Hot New Topics from The Journal Of Pediatric Surgery: Update Course 2017

Um, we're gonna go over 5 or 6 clinical scenarios. Uh, we may not have time to get through all of them, but they're, um, they're interesting, and I, I think I'll ask Todd if you, if you'll come back just for a second, uh, because, uh, Todd is the, um, editor for, uh, social and digital media for the Journal of Pediatric Surgery, and he, uh, has, uh, initiated. Uh, two new, uh, aspects, uh, on the digital media scene that is what I call the, um, Journal of Pediatric Surgery Facebook page and the face, uh, the Face group, uh, and in that he has, uh, started, um, uh, two really interesting, um, uh, things and, uh, it's the 2 minute video reviews and the, uh, visual abstracts. And Todd, if you'll just take maybe a couple of minutes to talk about the Facebook page and the Facebook group, and then we'll go through some of these, uh, clinical scenarios. So the biggest accomplishment of 2017 was that Whitt Holcomb joined Facebook. That was one of our, and actually probably a bigger accomplishment is that Dan von Almen uh joined Facebook. Um, no, uh, you know, I think that, that I really want to thank uh the Witt and Jay Grossfeld for, for seeing the vision of better ways of, of taking this incredible content from the Journal and reaching more people. Uh, and I don't know if you know this, Witt, but uh uh uh in London, was it 2 weeks ago we had 7. 000 and now we have 9000. It's only been so we're we're rapidly growing to where we have a huge presence and visibility on this on this Facebook page and Twitter, and it's finally the best way not only to send out the best articles but to narrow down and filter what we think are the ones you really need to know. So please go to Facebook and join the Facebook page and the Facebook group for JPS. OK, so our first, uh, clinical scenario, uh, and, uh, we'll allow our audience, uh, 30 or 40 seconds to, uh, vote on this, but a 12 year old girl comes to the ER with chest pain and an X-ray that shows a pneumo mediastinum. uh, what should be done next? The choices are, uh, nothing. Uh, that's A. B is perform an esophagram to look for an esophageal injury. C is to perform a CT scan, uh, and D is to, um, utilize serial X-rays. Mike, do you have any thoughts about, about this, uh. Yeah, you know, for, for kind of unexplained pneumo media sign that comes in, you know, if there's not a history of trauma or a foreign body, I guess in my experience. Anything else you do is typically not very helpful. Um, Most of the time at our institution they'll do a couple X-rays to make sure it's going away, but again, if this doesn't seem like it, it seems like this is not an uncommon problem that that I see coming from the ER. You just get where you have some pneumosty. All right, rapid fire. David, what do you do? An inhaler and go home. Inhaler and go home. And go home. No imaging, Chris. Typically these patients get an esophagram without good data to support esophagram. David, no imaging. Nothing. Mark, nothing. Wit, you can't answer, Dan. Nothing. OK. Anyone here have a disagreement on nothing? So everyone here says either esophagram or nothing. We're spoiling the fun here. All right. So do you run this, uh, yeah, just, uh, hit the button. It should play. OK, so this is a paper from the Journal of Pediatric Surgery, uh, entitled Our esophagrams indicated in pediatric Patients with spontaneous pneumo mediastinum, and this is one of the 2 minute, uh, video, uh, abstracts that, uh, Todd has done. This is Todd Ponsky doing another review for the Journal of Pediatric Surgery. Today we're going to review our esophagrams indicated in pediatric patients with spontaneous pneumo mediastinum. The first author is Doctor Edward Richer, and the second author is Ramon Sanchez from CS Mott Children's Hospital, University of Michigan. This study addresses that common problem of when kids come in with either spontaneous or traumatic pneumo mediastinum, trying to figure out how much workup we have to do. Do they need additional studies such as esophagrams or CT scans. So they did a 16 year retrospective review looking at all patients that had an esophagram when for the diagnosis of pneumo mediastinum. And what they found is in the patients with spontaneous pneumo mediastinum, the esophagrams never showed anything. Of all the patients, there was no leak or no injury shown on the esophagram. 55% of these patients also had a CAT scan, and none of the CAT scans came back with any positive findings. Also, all the additional X-rays that were done to find out more about the pneumo mediastinum, none of them helped either. Then they looked at traumatic pneumo mediastinum, and they found that again the esophagram never showed any findings. It did not help. It did not show a leak or a rupture in patients that looked clinically well. They did not mention anything about CAT scan. They did say that the, the CAT scans were done, but they did not mention the results. And then they also didn't mention anything about additional X-rays in this group. So overall, it looks like in patients that are looking clinically well with spontaneous pneumo mediastinum or traumatic pneumo mediastinum, there's really no benefit or need to getting additional studies such as esophagrams or CT scans. I want to thank Ian Glenn for helping review this article and editing the video. Uh, please leave comments or questions below and let us know, uh, any other studies you'd like us to review. Thanks. OK, so Todd, what did the, uh, what did our audience say? Oh, so almost everyone said CT, uh, but let's go back to look at that poll if it's updated since then, huh? Let's see, yeah, so now it's changed. It was, so now 50% said CT, 19.2% said esophagram, 23% said no further imaging. It'd be wonderful to see if those answers change after that. Uh, well, well, so I would, I would say that, that, uh, the audience before we, uh, showed this, uh, 2 minute video abstract thought 11 type of management, and now I think that most of them will be convinced that nothing needs to be done, right? So let's see if you guys can, uh, answer in the chat from the virtual audience if this would change your mind. Yeah, I wanna make a really quick comment, um, no more comments. So you know, a new mediastinum and trauma is absolutely not predictive unless you have a wide mediastinum. And so, and, and so again you, um, you can't say, oh you, you have new mediastinum, you shouldn't get any additional imaging if you have a new mediastinium incidentally and you have a widened mediastinum, those are the patients who still need imaging. OK, now here, here's an interesting question. Sorry, I'll get back in your view, Mark. Sorry. So here's an interesting question related to David's comment, David Rothstein. OK, fine, we all agree we don't need imaging or at least many of us agree, but now what? Do we admit them? Do we give them an inhaler and send them home? I wasn't being facetious. That was, I think I believe you a high percentage of patients had a comorbidity of asthma. That was the only kind of common thread, right? Who else would send them home. If they had asthma or some reason that you can observation. protocols 4 hours and then OK, I'm still a wimp. I still admit the patients, but, uh, for overnight ops, but I'm probably, well, maybe I'll change. Has that ever resulted in anything other than sending home? So that is the next study. That is the next study, and I, I agree with you. We can probably just send them home. I think that's a good idea or a short ops so that probably doesn't make a difference either. Great. OK. Oh, just, uh, hit it again, yep. Uh, here's, um. Here's a, uh, visual abstract that's gotten, uh, a lot of, uh, interest in the last several months. A 4 week old male presents with pyloric stenosis and has the following electrolytes. The sodium is normal, potassium is 3.4. The chloride is 85, and the CO2 is 34. Uh, so, a little low potassium, markedly low, uh, chloride and high, uh, bicarbonate. So the question is how many normal saline boluss should this, uh, baby receive? The answers are 0 is A, 1 is B, 2 is C, and 3 is D. So far, about half of the people are saying C. But it's changing rapidly, so we'll give it another 20 seconds, OK. David, do you have any thoughts about this? Dave Ross, uh, I would refer to that paper. I can't remember 2 or 3, but you're right. No, I mean, I think this is brilliant because we spent so much time giving a bolus and then getting repeat labs, and the only one that really matters, probably from an aesthetic stand but truly is the potassium. So that's the only reason to repeat labs after this paper to me. So, so I, I think a good question while we're waiting for the answers to come in is what mechanism do people use to determine how much fluid to give? How do you know? How do you give for this? Is it just a gestalt? Is there some calculation you have before this article came out that we're about to talk about? What time is it? So I mean, the, the other, the other question we talk about correcting this is the baby doesn't get post-op apnea, right? And the other pieces that where we've looked at what are the outcomes of post-op apnea and how, you know, because we have different, we have different anesthesiologists that have different, you know, even though we have a protocol like sometimes there's different anesthesiologists that like different numbers, uh, you know, at least during my training it's like, you know, I've, I've worked in 3 children's hospitals and everyone had different numbers that we used. Is there evidence for that? I don't know. Well, wait, let me, uh, it's a great point. Uh, and so we have, it keeps changing, but, uh, it's, it's all over the place. So yeah, even 0. So someone might go to the OR with a chloride of 85. So here's a, uh, paper that came from our institution, uh, that Brian Dalton was the first author on. He was one of our, uh, surgery research fellows at the time, and, uh, Sean Saint Peter was the senior author, and, um. This little uh visual abstract is uh is nice for this scenario. So if the chloride is less than 85, the answer is 3 boluss. The chloride's less than or equal to 97, it's 2 boluss, and if the chloride's greater than 97, but the bicarbonate's less than 33, it's 1 bolus. And here's a 2 minute video abstract on this, uh. Before you start that, what's the end point? What are you trying to achieve with this to achieve this video will explain it, but it's to achieve normal electrolytes without having to recheck the labs again. OK, so this is Todd Ponsky reviewing another article for the Journal of Pediatric Surgery. Today we're going to review an article entitled Optimizing Fluid Resuscitation for Hypertrophic pyloric Stenosis. First author is Doctor Brian Dalton. The senior author is Doctor Sean Saint Peter. Yet another fantastic paper from the group at Kansas City. I love this article. This article is a retrospective review that helps to define how much fluid we should be giving patients with abnormal electrolytes. The purpose is to try to avoid the problem of randomly guessing how much fluid to give, rechecking electrolytes, and then giving more fluid. What they did is retrospectively look at 505 patients, 202 of which had abnormal electrolytes. They defined abnormal as a chloride less than 100, a bicarb greater than 30, and a potassium greater than 5.2 or less than 3.1. The boluss they gave in this study were 20 cc per kilo boluss of normal saline. While the patients were not receiving a bolus, they were held on maintenance fluid of 1.5 ccs per kilo of D5 half normal saline. 20 of KCL was added to that maintenance fluid depending on if their potassium was abnormal and based on their urine output. And what they did is they looked to see how much fluid ended up being required to resuscitate patients, and they did this by the severity of their electrolyte abnormalities so here's what they found. The first thing they did is always look at just the chloride. If the chloride was abnormal and less than 85, they gave three normal saline boluss of 20 ccs per kilo, then they rechecked the labs. If the chloride was less than or equal to 97, they gave two normal saline boluss and then rechecked the labs. If the chloride was greater than 97 but the bicarb was less than 33, they gave one bolus of normal saline. If the chloride was normal, then they look at the bicarb. If the bicarb was greater than 40, then they gave 3 normal saline boluss. If the bicarb were greater equal to 33, then they gave two normal saline boluss and rechecked the electrolytes. So if the chloride and the bicarb are normal, but the potassium is abnormal, Then they gave one normal saline bolus and rechecked the electrolytes. If the electrolytes were normal, then they just took the patient to the operating room when the patient was physiologically appropriate. I thought this was a great study. We hope you enjoyed this review. I wanna thank Ian Glenn for help in putting this review together. Please leave comments below and let us know any other studies you'd like us to review. Thanks. Yeah, and again, I want to thank Ian Glenn, uh, who put that together. So any, any other comments from the audience? So. You still, the idea is to just to to guide how much fluid to give before rechecking the electrolytes. It's not suggesting you would take them because I'm not sure, right, that's what I was just going to say anesthesia is never going to let you take the patient to the operating room unless you can show them normal electrolytes. So the idea is not to get a lab draw after each boat after each that's, that's the big issue is that we would check it in the morning and it. Would still be abnormal and we'd give more and we said this this gets you there with one shot usually without rechecks. I like this because our, our practice typically you give a bolus, check the electrolytes, give a bolus and the interns following it through the night trying to decide. But, but the reality is that, you know, does, do the electrolytes need to be normal to go to the OR because I, you know, I, during my, my training in, in. Birmingham, it's like something makes me think that it was like, you know, I think there was one of the guys was like, yeah, if it's over 90, which is pretty darn low, OK, that didn't make me very comfortable, but you know, there are other folks who are like, well, 95. It was always the bicarb. I mean that's what we were taught is the bicarb, but the bicarb wasn't less than 30, the anesthesia would not put so then who cares about the chloride and then what about the potassium because these kids, you know, it's probably the potassium resuscitation, yet, you know. Well I think we're we're all at the whim if not whim's not right, but all of the whim of the anesthesiologist so so this is a way to make them comfortable, uh, and also not to keep uh. Not a great way to guide the recess. There is a question here that's, that I was going to actually say the same thing. We, we all use the term bolus, and some of us use it differently. Uh, in this study, a bolus was 20 ccs per kilo, and the audience, the, the virtual audience asking about is a bolus isn't that at 10 ccs per kilo. So as long as we make sure we're all talking about this is a 20 cc per kilo bolus. That's a big bolus that that's a big that's like a trauma resuscitation bolus is 20 per cub. So when you say bolus normally, you're saying 10 cc. I would have thought 10, but this, so it's important that that's specifically defined. Yeah. What's really, um, wild going back to what Mark said, you know, all this data that we were taught about, um, about the kids having apnea if we don't get their electrolytes up, um, it was probably all based on anesthetics that we haven't used in, in 5 decades. So I'm not saying it's wrong. I'm just saying that that it's, I'm not sure it's comparable in 2017 to, to the time when, when these guidelines were developed. Yeah, I think the best, those, uh, a paper from this is probably 10 years ago just talked about, you know, you give them, you give them fluids until they pee, and then if the, if you give them fluids until they pee, then you can take them to the OR. Was that, and it may have been from Cincinnati. I don't remember where it came from. Do you remember that? Yeah, and, and that to me actually made the most sense, yeah. All right, let's keep going. All right, so I, I put this, uh, question up a little early as we were finishing up the last, uh, question. So, uh, there's a, a baby who underwent a repair of oesophageal atresia and tracheoesophageal fistula a week ago, and an esophagram is performed, and then there's a leak. Uh, after one week there's a persistent leak. The patient is stable and the leak is well controlled and, um, coming out the chest tube. The question is what would you do next? Uh, A is continue observation. B is explore the baby. C is start uh intravenous, uh, glycopyrrolate, and D is something else. So, uh, Steve, you're an expert in this area. What would you do? Now, now I must, I'll, I'll preface that you ever see this. You're right, it's never had this problem. in this child, I would just do continued observation. The best course of treatment in these patients, most of these leaks will resolve spontaneously and as long as the child's not getting sick or there are other issues, we just give it time to seal close. And with 82 84.2%. This is the biggest one we've had with everyone and most people agreeing say continue observation. What do you think, Dan? I would continue observation. Anyone have anything else? You know, it, it's interesting you said that there was a leak on the esophagogram, and then you said after 1 week, and I'm trying to think when did you do your esophagram, uh, at 1 week, at 1 week, OK, and then they waited 1 week, so you're really 2 weeks after the operation, OK, if, if you had detected the, the leak early, so say, say it's, you know, you're, you're 2 or 3 days out and you, and you've got a, a pneumothorax and you've got a bunch of stuff pouring out, um. Would you, would that change it? Yeah, I think if there's a if you can't control the pneumothorax, that's a, that's not a leak, that's a disruption of the anastomosis in my mind so that would that would push me to do something more. That's a different scenario than, than this. I mean, if you, I think in a case where you're 2 or 3 days out and you have evidence of a complete disruption, then you should go back in and repair it. I think that's a lot different than having a small pneumo, which you control with the chest tube or a small leak shown on an esophagram. But yeah, if you have a complete disruption and you're within a couple of days of surgery, you should go back and fix it. Great. OK. Oh wait, David, uh, before we play it, David Lanning, what's the role of the tube, uh, in the esophagus to, to drain and or feed distally? Can someone comment on that? So another, another talk. It was actually studied, uh, the Midwest Pediatric Surgery Consortium did a review of 400 some patients, um, and looked one of the findings which was surprising to me is that a tube through the anastomosis actually increases the risk that you're going to have stricture and other complications. So I've actually personally stopped putting a tube through. Now would you say, Dan, that the study showed that. It increases the risk or there's an association with an increased risk of having a tube in there. It's a retrospective study, so, so cause and effect you can't, you know, we don't have the power in that study to make that determination, but clearly there was an association between a trans anastomotic tube and an increased complication rate. And do you have a, so there's selection bias and everything else in there that we that you can't sort out. Can you, uh, can you explain why that might be? Why, why you mean what's the physiology that it causes that? Is it irritation from the tube? Is it traction? I, I, so the answer is no, I can't explain that. If you can hypothesize, you know, I mean, colorectal surgery 50 years ago, people left Penrose drains and then people started leaving closed suction drains around bowel anastomosis and found that they increased leak rates. So maybe it's just having a piece of plastic near your. Anastomosis irritates it or something. I think you have, yeah, I, I think you also have to take into account the fact that the knots are, at least for a lot of people, the knots are on the inside and so you're, you're not just have the tube rubbing against a bowel, you have the tube rubbing against your knots and, you know, and irritating them and woolan doesn't tie good knots anyway, so that's a big problem because they're gonna lead to a higher leak. It's, I, I don't know that there, there, there, there are suggestions that you don't leave a, uh, that you don't need to leave a chest tube. That's certainly out there. So maybe we shouldn't leave no chest tube, no transit, then get no esophagram and just feed. Yeah, well, well, there are people, there are people that do that, yeah, yeah, no, there are people that do that. I mean, to one of the biggest. In the world, and it's not thoracoscopic but open. It's from Great Ormond Street. Great Ormond Street, they don't leave nasogastric tubes. They don't leave chest tubes, and they routinely feed on day 2 or 3 following, um, without a contrast study. They've been Louis Spitz and, um, and his crew has been doing that for 20 years and they. Um, have great results and, and some of those who are now doing it thoracoscopically are applying the same. So maybe some of our participants from the UK could respond to that in the chat. So what, what did the, uh, here's another, uh, 2 minute, uh, visual, uh, or video abstract. This is Todd Ponsky from the Journal of Pediatric Surgery, and today we have a guest reviewer, Doctor Abdul Raoof Lamoshi. Raouf, thanks for joining us. Thank you, Todd. Raoof is a research fellow here at Akron Children's Hospital, and today he reviewed a great paper. The title of today's article is Role of Glycopyrolate in Healing of Anastomotic dehiscence after Primary Repair of esophageal atresia in a Low Resource setting, a randomized Control Study. The first author on this paper was Doctor Vela. This was a prospective randomized control trial studying the effect of glycopyrolate on patients that had leak after oesophageal atresia repair. There were 297 patients over a 10 year period that underwent esophageal atresia repair. Of the 297, there were 42 leaks. That's about 14%. They then prospectively randomized the the 42 patients into two groups, 21 each, the one group receiving glycopyrrolate and the other group receiving placebo, which was saline. The observer was blinded to which treatment group the patient was in. And Raouf, what were the results? So the main explored variables were chest tube output, which was 124 mL in the treatment group, compared to 370 mL in the placebo group. The Second variable was the leak resolution, which was accomplished in 76% of the treatment group compared to 29% of the placebo group. And oral feeding, which was achieved in 71% of treatment group compared to only 14% of the placebo group. OK, so the results are pretty astounding. The Robinol or the glycopyrrolate group really had impressive results compared to the placebo group. What about the quality of the study? I think this was a very well done study because it's a randomized controlled trial and has a very good. Sample size and the results were both statistically and clinically significant. Yeah, I agree. I, uh, think this is a great study to review because it's a novel treatment that can have substantial effect on a very complicated problem we all deal with. I know that I'll change my practice based on this and start giving Roben all to my, uh, leaks after TEF repair, but I'm curious what you all would do. So leave your comments below. Thanks for watching, Rove. Thanks for the review. Thank you, Todd, and we'll see you next time. Minimized controlled trial. I mean, it's got great study design, I assume from what was described. I haven't read the particular study. The thing that struck me was that the closure rate in the in the non-intervention group was very low, 6% I think, or 6 patients, 29% something was not in the glycopyrolate group, but in the other group that didn't get glycopyrrolate. That just seemed surprisingly low to me. I think the follow up period was that that was the issue because they waited like maybe just for a few days. where the Rubino group achieved good results while the other group, so they didn't wait for a week or 10 days. So the conclusion then would be that it potentially would speed the closure as opposed to a great point it would change whether they close or not. Great great point because I think they all eventually close. Exactly. So yeah, it's pretty uncommon that they would close. So Todd, an interesting follow up from that study by those authors would be. To look two years later and see how, how many in each group required dilations or repairs or re-operations or because it's a great, it's 42 patients that have been randomized so it's a great subset cohort to to follow. So maybe we should do a letter to the editor and and ask for that to happen. um uh we, we have tried it uh we had a leak. um, I don't know the exact situation, but I know that the patient after several days was still leaking. They gave Robenal within. Uh, 24 to 48 hours the, the, the output completely stopped, so we were very impressed the Robinol. What's that? When did you stop the Robinol? Oh, did we keep it going afterwards, because did you just the leak stopped because there's no saliva coming down the tube, or did it stop because it healed? Was it restudied? They studied. They restudied after that happened. No, no, no, it's clogged up and it's filled up in the chest. Actually, uh, let me, let me answer that two ways. That was exactly what we were concerned. Whenever it stops, your first concern is, is the chest tube draining, and, uh, they got a chest X-ray and there was no fluid in the chest, and they did get a restudy and it was closed. I have to tell you, I was very impressed. I will tell you that our neonatologists hate it. And the reason is that they are concerned about mucus plugs by giving the Robinol. So what we do is we give half the dose in that patient that they recommended in that paper because they, it was a compromise. They were afraid to give Robinal because it was gonna cause mucus plugging, and we wanted to give it to see if it would stop the leak earlier. So that's something you'll have to have a discussion with your new, but this, this we thought was a great study. So, uh, yeah, yeah.