiotics versus day surgery appendicitis, if you will, for acute appendicitis↗
▶Ep 7 · 27:33
opinionRationale for same-day discharge includes patient satisfaction, opening hospital beds for patients who need them, and preparing for potential future trials of antibiotics versus day-surgery appendectomy↗
▶Ep 7 · 28:30
clinicalSingle-incision approach had longer operative time (5 minutes, statistically significant but not clinically relevant), more narcotic doses, greater surgical difficulty, and higher hospital charges than three-port↗
▶Ep 7 · 28:30
clinicalOctober 2011 Annals of Surgery study randomized 360 patients (August 2009-November 2010) comparing single-incision to three-port laparoscopy for non-perforated appendicitis↗
▶Ep 7 · 28:30
clinicalSingle-incision appendectomy showed no difference versus three-port in wound infection rate, time to regular diet, length of hospitalization, or time to return to full activity↗
▶Ep 7 · 31:32
clinicalFor single-incision approach, umbilical fascia is closed and interrupted plain sutures placed in umbilical skin; for three-port, umbilical incision closed similarly and 5mm port sites closed with 5-0 Vicryl in U-fashion↗
▶Ep 7 · 32:09
clinicalInterrupted plain sutures allow wound infection drainage while not requiring removal due to short half-life; wounds dressed with rolled gauze and Tegaderm↗
▶Ep 7 · 33:00
clinicalStudy used strict perforation definition (hole in appendix or fecalith in abdomen), not just distended, angry, necrotic, or gangrenous appendix↗
▶Ep 7 · 33:00
clinicalSt. Peter study compared irrigation plus suction versus suction-only for perforated appendicitis and found no difference in abscess rate or location; both groups had approximately 20% postoperative abscess rate↗
▶Ep 7 · 34:28
quotein every study for perforated disease. And so I tell families 20%, uh, and I think that's a pretty good ballpark for the, the, um Development of an abscess↗
▶Ep 7 · 34:28
opinionSurgeons reporting lower abscess rates for perforation likely include gangrenous/necrotic non-perforated cases in their perforated group, lowering the rate↗
▶Ep 7 · 34:28
clinicalAcross 6-7 appendectomy studies for perforated disease at Children's Mercy, abscess rate has consistently been 15-20%; Holcomb counsels families on 20% abscess risk↗
▶Ep 7 · 38:21
clinicalAt Children's Mercy, OR billing is $225 per minute; a $600 stapler is cost-effective if it saves 3 minutes of OR time↗
▶Ep 7 · 38:21
clinicalChildren's Mercy surgeons use stapler for both mesoappendix and appendix because it can be justified as cost-effective under their per-minute billing model↗
▶Ep 7 · 38:21
clinicalStandard stapler load is used for appendix and vascular load for mesoappendix, which is another reason not to staple both simultaneously↗
▶Ep 7 · 38:21
clinicalWhen using cautery for appendectomy, must carefully watch entire field to prevent electrical arc to adjacent small bowel loops↗
▶Ep 7 · 38:21
quoteif you do use cautery, I think it's important to be sure to watch everything that's going on↗
▶Ep 7 · 38:21
clinicalIn early 1990s at Vanderbilt, three children who had cautery used for appendectomy developed adjacent small bowel injuries requiring reoperation due to electrical arc↗
▶Ep 7 · 39:48
clinicalIn single-incision approach, pelvic fluid should be suctioned before incising the bridge between ports because it becomes difficult to suction after appendix removal↗
▶Ep 7 · 39:48
clinicalMurky fluid throughout abdomen in non-perforated appendicitis is very unusual and would prompt placement of additional port for better visualization and investigation of source↗
▶Ep 7 · 41:15
clinicalFor normal appendix found at surgery, if imaging study was done preoperatively, full small bowel run is often not performed; without prior imaging, full small bowel examination is done↗
▶Ep 7 · 42:05
clinicalEarly discharge study found no difference in postoperative abscess rate between groups; 40% of patients in early discharge group went home before day 5↗
▶Ep 7 · 42:05
clinicalInitial perforated appendicitis protocol at Children's Mercy was 5 days of IV antibiotics postoperatively, developed when beginning prospective randomized trials↗
▶Ep 7 · 42:05
clinicalDischarge criteria for perforated appendicitis: normal WBC on day 5, afebrile, tolerating regular diet; then discharged without oral antibiotics↗
▶Ep 7 · 42:05
clinicalIf WBC elevated on day 5, patient receives 2 additional days of antibiotics and repeat WBC; if still elevated, receives 3 more days and CT scan to look for abscess↗
▶Ep 7 · 42:05
clinicalAlmost all postoperative abscesses in perforated appendicitis develop while patient is in hospital, very few develop after discharge↗
▶Ep 7 · 42:05
clinicalFollow-up study randomized 100 patients (50 per group) comparing mandatory 5 days IV antibiotics versus early discharge with oral Augmentin to complete 7 total days if discharge criteria met↗
▶Ep 7 · 42:05
quotealmost all, not all, but almost all of the patients who develop an abscess postoperatively develop it in the hospital↗
▶Ep 7 · 46:12
quoteit's easier on the patient and it's easier on the surgeon. To treat them non-operatively and then allow the inflammation to quiet down and return 8 to 10 weeks later for an interval laparoscopic appendectomy↗
▶Ep 7 · 46:12
clinicalInitial appendectomy took longer (61 minutes) versus interval appendectomy (42 minutes)↗
▶Ep 7 · 46:12
clinicalStudy found no difference between immediate versus interval appendectomy in total length of hospitalization, recurrent abscess rates, or overall charges↗
▶Ep 7 · 46:12
clinical2010 Journal of Pediatric Surgery study of 40 patients compared initial appendectomy versus initial non-operative management with interval appendectomy for well-defined abscess from perforated appendicitis↗
▶Ep 7 · 46:12
clinicalFor well-defined abscess at 5-6 days symptom duration, two options exist: immediate appendectomy or non-operative management with interval appendectomy↗
▶Ep 7 · 46:12
clinicalInterval appendectomy is performed 8-10 weeks after non-operative abscess management and is becoming a day surgery procedure↗
▶Ep 7 · 46:12
opinionHolcomb prefers initial non-operative management with interval appendectomy because immediate operations can be difficult, patients have prolonged hospitalization, bad ileus, sometimes need NG tube, and risk recurrent abscess complications↗
▶Ep 7 · 50:23
clinicalAt 3-4 days symptom duration, would operate; at 6-7 days with well-defined abscess, would treat non-operatively; 5 days is transition zone requiring clinical judgment↗
▶Ep 7 · 51:01
opinionEven if abscess can be managed for 2 weeks non-operatively, that operation is much easier than going in early through dense inflammation and purulent material↗
▶Ep 7 · 52:18
opinionCurrent data is not mature enough to justify non-operative management, especially when patients can have surgery and go home same day returning to routine activities↗
▶Ep 7 · 52:18
opinionLong-term follow-up of 25-30 years will be needed to determine if non-operatively treated patients develop recurrent appendicitis years later↗
▶Ep 7 · 52:18
opinionInflammation and infection may cause appendiceal scarring leading to closed-loop obstruction and recurrent appendicitis, but this won't be known for 25-30 years↗
▶Ep 7 · 52:18
clinicalCurrent data suggests 50-60% of patients could likely be managed non-operatively with antibiotics↗
▶Ep 7 · 52:18
opinionHigh-quality studies on non-operative appendicitis management will emerge in next 5 years showing good percentage can be treated without operation↗
▶Ep 7 · 56:15
opinionLonger-term data (5, 10, 20 years) is needed to determine true recurrence rate after non-operative management; if patients return years later, this justifies interval appendectomy when young↗
▶Ep 7 · 57:28
clinicalChildren's Mercy currently proceeds with interval laparoscopic appendectomy after non-operative abscess management because families do not want child at risk for recurrent appendicitis↗
quoteSo I'm gonna present on the uh mundane topic of perforated appendicitis.↗
▶Ep 8 · 8:11
quoteYeah, so I would say that's because of the definition that we used.↗
▶Ep 8 · 10:51
opinionThe best quality study on irrigation showed no difference in outcomes, while a more recent but less well-designed study showed a difference favoring standardized large-volume irrigation.↗
▶Ep 8 · 10:51
quoteUh, the answer is we don't have an answer. The, the best quality study said no difference. The more recent study that was, uh, Uh, not as a well-designed study did show a difference. I, I do think it's, it really would behoove all of us if we came up with some standardized definitions. So we're all talking about the, the same disease process.↗
quoteI don't believe that the surgeons should be the ones doing the workup of these children.↗
▶Ep 1 · 13:36
quoteI don't believe that the surgeons should be the ones doing the workup of these children.↗
▶Ep 1 · 22:32
quoteAn upper GI is really not a good study for reflux.↗
▶Ep 1 · 22:32
quoteAn upper GI is really not a good study for reflux.↗
▶Ep 1 · 22:32
clinicalAn upper GI is really not a good study for reflux; it doesn't document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 1 · 22:32
clinicalAn upper GI is really not a good study for reflux; it doesn't document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 1 · 23:19
epidemiologicalIn a study of patients who had upper GI and pH studies, the upper GI did not help with diagnosing reflux, but it did help identify an anatomical problem in about 4% of patients.↗
▶Ep 1 · 23:19
epidemiologicalIn a study of patients who had upper GI and pH studies, the upper GI did not help with diagnosing reflux, but it did help identify an anatomical problem in about 4% of patients.↗
▶Ep 1 · 36:08
quoteI would like to thank Rachel for not sending that child who's retching preoperatively to the surgeons.↗
▶Ep 1 · 36:08
quoteI would like to thank Rachel for not sending that child who's retching preoperatively to the surgeons.↗
▶Ep 1 · 46:40
epidemiologicalIn Kansas City's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap; the primary reason for redo historically was transmigration of the wrap into the chest.↗
▶Ep 1 · 46:40
epidemiologicalIn Kansas City's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap; the primary reason for redo historically was transmigration of the wrap into the chest.↗
▶Ep 1 · 57:32
epidemiologicalBy doing minimal mobilization and not disrupting the phrenoesophageal membrane, we were able to drop our transmigration rate from 12% to 5%, and in our final study there was zero recurrence and zero redo fundoplication rate in both groups.↗
▶Ep 1 · 57:32
epidemiologicalBy doing minimal mobilization and not disrupting the phrenoesophageal membrane, we were able to drop our transmigration rate from 12% to 5%, and in our final study there was zero recurrence and zero redo fundoplication rate in both groups.↗
▶Ep 1 · 59:22
clinicalThe surgical message is that we need to do less rather than more dissection around the GE junction to prevent wrap transmigration.↗
▶Ep 1 · 59:22
clinicalThe surgical message is that we need to do less rather than more dissection around the GE junction to prevent wrap transmigration.↗
▶Ep 1 · 59:22
quoteThe surgical message that we should impart is that we need to do less rather than more dissection around the GE junction.↗
▶Ep 1 · 59:22
quoteThe surgical message that we should impart is that we need to do less rather than more dissection around the GE junction.↗
▶Ep 1 · 1:00:49
clinicalYou've got to know where the left gastric artery is, and you've got to be sure that you are cephalad to that to ensure the wrap is at the level of the lower esophagus, not the stomach.↗
▶Ep 1 · 1:00:49
clinicalYou've got to know where the left gastric artery is, and you've got to be sure that you are cephalad to that to ensure the wrap is at the level of the lower esophagus, not the stomach.↗
▶Ep 1 · 1:03:46
epidemiologicalUsing an esophageal bougie at the time of fundoplication has resulted in very little need for postoperative dilation; in all our prospective studies, we've dilated one or two patients.↗
▶Ep 1 · 1:03:46
epidemiologicalUsing an esophageal bougie at the time of fundoplication has resulted in very little need for postoperative dilation; in all our prospective studies, we've dilated one or two patients.↗
Gastroesophageal Reflux Disease
▶Ep 2 · 13:36
quoteI don't think that the surgeons should be the ones doing the workup of these children.↗
▶Ep 2 · 22:38
clinicalAn upper GI study does not document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 2 · 23:17
epidemiologicalIn a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients.↗
▶Ep 2 · 36:08
quoteI would like to thank Rachel for not sending that child who's wretching preoperatively to the surgeons.↗
▶Ep 2 · 46:40
clinicalIn Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique.↗
▶Ep 2 · 46:43
clinicalThe primary reason for redo fundoplication is transmigration of the wrap into the chest.↗
▶Ep 2 · 47:09
quoteWe spent 15 years or so trying to investigate this issue surgically and we feel like we've come up with, you know, what we call, you know, jokingly the perfect Nissen.↗
▶Ep 2 · 57:23
epidemiologicalBefore adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change.↗
▶Ep 2 · 1:00:49
clinicalThe key technical point is that the fundoplication wrap must be cephalad to the left gastric artery to ensure it's at the level of the lower esophagus rather than the stomach.↗
▶Ep 2 · 1:03:42
clinicalUsing an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation.↗
Whit's statements about Biliary Atresia30 statements
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 6 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 6 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 6 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 6 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 6 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 6 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 6 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 6 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 6 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 6 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 6 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 6 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 10 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 10 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 10 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 10 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 10 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 10 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 10 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 10 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 10 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 10 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 10 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 10 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
▶Ep 23 · 12:05
quoteThis is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.↗
▶Ep 23 · 12:09
quoteI just wanted to highlight the importance of transitioning care because I thought this topic was important.↗
▶Ep 23 · 14:22
clinicalThere was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner↗
▶Ep 23 · 14:22
quoteThis one sentence says it all. There was little evidence from patients that transfer happened in a timely or coordinated manner. And patients felt that the clinicians did not always understand the significance of transfer to an adult service. No models of transfer of care were identified.↗
▶Ep 23 · 14:38
clinicalNo models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review↗
▶Ep 23 · 15:21
quoteWe need to do a better job. Of structuring this transition, we're doing better with handoffs in the hospital with patient care. We need to do a better job with handing off the care for any pediatric patient who needs a transitioning to adult providers.↗
Whit's statements about Colorectal / ARM & Hirschsprung32 statements
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 76 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 76 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 76 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 76 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 76 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 76 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 76 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 76 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 76 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 76 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 76 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 76 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Journal of Pediatric Surgery Article Review: September 2023
▶Ep 159 · 3:34
quoteIt's not very commonly seen. But you need to recognize the patient that has this particular problem.↗
▶Ep 159 · 6:21
clinicalSome pediatric surgeons perform CDH repair after the patient gets off ECMO rather than while on ECMO.↗
▶Ep 159 · 9:47
opinionEvery surgeon will have adversity in practice with patients where despite best efforts there is not a good result.↗
▶Ep 159 · 9:55
clinicalSupport systems are available to help physicians through difficult situations and adversity.↗
▶Ep 159 · 10:48
quoteI just think that the letter is, is a good reminder that there are support systems available for all of us when we have adversity and and conflicts that we just don't know how to get through, and we see people who are the kindest to their patients cannot show the same kindness to themselves, and unfortunately we lose them to these battles↗
▶Ep 159 · 11:30
opinionPhysician mental health is discussed more openly now versus 10 years ago, but should still be discussed more openly.↗
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
▶Ep 164 · 12:05
quoteThis is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.↗
▶Ep 164 · 12:09
quoteI just wanted to highlight the importance of transitioning care because I thought this topic was important.↗
▶Ep 164 · 14:22
quoteThis one sentence says it all. There was little evidence from patients that transfer happened in a timely or coordinated manner. And patients felt that the clinicians did not always understand the significance of transfer to an adult service. No models of transfer of care were identified.↗
▶Ep 164 · 14:22
clinicalThere was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner↗
▶Ep 164 · 14:38
clinicalNo models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review↗
▶Ep 164 · 15:21
quoteWe need to do a better job. Of structuring this transition, we're doing better with handoffs in the hospital with patient care. We need to do a better job with handing off the care for any pediatric patient who needs a transitioning to adult providers.↗
Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
▶Ep 167 · 14:30
clinicalThere was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.↗
▶Ep 167 · 14:30
clinicalThe Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.↗
▶Ep 167 · 14:30
quoteWe didn't really have a classification system that was unique to pediatric surgery, so that's why we have used the Clavian dindo classification, although that was validated in the adult world.↗
▶Ep 167 · 15:19
quoteThis is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.↗
▶Ep 167 · 16:39
clinicalThe Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.↗
▶Ep 167 · 16:39
quoteBased on the ratings of the various case scenarios, the Clavian Madati classification showed improved agreement rates of the respondents, 85% versus 76%. And it was less frequently considered inaccurate for rating in the pediatric population when compared to the lavian dindo classification.↗
▶Ep 167 · 16:53
clinicalThe Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.↗
▶Ep 167 · 17:46
quoteThis was a good first attempt at trying to find a reliable instrument for pediatric surgeons, and I think that we'll figure out by using it whether it's good or bad or appropriate for pediatric surgeons, but right now we don't have anything, and so obviously a first step is better than no step at all.↗
Whit's statements about Esophageal Atresia1 statement
quoteI don't think that the surgeons should be the ones doing the workup of these children.↗
▶Ep 23 · 22:38
clinicalAn upper GI study does not document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 23 · 23:17
epidemiologicalIn a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients.↗
▶Ep 23 · 36:08
quoteI would like to thank Rachel for not sending that child who's wretching preoperatively to the surgeons.↗
▶Ep 23 · 46:40
clinicalIn Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique.↗
▶Ep 23 · 46:43
clinicalThe primary reason for redo fundoplication is transmigration of the wrap into the chest.↗
▶Ep 23 · 47:09
quoteWe spent 15 years or so trying to investigate this issue surgically and we feel like we've come up with, you know, what we call, you know, jokingly the perfect Nissen.↗
▶Ep 23 · 57:23
epidemiologicalBefore adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change.↗
▶Ep 23 · 1:00:49
clinicalThe key technical point is that the fundoplication wrap must be cephalad to the left gastric artery to ensure it's at the level of the lower esophagus rather than the stomach.↗
▶Ep 23 · 1:03:42
clinicalUsing an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 26 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 26 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 26 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 26 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 26 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 26 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 26 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 26 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 26 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 26 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 26 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 26 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
▶Ep 55 · 12:05
quoteThis is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.↗
▶Ep 55 · 12:09
quoteI just wanted to highlight the importance of transitioning care because I thought this topic was important.↗
▶Ep 55 · 14:22
quoteThis one sentence says it all. There was little evidence from patients that transfer happened in a timely or coordinated manner. And patients felt that the clinicians did not always understand the significance of transfer to an adult service. No models of transfer of care were identified.↗
▶Ep 55 · 14:22
clinicalThere was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner↗
▶Ep 55 · 14:38
clinicalNo models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review↗
▶Ep 55 · 15:21
quoteWe need to do a better job. Of structuring this transition, we're doing better with handoffs in the hospital with patient care. We need to do a better job with handing off the care for any pediatric patient who needs a transitioning to adult providers.↗
Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
▶Ep 56 · 14:30
quoteWe didn't really have a classification system that was unique to pediatric surgery, so that's why we have used the Clavian dindo classification, although that was validated in the adult world.↗
▶Ep 56 · 14:30
clinicalThere was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.↗
▶Ep 56 · 14:30
clinicalThe Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.↗
▶Ep 56 · 15:19
quoteThis is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.↗
▶Ep 56 · 16:39
quoteBased on the ratings of the various case scenarios, the Clavian Madati classification showed improved agreement rates of the respondents, 85% versus 76%. And it was less frequently considered inaccurate for rating in the pediatric population when compared to the lavian dindo classification.↗
▶Ep 56 · 16:39
clinicalThe Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.↗
▶Ep 56 · 16:53
clinicalThe Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.↗
▶Ep 56 · 17:46
quoteThis was a good first attempt at trying to find a reliable instrument for pediatric surgeons, and I think that we'll figure out by using it whether it's good or bad or appropriate for pediatric surgeons, but right now we don't have anything, and so obviously a first step is better than no step at all.↗
Whit's statements about Gastroesophageal Reflux10 statements
quoteI'm very reluctant to do a fund in a newborn in the first month of life. In fact, I extend that to about 6 months of life.↗
▶Ep 1 · 4:16
quoteThese are desperate parents. It will not work for you to say don't feed them at night. This is they are exhausted. They stay up every night.↗
▶Ep 1 · 7:17
quoteI tell them that there's a 95% chance that the operation will be done successfully and that, and that they won't have another, they won't need another operation.↗
▶Ep 1 · 7:17
clinicalThere is a 95% chance fundoplication will be done successfully without need for another operation↗
▶Ep 1 · 20:20
quoteI would not say that that's the surgeons have enough experience with either technique really over 7 years, 5 patients a year to come to valid conclusions.↗
▶Ep 1 · 22:12
quoteWhichever one you do the best you ought to do. If you do a partial one better than a Nissan, you ought to do a partial one. I think the, the results are probably equivalent, but it's whatever you do best.↗
▶Ep 1 · 22:42
opinionWhichever fundoplication technique (complete or partial) a surgeon does best, they should perform that technique↗
▶Ep 1 · 25:58
quoteI think that like Max said, the trial of bolus G tube feedings with the baby does fine. I think that's a really good test because it's a functional test. You know, if you start going down the, the rabbit hole of pH impedance probes and things like that, and sometimes some of our medical colleagues will want to do that, it, it to me it doesn't inform you what you need to do ultimately for that baby.↗
▶Ep 1 · 25:58
clinicalBolus gastric feeding trial is the most helpful functional test for determining need for fundoplication, more informative than pH impedance probes↗
▶Ep 1 · 29:02
clinicalThere is probably a 10-15% incidence of patients needing fundoplication after initial G-tube placement↗
Whit's statements about Gastroesophageal Reflux Disease31 statements
quoteI don't believe that the surgeons should be the ones doing the workup of these children.↗
▶Ep 1 · 22:32
clinicalAn upper GI is really not a good study for reflux; it doesn't document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 1 · 22:32
quoteAn upper GI is really not a good study for reflux.↗
▶Ep 1 · 23:19
epidemiologicalIn a study of patients who had upper GI and pH studies, the upper GI did not help with diagnosing reflux, but it did help identify an anatomical problem in about 4% of patients.↗
▶Ep 1 · 36:08
quoteI would like to thank Rachel for not sending that child who's retching preoperatively to the surgeons.↗
▶Ep 1 · 46:40
epidemiologicalIn Kansas City's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap; the primary reason for redo historically was transmigration of the wrap into the chest.↗
▶Ep 1 · 57:32
epidemiologicalBy doing minimal mobilization and not disrupting the phrenoesophageal membrane, we were able to drop our transmigration rate from 12% to 5%, and in our final study there was zero recurrence and zero redo fundoplication rate in both groups.↗
▶Ep 1 · 59:22
clinicalThe surgical message is that we need to do less rather than more dissection around the GE junction to prevent wrap transmigration.↗
▶Ep 1 · 59:22
quoteThe surgical message that we should impart is that we need to do less rather than more dissection around the GE junction.↗
▶Ep 1 · 1:00:49
clinicalYou've got to know where the left gastric artery is, and you've got to be sure that you are cephalad to that to ensure the wrap is at the level of the lower esophagus, not the stomach.↗
▶Ep 1 · 1:03:46
epidemiologicalUsing an esophageal bougie at the time of fundoplication has resulted in very little need for postoperative dilation; in all our prospective studies, we've dilated one or two patients.↗
Gastoesophageal Reflux: Update Course 2015
▶Ep 5 · 4:05
quoteI'm very reluctant to do a fund in a newborn in the first month of life. In fact, I extend that to about 6 months of life.↗
▶Ep 5 · 4:16
quoteThese are desperate parents. It will not work for you to say don't feed them at night. This is they are exhausted. They stay up every night.↗
▶Ep 5 · 7:17
clinicalThere is a 95% chance fundoplication will be done successfully without need for another operation↗
▶Ep 5 · 7:17
quoteI tell them that there's a 95% chance that the operation will be done successfully and that, and that they won't have another, they won't need another operation.↗
▶Ep 5 · 20:20
quoteI would not say that that's the surgeons have enough experience with either technique really over 7 years, 5 patients a year to come to valid conclusions.↗
▶Ep 5 · 22:12
quoteWhichever one you do the best you ought to do. If you do a partial one better than a Nissan, you ought to do a partial one. I think the, the results are probably equivalent, but it's whatever you do best.↗
▶Ep 5 · 22:42
opinionWhichever fundoplication technique (complete or partial) a surgeon does best, they should perform that technique↗
▶Ep 5 · 25:58
quoteI think that like Max said, the trial of bolus G tube feedings with the baby does fine. I think that's a really good test because it's a functional test. You know, if you start going down the, the rabbit hole of pH impedance probes and things like that, and sometimes some of our medical colleagues will want to do that, it, it to me it doesn't inform you what you need to do ultimately for that baby.↗
▶Ep 5 · 25:58
clinicalBolus gastric feeding trial is the most helpful functional test for determining need for fundoplication, more informative than pH impedance probes↗
▶Ep 5 · 29:02
clinicalThere is probably a 10-15% incidence of patients needing fundoplication after initial G-tube placement↗
Gastroesophageal Reflux Disease
▶Ep 7 · 13:36
quoteI don't think that the surgeons should be the ones doing the workup of these children.↗
▶Ep 7 · 22:38
clinicalAn upper GI study does not document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 7 · 23:17
epidemiologicalIn a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients.↗
▶Ep 7 · 36:08
quoteI would like to thank Rachel for not sending that child who's wretching preoperatively to the surgeons.↗
▶Ep 7 · 46:40
clinicalIn Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique.↗
▶Ep 7 · 46:43
clinicalThe primary reason for redo fundoplication is transmigration of the wrap into the chest.↗
▶Ep 7 · 47:09
quoteWe spent 15 years or so trying to investigate this issue surgically and we feel like we've come up with, you know, what we call, you know, jokingly the perfect Nissen.↗
▶Ep 7 · 57:23
epidemiologicalBefore adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change.↗
▶Ep 7 · 1:00:49
clinicalThe key technical point is that the fundoplication wrap must be cephalad to the left gastric artery to ensure it's at the level of the lower esophagus rather than the stomach.↗
▶Ep 7 · 1:03:42
clinicalUsing an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation.↗
Whit's statements about Gastroesophageal Reflux Disease31 statements
quoteI don't believe that the surgeons should be the ones doing the workup of these children.↗
▶Ep 1 · 22:32
quoteAn upper GI is really not a good study for reflux.↗
▶Ep 1 · 22:32
clinicalAn upper GI is really not a good study for reflux; it doesn't document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 1 · 23:19
epidemiologicalIn a study of patients who had upper GI and pH studies, the upper GI did not help with diagnosing reflux, but it did help identify an anatomical problem in about 4% of patients.↗
▶Ep 1 · 36:08
quoteI would like to thank Rachel for not sending that child who's retching preoperatively to the surgeons.↗
▶Ep 1 · 46:40
epidemiologicalIn Kansas City's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap; the primary reason for redo historically was transmigration of the wrap into the chest.↗
▶Ep 1 · 57:32
epidemiologicalBy doing minimal mobilization and not disrupting the phrenoesophageal membrane, we were able to drop our transmigration rate from 12% to 5%, and in our final study there was zero recurrence and zero redo fundoplication rate in both groups.↗
▶Ep 1 · 59:22
quoteThe surgical message that we should impart is that we need to do less rather than more dissection around the GE junction.↗
▶Ep 1 · 59:22
clinicalThe surgical message is that we need to do less rather than more dissection around the GE junction to prevent wrap transmigration.↗
▶Ep 1 · 1:00:49
clinicalYou've got to know where the left gastric artery is, and you've got to be sure that you are cephalad to that to ensure the wrap is at the level of the lower esophagus, not the stomach.↗
▶Ep 1 · 1:03:46
epidemiologicalUsing an esophageal bougie at the time of fundoplication has resulted in very little need for postoperative dilation; in all our prospective studies, we've dilated one or two patients.↗
Gastoesophageal Reflux: Update Course 2015
▶Ep 5 · 4:05
quoteI'm very reluctant to do a fund in a newborn in the first month of life. In fact, I extend that to about 6 months of life.↗
▶Ep 5 · 4:16
quoteThese are desperate parents. It will not work for you to say don't feed them at night. This is they are exhausted. They stay up every night.↗
▶Ep 5 · 7:17
quoteI tell them that there's a 95% chance that the operation will be done successfully and that, and that they won't have another, they won't need another operation.↗
▶Ep 5 · 7:17
clinicalThere is a 95% chance fundoplication will be done successfully without need for another operation↗
▶Ep 5 · 20:20
quoteI would not say that that's the surgeons have enough experience with either technique really over 7 years, 5 patients a year to come to valid conclusions.↗
▶Ep 5 · 22:12
quoteWhichever one you do the best you ought to do. If you do a partial one better than a Nissan, you ought to do a partial one. I think the, the results are probably equivalent, but it's whatever you do best.↗
▶Ep 5 · 22:42
opinionWhichever fundoplication technique (complete or partial) a surgeon does best, they should perform that technique↗
▶Ep 5 · 25:58
quoteI think that like Max said, the trial of bolus G tube feedings with the baby does fine. I think that's a really good test because it's a functional test. You know, if you start going down the, the rabbit hole of pH impedance probes and things like that, and sometimes some of our medical colleagues will want to do that, it, it to me it doesn't inform you what you need to do ultimately for that baby.↗
▶Ep 5 · 25:58
clinicalBolus gastric feeding trial is the most helpful functional test for determining need for fundoplication, more informative than pH impedance probes↗
▶Ep 5 · 29:02
clinicalThere is probably a 10-15% incidence of patients needing fundoplication after initial G-tube placement↗
Gastroesophageal Reflux Disease
▶Ep 7 · 13:36
quoteI don't think that the surgeons should be the ones doing the workup of these children.↗
▶Ep 7 · 22:38
clinicalAn upper GI study does not document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 7 · 23:17
epidemiologicalIn a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients.↗
▶Ep 7 · 36:08
quoteI would like to thank Rachel for not sending that child who's wretching preoperatively to the surgeons.↗
▶Ep 7 · 46:40
clinicalIn Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique.↗
▶Ep 7 · 46:43
clinicalThe primary reason for redo fundoplication is transmigration of the wrap into the chest.↗
▶Ep 7 · 47:09
quoteWe spent 15 years or so trying to investigate this issue surgically and we feel like we've come up with, you know, what we call, you know, jokingly the perfect Nissen.↗
▶Ep 7 · 57:23
epidemiologicalBefore adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change.↗
▶Ep 7 · 1:00:49
clinicalThe key technical point is that the fundoplication wrap must be cephalad to the left gastric artery to ensure it's at the level of the lower esophagus rather than the stomach.↗
▶Ep 7 · 1:03:42
clinicalUsing an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation.↗
Whit's statements about Gastroschisis14 statements
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
▶Ep 21 · 12:05
quoteThis is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.↗
▶Ep 21 · 12:09
quoteI just wanted to highlight the importance of transitioning care because I thought this topic was important.↗
▶Ep 21 · 14:22
quoteThis one sentence says it all. There was little evidence from patients that transfer happened in a timely or coordinated manner. And patients felt that the clinicians did not always understand the significance of transfer to an adult service. No models of transfer of care were identified.↗
▶Ep 21 · 14:22
clinicalThere was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner↗
▶Ep 21 · 14:38
clinicalNo models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review↗
▶Ep 21 · 15:21
quoteWe need to do a better job. Of structuring this transition, we're doing better with handoffs in the hospital with patient care. We need to do a better job with handing off the care for any pediatric patient who needs a transitioning to adult providers.↗
Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
▶Ep 22 · 14:30
quoteWe didn't really have a classification system that was unique to pediatric surgery, so that's why we have used the Clavian dindo classification, although that was validated in the adult world.↗
▶Ep 22 · 14:30
clinicalThe Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.↗
▶Ep 22 · 14:30
clinicalThere was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.↗
▶Ep 22 · 15:19
quoteThis is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.↗
▶Ep 22 · 16:39
quoteBased on the ratings of the various case scenarios, the Clavian Madati classification showed improved agreement rates of the respondents, 85% versus 76%. And it was less frequently considered inaccurate for rating in the pediatric population when compared to the lavian dindo classification.↗
▶Ep 22 · 16:39
clinicalThe Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.↗
▶Ep 22 · 16:53
clinicalThe Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.↗
▶Ep 22 · 17:46
quoteThis was a good first attempt at trying to find a reliable instrument for pediatric surgeons, and I think that we'll figure out by using it whether it's good or bad or appropriate for pediatric surgeons, but right now we don't have anything, and so obviously a first step is better than no step at all.↗
Whit's statements about Gastroschisis14 statements
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
▶Ep 22 · 12:05
quoteThis is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.↗
▶Ep 22 · 12:09
quoteI just wanted to highlight the importance of transitioning care because I thought this topic was important.↗
▶Ep 22 · 14:22
clinicalThere was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner↗
▶Ep 22 · 14:22
quoteThis one sentence says it all. There was little evidence from patients that transfer happened in a timely or coordinated manner. And patients felt that the clinicians did not always understand the significance of transfer to an adult service. No models of transfer of care were identified.↗
▶Ep 22 · 14:38
clinicalNo models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review↗
▶Ep 22 · 15:21
quoteWe need to do a better job. Of structuring this transition, we're doing better with handoffs in the hospital with patient care. We need to do a better job with handing off the care for any pediatric patient who needs a transitioning to adult providers.↗
Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
▶Ep 23 · 14:30
quoteWe didn't really have a classification system that was unique to pediatric surgery, so that's why we have used the Clavian dindo classification, although that was validated in the adult world.↗
▶Ep 23 · 14:30
clinicalThe Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.↗
▶Ep 23 · 14:30
clinicalThere was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.↗
▶Ep 23 · 15:19
quoteThis is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.↗
▶Ep 23 · 16:39
quoteBased on the ratings of the various case scenarios, the Clavian Madati classification showed improved agreement rates of the respondents, 85% versus 76%. And it was less frequently considered inaccurate for rating in the pediatric population when compared to the lavian dindo classification.↗
▶Ep 23 · 16:39
clinicalThe Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.↗
▶Ep 23 · 16:53
clinicalThe Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.↗
▶Ep 23 · 17:46
quoteThis was a good first attempt at trying to find a reliable instrument for pediatric surgeons, and I think that we'll figure out by using it whether it's good or bad or appropriate for pediatric surgeons, but right now we don't have anything, and so obviously a first step is better than no step at all.↗
Whit's statements about Hirschsprung disease14 statements
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
▶Ep 71 · 12:05
quoteThis is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.↗
▶Ep 71 · 12:09
quoteI just wanted to highlight the importance of transitioning care because I thought this topic was important.↗
▶Ep 71 · 14:22
clinicalThere was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner↗
▶Ep 71 · 14:22
quoteThis one sentence says it all. There was little evidence from patients that transfer happened in a timely or coordinated manner. And patients felt that the clinicians did not always understand the significance of transfer to an adult service. No models of transfer of care were identified.↗
▶Ep 71 · 14:38
clinicalNo models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review↗
▶Ep 71 · 15:21
quoteWe need to do a better job. Of structuring this transition, we're doing better with handoffs in the hospital with patient care. We need to do a better job with handing off the care for any pediatric patient who needs a transitioning to adult providers.↗
Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
▶Ep 73 · 14:30
clinicalThe Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.↗
▶Ep 73 · 14:30
clinicalThere was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.↗
▶Ep 73 · 14:30
quoteWe didn't really have a classification system that was unique to pediatric surgery, so that's why we have used the Clavian dindo classification, although that was validated in the adult world.↗
▶Ep 73 · 15:19
quoteThis is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.↗
▶Ep 73 · 16:39
quoteBased on the ratings of the various case scenarios, the Clavian Madati classification showed improved agreement rates of the respondents, 85% versus 76%. And it was less frequently considered inaccurate for rating in the pediatric population when compared to the lavian dindo classification.↗
▶Ep 73 · 16:39
clinicalThe Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.↗
▶Ep 73 · 16:53
clinicalThe Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.↗
▶Ep 73 · 17:46
quoteThis was a good first attempt at trying to find a reliable instrument for pediatric surgeons, and I think that we'll figure out by using it whether it's good or bad or appropriate for pediatric surgeons, but right now we don't have anything, and so obviously a first step is better than no step at all.↗
Whit's statements about Intestinal Failure24 statements
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 3 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 3 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 3 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 3 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 3 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 3 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 3 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 3 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 3 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 3 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 3 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 3 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 7 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 7 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 7 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 7 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 7 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 7 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 7 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 7 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 7 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 7 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 7 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 7 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Whit's statements about Intestinal Rehab48 statements
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 14 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 14 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 14 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 14 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 14 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 14 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 14 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 14 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 14 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 14 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 14 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 14 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Gastroesophageal Reflux Disease
▶Ep 32 · 13:36
quoteI don't think that the surgeons should be the ones doing the workup of these children.↗
▶Ep 32 · 22:38
clinicalAn upper GI study does not document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 32 · 23:17
epidemiologicalIn a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients.↗
▶Ep 32 · 36:08
quoteI would like to thank Rachel for not sending that child who's wretching preoperatively to the surgeons.↗
▶Ep 32 · 46:40
clinicalIn Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique.↗
▶Ep 32 · 46:43
clinicalThe primary reason for redo fundoplication is transmigration of the wrap into the chest.↗
▶Ep 32 · 47:09
quoteWe spent 15 years or so trying to investigate this issue surgically and we feel like we've come up with, you know, what we call, you know, jokingly the perfect Nissen.↗
▶Ep 32 · 57:23
epidemiologicalBefore adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change.↗
▶Ep 32 · 1:00:49
clinicalThe key technical point is that the fundoplication wrap must be cephalad to the left gastric artery to ensure it's at the level of the lower esophagus rather than the stomach.↗
▶Ep 32 · 1:03:42
clinicalUsing an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 35 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 35 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 35 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 35 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 35 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 35 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 35 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 35 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 35 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 35 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 35 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 35 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
▶Ep 84 · 12:05
quoteThis is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.↗
▶Ep 84 · 12:09
quoteI just wanted to highlight the importance of transitioning care because I thought this topic was important.↗
▶Ep 84 · 14:22
clinicalThere was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner↗
▶Ep 84 · 14:22
quoteThis one sentence says it all. There was little evidence from patients that transfer happened in a timely or coordinated manner. And patients felt that the clinicians did not always understand the significance of transfer to an adult service. No models of transfer of care were identified.↗
▶Ep 84 · 14:38
clinicalNo models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review↗
▶Ep 84 · 15:21
quoteWe need to do a better job. Of structuring this transition, we're doing better with handoffs in the hospital with patient care. We need to do a better job with handing off the care for any pediatric patient who needs a transitioning to adult providers.↗
Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
▶Ep 85 · 14:30
clinicalThe Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.↗
▶Ep 85 · 14:30
clinicalThere was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.↗
▶Ep 85 · 14:30
quoteWe didn't really have a classification system that was unique to pediatric surgery, so that's why we have used the Clavian dindo classification, although that was validated in the adult world.↗
▶Ep 85 · 15:19
quoteThis is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.↗
▶Ep 85 · 16:39
quoteBased on the ratings of the various case scenarios, the Clavian Madati classification showed improved agreement rates of the respondents, 85% versus 76%. And it was less frequently considered inaccurate for rating in the pediatric population when compared to the lavian dindo classification.↗
▶Ep 85 · 16:39
clinicalThe Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.↗
▶Ep 85 · 16:53
clinicalThe Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.↗
▶Ep 85 · 17:46
quoteThis was a good first attempt at trying to find a reliable instrument for pediatric surgeons, and I think that we'll figure out by using it whether it's good or bad or appropriate for pediatric surgeons, but right now we don't have anything, and so obviously a first step is better than no step at all.↗
Whit's statements about Intestinal Transplant12 statements
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 4 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 4 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 4 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 4 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 4 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 4 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 4 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 4 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 4 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 4 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 4 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 4 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Whit's statements about Pectus Carinatum6 statements
Journal of Pediatric Surgery Article Review: September 2023
▶Ep 15 · 3:34
quoteIt's not very commonly seen. But you need to recognize the patient that has this particular problem.↗
▶Ep 15 · 6:21
clinicalSome pediatric surgeons perform CDH repair after the patient gets off ECMO rather than while on ECMO.↗
▶Ep 15 · 9:47
opinionEvery surgeon will have adversity in practice with patients where despite best efforts there is not a good result.↗
▶Ep 15 · 9:55
clinicalSupport systems are available to help physicians through difficult situations and adversity.↗
▶Ep 15 · 10:48
quoteI just think that the letter is, is a good reminder that there are support systems available for all of us when we have adversity and and conflicts that we just don't know how to get through, and we see people who are the kindest to their patients cannot show the same kindness to themselves, and unfortunately we lose them to these battles↗
▶Ep 15 · 11:30
opinionPhysician mental health is discussed more openly now versus 10 years ago, but should still be discussed more openly.↗
Whit's statements about Pectus Excavatum6 statements
Journal of Pediatric Surgery Article Review: September 2023
▶Ep 42 · 3:34
quoteIt's not very commonly seen. But you need to recognize the patient that has this particular problem.↗
▶Ep 42 · 6:21
clinicalSome pediatric surgeons perform CDH repair after the patient gets off ECMO rather than while on ECMO.↗
▶Ep 42 · 9:47
opinionEvery surgeon will have adversity in practice with patients where despite best efforts there is not a good result.↗
▶Ep 42 · 9:55
clinicalSupport systems are available to help physicians through difficult situations and adversity.↗
▶Ep 42 · 10:48
quoteI just think that the letter is, is a good reminder that there are support systems available for all of us when we have adversity and and conflicts that we just don't know how to get through, and we see people who are the kindest to their patients cannot show the same kindness to themselves, and unfortunately we lose them to these battles↗
▶Ep 42 · 11:30
opinionPhysician mental health is discussed more openly now versus 10 years ago, but should still be discussed more openly.↗
Whit's statements about Primary Spontaneous Pneumothorax1 statement
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 5 · 11:20
host summaryWhit Holcomb summarizing the discussion: A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 5 · 13:49
host summaryWhit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 5 · 14:20
host summaryWhit Holcomb summarizing the discussion: The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 5 · 14:48
host summaryWhit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 5 · 20:35
host summaryWhit Holcomb summarizing the discussion: A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 5 · 22:42
host summaryWhit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 5 · 23:14
host summaryWhit Holcomb summarizing the discussion: In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 5 · 24:35
host summaryWhit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 5 · 24:55
host summaryWhit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 5 · 25:20
host summaryWhit Holcomb summarizing the discussion: The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 5 · 29:19
host summaryWhit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
Appendicitis with Dr. Whit Holcomb
▶Ep 6 · 23:41
host summaryWhit Holcomb summarizing a resource: Inter-observer variation study (Journal of Laparoendoscopic and Advanced Surgical Techniques) showed only 25% agreement among attending surgeons on perforation status when viewing operative images without defined criteria↗
▶Ep 6 · 23:41
host summaryWhit Holcomb summarizing a resource: the take-home message was that in your paper, at least about 25%, there was only agreement among attending surgeons looking at the pictures that there was 25% agreement on whether there was perforation or not.↗
▶Ep 6 · 52:11
host summaryWhit Holcomb summarizing a resource: Adult literature and Nationwide Children's Hospital data suggest approximately 50-60% of non-perforated appendicitis patients could be managed with antibiotics alone; about one-third require operation↗
▶Ep 6 · 52:11
host summaryWhit Holcomb summarizing a resource: Prospective randomized trials on non-operative appendicitis management are underway at Nationwide Children's Hospital and other hospital groups↗
▶Ep 6 · 56:15
host summaryWhit Holcomb summarizing a resource: Los Angeles study: 10% recurrence rate of appendicitis without interval appendectomy after non-operative management, but follow-up only 1-1.5 years↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 10 · 11:20
host summaryWhit Holcomb summarizing the discussion: A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 10 · 13:49
host summaryWhit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 10 · 14:20
host summaryWhit Holcomb summarizing the discussion: The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 10 · 14:48
host summaryWhit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 10 · 20:35
host summaryWhit Holcomb summarizing the discussion: A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 10 · 22:42
host summaryWhit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 10 · 23:14
host summaryWhit Holcomb summarizing the discussion: In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 10 · 24:35
host summaryWhit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 10 · 24:55
host summaryWhit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 10 · 25:20
host summaryWhit Holcomb summarizing the discussion: The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 10 · 29:19
host summaryWhit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
Evidence-based diagnosis and management of pediatric appendicitis with Dr. Whit Holcomb
▶Ep 12 · 23:41
host summaryWhit Holcomb summarizing a resource: In Ponsky's inter-observer variation study published in Journal of Laparoendoscopic and Advanced Surgical Techniques, attending surgeons viewing same images agreed on perforation status only 25% of the time without defined criteria↗
▶Ep 12 · 23:41
host summaryWhit Holcomb summarizing a resource: you can't really assess perforation visually without a well-defined criteria and that different surgeons will view perforation in a different fashion↗
▶Ep 12 · 52:18
host summaryWhit Holcomb summarizing a resource: Adult literature reports approximately 2/3 of appendicitis patients can be treated non-operatively without surgery, about 1/3 require operation↗
▶Ep 12 · 52:18
host summaryWhit Holcomb summarizing a resource: Nationwide Children's Hospital has performed work on non-operative appendicitis management and has ongoing prospective randomized trial; another multi-hospital trial is in planning stages↗
▶Ep 12 · 52:18
host summaryWhit Holcomb summarizing a resource: Non-operative candidates will likely be non-perforated appendicitis patients, though Marty Blakely's study shows some perforated patients can also be treated non-operatively↗
▶Ep 12 · 56:15
host summaryWhit Holcomb summarizing a resource: Los Angeles study showed approximately 10% of patients initially managed non-operatively for perforated appendicitis without interval appendectomy returned for recurrent appendicitis, but follow-up was only 1-1.5 years↗
host summaryWhit Holcomb summarizing the discussion: In Doctor Ponsky's study, when the same laparoscopic image was shown upside down and flipped, surgeons did not agree with their own previous assessment, demonstrating intra-observer variability close to chance alone.↗
▶Ep 13 · 5:15
host summaryWhit Holcomb summarizing the discussion: But the funniest is we took one of the images, turned it upside down, and flipped it to the left, and even people didn't agree with themselves when they saw the same picture later on in the study. So inter and intra-observer variability was close to chance alone.↗
▶Ep 13 · 8:40
host summaryWhit Holcomb summarizing the discussion: In a study comparing standardized large-volume irrigation (3-12 liters in small focused aliquots) to surgeon preference irrigation, patients receiving standardized irrigation had 0% abscess rate versus 19% with surgeon discretion.↗
▶Ep 13 · 10:09
host summaryWhit Holcomb summarizing the discussion: A 2018 meta-analysis comparing suction alone versus irrigation in children and adults found no difference in the rate of postoperative abscess.↗
Summaries Whit gave as host · Appendicitis33 summaries
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 4 · 11:20
host summaryWhit Holcomb summarizing the discussion: A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 4 · 13:49
host summaryWhit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 4 · 14:20
host summaryWhit Holcomb summarizing the discussion: The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 4 · 14:48
host summaryWhit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 4 · 20:35
host summaryWhit Holcomb summarizing the discussion: A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 4 · 22:42
host summaryWhit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 4 · 23:14
host summaryWhit Holcomb summarizing the discussion: In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 4 · 24:35
host summaryWhit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 4 · 24:55
host summaryWhit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 4 · 25:20
host summaryWhit Holcomb summarizing the discussion: The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 4 · 29:19
host summaryWhit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
Appendicitis with Dr. Whit Holcomb
▶Ep 5 · 23:41
host summaryWhit Holcomb summarizing a resource: the take-home message was that in your paper, at least about 25%, there was only agreement among attending surgeons looking at the pictures that there was 25% agreement on whether there was perforation or not.↗
▶Ep 5 · 23:41
host summaryWhit Holcomb summarizing a resource: Inter-observer variation study (Journal of Laparoendoscopic and Advanced Surgical Techniques) showed only 25% agreement among attending surgeons on perforation status when viewing operative images without defined criteria↗
▶Ep 5 · 52:11
host summaryWhit Holcomb summarizing a resource: Adult literature and Nationwide Children's Hospital data suggest approximately 50-60% of non-perforated appendicitis patients could be managed with antibiotics alone; about one-third require operation↗
▶Ep 5 · 52:11
host summaryWhit Holcomb summarizing a resource: Prospective randomized trials on non-operative appendicitis management are underway at Nationwide Children's Hospital and other hospital groups↗
▶Ep 5 · 56:15
host summaryWhit Holcomb summarizing a resource: Los Angeles study: 10% recurrence rate of appendicitis without interval appendectomy after non-operative management, but follow-up only 1-1.5 years↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 7 · 11:20
host summaryWhit Holcomb summarizing the discussion: A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 7 · 13:49
host summaryWhit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 7 · 14:20
host summaryWhit Holcomb summarizing the discussion: The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 7 · 14:48
host summaryWhit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 7 · 20:35
host summaryWhit Holcomb summarizing the discussion: A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 7 · 22:42
host summaryWhit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 7 · 23:14
host summaryWhit Holcomb summarizing the discussion: In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 7 · 24:35
host summaryWhit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 7 · 24:55
host summaryWhit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 7 · 25:20
host summaryWhit Holcomb summarizing the discussion: The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 7 · 29:19
host summaryWhit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
Evidence-based diagnosis and management of pediatric appendicitis with Dr. Whit Holcomb
▶Ep 9 · 23:41
host summaryWhit Holcomb summarizing a resource: you can't really assess perforation visually without a well-defined criteria and that different surgeons will view perforation in a different fashion↗
▶Ep 9 · 23:41
host summaryWhit Holcomb summarizing a resource: In Ponsky's inter-observer variation study published in Journal of Laparoendoscopic and Advanced Surgical Techniques, attending surgeons viewing same images agreed on perforation status only 25% of the time without defined criteria↗
▶Ep 9 · 52:18
host summaryWhit Holcomb summarizing a resource: Non-operative candidates will likely be non-perforated appendicitis patients, though Marty Blakely's study shows some perforated patients can also be treated non-operatively↗
▶Ep 9 · 52:18
host summaryWhit Holcomb summarizing a resource: Nationwide Children's Hospital has performed work on non-operative appendicitis management and has ongoing prospective randomized trial; another multi-hospital trial is in planning stages↗
▶Ep 9 · 52:18
host summaryWhit Holcomb summarizing a resource: Adult literature reports approximately 2/3 of appendicitis patients can be treated non-operatively without surgery, about 1/3 require operation↗
▶Ep 9 · 56:15
host summaryWhit Holcomb summarizing a resource: Los Angeles study showed approximately 10% of patients initially managed non-operatively for perforated appendicitis without interval appendectomy returned for recurrent appendicitis, but follow-up was only 1-1.5 years↗
Summaries Whit gave as host · Appendicitis10 summaries
Evidence-based diagnosis and management of pediatric appendicitis with Dr. Whit Holcomb
▶Ep 7 · 23:41
host summaryWhit Holcomb summarizing a resource: you can't really assess perforation visually without a well-defined criteria and that different surgeons will view perforation in a different fashion↗
▶Ep 7 · 23:41
host summaryWhit Holcomb summarizing a resource: In Ponsky's inter-observer variation study published in Journal of Laparoendoscopic and Advanced Surgical Techniques, attending surgeons viewing same images agreed on perforation status only 25% of the time without defined criteria↗
▶Ep 7 · 52:18
host summaryWhit Holcomb summarizing a resource: Adult literature reports approximately 2/3 of appendicitis patients can be treated non-operatively without surgery, about 1/3 require operation↗
▶Ep 7 · 52:18
host summaryWhit Holcomb summarizing a resource: Nationwide Children's Hospital has performed work on non-operative appendicitis management and has ongoing prospective randomized trial; another multi-hospital trial is in planning stages↗
▶Ep 7 · 52:18
host summaryWhit Holcomb summarizing a resource: Non-operative candidates will likely be non-perforated appendicitis patients, though Marty Blakely's study shows some perforated patients can also be treated non-operatively↗
▶Ep 7 · 56:15
host summaryWhit Holcomb summarizing a resource: Los Angeles study showed approximately 10% of patients initially managed non-operatively for perforated appendicitis without interval appendectomy returned for recurrent appendicitis, but follow-up was only 1-1.5 years↗
host summaryWhit Holcomb summarizing the discussion: But the funniest is we took one of the images, turned it upside down, and flipped it to the left, and even people didn't agree with themselves when they saw the same picture later on in the study. So inter and intra-observer variability was close to chance alone.↗
▶Ep 8 · 5:15
host summaryWhit Holcomb summarizing the discussion: In Doctor Ponsky's study, when the same laparoscopic image was shown upside down and flipped, surgeons did not agree with their own previous assessment, demonstrating intra-observer variability close to chance alone.↗
▶Ep 8 · 8:40
host summaryWhit Holcomb summarizing the discussion: In a study comparing standardized large-volume irrigation (3-12 liters in small focused aliquots) to surgeon preference irrigation, patients receiving standardized irrigation had 0% abscess rate versus 19% with surgeon discretion.↗
▶Ep 8 · 10:09
host summaryWhit Holcomb summarizing the discussion: A 2018 meta-analysis comparing suction alone versus irrigation in children and adults found no difference in the rate of postoperative abscess.↗
Summaries Whit gave as host · Biliary Atresia22 summaries
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 6 · 11:20
host summaryWhit Holcomb summarizing the discussion: A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 6 · 13:49
host summaryWhit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 6 · 14:20
host summaryWhit Holcomb summarizing the discussion: The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 6 · 14:48
host summaryWhit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 6 · 20:35
host summaryWhit Holcomb summarizing the discussion: A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 6 · 22:42
host summaryWhit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 6 · 23:14
host summaryWhit Holcomb summarizing the discussion: In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 6 · 24:35
host summaryWhit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 6 · 24:55
host summaryWhit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 6 · 25:20
host summaryWhit Holcomb summarizing the discussion: The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 6 · 29:19
host summaryWhit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 10 · 11:20
host summaryWhit Holcomb summarizing the discussion: A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 10 · 13:49
host summaryWhit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 10 · 14:20
host summaryWhit Holcomb summarizing the discussion: The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 10 · 14:48
host summaryWhit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 10 · 20:35
host summaryWhit Holcomb summarizing the discussion: A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 10 · 22:42
host summaryWhit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 10 · 23:14
host summaryWhit Holcomb summarizing the discussion: In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 10 · 24:35
host summaryWhit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 10 · 24:55
host summaryWhit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 10 · 25:20
host summaryWhit Holcomb summarizing the discussion: The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 10 · 29:19
host summaryWhit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
Summaries Whit gave as host · Colorectal / ARM & Hirschsprung14 summaries
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 76 · 11:20
host summaryWhit Holcomb summarizing the discussion: A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 76 · 13:49
host summaryWhit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 76 · 14:20
host summaryWhit Holcomb summarizing the discussion: The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 76 · 14:48
host summaryWhit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 76 · 20:35
host summaryWhit Holcomb summarizing the discussion: A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 76 · 22:42
host summaryWhit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 76 · 23:14
host summaryWhit Holcomb summarizing the discussion: In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 76 · 24:35
host summaryWhit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 76 · 24:55
host summaryWhit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 76 · 25:20
host summaryWhit Holcomb summarizing the discussion: The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 76 · 29:19
host summaryWhit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
Journal of Pediatric Surgery Article Review: September 2023
▶Ep 159 · 4:40
host summaryWhit Holcomb summarizing the discussion: Early CDH repair was defined as during the first 48 hours after ECMO cannulation, and delayed repair was anything after that time.↗
▶Ep 159 · 7:29
host summaryWhit Holcomb summarizing the discussion: The ERAS meta-analysis examined 10 studies involving 1300 patients from databases including PubMed, Embase, and Cochrane Library.↗
▶Ep 159 · 8:09
host summaryWhit Holcomb summarizing the discussion: ERAS protocols have a beneficial role in accelerating rehabilitation and shortening length of hospitalization.↗
Summaries Whit gave as host · Esophageal Atresia8 summaries
Journal of Pediatric Surgery Article Review: December 2023
▶Ep 58 · 2:14
host summaryWhit Holcomb summarizing the discussion: 11 of 12 patients with complete varicocele elimination had significant improvement in total motile sperm count↗
▶Ep 58 · 2:14
host summaryWhit Holcomb summarizing the discussion: Over half of patients had sperm count improve from abnormal range to normal range↗
▶Ep 58 · 2:14
host summaryWhit Holcomb summarizing the discussion: 15 Tanner stage 5 patients with varicocele were identified; 12 of 15 achieved complete elimination of varicocele (80% success rate)↗
▶Ep 58 · 3:19
host summaryWhit Holcomb summarizing the discussion: Mean percentage improvement in total motile sperm count was 650%↗
▶Ep 58 · 5:16
host summaryWhit Holcomb summarizing the discussion: 139 patients underwent 148 surgeries with treatments including strictureplasty, segmental resection, or resection with delayed anastomosis after lengthening↗
▶Ep 58 · 5:16
host summaryWhit Holcomb summarizing the discussion: Surgical repair occurred if anastomotic stricture was refractory to endoscopic therapy or was clinically symptomatic and patient was undergoing surgery for another indication↗
▶Ep 58 · 5:16
host summaryWhit Holcomb summarizing the discussion: Follow-up was nearly 40 months↗
▶Ep 58 · 5:16
host summaryWhit Holcomb summarizing the discussion: Evaluated outcomes included anastomotic leak, repeat surgery for strictures, and need for esophageal replacement↗
Summaries Whit gave as host · Etiologies (Gastroschisis/NEC/Atresia/Volvulus)11 summaries
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 26 · 11:20
host summaryWhit Holcomb summarizing the discussion: A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 26 · 13:49
host summaryWhit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 26 · 14:20
host summaryWhit Holcomb summarizing the discussion: The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 26 · 14:48
host summaryWhit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 26 · 20:35
host summaryWhit Holcomb summarizing the discussion: A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 26 · 22:42
host summaryWhit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 26 · 23:14
host summaryWhit Holcomb summarizing the discussion: In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 26 · 24:35
host summaryWhit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 26 · 24:55
host summaryWhit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 26 · 25:20
host summaryWhit Holcomb summarizing the discussion: The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 26 · 29:19
host summaryWhit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
Summaries Whit gave as host · Gastroesophageal Reflux3 summaries
host summaryWhit Holcomb summarizing the discussion: Time to diagnosis of hiatal hernia was significantly longer in minimal mobilization group compared to maximum mobilization group↗
▶Ep 1 · 23:19
host summaryWhit Holcomb summarizing the discussion: Kansas City/Birmingham prospective RCT showed aggressive esophageal mobilization had 23% to 37% incidence of transmigration over 6.5 years, while minimal mobilization increased from 3% to 12%↗
▶Ep 1 · 23:19
host summaryWhit Holcomb summarizing the discussion: There was no significant difference in reflux symptoms or medication use between minimal and maximal mobilization groups at 6.5 years↗
Summaries Whit gave as host · Gastroesophageal Reflux Disease3 summaries
host summaryWhit Holcomb summarizing the discussion: Kansas City/Birmingham prospective RCT showed aggressive esophageal mobilization had 23% to 37% incidence of transmigration over 6.5 years, while minimal mobilization increased from 3% to 12%↗
▶Ep 5 · 23:19
host summaryWhit Holcomb summarizing the discussion: There was no significant difference in reflux symptoms or medication use between minimal and maximal mobilization groups at 6.5 years↗
▶Ep 5 · 23:19
host summaryWhit Holcomb summarizing the discussion: Time to diagnosis of hiatal hernia was significantly longer in minimal mobilization group compared to maximum mobilization group↗
Summaries Whit gave as host · Gastroesophageal Reflux Disease3 summaries
host summaryWhit Holcomb summarizing the discussion: Kansas City/Birmingham prospective RCT showed aggressive esophageal mobilization had 23% to 37% incidence of transmigration over 6.5 years, while minimal mobilization increased from 3% to 12%↗
▶Ep 5 · 23:19
host summaryWhit Holcomb summarizing the discussion: Time to diagnosis of hiatal hernia was significantly longer in minimal mobilization group compared to maximum mobilization group↗
▶Ep 5 · 23:19
host summaryWhit Holcomb summarizing the discussion: There was no significant difference in reflux symptoms or medication use between minimal and maximal mobilization groups at 6.5 years↗
Summaries Whit gave as host · Intestinal Failure22 summaries
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 3 · 11:20
host summaryWhit Holcomb summarizing the discussion: A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 3 · 13:49
host summaryWhit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 3 · 14:20
host summaryWhit Holcomb summarizing the discussion: The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 3 · 14:48
host summaryWhit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 3 · 20:35
host summaryWhit Holcomb summarizing the discussion: A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 3 · 22:42
host summaryWhit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 3 · 23:14
host summaryWhit Holcomb summarizing the discussion: In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 3 · 24:35
host summaryWhit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 3 · 24:55
host summaryWhit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 3 · 25:20
host summaryWhit Holcomb summarizing the discussion: The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 3 · 29:19
host summaryWhit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 7 · 11:20
host summaryWhit Holcomb summarizing the discussion: A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 7 · 13:49
host summaryWhit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 7 · 14:20
host summaryWhit Holcomb summarizing the discussion: The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 7 · 14:48
host summaryWhit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 7 · 20:35
host summaryWhit Holcomb summarizing the discussion: A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 7 · 22:42
host summaryWhit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 7 · 23:14
host summaryWhit Holcomb summarizing the discussion: In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 7 · 24:35
host summaryWhit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 7 · 24:55
host summaryWhit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 7 · 25:20
host summaryWhit Holcomb summarizing the discussion: The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 7 · 29:19
host summaryWhit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
Summaries Whit gave as host · Intestinal Rehab22 summaries
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 14 · 11:20
host summaryWhit Holcomb summarizing the discussion: A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 14 · 13:49
host summaryWhit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 14 · 14:20
host summaryWhit Holcomb summarizing the discussion: The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 14 · 14:48
host summaryWhit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 14 · 20:35
host summaryWhit Holcomb summarizing the discussion: A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 14 · 22:42
host summaryWhit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 14 · 23:14
host summaryWhit Holcomb summarizing the discussion: In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 14 · 24:35
host summaryWhit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 14 · 24:55
host summaryWhit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 14 · 25:20
host summaryWhit Holcomb summarizing the discussion: The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 14 · 29:19
host summaryWhit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 35 · 11:20
host summaryWhit Holcomb summarizing the discussion: A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 35 · 13:49
host summaryWhit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 35 · 14:20
host summaryWhit Holcomb summarizing the discussion: The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 35 · 14:48
host summaryWhit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 35 · 20:35
host summaryWhit Holcomb summarizing the discussion: A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 35 · 22:42
host summaryWhit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 35 · 23:14
host summaryWhit Holcomb summarizing the discussion: In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 35 · 24:35
host summaryWhit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 35 · 24:55
host summaryWhit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 35 · 25:20
host summaryWhit Holcomb summarizing the discussion: The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 35 · 29:19
host summaryWhit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
Summaries Whit gave as host · Intestinal Transplant11 summaries
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 4 · 11:20
host summaryWhit Holcomb summarizing the discussion: A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 4 · 13:49
host summaryWhit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 4 · 14:20
host summaryWhit Holcomb summarizing the discussion: The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 4 · 14:48
host summaryWhit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 4 · 20:35
host summaryWhit Holcomb summarizing the discussion: A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 4 · 22:42
host summaryWhit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 4 · 23:14
host summaryWhit Holcomb summarizing the discussion: In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 4 · 24:35
host summaryWhit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 4 · 24:55
host summaryWhit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 4 · 25:20
host summaryWhit Holcomb summarizing the discussion: The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 4 · 29:19
host summaryWhit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
Summaries Whit gave as host · Pectus Carinatum3 summaries
Journal of Pediatric Surgery Article Review: September 2023
▶Ep 15 · 4:40
host summaryWhit Holcomb summarizing the discussion: Early CDH repair was defined as during the first 48 hours after ECMO cannulation, and delayed repair was anything after that time.↗
▶Ep 15 · 7:29
host summaryWhit Holcomb summarizing the discussion: The ERAS meta-analysis examined 10 studies involving 1300 patients from databases including PubMed, Embase, and Cochrane Library.↗
▶Ep 15 · 8:09
host summaryWhit Holcomb summarizing the discussion: ERAS protocols have a beneficial role in accelerating rehabilitation and shortening length of hospitalization.↗
Summaries Whit gave as host · Pectus Excavatum3 summaries
Journal of Pediatric Surgery Article Review: September 2023
▶Ep 42 · 4:40
host summaryWhit Holcomb summarizing the discussion: Early CDH repair was defined as during the first 48 hours after ECMO cannulation, and delayed repair was anything after that time.↗
▶Ep 42 · 7:29
host summaryWhit Holcomb summarizing the discussion: The ERAS meta-analysis examined 10 studies involving 1300 patients from databases including PubMed, Embase, and Cochrane Library.↗
▶Ep 42 · 8:09
host summaryWhit Holcomb summarizing the discussion: ERAS protocols have a beneficial role in accelerating rehabilitation and shortening length of hospitalization.↗
