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Pediatric Surgery Update for Office-Based Pediatricians · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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I'm Holly Wayment, and this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner.
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Click on the link in this podcast for free credit that may include CME,
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MOC, and ethics credit depending on our topic or podcast.
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Today we're talking about pediatric surgery for the office-based pediatrician.
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And I'm thrilled today because joining me back on the show here in the studio is Dr. Ian Mitchell.
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Dr. Mitchell, thank you so much for being here today on Pediatrics Now.
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My pleasure. It's great to be back.
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So you're Associate Professor of Surgery at UT Health San Antonio and Chief
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of Pediatric Surgery at University Hospital?
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That's correct. The new UH Surgery Center at the Multi-Assistance Center next
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to Morgan's Wonderland, for our listeners here in San Antonio and the surrounding area,
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is about to open, and that's in partnership with Morgans and the Gordon Hartman Foundation.
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Yeah, we're really excited about that. It should be opening in September.
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It's a five-bed surgery center that is inside the multi-assistance center.
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Many of your listeners may know or our listeners may know that the multi-assistance
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center is an area that brings together a whole number of medical and social services specialties,
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including even physical therapy and even a hair salon for children and adults with special needs.
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And in partnership with Gordon Hartman and with Morgan's University,
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we'll be running a five-bed outpatient surgery center in that building that's
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specifically designed to cater to the needs of those people and prioritize them.
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We'll be doing surgery and procedures in all kinds of patients,
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but the real focus will be a great home for those patients. So we're super excited.
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Should be opening just a little over a month from now.
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So you're finishing out your non-compete clause, Ian, and no longer doing locum's
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work in Houston or West Texas.
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So you'll be seeing patients again doing surgery in October.
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That's right, October 1. I think they're going to allow me to start at midnight
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plus one minute on October 1st.
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And how has it been this two years, this incredibly talented surgeon not being
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able to do as much surgery as
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you want? I would say slightly above average surgeon, no more than that.
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It's been a little rough. Fortunately, I was able to work at Women's Hospital
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of Texas in Houston and really had a great experience working at Covenant Hospital
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in Lubbock, which was just a fantastic facility and a great staff.
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And here, both at UT and at University Hospital, they have kept me busy,
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obviously, with the surgery center open and our volumes growing significantly.
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So I look forward to continuing the administrative work that I'm doing,
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but definitely want to get my hands busy again.
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You've been helping out a lot with the new Women's and Children's Hospital. It's gorgeous.
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So your new clinic number, and I'll put this in the text for the podcast, but it's 210-743-2500.
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That's correct. correct?
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We're talking today about pediatric surgery for the office-based pediatrician.
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And we can literally start from the bottom and go over what's changed in management
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of conditions that are important to know for our listeners.
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Yeah. So we'll start, we'll basically just go from top, literally all the way to the bottoms.
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And we can go with some chest stuff and then go through G-tubes,
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the hernias, and then finish up with fuzzy butts, which would be pyelonidal
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disease for the uninitiated. So in the chest...
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A couple, two real areas in which the pediatricians are often involved at the
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very beginning and then obviously afterwards when the patients have left the hospital.
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And the first is spontaneous pneumothorax.
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And so spontaneous pneumothorax, I'm sure all of the listeners out there have
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at least seen those patients in residency.
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And many may have had them in the clinic. The typical patient is that skinny,
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lanky, kind of gangly teenager who can almost pinpoint point to the exact minute
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I was doing this or doing that or had a coughing fit and all of a sudden experienced
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some chest pain or maybe very mild shortness of breath.
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The physiology of these kids is amazing.
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I have seen kids with their entire left lung down who are sitting in the ED
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setting, 94% one play PlayStation.
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But overall, as a disease, what's been interesting is the the evolution,
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even in the 12 years that I've been in practice, where we have began to do both
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less in the short term and then more quicker.
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And so APSA, our professional society, American Pediatric Surgical Association,
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came out with some guidelines last year that really put together a lot of what
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we know and then sort of what's still out there and missing.
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Some things that'll surprise people is kids that have a small spontaneous pneumothorax,
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maybe you see them in the office and you order a chest x-ray and it says,
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oh, there's a pneumo, and they get rushed to the hospital.
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If it's small and their symptoms have pretty much resolved and kind of that
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patient I described and they're still just fine, they might get four hours observation,
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repeat the chest x-ray if it still looks the same. You may just send them home.
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And that actually does not fail, as many people might think,
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nearly as much as you thought.
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The next step is, well, maybe they are having more symptoms,
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or you get that repeat x-ray and it's bigger, or it's a very large pneumothorax.
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People talk about doing aspiration and aspiration covers a whole manner of different
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sins to different people.
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Some people have interpreted aspiration as doing it, literally putting a needle
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in, aspirating the air out and pull the needle out.
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What a lot of people have actually turned to instead is putting a small pigtail catheter.
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We're talking about like a 10 French or even a 12 French catheter into these
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big teenagers, draining the air out, connecting that to water seal,
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and then just leaving it. Same thing.
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Putting a clamp on the end of it, and they've now aspirated the air,
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get a chest x-ray, said, okay, the pneumothorax is better.
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Wait a couple hours, get another chest x-ray. If the pneumothorax hasn't changed,
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pull the catheter out, send them home.
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That has also changed. Now, the failure rate of that is, you know,
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can be up to 30 to 40%, but that means 60% of these kids may go home,
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not need anything else in that admission.
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What we also know and are learning, I think, pretty well is that if you fail at an aspiration,
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you put a catheter in, you drain the air out, but the airway accumulates,
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then that's really becoming an indication for us to operate quicker,
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not emergently, somewhere between six to 48 hours.
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But as it used to be, these kids might sit in the hospital with a chest tube
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for four days, and then we decide to operate. So as I said, we're doing less
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up front, but then if they fail that aspiration test, we're doing more quicker
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and taking them to the operating room.
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And these cases can all be done now thoracoscopically where we'll staple off
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a little piece of the lung, do something with the pleura to try and prevent
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pneumothoraces in the future, and the kids do very well.
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Do you want to talk at all about what causes that, or can it be prevented?
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We don't really know about prevention. We know the patient type.
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We know that it's tall, skinny teenagers and young adults, so you certainly
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see this in the 20-year-old crowd as well.
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We do know that there's often some kind of inciting event, and we do know that
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many of them have, we call it Bull's disease or bleb disease,
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and truly I have, the things you see on a surgeon's phone, I have one of the
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world's best pictures of a blown bleb that you can actually see the air coming out of it.
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But literally, they get bubbles at the top of their lungs. They're almost always
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at the apex or the top of one of the lower lobes.
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And we do know that we don't cure the problem by taking those blebs off because
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their lungs can form other blebs.
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But usually between that and the scarring that we create in the chest,
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if they were to blow another bleb
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again, they wouldn't get a big pneumothorax and it's not a a big deal.
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So even though we do all this, they can recur, but it's not very common.
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So these are older kids with well-formed lungs, and they don't have an underlying
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reason other than having blebs to really get a pneumothorax.
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So it's very different from if you're a baby and you're getting positive pressure
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violation or trauma or some other process that causes the pneumothorax.
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Is there anything else you want the pediatric practitioner to know about that
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before we move on to our next topic?
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Just for us, two things that we tell everybody is I think that we can finally
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close the book on CT scans for these patients.
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They don't help. You get CT scans to see often what to do about the other side.
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And the conclusion is don't do anything about the other side.
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Remember, we probably know there are probably millions of people out there that
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form blebs and we don't know anything about it and never present.
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And so using a CT to try and figure out what to do the other side isn't useful anymore.
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We basically just say treat the opposite side as if it doesn't exist.
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And if kids do develop something on the other side, you'd follow the same algorithm.
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Okay. And do you want to mention a case?
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A good case and truly a funny story. When I was a fellow, I actually had a young
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boy, a teenage boy and a teenage girl who both presented with spontaneous pneumothoraces
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one day apart from each other.
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And this was back in a time when we used to keep them on on suction with a chest
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tube in the hospital for about four days.
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And after four days, if it still hadn't resolved, then we would take him to
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the operating room. I set them up on a date.
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Oh, really? And actually, the two of them were, I got them to walk down the
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same hallway in the opposite direction while crossing paths,
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unfortunately, both with their mothers.
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But it was kind of funny to have successfully set the two of them up to meet.
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Unfortunately, he was really into football and she was really into going to
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the Ivy League. so I don't think it would have worked.
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But nowadays, that situation would be unlikely to happen since we're keeping
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these kids in the hospital less.
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Surgeon Ian Mitchell, this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner.
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Coming up next, we'll talk about empyema, and we'll be right back.
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Music.
10:33
Coming up next week i'll interview the editor-in-chief of the american academy
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of pediatrics journal pediatrics he's been a pediatrician for 30 years and he
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says he's just getting started,
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medical education as a lifesaver for our field of pediatrics.
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And when I talk about education, it's not just education of pediatricians or education of students.
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It's education of families, something that pediatricians do each and every day.
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And I presented pediatrics right now as a fairly medical education as a patient
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who had a number of maladies, illnesses that we needed to save.
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And the way we save it is by figuring out how we can better care for our children
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and families, better care for each other, better care for our patients.
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He'll also talk to us about becoming a leadiatrician. That's coming up next
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week on Pediatrics Now, cases, updates, and discussions for the busy pediatric practitioner.
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We are back. You're listening to Pediatrics Now, Cases, Updates,
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and Discussions for the Busy Pediatric Practitioner.
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And here in the podcast studio with me is Dr. Ian Mitchell.
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Ian, what do you want us to know about empyema?
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I always tell you we can have a full-day course on the management of empyema
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and come up with no specific conclusions, and I don't think anybody would come
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to a consensus, but we'll try and do our best.
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I just wanted to add one thing that we didn't touch on in the last section about
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spontaneous pneumothorax.
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Spontaneous pneumomediastinum is an interesting thing.
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It doesn't get nearly the workup in the literature,
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and rare enough, but interestingly, something we do see in the hospital,
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and I thought the audience may just want to know about it, what we do,
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the one-liner for spontaneous pneumomediastinum is actually most of those kids
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get sent home from the emergency department, which sounds strange, right?
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You have air that is in the middle of the chest, in places where there's not supposed to be air.
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And the evolution of this has really come to the more and more we know, the less and less we do.
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And in fact, kids who have just had pain and now the pain is better, we just send them home.
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If they have other symptoms which haven't resolved yet, then a lot of times
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we'll keep them in the house.
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And spontaneous pneumomedicine is one of those things where a kid has a coughing
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fit. A kid has a big Valsalva maneuver. uber.
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The kid has some reason why that occurred.
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It's very different from pneumomediastatum after a trauma or an ingestion of something.
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That's obviously completely different. But these are, again,
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usually skinny, healthy teenagers that for some reason have this air in their chest.
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And I think the take-home message was, is that after years and years of doing
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esophagrams in these kids, when they come into the emergency department,
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guess what? They're all negative.
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They were always negative. And so now, if the kids come home with this,
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pretty much get an x-ray.
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As long as they're doing fine, just send them home.
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The conclusion is the air is not coming from the esophagus.
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There's not a leak in the esophagus. Now, where the air is coming from,
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I think all we can say is the bronchial tree somewhere.
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But at any rate, these kids do really well. So just as the audience may someday
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get one of these patients or maybe get a follow-up of one one of their own patients
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who's left the hospital and been discharged,
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don't be surprised if they went, got an x-ray, and we didn't know anything about it.
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And bottom line, so don't do an esophagrame. Don't do an esophagrame,
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which that's a problem for me.
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I don't think any of our audience out there is going to be ordering esophagrams,
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but don't be surprised if we don't do an esophagrame either and just send the kids home.
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Let's pivot and let's talk about empyema. Empyema.
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Empyema is one of those things where, again,
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I feel silly talking to a group of pediatricians about managing empyema since
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while that is what I do, pediatricians see so much more pneumonia than I ever will in my practice.
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And obviously most of that is managed as an outpatient. And then there's that
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small slice of the pie that are sick enough that need to come into the hospital.
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And then an even smaller slice of the pie that get a perinemonic effusion,
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they get fluid along the lungs.
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And then finally, when that fluid gets infected.
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So I always tell this, you know, for me talking to pediatricians about pneumonia
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is like the carrot on the tip of the penguin's nose on top of the iceberg.
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And you may wonder why penguins are eating carrots, but I'm going to go with it.
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What I can say about empyema is fortunately that it's rare and that its treatment
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is, I think, less controversial than it was before in that
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having these patients putting a chest tube in, giving TPA or tissue plasminogen
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activator over a course of 48 hours, pulling the tube out,
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and VATs taking the kits to the operating room, actually putting a camera into
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the chest and essentially roto-rootering out the pleural space,
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they pretty much have equivalent results.
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If you look at, you can get into arguments all day long with different people
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about crossover from one treatment modality to another.
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Oh, when When chest tube TPA fails, you have to go to VATS. There are other
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people who have rescued VATS failures with chest tube TPA.
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But what I think we can definitively say is that both of them work.
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Neither one is perfect. Some prefer one to the other.
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There are always cost questions and things like that.
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But for the community practitioner, I think the main thing to know is that these
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kids are overall going to do very well when they leave the hospital.
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But it'll take a long time. They're often on antibiotics. Even after we've done
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our thing, they're still going home with antibiotics. antibiotics,
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and that when we do put a chest tube in TPA, we're doing it with small tubes,
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not really the big ones that we used to do.
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And I think it really works well for big effusions with a few loculations.
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It's the perfect for chest tube TPA.
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When it looks like there's a big rind and that infection, maybe that's an infection
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that's been there for days or even weeks, oftentimes we'll treat it more with that.
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But right now, I don't think there's a consensus one way or the other.
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So ultimately, regardless of whether treated with chest tube,
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TPA, or VATS, these kids overall do well, but can still require long courses
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of outpatient antibiotics.
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That's right. The other thing that they do have a small risk for,
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but it's usually more with necrotizing pneumonia, is a pneumatocel.
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And a pneumatocel is just a hole in the lung.
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That's exactly what it sounds like. It's not connected to an airway.
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It's not a pneumothorax.
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It's actually a hole in the lung. And you see that with necrotizing pneumonias often.
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I think of the strep and staph pneumonias as being the main culprits there.
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And the main thing there is those will go away.
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Probably a couple of times a year, we get a phone call or a concern about what
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to do about this child that has a pneumatocel.
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And I have never operated on one now.
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If they were to get enormous and cause some kind of compromise we might.
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We just don't operate on them. Eventually, after years, those holes usually shrink and go away.
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So is there anything else pediatricians should be aware of for these kids long term?
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No. As long as their lung capacity stays good.
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The one thing that we always do ask, if the kids are getting repeated infections
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more than you would expect in a healthy child or even in an unhealthy child, more than you'd expect,
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the goal is to kind of think about what the reasons why might be.
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That's when you start looking for zebras, right? Do they have a congenital lung
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abnormality like a CPAM?
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Do they have potentially even an H-type T officially?
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You do a little bit more workup to try and figure out why those kids might be
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getting those frequent pneumonias.
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And again, sounds like a surgeon, right? I went through all the anatomic reasons.
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We haven't even talked about immune deficiencies and all of those things.
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So I think the take-home message is it's very common for kids to get severe
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pneumonias, and occasionally they'll need an empyema.
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But keep getting pneumonias. You want to try and work on why.
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Now let's start our dive below the diaphragm. I believe there have been some
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big changes with how feeding difficulties are managed.
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So there absolutely have been. You know, when I first started in San Antonio,
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if a child needed feeding access, if they needed a gastrostomy tube, the words—,
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G-tube nissen just rolled off the tongue, right? If you put,
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especially in babies and young children, if you put a gastrostomy tube in,
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it was anathema not to do a fundoplication at that time.
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And a lot of those were for kids with neurologic difficulties,
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but it could also be for just kids who had other anatomic problems or were just
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basic poor feeders, kids with neonatal abstinence syndrome.
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Sometimes for any reason that kids were getting G-tubes, we were doing fundoplications.
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And I think that was also truly the trend nationally.
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What's fascinating is actually, there's been a recent study that looked at data
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now from 2010 to 2020 and looked at 15,000 G-tubes that were put in nationally over that time.
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And 25% of the kids had a diagnosis of some neurologic impairment.
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So for some reason, and these are kids under the age of 17, but obviously most
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are going to be babies and infants.
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But what's fascinating is that over a five-year period, less than 15% of that
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total number of all of those children ended up getting a fundoplication or needed
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a Fundo or a GJ tube later.
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So, you know, it used to be in many cases, you'd say, oh, if the kids were neurologically
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compromised, then they must get a fundoplication to protect against reflux.
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And what we're finding is that that's not really the case.
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In fact, if you look at that study in 2009, 17% of all kids that got G-tubes
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got a fundoplication, whether they were neurologically impaired or not, overall.
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That rate is now less than 5% by 2017. And I personally, I see it just looking
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at the operating room board.
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If you look at our board here at university, we're doing still,
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you know, with a busy NICU, you do a decent number of gastrostomy tubes,
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but the number of fundoplications has gone way down.
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Now, some people, and I'm sure members of your audience have seen this,
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the number of GJ tubes of gastrojejunostomies has gone up.
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I mean, I think, wow, we could have a whole podcast on that one.
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So that number has gone up and the pluses and minuses of that,
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I think many of your listeners will know quite well, GJ tubes are not a perfect solution either.
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They fall out, they slip, the J limb gets lost, their size leaking,
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all those things. So I think the jury's not out, but we do know that we're doing
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a lot less fundoplications that we used to.
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So does this mean kids are now all just getting straight gastronomy buttons?
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Yeah. So most kids are getting straight gastrostomy buttons, I think.
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Whereas, again, we used to do this routinely. All kids or most kids got a Nissen
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fundoplication and a gastrostomy tube.
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Now I would say the vast majority of kids are only getting a gastrostomy tube.
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So obviously you want to check the op reports, but don't be surprised now to
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be seeing kids who may have some neurologic issues and did not get a fundoplication.
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There are certain anatomic conditions that we still do fundoplications on routinely,
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but they're getting less and less.
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Okay, this is something I never thought you would have a breakthrough in.
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Can you tell me about breakthroughs in umbilical granuloma treatment? You got it.
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Probably everybody in listening to this who's a pediatrician said, a breakthrough in what?
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Well, an umbilical granuloma is one of the most probably common umbilical things you see.
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In fact, a lot of people have an umbilical granuloma. And all it is is a fleshy
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piece of tissue at the bottom of a baby's belly button that never really fell off the way it should.
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It's not connected to anything, so it's very different from a patent vitiline duct or a patent uracus.
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So there's not stuff coming out of it except occasionally some clear-looking
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fluid or a little bit of grody-looking stuff.
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But it's just a little fleshy red thing at the bottom of their belly button.
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And truly, you know, as a person who spends a lot of time rooting around in
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people's belly buttons, especially with laparoscopy, we always joke the reason
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people have belly buttons is it's a convenient place to put the camera for laparoscopy.
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You find a tremendous number of kids that actually have little healed umbilical
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granulomas that you couldn't even see.
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But when you're somebody who opens up a lot of belly buttons, you see a bunch.
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But this has been, since I've known, always treated with silver nitrate.
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And actually what is fascinating is if you look at the literature,
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and there's actually a great study out of Malaysia from 2021 that looks at people
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who are in limited resource areas, you can actually put salt on them.
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Just table salt. Really? And actually just dry them out.
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So with silver nitrate, what we would do is take some silver nitrate sticks
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in the clinic, and I'm sure everyone in your audience has done this,
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and touch the umbilical granuloma with some silver nitrate.
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And the kids don't like it, but it's mostly because you're messing with them,
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not more than anything else.
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And my wife would always laugh. She could tell when I'd been treating silver
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nitrate and umbilical granulomas because my hands would always turn a little
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bit gray, the skin of my fingers if some of it ran.
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And, you know, the parents don't like it if the skin around it turns gray,
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although it doesn't cause any problems. It just turns gray for a couple weeks.
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But what's fascinating is actually in an area in Malaysia, they said,
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look, you can actually just take table salt.
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And what they would do is put table salt on an umbilical granuloma,
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put a tape over it for 30 minutes. Do that twice a day. Do it for five days.
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They had a 92% success rate. Wow. Versus actually only 70% success rate.
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Now, they were using copper sulfate, so...
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I would say, not to a horrible pun, take it with a grain of salt.
25:00
But actually, one thing that was fascinating to me is, yep, you can actually
25:05
just put table salt in a baby's belly button, put some tape over it twice a day.
25:09
And if you do that for five days, then their success rate was 92% in fairly rural Malaysia.
25:16
And so an interesting thing for pediatricians, I'm not trying to kill the silver
25:20
nitrate industry, but it's less messy.
25:22
And it's something that the families can do at home. And that may help with
25:26
folks who have parents who are anxious to actually do something about this. There's no harm in it.
25:31
That's what I was going to say. There's no downside. It can't cause harm.
25:35
Nope. And other horrible pun, but you don't put salt on the,
25:40
you know, salt on the wound.
25:41
Do put salt on this. Do put salt on this. Rub some salt into this wound.
25:45
Wow. That's so interesting. Yeah. And I love how a lot of times when we're talking,
25:51
you talk about the simple solution, solution less is more you often give families
25:58
your give the parents your cell phone number.
26:02
When a child's coming in for appendicitis last time we talked and they come
26:06
into the hospital but you're saying let's wait until tomorrow morning and call me if something happens,
26:11
yep pretty amazing okay so since we're focused on the belly button for a minute
26:17
umbilical hernias are an incredibly common problem in the outpatient setting
26:22
and often a focus for parents.
26:25
When should an umbilical hernia be repaired?
26:29
Fortunately, we have some great guidelines on this, and I'm sure,
26:32
again, the audience is well-versed. The AAP put out the Choosing Wisely guidance
26:37
in 2019, which really put the definitive focus.
26:42
Answer to this down and saying that umbilical hernias should wait until the
26:46
child is about four or five years old, certainly no less than four years old.
26:50
And the reason is because 85% of the time these will resolve on their own by age five.
26:55
Parents can be particularly concerned about umbilical hernias.
27:00
And I would say with good reason from a standpoint that, you know,
27:04
I always laugh, I said, pediatrics is a little bit like veterinary medicine.
27:08
Is the baby happy? Is the baby sad? Tough to tell.
27:11
We're trying to interpret what they're doing. And oftentimes,
27:15
other reasons for abdominal pain, such as anything from colic to constipation
27:20
to you name it, to a viral illness, can be focused on the belly button.
27:25
And if you touch the belly button, it hurts. The child has a hernia,
27:27
and it's perfectly logical for
27:29
a parent to go, you know, whenever we touch the hernia, the baby cries.
27:33
Well, we know from adults that umbilical hernias, small umbilical hernias generally don't hurt.
27:40
We know from studies that in children, they almost never cause a significant anatomic problem.
27:46
And so it's understandable that parents would be anxious to have those repaired.
27:50
But I think we are fortunate in that real recognition that unnecessary anesthesia
27:57
and certainly unnecessary surgery is not really the best thing for kids.
28:01
And so we are now in that post-guideline area.
28:05
We've actually had a large study that was done to see how are we doing on following these guidelines.
28:10
And I'm happy to note that 81% of the repairs that were done in a study that
28:15
came out in 2022 were guideline adherent.
28:18
So we still got a fair ways to go. There are always some exceptions to these
28:22
things that I can talk about really quickly.
28:24
And I think one of them is, it's unusual, but probably everyone might have seen one of these before.
28:30
And what I call them, they're called covered omphalocele.
28:33
There's an umbilical hernia and it doesn't matter how big the piece of skin
28:37
coming out of it is. That doesn't matter.
28:39
But that fascial defect, when you put your finger in and you feel how big the
28:43
actual hole is, once in a while you have kids who have these big,
28:48
I mean, we're talking four, five, six centimeter holes,
28:51
and they truly do look like an omphalocele, except it has skin over it and the
28:55
baby's perfectly healthy.
28:57
Those are really the only ones in my mind that we repair early.
29:01
Now, occasionally I'll repair one because I'm already there.
29:04
If you're putting a camera into the belly button and there's an umbilical hernia,
29:07
you just fix it because you're there.
29:09
But really, the need to repair these earlier is just not there.
29:14
And a lot of it is related to parental concerns. So I am happy to have a conversation
29:20
with the family and tell them, I'm not going to do anything.
29:23
These are the reasons why. And some parents will want that assurance and that's fine.
29:27
But you can rest assured, I'm not going to be giving them any different information
29:31
than what you've already given them.
29:34
It's also fascinating to me is that you can start to tell when there'll be tiny
29:38
little hidden umbilical hernias.
29:40
You look inside enough people's belly buttons and you kind of figure out what
29:44
you're going to find under there.
29:46
And we do find that even in those who have closed, there's no way you could
29:50
tell that there's an umbilical hernia.
29:52
You kind of look at their belly button and you go, I bet there's going to be
29:55
just a little something there. And we often find one.
29:58
And some people may ask why repair a small umbilical hernia if it doesn't bother
30:03
the kid if you can appreciate one, why fix it?
30:07
And my answer to that is if you've gotten to about five years old and you haven't
30:11
fixed it, I think the chances that it's going to go away are very, very low.
30:15
What concerns me more is actually what about on the adult side?
30:18
So in children, it's just a couple sutures, a little bit of glue,
30:22
a few popsicles, go home, and most of these kids are bouncing off the walls
30:25
within a couple days. And that's great.
30:27
If people have umbilical hernias and then carry them through as adults,
30:31
when you get to adults, then it's a bigger operation. It's a bigger recovery.
30:35
Now in larger adult hernias, they're using mesh.
30:38
And so I think the need to repair the hernia is still there.
30:42
It just, we can wait a while.
30:44
But, and if it isn't repaired as an adult and it gets worse,
30:47
there can be some of the side effects.
30:50
And there can be problems. In fact, another great way to reassure parents who
30:54
are of course going to go to, well, I used to say Dr. Google, and now it's Dr.
30:58
ChatGPT. Oh, right. The way it's going. But one of the things you'll first learn
31:03
is what's the risk of an umbilical hernia, and they're going to say incarceration, strangulation.
31:06
And what's actually great about that data that I spoke about with the study
31:10
that looked at following the Choosing Wisely guidance is that only 0.5% of those
31:16
operations were urgent.
31:18
And it didn't actually say why they were urgent. It could be that they got the
31:23
repair as part of something else that was urgent.
31:25
So So while we recommend in adults fixing all umbilical hernias quickly or relatively
31:30
quickly because of the chance of a problem happening, the chances of that happening
31:34
in a child, especially a young child, are so low it's not worth it.
31:40
Is there anything else you want to mention in your clinical experience?
31:43
One of the analogs that we're learning about to this is actually pectus excavatum.
31:48
So what we are learning with pectus excavatum is some of those patients,
31:52
so patients that have an indented chest or a cave chest,
31:56
people say, well, you don't need to fix that because they don't have any exercise
32:00
changes or problems, and these kids are perfectly fine as teenagers,
32:04
and it's a cosmetic operation,
32:05
all of which is a very valid potential argument.
32:09
What we are finding now as we start to prepare some of these in adults,
32:14
in 40-year-olds and 50-year-olds, what we're finding is that,
32:18
yes, you didn't have any exercise changes when you were a healthy 17-year-old
32:23
or a healthy 16-year-old.
32:25
But when you're slightly less, speaking as a 47-year-old healthy person,
32:30
you are starting to see some real respiratory benefit and benefit to people's
32:36
ability to do things as adults.
32:38
And so I kind of hearken it back to umbilical hernias.
32:42
Yes, it's a small umbilical hernia and maybe it doesn't bother the child,
32:45
but we don't know what that umbilical hernia is going to look like when they're
32:49
30, when they're 40, when they're 50.
32:50
And if we can fix it when they've got great physiology and great tissue as a
32:55
five-year-old, far better than having to do it as a 45 or 40,
32:58
you know, 50, heaven forbid, even older year old.
33:02
Wow. And the way you explain it, it's kind of a, sounds like a no-brainer,
33:05
but it may be hard for parents to like, okay, let's go ahead with this now.
33:10
If we're in the lower half of the abdomen and talking about hernias,
33:14
let's talk about inguinal hernias in kids and something called the PIRS.
33:22
The PIRS technique. So inguinal hernias, you can't talk to a pediatric surgeon
33:27
without talking about growing hernias, it's impossible, right?
33:31
And so the PIRS technique, everybody after this, you can pause your podcast,
33:37
turn on YouTube and just put in PIRS hernia.
33:41
And what you'll see there is a video of how a lot of people,
33:44
myself included, are now fixing inguinal hernias in children.
33:49
Obviously, if you're driving, please pull over. So one of the things that you'll
33:54
notice, and this has really taken off over the last 10 years,
33:57
I would say we were fiddling around with this about 15 years ago.
34:01
And now I would say in looking at the studies, almost the majority or starting
34:05
to be the majority of hernias are taken care of in this way.
34:09
And it is a laparoscopic hernia repair, but it's very, very different from the
34:14
way adults repair hernias. As adults, you can either do it open,
34:18
but you can do it laparoscopically, or now, very commonly with a robot, you do a big dissection.
34:23
You take the peritoneum down, you pull the stuff out of the hernia sac,
34:26
you put a big piece of mesh up there, and you close the peritoneum.
34:29
And even though it's done minimally
34:32
invasively, what you're doing on the inside, it's pretty invasive.
34:36
If you watch that video or if you've seen any videos of us doing these,
34:40
ours is almost like a sneak attack. We put a camera in through the belly button
34:44
and just put a needle and get that needle right onto the edge of the hernia sac.
34:49
And a boy, you'll use hydro dissection to just move the vas deferens and the vessels are up.
34:54
And all we do is tie that sac off. There's no mesh. There's no anything else.
34:59
There's one incision for the inside the belly button.
35:03
There's a tiny little three millimeter incision, which only mom can find,
35:07
you know, two months later for an instrument and then just a needle poke.
35:10
The other beauty of it is, is that we can do both sides.
35:14
So just because you see a hernia on one side doesn't mean there isn't one on
35:18
the other. Great chance to take a look and fix the other side.
35:21
So it's a great technique. I personally have found it very, very useful in my young babies.
35:27
So when you were doing these in two and a half, three kilogram babies who have
35:31
really tough tissue to deal with, I prefer it than the open technique.
35:35
They're both great operations.
35:37
There's no, you know, recurrence differences of any significance or anything like that.
35:42
Just personally, got to be honest, it's fun and it's a little bit an easier
35:45
operation that I found than the open one.
35:49
Now we have some data though, and it's not really on the technique because I
35:53
can tell you that in this trial, the technique was 50-50.
35:55
So the technique wasn't anything else, but many of you who take care of any
36:00
babies that are coming out of the NICU would want to know that one question
36:04
is when do we repair the hernias in a baby?
36:07
And it has been a subject of great controversy for a long time.
36:11
I was certainly trained that all babies got their hernias repaired before they
36:15
left the NICU because of the risk of incarceration.
36:18
And people have been pushing that for some time.
36:21
Now, one of the downsides of waiting is that because of the risk of apnea,
36:27
when you operate on these babies until they're a little bit older, you had to wait.
36:32
In fact, you had to wait until 55 weeks post-conceptual age to put them to sleep
36:37
and then send them home same day.
36:39
So one of the issues was is always, well, we should operate on them before they
36:44
leave the NICU because they're going to otherwise will have to wait months and
36:47
they'll have this hernia for months and it will become incarcerated.
36:50
And so it took a long time, but we finally had something called the HIP trial,
36:55
H-I-P, that looked at babies less than 37 weeks that have a hernia.
36:59
It took a while to do it, September 2013 to August 21, but we did get some data.
37:04
And that was in JAMA in March of this year? Just came out in JAMA March of this
37:08
year. Like I said, you know, lukewarm off the press if you want to put it that way.
37:13
And what I want to say is first, just to mention the exclusions.
37:16
So the things that stopped you from enrolling in the trial were obviously if
37:20
you were doing another operation on the baby and they have a hernia,
37:23
so you just fixed it while you're there.
37:25
If there was a known major congenital or chromosomal abnormality that would
37:29
influence the development of their outcomes.
37:31
So these have to be relatively normal, healthy babies.
37:35
So again, that gets back to if you have severe, for example,
37:38
if you have intraventricular hemorrhage or other developmental issues that may not be able to.
37:44
And honestly, one thing that concerned me or that I think about in some of our
37:49
population is the family was
37:50
unable to return for follow-up and then get a late angle to hernia repair.
37:54
So if you have patients or families that were really concerned that they,
37:58
that for whatever reason of the million reasons, they may not be able to come
38:02
back, spend a whole day here in the hospital, get an operation, take that baby home.
38:06
Those patients were excluded. Now, I don't know how they determined that,
38:10
but it's also something to consider when you think of the results.
38:14
In the end, what was interesting too, they assessed 1,500 babies.
38:19
730 of the parents said no, they were not interested in the trial or were unavailable.
38:24
So I think there was a lot of parental hesitancy, honestly, probably to take
38:29
these babies home without having those hernias fixed. So eventually it was about 150 in each group.
38:34
And what they really were focusing on was what's the adverse events?
38:37
What were the bad things that happened?
38:39
And it was very clear that in the early group, so the group that got their hernias
38:44
fixed before they left the NICU, they had a 28% risk of an adverse event.
38:51
And almost all of those adverse events were apneas, so the baby not breathing
38:56
quite right, requiring intervention, and then a prolonged intubation.
38:59
And that's kind of what you'd think, right? We have babies who are still,
39:02
you know, their lungs are still very much developing and getting ready from
39:07
coming out of the womb, as opposed to the late group, where they only 18% of
39:12
them had an adverse event.
39:13
And again, a few more of the other kinds, but overall, we see that there is
39:18
definitely more adverse events in those early repairs.
39:22
So those kids were doing, before you're leaving the NICU, from a respiratory
39:27
standpoint, from an overall physiologic standpoint, they did better with a late repair.
39:31
And that should make intuitive sense, right? We're going to operate on a baby
39:35
sometime later when they're a little bit bigger, and certainly they were bigger,
39:39
and they're a little bit more robust, and so they tolerate the operation well.
39:43
What was fascinating to me about this is that the incarceration rate,
39:47
so the real problem that we're worried about that we're operating for in the
39:52
late repair group was only 4%. And it was 1% in the early repair.
39:56
So one kid actually, even though you operate early, still incarcerated.
40:00
I think the take-home message to the listeners and to everybody that's out there
40:04
is to say, we now have a randomized control study that says in this particular
40:09
patient population, and I would emphasize that, it's probably better.
40:13
If you can, to wait to fix those hernias until the kids are bigger.
40:18
And I mentioned the PEARS technique at the very beginning, because I have to
40:22
be honest, in my practice,
40:23
I used to prefer doing this before the kids lived in ECU, because why fix a
40:28
hernia in a kid that's been sitting there for 12 weeks when I could fix it when
40:32
the kids just had it for a few weeks?
40:37
So it's a smaller hernia in my mind, and it was easier to handle.
40:40
But I think now, especially with the laparoscopic technique.
40:43
It's pretty fun and pretty straightforward either way.
40:47
And so I think what you'll see as a pediatrician is that you may start to see
40:51
more kids coming home with a known hernia that we are going to wait to fix until
40:56
a later date. Anything else you want to add?
40:59
No, for that, I just think that this represents kind of a real shift in the thinking.
41:06
Thank you, Ian. You're listening to Pediatrics Now.
41:10
I'm talking to pediatric surgeon-in-chief at University Hospital, Dr. Ian Mitchell.
41:15
And coming up next, I think I'm reading this right, we're going to talk about fuzzy butts.
41:20
Fuzzy butts. The last thing we'll talk about for any pediatrician out there
41:24
and goes, fuzzy, oh, pilonidal disease.
41:27
This is the bane of a lot of pediatric surgeons' existence, and I always laugh.
41:33
Somewhat like trauma, but even more so, So there is a small core group of pediatric
41:37
surgeons, and I will admit to being one of them, who are somehow,
41:40
for some reason, fascinated with the care of this disease.
41:43
And I got to tell you, pretty much every group has somebody like this.
41:47
And you don't get a lot asked of you if you will be the person who takes care of pyelonidal disease.
41:54
But I'm happy to do it. And actually, it's a disease that just is so embarrassing
42:00
for so many teenagers, and it's so great if you can actually help them.
42:05
And so most of the listeners are obviously familiar with pyelonylasease,
42:08
but it's basically pits and infections that happen at the middle of your butt crack.
42:13
And what's fascinating to me is the number of people that actually have those
42:17
pits, but never actually develop any disease.
42:19
We know that in the hirsute population, it's much more common.
42:23
And I would also put a plug in for in San Antonio, in my personal experience,
42:28
we have a lot of girls that have this problem.
42:30
And you have to think how embarrassing it might be as a teenage girl to have
42:34
an infection that's due to hair in the middle of your bottom.
42:38
It's really something that I think weighs on kids a lot.
42:42
And you might say, well, that's not a big deal, but imagine being in high school
42:45
and that's your problem.
42:47
It would be so stressful. The good news is, is that before about 15,
42:53
maybe 20 years ago, we had about six or seven different operations that were
42:58
meant to fix pilonidal disease.
43:00
And I I think every time you go, there are six or seven different operations to fix something.
43:04
I think the next question is, well, they probably don't work that well because
43:08
otherwise there just would have been one. And...
43:11
We owe a lot to an Israeli army surgeon named Gips, G-I-P-S,
43:16
and I still refer to it as a Gips procedure,
43:18
who had an idea of actually, instead of operating out, taking a skin trophene,
43:22
which are those little punch biopsies that dermatologists use,
43:26
and instead of doing these big flaps and operations,
43:29
coring out the pits, getting all the stuff and the hair and everything out from
43:33
underneath, and then mandating good hygiene.
43:36
And what we have found is actually that has, I would say, revolutionized the
43:40
care of this disease in the last 10 to 15 years.
43:43
When I left fellowship, I was doing probably 10 to 20 flaps a year.
43:49
And in my last five years of practice, I think I did two.
43:53
And they were for people who had failed multiple other surgeries previously.
43:59
And so two things that people should know about.
44:02
Number one is we finally have data that proves that lasers work.
44:08
And while you might think, Well, duh.
44:10
But actually, we used to try and get all of these patients that had mild disease,
44:15
teach them how to clean their butt, because as you as a parent probably know,
44:19
sometimes getting a teenage male to clean his butt is not the easiest thing in the world.
44:23
Yes, I have a 16-year-old son. So, but we were using saying soap and water and
44:28
actually shaving or using narrow depilatories and those sorts of things.
44:32
And we would always suggest, hey, laser is the best.
44:35
Laser will get rid of the hair. And if you get rid of the hair,
44:38
the disease gets better. of the problem is I have argued with,
44:41
I don't know how many people from insurance companies who would refuse to pay
44:45
for laser hair removal because it was argued as being cosmetic.
44:49
And it doesn't matter. I'm trying to explain to them, you know where I'm asking them to laser?
44:54
Like there is nothing cosmetic about this area. And I would lose.
44:58
But actually we've been very fortunate.
45:00
There have been a couple articles recently that actually looked at first,
45:05
just not even doing necessarily, we call it surgery, doing in-office treatments
45:09
where the kids are personally, they're put on a hygiene program.
45:13
So you got to take a shower twice a day. You got to wipe your butt with soap and water.
45:16
They actually have a laser in the office. I said, it's Boston Children's.
45:20
So of course they have a laser in the office, but they take care of these kids
45:24
with laser and they do the little punch technique, the Gibbs technique in the
45:28
office, which you can do under local in a lot of teenagers.
45:32
And so they actually were able to prove that in mild disease,
45:36
and mild disease was defined as kids that only have, they can have as many pits
45:42
as you want, but none are bigger than two millimeters, that actually 99% resolve their disease.
45:48
If they got laser, proper adherence to the program, and they got their pits
45:53
done in the office, 99% resolve their disease.
45:56
Now, again, this is those with mild disease, and those are probably not the
46:00
ones that make it to my office.
46:01
But what it did show is that laser hair removal actually works and has a benefit.
46:07
And finally, there was actually a randomized control trial.
46:10
So January, JAMA again wins the prize this year, but January 2024,
46:15
JAMA showed that actually proved a 23% decrease in infections and problems with laser hair removal.
46:22
And so that's really one thing that we're now able to definitively say laser
46:28
hair removal for pilonidal disease works.
46:30
And if it doesn't, or if these get infected, or if they have more severe disease,
46:35
we have really shifted to this minimally invasive approach where it's something
46:40
you could do in the office, but with the amount of inflammation that a lot of
46:43
these kids have, honestly, it's better in the operating room.
46:47
We turn them on their sides and actually do it on a stretcher because it's from
46:50
a surgical standpoint, it's really straightforward to do, but we clean everything
46:54
out and get them to heal up on the inside.
46:57
You won't believe this, and your listeners won't, but there are actually people
47:01
who are now putting cameras into the pits to make sure that they got everything out.
47:06
So you're actually doing an endoscopic pilonidal abscess or cyst procedure.
47:11
I think that's fancy but unnecessary is how I would describe it.
47:15
We've had really great success just doing this the old-fashioned way,
47:18
and the kids have really done well.
47:20
Wow. So really, again, so much of this is good cleft care and laser hair hair
47:25
removal, this can help actually cure disease or at least minimize the surgery that needs to be done?
47:31
Absolutely. And I'm sure that.
47:34
Dr. Wiggins, my partner, is very happy to have somebody who likes pilonidal
47:38
disease coming back into the clinic.
47:40
So I'm sure I'll be seeing a lot of these patients moving forward.
47:43
And Dr. Wiggins is going to be on the show in a couple months talking about
47:47
what to say in the exam room about guns to parents.
47:51
And she's really involved in that complicated topic and an important one. Yep.
47:59
Do you want to say anything about the laser hair removal? Is it so much just,
48:03
is that, you know, to say to a teenager about that, that probably sounds very painful.
48:08
And I think to a teenager explaining leaves or hair removal is the way I do
48:13
it with them is if you just grab somebody's forearm a little tight and then
48:17
pull your, pull your hand off to tell you that it tickles, the answer is no.
48:22
But I've actually had someone test a laser on me, not in my butt,
48:26
but just to, you know, they needed some people to literally test the laser. And so they tested on me.
48:31
And my answer to that is that's what it feels like. It feels like somebody grabbing
48:35
your arm and stretching your skin.
48:36
It's certainly not comfortable, especially in that sensitive area.
48:40
But after the first or second treatments also, it becomes pretty straightforward.
48:44
Is there a particular type of laser hair removal treatment center to look for?
48:49
Anything you want to say there? Most dermatology offices, anyone that is equipped
48:56
to do laser hair removal that's reputable and good at it should be able to handle
49:00
what needs to be done. There's not anything specific.
49:03
The only thing that I do recommend is going to a dermatology office because
49:08
what I have found is that if you go to some of the more cosmetic places,
49:12
they actually miss the very bottom.
49:15
So I have a couple people who have, unfortunately, these poor kids have gone
49:18
through eight laser treatments, and they didn't do the inside,
49:22
literally the bottom of their butt crack.
49:24
And so they have very nice, smooth bottoms, except for the one part that I needed.
49:29
And so I always tell everybody, make sure you go to a dermatologist's office
49:33
because they know exactly where to go.
49:36
This has been so fascinating. It's such an honor to talk to you today, and I thank you.
49:41
Nothing, only to say that we're always here. A lot of times I think.
49:46
People have a concern that they have to get all the answers right the first time.
49:50
And I always encourage anybody, no, as I said, this audience sees so many children
49:57
and I see a very, very small number and a very small part of them.
50:01
And so I always emphasize that we're always here to ask questions.
50:06
Most of what I do in this part of the arena is not urgent.
50:10
And so telling a family that I'm going to check with the pediatric surgeons
50:13
and get back to you, We're always happy to do that.
50:16
And so that parents and families can feel comfortable.
50:19
And also that you can be backed up by knowing that if they go to Dr.
50:23
Google, you'll have somebody else on your side too.
50:27
Is it okay if I put your email address in the text? Absolutely.
50:31
And so you do surgery, you will be doing surgery at University Hospital?
50:35
That's correct. At the new Women's and Children's Tower? tower?
50:38
And clinic will be starting on Wednesdays. It sounds like it will be at the
50:42
Robert B. Green building downtown.
50:44
So that will be our first clinic outside of this building.
50:48
And as university continues to build more buildings, we anticipate having more clinics.
50:53
And then you'll be seeing patients at that new multi-assistant center next to Morgan's Wonderland.
50:59
And there will be operating. So we won't have a clinic there.
51:02
In fact, it has been such a smashing success that there is no more clinic space
51:07
in that building, but we'll certainly be operating there.
51:10
And most of what we've talked about today would be the kind of operations that are perfect.
51:14
You come in, drive up, we do the operation in a really nice setting.
51:19
For those who haven't seen it, if you're driving up 35 and the person who's
51:24
not driving looks to the left near Toyota Field, you see a giant,
51:27
beautiful purple building.
51:28
It couldn't be a better place for a child or an adult, honestly,
51:33
to have surgery here in San Antonio, and so we're really looking forward to
51:37
it. And that's called the Multi-Assistance Center?
51:39
Mm-hmm. And the phone number again is 210-743-2500.
51:44
Yeah, that's for appointments for our clinic. That's amazing.
51:47
And another recent development that...
51:51
It would be nice for us to mention, this is off topic, but the new pediatric
51:56
for our listeners in town and in the area, the new pediatric ENT clinic in the
52:02
Deerfield area of town, that's a university hospital facility,
52:05
is opening August 5th.
52:08
That's correct, Dr. Don Moe, Dr. Wazel Sharameda. Many of your listeners might
52:13
remember Dr. Bonilla. Dr.
52:15
Bonilla is, I would say, 90% retired, but Dr. Moe and Dr.
52:20
Sharameda's clinic is now being open, is reopening under the guise of university.
52:25
And so we're excited. They have already toured the MAC Surgery Center.
52:29
And again, what better place to have ear tubes, tonsils, and all the ENT needs
52:33
taken care of than a surgery center designed for this population.
52:37
And there's been such a shortage of doctors, still is a shortage.
52:41
That's correct. And we're still looking for more. Yes.
52:46
That's great news. So by the time when this podcast airs, that clinic will be
52:50
up and running and they're already accepting referrals.
52:54
And then is there a new pediatric plastic surgeon coming from England? Glenn.
52:57
Dr. Richard Thompson will be joining us. The timeframe for that isn't quite clear yet.
53:03
I think that we know when he's going to get here, but you know,
53:06
Texas license and all that sort of stuff needs to get taken care of,
53:10
but we're excited for him to be helping both with a lot of our trauma needs.
53:14
So obviously he's a level one trauma center. Having someone who is dedicated
53:18
to pediatric care will be really important and all he has a significant amount
53:23
of craniofacial experience as well.
53:25
And so we'll be looking at how to integrate him in multiple areas.
53:28
Our vascular anomalies clinic can also use the benefit of having a pediatric
53:32
plastic surgeon. So he'll be busy.
53:37
And I interviewed Dr. Priyanka Kondal about the ER and summer safety.
53:42
Is there anything you want to mention, too, about the urgent side of things, the ER?
53:47
I think from this standpoint, we are the ER is probably waiting for all the
53:52
kids to get back into school because the trauma levels go down.
53:57
And then you just say, well, but
53:58
the orthopedic surgeons will tell you the football season will start soon.
54:01
So I think the answer that we've certainly found here with Women's and Children's
54:06
Opening is that the the lull in our census, which you would typically see in
54:11
the summer, never happened.
54:12
And so we've been busy from the day we opened the building and it's a little
54:17
bit less like less than we expect in respiratory season, but it's a lot busier
54:22
than it's been before. So we're ready.
54:24
And here on Pediatrics Now, I love to focus on doing things outside of medicine
54:30
in this high stress, high burnout career, recharging our batteries.
54:34
I know you'd like to travel.
54:35
Is there a trip you'd like to tell us about that you've gone on recently?
54:38
Oh, just my recent one was I grew up in Toronto and went up to took my children
54:44
five, eight and nine up to camp north of Toronto up in Algonquin Park.
54:48
And then we went to go visit a cousin who lives in rural Nova Scotia just about
54:52
an hour outside of Halifax.
54:54
And I laughed because I got to the town and said, this place looks like a Hallmark
54:58
movie, to which my cousin turned to me and said, they've actually filmed the
55:01
Hallmark movie. Really? Wow.
55:06
Just it must be amazing. It was great. Dr.
55:10
Ian Mitchell, Surgeon-in-Chief for Pediatrics at University Hospital and the
55:16
University of Texas Health Science Center, thank you so much for being here
55:19
on Pediatrics Now. My pleasure.
55:21
Music.