Update Course 2021: APSA PDC UPDATES

Now we're going to get to something that I really think is incredible and that's the PDC, the APSA PDC. What what is the PDC? Well, I'm going to turn it over to Marge Arca and Rob Rica who are going to explain to you what it is, why it's important. And then we're going to fly through their cases because they got a lot to say in a short amount of time. Marge. Hi, uh good morning. Um my name is Marjorie Arca and I'm a surgeon at the University of Rochester Medical Center. And I've been uh fortunate to be part of the professional development committee of APSA. So, um, about uh five years ago, um we looked to see, um, how we can curate the information that's coming to us from several places, whether it's journals or blogs or guidelines. And there's a number of I I hate to say because it ages me, um of senior surgeons that come together, um monthly, uh and uh also um twice a year uh to take a look at these um, these journals like uh Jose just uh presented to you. Um every uh month we look at some articles uh that um are impactful. In fact, some of the articles that Jose presented to you have been part of the eBlast that APSA um has received from many of our committees. And uh we actually say, okay, this is important, um, this is not we highlight um one or two articles but we present uh everything. So, the professional development committee is uh there for you. We love doing this. Uh we actually have uh communication uh with um the American Board of Surgery and I use some of these information as part of the continuous certification which uh then kind of creates this how can we uh implement this in our um in our lives uh and gives you the data um that's impactful. So, um, the uh professional development committee also uh um puts together the topics for the top edge educational content. It's uh a tech talk uh that uh we have uh for an annual meeting. And we highlight uh several things uh for our tech talks and um the points of these are some of the things that uh Dr. Rica and I will be presenting to you. We're we're your um, your PDC representatives, also a number of you here are also uh PDC members. So, um, oh. Oh no, I'm the first one to uh figure out the um. So so Marge, so what we can advance while you get that going. Oh yeah, sure. I also have a little trick for the faculty by the way. So Garrett just told me, if you pin the one square that has the PowerPoint, it will make it big for you and it won't mess up uh the others. So, you can pin for people like me that can't see it that small. So, uh Marge, do you have the clicker ready or do you want um. No, I think I'll just have you. I'll just have you do that. Okay. All right. Uh Garrett, can we go to the next slide? All right. Next. All right, so the first thing that um we are going to talk about is uh family centered care. This was highlighted at our May at 2021 meeting. Um so go ahead and advance this uh for us uh Garrett. Um this scenario that I'll present to you actually happened to me. A three-year-old uh girl of Mong descent. I put that there just because of our um recent Olympics and I wanted to highlight the Mong community. Uh this girl has a necrotizing soft tissue infection of the lower extremity. As the patient is being wheeled back to the pre-ap suite, her grandmother placed a red string bracelet on her left wrist. You ask about it and the interpreter said that it is to help protect her during the surgery. Your nursing team in the OR is uncomfortable with the sterility of the bracelet. So the best course of action is, A, tell the family the bracelet is not sterile and ask them to remove it. B, tell the nurses that they're being ridiculous and just keep the bracelet on, uh keep the case going. Um, C, remove the bracelet once the child is in the operating room. D, acknowledge the bracelet's importance and ask if it can be covered while the patient is in the operating room. and E just ask the anesthesia staff uh to deal with the situation. All right, what do you guys think? All right, so let's put the poll up there which it's up there. So what do people think here in the faculty? Steve, you're unmuted. I would say D. Uh definitely want to incorporate parents' wishes and and really see how um what can be done and and respect uh respect their uh their beliefs and values. Agreed. Anybody else think differently? I agree with D. Most people in the poll agree too. Okay. Was there anyone that did not um uh pick uh D, Ellen? Yeah, a very small percentage are saying to tell the family the bracelet is not sterile and it needs to be removed, but it's like 13%. Okay. Let me say one thing, if I I love that you ask that Marge. If there's a if there's a small minority, please you will see put your comments on why. You'll see how how how little most of us know about anything. So, don't be shy, say why you did something different. This is the time to do it. So, um, why don't we keep going, but this is this is uh I like that you called out what why someone answered something different. Were there any comments, Ellen? Not, not yet. Um they someone's asking if we can take it off and put it next to the patient instead of on their wrist. Right. Well, um, I should like I said, this was uh something that happened to me and thankfully, um, a few years ago and D was not what was done. Um, uh the anesthesia staff actually said it's not sterile for God's sake, this is a necrotizing soft tissue infection uh and all that stuff. But um, you know, I think it is part of our DEI uh concept, part of our family engagement and uh really knowing that uh the way that we could get to the best possible outcomes is um by engaging the family, respecting their beliefs, listening to them. Um, there's um, you know, I I believe that the PowerPoint presentation is uh available to everybody and there's actually a relatively busy uh slide um that came from the AAP committee on uh patient and uh family engagement and that uh took a look at this and um had six pillars of um of engagement uh for the families including uh listening to them, incorporating their beliefs. Um, also um looking at the policies and procedures of your hospital to make sure that they are um uh facilitating uh the family engagement as opposed to um obstructing uh the um respect that people can have uh for people's beliefs. Um also um uh um incorporating them, sharing with them information as best as you can, uh specifically with interpreters. Um, only and and not uh diminishing uh their knowledge about their own um children, um so that they can make the most loving and most thoughtful um, uh contribution to their children's care. All right, let's go to the next one. Can I just make one quick comment um as a plug for the um the cultural differences that we have. Um I think it's really important for us to be um educating ourselves on different cultures um and particularly the uh people just um uh in terms of um education. There's a really great book called the spirit catches you and you fall down and it is um it is just a fantastic uh way to connect with that culture in particular and understand why they have those differences in opinion and why they don't trust the medical system. But I think it's something that we need to do for all cultures, not just the month. That's a great. Okay. Thank you. This is very very helpful case to present because we haven't had one like that before. Let's go to the next one. Okay. Keep um advancing, please. We'll go to a next um thing. I'm trying to uh catch up our time. Um, so we focus on family centered care because it actually um does a lot of things. It reduces uh ED visits. It increases the anxiety of parents and children and as you know, if parents are anxious, children are anxious, if children are anxious, parents are anxious and the staff is anxious. And having them know, having them feel respected, engaged and involved decreases their length of stay, reduces medical errors and also improves staff satisfaction. Thus it's cost effective and uh decreases legal claims and legal expenses. So I think it's a win-win uh for everybody. Our next talk is about intestinal rehabilitation. Again, this is one of our top um educational content from APSA and there's a few things that are actually quite interesting. And um on the PowerPoint I should uh let you know that if you are interested, the um the references uh that I used are are listed in um as you can see under section um page. All right, let's uh go ahead and look at our case scenario. A five-month old child underwent laparotomy for midgut volvulous. They actually had an upper GI and not an ultrasound associated with malrotation. Unfortunately, he has uh 20 centimeters of small bowel distal to the pylorus that was anastomosed to the mid transverse colon. Which medication should he receive as he starts enteral feedings? So our choices are proton pump inhibitor, Lomide, Metrozol, uh perhaps for bowel overgrowth, Tide orline. So as people are putting this together, um, I'm going to ask um, Dr. St. Peter, what do you think? Or anybody else from the panel, what um, what do you think uh we should start on this um, this poor baby? I think you I think you stumped everybody. Really? We should put this under CCA. So to reiterate the question. Oh, Mark, were you going to say something? Oh, I think I think you know that the the the initial gut feeling, pun intended is the patient should be on a PPI. Uh but I have a feeling that the answer might be something different. So, I mean, um, we'll talk us through it. It looks like let's see what the answers are here, Ellen. Yeah, it's about there's we're in thirds. A third are saying PPI, a third are saying Lomide and a third are saying Tide. Okay. Um, so actually the answer is PPI, Dr. Walton. So I'm um, I'm pretty stoked about that. Oh no. His head's going to get so big. And and and Marge, you know, I don't know, maybe a trust thing. It's like I wasn't trusting you not to be tricking us. I I I do have a reputation for being a trickster. So um let's go ahead and advance um a little bit because uh this is a it's a really important topic uh because there's a lot of things going on. So just very briefly uh factors associated with achieving enteral autonomy that is to say they're being fed uh without needing um TPN include obviously, longer residual um small bowel, younger age at the time of intestinal resection because they it allows for more length as they grow, um, preservation of the ileocecal valve. Um a lot uh being written about having that valve actually decrease uh small intestinal bacterial overgrowth. The diagnosis of necrotizing enterocolitis, um as opposed to other diagnosis such as midgut volvulous unfortunately, um, absence of liver disease and normal gastrointestinal motility. Can you advance the um slide for me please? So this is a very dense slide um and looks at current guidelines that are put together by the by NASgan uh which and Esgan uh the European and uh North American uh gastrointestinal uh groups that look at um trying to get children uh to enteral autonomy. So here are the current guidelines. If possible, start enteral nutrition. Um start and advance enteral feeding as possible because that helps uh with intestinal rehabilitation. When possible, start human milk and uh whether it's the mother's expressed breast milk or donor milk, um it is helpful because this um substrate is associated with fewer days of parental nutrition and also um protective uh for the liver. But if you are not able to give um milk, amino acid based formulas seem to have more favorable outcomes than protein hydrolysis formulas. Now if the baby has diarrhea, of course, um, you know, start continuous feedings. However, if bowl feedings are tolerated, that helps too with cyclical secretion of hormones and therefore what is thought is that that also helps uh with uh the growth of the GI tract. In terms of parental nutrition, um the guidelines say use uh asf lipids uh which is a four combination lipids of um soy, um fish oil, uh olive oil, um here and um uh and fish oil medium tray uh chain oil, sorry about that. Um, and um because this is protective. Now, if the the liver function tests go up and there's evidence of uh liver dysfunction, then you can use Omega van. Um, the Omegaven um however can decrease uh the amount of lipids that they get. So that's something that one should um uh their weight should be something that one should monitor uh if this is to be employed. So, right when you do a massive uh small bowel resection, um people say start PPI because there's a reflex hypergastronemia that happens and that actually um impacts how much you can feed. And that that high level of gastrin is part of the the stuff that comes out of their ostomy or their bottom. And so PPI or H2 blockers um are recommended with a high um a strong recommendation in high level of evidence. Now, Tide is something that's creeping up uh in our uh literature. It's being used in adults more, but it's glugon like peptide 2 and it increases epithelial proliferation. It has been um approved uh in children uh but the outcomes are not um as um as impactful in adults because the outcomes that they look at are number of days off TPN. Now with our kids sometimes it's number of hours off TPN. So I think we should continue to look at this literature as it evolves. Um, other types of medical therapy include uh aggressive uh treatment of small intestinal overgrowth and citruline is just something that I put as like E. It's actually a mat marker of intestinal absorption is not something that you give the child. And then for us surgeons, it's um imperative that we establish intestinal continuity as soon as possible because um having this enteral nutrition start, um with the human milk, um etc etc really helps with their intestinal uh rehabilitation. And and try not to do the intestinal lengthening procedure um as soon as possible. And this is something that's also evolving. Um, what they've said is hold off um for a few months until adaptation actually starts because then you could get more length uh to that bowel that you have. And then intestinal transplantation interestingly is getting less and less um um uh common uh nowadays because our centers are just getting very, very good at doing this. All right. Any um, any questions or any comments, Ellen uh from our audience? There's time for a short comment. Of course. Yeah, so we we always hear the the role of the valve in prognostication for TPN dependence but uh I think the valve is unble from the terminal. So uh and some recent studies have actually shown that that it's more relevant the the section of the terminalum. If you actually categorize those sections with certain degrees of terminal section. The valve is not that important, it's more of a marker of how much terminalum you have resected. The um the literature that I've I've seen Dr. Campose, um um does I mean, that is actually a very valid point. But um some of the gastrin uh intestinal literature actually just highlights it because of the ability of the uh ical valve uh to um to decrease the um occurrence of um of CBO or a bacterial overgrowth and a lot of times that actually impedes uh your ability to uh increase. But that's a really a really interesting and compelling uh point that it's just a prognosticator of how much ileum you actually have and we all know that the ileum has reabsorptive capacities of certain very important um um nutrients. And a couple questions from from the chat. Someone asked um so the PPI should be started right away and not just when we're starting feeds, correct? Yes, correct. Um and then they also ask how do you determine the time to hold off before you decide about the length lengthening procedure? So, I think um this is kind of like where the art of surgery starts, right? So, um, um what we um about a year of ageish and also you want to take a look at the um the width of your um of your intestine. So it it needs to be something that you could do an intestinal lengthening procedure on at least in my hands I use the the um the step procedure. Um, and um I also look to see how much um they've stalled on their feedings. If they're doing well, then allow them to to feed and grow. But if they're they've gotten to a point where they have uh stalled they have stalled on their feedings because um of you know, several bouts of uh um small intestinal uh bacterial overgrowth or um or things are just not getting absorbed, then that's something I start I start planning at that time. Hey Marge, can I just comment um this is not my area of specialty uh for sure but I know that uh in the folks in our organization who treat this, they have real concerns about the lengthening procedures and um that they have um really deleterious effects on motility and that that can actually be worse than than having uh a bowel that's uh short. So, I think it is an area of controversy as to when and and upon whom do you uh do a uh intestinal lengthening procedure and then which one is the right procedure to do. I agree, Dr. Von Alman. I think um now I I would say that uh before uh in you know my previous practice I would do um an intestinal lengthening procedure probably twice a year uh and it's it's kind of one of those things that uh, you know, he hasn't uh uh he hasn't advanced in about two months now and all that stuff. But now I do think um, I mean that the intestinal lengthening procedures are becoming rare, rarer and rarer. Now to to be sure, um we have um uh uh database uh that is kept at Boston Children's uh regarding this and it would be uh amazing uh if uh we have some outcomes uh from that database uh in consortium uh soon. However, um I would say that we have gotten so good at our medical therapy, at you know, being on top of giving them the nutrients that they need, of starting enteral therapy soon and um having all these other um things in our armentarium uh with our uh intestinal rehabilitation centers that it's uh uh it's becoming rare to do this intestinal lengthening procedure and I I um share the concerns that your colleagues have as well. Okay. All right, um let's move on. Yeah. All right. So this, all right, let's take a look at our next um our next slide, please. All right. An 11-month old child was seen by his babysitter to put something in his mouth. At an outside urgent care, um at a critical access hospital, a chest x-ray was obtained below. The patient should undergo immediate A, contrast esophagram, B, administration of honey, C, administration of crate, D, Buge or E transfer to a pediatric center. Now before people answer that, um do you want to leave it as is or do you want to highlight specific things on that x-ray or I would like the x-ray to if possible, can we look at the x-ray a little bit bigger or not? Probably not. I don't know if there's a way to But. Oh wow. Oh, Garrett. Dr. whoever that was is amazing. What? All right. Talk us through that, Marge. Yeah, so, um, this is as you could see a foreign body uh in the upper uh thoracic uh inlet in the mid clavicular area. Now, um if you take a look a little bit to um screen left is um uh you could see the airway there getting a little bit pushed over and then you could see a um circumferential thing with a halo, a circumferential um radio opaque um material that has a halo. This strikes fear at the heart of of uh ENT surgeons, gastroenterologists and pediatric surgeons. So um anyway, uh I what what do you think this is, Dr. This is the dreaded button battery. You and I have had our fair share of uh interesting foreign objects lodged in infants uh the esophagus and and uh oral fairings but um this is I would take our fish bone one, Dr. Selen, uh uh over this to be sure. that's a critical picture that should be burned into everyone's mind that ring, that little ring there indicating that this is a battery that they swallowed and not a coin. All right. So back to the question. So what do people want to do with this? Um so do you want to get do you want to get an esophagram? Do you want to give honey? Do you want to give socfate? Do you want to do put a bougie down uh or do you want to transfer to a pediatric center? And while we're waiting for those answers it if the bougienage thing is interesting. We that's you know what? I don't even want to go there because the whole question for for how do we treat a coin is going to take us to a whole different discussion. I I know. I just put that there to be to tease you all. I love it. Ellen, what do we got here? Um yeah, most people are saying to transfer. About well 50% are saying to transfer to center and then um about a quarter are saying administer honey and a small 15% are saying Buge. Okay. All right. Marge Marge, what do we got? What do people want to say, Marge, tell us. Okay. Um so, uh we actually, um, this is it this is one of those things that really um this is more to me this strikes fear in my heart as much as a level one trauma gunshot to the got, you know, cavity of something. Um, we we have developed some guidelines regarding how to deal with this because this is a time limited issue much like mid gut volvulous is. So, indeed, if you're in a critical access hospital, someone needs to be calling the pediatric transfer center. But right now, this button battery is doing two things. It's creating an alkali burn uh in the esophagus and it's also um it it's it's alive battery. It's uh causing an electrical burn uh in the area. So, um, about three years ago, uh the US put together um something poison.org um and there's a lot of of people who experts who's actually looked at this. And as you are transferring to the pediatric center, that may take you some time and what you need to do is cut down on the um uh damage, the injury that this is this is um doing. So the two things that we have um been taught to do is to give honey, uh 10 ml every 10 minutes um as much as you can, or you could give uh sofate. Um, now this is the trick question, um, because um you're not supposed to give honey in children uh less than 11 months old. Um, I asked my colleagues if I should use this on uh an administered administered test but they thought that was too tricky. But I thought this would be fair game for for our audience. So for this particular child, it would be car fate because he's 11 months old and he's not supposed uh to get honey. Uh Buge absolutely not. Absolutely not because you need to see um once they get to pediatric center, this is one of those, you know, um you know, uh immediate to the operating room. One needs to go at um remove it under direct visualization and actually take a look at the injury that's there. Um, and so if you, if you go ahead and uh uh go to the next slide, please. So here's the immediate management and I put it there because, you know, hopefully we don't have it like committed to memory because it doesn't happen every day. But in a child greater than 12 months, give honey 10 ml every 10 minutes. in a child less than 12 months, give a care fate suspension um 1 gram per per 10 ml or 10 ml every um every hour times 3 and that coats the um the battery. And then