2025 Pediatric Surgery Update Course - Updates in Lap Chole and Cholecystitis Management

So the way that works by the way, if anyone identifies a critical article, we should be reviewing Let Us Know. And we'd love for you guys to do these videos. We send them to us or let us know and you could join our lab. We have a lab meeting every week where anyone's invited and we need help spreading the word. This was all done by Dr. Rodrigo Casaz, part of the Chilean society and part of the Journal of Hive. He couldn't be here because of visa issues. So go ahead Rodrigo, do we have him online or not? Yes, I think so. I don't know if you can hear me. We can hear your will and go ahead. Okay, hi everyone. I'm the last guy to present here so I'll try to maintain your attention and keep it fast. For starters, I'm Rodrigo Casaz. As I was presented from Chile, representing the whole bunch from Journal Hive. And thinking I want to thank the organization for letting me give this keynote remotely. And fortunately, I have the best partner over there. So in case of emergency or whatever, you can just ask Jose and he'll be glad to help. So today we're going to talk about pediatric colisestectomy. Despite being a routine procedure, it's always full of controversies and opportunities. I don't know if the, okay, the keynote just appeared over there. We can see signs tonight. And I have the thing to move them so it's okay. Okay, thank you very much. So as I was telling you, we're going to dive into the updates in pediatric colisestectomy. And the first, can you pass it please? The first round is the cute colisestatus dilemma. This is a very common scenario in our emergency departments. So we're going to just jump into the first case scenario. It's a 14 year old girl, otherwise healthy, presenting with the classic symptoms. I'm not going to detail that of a cure colisestitis confirmed by ultrasound and labs. And based on your actual practice and emphasizing on that, not the ideal practice, your actual practice. What is the management strategy you typically employ? I admit for a IV antibiotic treatment for, I don't know, five, seven days and schedule a delayed colisestectomy. Perform a laparoscopic colisestectomy during this index admission. This charge with oral antibiotics or observing the hospital for 24, 48 hours with IV antibiotics. And if it results, just go home and complete oral antibiotics. So put the all up. I don't know if we have the pulse. So the audience is voting B, but we don't have, oh, there's the proposal. So 51% is doing half of them are doing B laparoscopic colisestectomy during index admission. Yeah, I'm pretty grateful that you're ready for me because I can't see it from here. I'm seeing the TV. So I don't have Superman eyesight. I'll read the pulse. Okay, 50% index admission, right? Yeah, 50% index admission and the following one is I'd meet for IV antibiotics and schedule for elective colisestectomy in six weeks. So basically, B early and eight late. Okay, that's the controversy, the usual controversy here. So let's move on and let's see the results about this one. And the data here is quite compelling. There's a paper published in the surgical and the scopy on 2024. And we look to the outcomes of this. The index colisestectomy performed during the initial admission dramatically reduces the third day of rate mission rate from 22 to 2 or 3%. And also significantly shortens the length of day of stay around all versus days from 22 to 6. So this strongly supports the early surgical intervention for acute colisestitis in pre-attroxpation. So the question here is why are we still delaying it? Are there some specific cases in which we want to delay the surgery or index admission surgery? Please anyone over there in the audience wants to comment about this? Reasons to do it late? Anyone? Symptoms over a week or 10 days, maybe too difficult to operate on elective admission? I suspect it has a lot to do with how a person's practice is structured. Okay. Like if you have, like it works very well in my institution because we have an acute care surgery program. You know, we're like sharks teeth. Every day there's a new person in ready to do whatever cases need to be done. And you don't count on that case to make your salary. So if you like use survive by doing that case and you have a full day of office and the next day a full day of elective, when are you going to do it? So I completely get that. Lots of practice things come into this decision. A war time. A war time? Okay. So unable to fit it into your normal conduct? No, you can't get it all up. You can't get it all up. So this is the infographic with it? Yeah. Round two. Good coming. I think one of the reasons to delay is in the case of Galtz and Pancreatitis. Now, data supports index operation before these sharks. Even with Galtz and Pancreatitis. They not send these people home and then plan for later. They're going to come back with Pancreatitis again. Great point. So moving on to round two, the proper Lexus products. This is a question I believe that many of us have have had in the past. And please pass the next one. So the clinical scenario here, you have a 10 year old boy on the or table ready for anesthesia. And for an elective laparoscopic, I was attacked to me for an uncomplicated quality assist. And you're in turn fresh from adult surgery rotations, ask you, are you going to give an antibiotic for this case? And you give the look back and say go to study. So the alternatives here are. Please read it. Read them for me because I can't. Sorry, A, no prophylaxis as adult guidelines recommends against it. Prophylaxis with an extended spectrum antibiotic to cover all potential pathogens. C, prophylaxis with a narrow spectrum antibiotic like sephasaline. Only the only administer antibiotics if signs of infection appear or pre or post-op. Do we have pole results? So, Rodrigo, everyone's saying prophylaxis with a narrow spectrum antibiotic like sephasaline, which is what you and I normally do at the hospital. Yeah. So we're both surprised to see study that guidelines actually recommend against it anyway. Yeah. So please put the next slide. The evidence here from this JAMA article published in 2025, this, the adult guidelines like the infectious disease society recommend against it. They are citing concerns about anti-microbial resistance, but in the real world of our pediatric practice, there's a different story. I'm a two center study here over 2000 children found that more than 90% received prophylaxis. So there's clearly two different paths from adult surgery and pediatric surgery in terms of antibiotic prophylaxis. And this study also showed that prophylaxis antibiotics were associated with a dramatic 72 reduction of the odds of surgical infection, and the number needed to treat with prophylaxis to prevent a single SSI was calculated around 35. So this isn't just a marginal benefit. It's a powerful data that justifies the widespread use of prophylaxis in pediatric psychosis. And the other finding, really important finding of this paper was that besides that prophylaxis is clearly beneficial, there is no additional benefit from using extended spectrum compared with the narrow spectrum as sephasaline. So as the poll results were clear, use prophylaxis and narrow spectrum. Comments from the audience. What are you guys doing normally? So we were giving antibiotics, I was giving Anseph before we got our NISQIP standardized antibiotic prophylaxis results back. And those said we were not compliant with the guidelines, so then we started to switch and then we saw this paper and now we started giving Anseph again. Does that represent what happened here in the US, mainly or not? Okay, round three. Okay, round three. The errors revolution, and this is specifically for the pediatric leproscopic colisistectomy. We already heard about the errors before, so maybe it would be kind of obvious. So let's move along to the clinical scenario. You just already jumped to it. A seven-year-old girl with symptomatic coli-litiasis is a candidate for laproscopic colisistectomy. You have programming for an overnight state, but again, the surgery resident asks why? Why would you do that? So usually you discharge your patients. Could have the audience involved, please. Yeah, we have the audience involved. Yeah, you usually discharge your patients between four to six hours overnight, 12-hour observation. Or this is the perfect out-case scenario. Just two hours, eat, drink, pee, and go home. Oh, sorry. Do we have Paul Rissol? They're already there, sorry. I was looking at the wrong screen. So Rodrigo, it's a rainbow, like to say. Yeah. So most common answer, I think it's green, is it? Can you scroll over? So we're 30% overnight state. So one third of an insane, and the rest is two thirds different, different timings. And which one is the D? D is 28%, which is outpatient setting. Let's hear about the article. Yeah, I thought that after the ERS presentation, it would be like, then the whole audience would go for the four to six hours. But this is a French paper from a French hospital. And they addressed, and they assessed the ERS article for the pediatric laparoscopic calisistectomy over five-year course. And they successfully implemented the protocol in an impressive 90% of the patients. And what they find was that there were no postoperative complications or re-admissions during the 30-day observation. And a medium-long term follow up to 55 months, there were no health issues associated with it. So this is just one of many papers talking about the ERS protocol. But this improves that the same day this charge is not only feasible, but also safe for the uncomplicated pediatric patients. So I have the feeling that we're doing ERS and same-day discharge for much more complex conditions. But then you look at the data, and it's not very common, at least in the world, to do a same-day discharge for laparoscopic calisist. What are people doing here? Go back and look at the slide, directly. Yeah, yeah, yeah. Are you ready, Ron? Yeah, it does set for the stackings, not for the stackings, not for the stackings. I hope you get it for the day. I think you read. Also, apparently our case scenario says calisistitis, and we're doing an article. So we were always meant to do simple calisistitis. Yeah, no. It was an uncomplicated calisist attack. So apologies for that, but is people doing here same-day discharge for laparoscopic calis? Yes, everyone. So opposed to the rest of the world. Cool. Should we keep going? So comments? This is not working anymore? You have to aim it here. No, sorry. I can do it. Hold on. So we have time to do it. I'll start talking. Yeah, go ahead. Yeah. Finally, we come to our round four. The operators, the lemma. And this is a question of who is best suited to perform uncomplicated calisistectomy in adolescence. Maybe this is a sensitive subject considering that there are different realities, especially in the audience. Between, are we trained as a general surgeon and afterwards as a pediatric surgeon or directly as a pediatric surgeon? Do we work at a pediatric center or a hospital with both adults and and fit specialties? So the question here is we have a 16 year old adolescent presenting with uncomplicated symptomatic calisity assist to the yard. And they're both general, adult general and pediatric surgeon available. So usually who really performs these calisistectomy at your place? So A, of course, is going to be me. This is easy PC, B, me. But I ask the adult surgeon to be my assistant in case it gets difficult to see. Usually they end up with the adult surgeon. D, neither the boss of the boss of the state the price. So we have some pole results and two thirds it's me, which is, I think, pediatric surgeons. Of course, in the US, we have some different situation as you mentioned, because they all have done general surgery beforehand. So I think it's going to be a bit different. And so let's move on to the next slide. And the evidence from a systematic review cohort from the pediatric surgery international from 2024 reviewed over 19,000 pediatric laparoscopic calisistectomy. And they concluded that for simple quality thesis, a higher operative volume is the key determinant for favorable outcomes. And the high operative volume, they rounded up in adult surgeons. So there's a statistically significant reduction in post-operative complications and 30 day admission rates when they were handled under this high volume surgeons. But they also and doesn't take away the critical role of pediatric surgeons. The systematic review explicitly explicitly recommends that for more complex children with special needs. Such as for example, they name a hemoletic disorders. They say that the participation from the pediatric surgeon is the most important one. So here the most important conclusion is that it doesn't matter if it is an adult surgeon, pediatric surgeon, whether which surgeon is the best suited for the specific patients. That's in long term the conclusion of this paper. So should we go through the take-home messages? Yeah, the take-home messages if you don't remember anything from what we speak today. So in this admission, calisistectomy is after 2025 should be the standard for acute calisistitis. In terms of antibiotic prophylaxis, considered the antibiotics, they reviews the SSI risk by the keeping narrow. The treatment is the best choice. The arrest print tables, they apply for pediatric paralysis, and complicate calisistectomy. And early discharge is safe, is feasible, so trust about it. And surgeon selection, piz, adults, it depends on your personal capacities, your personal expertise, your institutional scenario of course, and collaboration and patient based decisions always wins. Thank you, Rodeo. So thank you very much for your attention. I'll give the mic. You already have it on your hands. So any other comments or questions? I think we're good. So thank you so much for, sorry, you couldn't make it here, but thanks for your forgiveness.