Journal of Pediatric Surgery Article Review: March 2022

We're back with the article review from the Journal of Pediatric Surgery. I'm Ellen and Cisco. I'm Britney Levy. I'm Em Tombash. We're research residents at the Cincinnati Children's Hospital, and this month we are reviewing articles from the March issue of JPS. These articles were chosen by one of the editors, Dr. Pekarinen. I'm Mikko Pekarinen. I'm Professor of Pediatric Surgery in in University Helsinki Hospital, Children's Hospital in in Finland. And as a reminder, all these articles you can find in the media player are linked below in the media player or wherever you're watching or listening, if you want to follow along. So let's get started. So the first article is Laparoscopic versus open appendectomy for complicated appendicitis in children. And this article is coming out of India. It was a systematic review and meta-analysis of the current literature comparing the associations of laparoscopic appendectomy and open appendectomy for various postoperative outcomes. They looked at four randomized controlled trials and 36 case control trials and they compared a few different outcomes. The overall findings show that laparoscopic appendectomy is associated with shorter length of stay, a lower rate of surgical site infection and lower overall complication rate. But the rates of intra-abdominal abscess, post-operative fever, pneumonia and ileus are similar between the two groups. The only metric that favors for open appendectomy was the shorter operative time. And although many of us already perform most of the appendectomies laparoscopically, and findings of this meta-analysis surely support that practice. While here in the US a lot of appendectomies are mostly laparoscopic, but around the world, uh open appendectomies is more frequent than we might think. And I have a friend who's a pediatric surgery resident back in Turkey. He told me that they prefer open appendectomies nearly half of the children, especially the ones with the lower BMIs. It's kind of interesting because as a resident and as a medical student, I've actually never seen an open appendectomy in a child, only for um a adult patient with appendiceal cancer. So these results don't seem surprising to me, but might be different when I consider places that have more open appendectomies in pediatric patients. I don't think it's a slam dunk that the laparoscopic appendectomy is necessarily better than the open appendectomy. I think there's two ways of doing it. Obviously, this won't change my practice, but it may change the practice of surgeons in other countries. This is specifically for complicated appendicitis. So I don't know if that makes some people more nervous to do it laparoscopically and maybe they just go ahead and open if they think it's going to be more difficult because because it's perforated or something. Non-complicated and complicated appendicitis, the total different disease as we all well know. And and most of the non complicated probably in some centers already treated by antibiotics. But what's really interesting is that do we need to treat part of them at all? And that's something we need to answer in the in the future studies. Let us know what you think about laparoscopic versus open appendectomy for complicated appendicitis. The next paper is management and clinical outcomes of congenital esophageal stenosis in pediatric patients. Experience of a tertiary referral center. This paper is from a University Hospital in Turkey. This is a relatively large series on a very rare and little studied congenital condition. The most common form of stenosis that we deal with is iatrogenic, like we cause it. We do anastomosis, it closes tight, we have to dilate it. But sometimes kids are born with it. And in their study of 19 patients, they successfully treated 14 with median of five dilatations and two patients had some residual symptoms and three where were operated on later on. And we spoke with the first author Gerek Selchuk Kılıç. He's an attending pediatric surgeon at Chukuva University Faculty of Medicine Hospital. We got to talk to him over Zoom. Lucky for us, we have a Turkish translator. Bizim özelliğimiz. What makes us special with this step up approach is we see the surgery as the last resort and we try to make the process as conservative as possible. And the big debate that we debate at our hospital all the time is, and this would be an acronym, do you dilate or do you resect? And here's why it's a debate. If you dilate, you have a risk of rupture. And that could be catastrophic. So a lot of people believe that you should just go straight to resection. A lot of discussion about multiple different kinds of congenital esophageal stenosis, if they have cartilagenous component or it's just a membranous component and how currently what to do is really dependent on those features. If it's cartilagenous, don't try to dilate, just go to resect. If there's no cartilage, then dilate. It's a good topic for discussion because maybe there's not a whole consensus on what exactly to do. Um whether you start with dilatations or if you try to determine if they have cartilage and then maybe they just go ahead and need surgery right away. A lot of people believe all comers, even those that have cartilage, you should try to do dilatation first. I agree with starting with dilatation in a membranous ones. But if there's cartilage, that's where I'm torn. İlk önce balonu denedik. First we tried balloon dilatation for every patient. Then we moved onto the surgery according to the balloon dilatation results. Even if we think that there is no benefit from the balloon dilatation, we continue to do that as long as it improves the patient's clinic. We had to move on to the surgery in cases such as recurring lung infections, growth retardation, and the times the patient wasn't healthy enough to even be included in the dilatation program. And the results were hopeful. Out of 19 patients that underwent esophageal balloon dilatations, 16 of them were successful. And the last three did require an operation and overall, 17 patients were symptom free after 48 months of follow up. Based on their findings, I would be willing to try up to five dilatations before considering operative treatment and in this sense, I think that this paper has uh potential to to change my practice also. And I was quite surprised that they achieved such a good results by by doing dilatations. So our last article is the use of expedited post-operative protocol for children undergoing appendicostomy reduced the length of hospitalization. And this is from here in the US at the University of Utah. We talked to the first author. I'm Scott Short at uh Primary Children's Hospital in Salt Lake City and um one of the faculty in the colorectal program. And the senior author. I am Michael Rollins, a pediatric surgeon at Primary Children's Hospital in Salt Lake City, Utah, and the director of our colorectal program. And this study really looked at an ERAS protocol, which is the hot new topic in pretty much all of pediatric surgery these days on how that can improve length of stay, surgical site infections and overall patient outcomes. We changed our uh post-operative protocol um based on the fact that uh many of our patients uh uh displayed clinical signs that they were ready uh to initiate a diet immediately after surgery and uh historically we uh did not initiate a diet following uh creation of appendicostomy until the day after surgery. And in this study, uh short and coworkers showed that they were able to reduce hospital stay from three days to one after implantation of expedited postoperative protocol after appendicostomy without increasing complications or unplanned hospital visits. We've talked a number of times through different articles and different discussions about how ERAS and these protocols have helped get kids out of the hospital sooner, which has also been beneficial. I feel like we always say with COVID. And I think this is a nice example how we should all continuously think ways to improve our daily practice and routine management protocols. From an actual implementation standpoint. I think implementing change and protocols is really important to make sure that your colleagues, your nurses, and your staff around you are are supportive of you making these shifts and in care management. Well, how just having a protocol seems to have beneficial beneficial effects, you know, whether or not you and your hospital are using this exact protocol after appendicostomies, um just having some sort of standardization can be helpful. Another example of us figuring out that we can break dogma and and make things more efficient for the patient. And our own current protocol is pretty similar to their historical historical one and based on this study, uh further reduction in hospital stay seems to be achievable. So I I definitely think that this study will change my practice and and we'll we'll give it a go and see it. This time, we've had other months where we have a lot of basic science um or kind of a mix of basic science with clinical. And these are all very clinical which is which is nice. We like I feel like in our podcast, we we love clinical based things. Um so we talked about laparoscopic versus open appendectomy and it sounds like probably it won't change the management for a lot of people. A lot of us are a lot of people are already doing laparoscopic appendectomies even for complicated appendicitis. The second one was about congenital esophageal stenosis and how to manage that. It sounds like maybe there's more discussion here. Um and maybe we'll change practice for some people. And then the last one was protocol after appendicostomies and that one may or may not change your practice depending on what kind of post-operative protocol or standard stay your patients have. Well, that's what we have. If you like what you heard, make sure you leave us a comment on our social media and our YouTube channel. Make sure you download the Stay Current and Pediatric Surgery app. Until next time, I'm Ellen. I'm Britney. And I'm Em. And remember knowledge knowledge should be.