If we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.
If we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.
If we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.
If we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.
If we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.
If we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
▶Ep 36 · 12:05
quoteThis is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.↗
▶Ep 36 · 12:09
quoteI just wanted to highlight the importance of transitioning care because I thought this topic was important.↗
▶Ep 36 · 14:22
quoteThis one sentence says it all. There was little evidence from patients that transfer happened in a timely or coordinated manner. And patients felt that the clinicians did not always understand the significance of transfer to an adult service. No models of transfer of care were identified.↗
▶Ep 36 · 14:22
clinicalThere was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner↗
▶Ep 36 · 14:38
clinicalNo models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review↗
▶Ep 36 · 15:21
quoteWe need to do a better job. Of structuring this transition, we're doing better with handoffs in the hospital with patient care. We need to do a better job with handing off the care for any pediatric patient who needs a transitioning to adult providers.↗
Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
▶Ep 37 · 14:30
clinicalThere was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.↗
▶Ep 37 · 14:30
clinicalThe Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.↗
▶Ep 37 · 14:30
quoteWe didn't really have a classification system that was unique to pediatric surgery, so that's why we have used the Clavian dindo classification, although that was validated in the adult world.↗
▶Ep 37 · 15:19
quoteThis is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.↗
▶Ep 37 · 16:39
clinicalThe Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.↗
▶Ep 37 · 16:39
quoteBased on the ratings of the various case scenarios, the Clavian Madati classification showed improved agreement rates of the respondents, 85% versus 76%. And it was less frequently considered inaccurate for rating in the pediatric population when compared to the lavian dindo classification.↗
▶Ep 37 · 16:53
clinicalThe Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.↗
▶Ep 37 · 17:46
quoteThis was a good first attempt at trying to find a reliable instrument for pediatric surgeons, and I think that we'll figure out by using it whether it's good or bad or appropriate for pediatric surgeons, but right now we don't have anything, and so obviously a first step is better than no step at all.↗
quoteI don't believe that the surgeons should be the ones doing the workup of these children.↗
▶Ep 1 · 13:36
quoteI don't believe that the surgeons should be the ones doing the workup of these children.↗
▶Ep 1 · 22:32
clinicalAn upper GI is really not a good study for reflux; it doesn't document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 1 · 22:32
clinicalAn upper GI is really not a good study for reflux; it doesn't document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 1 · 22:32
quoteAn upper GI is really not a good study for reflux.↗
▶Ep 1 · 22:32
quoteAn upper GI is really not a good study for reflux.↗
▶Ep 1 · 23:19
epidemiologicalIn a study of patients who had upper GI and pH studies, the upper GI did not help with diagnosing reflux, but it did help identify an anatomical problem in about 4% of patients.↗
▶Ep 1 · 23:19
epidemiologicalIn a study of patients who had upper GI and pH studies, the upper GI did not help with diagnosing reflux, but it did help identify an anatomical problem in about 4% of patients.↗
▶Ep 1 · 36:08
quoteI would like to thank Rachel for not sending that child who's retching preoperatively to the surgeons.↗
▶Ep 1 · 36:08
quoteI would like to thank Rachel for not sending that child who's retching preoperatively to the surgeons.↗
▶Ep 1 · 46:40
epidemiologicalIn Kansas City's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap; the primary reason for redo historically was transmigration of the wrap into the chest.↗
▶Ep 1 · 46:40
epidemiologicalIn Kansas City's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap; the primary reason for redo historically was transmigration of the wrap into the chest.↗
▶Ep 1 · 57:32
epidemiologicalBy doing minimal mobilization and not disrupting the phrenoesophageal membrane, we were able to drop our transmigration rate from 12% to 5%, and in our final study there was zero recurrence and zero redo fundoplication rate in both groups.↗
▶Ep 1 · 57:32
epidemiologicalBy doing minimal mobilization and not disrupting the phrenoesophageal membrane, we were able to drop our transmigration rate from 12% to 5%, and in our final study there was zero recurrence and zero redo fundoplication rate in both groups.↗
▶Ep 1 · 59:22
clinicalThe surgical message is that we need to do less rather than more dissection around the GE junction to prevent wrap transmigration.↗
▶Ep 1 · 59:22
quoteThe surgical message that we should impart is that we need to do less rather than more dissection around the GE junction.↗
▶Ep 1 · 59:22
clinicalThe surgical message is that we need to do less rather than more dissection around the GE junction to prevent wrap transmigration.↗
▶Ep 1 · 59:22
quoteThe surgical message that we should impart is that we need to do less rather than more dissection around the GE junction.↗
▶Ep 1 · 1:00:49
clinicalYou've got to know where the left gastric artery is, and you've got to be sure that you are cephalad to that to ensure the wrap is at the level of the lower esophagus, not the stomach.↗
▶Ep 1 · 1:00:49
clinicalYou've got to know where the left gastric artery is, and you've got to be sure that you are cephalad to that to ensure the wrap is at the level of the lower esophagus, not the stomach.↗
▶Ep 1 · 1:03:46
epidemiologicalUsing an esophageal bougie at the time of fundoplication has resulted in very little need for postoperative dilation; in all our prospective studies, we've dilated one or two patients.↗
▶Ep 1 · 1:03:46
epidemiologicalUsing an esophageal bougie at the time of fundoplication has resulted in very little need for postoperative dilation; in all our prospective studies, we've dilated one or two patients.↗
Gastroesophageal Reflux Disease
▶Ep 8 · 13:36
quoteI don't think that the surgeons should be the ones doing the workup of these children.↗
▶Ep 8 · 22:38
clinicalAn upper GI study does not document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 8 · 23:17
epidemiologicalIn a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients.↗
▶Ep 8 · 36:08
quoteI would like to thank Rachel for not sending that child who's wretching preoperatively to the surgeons.↗
▶Ep 8 · 46:40
clinicalIn Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique.↗
▶Ep 8 · 46:43
clinicalThe primary reason for redo fundoplication is transmigration of the wrap into the chest.↗
▶Ep 8 · 47:09
quoteWe spent 15 years or so trying to investigate this issue surgically and we feel like we've come up with, you know, what we call, you know, jokingly the perfect Nissen.↗
▶Ep 8 · 57:23
epidemiologicalBefore adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change.↗
▶Ep 8 · 1:00:49
clinicalThe key technical point is that the fundoplication wrap must be cephalad to the left gastric artery to ensure it's at the level of the lower esophagus rather than the stomach.↗
▶Ep 8 · 1:03:42
clinicalUsing an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 3 · 11:20
host_summaryA Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 3 · 13:49
host_summaryIsopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 3 · 14:20
host_summaryThe registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 3 · 14:48
host_summaryMost SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 3 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 3 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 3 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 3 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 3 · 20:35
host_summaryA pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 3 · 22:42
host_summaryOf 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 3 · 23:14
host_summaryIn the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 3 · 24:35
host_summaryMedian time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 3 · 24:55
host_summaryCost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 3 · 25:20
host_summaryThe pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 3 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 3 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 3 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 3 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 3 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 3 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 3 · 29:19
host_summarySome parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
▶Ep 3 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 3 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 6 · 11:20
host_summaryA Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 6 · 13:49
host_summaryIsopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 6 · 14:20
host_summaryThe registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 6 · 14:48
host_summaryMost SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 6 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 6 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 6 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 6 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 6 · 20:35
host_summaryA pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 6 · 22:42
host_summaryOf 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 6 · 23:14
host_summaryIn the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 6 · 24:35
host_summaryMedian time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 6 · 24:55
host_summaryCost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 6 · 25:20
host_summaryThe pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 6 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 6 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 6 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 6 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 6 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 6 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 6 · 29:19
host_summarySome parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
▶Ep 6 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 6 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Evidence-based diagnosis and management of pediatric appendicitis with Dr. Whit Holcomb
▶Ep 8 · 1:53
quotemuch of this work has been done and certainly has been spearheaded by Dr. Sean St. Peter, who directs our Center for Prospective Clinical Trials, and it is through his efforts and his leadership that much of the information that we'll discuss today has come about↗
▶Ep 8 · 3:25
quoteif that case came in and the emergency physicians had not already performed an imaging study, which would be ultrasound usually initially at least today, then we would take that patient to the operating room↗
▶Ep 8 · 3:25
clinicalClassic acute appendicitis presentation (pain migration to right lower quadrant, McBurney's point tenderness, elevated WBC and CRP, low-grade fever in thin patient with short symptom duration) can proceed directly to laparoscopic appendectomy without imaging↗
▶Ep 8 · 4:00
clinicalAt Children's Mercy Hospital, emergency department physicians often perform imaging studies before surgical consultation, though this is at their discretion not surgeon direction↗
▶Ep 8 · 5:11
clinicalSymptom duration over 24-36 hours raises concern for perforation and warrants imaging starting with ultrasound↗
▶Ep 8 · 6:25
clinicalIf ultrasound is not diagnostic but raises concern, proceed to CT scan; if ultrasound is diagnostic of appendicitis, CT is not needed↗
▶Ep 8 · 7:28
clinicalNon-visualization of appendix on CT at 4 days should show secondary signs of appendicitis and likely perforation; absence of both findings makes appendicitis unlikely though not zero↗
▶Ep 8 · 8:40
clinicalChildren's Mercy uses IV contrast for CT and performs limited/focused CT scans to minimize radiation exposure; rectal contrast protocol was attempted but not adopted by ED physicians↗
▶Ep 8 · 11:11
clinicalCeftriaxone and metronidazole is the most cost-effective antibiotic combination for appendicitis and has similar efficacy to triple antibiotic regimens↗
▶Ep 8 · 12:58
clinicalNon-perforated appendicitis receives only single preoperative antibiotic dose with no postoperative antibiotics↗
▶Ep 8 · 13:29
clinicalOnce-daily ceftriaxone/metronidazole dosing facilitates home health care transition if needed, does not require serum levels like gentamicin, and avoids gentamicin toxicities↗
▶Ep 8 · 14:18
clinicalIn 2008 Journal of Pediatric Surgery randomized trial of 100 patients, daily ceftriaxone/metronidazole showed no difference in abscess rate or wound infections versus ampicillin/gentamicin/clindamycin but resulted in lower antibiotic charges↗
▶Ep 8 · 15:11
clinicalCeftriaxone dosing is 50 mg/kg once daily and metronidazole is 30 mg/kg once daily for appendicitis↗
▶Ep 8 · 16:35
clinicalSingle-incision or double-incision laparoscopic approaches are used only for thin patients with non-perforated appendicitis↗
▶Ep 8 · 17:51
clinicalIn double-incision approach, 5mm umbilical port is placed with 5mm suprapubic port for mobilization, then appendix is exteriorized through umbilicus for extracorporeal appendectomy↗
▶Ep 8 · 19:40
quoteI think it's very important to use a locking grasper when you're bringing the appendix out through the abdominal cavity because If not, I've had several occasions where the appendix has slipped off the, the uh non-locking grasper↗
▶Ep 8 · 19:40
clinicalLocking grasper is essential when exteriorizing appendix to prevent dropping it back into abdomen↗
▶Ep 8 · 20:53
clinicalFascial incision of 10-12mm is needed to safely exteriorize appendix because grasper creates U-shaped configuration rather than end-on grasp↗
▶Ep 8 · 21:58
clinicalPerforation is strictly defined as stool in the abdomen (fecalith in abdominal cavity) or a visible hole in the appendix; without these findings the patient does not have perforation↗
▶Ep 8 · 21:58
clinicalThis strict perforation definition was necessary because literature uses terms like gangrenous, necrotic, and perforated inconsistently, all meaning different things to different surgeons↗
▶Ep 8 · 23:41
quoteyou can't really assess perforation visually without a well-defined criteria and that different surgeons will view perforation in a different fashion↗
▶Ep 8 · 23:41
host_summaryIn Ponsky's inter-observer variation study published in Journal of Laparoendoscopic and Advanced Surgical Techniques, attending surgeons viewing same images agreed on perforation status only 25% of the time without defined criteria↗
▶Ep 8 · 24:45
quotewe're trying to send the non-perforated patients home within around 6 hours of having their appendectomy↗
▶Ep 8 · 25:46
clinicalChildren's Mercy has been sending non-perforated appendicitis patients home the same day (within 6 hours of surgery) for over a year with over 100 patients managed this way↗
▶Ep 8 · 25:46
clinicalSame-day discharge for non-perforated appendicitis uses local anesthesia in incisions, pain medications at home, and no postoperative antibiotics↗
▶Ep 8 · 27:33
opinionRationale for same-day discharge includes patient satisfaction, opening hospital beds for patients who need them, and preparing for potential future trials of antibiotics versus day-surgery appendectomy↗
▶Ep 8 · 27:33
quoteI can see down the line. A nice randomized trial of antibiotics versus day surgery appendicitis, if you will, for acute appendicitis↗
▶Ep 8 · 28:30
clinicalSingle-incision approach had longer operative time (5 minutes, statistically significant but not clinically relevant), more narcotic doses, greater surgical difficulty, and higher hospital charges than three-port↗
▶Ep 8 · 28:30
clinicalSingle-incision appendectomy showed no difference versus three-port in wound infection rate, time to regular diet, length of hospitalization, or time to return to full activity↗
▶Ep 8 · 28:30
clinicalOctober 2011 Annals of Surgery study randomized 360 patients (August 2009-November 2010) comparing single-incision to three-port laparoscopy for non-perforated appendicitis↗
▶Ep 8 · 31:32
clinicalFor single-incision approach, umbilical fascia is closed and interrupted plain sutures placed in umbilical skin; for three-port, umbilical incision closed similarly and 5mm port sites closed with 5-0 Vicryl in U-fashion↗
▶Ep 8 · 32:09
clinicalInterrupted plain sutures allow wound infection drainage while not requiring removal due to short half-life; wounds dressed with rolled gauze and Tegaderm↗
▶Ep 8 · 33:00
clinicalStudy used strict perforation definition (hole in appendix or fecalith in abdomen), not just distended, angry, necrotic, or gangrenous appendix↗
▶Ep 8 · 33:00
clinicalSt. Peter study compared irrigation plus suction versus suction-only for perforated appendicitis and found no difference in abscess rate or location; both groups had approximately 20% postoperative abscess rate↗
▶Ep 8 · 34:28
opinionSurgeons reporting lower abscess rates for perforation likely include gangrenous/necrotic non-perforated cases in their perforated group, lowering the rate↗
▶Ep 8 · 34:28
clinicalAcross 6-7 appendectomy studies for perforated disease at Children's Mercy, abscess rate has consistently been 15-20%; Holcomb counsels families on 20% abscess risk↗
▶Ep 8 · 34:28
quotein every study for perforated disease. And so I tell families 20%, uh, and I think that's a pretty good ballpark for the, the, um Development of an abscess↗
▶Ep 8 · 38:21
clinicalStandard stapler load is used for appendix and vascular load for mesoappendix, which is another reason not to staple both simultaneously↗
▶Ep 8 · 38:21
quoteif you do use cautery, I think it's important to be sure to watch everything that's going on↗
▶Ep 8 · 38:21
clinicalWhen using cautery for appendectomy, must carefully watch entire field to prevent electrical arc to adjacent small bowel loops↗
▶Ep 8 · 38:21
clinicalAt Children's Mercy, OR billing is $225 per minute; a $600 stapler is cost-effective if it saves 3 minutes of OR time↗
▶Ep 8 · 38:21
clinicalChildren's Mercy surgeons use stapler for both mesoappendix and appendix because it can be justified as cost-effective under their per-minute billing model↗
▶Ep 8 · 38:21
clinicalIn early 1990s at Vanderbilt, three children who had cautery used for appendectomy developed adjacent small bowel injuries requiring reoperation due to electrical arc↗
▶Ep 8 · 39:48
clinicalIn single-incision approach, pelvic fluid should be suctioned before incising the bridge between ports because it becomes difficult to suction after appendix removal↗
▶Ep 8 · 39:48
clinicalMurky fluid throughout abdomen in non-perforated appendicitis is very unusual and would prompt placement of additional port for better visualization and investigation of source↗
▶Ep 8 · 41:15
clinicalFor normal appendix found at surgery, if imaging study was done preoperatively, full small bowel run is often not performed; without prior imaging, full small bowel examination is done↗
▶Ep 8 · 42:05
clinicalAlmost all postoperative abscesses in perforated appendicitis develop while patient is in hospital, very few develop after discharge↗
▶Ep 8 · 42:05
clinicalInitial perforated appendicitis protocol at Children's Mercy was 5 days of IV antibiotics postoperatively, developed when beginning prospective randomized trials↗
▶Ep 8 · 42:05
clinicalDischarge criteria for perforated appendicitis: normal WBC on day 5, afebrile, tolerating regular diet; then discharged without oral antibiotics↗
▶Ep 8 · 42:05
clinicalIf WBC elevated on day 5, patient receives 2 additional days of antibiotics and repeat WBC; if still elevated, receives 3 more days and CT scan to look for abscess↗
▶Ep 8 · 42:05
clinicalFollow-up study randomized 100 patients (50 per group) comparing mandatory 5 days IV antibiotics versus early discharge with oral Augmentin to complete 7 total days if discharge criteria met↗
▶Ep 8 · 42:05
clinicalEarly discharge study found no difference in postoperative abscess rate between groups; 40% of patients in early discharge group went home before day 5↗
▶Ep 8 · 42:05
quotealmost all, not all, but almost all of the patients who develop an abscess postoperatively develop it in the hospital↗
▶Ep 8 · 46:12
clinicalInterval appendectomy is performed 8-10 weeks after non-operative abscess management and is becoming a day surgery procedure↗
▶Ep 8 · 46:12
clinicalFor well-defined abscess at 5-6 days symptom duration, two options exist: immediate appendectomy or non-operative management with interval appendectomy↗
▶Ep 8 · 46:12
quoteit's easier on the patient and it's easier on the surgeon. To treat them non-operatively and then allow the inflammation to quiet down and return 8 to 10 weeks later for an interval laparoscopic appendectomy↗
▶Ep 8 · 46:12
clinical2010 Journal of Pediatric Surgery study of 40 patients compared initial appendectomy versus initial non-operative management with interval appendectomy for well-defined abscess from perforated appendicitis↗
▶Ep 8 · 46:12
clinicalStudy found no difference between immediate versus interval appendectomy in total length of hospitalization, recurrent abscess rates, or overall charges↗
▶Ep 8 · 46:12
clinicalInitial appendectomy took longer (61 minutes) versus interval appendectomy (42 minutes)↗
▶Ep 8 · 46:12
opinionHolcomb prefers initial non-operative management with interval appendectomy because immediate operations can be difficult, patients have prolonged hospitalization, bad ileus, sometimes need NG tube, and risk recurrent abscess complications↗
▶Ep 8 · 50:23
clinicalAt 3-4 days symptom duration, would operate; at 6-7 days with well-defined abscess, would treat non-operatively; 5 days is transition zone requiring clinical judgment↗
▶Ep 8 · 51:01
opinionEven if abscess can be managed for 2 weeks non-operatively, that operation is much easier than going in early through dense inflammation and purulent material↗
▶Ep 8 · 52:18
host_summaryAdult literature reports approximately 2/3 of appendicitis patients can be treated non-operatively without surgery, about 1/3 require operation↗
▶Ep 8 · 52:18
host_summaryNationwide Children's Hospital has performed work on non-operative appendicitis management and has ongoing prospective randomized trial; another multi-hospital trial is in planning stages↗
▶Ep 8 · 52:18
host_summaryNon-operative candidates will likely be non-perforated appendicitis patients, though Marty Blakely's study shows some perforated patients can also be treated non-operatively↗
▶Ep 8 · 52:18
opinionCurrent data is not mature enough to justify non-operative management, especially when patients can have surgery and go home same day returning to routine activities↗
▶Ep 8 · 52:18
clinicalCurrent data suggests 50-60% of patients could likely be managed non-operatively with antibiotics↗
▶Ep 8 · 52:18
opinionInflammation and infection may cause appendiceal scarring leading to closed-loop obstruction and recurrent appendicitis, but this won't be known for 25-30 years↗
▶Ep 8 · 52:18
opinionLong-term follow-up of 25-30 years will be needed to determine if non-operatively treated patients develop recurrent appendicitis years later↗
▶Ep 8 · 52:18
opinionHigh-quality studies on non-operative appendicitis management will emerge in next 5 years showing good percentage can be treated without operation↗
▶Ep 8 · 56:15
opinionLonger-term data (5, 10, 20 years) is needed to determine true recurrence rate after non-operative management; if patients return years later, this justifies interval appendectomy when young↗
▶Ep 8 · 56:15
host_summaryLos Angeles study showed approximately 10% of patients initially managed non-operatively for perforated appendicitis without interval appendectomy returned for recurrent appendicitis, but follow-up was only 1-1.5 years↗
▶Ep 8 · 57:28
clinicalChildren's Mercy currently proceeds with interval laparoscopic appendectomy after non-operative abscess management because families do not want child at risk for recurrent appendicitis↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 6 · 11:20
host_summaryA Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 6 · 13:49
host_summaryIsopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 6 · 14:20
host_summaryThe registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 6 · 14:48
host_summaryMost SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 6 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 6 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 6 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 6 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 6 · 20:35
host_summaryA pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 6 · 22:42
host_summaryOf 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 6 · 23:14
host_summaryIn the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 6 · 24:35
host_summaryMedian time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 6 · 24:55
host_summaryCost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 6 · 25:20
host_summaryThe pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 6 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 6 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 6 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 6 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 6 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 6 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 6 · 29:19
host_summarySome parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
▶Ep 6 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 6 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 10 · 11:20
host_summaryA Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 10 · 13:49
host_summaryIsopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 10 · 14:20
host_summaryThe registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 10 · 14:48
host_summaryMost SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 10 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 10 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 10 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 10 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 10 · 20:35
host_summaryA pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 10 · 22:42
host_summaryOf 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 10 · 23:14
host_summaryIn the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 10 · 24:35
host_summaryMedian time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 10 · 24:55
host_summaryCost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 10 · 25:20
host_summaryThe pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 10 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 10 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 10 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 10 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 10 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 10 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 10 · 29:19
host_summarySome parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
▶Ep 10 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 10 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
▶Ep 23 · 12:05
quoteThis is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.↗
▶Ep 23 · 12:09
quoteI just wanted to highlight the importance of transitioning care because I thought this topic was important.↗
▶Ep 23 · 14:22
clinicalThere was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner↗
▶Ep 23 · 14:22
quoteThis one sentence says it all. There was little evidence from patients that transfer happened in a timely or coordinated manner. And patients felt that the clinicians did not always understand the significance of transfer to an adult service. No models of transfer of care were identified.↗
▶Ep 23 · 14:38
clinicalNo models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review↗
▶Ep 23 · 15:21
quoteWe need to do a better job. Of structuring this transition, we're doing better with handoffs in the hospital with patient care. We need to do a better job with handing off the care for any pediatric patient who needs a transitioning to adult providers.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 76 · 11:20
host_summaryA Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 76 · 13:49
host_summaryIsopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 76 · 14:20
host_summaryThe registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 76 · 14:48
host_summaryMost SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 76 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 76 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 76 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 76 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 76 · 20:35
host_summaryA pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 76 · 22:42
host_summaryOf 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 76 · 23:14
host_summaryIn the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 76 · 24:35
host_summaryMedian time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 76 · 24:55
host_summaryCost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 76 · 25:20
host_summaryThe pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 76 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 76 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 76 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 76 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 76 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 76 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 76 · 29:19
host_summarySome parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
▶Ep 76 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 76 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Journal of Pediatric Surgery Article Review: September 2023
▶Ep 159 · 3:34
quoteIt's not very commonly seen. But you need to recognize the patient that has this particular problem.↗
▶Ep 159 · 3:34
quoteIt's not very commonly seen. But you need to recognize the patient that has this particular problem.↗
▶Ep 159 · 4:40
host_summaryEarly CDH repair was defined as during the first 48 hours after ECMO cannulation, and delayed repair was anything after that time.↗
▶Ep 159 · 4:40
clinicalEarly CDH repair was defined as during the first 48 hours after ECMO cannulation, and delayed repair was anything after that time.↗
▶Ep 159 · 6:21
clinicalSome pediatric surgeons perform CDH repair after the patient gets off ECMO rather than while on ECMO.↗
▶Ep 159 · 6:21
clinicalSome pediatric surgeons perform CDH repair after the patient gets off ECMO rather than while on ECMO.↗
▶Ep 159 · 7:29
host_summaryThe ERAS meta-analysis examined 10 studies involving 1300 patients from databases including PubMed, Embase, and Cochrane Library.↗
▶Ep 159 · 7:29
clinicalThe ERAS meta-analysis examined 10 studies involving 1300 patients from databases including PubMed, Embase, and Cochrane Library.↗
▶Ep 159 · 8:09
clinicalERAS protocols have a beneficial role in accelerating rehabilitation and shortening length of hospitalization.↗
▶Ep 159 · 8:09
host_summaryERAS protocols have a beneficial role in accelerating rehabilitation and shortening length of hospitalization.↗
▶Ep 159 · 9:47
opinionEvery surgeon will have adversity in practice with patients where despite best efforts there is not a good result.↗
▶Ep 159 · 9:47
opinionEvery surgeon will have adversity in practice with patients where despite best efforts there is not a good result.↗
▶Ep 159 · 9:55
clinicalSupport systems are available to help physicians through difficult situations and adversity.↗
▶Ep 159 · 9:55
clinicalSupport systems are available to help physicians through difficult situations and adversity.↗
▶Ep 159 · 10:48
quoteI just think that the letter is, is a good reminder that there are support systems available for all of us when we have adversity and and conflicts that we just don't know how to get through, and we see people who are the kindest to their patients cannot show the same kindness to themselves, and unfortunately we lose them to these battles↗
▶Ep 159 · 10:48
quoteI just think that the letter is, is a good reminder that there are support systems available for all of us when we have adversity and and conflicts that we just don't know how to get through, and we see people who are the kindest to their patients cannot show the same kindness to themselves, and unfortunately we lose them to these battles↗
▶Ep 159 · 11:30
opinionPhysician mental health is discussed more openly now versus 10 years ago, but should still be discussed more openly.↗
▶Ep 159 · 11:30
opinionPhysician mental health is discussed more openly now versus 10 years ago, but should still be discussed more openly.↗
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
▶Ep 164 · 12:05
quoteThis is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.↗
▶Ep 164 · 12:09
quoteI just wanted to highlight the importance of transitioning care because I thought this topic was important.↗
▶Ep 164 · 14:22
quoteThis one sentence says it all. There was little evidence from patients that transfer happened in a timely or coordinated manner. And patients felt that the clinicians did not always understand the significance of transfer to an adult service. No models of transfer of care were identified.↗
▶Ep 164 · 14:22
clinicalThere was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner↗
▶Ep 164 · 14:38
clinicalNo models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review↗
▶Ep 164 · 15:21
quoteWe need to do a better job. Of structuring this transition, we're doing better with handoffs in the hospital with patient care. We need to do a better job with handing off the care for any pediatric patient who needs a transitioning to adult providers.↗
Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
▶Ep 167 · 14:30
clinicalThe Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.↗
▶Ep 167 · 14:30
clinicalThere was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.↗
▶Ep 167 · 14:30
quoteWe didn't really have a classification system that was unique to pediatric surgery, so that's why we have used the Clavian dindo classification, although that was validated in the adult world.↗
▶Ep 167 · 15:19
quoteThis is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.↗
▶Ep 167 · 16:39
quoteBased on the ratings of the various case scenarios, the Clavian Madati classification showed improved agreement rates of the respondents, 85% versus 76%. And it was less frequently considered inaccurate for rating in the pediatric population when compared to the lavian dindo classification.↗
▶Ep 167 · 16:39
clinicalThe Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.↗
▶Ep 167 · 16:53
clinicalThe Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.↗
▶Ep 167 · 17:46
quoteThis was a good first attempt at trying to find a reliable instrument for pediatric surgeons, and I think that we'll figure out by using it whether it's good or bad or appropriate for pediatric surgeons, but right now we don't have anything, and so obviously a first step is better than no step at all.↗
quoteI don't think that the surgeons should be the ones doing the workup of these children.↗
▶Ep 24 · 22:38
clinicalAn upper GI study does not document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 24 · 23:17
epidemiologicalIn a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients.↗
▶Ep 24 · 36:08
quoteI would like to thank Rachel for not sending that child who's wretching preoperatively to the surgeons.↗
▶Ep 24 · 46:40
clinicalIn Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique.↗
▶Ep 24 · 46:43
clinicalThe primary reason for redo fundoplication is transmigration of the wrap into the chest.↗
▶Ep 24 · 47:09
quoteWe spent 15 years or so trying to investigate this issue surgically and we feel like we've come up with, you know, what we call, you know, jokingly the perfect Nissen.↗
▶Ep 24 · 57:23
epidemiologicalBefore adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change.↗
▶Ep 24 · 1:00:49
clinicalThe key technical point is that the fundoplication wrap must be cephalad to the left gastric artery to ensure it's at the level of the lower esophagus rather than the stomach.↗
▶Ep 24 · 1:03:42
clinicalUsing an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 26 · 11:20
host_summaryA Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 26 · 13:49
host_summaryIsopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 26 · 14:20
host_summaryThe registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 26 · 14:48
host_summaryMost SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 26 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 26 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 26 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 26 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 26 · 20:35
host_summaryA pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 26 · 22:42
host_summaryOf 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 26 · 23:14
host_summaryIn the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 26 · 24:35
host_summaryMedian time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 26 · 24:55
host_summaryCost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 26 · 25:20
host_summaryThe pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 26 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 26 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 26 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 26 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 26 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 26 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 26 · 29:19
host_summarySome parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
▶Ep 26 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 26 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
▶Ep 56 · 12:05
quoteThis is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.↗
▶Ep 56 · 12:09
quoteI just wanted to highlight the importance of transitioning care because I thought this topic was important.↗
▶Ep 56 · 14:22
quoteThis one sentence says it all. There was little evidence from patients that transfer happened in a timely or coordinated manner. And patients felt that the clinicians did not always understand the significance of transfer to an adult service. No models of transfer of care were identified.↗
▶Ep 56 · 14:22
clinicalThere was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner↗
▶Ep 56 · 14:38
clinicalNo models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review↗
▶Ep 56 · 15:21
quoteWe need to do a better job. Of structuring this transition, we're doing better with handoffs in the hospital with patient care. We need to do a better job with handing off the care for any pediatric patient who needs a transitioning to adult providers.↗
Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
▶Ep 57 · 14:30
clinicalThe Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.↗
▶Ep 57 · 14:30
clinicalThere was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.↗
▶Ep 57 · 14:30
quoteWe didn't really have a classification system that was unique to pediatric surgery, so that's why we have used the Clavian dindo classification, although that was validated in the adult world.↗
▶Ep 57 · 15:19
quoteThis is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.↗
▶Ep 57 · 16:39
clinicalThe Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.↗
▶Ep 57 · 16:39
quoteBased on the ratings of the various case scenarios, the Clavian Madati classification showed improved agreement rates of the respondents, 85% versus 76%. And it was less frequently considered inaccurate for rating in the pediatric population when compared to the lavian dindo classification.↗
▶Ep 57 · 16:53
clinicalThe Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.↗
▶Ep 57 · 17:46
quoteThis was a good first attempt at trying to find a reliable instrument for pediatric surgeons, and I think that we'll figure out by using it whether it's good or bad or appropriate for pediatric surgeons, but right now we don't have anything, and so obviously a first step is better than no step at all.↗
quoteI don't believe that the surgeons should be the ones doing the workup of these children.↗
▶Ep 1 · 22:32
clinicalAn upper GI is really not a good study for reflux; it doesn't document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 1 · 22:32
quoteAn upper GI is really not a good study for reflux.↗
▶Ep 1 · 23:19
epidemiologicalIn a study of patients who had upper GI and pH studies, the upper GI did not help with diagnosing reflux, but it did help identify an anatomical problem in about 4% of patients.↗
▶Ep 1 · 36:08
quoteI would like to thank Rachel for not sending that child who's retching preoperatively to the surgeons.↗
▶Ep 1 · 46:40
epidemiologicalIn Kansas City's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap; the primary reason for redo historically was transmigration of the wrap into the chest.↗
▶Ep 1 · 57:32
epidemiologicalBy doing minimal mobilization and not disrupting the phrenoesophageal membrane, we were able to drop our transmigration rate from 12% to 5%, and in our final study there was zero recurrence and zero redo fundoplication rate in both groups.↗
▶Ep 1 · 59:22
quoteThe surgical message that we should impart is that we need to do less rather than more dissection around the GE junction.↗
▶Ep 1 · 59:22
clinicalThe surgical message is that we need to do less rather than more dissection around the GE junction to prevent wrap transmigration.↗
▶Ep 1 · 1:00:49
clinicalYou've got to know where the left gastric artery is, and you've got to be sure that you are cephalad to that to ensure the wrap is at the level of the lower esophagus, not the stomach.↗
▶Ep 1 · 1:03:46
epidemiologicalUsing an esophageal bougie at the time of fundoplication has resulted in very little need for postoperative dilation; in all our prospective studies, we've dilated one or two patients.↗
Gastoesophageal Reflux: Update Course 2015
▶Ep 5 · 4:05
quoteI'm very reluctant to do a fund in a newborn in the first month of life. In fact, I extend that to about 6 months of life.↗
▶Ep 5 · 4:16
quoteThese are desperate parents. It will not work for you to say don't feed them at night. This is they are exhausted. They stay up every night.↗
▶Ep 5 · 7:17
quoteI tell them that there's a 95% chance that the operation will be done successfully and that, and that they won't have another, they won't need another operation.↗
▶Ep 5 · 7:17
clinicalThere is a 95% chance fundoplication will be done successfully without need for another operation↗
▶Ep 5 · 20:20
quoteI would not say that that's the surgeons have enough experience with either technique really over 7 years, 5 patients a year to come to valid conclusions.↗
▶Ep 5 · 22:12
quoteWhichever one you do the best you ought to do. If you do a partial one better than a Nissan, you ought to do a partial one. I think the, the results are probably equivalent, but it's whatever you do best.↗
▶Ep 5 · 22:42
opinionWhichever fundoplication technique (complete or partial) a surgeon does best, they should perform that technique↗
▶Ep 5 · 23:19
host_summaryKansas City/Birmingham prospective RCT showed aggressive esophageal mobilization had 23% to 37% incidence of transmigration over 6.5 years, while minimal mobilization increased from 3% to 12%↗
▶Ep 5 · 23:19
host_summaryThere was no significant difference in reflux symptoms or medication use between minimal and maximal mobilization groups at 6.5 years↗
▶Ep 5 · 23:19
host_summaryTime to diagnosis of hiatal hernia was significantly longer in minimal mobilization group compared to maximum mobilization group↗
▶Ep 5 · 25:58
clinicalBolus gastric feeding trial is the most helpful functional test for determining need for fundoplication, more informative than pH impedance probes↗
▶Ep 5 · 25:58
quoteI think that like Max said, the trial of bolus G tube feedings with the baby does fine. I think that's a really good test because it's a functional test. You know, if you start going down the, the rabbit hole of pH impedance probes and things like that, and sometimes some of our medical colleagues will want to do that, it, it to me it doesn't inform you what you need to do ultimately for that baby.↗
▶Ep 5 · 29:02
clinicalThere is probably a 10-15% incidence of patients needing fundoplication after initial G-tube placement↗
Gastroesophageal Reflux Disease
▶Ep 7 · 13:36
quoteI don't think that the surgeons should be the ones doing the workup of these children.↗
▶Ep 7 · 22:38
clinicalAn upper GI study does not document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 7 · 23:17
epidemiologicalIn a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients.↗
▶Ep 7 · 36:08
quoteI would like to thank Rachel for not sending that child who's wretching preoperatively to the surgeons.↗
▶Ep 7 · 46:40
clinicalIn Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique.↗
▶Ep 7 · 46:43
clinicalThe primary reason for redo fundoplication is transmigration of the wrap into the chest.↗
▶Ep 7 · 47:09
quoteWe spent 15 years or so trying to investigate this issue surgically and we feel like we've come up with, you know, what we call, you know, jokingly the perfect Nissen.↗
▶Ep 7 · 57:23
epidemiologicalBefore adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change.↗
▶Ep 7 · 1:00:49
clinicalThe key technical point is that the fundoplication wrap must be cephalad to the left gastric artery to ensure it's at the level of the lower esophagus rather than the stomach.↗
▶Ep 7 · 1:03:42
clinicalUsing an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation.↗
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
▶Ep 22 · 12:05
quoteThis is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.↗
▶Ep 22 · 12:09
quoteI just wanted to highlight the importance of transitioning care because I thought this topic was important.↗
▶Ep 22 · 14:22
clinicalThere was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner↗
▶Ep 22 · 14:22
quoteThis one sentence says it all. There was little evidence from patients that transfer happened in a timely or coordinated manner. And patients felt that the clinicians did not always understand the significance of transfer to an adult service. No models of transfer of care were identified.↗
▶Ep 22 · 14:38
clinicalNo models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review↗
▶Ep 22 · 15:21
quoteWe need to do a better job. Of structuring this transition, we're doing better with handoffs in the hospital with patient care. We need to do a better job with handing off the care for any pediatric patient who needs a transitioning to adult providers.↗
Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
▶Ep 23 · 14:30
quoteWe didn't really have a classification system that was unique to pediatric surgery, so that's why we have used the Clavian dindo classification, although that was validated in the adult world.↗
▶Ep 23 · 14:30
clinicalThere was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.↗
▶Ep 23 · 14:30
clinicalThe Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.↗
▶Ep 23 · 15:19
quoteThis is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.↗
▶Ep 23 · 16:39
clinicalThe Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.↗
▶Ep 23 · 16:39
quoteBased on the ratings of the various case scenarios, the Clavian Madati classification showed improved agreement rates of the respondents, 85% versus 76%. And it was less frequently considered inaccurate for rating in the pediatric population when compared to the lavian dindo classification.↗
▶Ep 23 · 16:53
clinicalThe Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.↗
▶Ep 23 · 17:46
quoteThis was a good first attempt at trying to find a reliable instrument for pediatric surgeons, and I think that we'll figure out by using it whether it's good or bad or appropriate for pediatric surgeons, but right now we don't have anything, and so obviously a first step is better than no step at all.↗
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
▶Ep 71 · 12:05
quoteThis is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.↗
▶Ep 71 · 12:09
quoteI just wanted to highlight the importance of transitioning care because I thought this topic was important.↗
▶Ep 71 · 14:22
quoteThis one sentence says it all. There was little evidence from patients that transfer happened in a timely or coordinated manner. And patients felt that the clinicians did not always understand the significance of transfer to an adult service. No models of transfer of care were identified.↗
▶Ep 71 · 14:22
clinicalThere was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner↗
▶Ep 71 · 14:38
clinicalNo models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review↗
▶Ep 71 · 15:21
quoteWe need to do a better job. Of structuring this transition, we're doing better with handoffs in the hospital with patient care. We need to do a better job with handing off the care for any pediatric patient who needs a transitioning to adult providers.↗
Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
▶Ep 73 · 14:30
quoteWe didn't really have a classification system that was unique to pediatric surgery, so that's why we have used the Clavian dindo classification, although that was validated in the adult world.↗
▶Ep 73 · 14:30
clinicalThere was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.↗
▶Ep 73 · 14:30
clinicalThe Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.↗
▶Ep 73 · 15:19
quoteThis is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.↗
▶Ep 73 · 16:39
quoteBased on the ratings of the various case scenarios, the Clavian Madati classification showed improved agreement rates of the respondents, 85% versus 76%. And it was less frequently considered inaccurate for rating in the pediatric population when compared to the lavian dindo classification.↗
▶Ep 73 · 16:39
clinicalThe Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.↗
▶Ep 73 · 16:53
clinicalThe Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.↗
▶Ep 73 · 17:46
quoteThis was a good first attempt at trying to find a reliable instrument for pediatric surgeons, and I think that we'll figure out by using it whether it's good or bad or appropriate for pediatric surgeons, but right now we don't have anything, and so obviously a first step is better than no step at all.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 3 · 11:20
host_summaryA Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 3 · 13:49
host_summaryIsopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 3 · 14:20
host_summaryThe registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 3 · 14:48
host_summaryMost SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 3 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 3 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 3 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 3 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 3 · 20:35
host_summaryA pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 3 · 22:42
host_summaryOf 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 3 · 23:14
host_summaryIn the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 3 · 24:35
host_summaryMedian time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 3 · 24:55
host_summaryCost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 3 · 25:20
host_summaryThe pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 3 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 3 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 3 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 3 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 3 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 3 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 3 · 29:19
host_summarySome parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
▶Ep 3 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 3 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 7 · 11:20
host_summaryA Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 7 · 13:49
host_summaryIsopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 7 · 14:20
host_summaryThe registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 7 · 14:48
host_summaryMost SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 7 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 7 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 7 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 7 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 7 · 20:35
host_summaryA pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 7 · 22:42
host_summaryOf 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 7 · 23:14
host_summaryIn the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 7 · 24:35
host_summaryMedian time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 7 · 24:55
host_summaryCost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 7 · 25:20
host_summaryThe pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 7 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 7 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 7 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 7 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 7 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 7 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 7 · 29:19
host_summarySome parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
▶Ep 7 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 7 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 14 · 11:20
host_summaryA Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 14 · 13:49
host_summaryIsopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 14 · 14:20
host_summaryThe registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 14 · 14:48
host_summaryMost SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 14 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 14 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 14 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 14 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 14 · 20:35
host_summaryA pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 14 · 22:42
host_summaryOf 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 14 · 23:14
host_summaryIn the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 14 · 24:35
host_summaryMedian time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 14 · 24:55
host_summaryCost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 14 · 25:20
host_summaryThe pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 14 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 14 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 14 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 14 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 14 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 14 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 14 · 29:19
host_summarySome parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
▶Ep 14 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 14 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Gastroesophageal Reflux Disease
▶Ep 33 · 13:36
quoteI don't think that the surgeons should be the ones doing the workup of these children.↗
▶Ep 33 · 22:38
clinicalAn upper GI study does not document reflux very well because if the child's not refluxing right when the x-ray is taken, it won't show reflux.↗
▶Ep 33 · 23:17
epidemiologicalIn a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients.↗
▶Ep 33 · 36:08
quoteI would like to thank Rachel for not sending that child who's wretching preoperatively to the surgeons.↗
▶Ep 33 · 46:40
clinicalIn Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique.↗
▶Ep 33 · 46:43
clinicalThe primary reason for redo fundoplication is transmigration of the wrap into the chest.↗
▶Ep 33 · 47:09
quoteWe spent 15 years or so trying to investigate this issue surgically and we feel like we've come up with, you know, what we call, you know, jokingly the perfect Nissen.↗
▶Ep 33 · 57:23
epidemiologicalBefore adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change.↗
▶Ep 33 · 1:00:49
clinicalThe key technical point is that the fundoplication wrap must be cephalad to the left gastric artery to ensure it's at the level of the lower esophagus rather than the stomach.↗
▶Ep 33 · 1:03:42
clinicalUsing an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 35 · 11:20
host_summaryA Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 35 · 13:49
host_summaryIsopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 35 · 14:20
host_summaryThe registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 35 · 14:48
host_summaryMost SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 35 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 35 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 35 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 35 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 35 · 20:35
host_summaryA pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 35 · 22:42
host_summaryOf 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 35 · 23:14
host_summaryIn the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 35 · 24:35
host_summaryMedian time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 35 · 24:55
host_summaryCost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 35 · 25:20
host_summaryThe pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 35 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 35 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 35 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 35 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 35 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 35 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 35 · 29:19
host_summarySome parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
▶Ep 35 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 35 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
▶Ep 85 · 12:05
quoteThis is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.↗
▶Ep 85 · 12:09
quoteI just wanted to highlight the importance of transitioning care because I thought this topic was important.↗
▶Ep 85 · 14:22
quoteThis one sentence says it all. There was little evidence from patients that transfer happened in a timely or coordinated manner. And patients felt that the clinicians did not always understand the significance of transfer to an adult service. No models of transfer of care were identified.↗
▶Ep 85 · 14:22
clinicalThere was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner↗
▶Ep 85 · 14:38
clinicalNo models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review↗
▶Ep 85 · 15:21
quoteWe need to do a better job. Of structuring this transition, we're doing better with handoffs in the hospital with patient care. We need to do a better job with handing off the care for any pediatric patient who needs a transitioning to adult providers.↗
Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
▶Ep 86 · 14:30
clinicalThere was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.↗
▶Ep 86 · 14:30
clinicalThe Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.↗
▶Ep 86 · 14:30
clinicalThe Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.↗
▶Ep 86 · 14:30
quoteWe didn't really have a classification system that was unique to pediatric surgery, so that's why we have used the Clavian dindo classification, although that was validated in the adult world.↗
▶Ep 86 · 14:30
quoteWe didn't really have a classification system that was unique to pediatric surgery, so that's why we have used the Clavian dindo classification, although that was validated in the adult world.↗
▶Ep 86 · 14:30
clinicalThere was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.↗
▶Ep 86 · 15:19
quoteThis is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.↗
▶Ep 86 · 15:19
quoteThis is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.↗
▶Ep 86 · 16:39
clinicalThe Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.↗
▶Ep 86 · 16:39
clinicalThe Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.↗
▶Ep 86 · 16:39
quoteBased on the ratings of the various case scenarios, the Clavian Madati classification showed improved agreement rates of the respondents, 85% versus 76%. And it was less frequently considered inaccurate for rating in the pediatric population when compared to the lavian dindo classification.↗
▶Ep 86 · 16:39
quoteBased on the ratings of the various case scenarios, the Clavian Madati classification showed improved agreement rates of the respondents, 85% versus 76%. And it was less frequently considered inaccurate for rating in the pediatric population when compared to the lavian dindo classification.↗
▶Ep 86 · 16:53
clinicalThe Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.↗
▶Ep 86 · 16:53
clinicalThe Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.↗
▶Ep 86 · 17:46
quoteThis was a good first attempt at trying to find a reliable instrument for pediatric surgeons, and I think that we'll figure out by using it whether it's good or bad or appropriate for pediatric surgeons, but right now we don't have anything, and so obviously a first step is better than no step at all.↗
▶Ep 86 · 17:46
quoteThis was a good first attempt at trying to find a reliable instrument for pediatric surgeons, and I think that we'll figure out by using it whether it's good or bad or appropriate for pediatric surgeons, but right now we don't have anything, and so obviously a first step is better than no step at all.↗
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
▶Ep 4 · 11:20
host_summaryA Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other.↗
▶Ep 4 · 13:49
host_summaryIsopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.↗
▶Ep 4 · 14:20
host_summaryThe registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge.↗
▶Ep 4 · 14:48
host_summaryMost SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.↗
▶Ep 4 · 16:30
clinicalDr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).↗
▶Ep 4 · 17:03
opinionMost pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.↗
▶Ep 4 · 18:16
clinicalChloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.↗
▶Ep 4 · 18:40
quoteIf you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.↗
▶Ep 4 · 20:35
host_summaryA pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year.↗
▶Ep 4 · 22:42
host_summaryOf 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.↗
▶Ep 4 · 23:14
host_summaryIn the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate).↗
▶Ep 4 · 24:35
host_summaryMedian time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.↗
▶Ep 4 · 24:55
host_summaryCost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.↗
▶Ep 4 · 25:20
host_summaryThe pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned.↗
▶Ep 4 · 26:33
opinionDr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.↗
▶Ep 4 · 27:00
clinicalImmunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.↗
▶Ep 4 · 27:22
opinionThe challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.↗
▶Ep 4 · 27:36
quoteThe trick for us will be to figure out which population can be treated successfully and which population should undergo the undergo the operation relatively soon after presentation.↗
▶Ep 4 · 27:52
opinionLong-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis.↗
▶Ep 4 · 28:07
quoteAre they at risk for developing appendicitis, you know, after they get out of the pediatric surgeon's age group, and so it'd be really important to try to follow these patients for a very long time, and we may not even see the answer in our lifetimes, but it may be apparent in our The next generation's lifetime.↗
▶Ep 4 · 29:19
host_summarySome parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.↗
▶Ep 4 · 29:33
quoteIf we can take the appendix, if we can see the patient, assess them, take the appendix out within a few hours, and then discharge them that same day. It's sort of like an outpatient procedure and it may be difficult to argue against just doing that versus treating them for a day or two with antibiotics and then wondering whether they're going to relapse the next week or next year or 10 years later.↗
▶Ep 4 · 29:45
opinionIf appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk.↗
Journal of Pediatric Surgery Article Review: September 2023
▶Ep 13 · 3:34
quoteIt's not very commonly seen. But you need to recognize the patient that has this particular problem.↗
▶Ep 13 · 3:34
quoteIt's not very commonly seen. But you need to recognize the patient that has this particular problem.↗
▶Ep 13 · 4:40
host_summaryEarly CDH repair was defined as during the first 48 hours after ECMO cannulation, and delayed repair was anything after that time.↗
▶Ep 13 · 4:40
clinicalEarly CDH repair was defined as during the first 48 hours after ECMO cannulation, and delayed repair was anything after that time.↗
▶Ep 13 · 6:21
clinicalSome pediatric surgeons perform CDH repair after the patient gets off ECMO rather than while on ECMO.↗
▶Ep 13 · 6:21
clinicalSome pediatric surgeons perform CDH repair after the patient gets off ECMO rather than while on ECMO.↗
▶Ep 13 · 7:29
host_summaryThe ERAS meta-analysis examined 10 studies involving 1300 patients from databases including PubMed, Embase, and Cochrane Library.↗
▶Ep 13 · 7:29
clinicalThe ERAS meta-analysis examined 10 studies involving 1300 patients from databases including PubMed, Embase, and Cochrane Library.↗
▶Ep 13 · 8:09
clinicalERAS protocols have a beneficial role in accelerating rehabilitation and shortening length of hospitalization.↗
▶Ep 13 · 8:09
host_summaryERAS protocols have a beneficial role in accelerating rehabilitation and shortening length of hospitalization.↗
▶Ep 13 · 9:47
opinionEvery surgeon will have adversity in practice with patients where despite best efforts there is not a good result.↗
▶Ep 13 · 9:47
opinionEvery surgeon will have adversity in practice with patients where despite best efforts there is not a good result.↗
▶Ep 13 · 9:55
clinicalSupport systems are available to help physicians through difficult situations and adversity.↗
▶Ep 13 · 9:55
clinicalSupport systems are available to help physicians through difficult situations and adversity.↗
▶Ep 13 · 10:48
quoteI just think that the letter is, is a good reminder that there are support systems available for all of us when we have adversity and and conflicts that we just don't know how to get through, and we see people who are the kindest to their patients cannot show the same kindness to themselves, and unfortunately we lose them to these battles↗
▶Ep 13 · 10:48
quoteI just think that the letter is, is a good reminder that there are support systems available for all of us when we have adversity and and conflicts that we just don't know how to get through, and we see people who are the kindest to their patients cannot show the same kindness to themselves, and unfortunately we lose them to these battles↗
▶Ep 13 · 11:30
opinionPhysician mental health is discussed more openly now versus 10 years ago, but should still be discussed more openly.↗
▶Ep 13 · 11:30
opinionPhysician mental health is discussed more openly now versus 10 years ago, but should still be discussed more openly.↗
Journal of Pediatric Surgery Article Review: September 2023
▶Ep 42 · 3:34
quoteIt's not very commonly seen. But you need to recognize the patient that has this particular problem.↗
▶Ep 42 · 3:34
quoteIt's not very commonly seen. But you need to recognize the patient that has this particular problem.↗
▶Ep 42 · 4:40
host_summaryEarly CDH repair was defined as during the first 48 hours after ECMO cannulation, and delayed repair was anything after that time.↗
▶Ep 42 · 4:40
clinicalEarly CDH repair was defined as during the first 48 hours after ECMO cannulation, and delayed repair was anything after that time.↗
▶Ep 42 · 6:21
clinicalSome pediatric surgeons perform CDH repair after the patient gets off ECMO rather than while on ECMO.↗
▶Ep 42 · 6:21
clinicalSome pediatric surgeons perform CDH repair after the patient gets off ECMO rather than while on ECMO.↗
▶Ep 42 · 7:29
clinicalThe ERAS meta-analysis examined 10 studies involving 1300 patients from databases including PubMed, Embase, and Cochrane Library.↗
▶Ep 42 · 7:29
host_summaryThe ERAS meta-analysis examined 10 studies involving 1300 patients from databases including PubMed, Embase, and Cochrane Library.↗
▶Ep 42 · 8:09
host_summaryERAS protocols have a beneficial role in accelerating rehabilitation and shortening length of hospitalization.↗
▶Ep 42 · 8:09
clinicalERAS protocols have a beneficial role in accelerating rehabilitation and shortening length of hospitalization.↗
▶Ep 42 · 9:47
opinionEvery surgeon will have adversity in practice with patients where despite best efforts there is not a good result.↗
▶Ep 42 · 9:47
opinionEvery surgeon will have adversity in practice with patients where despite best efforts there is not a good result.↗
▶Ep 42 · 9:55
clinicalSupport systems are available to help physicians through difficult situations and adversity.↗
▶Ep 42 · 9:55
clinicalSupport systems are available to help physicians through difficult situations and adversity.↗
▶Ep 42 · 10:48
quoteI just think that the letter is, is a good reminder that there are support systems available for all of us when we have adversity and and conflicts that we just don't know how to get through, and we see people who are the kindest to their patients cannot show the same kindness to themselves, and unfortunately we lose them to these battles↗
▶Ep 42 · 10:48
quoteI just think that the letter is, is a good reminder that there are support systems available for all of us when we have adversity and and conflicts that we just don't know how to get through, and we see people who are the kindest to their patients cannot show the same kindness to themselves, and unfortunately we lose them to these battles↗
▶Ep 42 · 11:30
opinionPhysician mental health is discussed more openly now versus 10 years ago, but should still be discussed more openly.↗
▶Ep 42 · 11:30
opinionPhysician mental health is discussed more openly now versus 10 years ago, but should still be discussed more openly.↗
