Shawn St. Peter

Shawn's statements about Appendicitis 7 statements

Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos

Statement One participating hospital in the appendicitis antibiotic trial did not see a difference in abscess rates between the two antibiotic regimens in their cohort, while the overall study results were driven entirely by Phoenix Children's Hospital's experience. Open

Quotation I would be remiss not to mention that we were one of the two hospitals that were in this trial and we did not see a difference in abscess rate in our cohort. So the overall group was swayed entirely by Phoenix's experience. Open

Statement NSQIP-P national data shows no difference in abscess rates between ceftriaxone-metronidazole and piperacillin-tazobactam across much larger patient numbers. Open

Quotation I don't think it's binary, so I don't think it's going to be something that we're going to be able to answer as a yes or no. Open

Statement In the NEC trial, there was significant surgeon intention to treat, with most patients who received initial peritoneal drainage going to laparotomy shortly after drain placement. Open

Quotation Most of these patients went to laparotomy shortly after drain placement, so that also kind of convolutes it. Open

Statement Peritoneal drainage for NEC often serves as a temporizing measure to stabilize septic patients before laparotomy rather than as definitive therapy. Open

Shawn's statements about Colorectal / ARM & Hirschsprung 6 statements

Open the Colorectal / ARM & Hirschsprung collection →

Update Course Rewind: 2020 Colorectal Part 2

Quotation I've got a low threshold for starting with sclerotherapy because it's, it's simple, it's innocuous, and then sometimes they just need that head start, particularly in that last case with a younger kid. They just need that window of a couple of months to not have a prolapse, and then they start seeing it less frequently. Open

Statement Sclerotherapy has a low threshold for use because it is simple, innocuous, and can provide a window of a couple months without prolapse that allows younger children to see less frequent episodes. Open

Quotation I've got a low threshold for starting with sclerotherapy because it's, it's simple, it's innocuous, and then sometimes they just need that head start, particularly in that last case with a younger kid. They just need that window of a couple of months to not have a prolapse, and then they start seeing it less frequently. Open

Statement Sclerotherapy has a low threshold for use because it is simple, innocuous, and can provide a window of a couple months without prolapse that allows younger children to see less frequent episodes. Open

Statement Dr. Sean St. Peter's sclerotherapy technique uses 5 ccs of Sotradechol injected in 4 quadrants with any remaining volume injected in between. Open

Shawn's statements about Empyema 64 statements

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Empyema with Dr. Shawn St. Peter

Statement Greater than 10,000 white blood cells in pleural fluid tap was used as the empyema definition and enrollment criterion for the randomized trial, and patients meeting this criterion who were randomized to VATS had findings consistent with typical empyema on thoracoscopy. Open

Statement Patients with fibrinolysis never got sicker during treatment, whereas patients undergoing VATS sometimes fly pretty close to the treetop after the operation due to barotrauma to the good lung and manipulation of the bad lung. Open

Quotation it really struck me that none of those kids got sicker. I didn't even have the data yet, but what I did know is that sometimes you do a vat and with the barrel trauma to the to the good lung and beating up the bad lung, they fly pretty close to the treetop sometimes after the operation, but nobody gets sicker with the fibrinolysis. Open

Statement Chest tube alone for empyema is not adequate treatment. Open

Statement Historical antibiotic practice at Children's Mercy showed an average of 25 days total antibiotics with 19 days after becoming afebrile, and 40% of patients had complications from antibiotic therapy ranging from diarrhea to fungal superinfections. Open

Statement Once empyema is treated, the chance of having another empyema is next to none because it is typically a cemented space, resulting in a zero historical event rate for recurrence. Open

Statement The current antibiotic protocol is 7 days after meeting all three criteria: completed fibrinolysis, off oxygen, and afebrile. Open

Statement Ultrasound has no disadvantage compared to CT for diagnosing empyema and identifying pleural stranding, and prospective studies show that placing ultrasound before CT decreases CT utilization without changing outcomes. Open

Statement The fibrinolysis protocol uses 4 mg of TPA mixed into 40 mL of normal saline, instilled into the chest tube with a one-hour dwell time, administered at time of diagnosis, 24 hours, and 48 hours (three doses over 48 hours). Open

Statement The randomized trial comparing primary VATS to primary fibrinolysis showed no difference in length of stay between the two groups. Open

Statement The failure rate for fibrinolysis in the Kansas City randomized trial was 1 in 6 (approximately 16%). Open

Statement When you are not getting an advantage from an operation compared to not doing an operation, and the results are equal, there is no way to recommend the operation. Open

Quotation You say, Well, we can take you to the operating room and do this, or we cannot, and the results are the same. Everyone's going to say, let's do the knot. Open

Statement In 100 consecutive patients treated with fibrinolysis after the randomized trial, the results remained consistent with a 15% failure rate and similar length of stay. Open

Statement There was no difference in operative time or blood loss in patients who underwent VATS after failed fibrinolysis compared to those who had primary VATS. Open

Statement Performing limited debridement with VATS when general anesthesia is required nullifies some advantages of fibrinolysis because mechanical debridement kicks up the serum response and positive pressure ventilation affects the other lung. Open

Statement When sedation is required for chest tube placement, it can be done in the operating room without intubation or positive pressure ventilation using a needle-guided 12-French chest tube, which is less involved than placing a PICC line. Open

Statement For older children, chest tube placement can be done with local anesthetic injection alone without sedation, as it can be completed in less than a minute. Open

Statement Chest X-rays after completing fibrinolysis are not terribly useful because they will look pretty bad for quite a while and are not helpful in discerning whether a patient is a candidate for VATS after failed fibrinolysis. Open

Statement A second round of fibrinolysis is indicated only when there is a temporal and regional explanation for failure, such as a walled-off collection not in continuity with the initial chest tube location. Open

Statement Failure of fibrinolysis should be defined by persistent clinical illness (requiring oxygen or not eating well) rather than fever alone, typically assessed at 3-4 days after completing treatment. Open

Statement Patients with extensive pulmonary necrosis should not undergo operative intervention because you risk hurting them much more than helping by manipulating the lung. Open

Statement Protracted courses with bronchopleural fistulas and Heimlich valves for months only occur when operating in a field of necrosis and debriding that necrosis, getting into the proximal lung rather than peripheral lesions which heal. Open

Statement During VATS for empyema, if the lung looks necrotic, the principle is to leave the lung alone and clean out the pleural space only. Open

Statement A patient with complete pulmonary necrosis who underwent needle biopsy died by exsanguinating out of the wound and into the bronchi, demonstrating that necrotic lung does not tolerate being touched. Open

Statement A 3-year-old patient with bilateral pulmonary necrosis stayed on VV ECMO for almost a month with CT showing hardly any viable lung on either side, did not undergo surgery, came off ECMO and did fine, and would not have survived if anyone had tried to operate. Open

Quotation I'm convinced that she would have not survived if anybody would have tried to operate on that lung in either side Open

Statement Multifocal abscesses and complex abscesses can be treated like necrosis by being patient, and even fields of abscesses in patients with underlying disease will typically heal up. Open

Statement A well-defined peripheral pulmonary abscess can be drained if it is well out into the lung parenchyma with a thick rind, ensuring you are getting into abscess and not airway. Open

Statement Necrotic lung heals remarkably well without surgical intervention, as demonstrated by a patient with no viable lung on either side after two weeks of ECMO who left the hospital without oxygen. Open

Statement Available fibrinolytic agents worldwide are urokinase or TPA, and since urokinase is not available in the US after streptokinase came off the market, TPA is the only option in the United States. Open

Empyema with Dr. Shawn St. Peter

Statement Mary Anne Jackson, an infectious disease physician, recommended the >10,000 white cell entry criterion for the trial, which initially seemed too soft but proved completely correct. Open

Statement Empyema is defined by pleural fluid with greater than 10,000 white blood cells, which was the enrollment criterion used in the randomized trial. Open

Statement When pleural fluid has >10,000 white cells and the patient undergoes VATS, the pleural space appearance is consistent with typical empyema. Open

Statement The randomized trial at Children's Mercy compared primary VATS to primary fibrinolysis and found no difference in length of stay, with a 16% failure rate in the fibrinolysis group. Open

Statement Patients do not get sicker with fibrinolysis, unlike VATS where barrel trauma to the good lung and manipulation of the bad lung can cause patients to 'fly pretty close to the treetop' postoperatively. Open

Quotation none of those kids got sicker Open

Statement At Children's Mercy, the average duration of antibiotics was 25 days total with 19 days after becoming afebrile, and 40% of patients had complications from antibiotic therapy including diarrhea and fungal superinfections. Open

Statement Recurrent empyema after successful treatment is extremely rare because the pleural space is typically obliterated (cemented space), making randomized trials of antibiotic duration unfeasible due to zero event rate. Open

Statement The current antibiotic protocol at Children's Mercy is 7 days after meeting three criteria: completed fibrinolysis, off oxygen, and afebrile. Antibiotics can be switched to oral if the patient is a candidate. Open

Statement Ultrasound has no disadvantage compared to CT for diagnosing empyema and identifying pleural stranding, and prospective studies show that placing ultrasound before CT decreases CT utilization without changing outcomes. Open

Statement The TPA protocol is 4mg mixed in 40mL normal saline, instilled into a 12 French chest tube with 1-hour dwell time, repeated at 24 and 48 hours (three doses total over 48 hours). Open

Statement Great Ormond Street published a study of 60 patients using urokinase with 4-hour dwell time that found identical results: no difference in length of stay and a 1 in 6 (approximately 16%) failure rate. Open

Statement When comparing an operation to a non-operative approach, if results are equal, there is no way to recommend the operation and no parent would choose surgery when outcomes are the same. Open

Quotation if you're getting equal results without requiring an operation, then there's no way you can recommend the operation Open

Statement A Spanish randomized trial of 100 patients using urokinase found no difference in length of stay and a 15% failure rate, consistent with prior studies. Open

Statement Three randomized trials totaling 200 patients all show the same results: no difference in length of stay between VATS and fibrinolysis, with 15-16% failure rate for fibrinolysis. Open

Statement In 100 consecutive patients treated with fibrinolysis after the trial, there was no difference in operative time or blood loss for patients who required subsequent VATS compared to primary VATS, contradicting concerns that fibrinolysis makes subsequent surgery more difficult. Open

Statement Placing a 12 French chest tube under ultrasound guidance is less invasive and faster than placing a PICC line, taking less than a minute. Open

Statement In older children who are not severely tachypneic, chest tube placement can be performed with local anesthetic alone without sedation. Open

Statement Daily chest X-rays after fibrinolysis are not useful because the chest will look bad for quite a while even after completing treatment, and X-ray appearance does not help determine if fibrinolysis has failed. Open

Statement Failure of fibrinolysis should be defined by persistent clinical illness (oxygen requirement, poor feeding) at 3-4 days after treatment, not by fever alone, since fever may be due to parenchymal disease. Open

Statement A second round of fibrinolysis is only indicated when imaging shows a walled-off collection not in continuity with the initial chest tube placement; if the tube is well-positioned and there is persistent pleural disease in continuity with the tube, a second round is not recommended. Open

Statement Extensive pulmonary necrosis is an absolute contraindication to surgical intervention because manipulating necrotic lung risks protracted bronchopleural fistulas requiring Heimlich valves for months. Open

Statement Bronchopleural fistulas only occur when operating in a field of necrosis and debriding that necrosis; peripheral lung lesions heal without this complication. Open

Statement During VATS for failed fibrinolysis, if the lung appears necrotic (black, necrotic-appearing), it should be left alone and only the pleural space should be debrided. Open

Statement A patient with complete unilateral pulmonary necrosis who underwent needle biopsy died from exsanguination into the wound and bronchi, demonstrating that necrotic lung does not tolerate being touched. Open

Quotation that lung does not tolerate being touched in that situation Open

Statement A 3-year-old with bilateral pulmonary necrosis requiring VV ECMO for almost a month survived without surgical intervention and left the hospital without oxygen, demonstrating that necrotic lung heals with conservative management. Open

Statement Well-defined peripheral pulmonary abscesses can be drained percutaneously with a drain left in place, but multifocal or complex abscesses should be managed conservatively like necrosis. Open

Quotation I'm convinced that she would have not survived if anybody would have tried to operate on that lung in either side Open

Quotation the lung does figure it out Open

Statement In the United States, TPA is the only available fibrinolytic agent for empyema since urokinase is not available and streptokinase has come off the market. Open

Statement A randomized trial in adults suggested more rapid clearance by adding DNase to fibrinolytic therapy, but DNase is not approved for intrapleural use and requires an IND for pediatric study. Open

Shawn's statements about Etiologies (Gastroschisis/NEC/Atresia/Volvulus) 7 statements

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Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos

Quotation I would be remiss not to mention that we were one of the two hospitals that were in this trial and we did not see a difference in abscess rate in our cohort. So the overall group was swayed entirely by Phoenix's experience. Open

Statement One participating hospital in the appendicitis antibiotic trial did not see a difference in abscess rates between the two antibiotic regimens in their cohort, while the overall study results were driven entirely by Phoenix Children's Hospital's experience. Open

Statement NSQIP-P national data shows no difference in abscess rates between ceftriaxone-metronidazole and piperacillin-tazobactam across much larger patient numbers. Open

Quotation I don't think it's binary, so I don't think it's going to be something that we're going to be able to answer as a yes or no. Open

Statement In the NEC trial, there was significant surgeon intention to treat, with most patients who received initial peritoneal drainage going to laparotomy shortly after drain placement. Open

Quotation Most of these patients went to laparotomy shortly after drain placement, so that also kind of convolutes it. Open

Statement Peritoneal drainage for NEC often serves as a temporizing measure to stabilize septic patients before laparotomy rather than as definitive therapy. Open

Shawn's statements about Hirschsprung disease 6 statements

Open the Hirschsprung disease collection →

Update Course Rewind: 2020 Colorectal Part 2

Statement Sclerotherapy has a low threshold for use because it is simple, innocuous, and can provide a window of a couple months without prolapse that allows younger children to see less frequent episodes. Open

Quotation I've got a low threshold for starting with sclerotherapy because it's, it's simple, it's innocuous, and then sometimes they just need that head start, particularly in that last case with a younger kid. They just need that window of a couple of months to not have a prolapse, and then they start seeing it less frequently. Open

Statement Sclerotherapy has a low threshold for use because it is simple, innocuous, and can provide a window of a couple months without prolapse that allows younger children to see less frequent episodes. Open

Quotation I've got a low threshold for starting with sclerotherapy because it's, it's simple, it's innocuous, and then sometimes they just need that head start, particularly in that last case with a younger kid. They just need that window of a couple of months to not have a prolapse, and then they start seeing it less frequently. Open

Statement Dr. Sean St. Peter's sclerotherapy technique uses 5 ccs of Sotradechol injected in 4 quadrants with any remaining volume injected in between. Open

Shawn's statements about Intestinal Rehab 7 statements

Open the Intestinal Rehab collection →

Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos

Quotation I would be remiss not to mention that we were one of the two hospitals that were in this trial and we did not see a difference in abscess rate in our cohort. So the overall group was swayed entirely by Phoenix's experience. Open

Statement One participating hospital in the appendicitis antibiotic trial did not see a difference in abscess rates between the two antibiotic regimens in their cohort, while the overall study results were driven entirely by Phoenix Children's Hospital's experience. Open

Statement NSQIP-P national data shows no difference in abscess rates between ceftriaxone-metronidazole and piperacillin-tazobactam across much larger patient numbers. Open

Quotation I don't think it's binary, so I don't think it's going to be something that we're going to be able to answer as a yes or no. Open

Statement In the NEC trial, there was significant surgeon intention to treat, with most patients who received initial peritoneal drainage going to laparotomy shortly after drain placement. Open

Quotation Most of these patients went to laparotomy shortly after drain placement, so that also kind of convolutes it. Open

Statement Peritoneal drainage for NEC often serves as a temporizing measure to stabilize septic patients before laparotomy rather than as definitive therapy. Open

Shawn's statements about Pectus Excavatum 61 statements

Open the Pectus Excavatum collection →

Update Course Rewind 2021 - Updates in Pectus

Statement In a randomized trial of 110 patients comparing epidural to PCA, maximum pain scores did not drop off in the epidural group due to day 2-3 transition pain, whereas PCA group pain decreased over 4.5 days. Open

Quotation this is the final nail in the coffin for the epidural, because there has to be an advantage to something that is time consuming, is an extra procedure, and imposes risk Open

Statement Cryotherapy technique involves freezing ribs 4 through 7 for two minutes per rib; should not go to rib 8 or below due to risk of abdominal wall paralysis. Open

Quotation when that patient went home on post-op day one, equipoise was lost Open

Statement In prospective observational cryoanalgesia study, six of nine patients in initial retrospective cohort went home on post-op day one. Open

Statement With cryoanalgesia, length of stay that couldn't get below four days became one day, with tight range except for occasional failures that look like traditional four-day stays. Open

Statement Median morphine equivalents with cryoanalgesia versus traditional approaches are not on the same planet in terms of magnitude of difference. Open

Quotation when Samuel had his, it took him two weeks before he could put his own shirt on. And he goes, this morning, Jacob took a shower, put his own shirt on Open

Quotation if the leap is so big, that how can you then ethically randomize when you already start with such a radical difference in outcome? Open

Quotation I'm impressed with how many kids have normal sensation, even in the early post-op phase, two, three weeks that they can feel their anterior chest Open

Statement Many patients have normal anterior chest sensation even in early post-op phase (two to three weeks) after cryoanalgesia, suggesting nerve stunning rather than complete death. Open

Statement Adult experience using cryotherapy with thoracotomies goes back 20 years without high enough incidence of complications to warrant backing away from the treatment advantage. Open

Statement Activity restrictions beyond two weeks post-Nuss can be liberalized to anything the patient can handle, including bull riding, boxing, football, and hockey. Open

Statement When bars flip, it is always technical - related to bar sitting in funky inner space, bad spot, not wrapped tight enough, or not secured well - not related to patient activity or pain modality. Open

Quotation when bars flip, it's always technical Open

Quotation You go back to the OR and you'll find a reason why it flipped and it's not the patient Open

Statement In updated series of 554 patients, bar rotation rate was 0.7%, with most occurring within first few years of surgeon experience. Open

Statement Sub-xiphoid dissection technique allows palpation-guided bar passage and has resulted in 0% incidence of pericarditis. Open

Statement In 15-patient magnetic repair trial, magnets were safe to place in children's chests and well-tolerated, but results were not as effective as hoped; appears most effective in young children with flexible chests. Open

Update Course Rewind: Pectus Excavatum 2021

Statement Dr. Saint Peter's institution completed a randomized trial of 110 patients comparing epidural to PCA for pectus excavatum pain control, and epidurals did not show superior performance. Open

Quotation We, of course, struggled with post-operative pain management as everybody did, and we had completed a randomized trial, 110 patients to epidural and PCA. Open

Statement Dr. Saint Peter's institution completed a randomized trial of 110 patients comparing epidural to PCA for pectus excavatum pain control, and epidurals did not show superior performance. Open

Quotation We, of course, struggled with post-operative pain management as everybody did, and we had completed a randomized trial, 110 patients to epidural and PCA. Open

Statement In Dr. Saint Peter's cryoanalgesia trial with approximately 30 patients per group, equipoise was lost when patients went home on post-op day one. Open

Quotation We had about 30 patients in each group when we tried the cryotherapy and when that patient went home on post-op day one, equipoise was lost. Open

Quotation Once you, once you see it, it's, it's sort of a different game. Open

Statement The cryoanalgesia technique involves counting down to the 4th rib and freezing underneath it for 2 minutes per rib, treating ribs 4 through 7. Open

Quotation You literally just count down to the 4th rib and then freeze underneath it. Open

Quotation It's 2 minutes per rib. Open

Statement Cryoanalgesia should not be performed on rib 8 or below because it can cause abdominal wall paralysis. Open

Quotation You're not supposed to go 8 or below because you can get some abdominal wall paralysis. Open

Statement With cryoanalgesia, hospital length of stay decreased from 4 days to 1 day at Dr. Saint Peter's institution. Open

Quotation What we saw there is the length of stay where we just couldn't get below 4 days, all of a sudden became 1. Open

Statement With cryoanalgesia, hospital length of stay decreased from 4 days to 1 day at Dr. Saint Peter's institution. Open

Statement Cryoanalgesia dramatically reduced median morphine equivalents compared to previous pain management approaches. Open

Quotation So typically if bars are going to flip, they're going to flip early and it's going to be because they were sitting in a in a funky inner space. Open

Statement Bar flippage typically occurs early and is caused by the bar sitting in a funky interspace, sitting in a bad spot, not being wrapped tight enough, or not being secured well. Open

Quotation So typically if bars are going to flip, they're going to flip early and it's going to be because they were sitting in a in a funky inner space. Open

Statement Bar flippage typically occurs early and is caused by the bar sitting in a funky interspace, sitting in a bad spot, not being wrapped tight enough, or not being secured well. Open

Statement The bar must sit in a comfortable position before securing or it will not stay in place; securing alone does not prevent bar flippage. Open

Quotation That bar's got to sit in a comfortable position before you start to secure it or it's probably not going to stay there. Open

Statement The bar must sit in a comfortable position before securing or it will not stay in place; securing alone does not prevent bar flippage. Open

Quotation That bar's got to sit in a comfortable position before you start to secure it or it's probably not going to stay there. Open

Statement Dr. Saint Peter continues to use subxiphoid incision along with thoracoscopy, sternal elevator, or vacuum bell in the operating room as safety techniques to avoid cardiac injury. Open

Quotation The idea is to Uh, not injure the heart. So whatever technique helps you do that, I, I think is the technique you ought to use. Open

Statement Dr. Holcomb's principle is that whatever technique helps avoid injuring the heart is the technique that should be used. Open

Statement One surgeon learned left to right but switched to right to left and found it easier, particularly when using external elevator and thoracoscopy for safety. Open

Statement Direction of bar passage is likely surgeon preference and does not make much difference as long as the substernal space is well dissected and everything is clear. Open

Shawn's statements about Pneumonia 64 statements

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