Spleen/Liver injury: Grade + 1 = days of bed rest; What is the current status?

Phone conversation with R3 on call:
R3: got a kid down here, has grade 4 splenic lac. Stable
Me: so, what do you want to do?
R3: "take it out"

To be fair, the kid did "collapse" on the way to the bathroom, but probably form a vagal response.

Obviously, very few Pediatric Surgeons would argue that non-operative management is the general strategy in a stable child with blunt liver or splenic trauma. What constitutes non-operative management, on the other hand, is slightly more controversial.

Until recently, we had been treating kids with liver and splenic injury with bed rest, where the days in bed were determined by the grade of the injury. Grade + 1 = days in bed (grade + 2 = weeks of limited activity). In this protocol, as pointed out by St Peter et al. in a paper published in this month's JPS, days of bed rest are considered treatment variables, suggesting that a Grade 3 splenic lac needs 4 days to stabilize. Recent literature on the subject of non-operative management of liver and splenic injury has shifted focus from an absolute grade-defined management algorithm to one determined by hemodynamic stability and physical findings in an attempt to safely truncate what some would concider to be an overkill in terms of hospital stay.

St Peter et al prospectively studies 131 patients with liver and splenic injury from blunt trauma and noted that a protocol for monitoring (not therapy), where stable patients with grades I or II splenic injury are monitored for one night (defined as spending a night in their room regardless of time admission), while those who had a grade III or more, spend two nights in the hospital, is a safe alternative that could shorten hospital stay. Based on their protocol, if a patient needed a transfusion, the clock on observation was re-zero'd.

Using this protocol, the splenic salvage rate was 98.7%, regardless of associated injuries and transfusion requirements (13% required blood transfusion for their splenic and liver injuries). Obviously, and based on this protocol, there was a substantial decrease in hospital stay requirements.

St Peter et al. Prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. Journal of Pediatric Surgery (2011) 46, 173-177

What is the significance of CT-only lung lesions in Wilms' Tumor

The advent of CT imaging of the chest as part of the work up of Wilm's tumor has created substantial controversy. It is natural to assume that lesions of the lung found on CT scan,in the setting of a known primary tumor, represent metastatic disease. False. A study by Ehrlich et al, from the National Wilms' Tumor Study 5 showed that up to a third of lung lesions found on CT only (negative CXR) were not malignant (by pathology). This raises the question of how CT-only lesions should change the management.

Based on COG recommendations, patients who are local stage I or II FH Wilms' tumor should undergo biopsy of CT-only lung lesions to gauge therapy. Patients with Stage III or IV disease, who are enrolled in AREN0533 trial (evaluating response of lung lesions to 3 drug therapy after 6 weeks) are not treated differently in the presence of lung lesions unless these lesions persist after 6 weeks, at which time they would be treated with additional lung radiation, preferably after confirming their malignant nature with biopsy.

Erlich PF. The value of surgery in directing therapy for patients with Wilms’ tumor with pulmonary disease. J Ped Surg (2006) 41, 162-167

"We may need to recannulate this CDH baby!"

That's probably the last thing one wants to hear after answering a page!

Fortunately, the kiddo is doing better and did not require a second ECMO run (near diaphragmatic agenesis). This prompted a search for some literature on the subject of second run ECMO. Took a bit of research but found an article by Meehan et al. that looked at 205 patients from the ELSO neonatal registry who underwent multiple ECMO runs.

My main concern whenever the subject of potential need for recannulation comes up is the issue of recannulating the right CCA and CJV (A scenario encountered in 56% of patients in this study), with the potential for embolic events.

In their review, the authors noted a 20% increase in complication rates, with the largest increase in complication rates being for neurologic (134% increase) and infectious complications (79% increase). The most common type of neurologic complications were clinical seizures and radiologically documented cerebral strokes.

Overall survival after a second run was 38% (32% for CDH).

Journal of Pediatric Surgery, Vol 37, No 6 (June), 2002:pp 845-850

PDA ligation controversies

Well, that was another excellent joint neonatal-Pediatric surgery conference at WCHOB. The subject was PDA and the discussion included basic PDA physiology, morbidity, treatment strategies, post ligation syndrome, and most importantly looked at the evidence (or lack of) supporting the need for PDA ligation.

The discussion began with the general principles of PDA physiology, including the normal role of prostaglandins produced by the placenta and the high intraluminal blood pressure in the ductus (secondary to high pulmonary vascular resistance) in keeping the ductus patent in utero. Normal term delivery reverses these factors and results in closure of the ductus initially by smooth muscle constriction then then anatomic remodeling.

The clinical consequences of a PDA are a result of the left to right shunt, and subsequent change in blood flow to vital organs with subsequent metabolic acidosis, increased risk of IVH and NEC secondary to diastolic steal, and pulmonary vascular disease due to continuous dilation of pulmonary vessels during diastole.

The main strategy for prophylaxis and treatment is the administration of Indomethacin, and when that fails, surgical ligation.

The first issue that comes up is the evidence for the need for the prophylaxis and treatment of PDA.

The literature supports the benefit of the prophylactic use of indomethacin for it's effectiveness of PDA closure, decrease the need for surgical ligation, decrease in the incidence and severity of pulmonary hemorrhage, and decrease in incidence of grade 3 and 4 IVH.

Indomethacin, however, is not innocuous. It can cause a transient change in renal function, increases the risk of GI perforation when administered simultaneously with steroids. It was not found to have any neurodevelopemental effects.

So why should a PDA be treated? A study looking at infants <1500 g showed an 8 fold increase in mortality in the presence of a PDA.

When it came to the subject of surgical ligation of PDA, the data was much less convincing and somewhat troubling. Studies not only shed doubt on the proposed rapid improvement of cardiovascular parameters (Raval et al. J Ped Surg 2007.42(1):69), some actually showed that surgical ligation may be associated with an increased risk of BPD, severe ROP, and neurosensory impairment in ELBW infants (Kabra et al. J Peds 2007;150:229).

Finally, the subject of post ligation cardiac dysfunction was addressed. This results from ligation of the PDA, which results in a sudden switch from volume to pressure overload on the heart which was, as a baseline, subjected to impaired coronary perfusion (form diastolic steal with a PDA), and preexisting pulmonary edema and cardiac failure. Post ligation cardiac dysfunction presents with severe hypotension, failure of oxygenation, and myocardial dysfunction. The hemodynamic profile shifts from pre ligation state of a high preload/low after load and myocardial ischemia from decreased diastolic perfusion, to post ligation state of a sudden increase in after load, decreased LV end diastolic volume, and decreased LV output.

Importantly, the extent of post ligation dysfunction depends on pre ligation hemodynamic, with some authors supporting the prophylactic use of milrinone when the pre ligation LV output is < 200 ml/kg/minute.

As to the management of post ligation cardiac dysfunction, the strategy is to use inotropes that do not increase after load (Milrinone/dobutamine), optimize oxygen carrying capacity, and fluid management.

The upshot on PDA interventions was that prophylactic ligation does not improve outcome, indomethacin prophylaxis decreases IVH and need for PDA ligation, indomethacin prophylaxis does not improve neurodevelopemental outcome in survivors, earlier Indomethacin treatment is associated with higher rates of DA closure. As to the ideal timing of medical or operative closure, that remains to be clarified.

With the current available data, many questions remain unanswered:

can we identify infants whose ductus will close spontaneously?
can we reduce the number of doses of indomethacin without compromising outcome?

Perforated appendicitis: an evidence-based definition

Papers that cause the coveted “ahah!” feeling are very few and far-between. But this one certainly made me go ahah!

In this paper, the authors set out to unify the definition of perforated appendicitis. They pointed out that since the definition of perforation was all over the board, no true conclusions could be made of studies looking at outcome.

The authors defined perforation as the presence of a visible hole in the appendix or the finding of an extruded appendicolith (this definition was used for a prior study they performed). Patients with purulent fluid in the peritoneal cavity who did not have a visible hole as well as patients with a gangrenous appendix were considered non-perforated. Patients in the perforated appendicitis group received a prolonged course of postoperative antibioitcs while those in the non-perforated group received only preoperative antibiotics. The authors then studies the effect of this strict definition on patient outcome, including the rate of intraabdominal abscess formation.

The results were very interesting. Expectedly, the rate of postoperative abscess formation in the perforated group increased from 14% to 18%. This made sense since the denominator in the perforated group was smaller with this strict definition. More importantly, the rate of abscess formation in the non-perforated group decreased, from 1.7% to 0.8%. This was the most important finding in this study. This confirmed that withholding postoperative antibiotics from patients with a gangrenous appendix, or those with “puss” in the abdomen but no true hole, did not result in worse infectious complications.

Defining perforation in clear simple terms, and showing that this definition works, should help prevent unnecessary antibiotic administration, waste of resources, as well as inter-study inconsistencies.

St Peter et al. An evidence-based definition for perforated appendicitis derived from a prospective randomized trial. J Ped Surg (2008) 43:2242-45

Rotational anomalies of the midgut... what's what?

At least once a year, a funny looking UGI study sparks the traditional discussion on rotational anomalies of the GI tract. And the fact that radiologists and surgeons don't necessarily agree on the terms used to describe different types of rotational anomalies doesn't help. Assuming radiologic findings reflect intra-operative findings (and this is assuming with a capital "A"), the following classification is helpful.

Rotational anomalies refers to situations where normal 270 degree counter-clockwise rotation and subsequent fixation of the bowel between the 5th to 10th week of gestation is not completed. Normal rotation results in a wide mesenteric base, which protects the bowel from volvulus (Fig 1. Red line). The most important implication of rotational anomalies is that they result in a spectrum of abnormal mesenteric base lengths, and subsequently variable risks for midgut volvulus. Based on the radiologic literature, the two main types of intestinal rotational anomalies are incomplete rotation and non-rotation.

In the case of incomplete rotation, the most common type, the proximal and distal midgut both rotate between 90 and 180 degrees. This places both the duodeno-jejunal junction (DJJ) and the cecum in close proximity to each other, and thus results in a narrow mesenteric base, prone to volvulus (Fig 2).

The second most common type of rotational anomaly is intestinal non-rotation. In this form, there is minimal rotation (<90 degrees) of both the proximal and distal midgut. This keeps the proximal mesenteric attachment (DJJ) and the distal attachment (cecum) far enough from each other that the risk of volvulus is much lower than that with incomplete rotation.

Although this is a useful classification, it is important to always keep in mind that radiologic findings do not necessarily always reflect true anatomy, and the potential for false positive and negative findings on UGI exist.

Shew S B. Surgical concerns in malrotation and midgut volvulus. Pediatric Radiology (2009); 39:S167-181

My take-home summary of PS233 : To tweet or become extinct?: why surgeons need to understand social networking

The panel discussion started at 230 pm with an enthusiastic crowd and a very welcomed skepticism from a few of the attendants. I say welcomed because such skepticism is critical in keeping a check on how we use social media. Patients are NOT our friends (thank you @jcparamo), but they can be fans of your practice’s FB page, which can be configured to work like a read-only “yellow page” (via @Z1G1).

Dr Philip Glick kicked off the discussion by encouraging the audience to sign up on Twitter and engage the panel through a live Twitter feed (which I’m very pleased to say, many did). Someone even coined the term “loss of Twitter virginity” at the session!
Dr Glick then showed some statistics that reflect the use of social media by members of the American College of Surgeons (ACS). Only one third of ACS members participate in online forums or read online health blogs, which are a major player in patient education. If patients go to health blogs and forums for information, and we are not participating in them, WHO is giving them information?

Zach Glick then proceeded to give the audience an introduction to Twitter, including how to set up the account and “tweak” security setting. Always remember to look for boxes checked by default and uncheck them as necessary! Zach’s section helped audience members sign up on Twitter there and then and experience it’s capacity to spread and exchange information instantaneously by transmitting their tweeted comments and criticisms to a live Twitter feed projected on a screen in the room.

In my section I discussed the use of Twitter in the spread and exchange of information. Twitter’s reputation as a social gimmick has given it a “bad rap”, to the extent that it is difficult to get other surgeons to even listen to the argument for its use. Fortunately, Twitter has become more of a tool used to spread and exchange information than a way to keep up with your friends’ minute to minute activity. When a group of surgeons of similar interest are linked through Twitter, they can exchange pertinent information they find on the web (whether it’s a great YouTube video, or a blog that can help with patient education, or an excellent paper) by sending out a brief tweet with a link (shortened URL) to that source.

Twitter can help surgeons sift through the mass of information on the internet, share what’s relevant, and enrich it with their own thoughts and experiences.

Sussanah Fox (our social media guru!), discussed the different levels of participation in social media, from “lurking” and simply listening-in on what others have to say, to sharing interesting findings with others, to actually creating and contributing to online content. I found this section particularly interesting, given that several of the surgeons in the audience voiced their concern about tweeting and blogging “on a daily basis”. We do not all have to contribute to these resources, but they are there for us to use and experience. We do not have to jump into the deep end right away (via @SusannahFox). I think surgeons should start with simply searching for blogs and forums that discuss medical education (blogs.usask.ca/medical_education), surgical issues (forsurgeons.net), and provide patients with information (preop.com) to get an idea of what’s “out there”. Some may proceed to share and create, others may just keep listening. But I truly believe that we have to, at least, listen.

Rebekah Monson, as Susannah put it, made us all feel appropriately apprehensive about social media. Her contribution was central to bringing home the point that social media, when integrated into our professional, and personal lives for that matter, must be handled with care and reason. She also brought the point home by pointing out that employers hire and fire based on the contents of social media.

Dr Scott Lind wrapped up the session by giving examples of how social media can be incorporated into a practice, sighting how the Georgia Society of the American College of Surgeons has created a mobile app! He also discussed the issue of how surgeons are perceived as arrogant and aloof, based on a patient survey, and how the use of social media can help fight that perception.

The session ended with some very relevant question by the audience, including some very legitimate concerned voiced.

Overall I learned a lot from this panel discussion and particularly from the audience’s reaction and participation. Surgeons seem to be very interested in social media, but have legitimate concerns about ramifications.

ACS congress news report at:
http://www.facs.org/clincon2010/press/thurs.pdf

Bulletin of American College of Surgeons article:
http://www.facs.org/fellows_info/bulletin/2011/peregrin0211.pdf