1 00:00:00,000 --> 00:00:05,000 GlobalCastMD, along with Cincinnati Children's Hospital, 2 00:00:05,080 --> 00:00:08,480 sharing knowledge to improve child health around the globe. 3 00:00:08,480 --> 00:00:09,360 Hi everyone. 4 00:00:09,360 --> 00:00:11,760 As you may know, in August, 2023, 5 00:00:11,760 --> 00:00:15,600 we held our 11th annual update course in pediatric surgery. 6 00:00:15,600 --> 00:00:19,000 And today we are bringing you the top 10 key takeaways 7 00:00:19,000 --> 00:00:20,500 from that day. 8 00:00:20,500 --> 00:00:23,560 We are starting our video with number 10. 9 00:00:23,560 --> 00:00:25,420 Our first key takeaway is 10 00:00:25,420 --> 00:00:28,400 poem procedure for ecclesiastreatment. 11 00:00:28,400 --> 00:00:32,240 In this session, Dr. Mikhail Petrosyan and Timothy Kane 12 00:00:32,240 --> 00:00:34,120 went through different cases 13 00:00:34,120 --> 00:00:36,560 and presented us the types of ecclesia 14 00:00:36,560 --> 00:00:38,720 and how we can manage them. 15 00:00:38,720 --> 00:00:41,320 As we know, the gold standard for ecclesiastreatment 16 00:00:41,320 --> 00:00:43,760 is the laparoscopic heller myotomy. 17 00:00:43,760 --> 00:00:45,920 But there is one new technique, 18 00:00:45,920 --> 00:00:49,560 peroral endoscopic myotomy, or poem procedure, 19 00:00:49,560 --> 00:00:51,700 that is becoming more and more popular, 20 00:00:51,700 --> 00:00:54,280 and our experts showed us the benefits of poem 21 00:00:54,280 --> 00:00:55,800 amongst these patients. 22 00:00:55,800 --> 00:01:00,800 So tell us why you feel this is the best way to go, 23 00:01:00,880 --> 00:01:02,960 or what are the advantages of poem 24 00:01:02,960 --> 00:01:06,040 over the laparoscopic esophageal myotomy? 25 00:01:06,040 --> 00:01:09,240 Yeah, I think you have 360 degrees of options 26 00:01:09,240 --> 00:01:10,520 to do a myotomy. 27 00:01:10,520 --> 00:01:12,920 Whereas with a heller, you're kind of more anterior. 28 00:01:12,920 --> 00:01:14,760 So you've got maybe 180. 29 00:01:14,760 --> 00:01:16,320 You don't even, you got the vagus there 30 00:01:16,320 --> 00:01:18,040 that you've got to worry about. 31 00:01:18,040 --> 00:01:22,040 And a re-op for a heller, you have all those issues. 32 00:01:22,040 --> 00:01:26,000 So you can do a, you read your poem after a heller or a poem, 33 00:01:26,000 --> 00:01:29,640 and you can choose a different side to do your dissection 34 00:01:29,640 --> 00:01:30,920 once you get in a clean spot. 35 00:01:30,920 --> 00:01:32,520 So you don't burn any bridges. 36 00:01:32,520 --> 00:01:33,960 You don't dissect the hiatus, 37 00:01:33,960 --> 00:01:36,360 so you're not worried about reflux. 38 00:01:36,360 --> 00:01:39,680 In conclusion, poem is a safe procedure for ecclesia 39 00:01:39,680 --> 00:01:42,280 and has an advantage since it has a larger surface 40 00:01:42,280 --> 00:01:44,400 to perform the myotomy. 41 00:01:44,400 --> 00:01:46,800 Poem comes with very few to zero chances 42 00:01:46,800 --> 00:01:49,820 of damaging the vagus nerve, less reflex rates, 43 00:01:49,820 --> 00:01:53,000 and it's useful when there is a lot of scarring tissue. 44 00:01:53,000 --> 00:01:55,720 In number nine, we will explain the importance 45 00:01:55,720 --> 00:01:57,760 of blunt cerebrovascular trauma, 46 00:01:57,760 --> 00:02:00,700 or BCVI screening, in head trauma patients, 47 00:02:00,700 --> 00:02:02,640 and see when is it necessary. 48 00:02:02,640 --> 00:02:06,440 BCVI occurs in 1.3% of the all head trauma 49 00:02:06,440 --> 00:02:08,320 in pediatric population, 50 00:02:08,320 --> 00:02:11,120 and nearly one third of them will have a stroke, 51 00:02:11,120 --> 00:02:14,120 increasing their mortality up to 20%. 52 00:02:14,120 --> 00:02:16,800 So it is really important that pediatric surgeons 53 00:02:16,800 --> 00:02:18,760 start screening patients for it. 54 00:02:18,760 --> 00:02:21,680 Let's hear from Dr. Zmeera Kodakal and Katie Russell, 55 00:02:21,680 --> 00:02:24,080 who originally gave this presentation. 56 00:02:24,080 --> 00:02:26,160 We had a couple of patients, 57 00:02:26,160 --> 00:02:28,520 one with a delayed diagnosis stroke from a BCVI 58 00:02:28,520 --> 00:02:32,440 that was missed, that really prompted us last year 59 00:02:32,440 --> 00:02:34,800 to make a routine protocol for BCVI 60 00:02:34,800 --> 00:02:37,200 and to determine all of these patients 61 00:02:37,200 --> 00:02:40,100 should get CTA head and neck because of concern. 62 00:02:40,100 --> 00:02:43,440 Also in this session, we reviewed various scoring systems 63 00:02:43,440 --> 00:02:45,700 that can help us determine which patients 64 00:02:45,700 --> 00:02:47,800 are at risk of having a BCVI, 65 00:02:47,800 --> 00:02:49,600 and for which ones we should order a CT 66 00:02:49,600 --> 00:02:51,480 and geography of head and neck. 67 00:02:51,480 --> 00:02:55,160 In this atomic paper, the Memphis score is what they use, 68 00:02:55,160 --> 00:02:57,560 and it is the most sensitive score. 69 00:02:57,560 --> 00:03:00,640 To summarize, we learned that performing a BCVI screening 70 00:03:00,640 --> 00:03:02,880 in head trauma patients is crucial. 71 00:03:02,880 --> 00:03:05,400 And even though there are many tools and scoring systems 72 00:03:05,400 --> 00:03:07,840 that can help us determine whom to screen, 73 00:03:07,840 --> 00:03:10,000 the most sensitive score for this population 74 00:03:10,000 --> 00:03:12,400 showed to be the Memphis score. 75 00:03:12,400 --> 00:03:14,080 For number eight, we picked a topic 76 00:03:14,080 --> 00:03:16,400 from one of our most popular sessions, 77 00:03:16,400 --> 00:03:18,760 who to send home from the OR. 78 00:03:18,760 --> 00:03:21,760 This time, Dr. Philip Benham presented different cases 79 00:03:21,760 --> 00:03:23,120 of pilaromyotomy. 80 00:03:23,120 --> 00:03:26,280 Two patients, one over and one under 37 weeks 81 00:03:26,280 --> 00:03:29,020 of gestational age, looking for an answer to see 82 00:03:29,020 --> 00:03:32,720 who can be discharged early after pilaric stenosis surgery. 83 00:03:32,720 --> 00:03:35,560 I say that if they're full term 84 00:03:35,560 --> 00:03:37,840 and more than four weeks old, 85 00:03:37,840 --> 00:03:40,080 then they don't have to be observed for 12 hours, 86 00:03:40,080 --> 00:03:42,680 but it will be institution specific. 87 00:03:42,680 --> 00:03:44,720 They each have to come up with their own. 88 00:03:44,720 --> 00:03:46,760 Dr. Hem and our audience both agreed 89 00:03:46,760 --> 00:03:49,640 that patients under 37 weeks of gestation 90 00:03:49,640 --> 00:03:52,640 require overnight monitoring following anesthesia, 91 00:03:52,640 --> 00:03:56,120 even if they're tolerating full feeds shortly after surgery. 92 00:03:56,120 --> 00:03:59,100 However, a full term baby over four weeks old 93 00:03:59,100 --> 00:04:01,800 may be eligible for discharge from the PACU. 94 00:04:01,800 --> 00:04:05,760 Looking at NISQIP data, only 1.5% of pilarics 95 00:04:05,760 --> 00:04:08,240 were discharged on the day of surgery, 96 00:04:08,240 --> 00:04:11,400 and there was no difference in the odds of readmission. 97 00:04:12,380 --> 00:04:14,360 So there's a little data, Todd, 98 00:04:14,360 --> 00:04:17,960 and then no difference in complications for them. 99 00:04:17,960 --> 00:04:19,800 So it is safe to say that patients 100 00:04:19,800 --> 00:04:22,320 under 37 weeks of gestational age 101 00:04:22,320 --> 00:04:24,300 or younger than four weeks old 102 00:04:24,300 --> 00:04:27,320 should be monitored overnight post procedure. 103 00:04:27,320 --> 00:04:31,280 Meanwhile, those over 37 weeks of gestational age 104 00:04:31,280 --> 00:04:34,160 or older than four weeks can be discharged 105 00:04:34,160 --> 00:04:36,660 for living successful feeding tolerance. 106 00:04:36,660 --> 00:04:40,040 Coming up number seven, we will review the ICG application 107 00:04:40,040 --> 00:04:42,640 for identification of sentinel nodes. 108 00:04:42,640 --> 00:04:45,500 This topic was presented by Dr. Seth Goldstein. 109 00:04:46,940 --> 00:04:49,640 As we know, ICG, efflorescent dye, 110 00:04:49,640 --> 00:04:51,640 has become increasingly integrated 111 00:04:51,640 --> 00:04:55,160 into biliary-related surgeries, such as cholecystectomies, 112 00:04:55,160 --> 00:04:57,600 due to its hepatic excretion. 113 00:04:57,600 --> 00:05:00,560 The sentinel node, defined as the initial lymph node, 114 00:05:00,560 --> 00:05:02,600 where cancer cells are most likely to spread 115 00:05:02,600 --> 00:05:05,680 from a primary tumor, often necessitates a biopsy 116 00:05:05,680 --> 00:05:08,600 to classify and treat tumors effectively. 117 00:05:08,600 --> 00:05:12,000 Historically, technetium-99 served as the primary marker 118 00:05:12,000 --> 00:05:14,240 for identifying the sentinel nodes. 119 00:05:14,240 --> 00:05:17,400 And even though it works, it requires a special machine 120 00:05:17,400 --> 00:05:20,280 to detect it, and it's hard to control the injection. 121 00:05:20,280 --> 00:05:22,560 In the operating room, you can take charge 122 00:05:22,560 --> 00:05:27,560 because the ICG technique is real-time in the operating room. 123 00:05:27,820 --> 00:05:32,820 With equipment, you either have or are about to have standard 124 00:05:32,820 --> 00:05:35,280 in all your laparoscopic towers. 125 00:05:35,280 --> 00:05:37,780 The main point is to find the node 126 00:05:37,780 --> 00:05:40,400 that is your first sentinel drainage, 127 00:05:40,400 --> 00:05:44,320 and that's ever so important, and ICG can do that. 128 00:05:44,320 --> 00:05:46,920 So here, Dr. Goldstein will demonstrate 129 00:05:46,920 --> 00:05:48,760 how ICG can enhance our ability 130 00:05:48,760 --> 00:05:50,940 to locate these crucial structures, 131 00:05:50,940 --> 00:05:52,720 aiding in surgical procedures. 132 00:05:52,720 --> 00:05:57,380 So, indocyanin injection into the tumor, 133 00:05:57,380 --> 00:05:59,840 and then look at that right below it 134 00:05:59,840 --> 00:06:01,640 with the lights off contrast. 135 00:06:01,640 --> 00:06:06,120 You can just watch over the course of 45, 60, 75 seconds, 136 00:06:06,120 --> 00:06:09,240 the ICG head to the sentinel node. 137 00:06:09,240 --> 00:06:12,600 In conclusion, ICG can be used to detect sentinel nodes 138 00:06:12,600 --> 00:06:14,080 in many types of cancer, 139 00:06:14,080 --> 00:06:16,280 allowing the surgeon to control the time and place 140 00:06:16,280 --> 00:06:18,480 of the injection, and avoiding the issues 141 00:06:18,480 --> 00:06:21,200 that may occur with technetium-99. 142 00:06:21,200 --> 00:06:23,120 This time, we have number six, 143 00:06:23,120 --> 00:06:25,040 anal dilation following a PSARF. 144 00:06:26,760 --> 00:06:28,600 This was a part of Dr. Caitlin Smith 145 00:06:28,600 --> 00:06:30,580 and Julia Grabowski's presentation. 146 00:06:32,120 --> 00:06:34,940 Anal dilations were traditionally a common practice 147 00:06:34,940 --> 00:06:36,400 following PSARF to mitigate 148 00:06:36,400 --> 00:06:39,360 or prevent stricture formation post-procedure. 149 00:06:39,360 --> 00:06:42,360 However, recent studies have challenged this approach, 150 00:06:42,360 --> 00:06:44,200 revealing a lack of firm correlation 151 00:06:44,200 --> 00:06:47,260 between anal dilations and stricture development. 152 00:06:47,260 --> 00:06:50,320 Twice a day dilations for however many weeks and months 153 00:06:50,320 --> 00:06:52,840 might be able to be teased down a little bit 154 00:06:52,840 --> 00:06:56,000 so that the family's stress, which does seem to be a stress, 155 00:06:56,000 --> 00:06:58,120 but that we can sort of mitigate that a little bit 156 00:06:58,120 --> 00:07:02,440 by just modifying the dilation plan. 157 00:07:02,440 --> 00:07:03,960 One other interesting fact is 158 00:07:03,960 --> 00:07:06,600 that many of these patients have a colostomy, 159 00:07:06,600 --> 00:07:08,560 so they are going to have another procedure 160 00:07:08,560 --> 00:07:11,240 for colostomy closure, which is a perfect moment 161 00:07:11,240 --> 00:07:13,440 to perform a strictureplasty if needed. 162 00:07:13,440 --> 00:07:16,080 I personally see them anywhere from, 163 00:07:16,080 --> 00:07:19,080 I see them about two to four weeks after the operation, 164 00:07:19,080 --> 00:07:20,480 whenever I can get them into clinic 165 00:07:20,480 --> 00:07:21,640 in that kind of timeframe, 166 00:07:21,640 --> 00:07:24,400 and then I size the anoplasty in the office, 167 00:07:24,400 --> 00:07:26,840 and when I size it, I'm like, okay, 168 00:07:26,840 --> 00:07:28,680 like here's the time where we can talk about 169 00:07:28,680 --> 00:07:31,360 what dilations look like, we can do them or not, 170 00:07:31,360 --> 00:07:32,400 this is what might happen, 171 00:07:32,400 --> 00:07:34,920 you might need to get a strictureplasty. 172 00:07:34,920 --> 00:07:36,480 I've talked to the family before the surgery 173 00:07:36,480 --> 00:07:38,720 about dilations as an option, so they're not surprised, 174 00:07:38,720 --> 00:07:41,880 but if it looks really good, I will skip it. 175 00:07:41,880 --> 00:07:44,080 In summary, dilations following PSARP 176 00:07:44,080 --> 00:07:46,360 are not recommended for every patient. 177 00:07:46,360 --> 00:07:48,720 This procedure can be distressing for families 178 00:07:48,720 --> 00:07:50,360 and may be unnecessary, 179 00:07:50,360 --> 00:07:53,760 particularly if the patient requires a colostomy closure. 180 00:07:53,760 --> 00:07:55,080 In the event of a stricture, 181 00:07:55,080 --> 00:07:58,400 it can be addressed through a strictureplasty at that time. 182 00:07:58,400 --> 00:08:00,480 We're halfway through our list, 183 00:08:00,480 --> 00:08:02,640 and number five brings us to the updates 184 00:08:02,640 --> 00:08:04,680 in fertility preservation session. 185 00:08:05,800 --> 00:08:08,520 Here, Dr. Erin Rowell will discuss the process 186 00:08:08,520 --> 00:08:11,920 of removing ovarian tissue for cryopreservation. 187 00:08:11,920 --> 00:08:15,440 Dr. Rowell shared a case involving a six-year-old female 188 00:08:15,440 --> 00:08:20,440 diagnosed with hemophagocytic lymphohistiocytosis, or HLH, 189 00:08:20,600 --> 00:08:22,160 requiring chemotherapy, 190 00:08:22,160 --> 00:08:25,720 and thus ovarian tissue preservation for future fertility. 191 00:08:25,720 --> 00:08:28,120 It is very important to note the emphasis 192 00:08:28,120 --> 00:08:32,440 placed by every society on fertility preservation counseling, 193 00:08:32,440 --> 00:08:34,680 even when surgery isn't planned. 194 00:08:34,680 --> 00:08:36,720 So how does the counseling process work? 195 00:08:36,720 --> 00:08:39,680 When we have a patient who's got a new diagnosis of cancer 196 00:08:39,680 --> 00:08:41,800 or is gonna come up to stem cell transplant, 197 00:08:41,800 --> 00:08:44,560 they activate our counseling service 198 00:08:44,560 --> 00:08:45,800 through an order set in Epic. 199 00:08:45,800 --> 00:08:47,320 It's easily available to anyone, 200 00:08:47,320 --> 00:08:49,600 and then that triggers a consult by, 201 00:08:49,600 --> 00:08:52,400 we have an advanced practice nurse practitioner. 202 00:08:52,400 --> 00:08:53,960 I do some of the counseling. 203 00:08:53,960 --> 00:08:55,840 We also have somebody from oncology. 204 00:08:55,840 --> 00:08:57,080 So we have multiple different people 205 00:08:57,080 --> 00:08:58,840 who could be available to talk to the family 206 00:08:58,840 --> 00:09:00,600 about that risk assessment. 207 00:09:00,600 --> 00:09:02,720 Another important factor is deciding 208 00:09:02,720 --> 00:09:05,600 what is the best procedure for preserving ovarian tissue. 209 00:09:05,600 --> 00:09:07,080 It's really important to recognize 210 00:09:07,080 --> 00:09:08,240 this is a prepuberty child. 211 00:09:08,240 --> 00:09:11,200 The size of this child's ovary is about two centimeters. 212 00:09:11,200 --> 00:09:12,560 It's about the size of a grape. 213 00:09:12,560 --> 00:09:14,280 And that really what you ought to do 214 00:09:14,280 --> 00:09:15,680 is a laparoscopic oophorectomy. 215 00:09:15,680 --> 00:09:17,560 That would be our best recommendation. 216 00:09:17,560 --> 00:09:20,360 So laparoscopic oophorectomy is recommended 217 00:09:20,360 --> 00:09:22,120 to reduce the risk of hemorrhage 218 00:09:22,120 --> 00:09:24,400 and ensure that any remaining ovarian tissue 219 00:09:24,400 --> 00:09:26,680 is preserved for the future fertility. 220 00:09:26,680 --> 00:09:29,120 So in conclusion, fertility preservation 221 00:09:29,120 --> 00:09:32,640 is very important for children undergoing chemotherapy. 222 00:09:32,640 --> 00:09:34,000 Counseling must be included 223 00:09:34,000 --> 00:09:36,040 in their multidisciplinary approach. 224 00:09:36,040 --> 00:09:37,720 And in females, the best way to do it 225 00:09:37,720 --> 00:09:40,720 is with a laparoscopic oophorectomy. 226 00:09:40,720 --> 00:09:44,160 Getting closer to the top three, and we have number four. 227 00:09:44,160 --> 00:09:46,680 To talk about the massive transfusion protocol, 228 00:09:46,680 --> 00:09:49,960 we'll tune into Dr. Dmyro Kodogal and Katie Russell. 229 00:09:49,960 --> 00:09:52,840 Massive transfusion protocol, or MTP, 230 00:09:52,840 --> 00:09:55,040 is a multidisciplinary process 231 00:09:55,040 --> 00:09:56,800 whereby blood and blood products 232 00:09:56,800 --> 00:10:00,480 can be rapidly obtained for severely bleeding patients. 233 00:10:00,480 --> 00:10:02,360 Effective communication is crucial 234 00:10:02,360 --> 00:10:04,480 due to the urgent nature of the situation, 235 00:10:04,480 --> 00:10:07,240 and having a protocol simplifies the process, 236 00:10:07,240 --> 00:10:10,360 ensuring timely access to essential blood products. 237 00:10:10,360 --> 00:10:13,120 But when should we activate MTP? 238 00:10:13,120 --> 00:10:15,720 And what kind of blood products should we give? 239 00:10:15,720 --> 00:10:18,880 If you're in the trauma bay and you're giving blood, 240 00:10:18,880 --> 00:10:20,200 you need to activate it. 241 00:10:20,200 --> 00:10:22,000 Like, it's go time. So blood equals MTP. 242 00:10:22,000 --> 00:10:23,800 Yes. That's its phrase to remember. 243 00:10:23,800 --> 00:10:25,560 So if you give blood, call MTP. 244 00:10:25,560 --> 00:10:27,040 Another important thing we learned 245 00:10:27,040 --> 00:10:29,080 is the ratio we should give the blood products, 246 00:10:29,080 --> 00:10:30,800 which is one to one to one, 247 00:10:30,800 --> 00:10:32,320 meaning for every bag of blood, 248 00:10:32,320 --> 00:10:35,120 you pass a blood of plasma and one of platelets. 249 00:10:35,120 --> 00:10:36,680 When do you give something 250 00:10:36,680 --> 00:10:39,400 other than packed red blood cells, and what do you give? 251 00:10:39,400 --> 00:10:43,080 If it's a bad trauma, bad trauma coming in, 252 00:10:43,080 --> 00:10:45,920 not stable or not normal at all. 253 00:10:45,920 --> 00:10:48,760 Whole blood. Yeah, whole blood would be the best, I think. 254 00:10:48,760 --> 00:10:51,040 So we have not been able to get our blood bank 255 00:10:51,040 --> 00:10:53,200 to make whole blood for kids because it needs to be open. 256 00:10:53,200 --> 00:10:55,240 We want to aim for one to one to one, for sure. 257 00:10:55,240 --> 00:10:57,160 And definitely FFP should be what you give 258 00:10:57,160 --> 00:10:58,640 after you give blood. 259 00:10:58,640 --> 00:11:00,480 Most of the time, an original trauma cooler 260 00:11:00,480 --> 00:11:01,920 that comes to the bay in most hospitals 261 00:11:01,920 --> 00:11:03,360 does not have platelets. 262 00:11:03,360 --> 00:11:05,480 So the MTP helps you get platelets 263 00:11:05,480 --> 00:11:06,520 or you can call for platelets, 264 00:11:06,520 --> 00:11:08,600 but they usually don't come in your trauma cooler. 265 00:11:08,600 --> 00:11:11,120 In summary, the massive transfusion protocol 266 00:11:11,120 --> 00:11:13,280 should be activated in the trauma bay 267 00:11:13,280 --> 00:11:17,440 after administering 20 milliliters per kilogram of blood. 268 00:11:17,440 --> 00:11:19,840 Following activation, the protocol dictates 269 00:11:19,840 --> 00:11:21,680 providing the patient with blood products 270 00:11:21,680 --> 00:11:24,320 in a ratio of one to one to one. 271 00:11:24,320 --> 00:11:25,960 We're finally in the top three. 272 00:11:25,960 --> 00:11:28,120 For number three, we will review the management 273 00:11:28,120 --> 00:11:31,120 of ovarian torsion with Dr. Lizzie Breach, 274 00:11:31,120 --> 00:11:32,680 a pediatric gynecologist. 275 00:11:33,600 --> 00:11:36,360 Dr. Breach started this session by presenting a case 276 00:11:36,360 --> 00:11:39,240 of a pre-puberty girl with a right ovarian torsion. 277 00:11:39,240 --> 00:11:40,520 Comes to the emergency department, 278 00:11:40,520 --> 00:11:42,800 gets an ultrasound, large cystic mass, 279 00:11:42,800 --> 00:11:44,520 no blood flow to the right ovary, 280 00:11:44,520 --> 00:11:46,920 and you decide to take this patient to the operating room, 281 00:11:46,920 --> 00:11:48,600 you find right ovarian torsion, 282 00:11:48,600 --> 00:11:51,360 and you can see this sort of dark purple ovary. 283 00:11:51,360 --> 00:11:52,920 The key thing to watch out for 284 00:11:52,920 --> 00:11:56,280 is the presence of a cystic area on the ultrasound. 285 00:11:56,280 --> 00:11:59,040 Often, this is less visible in the operating room. 286 00:11:59,040 --> 00:12:01,320 And although many surgeons may wanna go in 287 00:12:01,320 --> 00:12:03,040 and attempt to remove the cyst, 288 00:12:03,040 --> 00:12:05,240 Dr. Breach advises against it 289 00:12:05,240 --> 00:12:08,040 unless the edema makes it clearly visible. 290 00:12:08,040 --> 00:12:10,080 Now, there's more question about the fallopian tube, 291 00:12:10,080 --> 00:12:12,640 how to manage a blue-black fallopian tube. 292 00:12:12,640 --> 00:12:13,480 Take a look at the tube. 293 00:12:13,480 --> 00:12:15,880 If the tube is black, it's edematous, 294 00:12:15,880 --> 00:12:18,480 you have detourst it, you've given it plenty of time. 295 00:12:18,480 --> 00:12:23,480 I would say a consideration about what to do about that tube. 296 00:12:23,760 --> 00:12:26,560 Therefore, it's best to avoid removing the ovary 297 00:12:26,560 --> 00:12:29,440 because it may still regain some of its functionality, 298 00:12:29,440 --> 00:12:31,720 even if it appears to be black. 299 00:12:31,720 --> 00:12:34,840 Dr. Breach also advises against pixying the ovary. 300 00:12:34,840 --> 00:12:37,160 Instead, she recommends just detorsion 301 00:12:37,160 --> 00:12:39,400 and subsequent monitoring. 302 00:12:39,400 --> 00:12:43,400 In conclusion, ovarian torsion does not always involve cyst. 303 00:12:43,400 --> 00:12:45,840 Therefore, unless it is clearly visible, 304 00:12:45,840 --> 00:12:47,640 do not attempt to remove it. 305 00:12:47,640 --> 00:12:50,440 To preserve as much ovarian tissue as possible, 306 00:12:50,440 --> 00:12:52,200 avoid performing an oophorectomy 307 00:12:52,200 --> 00:12:54,040 and ensure the patient is followed up. 308 00:12:54,920 --> 00:12:57,520 And for number two, we'll review total pancreatectomy 309 00:12:57,520 --> 00:13:01,080 with islet ototransplantation, or TPIAT, 310 00:13:01,080 --> 00:13:04,160 from updates in pancreatitis management session. 311 00:13:04,160 --> 00:13:08,360 This time, Dr. Juan Guria will help us understand the topic. 312 00:13:08,360 --> 00:13:10,240 Chronic pancreatitis is a condition 313 00:13:10,240 --> 00:13:12,640 that causes pancreatic insufficiency 314 00:13:12,640 --> 00:13:14,720 and damage to the islet cells. 315 00:13:14,720 --> 00:13:17,320 One treatment option is TPIAT. 316 00:13:17,320 --> 00:13:20,400 This procedure involves a complete removal of the pancreas 317 00:13:20,400 --> 00:13:23,640 along with the spleen, followed by extraction of islet cells 318 00:13:23,640 --> 00:13:25,400 in a specialized lab. 319 00:13:25,400 --> 00:13:27,880 These cells are then injected into the portal vein. 320 00:13:27,880 --> 00:13:29,720 In the acute post-op period, 321 00:13:29,720 --> 00:13:32,040 you have to manage their glucose for them. 322 00:13:32,040 --> 00:13:34,960 If you put them under stress, the cells die. 323 00:13:34,960 --> 00:13:37,000 Everybody's on insulin in the ICU. 324 00:13:37,000 --> 00:13:39,480 I want the cells to be like just chilling, 325 00:13:39,480 --> 00:13:41,760 not doing any work until they implant 326 00:13:41,760 --> 00:13:45,200 and find new vessels from the liver to survive. 327 00:13:45,200 --> 00:13:47,360 It is important to understand that many patients 328 00:13:47,360 --> 00:13:49,720 with chronic pancreatitis have a gene mutation 329 00:13:49,720 --> 00:13:51,680 that triggers recurrent attacks, 330 00:13:51,680 --> 00:13:55,200 causing the gland to replace normal cells with fibrosis. 331 00:13:55,200 --> 00:13:58,000 This is why performing any surgical resection procedure 332 00:13:58,000 --> 00:13:59,640 without extracting the islet cells 333 00:13:59,640 --> 00:14:02,400 may result in continued pancreatitis attacks 334 00:14:02,400 --> 00:14:05,360 and an increased risk of diabetes after TPIAT 335 00:14:05,360 --> 00:14:07,520 due to the reduced pancreatic parenchyma. 336 00:14:08,680 --> 00:14:12,680 In conclusion, TPIAT is a surgery for chronic pancreatitis 337 00:14:12,680 --> 00:14:14,760 that helps the pain and the recurrent attacks 338 00:14:14,760 --> 00:14:18,080 with the idea of preserving as many islet cells as possible 339 00:14:18,080 --> 00:14:20,080 to avoid endocrine insufficiency. 340 00:14:22,160 --> 00:14:24,040 And we made it to the number one. 341 00:14:24,040 --> 00:14:26,720 I know everyone's been waiting for this. 342 00:14:26,720 --> 00:14:29,680 Let's hear from Drs. Mira Kodigal and Katie Russell 343 00:14:29,680 --> 00:14:33,240 on management of blunt trauma to the liver and spleen. 344 00:14:33,240 --> 00:14:35,160 Blunt trauma is a significant concern 345 00:14:35,160 --> 00:14:36,800 in the pediatric population, 346 00:14:36,800 --> 00:14:39,800 primarily due to the potential severity and complications 347 00:14:39,800 --> 00:14:41,640 associated with such injuries, 348 00:14:41,640 --> 00:14:45,280 and its management has been evolving for many years now. 349 00:14:45,280 --> 00:14:48,160 Last year, the American Pediatric Surgical Association, 350 00:14:48,160 --> 00:14:50,880 or APSA in short, released a guideline, 351 00:14:50,880 --> 00:14:52,560 including new updates. 352 00:14:52,560 --> 00:14:55,680 So the APSA guidelines are relatively new-ish 353 00:14:55,680 --> 00:14:57,600 that came out with revised guidelines 354 00:14:57,600 --> 00:14:59,640 around management of patients, 355 00:14:59,640 --> 00:15:01,760 and it includes four basic categories, 356 00:15:01,760 --> 00:15:03,880 thinking about where they should be admitted, 357 00:15:03,880 --> 00:15:06,160 procedures, when you would discharge them, 358 00:15:06,160 --> 00:15:08,920 and then what you might think about doing after discharge, 359 00:15:08,920 --> 00:15:10,400 and particularly in this instance, 360 00:15:10,400 --> 00:15:13,160 talking about patients not going to the ICU. 361 00:15:13,160 --> 00:15:16,320 For grades one and two blunt trauma to the liver and spleen, 362 00:15:16,320 --> 00:15:19,480 we can monitor patients who are hemodynamically stable 363 00:15:19,480 --> 00:15:22,800 and consider discharging them from the emergency department. 364 00:15:22,800 --> 00:15:25,200 Regarding lab results, should we repeat them? 365 00:15:25,200 --> 00:15:26,920 And if so, how frequently? 366 00:15:26,920 --> 00:15:28,000 They're gonna get one. 367 00:15:28,000 --> 00:15:31,360 I practice out in Utah, and 80% of our kids are transfers. 368 00:15:31,360 --> 00:15:33,320 Most likely, they've already had a CBC 369 00:15:33,320 --> 00:15:36,200 at the other hospital, but we do not repeat it. 370 00:15:36,200 --> 00:15:39,120 If it's a hemodynamically normal child, 371 00:15:39,120 --> 00:15:41,400 they will go to the floor and not get a repeat crit. 372 00:15:41,400 --> 00:15:42,440 Perfect, that's what we're doing, too, 373 00:15:42,440 --> 00:15:44,520 and there's actually data to support that, 374 00:15:44,520 --> 00:15:46,640 that we know there is some degree of hemodilution. 375 00:15:46,640 --> 00:15:48,440 The data suggests that the patients 376 00:15:48,440 --> 00:15:51,240 who are more likely to fail non-operative management 377 00:15:51,240 --> 00:15:53,920 have an initial hemoglobin less than 9.25. 378 00:15:53,920 --> 00:15:56,520 Therefore, for patients who are hemodynamically stable 379 00:15:56,520 --> 00:15:58,360 and have normal hemoglobin levels 380 00:15:58,360 --> 00:15:59,880 in their initial lab tests, 381 00:15:59,880 --> 00:16:01,880 there's no need to repeat the tests 382 00:16:01,880 --> 00:16:04,480 unless there are changes in their condition. 383 00:16:04,480 --> 00:16:07,760 In conclusion, for blunt liver and spleen trauma, 384 00:16:07,760 --> 00:16:10,360 there is increasing evidence that supports treating 385 00:16:10,360 --> 00:16:12,400 the patient based on signs and symptoms 386 00:16:12,400 --> 00:16:14,640 rather than solely on the injury grade. 387 00:16:16,040 --> 00:16:20,200 GlobalCast MD, along with Cincinnati Children's Hospital, 388 00:16:20,200 --> 00:16:39,200 sharing knowledge to improve child health around the globe.