2025 Pediatric Surgery Update Course - Updates in Pediatric Surgery feat. JPS Articles

So this is one of the longstanding sessions we do where we, for those of you who follow some of the content, I don't really know exactly how the magic happens, but the best articles are chosen. Quote unquote, can debate how it happens, but the editorial boards usually send us what they think are the most important papers. We also have Jose helping us non-pediatric surgery journals, but this is just JPS. So Alex Halpern and Jill Napworth, do I say your name right? No, say it right. You do pronounce the K, okay. So both of them are doing their research, their general surgery residents, so please take note. These are some badass pediatric surgeons to be, and they're going to go over the top JPS articles from the last year. Awesome, thank you. We'll start with the first one. So we have a four-year-old girl who undergoes hyposcopic gastroestomy tube placement, the case is completed at noon. Postoperatively, the patient is tolerating tube feeds and the family has received tube feed education either pre-op or immediately post-op. So what does your preferred discharge plan? So overnight observation, same day discharge or a plan 48 hours a day. Call it out in the audience. What would you guys do? Same day. Same day. Same day. Which is same day. Raise your hand, same days. Any overnight? No steroids. So we got to split here any 48 hours. Lires, okay. Alright, so we're going to go to a video and then we'll talk a little bit more after that. They identified 5,947 pediatric patients who under an elective laparoscopic gastroestomy tube placement. 4.7% of these patients were discharged the same day and same day discharge rates nearly tripled during the study period. They were not significant differences in any complications between the patients discharged the same day and those discharge are one to two days postoperatively. So it seems like same day discharge for pediatric patients after elective laparoscopic gastroestomy tube placement is safe and gaining popularity. So this was a nyscript study from 2017 to 2017, nyscript, nyscript pediatric study from 2017 to 2021 and they found 6.2% of patients were discharged the same day at the highest year and so it was a very low rate and much lower than what's reported here. Does this change your answer at all about whether these kids can go home the same day? But anyone who said overnight right now, Steve, I saw you raise your hand. Would you change right now to same day? I switched. My fourth time is not my decision to say pathway would follow. We'd have to re-structure pathways. Okay, so we're having debate about can you change the pathway? But yeah, behold, here it comes a mic. Oh, here. One of the biggest challenges we ran into when we were trying to do same day discharge for these is working with our home device delivery companies to make sure that these folks had a pump and that actually was a bigger bottleneck that we still struggle with. So really the scenario works best when these folks have an NG tube coming in and they already have their feeding pump set up and really the only thing that needs to happen is the G2 education and care which our nurses do. So once we coordinated that, then we were able to actually increase the proportion that we could send home the same day. Another bottleneck that we ran into was the same day's surgery nurses didn't want to increase the two beats. You know, that was something they hadn't done before and it was a big barrier to try to teach them all how to do it. So we started putting them on the floor, you know, but just for an observation status and then they go home the same day. Is they charged for that hospital semi day? Are they charged your patient for a half a day in the hospital? I need to improve my understanding of all billing and financial related things. Now I would have thought that a big bottleneck like at least from my perspective is they're so heterogeneous when they come to us about what they're doing for a feeding regimen that it's not clear what they're going to do post-op and then just like what's it going to be? And I really don't want to be in the business of deciding feeding regimens. I need that crystal clear up front. All right. So I just want to make sure those who raise their hand do it again don't be embarrassed. Raise your hand if you do not do same day discharge. Raise your hand of this group is the keep your hand up if it's a fear of medical safety of the patient. Zero. All right. So medically we're all fine with it. So we basically just decided we are keeping all these patients in the hospital for logistics. That is something we could solve, right? Get the pump ahead of time. Get the like figured out ahead of time, plan ahead of time. This is a simple thing. One day is the number we put in across the world. This is actually a big deal. So I think that's provocative paper. All right. We got another clinical scenario here. This time it's a 12-year-old female. She has a stab wound to her right lower quadrant. Okay. 12-year-old female stab wound to the right lower quadrant. She is hemodynamically stable on secondary survey. There's no other injuries but the right lower quadrant injury does clearly violate the fascia. So the decision is taken or made to take her to the OR. Our question is what is your operative plan? Do you start laparoscopically? Do you go straight to laparotomy or are you going to stick with a local wound exploration? All right. He would I never please say it well? What's that? Wait, wait, wait, wait, wait. All right. Himan themically normal patient that you know single stab wound why not a CT scan? What do you want to see? Any injury? No, what were you doing? No, what were you doing? Science of violation of the fascia that will require me to put a scope. Okay. So hold on. So fascia size. What was the other thing you said? Free air. What if there's no free air? Free air? That's a give me. I can give you that. That's two. Yeah. Okay. No free air. What do you do? No free air observation. Okay. Fair enough. So and that's there's been plenty of studies to show that morbidity is not change. It does not change if you have made him for 24 hours. Okay. What if it's a stab wound to and you see it going into the liver? Then you would maybe not operate, right? Right? Because it's a solid organ. A solid organ? That's what I was wondering what you're looking for because free air is not a good answer because not seeing free air doesn't tell you unless you're going to opt. Okay. Fair enough. We got a video here of this article. This first effect of cohort study was done by the American College of Surgeons, Comic Quality Improvement Program on about 1900 patients. Results showed that laparoscopy was done in 12% of cases mainly for stab wounds and at pediatric trauma centers with no increase in complications compared to open surgery. Patients who had laparoscopies had shorter hospital stays and fewer follow-up procedures. Many surgeons hesitate to use laparoscopy for penetrating trauma due to fear of missing injuries, but this study found a low occurrence in missed injuries after laparoscopic exploration. What? Mike? No, this being retrospective could be biased towards the patients that had a lesser probability of serious injury getting laparoscopy. I wouldn't be sure about that. I'm still worried about missing injuries. I would be worried if I did a laparoscopy. I didn't find anything because of my laparoscopic skills or because of the lack of injury. Injury severity score was lower for the patients who underwent laparoscopic surgery. All right, we got another clinical scenario. So now we have a healthy two-month-old baby boy presents with a perianal abscess for a time without obvious fistula. He is a febrile. He's feeding well and he has no systemic signs of illness. So what is your preferred treatment for this patient? Are you going to observe antibiotics and local wound care? Are you going to do antibiotics, local wound care, and then also an aspiration of the abscess? Or do you want to take them to the OR for an incision injury? Thoughts? We hear antibiotics. He's opposed to using a mic. So I will say it causes a decrease of forming a fistula in an anal. I think it was a 2008 article by Amasiacos at all. All right, play the video. And the poll was published. Oh yeah, the poll. What did they say? It was pretty much split between all four. It's a rainbow. Yeah, we love seeing rainbows. This retrospective cohort study looked at children less than 12 months old who underwent their first episode of perianal abscess at two pediatric surgery centers in the UK from 2012 to 2022. Forty-three patients were managed surgically with general anesthesia, incision and drainage with some needing fistula treatment as well. 73 patients were managed non-surgically with antibiotic, bedside aspiration, and bedside drainage. They found that the non-operatively managed group of patients had a higher risk of abscess recurrence and needing subsequent surgery, but they did avoid general anesthesia. This study shows the superiority of surgical management for perianal abscess and infants, but decisions should weigh the risks of surgery in anesthesia against the risk of recurrence. Yeah, I'm going to say no, it didn't show that, okay? Because recurrent abscess in this situation is just like a matter of degrees. You know, how many times have you gone to the operating room for a pimple? People get pimples, right? But they don't get operative management of their pimple. So when this kid has a little recurrent tiny little red bump in there, and I say first of all, look at your baby, and your baby's like, Google Gaga, like not freaking out. And just like, I don't poke it. Don't poke it. Leave that baby alone. That baby's fine. And that's the point. These things will go away. Okay, we wrote a very large paper on draining abscesses. And we didn't make a big cut. We made two very small holes. Flush the abscess out, put a vessel loop in, and send the kids home. Our recurrence rate was like one or two percent. And the referring doctors can cut the vessel out and slide it out after a week. And it worked great. And we didn't get fish because they know, you know, in doing that, there's no packing, all that went away. And it works great. I don't know other people are doing that or have done it. It's a large paper in JPS. The AP definitely recommends against incision and drainage to Nelson's point. But I also think they recommend against antibiotics if possible. So we should be probably not even doing antibiotics. Warm soaks let it come to a head and drain. We probably should be avoiding antibiotics as well. Maybe just warm soaks let it come to a head and drain or it'll go away on its own. Okay. Would anyone treat with just like see a go home, no antibiotics, nothing just warm soaks? Okay, we'll see next year. That's what the study that I referenced was all about. And the point was if you could cool it off with antibiotics, they showed that fewer of them formed the recurrent problem and then you nip it in the bud and don't have potentially nine months or 14 months of parental anxiety and freaking out, calling the pediatrician, running in for reassurance. Because before that study, we put out that if you don't operate on the fistulas, eventually they go away. And about, you know, in the high 90% of them do. But maybe that's avoidable. That was the whole point of the 2008 study. We're going to move on. I just want to make one call out here. These are not my fellows. So Jill is at University Hospitals, the Cleveland, Alex is at George Washington at Children's National. Carlos has done these, Lizzie's in St. Louis. So it's a plea to the world to help us. We need help making these videos. They're one minute tick tocks that get thousands and thousands of views. So they're good for your residents to get some exposure here. So we have one last one. Newborn male is diagnosed with an imperfect anus. He's otherwise stable and is passing a muconium via perineal fistula. What screening studies should this patient undergo? So we have Vactiro, Vactiro, plus a pelvic ultrasound and plus a pelvic ultrasound and a spinal ultrasound. Thoughts? What's that? It seems like most people are doing answers to both a pelvic and spinal ultrasound. Is anyone here not doing pelvic and spinal ultrasound? Everyone's doing them. The video essentially just says to do a pelvic and spinal ultrasound so it sounds like everyone's doing like, I don't think I don't know if everyone does spinal and pelvic ultrasound routinely. What's the V and Vactiro? It's not really that. Dude, yeah. What's the V and Vactiro? It's a vertebral, right? So what's the common thing? They get tethered cord. They get all sorts of things in the spinal dysraphism spectrum. So before it ossifies while it's cartilaginous, really nice to put an ultrasound probe over it. That was the argument of this paper. That's everything? And that is time. You finished literally perfect time. So let's hear it out for Alex and Jill.