Global Cast MD, along with Cincinnati Children's
Hospital, sharing knowledge to improve child
health around the globe. Hi, everyone. In August
2024, we held our 12th annual update course in
pediatric surgery. And in this video, we are
bringing you the top 10 key takeaways. Let's
start with number 10, collaboration of surgery
and interventional radiology in the OR. This
topic falls into the blue category as a newer
approach. Doctors Dan von Allman, John Racadio,
Timothy Louts, and interventional radiology technologist
Amanda Wallingford showed us different use cases
of image -guided surgery which uses real -time
imaging like CT, MRI, ultrasound. or fluoroscopy
to improve precision during procedures. This
session is really about combining the expertise
of surgeons with the expertise of our interventional
radiologists. There's cross training at Cincinnati
Children's. For example, interventional radiologists
teaching pediatric surgery fellows how to use
ultrasound guidance for vascular access. So it's
important to understand that you don't have to
have hybrid OR to be able to do this type of
collaboration. It can occur in your regular OR
by bringing in an ultrasound machine. A hybrid
operating room eliminates the need to transfer
patients between imaging and surgical areas.
It combines advanced imaging technology with
a traditional surgical setup. One key component
of a hybrid OR is the cone beam CT. So it's a
CT scan that's performed on a C -arm fluoroscopy
unit. Basically, it's positioned over the patient's
point of interest, and it rotates around the
patient, collecting multiple images, which are
then stacked together to create a CT. You can
also use it for identifying and protecting critical
structures during surgery. And then you can use
it at the end of the case to confirm vessel patency.
In conclusion, collaboration between surgeons
and interventional radiologists enhances patient
care by integrating ultrasound and cone beam
CT. Innovative image -guided techniques such
as lymph node localization and pulmonary nodule
marking further simplify complex surgeries. At
number nine, we hear from Drs. Rami Shaban and
Carlos Colunga. as they break down the top AI
tools of 2024. Information from this session
classifies as a blue square for promising newer
practice. We are researching how ChatGPT can
help us in the research process and I personally
use ChatGPT in systematic review and meta -analysis
and when you do systematic review you screen
thousands of articles. This process is intimidating.
We prompted ChatGPT with the following. I'm conducting
a systematic review on this specific topic. I
need you to act as a data analyst. Please analyze
the TASH Excel sheet and screen the included
articles based on title and abstract. Because
we don't trust ChatGVT a lot, I ask ChatGVT also
to add a column to explain why they decided that
decision. So you have a better understanding
about this data and we get an excellent result
with that. Let's review our next tool, Jenny
AI. Use AI to supercharge your research paper.
Genie AI, one of different academic models that
has been with research papers, and you literally
put your prompt. And the first thing that you'll
get is a suggestion. You can start writing this.
You, because you're the surgeon that has the
hand on the wheel, can say, yeah, I like it.
I want to modify it. You can also chat directly
with its built -in chatbot and say something
like, I want to research this topic. It will
provide relevant answers, cite supporting papers,
and even help format those citations according
to your preferred style. If you want to have
a personal trainer, we use also ChatGPT. Upload
a guideline to ChatGPT and then ask ChatGPT to
create a training session out of a guideline.
And then it creates a series of interactive questions
where you can interact with ChatGPT and get trained
on a specific thing. And Dr. Kolonga summarizes
in the best way. We have to have these talks.
We have to learn how to use it because it's here
to stay. We can't close our eyes and don't admit
that everyone's using it to increase their efficiency
and improve the way they manage their day -to
-day lives. In number eight, pediatric surgeon
Dr. John DeFiori discusses how he uses cryoanalgesia
in pectus. This topic falls into the blue category
as a newer approach. Cryoanalgesia is a minimally
invasive procedure to alleviate pain during chest
wall surgery by temporarily freezing the nerve.
We use a double lumen tube in all patients. A
double lumen endotracheal tube deflates the lung
on the side of the cryoablation and the surgeon
uses a thoracoscope to guide the cryoprobe through
axillary incisions. We go from T3 to T8. After
cryo, we do intercostal nerve blocks with subplural
injection. They start on the third rib with a
two -minute free cycle and work their way down.
After we do that, I do a subplural injection
with a quarter percent marcaine with epinephrine.
This works immediately as opposed to the eight
to 10 hour delay with the cryo nerve block. It
takes about 15 seconds per interspace. The double
lumen endotracheal tube also helps reduce the
risk of pneumothorax. I've gotten multiple calls
from other surgeons that say sometimes my blocks
don't work and invariably it's a surgeon using
a single lumen tube doing the block too far anteriorly.
In summary, cryoanalgesia is an effective tool
for pediatric practice procedures controlling
pain and decreasing hospital length stay with
few short -term complications. Double lumen tubes
enhance precision especially for targeting lateral
cutaneous nerves. Let's take a look at number
seven. Pediatric surgeons Dr. Stephen Lee and
Rebecca Stark discussed the techniques from performing
ECMO in severe congenital diaphragmatic hernia,
or CDH, cases, as well as strategies for determining
when and how to approach surgical repair. Information
from this session classifies as a blue square
for promising newer practice. So full -term neonate,
known diagnosis of a left -sided very severe
CDH you delivered about an hour ago, intubated
and resuscitated per your institutional protocols.
Preductal SATs are in the 70s, heart rate is
150, blood pressure is 35 over 25, pH is 6 .8,
PaCO2 is 130, and PaO2 is 28. What's your next
move for this patient? Would you prefer vena
arterial VA ECMO, vena venous VV ECMO, time to
reassess, or opt for comfort care? There are
lots of benefits to VV. There are lots of benefits
to VA. The majority of centers, as I said, still
do VA ECMO primarily for CDH babies. So both
answers are totally reasonable. Sphere Protocol
from Michigan used prenatal criteria to guide
decisions on offering ECMO versus comfort care
for severe unilateral CDH. and outcomes showed
that survival was equivalent between groups,
revealing we are often wrong about who will benefit
from it. I do think that if you had good prenatal
counseling with the parents, you should pursue
ECMO for every unilateral, isolated CDH. Same
case. Patient is on ECMO managed with bivaloridine.
When do you proceed with surgical repair? There
are many institutions that are lower volume where
neonatologists are very involved with the care
and switching to an early repair if you're only
putting one or two children on ECMO per year
for CDH is a challenge and you need a whole buy
-in. If you use BiVal you don't have to wait
for the circuit to kind of equilibrate. It's
very fast. You can operate after eight hours
of putting them on BiVal as long as your levels
are stable which happens really soon and it's
a much easier surgical repair. In summary, in
cases of very severe isolated unilateral CDH,
you should consider the patient a survivor until
proven otherwise. Additionally, early repair
while on ECMO is safe and can offer physiological
benefits with the optimal window open between
8 to 24 hours. Let's review number six with Dr.
Carlos Kaluga discussing how he uses the CO2
laser in surgical procedures. This topic falls
into the black diamond unproven category. The
laser emits infrared light and is highly absorbed
by water and biological tissues. We're using
it in the spectrum of 920 to 1400 which is really
well absorbed by water. It's very effective for
precise cutting and ablation and reduces blood
loss. We have great reduced pain and edema and
shorter operative time. They used it in 56 circumcision
cases using the sleeve technique with a dorsal
slit and cyanoacrylate adhesive. The complication
rate was only 3%. We've used it for phrenolectomy,
47 patients, low pain profile, no suture required.
Other conditions that they've used the CO2 laser
for include perianal fistulas, fistulotomy, and
pilonidal cysts. We do laser ablation, and there's
a sinus tract we also ablated. Lower labia fusion.
And condylomatosis, great for ablation. In summary,
CO2 laser is an evidence -based option with promising
outcomes, less bleeding, reduced pain, and shorter
operating time. Barriers include high equipment
costs, required training, and limited availability.
For number five, pediatric surgeons Dr. Justin
Huntington and Ben Hamm will discuss the use
of autofluorescence and ICG angiography for identifying
parathyroid glands and assessing their perfusion.
This session is classified as a black diamond.
for early adoptive practices only. One of the
things we think about in thyroid surgery is we
want to preserve the parathyroids and decrease
the risk of hypocalcemia and the need for calcium
supplementation, both initially and over a long
period of time. It's demonstrated in a randomized
control trial from France. Autofluorescence has
shown to reduce rates of hyperparathyroidism
and hypocalcemia following thyroidectomy. You
don't inject anything. It's just the parathyroids
naturally autofluoresce at that wavelength. So
it's using that technology. And then in addition,
you can inject ICG to look at the perfusion of
the actual parathyroid lands. There's a fluobeam
system in addition to the probe system. And they
noted hypocalcemia rates that were about half.
with using it versus not using it. So this just
shows an example where you can see the thyroid
gland lifted and exposed. And then with the autofluorescence,
you can see the bright areas signifying the superior
and inferior parathyroids to help identify them
early and then be able to separate them from
the thyroid and work to preserve both them and
their blood supply. And then this is adding ICG.
We have the flu optics machine. And like the
pictures that are sort of published in the studies,
like I haven't found it as nice as those pictures,
but I do think it's a helpful adjunct. In summary,
autofluorescence and ICD angiography help identify
parathyroid glands and assess perfusion, reducing
the risk of hypocalcemia after thyroid surgery.
In number four, doctors David Vitale, Luke Neff,
and Jeff Ponsky explain the surgery -first mindset
in pediatric biliary stone cases. This video
is classified as a green circle for established
practice. You have a 15 -year -old patient with
colicky right upper quadrant pain for 24 hours.
The ultrasound shows a dilated common bile duct
and a stone is visualized. What's the next step?
We've just recently published some work showing
that a surgery -first pathway, or at least that
mindset and embracing that concept, It really
does reduce resource utilization, including MRCP.
Before a gastroenterologist does an ERCP, often
the patient has had an ultrasound and an MRCP.
And we can utilize some of our predictive factors
where we can go straight to doing a procedure
if we need to, whether that be a combined procedure
with a laparoscopic cholecystectomy and IOC and
potentially call me into the room if an ERCP
is needed. We know that as good as you are at
ERCP, you're going to get pancreatitis 10 % of
the time. And if that kid gets pancreatitis and
you could have gone straight to surgery, that
was a mistake. In this paper published in the
Journal of Pediatric Surgery, they demonstrated
that with a surgery -first mindset, the stone
clearance rate reflected by a negative intraoperative
cholangiogram was 86%. If you just did flushing,
if you just got that catheter a little bit more,
just peek it in the common bile duct or maybe
ream the sphincter, that success rate was in
the 90s. So it doesn't take much. In summary,
a surgery -first approach for pediatric choledogolithiasis
can be highly effective with stone clearance
rates as high as 86 % and a reduced need for
preoperative imaging like MRCP. On number three,
we'll hear from pediatric surgeon Dr. Greg Thiao
on the use of MMP7 as a diagnostic tool in biliary
atresia. Information from this session classifies
as a blue square for promising newer practice.
The key to treating biliary atresia is making
an early diagnosis. This is where this biomarker
that really came out of Georgia Bezzera's lab,
my research mentor. He identified MMP7 about
10 years ago as a diagnostic biomarker for biliary
atresia. This all ties to this critical concept
that I think we all know, but we don't necessarily
integrate, which is you've got to get your casais
done as soon as possible. The sooner and sooner
you get it done, the more likely you'll save
the native liver. The key is to distinguish BA
from other non -physiologic, cholestatic, jaundiced
conditions so that we can get our casais done
at an earlier stage. Data from a recent Midwest
study shows that every 10 -day delay in treatment,
outcomes worsen by 20%. It's one of those cases
where the earlier we can intervene, the better
the outcome. This urgency helped drive the research
that led to the MMP study. So MMP7 is now evaluated
by a marker for biliary atresia. It's not perfect.
Actually, if you just look on the table here,
the sensitivity is pretty good, but the cutoffs
that the different teams used... vary because
it's an assay that's still evolving in front
of our eyes and depending on how you do it. But
this all translates to the next question here,
which is when are you going to do your CASAI
procedure? Our commitment to the patients who
come to our institution is within seven days
of them showing up, if they have it, they're
in the OR. In summary, timely diagnosis of biliary
atresia is vital for native liver survival, as
early intervention through the CASAI procedure
greatly improves outcomes. MMP7 has been validated
as a biomarker to aid in earlier diagnosis, though
its assay continues to evolve. We're so close
to number one. Let's check out number two. Pediatric
surgeon Dr. Regan -Williams is here to discuss
when to perform REBOA in pediatric patients.
This topic falls into two categories, both black
diamond and blue square, both unproven and newer
practices. A 16 -year -old shoots herself in
the abdomen while cleaning her rifle. She is
hypotensive and near cardiac arrest despite massive
transfusion. REBOA, resuscitative endovascular
balloon aortic occlusion, can be used in children.
We don't do a lot of this in a pediatric hospital,
but you can do it if you have that at your center
and you're good at it. REBOA is a procedure to
control bleeding and traumatic shock or cardiac
arrest. a catheter is inserted through the femoral
artery into the aorta then a balloon is inflated
to stop blood flow which buys time for surgical
intervention so this would be the patient to
do it if you could not get them to the operating
room to actually control the source of bleeding
reboa is often compared to resuscitative thoracotomy
which opens the chest surgically to control the
source of bleeding since both techniques occlude
the aorta It seems to me Raboa take longer than
opening the abdomen or the chest if you're just
needing to cross -clamp the aorta. In summary,
Raboa can be performed in pediatric patients
but is rarely done with no clear survival advantage
over laparotomy. Most surgeons favor laparotomy
over Raboa for quickly treating shock in a controlled
environment. Here's what we have been waiting
for, our number one key takeaway. Pediatric surgeon
Dr. Nelson Rosen is explaining the importance
of patient education and non -surgical management
of pilonidal disease. This one classified as
a green circle for established practice. One
thing that I can tell you that from our looking
at our own data is that patients presenting with
wounds as their initial presentation for pilonidal
tend to not always get to the finish line fully
healed with a minimally invasive approach. Joan
Armstrong, while serving in the U .S. Army, ran
a clinic with a captive patient population. They
implemented a protocol where patients were shaved
weekly, and they observed a dramatic improvement,
significantly reducing the need for surgical
intervention. Think if you're not pushing. hair
removal and meticulous hygiene to do the best
that you can, you're probably going to end up
operating on some people that might not need
an operation. But again, you have to talk to
your patient. So what are the best techniques
for hair removal and hygiene? Shaving? Diplomatic
hair removal agents like Nair? Or laser hair
removal? A lot of our patients are teenagers
or people going to college and sometimes they
don't have anybody to help with them. If there's
a parent or an active caregiver involved, We
believe that clipping is probably the easiest
and simplest approach, and having someone do
it once a week is recommended. In conclusion,
pyranidal disease severity varies, and treatment
options should be tailored to individual case.
Non -surgical measures like regular shaving,
hygiene, and even waxing can lead to significant
improvement and should be considered before moving
to surgery, especially in cases of mild to moderate
severity. along with Cincinnati Children's Hospital,
sharing knowledge to improve child health around
the globe.