2025 Pediatric Surgery Update Course - Updates in Pediatric Surgery feat. non-JPS Journals

That is it. We're going to go ahead and get started. And first I'd like to introduce Dr. Jose Campos, who has been with us now. How many years have you been doing it with us? Six years. Jose came up to me at a conference and said, Todd, it's nice to meet you. Thank you for this uptakes course, but it's not very good. Because you only talk about stuff that's in the pediatric journals. And you're missing all the publications that are in the non-pediatric surgery journals. And him and his team with this Chilean Society of Pediatric Surgery, they have a method where they identify the best articles that we don't really see, because they're not necessarily in our core journals. So every year and actually all year long through, stay current, you're giving us updates on what we need to pay attention to. So Jose, it's all yours now. But I need to take one minute just to acknowledge that I'm standing here. Oh, the way. Okay, sorry, I apologize. So I need to acknowledge that I'm standing here thanks to the Chilean Society of Pediatric Surgery. And also to this group of volunteers called Journal Hive, we screen through 1200 articles each month. We have a method of selecting what's good and what's not. And then we try to spread it out through our newsletter, our podcast, and through infographics and also within this course. So I wish all the 25 volunteers that are working with us would be here. I'm hoping that some of them are watching us from Chile. But here's just a glance of what the team looks like. Okay, let's keep going. So today we're going to talk about four things. It was kind of difficult to choose the articles this year. We're going to talk about nonoperative management of opined societies. We're going to talk about trauma, DVT prophylaxis, neuroendocrine tumors and the extent of surgery. And necrotizing entroglyte should we do a stoma? Should we do an anastomosis? So let's start with a clinical scenario. It's a very clear appendix, uncomplicated appendicitis. Let's imagine for a minute that we're treating a 12-year-old boy with 24-hour right iliac false pain. He has rebounds signs. His vitals are normal and the ultrasound confirms and non-complicated appendicitis. So can we please get the poll up? So the question is very simple. Have you treated patients with appendicitis nonoperatively in the last 12 months? Why don't we do a quick hands up voting here in the audience? Who has treated more than one patient nonoperatively this year? Hands up. Great. Who has treated more than five patients? Nonoperatively. Cool. Is it this? You have to know. Make sure everybody voting. Who has non treated someone nonoperatively? That's a one-one patient. Okay, one. One. Let's say, okay, sorry. Zero. We got one. We got Thomas Inche. Do we have results? Okay. So yes is about two-thirds and no is about one-third. Cool. So I might disappoint you myself because I mean the no group look, maybe this audience is not representative of the worldwide audience, neither am I, but at least in Chile it's heavily rooted in everyone's mind, patients, parents, physicians, pediatricians that this should be treated surgically. So I've been following this this intellectual debate for the last 15 years trying to push it and trying to introduce it in Chile without any success. People just freak out when you tell them that you're not going to do a surgery on them. So that's why we brought this the other way around. So that's why we brought this article. This has been published in Lancet. I think if we would give an award of the best article in Pianex surgery, it should go into this article. Why do we have to do this every year? So are we like I don't, are we either people don't like this concept or we're slow to pick it up, but I feel like we keep having to do this topic. The nonoperative? Yeah. So we're going to talk about it more after the lunch. We brought full presentation on it. But there are some reasons why previous trials did not address this question probably. There were either pilot studies or they were non-randomized studies. So I think this is kind of a breakthrough. It's very difficult to make such a study and we are fortunate enough to have Dr. Sean Stonstone Peter present with us here, who's the main author and also Dr. Simon Eton will be joining us. So why don't we play the video and see what it says. After years of today, we finally have the largest randomestrile in children addressing nonoperative management of appendicitis. This article published in the Lancet this year might interest you. It reports the ATT White trial and international multisenters study comparing appendicitomy versus antibiotics for acute uncomplicated appendicitis in children. 936 patients aged between 5 to 16 years were randomized across 11 hospitals in different countries. Importantly, treatment failure was defined differently in HR. In the antibiotic group, failure meant an appendicitomy needed within one year, while in the surgical group failure meant a negative appendicitomy, or any procedure under general anesthesia related to appendicitis within the next year. At one year, thirty-first percent of children in the antibiotic group failed treatment, compared with only seven percent in the appendicitomy group. The 26.7 percent difference exceeded the pre-stat 20 percent non-ephyrate margin, confirming that antibiotics were inferior. Still, children in the antibiotic group returned to school earlier and needed almost no pain medication. A limitation is that 10 percent of patients had incomplete data, and that consent, refusial reasons were not collected. Cool. Can I talk to Orinji? Can I ask for your opinion on this trial? Because you're the ones, I think you raised your hand when you had treated just one patient. I think that this trial really confirms what a lot of us were worried about, which is what is the pediatrics in large numbers, what is the failure rate? So over 30 percent is actually concerning. I think the end points are different when you look at non-op versus operative standpoint. So I think it's not an Apple's comparison, and I think the take-home message is still safe. There are no adverse events in both groups. So it's still a very safe to do non-operative management. I think this likes a very heated debate among the surgical community. We're going to pause this debate right now because we have a full 20-minute session after the lunch break. So please join us for that session, and we'll just keep going with these articles. So we also do infographics. I'm hoping that you've seen this into global caste, social media, or the Chilean society, social media. Anyway, so clinical scenario number two. So there's a patient admitted overnight after a car crash accident with a severe brain injury and a femur fracture. Now it's been repaired. Vitals and labs are stable now, and there's no signs of active bleeding. No signs of active bleeding in the brain injury, mainly. That's a key question. So let's vote. Would you give DVT for relaxes? The choice is yes. Give it now, please. B is yes, but maybe let's just hold it up until tomorrow. Not quite safe yet. And B is nope. Tourist key. The reason... How old? Eight-year-old. Eight. So the reason I brought this study is we were chatting with the volunteers and someone said, look, there's been published in JAMA. And what do you do about DVT for relaxes? And I had no idea. This was not part of my algorithm. I kind of was neglecting my patients. I was aware of non-operative management, they add to my guideline, etc. But this was not into my algorithm. So I brought this article just because of my own ignorance. Reading the article, then you find out that I'm not the only one like some guidelines actually recommend against it. In the study, we're going to see only 50% of the doctors caring for these children actually gave administrative DVT for relaxes. So we have vote results. Yes, give it now. It's about... Can someone move the cursor around to... It's about 15%. And 50% no, too risky. Let's find out about this. This was been published in JAMA surgery and Johan Karameez from Chile will give us a one-minute summary of this article. When facing us to burly into TIE, the question of an arises, should we start chemical reflexes against phanestromohembalism? And how soon this study published in JAMA surgery in 2024? Prespectively, evaluators 462 pediatric trauma patients with high risk for deep vein tomboses across a level one trauma centers. They compare outcome-based not only on whether the prophylaxis was given, but also when it was initiated. The recommendation for all patient was low molecular weight shepherds twice daily 24 hours after their injury. No major reading even a cure in any patient who received antico-abolations. Judgment who received prophylaxis within 24 hours had a venous rhombombohembalism rate of only 1.6%. In contrast, those who received after 24 hours had a rate of 6.9%, nearly identical to the 5.3% observed in patients who never received prophylaxis. In other words, a certain leg was essentially the same as not giving it at all. The main limitation of this study were the low adherence to VTE guidelines with almost half of the patient never received prophylaxis and the relatively low absolute numbers of VTE events, which restricts a statistical power. So here's the question. Do you use VTE prophylaxis in high risk, radiatic trauma patients? So how early do you study? Cool. Can I ask for Katie Rossel's opinion? Please? Yeah, thank you so much. I think Dr. Kodigal actually made probably the most important point already on this case in that this kid is 8 years old. And so typically in pediatric trauma, we use the cutoff of somewhere about the 12-year range or puberty to be that breaking point for when we think about VTE prophylaxis. So in this kid, I would not give them VTE prophylaxis. Cool. Does anyone want to share the opinion? Or should we move forward? I agree with you. But what if the kid's 14? Oh, B's in 14. So then we think that we should be thinking about that and that those kids are at risk. And so then the kid needs the femur fix. So you give it before the femur after? I mean, I think you started as soon as the patient is present and then, you know, as necessary. Standing up. Sorry. Yeah, I think you give it as soon as the patient is presented unless you have contraindications like TBI or something else. But I would start right on admission. I think that's a great point. After reading these, I think I need to come up with reasons not to give it. Like the default is you need to give it, but unless this or that. And you might be appointed very accurately that it has to be given early. Otherwise, there's no point. So that B choice is usually not the right one. Is it like, oh no, let's start. Let's went to tomorrow. Then you're not gaining any benefit of it. I think the other thing is that we we have a tendency to hold and we can move quicker to start if we have conversations. So a lot of times people will say, okay, no, no, that kid has a TBI. I don't start it. But if you call the neurosurgeons, they say, yeah, it's fine. Right. So a lot of it is really being proactive about how we initiate and making sure that we have a conversation with every patient that we need to, okay, should we be starting? Can we start now? Etc. So that we don't miss the window. Yeah. So this article was actually powered to detect any adverse event. And there was no adverse event whatsoever from prophylaxis. So that's another big take home message. We'll just keep going with article number three. Again, we're doing the infographic. I'm forgetting to show this. There's a lot of work behind this. So there are all across a global caste, state-current app and the Chilean society and the effects surgery social media. We're working on a repository for people just to look through things, but it's not ready yet. Maybe next year. Okay. Scenario number two. Lafars copy cap and dissect me on an eight-year-old girl. Histology just came back. It's a neuroendocrine tumor of the appendix 2.5 centimeters, possibly margin and present lymph nodes. What would you do about this patient? Very easy. Also, well, not easy to choose, but very easy, quite alternatives. She is treated no further management is needed or B, she needs a right hemicolectomy right away. The reason to bring this article, I wasn't a bit hesitant, but at the end, Dr. St. Peter convinced me to do it. It's just that this is so rare. Only one, every 1000 patients will come back with a tumor in the appendix and not all of them are neuroendocrine tumor. So what I'm trying to say is that every surgeon will only treat a handful of these cases in their lifetime. So it's important to get it right. No one can, I don't think anyone can accurately say out of my experience. So that's why we need to be mindful of this larger database studies that we're going to show. Do we have any data on the pulse? I made it especially difficult because I think most would agree that the finding on the astrology of a simple tumor would not trigger this question, but I made it especially difficult this tumor being more than two centimeters, positive margins and lymph nodes. So most would recommend no further management, but there's still like 40% that would recommend hemicolectomy a bit higher than this study we're going to show that's based on the US. Would you still take a child with an appendix, ill-neuron-dopharing tumor to a right hemicolectomy? This article published in the Journal of American College of Surgeons in 2025 might interest you. Using the National Cancer Database between 2004 and 2022, the authors identified 1339 patients under the age of 18 years with a appendix, and compared a appendix epiphyramid versus right hemicolectomy. Primary outcomes were 5 and 10 year overall survived. Right hemicolectomy patients had larger tumors and more lymph-bastular patients. Despite this, survival was excellent and equivalent. 99.9% at 5 years and 99.4% at 10 years without the use of chemotherapy or any other additional treatment or farther surgery. Notably, not that forced disease progression of curable children treated with appendix epiphyramid alone, even when high risk features like tumor larger than 2 centimeters, positive margins, or positive lymph nodes were present. Some limitations for this study through retrospective register and lack of recurrence as an important outcome to calculate this is free survival. Okay, now there's the infographic just summarizing what we just heard. Can I talk to Aldrin, can I get your opinion? Do you think there's a role for hemicolectomy in this situation or should we just leave it out of the equation? Yeah, I think you purposely left out some of the histology components in the way the cells look and the Mk and things like that, but I think regardless, multiple retrospective studies, this large database study has shown that appendectomy alone is sufficient and even to go further, you don't even need additional imaging because it doesn't really change management. So I agree with appendectomy alone. Thank you, Dr. Anyone else? So I totally agree with the with the fact of not jumping into a right-wing mechalectomy. The first year was an attending, I had actually four kids with carcinitis. So it's the start that they're having an interest in it and reviewed 5,000 kids who had an appendectomy at sick kids when it was still in Toronto and of these about 30 had a carcinoid and only 10 really and went a right-wing mechalectomy. But then we looked at these 10 actually maybe half of them only needed it. And so my please look at your pathology report, that's important because it can avoid, of course, further imaging and unnecessary surgery and it's not just to look at, you know, if there's tape warms or anything else, but it's actually interesting to see whether the carcinoid any fits, if it's there, the size, whether it fades, if there are clear margins, so it's just good practice. Thank you, Dr. Sousa. So I think everybody in the room would not consider me a surgical oncologist, but something about leaving margins that are positive, Jenny, I think many of us would be concerned about. Yeah, I think what we probably don't understand is it's a totally different biology in children compared to adults. And I think a lot of that hasn't been sorted out, but the behavior of the tumor in pediatric patients and adolescents is entirely different than the behavior in adults. So margins really haven't made a difference in doing appendectomy alone. And it's very difficult where you draw the line between children and adults. And actually this, the previous studies were kind of drawing the line up to 15 years and this database studies actually compared up to 18 years. So all these conclusions are still valid up to 18 years. I don't know how much further you can push that line, but that's another thing to take into consideration. So this happens every year taught. We never had time to run the last one. We have only one minute. So I'll just this and any C baby, we've resected 30 centimeters of small bowel and there's no more distal disease. So what would you do? Stoma or anastomosis. And there's a reason why this study is at the end, I would choose, I would prefer this study to be second because I think it comes second in the word of best quality article of last year. We have again Simon Eton present online and Dr. Augusto Sani who both are offers of this article. And to me, it was a dogma that stoma was the safest option. That was what I was told. This is a fragile population in which you don't want to risk it. And I think this article, I don't want to overstate it or overcoil it, but I think this article might inverse or change the narrative. So let's have a look at the video. Oh sorry, a poll results? 50, 50, cool. That's very cool. So we really don't know what we're doing here. We have no idea. Okay. There's no sound, I think. So this touch trial was the first multi-center randomized control trial. Time's up. Okay. Yeah, I'm trying not to steal a thunder for the extra. This is just a bridging, an introduction into the next presentation. That's why you kept it short. So sorry. Was there audio on the streamline? So I think I think we're running out of time. So they basically randomized patient during laparachomy either through stoma or anastomosis when two of the options were deemed feasible for the child. And they actually found no difference in mortality. They found no difference in complications in general, but when they analyzed for multiple intestinal and stoma complications, of course the group with stoma had up to 19% percent of complications. And the likelihood of being wind from parantonal nutrition, what's much higher in the anastomosis group and the children were wind 20 days earlier compared to the anastomosis group. I don't think we have time for comments. We'll keep talking about this in the next session. And thank you very much for all of you. Thank you for the thanks to the society. Thank you to the all the journal high volunteers. And hopefully I'll see you next year.