2025 Pediatric Surgery Update Course - Updates in NEC Management

Okay, so thank you Todd for the kind invitation. It's me here in person and Simon online, so we're going to talk about an exercise in chocolate. All right, so of course a lot of dilemmas still don't know what causes it, just for our surgeons, how do we really diagnose it? We really don't know and what's the right time to operate? Are there some babies that are too sick to be operated on? And then when we do an operation, which one we should choose, what is the best operation? When do we restart feeds for these babies? Antibiotics, which antibiotics and for our long? Do we refeed the mucus fister if you have one and when to close the stoma? So these are some we won't touch on everything but some of the surgical dilemmas still out there. So we have a 28 week male infant, 900 gram on CPAP, on trophic feeds, EBM and TPM. It's a day 12 of life, baby develops abdominal distension, episodes of bilis vomiting, and bloody stool. On exam, baby is irritable, tachycardic, tender, distended abdomen, labs show high-wide count metabolic acidosis and a high CRP. We do an X-ray that shows no free air, there's some bubbles in the intestine. So we decide to put the baby on triplantebiotics, amchent and flagell and bowel rest. So I'm PO. But how do you follow up on this baby beyond your physical exam? Should we do serial abdominal X-rays every four, six weeks? Should we do another X-ray in 24 hours? Should we do an abdominal ultrasound? Should we do an abdominal CT scan? Not four to six weeks, four to six hours. Oh, it says six weeks. Sorry. All right. Okay. All right. So would anybody do ultrasound to start with? Then I would agree with the knee cue in that case. And maybe it's not that popular. But the ultrasound really gives you a lot of more clues that the abdominal X-ray. The abdominal X-rays are highly specific, but very low sensitivity studies show a sensitive between 13 and 25%. What does it mean? When you have a low sensitive test, it means that there's poor ability to catch those patients with a condition, which condition? Of course, we want to know when the baby has surgical neck, when we need to operate. Well, an ultrasound scan can tell you a little bit more about the bowel, bowel wall, thickening, thinning, perfusion, perstalsis. What's inside the abdomen? What happens at the level of the peritoneum and the liver? So this study from end of 2023 touched on this, it's on pediatric radiology. So first of all, when not to do an ultrasound scan? When the baby has free air, of course, then the need a surgeon, not an ultrasound scan. When the baby we think is sick and we have an X-ray that actually gives us all the clues that we need. But when to do an ultrasound? When, for instance, the call has for a consult on a baby that we don't think has necrosisanticalitis and the X-ray is equivocal. Early stages of neck, when actually there's no much to see on an X-ray very low sensitivity, when the baby is really sick and the X-ray doesn't match the clinical scenario. So in this study, they looked at risk findings as they described them on the sonogram. So, a high once our neopereutinium, folic fluid collections, complex free fluid. These are more concerning for bowel perforation. Intermediate, you have increased bowel wall ecogeneity, absent perfusion, prolvenous gas, bowel thingy, and thickening. The more of these, you have the more likely you need to do something about it from a surgical standpoint. And low once like increased bowel perfusion, not so much. There's also more that have been described. Again, but the same group, you can see a thickening of the mesentery, hyperacioic interluminant content, and also there's this inability to see the tissue plane. So they divided patients group A and group B, group A, babies successfully treated medically, and they will need for surgery, group B, medical management failed, and they needed surgery. Now, all these findings are present in both groups, but much more in the ones, of course, that needed surgery. So we go on with the clinical scenario. Stay 14, baby gets worse, more abdominal distension, acidosis started on anitropes, high vent settings, blood transfusion needed. We do an X-ray, and there's free air. Okay, and so of course the classical controversy in negatizing intercollitis management. What do you do now? An intraperity on the brain, exploratory laparotomy, weight and sea, redirection of care. There's free air, yes. People voting on this? Okay, that's good. I agree with them. I agree with the majority that actually would do laparotomy, but obviously this is, as I said, the classical. We don't touch on these three randomized control trials in the past, so we decide to proceed with surgery, but then I ask you, which kind of surgery do you do a resection, an anastoma, a resection, an anastomosis, clip and drop, you just withdraw care? That's the client. Have you always seen that an healthcare is the baby? Yeah, of course, yes. But let's say it's a baby that is stable, not so sick, it's not total, so pancollitis, it's not a focal intestinal appropriations, just like 10 centimeters of an acrobatic bowel in the middle of the the theelium. What would you do? Oh, sorry, do we have the pole? Oh, cooking. All right. Welcome. Can we show the pole cooking? Yeah. What will people do? Anyone doing an anastomosis? Who would operate or who didn't ask do an asthmosis by showbhands? Not too sick, stay. Yeah. Who would do one? Interesting. Absolutely not. I'm still not convinced. Clearly. This is a problem. There's a sick post-op, whether you do the anastomosis or not. Sure. So how can you you don't have a reliable exam to know? Get out of the side. Bones up. Oh, okay, so the majority would do us. Does anybody use ICG in an neonate? In an neonate, does anybody use ICG in an neonate? But also, it's not very much about the profusion of the margins. People feel uncomfortable doing an anastomosis in a 500 gram or 800 gram or like this one. But I think the ICG thing is a great idea. I mean, if your facility has the ability to do ICG, who if you had ICG that showed you a good profusion, would you hesitate to do an anastomosis? Anybody? You'd still hesitate? Yes. Because it's progressing. It's a progressive disease. Is it when you take it out? Yeah. The bowel is a symptom is a result of the illness. It's not the cause of the illness. So the disease still progresses. Even that's the problem of going too early. You were sacked. It's still progressing. That's my concern. Because I feel like it could look totally different tomorrow. True. No old babies are the same. Of course, there are those ones which you open up. You just need to bring up a stowa because they're too unstable. But the ones which as I said, like let's say 10 cm of a segment, you remove it. You have source control. No necessarily they do so poorly. And then afterwards, when you actually looking at the next slides, you'll see that in the long run, actually there's a benefit. The benefit is not immediate survival, for instance. That would be, of course, there's babies that die unfortunately in both groups. So, when we have to listen to some recent progress, would you put a title and then come back and say, I would do, yeah, I would do, no. First of all, I change my practice every year when I do this. So I will change my practice. And part of me is a wimp. Well, we all know that. But I mean, like in general with this, if I was like, all right, I'm doing standard of care now. Like I'm not on the fringe. I would say, all right, this is accepted. The data shows it's better. I'm uneasy. I won't sleep for the next three nights. I won't be, right. So after this, if I'm convinced of the data, I probably, if I feel like the, if I feel like the baby's well, I would be convinced to do a primary nesmosis. Because I do agree doing a stoma, doing a silo, clip and drop. Maybe they won't do as well if the data shows that. Right now I'm a clip and dropper. I would come back 24, 48 hours later. I would not do a stoma. Because I feel like I would have an answer in a couple days. Why? What am I saying that you don't like? No, I think it depends on the human dynamics, right? And the kid, if you're, like, tick is correcting, if you're thermosytopini is correcting, if you're getting all phytonatropos, right? And you come back and explore and the bowel looks potentially viable. Yeah. You're recicting five instead of 35 potentially. Yeah. You can bring that up a stoma or doing an estomosis. It depends on the human dynamics. I think we do not have a standard of care. I said today. I agree, but can I just ask a question now? Is it, go ahead, Steve? Is this a bowel perfusion problem? Because I'm not sure it's the same as like anyone that has poor perfusion. This is a very more complex disease. So you come back and you do a clip and drop 24 hours later. You look pristine, no further progression. Would you do an ostomy? Would you do an estomosis now? Now, the case is of a perforation. Of course, there are those babies that we start somatic ammanagements and then they're just hover along and you don't know what to do. And then it's sort of failure of medical management. You don't know what to do. And those ones are the ones that maybe it's difficult to decide. But when you have clear, you have perforation, you have a necrotic bowel, you know, where the necrosis is. Yeah. I'm going to chat with Sean Sapper. Yeah. Spontaneous intestinal perforation is totally different. Totally different. Absolutely. Yeah. Definitely go pranthenics. 100%. So that was one of the exclusion criteria for the trial. So because the vast majority of babies can do well with an anastomosis. Same with prancolitis, which is the other end of the spectrum. There you can all do an anastomosis. And this trial randomizes intraoperatively. Introoperatively. So the decision was made in the operating matter, resection of the necrotic portion of bowel. Should we go ahead with the next? You want to bring heat in? Yes. Do you know what's the end of it? So Simon, can you hear us? Can you hear me? Very well. Yeah. Okay. I'm sorry. I was so do you mind moving to the next slide? We are at the meta-analysis. Yeah. Can you see that? You want the next one? I know the metronautic is. Yeah, that's fine. Okay. So in great industry, hospital, there's a, as they've been using primary and asthmosis. Here is the operative choice for quite some time. Under the guidance of Mr. Kylie and Professor Spitz. And also Agostino Chiarra. But a metronautic in 2017, I've highlighted that there may be some advantage in doing a primary and asthmosis compared to those at undergo stoma. However, none of these were from randomized controlled trials. And so this might have been due to differences in the severity of any scene. And this metronautic is concluded that a randomized controlled trial was necessary. Next slide, please, Agostino. Yeah. So we designed a randomized controlled trial. And I have to pay credit here to Dr. Agostino Chiarra, who was very much the driving force behind getting this trial started. It was a very, very difficult trial in many ways. Not just the difficulty of the trial itself, but also the fact that Dr. Chiarra moved from very on the street to Toronto, part the way through the trial. And so the key here was that the final decision on eligibility was dependent on the surgeon's judgment during the laparotomy. So some infants were always going to be candidates for primary and asthmosis, if they had a very small perforation, spontaneous intestinal perforation, where no one realistically would do a stoma. On the other end of the spectrum, you've got those infants that already always had very extensive disease, or it was very difficult to judge, where no one really would want to do a primary and asthmosis. They just want to get out after having done the stoma. Next slide, please, over stoma. And click through the other two. So consent was taken from the parents for randomisation before going to theatre. And then the decision was taken out laparotomy when the bowel could actually be examined and then introspective randomisation took place. For those of you that know me, you know I am not a surgeon, it's not me that's making the decision to randomise. So I'd just like to add back to Dr. Zani who actually did randomise a lot of the patients in this trial just to comment on that randomisation process. And how do you really have to feel comfortable every time that you could potentially do either operation? Yeah, thanks, Sam. Yeah, it was quite tricky. And of course it's you're in the middle of the operation. These means of course that the baby is stable, hemodynamically stable. And then you would unscrap and go to the computer and go for randomisation. It was of course also a conversation between me and the fellow. I randomised more than 20 of these babies for the whole trial. So and sometimes I really thought it was better to do one rather than the other, but it was just my gut feeling. There was no evidence. And so we did what the machine told us, whether the computer told us. And I can tell you that the fellow is when he was and I can and asked the most is where like, oh my god, now we're doing this to 500 grammars. But then they were the strongest believers when they saw how these babies progressed afterwards. Simon. Can you get back to the slides and to the next slide please? I don't see there's we on the. That's it. Yeah, thank you. And so the primary outcome for the trial was quite difficult to decide on because we knew that we were never going to be able to power a trial for mortality or for neurodivendant for now. So we decided to take the primary outcome on time on parental nutrition. And as you can see from this Cox regression analysis, those that had a primary and asthmosis got onto full-entral feeds sooner and finished their parental nutrition earlier. Next slide. And then there was no difference in terms of no significant difference in terms of mortality. If anything, mortality was ever say slightly higher from the stoma group, not significantly different. And then complications, stoma complications were inevitably in the stoma group. We did have obviously some complications in the primary and asthmosis group. But overall we felt the complications were worse in the stoma group than the primary and asthmosis group. Next slide please. So in conclusion, we decided the conclusions of this trial was that the primary and asthmosis led to reduced duration of PN, reduced intestine complications, and there was no difference in mortality. So although obviously we, one, accept that there are, if you are uncomfortable doing a primary and asthmosis, then doing a primary and asthmosis is not for you. But nevertheless, there are some children that we believe are definitely candidates for primary and asthmosis, where otherwise you might consider only doing a stoma. So moving on to the clinical scenario, in this particular patient then after having decided to do a primary and asthmosis, the patient then became markedly clinically unstable. So the decision was taken to do a stoma instead. And so there's all sorts of questions on almost every stage in any scene. So here we have a question how long do we make them, NPO, after a lateral proctomy. We don't have time to consider that today. But they're not post-operative week three. There's a conversation between surgeon's neonatologist and the nurses who are a pill and part of this conversation about mucus fistula refeeding. So we'd like to give you the next poll about mucus fistula refeeding. Should this baby be refanned by the mucus fistula? Yes, yes, yes. Is it the fall? Yes, the majority of people say yes. Okay, so where are we in terms of evidence for mucus fistula refeeding? Next slide please, over a step. Yeah, so there has been a systematic review and metronalysis from Bonnie Gisani, who's a neonatologist from Toronto, so kids. And the evidence isn't strong so far. Next slide please. Luckily there is a randomized controlled trial that's going on at the moment, which is again this is a very very difficult randomized controlled trial. We don't know the data from this at the moment, but it's a randomized controlled trial of mucus fistula refeeding, time to full entry feeds. Most of this population is an NEC population, but it does include other neonates with a bound reception. Next slide please. And then the final question we wanted to just pose is time to stoma closure. So, if you have done a stoma, do you attempt to close and think about closing it less than eight weeks, eight to 12 weeks, or you leave for even longer? So significant amount of people will close either, all it's shifting for a lot. My other question is are people in here answering the polls? You should. Here's what I'm guessing. If there's a delay on the polls, the initial response we're seeing is this room. Is that right? Because there's a delay on the, oh there's no delay. Okay never mind. I got excited that we were going to see if our audience disagrees. So just quickly the data from that show, there's a, the people have pretty split between the three possibilities there. Sorry, could you mind to go back one slide, I was so? Time's up. Yeah, okay. So optimal timing of stoma closure, recent paper in general of surgical research, basically showing that there's, it seems to be safe to close early. However, this study is very underpowered. So it's concerning in less than eight weeks, there are two infants that had a repeat episode of NEC. And I'll hand over to, I was stoma two, oh sorry, final thing there is that there isn't ongoing preparation for randomized trial in the UK. And I'll hand back to over the stoma there for the wrapping up person to practice. So take a message from our group on this session is that you can use an ultrasound if the abodex rate is a equivocal, primary is the most, this is a viable option in stable babies. Because basically feeding it seems to be nutrient advantageous and ultimacologic can safely be performed early, earlier than eight weeks. Thank you. That was awesome. Do we have time for one question? Yeah, actually, I was just texting you, can you, someone make sure I know how we are on the agenda timetable? Perfect, all right, go ahead, we'll get the later. We'll get delayed. So, I'll go, so yeah, coming back to the stat trial, given it was not a power to detect a difference in mortality, do you think there's a risk we're just looking at the benefit of early P and winning, but maybe giving them an increased risk of mortality because I know there's no statistical difference, but the numbers are quite shocking, it's 11th versus 21, isn't it? Well, of course, these babies are, you know, sick and obviously this is what you see, but this is the 80 babies that have been randomized and so mortality was definitely, we know that there will be mortality in both groups. I don't think that we have more babies and as a second trial, we'd necessarily see differences in that regard. Could you comment on how many babies were excluded, so how many out of the roughly 80 that went in the trial were considered and the surgeon thought, okay, this baby is not a viable option for both? Yeah, I mean, the exclusion was mainly upfront, parents that you don't want to give consent. So, first it's very dramatic when you talk with them and say, okay, your baby has preferred the bowel needs to go to the UR, so some parents are really too distressed. But during the surgery, again, I don't have the numbers, I don't know if Simon, you have the numbers, but definitely those with, as I said, a focal interstingial perforation instability and there's, of course, a bunch of babies that go to UR and still and are unstable, your anesthesiologist wants you to be as quick as possible. Those with papalitis or with distal colonic disease, those ones were definitely not considered. I don't know the number of those ones, Simon, do you have those numbers? We were unable to collect any numbers that I would give any kind of index of reliability to it. We have some, some information, but very little, on which to face any conclusions. Quick poll for the people in the room because we can't do it online. I'm a big believer of ultrasound. Like I've seen it, it's real, the radiologists are super good at it and the technologists are really good at it. If you had a baby that didn't show free air on a plane film, but the radiologist said this baby has a perforation, who would operate that baby based on the radiologist's toenies perforated? By ultrasound? Yeah. Yeah. You have to trust your radiologist, but I don't think as surgeons we've actually embraced ultrasound the way we should because on the radiology side, they're doing stuff that is just ridiculously sensitive. I think you need to be prepared to have some negative laparotomies. There will be some in which, unfortunately, you think it's perforated, actually, it's not, but definitely feels like terbid-free fluid. There's something going on there. But you don't see that in the x-ray. So you got to trust your radiologist, some extent, say like, this baby's perforated. Okay, people will get operate on that. Yeah. You don't see it on the x-ray, but eventually a lot of those kids will get better, but they won't open up. And then you'll go in there and you'll have clear evidence that there was a perforation that said we missed. All right, sorry. Does everybody do refeeding? All right, next person. Thank you. That was awesome.