Whit Holcomb
492 statements · 20 topics · summaries given as host listed separately
Abdominal Wall Defects
· guest expert
Aerodigestive / ENT
· guest expert
Biliary Atresia
· guest expert
Colorectal / ARM & Hirschsprung
· guest expert
Etiologies (Gastroschisis/NEC/Atresia/Volvulus)
· guest expert
Intestinal Failure
· guest expert
Intestinal Rehab
· guest expert
Intestinal Transplant
· guest expert
Featured statements
Uh, the answer is we don't have an answer. The, the best quality study said no difference. The more recent study that was, uh, Uh, not as a well-designed study did show a difference. I, I do think it's, it really would behoove all of us if we came up with some standardized definitions. So we're all talking about the, the same disease process.
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Appendicitis
Based 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.
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Abdominal Wall Defects
it'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
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Appendicitis
We 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.
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Abdominal Wall Defects
I 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.
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Gastroesophageal Reflux
I'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.
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Gastroesophageal Reflux
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Whit's statements about Abdominal Wall Defects 14 statements
Open the Abdominal Wall Defects collection →
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
Quotation
This is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.
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Quotation
I just wanted to highlight the importance of transitioning care because I thought this topic was important.
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Statement
There was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner
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Quotation
This 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.
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No models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review
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Quotation
We 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.
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Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
Statement
The Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.
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Quotation
We 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.
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Statement
There was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.
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This is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.
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Quotation
Based 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.
Open
Statement
The Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.
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The Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.
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Quotation
This 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.
Open
Whit's statements about Aerodigestive / ENT 32 statements
Open the Aerodigestive / ENT collection →
Pediatric Gastroesophageal Reflux Disease
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I don't believe that the surgeons should be the ones doing the workup of these children.
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Quotation
I don't believe that the surgeons should be the ones doing the workup of these children.
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Statement
An 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.
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An 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.
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In 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.
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In 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.
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I would like to thank Rachel for not sending that child who's retching preoperatively to the surgeons.
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I would like to thank Rachel for not sending that child who's retching preoperatively to the surgeons.
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In 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.
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In 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.
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By 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.
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By 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.
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Quotation
The surgical message that we should impart is that we need to do less rather than more dissection around the GE junction.
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The surgical message is that we need to do less rather than more dissection around the GE junction to prevent wrap transmigration.
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The surgical message is that we need to do less rather than more dissection around the GE junction to prevent wrap transmigration.
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Quotation
The surgical message that we should impart is that we need to do less rather than more dissection around the GE junction.
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Statement
You'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.
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You'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.
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Using 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.
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Statement
Using 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.
Open
Gastroesophageal Reflux Disease
Quotation
I don't think that the surgeons should be the ones doing the workup of these children.
Open
Statement
An 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.
Open
Statement
In a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients.
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Quotation
I would like to thank Rachel for not sending that child who's wretching preoperatively to the surgeons.
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Statement
In Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique.
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The primary reason for redo fundoplication is transmigration of the wrap into the chest.
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Quotation
We 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.
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Before adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change.
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The 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.
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Statement
Using an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation.
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Whit's statements about Appendicitis 137 statements
Open the Appendicitis collection →
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Statement
Dr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).
Open
Statement
Most pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.
Open
Statement
Chloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.
Open
Quotation
If you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.
Open
Statement
Dr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.
Open
Statement
Immunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.
Open
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The challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.
Open
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The 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.
Open
Statement
Long-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.
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Quotation
Are 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.
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Quotation
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.
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If 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.
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Appendicitis with Dr. Whit Holcomb
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I would like to acknowledge that much of this work has been done and certainly has been spearheaded by Dr. Sean St. Peter, who directs our Center for Prospective Clinical Trials
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For classic appendicitis presentation without prior imaging, patient should go directly to OR for laparoscopic appendectomy without imaging study
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Symptom duration >24-36 hours raises concern for perforation and warrants imaging starting with ultrasound
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Non-visualization of appendix on CT at 4 days should show secondary signs of appendicitis and likely perforation; if neither present, likelihood of appendicitis is low but not zero
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Limited CT scan protocol is used to minimize radiation exposure while focusing on appendicitis diagnosis
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We generally use IV contrast. Occasionally, oral contrast is given. We've tried to work on a protocol of using rectal contrast, and the ED physicians did not feel that it was the best way to go.
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Ceftriaxone 50mg/kg and metronidazole 30mg/kg given once daily has similar efficacy to triple antibiotic regimen (ampicillin, gentamicin, clindamycin) for appendicitis
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Quotation
ceftriaxone and metronidazole is the most cost effective antibiotic duo, and it also has similar efficacy to the so-called triple antibiotic regimens
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Statement
Single preoperative dose of antibiotics is given for non-perforated appendicitis; no additional doses needed postoperatively
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Quotation
it's a once daily dosing for each of them. So we find for those reasons, we find this to be a good antibiotic duo to use.
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Prospective randomized trial of 100 patients showed no difference in abscess rate or wound infections between ceftriaxone/metronidazole and ampicillin/gentamicin/clindamycin, published Journal of Pediatric Surgery 2008
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Once-daily dosing of ceftriaxone and metronidazole is more cost-effective than triple antibiotics and does not require serum level monitoring
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Single-incision laparoscopic approach uses 5mm port through upper umbilical fascia with stab incision below for Maryland dissector or grasper
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we would try or we, we might try a, uh, single incision laparoscopic approach through the umbilicus
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Locking grasper is important when exteriorizing appendix to prevent dropping it during removal
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I 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
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Perforation is defined as stool in the abdomen (fecalith in abdominal cavity) or a visible hole in the appendix
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Quotation
we had to come up with a definition of perforation. And again, we have chosen stool in the appendix, meaning a fecal lith in the, uh, excuse me, stool in the abdomen, meaning a fecal lith in the abdominal cavity or a visible hole in the appendix.
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Non-perforated appendicitis patients are discharged home within 6 hours of surgery without additional antibiotics
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in the last year or so, we have been sending our non-perforated appendix patients home the same day
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Randomized trial of 360 patients (August 2009-November 2010) comparing single-site to three-port laparoscopy showed no difference in wound infection rate, time to regular diet, length of hospitalization, or return to activity, published Annals of Surgery October 2011
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Mean operative time for single-site approach was 5 minutes longer than three-port, which was statistically significant but not clinically relevant
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there was no difference in wound infection rate, time to regular diet, length of hospitalization, or time to return to full activity between the two groups
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Single-site laparoscopic appendectomy had 3.3% wound infection rate vs 1.7% for three-port approach (p=0.5, not statistically significant)
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Study comparing irrigation plus suction vs suction alone in perforated appendicitis showed no difference in abscess rate or location, both groups had approximately 20% postoperative abscess development
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In all appendectomy studies for perforated disease (6-7 studies), abscess rate has consistently been between 15-20%
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Standard protocol for perforated appendicitis is 5 days of IV antibiotics postoperatively
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Quotation
there was no difference in the postoperative abscess rate between these two treatment groups. But we also found that it was possible to discharge patients before day 5 and 40% of the patients in what we call the IV and POR.
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Study of 50 patients randomized to mandatory 5 days IV vs early discharge on oral Augmentin showed no difference in abscess rate; 40% of early discharge group went home before day 5
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Almost all patients who develop postoperative abscess develop it in the hospital, very few go home and return with abscess
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If 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
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Discharge criteria for perforated appendicitis: normal white blood cell count on day 5, afebrile, tolerating regular diet
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Initial appendectomy for abscess takes longer than interval appendectomy (61 minutes vs 42 minutes)
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there was no difference in length of total hospitalization, recurrent abscess rates, or overall charges
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For well-defined abscess from perforated appendicitis, randomized trial showed no difference in total hospitalization length, recurrent abscess rates, or overall charges between immediate appendectomy vs non-operative management with interval appendectomy, published Journal of Pediatric Surgery 2010
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Quotation
I prefer the initial non-operative management with antibiotics and a return for an interval appendectomy
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Statement
Symptom duration of 3-4 days warrants immediate operation; 6-7 days suggests well-defined abscess suitable for non-operative management; 5 days is transition zone
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Estimated 50-60% of pediatric appendicitis patients could be managed non-operatively with antibiotics based on emerging data
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Quotation
it is likely possible that 50 to 60% of patients could probably be managed non-operatively with antibiotics
Open
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Statement
Dr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).
Open
Statement
Most pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.
Open
Statement
Chloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.
Open
Quotation
If you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.
Open
Statement
Dr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.
Open
Statement
Immunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.
Open
Statement
The challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.
Open
Quotation
The 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.
Open
Statement
Long-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.
Open
Quotation
Are 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.
Open
Quotation
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.
Open
Statement
If 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.
Open
Evidence-based diagnosis and management of pediatric appendicitis with Dr. Whit Holcomb
Quotation
much 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
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Quotation
if 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
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Statement
Classic 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
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At Children's Mercy Hospital, emergency department physicians often perform imaging studies before surgical consultation, though this is at their discretion not surgeon direction
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Symptom duration over 24-36 hours raises concern for perforation and warrants imaging starting with ultrasound
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If ultrasound is not diagnostic but raises concern, proceed to CT scan; if ultrasound is diagnostic of appendicitis, CT is not needed
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Non-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
Open
Statement
Children'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
Open
Statement
Ceftriaxone and metronidazole is the most cost-effective antibiotic combination for appendicitis and has similar efficacy to triple antibiotic regimens
Open
Statement
Non-perforated appendicitis receives only single preoperative antibiotic dose with no postoperative antibiotics
Open
Statement
Once-daily ceftriaxone/metronidazole dosing facilitates home health care transition if needed, does not require serum levels like gentamicin, and avoids gentamicin toxicities
Open
Statement
In 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
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Ceftriaxone dosing is 50 mg/kg once daily and metronidazole is 30 mg/kg once daily for appendicitis
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Single-incision or double-incision laparoscopic approaches are used only for thin patients with non-perforated appendicitis
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In double-incision approach, 5mm umbilical port is placed with 5mm suprapubic port for mobilization, then appendix is exteriorized through umbilicus for extracorporeal appendectomy
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Quotation
I 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
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Statement
Locking grasper is essential when exteriorizing appendix to prevent dropping it back into abdomen
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Fascial incision of 10-12mm is needed to safely exteriorize appendix because grasper creates U-shaped configuration rather than end-on grasp
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Perforation 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
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This strict perforation definition was necessary because literature uses terms like gangrenous, necrotic, and perforated inconsistently, all meaning different things to different surgeons
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Quotation
we're trying to send the non-perforated patients home within around 6 hours of having their appendectomy
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Statement
Children'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
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Same-day discharge for non-perforated appendicitis uses local anesthesia in incisions, pain medications at home, and no postoperative antibiotics
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Quotation
I can see down the line. A nice randomized trial of antibiotics versus day surgery appendicitis, if you will, for acute appendicitis
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Rationale 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
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October 2011 Annals of Surgery study randomized 360 patients (August 2009-November 2010) comparing single-incision to three-port laparoscopy for non-perforated appendicitis
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Statement
Single-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
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Statement
Single-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
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For 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
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Interrupted plain sutures allow wound infection drainage while not requiring removal due to short half-life; wounds dressed with rolled gauze and Tegaderm
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Study used strict perforation definition (hole in appendix or fecalith in abdomen), not just distended, angry, necrotic, or gangrenous appendix
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St. 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
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Quotation
in 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
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Statement
Surgeons reporting lower abscess rates for perforation likely include gangrenous/necrotic non-perforated cases in their perforated group, lowering the rate
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Across 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
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Quotation
if you do use cautery, I think it's important to be sure to watch everything that's going on
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Children's Mercy surgeons use stapler for both mesoappendix and appendix because it can be justified as cost-effective under their per-minute billing model
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Standard stapler load is used for appendix and vascular load for mesoappendix, which is another reason not to staple both simultaneously
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In early 1990s at Vanderbilt, three children who had cautery used for appendectomy developed adjacent small bowel injuries requiring reoperation due to electrical arc
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When using cautery for appendectomy, must carefully watch entire field to prevent electrical arc to adjacent small bowel loops
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At Children's Mercy, OR billing is $225 per minute; a $600 stapler is cost-effective if it saves 3 minutes of OR time
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In single-incision approach, pelvic fluid should be suctioned before incising the bridge between ports because it becomes difficult to suction after appendix removal
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Murky fluid throughout abdomen in non-perforated appendicitis is very unusual and would prompt placement of additional port for better visualization and investigation of source
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For 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
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Quotation
almost all, not all, but almost all of the patients who develop an abscess postoperatively develop it in the hospital
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Statement
Initial perforated appendicitis protocol at Children's Mercy was 5 days of IV antibiotics postoperatively, developed when beginning prospective randomized trials
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Discharge criteria for perforated appendicitis: normal WBC on day 5, afebrile, tolerating regular diet; then discharged without oral antibiotics
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Statement
If 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
Open
Statement
Almost all postoperative abscesses in perforated appendicitis develop while patient is in hospital, very few develop after discharge
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Follow-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
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Early discharge study found no difference in postoperative abscess rate between groups; 40% of patients in early discharge group went home before day 5
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Holcomb 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
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Interval appendectomy is performed 8-10 weeks after non-operative abscess management and is becoming a day surgery procedure
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For well-defined abscess at 5-6 days symptom duration, two options exist: immediate appendectomy or non-operative management with interval appendectomy
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Statement
2010 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
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Statement
Study found no difference between immediate versus interval appendectomy in total length of hospitalization, recurrent abscess rates, or overall charges
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Quotation
it'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
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Statement
Initial appendectomy took longer (61 minutes) versus interval appendectomy (42 minutes)
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At 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
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Even 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
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Current 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
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Statement
Inflammation and infection may cause appendiceal scarring leading to closed-loop obstruction and recurrent appendicitis, but this won't be known for 25-30 years
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Long-term follow-up of 25-30 years will be needed to determine if non-operatively treated patients develop recurrent appendicitis years later
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High-quality studies on non-operative appendicitis management will emerge in next 5 years showing good percentage can be treated without operation
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Current data suggests 50-60% of patients could likely be managed non-operatively with antibiotics
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Longer-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
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Children's Mercy currently proceeds with interval laparoscopic appendectomy after non-operative abscess management because families do not want child at risk for recurrent appendicitis
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Update Course Rewind: Perforated Appendicitis 2019
Statement
The higher abscess rates in the irrigation trial may be due to the specific definition of perforation used at that institution
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Statement
The best quality study on irrigation showed no difference in outcomes, while a more recent but less well-designed study showed a difference favoring standardized large-volume irrigation
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Quotation
Uh, the answer is we don't have an answer. The, the best quality study said no difference. The more recent study that was, uh, Uh, not as a well-designed study did show a difference. I, I do think it's, it really would behoove all of us if we came up with some standardized definitions. So we're all talking about the, the same disease process.
Open
Whit's statements about Appendicitis 4 statements
Open the Appendicitis collection →
Update Course Rewind: Perforated Appendicitis 2019
Statement
The higher abscess rates in the irrigation trial may be due to the specific definition of perforation used at that institution
Open
Statement
The best quality study on irrigation showed no difference in outcomes, while a more recent but less well-designed study showed a difference favoring standardized large-volume irrigation
Open
Quotation
Uh, the answer is we don't have an answer. The, the best quality study said no difference. The more recent study that was, uh, Uh, not as a well-designed study did show a difference. I, I do think it's, it really would behoove all of us if we came up with some standardized definitions. So we're all talking about the, the same disease process.
Open
Whit's statements about Aspiration 32 statements
Open the Aspiration collection →
Pediatric Gastroesophageal Reflux Disease
Quotation
I don't believe that the surgeons should be the ones doing the workup of these children.
Open
Quotation
I don't believe that the surgeons should be the ones doing the workup of these children.
Open
Statement
An 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.
Open
Statement
An 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.
Open
Statement
In 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.
Open
Statement
In 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.
Open
Quotation
I would like to thank Rachel for not sending that child who's retching preoperatively to the surgeons.
Open
Quotation
I would like to thank Rachel for not sending that child who's retching preoperatively to the surgeons.
Open
Statement
In 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.
Open
Statement
In 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.
Open
Statement
By 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.
Open
Statement
By 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.
Open
Statement
The surgical message is that we need to do less rather than more dissection around the GE junction to prevent wrap transmigration.
Open
Quotation
The surgical message that we should impart is that we need to do less rather than more dissection around the GE junction.
Open
Statement
The surgical message is that we need to do less rather than more dissection around the GE junction to prevent wrap transmigration.
Open
Quotation
The surgical message that we should impart is that we need to do less rather than more dissection around the GE junction.
Open
Statement
You'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.
Open
Statement
You'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.
Open
Statement
Using 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.
Open
Statement
Using 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.
Open
Gastroesophageal Reflux Disease
Quotation
I don't think that the surgeons should be the ones doing the workup of these children.
Open
Statement
An 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.
Open
Statement
In a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients.
Open
Quotation
I would like to thank Rachel for not sending that child who's wretching preoperatively to the surgeons.
Open
Statement
In Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique.
Open
Statement
The primary reason for redo fundoplication is transmigration of the wrap into the chest.
Open
Quotation
We 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.
Open
Statement
Before adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change.
Open
Statement
The 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.
Open
Statement
Using an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation.
Open
Whit's statements about Biliary Atresia 30 statements
Open the Biliary Atresia collection →
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Statement
Dr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).
Open
Statement
Most pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.
Open
Statement
Chloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.
Open
Quotation
If you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.
Open
Statement
Dr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.
Open
Statement
Immunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.
Open
Statement
The challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.
Open
Quotation
The 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.
Open
Statement
Long-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.
Open
Quotation
Are 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.
Open
Quotation
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.
Open
Statement
If 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.
Open
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Statement
Dr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).
Open
Statement
Most pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.
Open
Statement
Chloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.
Open
Quotation
If you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.
Open
Statement
Dr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.
Open
Statement
Immunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.
Open
Statement
The challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.
Open
Quotation
The 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.
Open
Statement
Long-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.
Open
Quotation
Are 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.
Open
Quotation
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.
Open
Statement
If 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.
Open
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
Quotation
This is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.
Open
Quotation
I just wanted to highlight the importance of transitioning care because I thought this topic was important.
Open
Statement
There was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner
Open
Quotation
This 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.
Open
Statement
No models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review
Open
Quotation
We 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.
Open
Whit's statements about Colorectal / ARM & Hirschsprung 32 statements
Open the Colorectal / ARM & Hirschsprung collection →
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Statement
Dr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).
Open
Statement
Most pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.
Open
Statement
Chloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.
Open
Quotation
If you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.
Open
Statement
Dr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.
Open
Statement
Immunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.
Open
Statement
The challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.
Open
Quotation
The 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.
Open
Statement
Long-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.
Open
Quotation
Are 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.
Open
Quotation
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.
Open
Statement
If 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.
Open
Journal of Pediatric Surgery Article Review: September 2023
Quotation
It's not very commonly seen. But you need to recognize the patient that has this particular problem.
Open
Statement
Some pediatric surgeons perform CDH repair after the patient gets off ECMO rather than while on ECMO.
Open
Statement
Every surgeon will have adversity in practice with patients where despite best efforts there is not a good result.
Open
Statement
Support systems are available to help physicians through difficult situations and adversity.
Open
Quotation
I 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
Open
Statement
Physician mental health is discussed more openly now versus 10 years ago, but should still be discussed more openly.
Open
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
Quotation
This is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.
Open
Quotation
I just wanted to highlight the importance of transitioning care because I thought this topic was important.
Open
Statement
There was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner
Open
Quotation
This 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.
Open
Statement
No models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review
Open
Quotation
We 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.
Open
Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
Quotation
We 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.
Open
Statement
The Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.
Open
Statement
There was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.
Open
Quotation
This is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.
Open
Statement
The Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.
Open
Quotation
Based 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.
Open
Statement
The Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.
Open
Quotation
This 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.
Open
Whit's statements about Etiologies (Gastroschisis/NEC/Atresia/Volvulus) 36 statements
Open the Etiologies (Gastroschisis/NEC/Atresia/Volvulus) collection →
Gastroesophageal Reflux Disease
Quotation
I don't think that the surgeons should be the ones doing the workup of these children.
Open
Statement
An 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.
Open
Statement
In a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients.
Open
Quotation
I would like to thank Rachel for not sending that child who's wretching preoperatively to the surgeons.
Open
Statement
In Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique.
Open
Statement
The primary reason for redo fundoplication is transmigration of the wrap into the chest.
Open
Quotation
We 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.
Open
Statement
Before adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change.
Open
Statement
The 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.
Open
Statement
Using an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation.
Open
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Statement
Dr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).
Open
Statement
Most pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.
Open
Statement
Chloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.
Open
Quotation
If you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.
Open
Statement
Dr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.
Open
Statement
Immunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.
Open
Statement
The challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.
Open
Quotation
The 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.
Open
Statement
Long-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.
Open
Quotation
Are 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.
Open
Quotation
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.
Open
Statement
If 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.
Open
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
Quotation
This is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.
Open
Quotation
I just wanted to highlight the importance of transitioning care because I thought this topic was important.
Open
Statement
There was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner
Open
Quotation
This 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.
Open
Statement
No models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review
Open
Quotation
We 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.
Open
Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
Quotation
We 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.
Open
Statement
The Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.
Open
Statement
There was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.
Open
Quotation
This is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.
Open
Quotation
Based 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.
Open
Statement
The Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.
Open
Statement
The Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.
Open
Quotation
This 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.
Open
Whit's statements about Gastroesophageal Reflux 10 statements
Open the Gastroesophageal Reflux collection →
Gastoesophageal Reflux: Update Course 2015
Quotation
I'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.
Open
Quotation
These 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.
Open
Quotation
I 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.
Open
Statement
There is a 95% chance fundoplication will be done successfully without need for another operation
Open
Quotation
I 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.
Open
Quotation
Whichever 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.
Open
Statement
Whichever fundoplication technique (complete or partial) a surgeon does best, they should perform that technique
Open
Statement
Bolus gastric feeding trial is the most helpful functional test for determining need for fundoplication, more informative than pH impedance probes
Open
Quotation
I 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.
Open
Statement
There is probably a 10-15% incidence of patients needing fundoplication after initial G-tube placement
Open
Whit's statements about Gastroesophageal Reflux Disease 31 statements
Open the Gastroesophageal Reflux Disease collection →
Pediatric Gastroesophageal Reflux Disease
Quotation
I don't believe that the surgeons should be the ones doing the workup of these children.
Open
Statement
An 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.
Open
Statement
In 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.
Open
Quotation
I would like to thank Rachel for not sending that child who's retching preoperatively to the surgeons.
Open
Statement
In 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.
Open
Statement
By 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.
Open
Statement
The surgical message is that we need to do less rather than more dissection around the GE junction to prevent wrap transmigration.
Open
Quotation
The surgical message that we should impart is that we need to do less rather than more dissection around the GE junction.
Open
Statement
You'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.
Open
Statement
Using 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.
Open
Gastoesophageal Reflux: Update Course 2015
Quotation
I'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.
Open
Quotation
These 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.
Open
Statement
There is a 95% chance fundoplication will be done successfully without need for another operation
Open
Quotation
I 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.
Open
Quotation
I 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.
Open
Quotation
Whichever 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.
Open
Statement
Whichever fundoplication technique (complete or partial) a surgeon does best, they should perform that technique
Open
Quotation
I 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.
Open
Statement
Bolus gastric feeding trial is the most helpful functional test for determining need for fundoplication, more informative than pH impedance probes
Open
Statement
There is probably a 10-15% incidence of patients needing fundoplication after initial G-tube placement
Open
Gastroesophageal Reflux Disease
Quotation
I don't think that the surgeons should be the ones doing the workup of these children.
Open
Statement
An 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.
Open
Statement
In a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients.
Open
Quotation
I would like to thank Rachel for not sending that child who's wretching preoperatively to the surgeons.
Open
Statement
In Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique.
Open
Statement
The primary reason for redo fundoplication is transmigration of the wrap into the chest.
Open
Quotation
We 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.
Open
Statement
Before adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change.
Open
Statement
The 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.
Open
Statement
Using an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation.
Open
Whit's statements about Gastroschisis 14 statements
Open the Gastroschisis collection →
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
Quotation
This is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.
Open
Quotation
I just wanted to highlight the importance of transitioning care because I thought this topic was important.
Open
Quotation
This 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.
Open
Statement
There was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner
Open
Statement
No models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review
Open
Quotation
We 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.
Open
Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
Statement
There was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.
Open
Statement
The Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.
Open
Quotation
We 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.
Open
Quotation
This is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.
Open
Quotation
Based 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.
Open
Statement
The Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.
Open
Statement
The Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.
Open
Quotation
This 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.
Open
Whit's statements about Hirschsprung disease 14 statements
Open the Hirschsprung disease collection →
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
Quotation
This is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.
Open
Quotation
I just wanted to highlight the importance of transitioning care because I thought this topic was important.
Open
Quotation
This 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.
Open
Statement
There was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner
Open
Statement
No models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review
Open
Quotation
We 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.
Open
Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
Statement
There was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.
Open
Quotation
We 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.
Open
Statement
The Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.
Open
Quotation
This is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.
Open
Quotation
Based 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.
Open
Statement
The Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.
Open
Statement
The Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.
Open
Quotation
This 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.
Open
Whit's statements about Intestinal Failure 24 statements
Open the Intestinal Failure collection →
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Statement
Dr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).
Open
Statement
Most pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.
Open
Statement
Chloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.
Open
Quotation
If you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.
Open
Statement
Dr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.
Open
Statement
Immunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.
Open
Statement
The challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.
Open
Quotation
The 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.
Open
Statement
Long-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.
Open
Quotation
Are 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.
Open
Quotation
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.
Open
Statement
If 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.
Open
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Statement
Dr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).
Open
Statement
Most pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.
Open
Statement
Chloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.
Open
Quotation
If you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.
Open
Statement
Dr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.
Open
Statement
Immunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.
Open
Statement
The challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.
Open
Quotation
The 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.
Open
Statement
Long-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.
Open
Quotation
Are 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.
Open
Quotation
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.
Open
Statement
If 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.
Open
Whit's statements about Intestinal Rehab 48 statements
Open the Intestinal Rehab collection →
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Statement
Dr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).
Open
Statement
Most pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.
Open
Statement
Chloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.
Open
Quotation
If you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.
Open
Statement
Dr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.
Open
Statement
Immunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.
Open
Statement
The challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.
Open
Quotation
The 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.
Open
Statement
Long-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.
Open
Quotation
Are 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.
Open
Quotation
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.
Open
Statement
If 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.
Open
Gastroesophageal Reflux Disease
Quotation
I don't think that the surgeons should be the ones doing the workup of these children.
Open
Statement
An 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.
Open
Statement
In a large study at Children's Mercy, upper GI identified anatomical problems in about 4% of patients.
Open
Quotation
I would like to thank Rachel for not sending that child who's wretching preoperatively to the surgeons.
Open
Statement
In Dr. Holcomb's prospective randomized trial of 107 patients, neither group required a redo fundoplication for a slipped wrap using minimal mobilization technique.
Open
Statement
The primary reason for redo fundoplication is transmigration of the wrap into the chest.
Open
Quotation
We 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.
Open
Statement
Before adopting minimal mobilization technique, Children's Mercy had a 12% transmigration rate which dropped to 5% after the technique change.
Open
Statement
The 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.
Open
Statement
Using an esophageal bougie at the time of fundoplication prevents the wrap from being too tight and reduces need for postoperative dilation.
Open
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Statement
Dr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).
Open
Statement
Most pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.
Open
Statement
Chloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.
Open
Quotation
If you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.
Open
Statement
Dr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.
Open
Statement
Immunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.
Open
Statement
The challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.
Open
Quotation
The 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.
Open
Statement
Long-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.
Open
Quotation
Are 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.
Open
Quotation
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.
Open
Statement
If 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.
Open
Journal of Pediatric Surgery Article Review: 2nd Quarter (Apr-Jun) 2024
Quotation
This is, uh, Whitt Holcomb. I'm the editor in chief of the Journal of Pediatric Surgery.
Open
Quotation
I just wanted to highlight the importance of transitioning care because I thought this topic was important.
Open
Quotation
This 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.
Open
Statement
There was little evidence that transfer of colorectal patients from pediatric to adult care happened in a timely or coordinated manner
Open
Statement
No models of transfer of care for colorectal patients from pediatric to adult settings were identified in the systematic review
Open
Quotation
We 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.
Open
Journal of Pediatric Surgery Article Review: 3rd Quarter (Jul-Sep) 2024
Statement
There was no pediatric surgery-specific classification system for complications prior to the Clavien-Madadi system.
Open
Statement
The Clavien-Dindo classification was validated in the adult world but used in pediatric surgery despite not being validated for that population.
Open
Quotation
We 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.
Open
Quotation
This is the first attempt at creating a classification system for pediatric surgery. So that's why I thought this was an important article.
Open
Quotation
Based 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.
Open
Statement
The Clavien-Madadi classification showed improved agreement rates of respondents at 85% versus 76% for the Clavien-Dindo classification.
Open
Statement
The Clavien-Madadi classification was less frequently considered inaccurate for rating in the pediatric population compared to the Clavien-Dindo classification.
Open
Quotation
This 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.
Open
Whit's statements about Intestinal Transplant 12 statements
Open the Intestinal Transplant collection →
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Statement
Dr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision).
Open
Statement
Most pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice.
Open
Statement
Chloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day.
Open
Quotation
If you're doing 6 or 7 cases a day, every minute seems to help get the cases moving along.
Open
Statement
Dr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics.
Open
Statement
Immunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics.
Open
Statement
The challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation.
Open
Quotation
The 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.
Open
Statement
Long-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.
Open
Quotation
Are 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.
Open
Quotation
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.
Open
Statement
If 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.
Open
Whit's statements about Non-perforated Appendicitis 4 statements
Open the Non-perforated Appendicitis collection →
Update Course Rewind: Perforated Appendicitis 2019
Statement
The higher abscess rates in the irrigation trial may be due to the specific definition of perforation used at that institution
Open
Statement
The best quality study on irrigation showed no difference in outcomes, while a more recent but less well-designed study showed a difference favoring standardized large-volume irrigation
Open
Quotation
Uh, the answer is we don't have an answer. The, the best quality study said no difference. The more recent study that was, uh, Uh, not as a well-designed study did show a difference. I, I do think it's, it really would behoove all of us if we came up with some standardized definitions. So we're all talking about the, the same disease process.
Open
Whit's statements about Pectus Carinatum 6 statements
Open the Pectus Carinatum collection →
Journal of Pediatric Surgery Article Review: September 2023
Quotation
It's not very commonly seen. But you need to recognize the patient that has this particular problem.
Open
Statement
Some pediatric surgeons perform CDH repair after the patient gets off ECMO rather than while on ECMO.
Open
Statement
Every surgeon will have adversity in practice with patients where despite best efforts there is not a good result.
Open
Statement
Support systems are available to help physicians through difficult situations and adversity.
Open
Quotation
I 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
Open
Statement
Physician mental health is discussed more openly now versus 10 years ago, but should still be discussed more openly.
Open
Whit's statements about Pectus Excavatum 6 statements
Open the Pectus Excavatum collection →
Journal of Pediatric Surgery Article Review: September 2023
Quotation
It's not very commonly seen. But you need to recognize the patient that has this particular problem.
Open
Statement
Some pediatric surgeons perform CDH repair after the patient gets off ECMO rather than while on ECMO.
Open
Statement
Every surgeon will have adversity in practice with patients where despite best efforts there is not a good result.
Open
Statement
Support systems are available to help physicians through difficult situations and adversity.
Open
Quotation
I 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
Open
Statement
Physician mental health is discussed more openly now versus 10 years ago, but should still be discussed more openly.
Open
Whit's statements about Primary Spontaneous Pneumothorax 3 statements
Open the Primary Spontaneous Pneumothorax collection →
Journal of Pediatric Surgery Article REview: August Issue 2023
Quotation
It seems like with this technique, the children are pain-free for a longer period of time and I think this would help for the patients' families who are maybe scared about the further effects of using opioids for a surgery like this.
Open
Quotation
the idea of the protocol is early thoracoscopic assisted surgery if that is needed. And I think it's very good. It cuts the delay from presentation to operation significantly.
Open
Statement
Over 22-23 years, solid organ injury management has been refined so patients don't need to be in hospital as long or on bed rest as long, with management now based on hemodynamic status rather than grade of injury.
Open
Whit's statements about Slipping Rib Syndrome 3 statements
Open the Slipping Rib Syndrome collection →
Journal of Pediatric Surgery Article REview: August Issue 2023
Quotation
It seems like with this technique, the children are pain-free for a longer period of time and I think this would help for the patients' families who are maybe scared about the further effects of using opioids for a surgery like this.
Open
Quotation
the idea of the protocol is early thoracoscopic assisted surgery if that is needed. And I think it's very good. It cuts the delay from presentation to operation significantly.
Open
Statement
Over 22-23 years, solid organ injury management has been refined so patients don't need to be in hospital as long or on bed rest as long, with management now based on hemodynamic status rather than grade of injury.
Open
Summaries Whit gave as host · 159 summaries
Recaps of other experts' statements, not Whit's own clinical position.
Summaries Whit gave as host · Appendicitis 35 summaries
Open the Appendicitis collection →
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.
Open
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.
Open
Host summary
Whit Holcomb summarizing the discussion: In 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).
Open
Host summary
Whit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.
Open
Host summary
Whit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.
Open
Appendicitis with Dr. Whit Holcomb
Host summary
Whit Holcomb summarizing a resource: Without strict perforation criteria, inter-observer agreement among attending surgeons on appendiceal perforation is only 25%
Open
Host summary
Whit Holcomb summarizing a resource: Adult literature shows approximately 2/3 of appendicitis patients can be managed non-operatively without operation, about 1/3 require operation
Open
Host summary
Whit Holcomb summarizing a resource: Los Angeles study showed approximately 10% of patients initially managed non-operatively without interval appendectomy returned for recurrent appendicitis, though follow-up period was only 1-1.5 years
Open
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.
Open
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.
Open
Host summary
Whit Holcomb summarizing the discussion: In 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).
Open
Host summary
Whit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.
Open
Host summary
Whit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.
Open
Evidence-based diagnosis and management of pediatric appendicitis with Dr. Whit Holcomb
Host summary
Whit Holcomb summarizing a resource: you can't really assess perforation visually without a well-defined criteria and that different surgeons will view perforation in a different fashion
Open
Host summary
Whit Holcomb summarizing a resource: In 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
Open
Host summary
Whit Holcomb summarizing a resource: Nationwide 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
Open
Host summary
Whit Holcomb summarizing a resource: Non-operative candidates will likely be non-perforated appendicitis patients, though Marty Blakely's study shows some perforated patients can also be treated non-operatively
Open
Host summary
Whit Holcomb summarizing a resource: Adult literature reports approximately 2/3 of appendicitis patients can be treated non-operatively without surgery, about 1/3 require operation
Open
Host summary
Whit Holcomb summarizing a resource: Los 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
Open
Update Course Rewind: Perforated Appendicitis 2019
Host summary
Whit Holcomb summarizing the discussion: Inter and intra-observer variability in assessing perforation from intraoperative images was close to chance alone, with surgeons not agreeing with themselves when shown the same image flipped and rotated
Open
Host summary
Whit Holcomb summarizing the discussion: But the funniest is we took one of the images, turned it upside down, and flipped it to the left, and even people didn't agree with themselves when they saw the same picture later on in the study. So inter and intra-observer variability was close to chance alone.
Open
Host summary
Whit Holcomb summarizing the discussion: A study comparing standardized large-volume irrigation (3-12L in small focused aliquots) to surgeon preference showed 0% abscess rate with standardized irrigation versus 19% with surgeon discretion
Open
Host summary
Whit Holcomb summarizing the discussion: A 2018 meta-analysis comparing suction alone versus irrigation in children and adults found no difference in postoperative abscess rates
Open
Summaries Whit gave as host · Appendicitis 4 summaries
Open the Appendicitis collection →
Update Course Rewind: Perforated Appendicitis 2019
Host summary
Whit Holcomb summarizing the discussion: But the funniest is we took one of the images, turned it upside down, and flipped it to the left, and even people didn't agree with themselves when they saw the same picture later on in the study. So inter and intra-observer variability was close to chance alone.
Open
Host summary
Whit Holcomb summarizing the discussion: Inter and intra-observer variability in assessing perforation from intraoperative images was close to chance alone, with surgeons not agreeing with themselves when shown the same image flipped and rotated
Open
Host summary
Whit Holcomb summarizing the discussion: A study comparing standardized large-volume irrigation (3-12L in small focused aliquots) to surgeon preference showed 0% abscess rate with standardized irrigation versus 19% with surgeon discretion
Open
Host summary
Whit Holcomb summarizing the discussion: A 2018 meta-analysis comparing suction alone versus irrigation in children and adults found no difference in postoperative abscess rates
Open
Summaries Whit gave as host · Biliary Atresia 22 summaries
Open the Biliary Atresia collection →
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.
Open
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.
Open
Host summary
Whit Holcomb summarizing the discussion: In 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).
Open
Host summary
Whit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.
Open
Host summary
Whit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.
Open
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.
Open
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.
Open
Host summary
Whit Holcomb summarizing the discussion: In 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).
Open
Host summary
Whit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.
Open
Host summary
Whit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.
Open
Summaries Whit gave as host · Colorectal / ARM & Hirschsprung 14 summaries
Open the Colorectal / ARM & Hirschsprung collection →
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.
Open
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.
Open
Host summary
Whit Holcomb summarizing the discussion: In 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).
Open
Host summary
Whit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.
Open
Host summary
Whit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.
Open
Journal of Pediatric Surgery Article Review: September 2023
Host summary
Whit Holcomb summarizing the discussion: Early CDH repair was defined as during the first 48 hours after ECMO cannulation, and delayed repair was anything after that time.
Open
Host summary
Whit Holcomb summarizing the discussion: The ERAS meta-analysis examined 10 studies involving 1300 patients from databases including PubMed, Embase, and Cochrane Library.
Open
Host summary
Whit Holcomb summarizing the discussion: ERAS protocols have a beneficial role in accelerating rehabilitation and shortening length of hospitalization.
Open
Summaries Whit gave as host · Etiologies (Gastroschisis/NEC/Atresia/Volvulus) 11 summaries
Open the Etiologies (Gastroschisis/NEC/Atresia/Volvulus) collection →
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.
Open
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.
Open
Host summary
Whit Holcomb summarizing the discussion: In 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).
Open
Host summary
Whit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.
Open
Host summary
Whit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.
Open
Summaries Whit gave as host · Gastroesophageal Reflux 3 summaries
Open the Gastroesophageal Reflux collection →
Gastoesophageal Reflux: Update Course 2015
Host summary
Whit Holcomb summarizing the discussion: Kansas 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%
Open
Host summary
Whit Holcomb summarizing the discussion: Time to diagnosis of hiatal hernia was significantly longer in minimal mobilization group compared to maximum mobilization group
Open
Host summary
Whit Holcomb summarizing the discussion: There was no significant difference in reflux symptoms or medication use between minimal and maximal mobilization groups at 6.5 years
Open
Summaries Whit gave as host · Gastroesophageal Reflux Disease 3 summaries
Open the Gastroesophageal Reflux Disease collection →
Gastoesophageal Reflux: Update Course 2015
Host summary
Whit Holcomb summarizing the discussion: There was no significant difference in reflux symptoms or medication use between minimal and maximal mobilization groups at 6.5 years
Open
Host summary
Whit Holcomb summarizing the discussion: Time to diagnosis of hiatal hernia was significantly longer in minimal mobilization group compared to maximum mobilization group
Open
Host summary
Whit Holcomb summarizing the discussion: Kansas 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%
Open
Summaries Whit gave as host · Intestinal Failure 22 summaries
Open the Intestinal Failure collection →
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.
Open
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.
Open
Host summary
Whit Holcomb summarizing the discussion: In 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).
Open
Host summary
Whit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.
Open
Host summary
Whit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.
Open
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.
Open
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.
Open
Host summary
Whit Holcomb summarizing the discussion: In 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).
Open
Host summary
Whit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.
Open
Host summary
Whit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.
Open
Summaries Whit gave as host · Intestinal Rehab 22 summaries
Open the Intestinal Rehab collection →
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.
Open
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.
Open
Host summary
Whit Holcomb summarizing the discussion: In 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).
Open
Host summary
Whit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.
Open
Host summary
Whit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.
Open
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.
Open
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.
Open
Host summary
Whit Holcomb summarizing the discussion: In 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).
Open
Host summary
Whit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.
Open
Host summary
Whit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.
Open
Summaries Whit gave as host · Intestinal Transplant 11 summaries
Open the Intestinal Transplant collection →
Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days.
Open
Host summary
Whit Holcomb summarizing the discussion: A 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation.
Open
Host summary
Whit Holcomb summarizing the discussion: In 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).
Open
Host summary
Whit Holcomb summarizing the discussion: Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization.
Open
Host summary
Whit Holcomb summarizing the discussion: Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation.
Open
Host summary
Whit Holcomb summarizing the discussion: The 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.
Open
Host summary
Whit Holcomb summarizing the discussion: Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment.
Open
Summaries Whit gave as host · Non-perforated Appendicitis 4 summaries
Open the Non-perforated Appendicitis collection →
Update Course Rewind: Perforated Appendicitis 2019
Host summary
Whit Holcomb summarizing the discussion: But the funniest is we took one of the images, turned it upside down, and flipped it to the left, and even people didn't agree with themselves when they saw the same picture later on in the study. So inter and intra-observer variability was close to chance alone.
Open
Host summary
Whit Holcomb summarizing the discussion: Inter and intra-observer variability in assessing perforation from intraoperative images was close to chance alone, with surgeons not agreeing with themselves when shown the same image flipped and rotated
Open
Host summary
Whit Holcomb summarizing the discussion: A study comparing standardized large-volume irrigation (3-12L in small focused aliquots) to surgeon preference showed 0% abscess rate with standardized irrigation versus 19% with surgeon discretion
Open
Host summary
Whit Holcomb summarizing the discussion: A 2018 meta-analysis comparing suction alone versus irrigation in children and adults found no difference in postoperative abscess rates
Open
Summaries Whit gave as host · Pectus Carinatum 3 summaries
Open the Pectus Carinatum collection →
Journal of Pediatric Surgery Article Review: September 2023
Host summary
Whit Holcomb summarizing the discussion: Early CDH repair was defined as during the first 48 hours after ECMO cannulation, and delayed repair was anything after that time.
Open
Host summary
Whit Holcomb summarizing the discussion: The ERAS meta-analysis examined 10 studies involving 1300 patients from databases including PubMed, Embase, and Cochrane Library.
Open
Host summary
Whit Holcomb summarizing the discussion: ERAS protocols have a beneficial role in accelerating rehabilitation and shortening length of hospitalization.
Open
Summaries Whit gave as host · Pectus Excavatum 3 summaries
Open the Pectus Excavatum collection →
Journal of Pediatric Surgery Article Review: September 2023
Host summary
Whit Holcomb summarizing the discussion: Early CDH repair was defined as during the first 48 hours after ECMO cannulation, and delayed repair was anything after that time.
Open
Host summary
Whit Holcomb summarizing the discussion: The ERAS meta-analysis examined 10 studies involving 1300 patients from databases including PubMed, Embase, and Cochrane Library.
Open
Host summary
Whit Holcomb summarizing the discussion: ERAS protocols have a beneficial role in accelerating rehabilitation and shortening length of hospitalization.
Open
Summaries Whit gave as host · Primary Spontaneous Pneumothorax 1 summary
Open the Primary Spontaneous Pneumothorax collection →
Journal of Pediatric Surgery Article REview: August Issue 2023
Host summary
Whit Holcomb summarizing the discussion: Updated APSA guidelines for solid organ injury use APSA framework: A for admission (identifying ICU risk factors), P for procedures (focusing on angiography, when to operate, transfuse, or use angio suite), S for set free/discharge, and A for aftercare.
Open
Summaries Whit gave as host · Slipping Rib Syndrome 1 summary
Open the Slipping Rib Syndrome collection →
Journal of Pediatric Surgery Article REview: August Issue 2023
Host summary
Whit Holcomb summarizing the discussion: Updated APSA guidelines for solid organ injury use APSA framework: A for admission (identifying ICU risk factors), P for procedures (focusing on angiography, when to operate, transfuse, or use angio suite), S for set free/discharge, and A for aftercare.
Open