WEBVTT 00:00:00.940 --> 00:00:04.660 Global Cast MD, along with Cincinnati Children's 00:00:04.660 --> 00:00:06.799 Hospital, sharing knowledge to improve child 00:00:06.799 --> 00:00:10.339 health around the globe. Hi, everyone. In August 00:00:10.339 --> 00:00:13.720 2024, we held our 12th annual update course in 00:00:13.720 --> 00:00:16.519 pediatric surgery. And in this video, we are 00:00:16.519 --> 00:00:19.879 bringing you the top 10 key takeaways. Let's 00:00:19.879 --> 00:00:22.399 start with number 10, collaboration of surgery 00:00:22.399 --> 00:00:25.039 and interventional radiology in the OR. This 00:00:25.039 --> 00:00:27.579 topic falls into the blue category as a newer 00:00:27.579 --> 00:00:30.480 approach. Doctors Dan von Allman, John Racadio, 00:00:30.620 --> 00:00:33.539 Timothy Louts, and interventional radiology technologist 00:00:33.539 --> 00:00:36.420 Amanda Wallingford showed us different use cases 00:00:36.420 --> 00:00:39.020 of image -guided surgery which uses real -time 00:00:39.020 --> 00:00:43.979 imaging like CT, MRI, ultrasound. or fluoroscopy 00:00:43.979 --> 00:00:46.640 to improve precision during procedures. This 00:00:46.640 --> 00:00:49.619 session is really about combining the expertise 00:00:49.619 --> 00:00:52.299 of surgeons with the expertise of our interventional 00:00:52.299 --> 00:00:54.460 radiologists. There's cross training at Cincinnati 00:00:54.460 --> 00:00:57.119 Children's. For example, interventional radiologists 00:00:57.119 --> 00:00:59.700 teaching pediatric surgery fellows how to use 00:00:59.700 --> 00:01:02.320 ultrasound guidance for vascular access. So it's 00:01:02.320 --> 00:01:03.840 important to understand that you don't have to 00:01:03.840 --> 00:01:06.810 have hybrid OR to be able to do this type of 00:01:06.810 --> 00:01:08.989 collaboration. It can occur in your regular OR 00:01:08.989 --> 00:01:11.609 by bringing in an ultrasound machine. A hybrid 00:01:11.609 --> 00:01:14.129 operating room eliminates the need to transfer 00:01:14.129 --> 00:01:16.370 patients between imaging and surgical areas. 00:01:16.629 --> 00:01:19.209 It combines advanced imaging technology with 00:01:19.209 --> 00:01:22.250 a traditional surgical setup. One key component 00:01:22.250 --> 00:01:25.819 of a hybrid OR is the cone beam CT. So it's a 00:01:25.819 --> 00:01:29.359 CT scan that's performed on a C -arm fluoroscopy 00:01:29.359 --> 00:01:32.260 unit. Basically, it's positioned over the patient's 00:01:32.260 --> 00:01:34.579 point of interest, and it rotates around the 00:01:34.579 --> 00:01:37.019 patient, collecting multiple images, which are 00:01:37.019 --> 00:01:39.400 then stacked together to create a CT. You can 00:01:39.400 --> 00:01:41.500 also use it for identifying and protecting critical 00:01:41.500 --> 00:01:43.680 structures during surgery. And then you can use 00:01:43.680 --> 00:01:46.260 it at the end of the case to confirm vessel patency. 00:01:46.379 --> 00:01:49.219 In conclusion, collaboration between surgeons 00:01:49.219 --> 00:01:52.030 and interventional radiologists enhances patient 00:01:52.030 --> 00:01:54.650 care by integrating ultrasound and cone beam 00:01:54.650 --> 00:01:57.269 CT. Innovative image -guided techniques such 00:01:57.269 --> 00:02:00.109 as lymph node localization and pulmonary nodule 00:02:00.109 --> 00:02:04.049 marking further simplify complex surgeries. At 00:02:04.049 --> 00:02:07.170 number nine, we hear from Drs. Rami Shaban and 00:02:07.170 --> 00:02:09.990 Carlos Colunga. as they break down the top AI 00:02:09.990 --> 00:02:12.930 tools of 2024. Information from this session 00:02:12.930 --> 00:02:16.069 classifies as a blue square for promising newer 00:02:16.069 --> 00:02:19.729 practice. We are researching how ChatGPT can 00:02:19.729 --> 00:02:22.969 help us in the research process and I personally 00:02:22.969 --> 00:02:26.009 use ChatGPT in systematic review and meta -analysis 00:02:26.009 --> 00:02:29.229 and when you do systematic review you screen 00:02:29.229 --> 00:02:33.090 thousands of articles. This process is intimidating. 00:02:33.689 --> 00:02:37.259 We prompted ChatGPT with the following. I'm conducting 00:02:37.259 --> 00:02:40.379 a systematic review on this specific topic. I 00:02:40.379 --> 00:02:43.240 need you to act as a data analyst. Please analyze 00:02:43.240 --> 00:02:45.560 the TASH Excel sheet and screen the included 00:02:45.560 --> 00:02:48.280 articles based on title and abstract. Because 00:02:48.280 --> 00:02:52.139 we don't trust ChatGVT a lot, I ask ChatGVT also 00:02:52.139 --> 00:02:55.780 to add a column to explain why they decided that 00:02:55.780 --> 00:02:59.099 decision. So you have a better understanding 00:02:59.099 --> 00:03:02.300 about this data and we get an excellent result 00:03:02.300 --> 00:03:05.099 with that. Let's review our next tool, Jenny 00:03:05.099 --> 00:03:08.520 AI. Use AI to supercharge your research paper. 00:03:09.039 --> 00:03:12.039 Genie AI, one of different academic models that 00:03:12.039 --> 00:03:14.879 has been with research papers, and you literally 00:03:14.879 --> 00:03:16.560 put your prompt. And the first thing that you'll 00:03:16.560 --> 00:03:19.800 get is a suggestion. You can start writing this. 00:03:20.300 --> 00:03:23.439 You, because you're the surgeon that has the 00:03:23.439 --> 00:03:26.139 hand on the wheel, can say, yeah, I like it. 00:03:26.180 --> 00:03:28.840 I want to modify it. You can also chat directly 00:03:28.840 --> 00:03:31.099 with its built -in chatbot and say something 00:03:31.099 --> 00:03:34.580 like, I want to research this topic. It will 00:03:34.580 --> 00:03:37.319 provide relevant answers, cite supporting papers, 00:03:37.400 --> 00:03:39.919 and even help format those citations according 00:03:39.919 --> 00:03:42.259 to your preferred style. If you want to have 00:03:42.259 --> 00:03:45.780 a personal trainer, we use also ChatGPT. Upload 00:03:45.780 --> 00:03:49.219 a guideline to ChatGPT and then ask ChatGPT to 00:03:49.219 --> 00:03:51.439 create a training session out of a guideline. 00:03:51.680 --> 00:03:53.939 And then it creates a series of interactive questions 00:03:53.939 --> 00:03:57.360 where you can interact with ChatGPT and get trained 00:03:57.360 --> 00:04:00.680 on a specific thing. And Dr. Kolonga summarizes 00:04:00.680 --> 00:04:03.159 in the best way. We have to have these talks. 00:04:03.259 --> 00:04:05.960 We have to learn how to use it because it's here 00:04:05.960 --> 00:04:09.939 to stay. We can't close our eyes and don't admit 00:04:09.939 --> 00:04:12.860 that everyone's using it to increase their efficiency 00:04:12.860 --> 00:04:16.100 and improve the way they manage their day -to 00:04:16.100 --> 00:04:19.220 -day lives. In number eight, pediatric surgeon 00:04:19.220 --> 00:04:22.699 Dr. John DeFiori discusses how he uses cryoanalgesia 00:04:22.699 --> 00:04:25.980 in pectus. This topic falls into the blue category 00:04:25.980 --> 00:04:29.300 as a newer approach. Cryoanalgesia is a minimally 00:04:29.300 --> 00:04:32.000 invasive procedure to alleviate pain during chest 00:04:32.000 --> 00:04:34.639 wall surgery by temporarily freezing the nerve. 00:04:34.779 --> 00:04:37.480 We use a double lumen tube in all patients. A 00:04:37.480 --> 00:04:40.160 double lumen endotracheal tube deflates the lung 00:04:40.160 --> 00:04:42.540 on the side of the cryoablation and the surgeon 00:04:42.540 --> 00:04:45.160 uses a thoracoscope to guide the cryoprobe through 00:04:45.160 --> 00:04:48.769 axillary incisions. We go from T3 to T8. After 00:04:48.769 --> 00:04:51.870 cryo, we do intercostal nerve blocks with subplural 00:04:51.870 --> 00:04:53.970 injection. They start on the third rib with a 00:04:53.970 --> 00:04:56.029 two -minute free cycle and work their way down. 00:04:56.310 --> 00:04:58.509 After we do that, I do a subplural injection 00:04:58.509 --> 00:05:01.550 with a quarter percent marcaine with epinephrine. 00:05:01.649 --> 00:05:04.050 This works immediately as opposed to the eight 00:05:04.050 --> 00:05:06.449 to 10 hour delay with the cryo nerve block. It 00:05:06.449 --> 00:05:09.769 takes about 15 seconds per interspace. The double 00:05:09.769 --> 00:05:12.209 lumen endotracheal tube also helps reduce the 00:05:12.209 --> 00:05:14.750 risk of pneumothorax. I've gotten multiple calls 00:05:14.750 --> 00:05:17.430 from other surgeons that say sometimes my blocks 00:05:17.430 --> 00:05:20.730 don't work and invariably it's a surgeon using 00:05:20.730 --> 00:05:24.750 a single lumen tube doing the block too far anteriorly. 00:05:24.810 --> 00:05:27.750 In summary, cryoanalgesia is an effective tool 00:05:27.750 --> 00:05:29.810 for pediatric practice procedures controlling 00:05:29.810 --> 00:05:32.129 pain and decreasing hospital length stay with 00:05:32.129 --> 00:05:35.089 few short -term complications. Double lumen tubes 00:05:35.089 --> 00:05:37.529 enhance precision especially for targeting lateral 00:05:37.529 --> 00:05:40.470 cutaneous nerves. Let's take a look at number 00:05:40.470 --> 00:05:43.399 seven. Pediatric surgeons Dr. Stephen Lee and 00:05:43.399 --> 00:05:46.240 Rebecca Stark discussed the techniques from performing 00:05:46.240 --> 00:05:49.319 ECMO in severe congenital diaphragmatic hernia, 00:05:49.379 --> 00:05:52.959 or CDH, cases, as well as strategies for determining 00:05:52.959 --> 00:05:56.069 when and how to approach surgical repair. Information 00:05:56.069 --> 00:05:58.850 from this session classifies as a blue square 00:05:58.850 --> 00:06:02.089 for promising newer practice. So full -term neonate, 00:06:02.149 --> 00:06:04.509 known diagnosis of a left -sided very severe 00:06:04.509 --> 00:06:07.350 CDH you delivered about an hour ago, intubated 00:06:07.350 --> 00:06:09.709 and resuscitated per your institutional protocols. 00:06:09.970 --> 00:06:12.050 Preductal SATs are in the 70s, heart rate is 00:06:12.050 --> 00:06:16.529 150, blood pressure is 35 over 25, pH is 6 .8, 00:06:16.810 --> 00:06:21.829 PaCO2 is 130, and PaO2 is 28. What's your next 00:06:21.829 --> 00:06:24.370 move for this patient? Would you prefer vena 00:06:24.370 --> 00:06:28.930 arterial VA ECMO, vena venous VV ECMO, time to 00:06:28.930 --> 00:06:31.850 reassess, or opt for comfort care? There are 00:06:31.850 --> 00:06:33.829 lots of benefits to VV. There are lots of benefits 00:06:33.829 --> 00:06:36.769 to VA. The majority of centers, as I said, still 00:06:36.769 --> 00:06:40.569 do VA ECMO primarily for CDH babies. So both 00:06:40.569 --> 00:06:43.370 answers are totally reasonable. Sphere Protocol 00:06:43.370 --> 00:06:46.350 from Michigan used prenatal criteria to guide 00:06:46.350 --> 00:06:49.050 decisions on offering ECMO versus comfort care 00:06:49.050 --> 00:06:52.620 for severe unilateral CDH. and outcomes showed 00:06:52.620 --> 00:06:54.740 that survival was equivalent between groups, 00:06:54.899 --> 00:06:57.600 revealing we are often wrong about who will benefit 00:06:57.600 --> 00:07:00.939 from it. I do think that if you had good prenatal 00:07:00.939 --> 00:07:02.680 counseling with the parents, you should pursue 00:07:02.680 --> 00:07:06.379 ECMO for every unilateral, isolated CDH. Same 00:07:06.379 --> 00:07:09.399 case. Patient is on ECMO managed with bivaloridine. 00:07:09.560 --> 00:07:12.129 When do you proceed with surgical repair? There 00:07:12.129 --> 00:07:14.769 are many institutions that are lower volume where 00:07:14.769 --> 00:07:17.250 neonatologists are very involved with the care 00:07:17.250 --> 00:07:20.250 and switching to an early repair if you're only 00:07:20.250 --> 00:07:22.589 putting one or two children on ECMO per year 00:07:22.589 --> 00:07:26.370 for CDH is a challenge and you need a whole buy 00:07:26.370 --> 00:07:29.189 -in. If you use BiVal you don't have to wait 00:07:29.189 --> 00:07:31.509 for the circuit to kind of equilibrate. It's 00:07:31.509 --> 00:07:33.730 very fast. You can operate after eight hours 00:07:33.730 --> 00:07:35.769 of putting them on BiVal as long as your levels 00:07:35.769 --> 00:07:39.089 are stable which happens really soon and it's 00:07:39.089 --> 00:07:41.980 a much easier surgical repair. In summary, in 00:07:41.980 --> 00:07:45.199 cases of very severe isolated unilateral CDH, 00:07:45.300 --> 00:07:48.000 you should consider the patient a survivor until 00:07:48.000 --> 00:07:50.939 proven otherwise. Additionally, early repair 00:07:50.939 --> 00:07:53.740 while on ECMO is safe and can offer physiological 00:07:53.740 --> 00:07:57.000 benefits with the optimal window open between 00:07:57.000 --> 00:08:01.360 8 to 24 hours. Let's review number six with Dr. 00:08:01.480 --> 00:08:04.040 Carlos Kaluga discussing how he uses the CO2 00:08:04.040 --> 00:08:06.959 laser in surgical procedures. This topic falls 00:08:06.959 --> 00:08:09.829 into the black diamond unproven category. The 00:08:09.829 --> 00:08:12.290 laser emits infrared light and is highly absorbed 00:08:12.290 --> 00:08:14.970 by water and biological tissues. We're using 00:08:14.970 --> 00:08:19.269 it in the spectrum of 920 to 1400 which is really 00:08:19.269 --> 00:08:22.149 well absorbed by water. It's very effective for 00:08:22.149 --> 00:08:24.569 precise cutting and ablation and reduces blood 00:08:24.569 --> 00:08:28.990 loss. We have great reduced pain and edema and 00:08:28.990 --> 00:08:32.230 shorter operative time. They used it in 56 circumcision 00:08:32.230 --> 00:08:35.049 cases using the sleeve technique with a dorsal 00:08:35.049 --> 00:08:38.200 slit and cyanoacrylate adhesive. The complication 00:08:38.200 --> 00:08:41.440 rate was only 3%. We've used it for phrenolectomy, 00:08:41.519 --> 00:08:45.139 47 patients, low pain profile, no suture required. 00:08:45.480 --> 00:08:47.440 Other conditions that they've used the CO2 laser 00:08:47.440 --> 00:08:50.600 for include perianal fistulas, fistulotomy, and 00:08:50.600 --> 00:08:53.899 pilonidal cysts. We do laser ablation, and there's 00:08:53.899 --> 00:08:56.279 a sinus tract we also ablated. Lower labia fusion. 00:08:56.940 --> 00:09:00.639 And condylomatosis, great for ablation. In summary, 00:09:00.879 --> 00:09:03.740 CO2 laser is an evidence -based option with promising 00:09:03.740 --> 00:09:06.659 outcomes, less bleeding, reduced pain, and shorter 00:09:06.659 --> 00:09:09.299 operating time. Barriers include high equipment 00:09:09.299 --> 00:09:11.679 costs, required training, and limited availability. 00:09:12.279 --> 00:09:14.919 For number five, pediatric surgeons Dr. Justin 00:09:14.919 --> 00:09:17.600 Huntington and Ben Hamm will discuss the use 00:09:17.600 --> 00:09:20.740 of autofluorescence and ICG angiography for identifying 00:09:20.740 --> 00:09:23.340 parathyroid glands and assessing their perfusion. 00:09:23.519 --> 00:09:26.240 This session is classified as a black diamond. 00:09:26.649 --> 00:09:29.149 for early adoptive practices only. One of the 00:09:29.149 --> 00:09:31.590 things we think about in thyroid surgery is we 00:09:31.590 --> 00:09:34.210 want to preserve the parathyroids and decrease 00:09:34.210 --> 00:09:38.929 the risk of hypocalcemia and the need for calcium 00:09:38.929 --> 00:09:42.409 supplementation, both initially and over a long 00:09:42.409 --> 00:09:44.730 period of time. It's demonstrated in a randomized 00:09:44.730 --> 00:09:47.720 control trial from France. Autofluorescence has 00:09:47.720 --> 00:09:50.120 shown to reduce rates of hyperparathyroidism 00:09:50.120 --> 00:09:53.340 and hypocalcemia following thyroidectomy. You 00:09:53.340 --> 00:09:55.940 don't inject anything. It's just the parathyroids 00:09:55.940 --> 00:09:59.100 naturally autofluoresce at that wavelength. So 00:09:59.100 --> 00:10:01.919 it's using that technology. And then in addition, 00:10:02.019 --> 00:10:05.159 you can inject ICG to look at the perfusion of 00:10:05.159 --> 00:10:08.879 the actual parathyroid lands. There's a fluobeam 00:10:08.879 --> 00:10:12.080 system in addition to the probe system. And they 00:10:12.080 --> 00:10:15.419 noted hypocalcemia rates that were about half. 00:10:16.639 --> 00:10:19.440 with using it versus not using it. So this just 00:10:19.440 --> 00:10:21.700 shows an example where you can see the thyroid 00:10:21.700 --> 00:10:25.720 gland lifted and exposed. And then with the autofluorescence, 00:10:25.779 --> 00:10:29.879 you can see the bright areas signifying the superior 00:10:29.879 --> 00:10:32.980 and inferior parathyroids to help identify them 00:10:32.980 --> 00:10:35.580 early and then be able to separate them from 00:10:35.580 --> 00:10:38.600 the thyroid and work to preserve both them and 00:10:38.600 --> 00:10:42.159 their blood supply. And then this is adding ICG. 00:10:42.419 --> 00:10:46.460 We have the flu optics machine. And like the 00:10:46.460 --> 00:10:49.679 pictures that are sort of published in the studies, 00:10:49.759 --> 00:10:54.000 like I haven't found it as nice as those pictures, 00:10:54.259 --> 00:10:58.279 but I do think it's a helpful adjunct. In summary, 00:10:58.419 --> 00:11:01.539 autofluorescence and ICD angiography help identify 00:11:01.539 --> 00:11:04.519 parathyroid glands and assess perfusion, reducing 00:11:04.519 --> 00:11:07.059 the risk of hypocalcemia after thyroid surgery. 00:11:08.779 --> 00:11:11.700 In number four, doctors David Vitale, Luke Neff, 00:11:11.799 --> 00:11:14.840 and Jeff Ponsky explain the surgery -first mindset 00:11:14.840 --> 00:11:17.879 in pediatric biliary stone cases. This video 00:11:17.879 --> 00:11:20.700 is classified as a green circle for established 00:11:20.700 --> 00:11:23.320 practice. You have a 15 -year -old patient with 00:11:23.320 --> 00:11:25.700 colicky right upper quadrant pain for 24 hours. 00:11:25.940 --> 00:11:28.740 The ultrasound shows a dilated common bile duct 00:11:28.740 --> 00:11:31.779 and a stone is visualized. What's the next step? 00:11:32.000 --> 00:11:33.919 We've just recently published some work showing 00:11:33.919 --> 00:11:36.299 that a surgery -first pathway, or at least that 00:11:36.299 --> 00:11:38.820 mindset and embracing that concept, It really 00:11:38.820 --> 00:11:41.860 does reduce resource utilization, including MRCP. 00:11:42.179 --> 00:11:45.419 Before a gastroenterologist does an ERCP, often 00:11:45.419 --> 00:11:47.899 the patient has had an ultrasound and an MRCP. 00:11:48.340 --> 00:11:51.460 And we can utilize some of our predictive factors 00:11:51.460 --> 00:11:53.960 where we can go straight to doing a procedure 00:11:53.960 --> 00:11:56.659 if we need to, whether that be a combined procedure 00:11:56.659 --> 00:11:59.460 with a laparoscopic cholecystectomy and IOC and 00:11:59.460 --> 00:12:01.779 potentially call me into the room if an ERCP 00:12:01.779 --> 00:12:04.700 is needed. We know that as good as you are at 00:12:04.700 --> 00:12:07.899 ERCP, you're going to get pancreatitis 10 % of 00:12:07.899 --> 00:12:10.639 the time. And if that kid gets pancreatitis and 00:12:10.639 --> 00:12:12.799 you could have gone straight to surgery, that 00:12:12.799 --> 00:12:15.600 was a mistake. In this paper published in the 00:12:15.600 --> 00:12:17.720 Journal of Pediatric Surgery, they demonstrated 00:12:17.720 --> 00:12:20.600 that with a surgery -first mindset, the stone 00:12:20.600 --> 00:12:23.139 clearance rate reflected by a negative intraoperative 00:12:23.139 --> 00:12:26.659 cholangiogram was 86%. If you just did flushing, 00:12:26.740 --> 00:12:28.759 if you just got that catheter a little bit more, 00:12:28.820 --> 00:12:30.639 just peek it in the common bile duct or maybe 00:12:30.639 --> 00:12:33.399 ream the sphincter, that success rate was in 00:12:33.399 --> 00:12:37.039 the 90s. So it doesn't take much. In summary, 00:12:37.220 --> 00:12:40.259 a surgery -first approach for pediatric choledogolithiasis 00:12:40.259 --> 00:12:42.860 can be highly effective with stone clearance 00:12:42.860 --> 00:12:46.100 rates as high as 86 % and a reduced need for 00:12:46.100 --> 00:12:49.659 preoperative imaging like MRCP. On number three, 00:12:49.720 --> 00:12:52.279 we'll hear from pediatric surgeon Dr. Greg Thiao 00:12:52.279 --> 00:12:56.200 on the use of MMP7 as a diagnostic tool in biliary 00:12:56.200 --> 00:12:59.179 atresia. Information from this session classifies 00:12:59.179 --> 00:13:01.919 as a blue square for promising newer practice. 00:13:02.700 --> 00:13:05.620 The key to treating biliary atresia is making 00:13:05.620 --> 00:13:08.860 an early diagnosis. This is where this biomarker 00:13:08.860 --> 00:13:10.519 that really came out of Georgia Bezzera's lab, 00:13:10.580 --> 00:13:13.899 my research mentor. He identified MMP7 about 00:13:13.899 --> 00:13:17.419 10 years ago as a diagnostic biomarker for biliary 00:13:17.419 --> 00:13:20.360 atresia. This all ties to this critical concept 00:13:20.360 --> 00:13:22.779 that I think we all know, but we don't necessarily 00:13:22.779 --> 00:13:25.139 integrate, which is you've got to get your casais 00:13:25.139 --> 00:13:27.639 done as soon as possible. The sooner and sooner 00:13:27.639 --> 00:13:29.960 you get it done, the more likely you'll save 00:13:29.960 --> 00:13:32.740 the native liver. The key is to distinguish BA 00:13:32.740 --> 00:13:36.759 from other non -physiologic, cholestatic, jaundiced 00:13:36.759 --> 00:13:39.240 conditions so that we can get our casais done 00:13:39.240 --> 00:13:42.419 at an earlier stage. Data from a recent Midwest 00:13:42.419 --> 00:13:45.460 study shows that every 10 -day delay in treatment, 00:13:45.659 --> 00:13:49.519 outcomes worsen by 20%. It's one of those cases 00:13:49.519 --> 00:13:52.360 where the earlier we can intervene, the better 00:13:52.360 --> 00:13:55.769 the outcome. This urgency helped drive the research 00:13:55.769 --> 00:14:00.169 that led to the MMP study. So MMP7 is now evaluated 00:14:00.169 --> 00:14:03.429 by a marker for biliary atresia. It's not perfect. 00:14:03.549 --> 00:14:05.350 Actually, if you just look on the table here, 00:14:05.429 --> 00:14:08.009 the sensitivity is pretty good, but the cutoffs 00:14:08.009 --> 00:14:10.799 that the different teams used... vary because 00:14:10.799 --> 00:14:13.220 it's an assay that's still evolving in front 00:14:13.220 --> 00:14:15.340 of our eyes and depending on how you do it. But 00:14:15.340 --> 00:14:17.860 this all translates to the next question here, 00:14:17.980 --> 00:14:20.019 which is when are you going to do your CASAI 00:14:20.019 --> 00:14:22.679 procedure? Our commitment to the patients who 00:14:22.679 --> 00:14:25.000 come to our institution is within seven days 00:14:25.000 --> 00:14:27.179 of them showing up, if they have it, they're 00:14:27.179 --> 00:14:30.720 in the OR. In summary, timely diagnosis of biliary 00:14:30.720 --> 00:14:34.080 atresia is vital for native liver survival, as 00:14:34.080 --> 00:14:35.919 early intervention through the CASAI procedure 00:14:35.919 --> 00:14:39.799 greatly improves outcomes. MMP7 has been validated 00:14:39.799 --> 00:14:43.100 as a biomarker to aid in earlier diagnosis, though 00:14:43.100 --> 00:14:46.139 its assay continues to evolve. We're so close 00:14:46.139 --> 00:14:49.360 to number one. Let's check out number two. Pediatric 00:14:49.360 --> 00:14:51.659 surgeon Dr. Regan -Williams is here to discuss 00:14:51.659 --> 00:14:54.179 when to perform REBOA in pediatric patients. 00:14:54.799 --> 00:14:57.460 This topic falls into two categories, both black 00:14:57.460 --> 00:15:00.279 diamond and blue square, both unproven and newer 00:15:00.279 --> 00:15:02.480 practices. A 16 -year -old shoots herself in 00:15:02.480 --> 00:15:04.419 the abdomen while cleaning her rifle. She is 00:15:04.419 --> 00:15:07.000 hypotensive and near cardiac arrest despite massive 00:15:07.000 --> 00:15:10.340 transfusion. REBOA, resuscitative endovascular 00:15:10.340 --> 00:15:13.159 balloon aortic occlusion, can be used in children. 00:15:13.340 --> 00:15:16.100 We don't do a lot of this in a pediatric hospital, 00:15:16.320 --> 00:15:19.000 but you can do it if you have that at your center 00:15:19.000 --> 00:15:21.419 and you're good at it. REBOA is a procedure to 00:15:21.419 --> 00:15:23.500 control bleeding and traumatic shock or cardiac 00:15:23.500 --> 00:15:26.600 arrest. a catheter is inserted through the femoral 00:15:26.600 --> 00:15:29.620 artery into the aorta then a balloon is inflated 00:15:29.620 --> 00:15:32.259 to stop blood flow which buys time for surgical 00:15:32.259 --> 00:15:34.940 intervention so this would be the patient to 00:15:34.940 --> 00:15:36.980 do it if you could not get them to the operating 00:15:36.980 --> 00:15:39.039 room to actually control the source of bleeding 00:15:39.039 --> 00:15:42.620 reboa is often compared to resuscitative thoracotomy 00:15:42.620 --> 00:15:44.940 which opens the chest surgically to control the 00:15:44.940 --> 00:15:47.379 source of bleeding since both techniques occlude 00:15:47.379 --> 00:15:50.470 the aorta It seems to me Raboa take longer than 00:15:50.470 --> 00:15:52.590 opening the abdomen or the chest if you're just 00:15:52.590 --> 00:15:54.649 needing to cross -clamp the aorta. In summary, 00:15:54.909 --> 00:15:57.330 Raboa can be performed in pediatric patients 00:15:57.330 --> 00:16:00.029 but is rarely done with no clear survival advantage 00:16:00.029 --> 00:16:03.509 over laparotomy. Most surgeons favor laparotomy 00:16:03.509 --> 00:16:06.110 over Raboa for quickly treating shock in a controlled 00:16:06.110 --> 00:16:08.629 environment. Here's what we have been waiting 00:16:08.629 --> 00:16:12.509 for, our number one key takeaway. Pediatric surgeon 00:16:12.509 --> 00:16:15.090 Dr. Nelson Rosen is explaining the importance 00:16:15.090 --> 00:16:17.649 of patient education and non -surgical management 00:16:17.649 --> 00:16:20.970 of pilonidal disease. This one classified as 00:16:20.970 --> 00:16:23.850 a green circle for established practice. One 00:16:23.850 --> 00:16:25.750 thing that I can tell you that from our looking 00:16:25.750 --> 00:16:29.009 at our own data is that patients presenting with 00:16:29.009 --> 00:16:32.789 wounds as their initial presentation for pilonidal 00:16:32.789 --> 00:16:37.450 tend to not always get to the finish line fully 00:16:37.450 --> 00:16:40.620 healed with a minimally invasive approach. Joan 00:16:40.620 --> 00:16:43.340 Armstrong, while serving in the U .S. Army, ran 00:16:43.340 --> 00:16:46.179 a clinic with a captive patient population. They 00:16:46.179 --> 00:16:48.460 implemented a protocol where patients were shaved 00:16:48.460 --> 00:16:51.139 weekly, and they observed a dramatic improvement, 00:16:51.500 --> 00:16:54.120 significantly reducing the need for surgical 00:16:54.120 --> 00:16:57.740 intervention. Think if you're not pushing. hair 00:16:57.740 --> 00:17:00.740 removal and meticulous hygiene to do the best 00:17:00.740 --> 00:17:03.240 that you can, you're probably going to end up 00:17:03.240 --> 00:17:05.319 operating on some people that might not need 00:17:05.319 --> 00:17:07.559 an operation. But again, you have to talk to 00:17:07.559 --> 00:17:09.539 your patient. So what are the best techniques 00:17:09.539 --> 00:17:13.220 for hair removal and hygiene? Shaving? Diplomatic 00:17:13.220 --> 00:17:16.480 hair removal agents like Nair? Or laser hair 00:17:16.480 --> 00:17:19.380 removal? A lot of our patients are teenagers 00:17:19.380 --> 00:17:22.339 or people going to college and sometimes they 00:17:22.339 --> 00:17:24.480 don't have anybody to help with them. If there's 00:17:24.480 --> 00:17:27.160 a parent or an active caregiver involved, We 00:17:27.160 --> 00:17:29.799 believe that clipping is probably the easiest 00:17:29.799 --> 00:17:32.559 and simplest approach, and having someone do 00:17:32.559 --> 00:17:35.039 it once a week is recommended. In conclusion, 00:17:35.440 --> 00:17:38.339 pyranidal disease severity varies, and treatment 00:17:38.339 --> 00:17:40.519 options should be tailored to individual case. 00:17:41.019 --> 00:17:43.220 Non -surgical measures like regular shaving, 00:17:43.480 --> 00:17:46.339 hygiene, and even waxing can lead to significant 00:17:46.339 --> 00:17:48.859 improvement and should be considered before moving 00:17:48.859 --> 00:17:52.000 to surgery, especially in cases of mild to moderate 00:17:52.000 --> 00:17:58.140 severity. along with Cincinnati Children's Hospital, 00:17:58.380 --> 00:18:00.539 sharing knowledge to improve child health around 00:18:00.539 --> 00:18:01.000 the globe.