This video, featuring Dr. Beth Rymeski from Cincinnati Children's, details the procedural aspects of Fetoscopic Endoluminal Tracheal Occlusion (FETO). It explains how a fetoscope is used to insert and inflate a balloon in the fetal trachea, facilitating fluid buildup and lung expansion to prevent pulmonary hypoplasia in babies with Congenital Diaphragmatic Hernia (CDH). The video provides an inside look at the navigation and key steps involved in this intricate fetal surgery.

Lizzie Lee from Cincinnati Children's discusses a study on pediatric pulmonary vein stenosis (PVS), a rare but serious condition. The research compares surgical and catheter-based interventions, revealing high recurrence rates for both approaches. It emphasizes the need for ongoing surveillance and multidisciplinary care for affected children.

Daiji Takajo, Paul J Critser, Awais Ashfaq, Russel Hirsch

Background: Pulmonary vein stenosis (PVS) is a rare but serious condition in children, often requiring surgical or catheter-based interventions. The initial optimal treatment strategy remains unclear due to disease complexity, progression, and high rates of recurrence.

Methods: In this retrospective, single-center study, we identified children with primary or secondary PVS from a cardiac catheterization and surgical database between 2015 and 2023. Patients with single ventricle physiology were excluded. Demographics and outcomes were compared between patients who underwent catheter-based intervention only and those who underwent at least one surgical pulmonary vein repair, with or without subsequent catheter-based reintervention. Reintervention following surgical repair was assessed using Kaplan-Meier analysis.

Results: Among 56 children with biventricular physiology and PVS (33 males, 59%), 16 (29%) underwent at least one surgical repair at a median age of 9 months (IQR 4-20), while 40 (71%) were managed with catheter-based interventions alone. Surgical repair was more frequently performed in patients with bilateral or complex disease, particularly those without prematurity or with coexisting congenital heart defects requiring open-heart surgery. Over time, catheter-based approaches became increasingly preferred. Overall, 92% of surgical patients required reintervention, most within the first year. Mortality did not significantly differ between groups (p = 0.294). In the surgical group, elevated right ventricular/systemic systolic pressure ratio (HR: 1.25, p = 0.048) and the presence of scimitar syndrome (HR: 8.25, p = 0.011) were associated with increased mortality.

Conclusions: Surgical pulmonary vein repair remains an important option, particularly in cases where catheter-based intervention is not feasible due to anatomical challenges or when multiple pulmonary veins are severely affected. However, recurrent pulmonary vein re-intervention is common, regardless of whether the initial approach was surgical or catheter-based.

https://pubmed.ncbi.nlm.nih.gov/41995823/

This video explores innovative technologies for central line management, focusing on solutions for blocked superior vena cava (SVC). Dr. Nathan Fagan discusses the MeritMedical Surfacer system for image-guided SVC recanalization via a femoral approach. The presentation also delves into the potential of 4D intracardiac echo catheters for radiation-free recanalization and reviews transhepatic and translumbar access as last-resort options when traditional venous access is lost.

Lizzy Lee from Cincinnati Children's discusses a pertinent study on the utility of invasive genetic testing, specifically Fluorescence In Situ Hybridization (FISH), prior to fetal surgery. The research questions whether FISH provides additional actionable information when non-invasive screening methods like ultrasounds and cell-free DNA already indicate a low risk for aneuploidy. The findings suggest that for carefully selected low-risk pregnancies, non-invasive screening may be sufficient, potentially avoiding the FISH procedure.

Ethan Lorence, Katelyn Seither, Hua He, Kara B Markham, Beatrix Wong

Objective: Current inclusion criteria for fetal surgery at most centers include the absence of multiple major anomalies and a normal chromosome analysis or fluorescence in situ hybridization (FISH) for aneuploidy. We evaluated the concordance of FISH with non-invasive screening methodologies to determine if invasive genetic testing provides additional information on fetal surgery candidacy.

Methods: A retrospective chart review was performed on 963 pregnancies evaluated for fetal surgery at the Cincinnati Children's Hospital Fetal Care Center between July 1, 2018 and July 31, 2023 for genetic testing results, fetal imaging, and surgical candidacy.

Results: FISH was concordant with screening results in 100% of pregnancies whose imaging and cell-free fetal DNA screening suggested a fetus at low risk for trisomy 21, trisomy 18, trisomy 13, and sex chromosome aneuploidies. Pregnancies with multiple congenital anomalies were significantly more likely to have abnormal genetic testing compared to pregnancies with isolated anomalies (52% vs. 17%, P = 0.0009).

Conclusions: In this study cohort, FISH did not provide additional information for the risk-benefit analysis of fetal surgery and introduced additional risk to the pregnancy due to the need for invasive fetal DNA collection.

This video discusses the critical challenge of maintaining surgical skills for rare procedures like posterior sagittal anorectoplasties (PSARP) due to low case volumes in pediatric surgery. It introduces a novel high-fidelity, 3D-printed PSARP simulator developed by researchers from leading children's hospitals. The simulator, which accurately replicates complex anatomy and haptics, has been validated as an effective teaching tool that reliably differentiates expert from novice surgeons.

Claire A Ostertag-Hill, Prathima Nandivada, Aaron P Garrison, Richard J Wood, Michael G Silver, Gregory Loan, Stephen F Wilson, Belinda Hsi Dickie

Background: The reconstruction of anorectal malformations (ARMs) is a technical but reproducible operation. The average number of ARM repairs performed by U.S. pediatric surgery trainees is 15 with recertifying pediatric surgeons performing an average of only 2 ARM repairs annually. The aim of this study was to investigate the validity of a surgical simulator that replicates the steps of repair.

Study design: A high-fidelity ARM simulator was designed using digital modeling software packages and fabricated using 3D-printing, hand-sculpting, and multi-stage silicone injection molding techniques. A cross-sectional observational study was performed at an international surgical meeting, recruiting 27 surgeons (n = 11 experts, n = 16 novice). Each participant performed a posterior sagittal anorectoplasty (PSARP) on the model and completed a questionnaire on the model's realism and didactic value. Each session of the simulation was recorded and independently assessed by 3 experienced pediatric colorectal surgeons (raters) using a standardized general skills (OSATS) and PSARP step-specific assessment tools.

Results: All items, including anatomical structures, haptics, and procedural steps, were evaluated as significantly better than neutral (p-values 0.003 to ‹0.0001). Significant differences between the groups were observed for multiple items in the OSATS checklist, including respect for tissue (p = 0.017), instrument handling (p = 0.012), flow of operation (p = 0.004), and knowledge of specific procedure (p = 0.014). Additionally, there were significant differences in performance by experts and novices on all PSARP steps as evaluated by experienced pediatric colorectal raters (p-values 0.005 to 0.046).

Conclusion: Evaluation of a newly developed high-fidelity, 3D-printed anorectal malformation surgical simulator demonstrated face, content, and discriminant construct validity. Given the low number of PSARPs performed annually by surgical fellows and attendings, this simulator can offer a high-fidelity training tool.

Dr. Nathan Fagan, a Pediatric Interventional Radiologist from Akron Children's Hospital, presents a clinical scenario on central line management from the 13th Annual Pediatric Surgery Update Course. He discusses diagnosing and managing a malfunctioning subclavian dual-lumen port, highlighting how proper access assessment can prevent unnecessary port removal. The video also covers interventional radiology techniques like sharp recanalization of the Superior Vena Cava (SVC) to restore vascular access for complex patients.

Don't forget to like and subscribe to see more entertaining medical educational videos!

See more lectures, articles, and more on the Stay Current app: https://www.globalcastmd.com/stay-current-app-download

Dr. Todd Ponsky from Cincinnati Children's Hospital leads an interactive course discussing controversies and various techniques for inguinal hernia repair, particularly focusing on the laparoscopic approach. He presents patient scenarios and audience polls on management of issues like an unconfirmed groin bulge, incidental patent processus vaginalis (PPV), and contralateral evaluation during surgery. The discussion delves into the advantages of laparoscopic repair, especially for incarcerated hernias in preemies and adolescents, while also addressing concerns related to cosmesis, pain, and potential infertility risks.

This video series recaps highlights from the 13th Annual Pediatric Surgery Update Course. Dr. Juan Gurria discusses the pros and cons of robotic surgery in pediatric patients, comparing it to laparoscopic surgery, and exploring its future. The discussion covers surgical proficiency, cost-effectiveness, and various indications for robotic interventions in children.

For more information on Dr. Juan Gurria at Cincinnati Children's, click here: https://www.cincinnatichildrens.org/bio/g/juan-pablo-gurria

This 2 hour course is focused on teaching the fine points of a particular technique, Laparoscopic Pediatric Hernia Repair

Recently, the non-mesh laparoscopic pediatric hernia repair in children and adolescents has gained immense popularity. This event, is designed to provide practicing surgeons what they need to know in order to perform this procedure on their own and
focused on the fine points of the technique.

This video discusses a new research study from Cincinnati Children's exploring the impact of remote patient monitoring (RPM) on NICU infants discharged with nasogastric (NG) tube feeding. The study found that babies in the RPM group went home earlier, experienced better growth, and had a significantly lower risk of unplanned ER visits or hospital admissions. This suggests that pairing NG tube feeds with RPM could help fragile babies thrive at home while reducing unexpected hospitalizations.

Rebecca D Henkel, Kristin Melton, Tanya Cahill, Melissa House, Julisa Muñoz, Christa Tabacaru, Chunyan Liu, Shelley R Ehrlich, Heather C Kaplan

Objective: To examine whether discharge with remote patient monitoring (RPM) is associated with improved outcomes among infants discharged from the neonatal intensive care unit with a nasogastric tube (NGT).

Study design: This was a retrospective cohort study of infants discharged with an NGT from the Cincinnati Children's Hospital Medical Center neonatal intensive care unit from 2015 to 2022. Infants were divided into pre-RPM and RPM cohorts. Differences in clinical characteristics, weight at follow-up, and unplanned health care utilization were evaluated using multivariable generalized linear regression models.

Results: There were 385 eligible patients (n = 139 pre-RPM, n = 246 RPM). Infants discharged with RPM had higher rates of prematurity. The RPM group was discharged at an earlier postmenstrual age (43.00 vs 44.12 weeks, P = .0102) and had more favorable change in weight z-score at follow-up (0.21 [0.03, 0.4] at 3 months, 0.34 [0.09, 0.58)] at 6 months). The risk of unplanned admissions or emergency department visits was 53% lower in the RPM group than in the pre-RPM group (risk ratio = 0.47 [0.28, 0.79]).

Conclusions: Patients discharged with an NGT plus RPM were discharged at earlier postmenstrual age, had more favorable growth trajectory, and had fewer unplanned health care encounters, indicating that discharge with NGT feeds with RPM appears to be safer and more effective than discharge with NGT feeds without RPM.

Full text: https://pubmed.ncbi.nlm.nih.gov/40945579/

This video breaks down a case series discussing levonorgestrel IUD placement in patients with uterine anomalies, challenging current CDC guidelines that classify IUD use in distorted uterine cavities as contraindicated. It highlights the experiences of five patients, their IUD expulsion rates (40% over 4.5 years), and crucial considerations for shared medical decision-making in this complex patient population. Key factors include the potential need for device modification and imaging (ultrasound or hysteroscopy) during placement.

This video, featuring experts from Cincinnati Children's and Akron Children's, provides an in-depth look at Vertebral Body Tethering (VBT) for pediatric scoliosis. It covers clinical scenarios, highlighting VBT's advantages as a minimally invasive, non-fusion alternative to standard spinal fusion. The discussion includes precise timing for the procedure, current indications for patient selection, detailed surgical techniques for thoracic and lumbar approaches, and post-operative outcomes, emphasizing improved recovery times for young athletes.

Dr. Megan Reed Ivaturi from Nationwide Children's Hospital discusses a recent study published in the Journal of Pediatric Surgery on the long-term outcomes of bowel neovagina creation for patients with cloacal malformations. The study evaluated 40 patients, comparing outcomes between small bowel and colonic neovaginas, and highlighted the importance of long-term follow-up for function, stenosis, and quality of life.

Kristine L Griffin, Wendy Jo Svetanoff, Megan A Read, Shruthi Srinivas, Geri Hewitt, Richard J Wood, Chelsea A Kebodeaux

Introduction: Up to 60 % of patients with a cloacal malformation have a Mullerian anomaly. In cases where the vagina is absent or cannot reach the perineum, an intestinal neovagina is often created. The complications and outcomes of this are not well described. We aimed to describe the gynecologic outcomes of patients who underwent neovagina creation followed at our institution.

Methods: A single institution retrospective review of patients ≥8 years old with cloacal malformation who underwent intestinal neovagina creation was performed. Demographics, surgical history, short-term complications, and long-term gynecologic outcomes were assessed.

Results: Forty patients were included. The median age at neovagina creation was 3.95 years (IQR 1.40, 7.61). Twelve patients (30 %) had uterine agenesis. Neovagina was colonic in 27 (67.5 %) and small bowel in 12 (30 %). Median age at most recent follow up was 9.7 years (IQR 7.6, 14.1). There was no difference in 30-day complications, incidence of vaginal prolapse, introital stenosis, or graft stenosis between those undergoing small bowel vs colonic neovagina. Two patients had documented menstrual obstruction, and 11 patients reported bothersome vaginal discharge. Of those with neovagina prolapse, one small bowel (8.3 %) and two colonic grafts (7.4 %) required prolapse repair. One small bowel (8.3 %) and 7 colonic (26 %) patients underwent introitoplasty for stenosis. Of the 3 patients having penetrative sex, 2 reported dyspareunia. No patients have become pregnant.

Conclusion: Bowel neovaginas remain a suitable choice for patients with cloacal malformations in whom the vagina is absent or cannot reach the perineum.

For more information, visit the Center for Colorectal and Pelvic Reconstruction (CCPR): https://www.nationwidechildrens.org/specialties/colorectal-and-pelvic-reconstruction-ccpr

This video details a retrospective study from Nationwide Children's Hospital exploring the safety and efficacy of long-acting triamcinolone acetonide (TAC) injections combined with dilation for post-operative strictures. The study focuses on pediatric patients who underwent surgery for anorectal malformation or Hirschsprung disease, aiming to reduce the need for repeat surgical procedures. Findings indicate high rates of stricture resolution with low short-term morbidity.

Megan A Read, Brenna Rachwal, Liese C C Pruitt, Andrew C Sager, Alessandra C Gasior, Ihab Halaweish, Richard J Wood

Purpose: Anastomotic stricture leads to significant post-operative morbidity for patients with anorectal malformations (ARM) and Hirschsprung Disease (HSCR). The injection of the long-acting steroid triamcinolone acetonide (TAC) after stricture dilation has been shown to decrease stricture recurrence and interventions needed to achieve resolution but has yet to be studied in patients with ARM or HSCR.

Methods: We performed a single-institution retrospective review of patients with ARM or HSCR who underwent TAC injection with dilation for anastomotic stricture. Clinical history, procedural details, and post-injection outcomes were assessed.

Results: From 2018 to 2024, 50 patients, 30 with ARM and 20 with HSCR, underwent dilation of anastomotic stricture followed by TAC injection. Stricture resolution was observed in 21 patients (70.0 %) with ARM and 17 patients with HSCR (85.0 %) after dilation with TAC injection. The median number of injections to achieve resolution was 1 in both groups, with a maximum of 5 in both diagnosis groups. Nine patients (30.0 %) with ARM and 2 with HSCR (10.0 %) ultimately required surgery to achieve resolution. There were no significant differences in clinical characteristics between those who required surgery and those who did not within each diagnosis group. There were no intraoperative complications; 30-day complication rate was 2.2 %.

Conclusions: Injection of TAC as an addition to dilation of post-operative stricture is a safe, minimally invasive approach to stricture management. The outcomes for our patients with ARM and HSCR are promising, and we plan for additional prospective study to further explore the benefits.

For more information, visit the Center for Colorectal and Pelvic Reconstruction (CCPR): https://www.nationwidechildrens.org/specialties/colorectal-and-pelvic-reconstruction-ccpr

Dr. Megan Read Ivaturi from Nationwide Children's Hospital discusses a study on how social determinants of health influence the choice of urinary reconstruction in children. The research, a single-institution retrospective study of 208 patients, reveals that while insurance type and childhood opportunity index had no impact, factors like food insecurity, missed appointments, and unmarried parents were associated with incontinent reconstruction. Interestingly, patients traveling from out of state were more likely to receive continent diversions. This highlights the critical role social stability and access to follow-up play in surgical decision-making and sustainable patient care.

Kristine L Griffin, Jeremy M Lun, Alexandra Bain, Shruthi Srinivas, Ihab Halaweish, Richard J Wood, Daniel DaJusta, Molly E Fuchs

Objective: To examine if social determinants of health (SDH) are associated with the type of urological reconstruction performed in patients with neurogenic bladder secondary to myelomeningocele and anorectal malformations.

Methods: A single-institution retrospective review was performed in children with incontinent urinary reconstruction (IUR) or continent urinary reconstruction (CUR) and a diagnosis of myelomeningocele, anorectal malformation, or spinal cord pathology from years 2014-2021. Demographic, clinical, and SDH data were collected and compared to reconstruction type. Categorical variables were analyzed via Fisher Exact Test. Ordinal variables were analyzed using Cochran-Armitage Test for Trend.

Results: From 2014 to 2021, 208 patients underwent urological reconstruction. Patients had a diagnosis of anorectal malformation (32.2%), myelomeningocele (30.8%), spinal cord pathology (18.8%), other diagnosis (18.3%), or cloacal exstrophy (4.8%). Of the cohort, 154 (74%) had a CUR, and 54 (26%) underwent IUR. Median age at reconstruction was higher in those who underwent CUR (6.7years [IQR 5.3, 9.8]) than for IUR (5.6 [IQR 1.5, 10.5]) (P=.01). There was no difference between insurance type for IUR vs CUR (P=.11). There was no association between Child Opportunity Index (COI) and reconstruction type (P=.5). Patients who underwent IUR were more likely to have experienced food insecurity (P=.02), missed at least one appointment (P=.02), or have unmarried parents (P=.03). Those who lived out of state more often pursued CUR (P=.01).

Conclusion: There was an association between SDH and type of urologic reconstruction performed in pediatric patients. Social factors must be considered in preoperative planning for urinary reconstruction.

For more information, visit the Center for Colorectal and Pelvic Reconstruction (CCPR): https://www.nationwidechildrens.org/specialties/colorectal-and-pelvic-reconstruction-ccpr

Paul McClure discusses the critical challenge of managing pediatric Crohn's disease when initial biologic therapies fail, particularly regarding surgical decisions. He introduces the CAPTURE IBD study, a large prospective multicenter cohort funded by the Crohn's and Colitis Foundation, aiming to advance precision medicine in pediatric IBD. This study collects comprehensive patient data and biospecimens to improve treatment matching and optimize surgical outcomes in pediatric Crohn's.

Shova Subedi, Lindsey G Albenberg, Julie A Bass, Laura Bauman, Rachel Chevalier, Matthew Egberg, Alka Goyal, Edward Hoffenberg, Jeannie Huang, Judith R Kelsen, Subra Kugathasan, Phillip Minar, Barbara Joanna Niklinska-Schirtz, Jodie Ouahed, Caroline Elizabeth Perry, Shervin Rabizadeh, Michael J Rosen, Jacobo Santolaya, Cary G Sauer, Jason M Shapiro, Luis Sifuentes-Domingue, Francisco Sylvester, Megan Villarreal, S Alandra Weaver, Kaitlin G Whaley, David Ziring, Edwin F de Zoeten, Stacy A Kahn

Discover how Cincinnati Children's Hospital implemented protocol changes to significantly improve outcomes for babies with Congenital Diaphragmatic Hernia (CDH). This video details updates in ventilator management, ECMO utilization, blood pressure support, nutrition, and sedation protocols, leading to increased survival rates and reduced mechanical ventilation time. Learn about the evidence-based adjustments that have enhanced care for these complex pediatric patients.

Lizzy Lee from Cincinnati Children's discusses a study on hemodialysis outcomes in infants after congenital heart surgery (CHS). Approximately 1% of infants undergoing CHS develop severe acute kidney injury (AKI) requiring dialysis, with a 1-year survival rate of 46% compared to 94% for those who don't need dialysis. The study highlights that hospitals with more frequent dialysis use showed significantly higher hospital and one-year survival rates, indicating the importance of specialized center experience for these critical cases.

Grant Chappell, Darren Turner, Amir Mehdizadeh-Shrifi, David Lehenbauer, Marco Ricci, Meghan M Chlebowski, Stuart L Goldstein, Awais Ashfaq, David L S Morales

Hemodialysis after infant congenital heart surgery (CHS) for acute kidney injury (AKI) presents a major challenge due to relatively low utilization, difficult vascular access and small patient size. Therefore, we performed a multi-institutional analysis for infants requiring hemodialysis post-CHS. The Pediatric Health Information System (PHIS) was queried for infants undergoing CHS from 2004 to 2024. Intermittent hemodialysis (iHD) and continuous renal replacement therapy (CRRT) were included, patients undergoing pre-CHS dialysis or post-CHS peritoneal dialysis during admission were excluded. High HD use centers were in the top 10% of HD usage while low HD use centers were all other centers. After CHS, 1% (332/31,634) of infants received a form of hemodialysis (HD); 61% (204/332) received CRRT, 11% (37/332) received iHD, 11% (36/332) received both, and 17% (55/332) had an unknown type. HD was provided in 2% (220/12,898) of neonates (‹ 31days-old at CHS) vs. 1% (112/18,736) of infants 31-365 days old (p ‹ 0.001). One-year survival was lower in the dialysis vs. non-dialysis cohort (46% vs. 94%, p ‹ 0.0001). CRRT patients had higher one-year survival vs. iHD (50% vs. 25%, weighted log-rank; p = 0.01), although there was no difference after adjustment upon multivariate analysis. HD infants at high HD use centers had improved hospital and 1-year survival vs. low HD use (66% vs. 23%; 67% vs. 28%, p ‹ 0.0001). Infants requiring hemodialysis (iHD or CRRT) post-CHS suffer from poor outcomes with ‹ 50% 1-year survival, with high HD use centers having triple the hospital survival and double the 1-year survival, suggesting modifiable factors may mitigate poor outcomes.

This video discusses a PubMed article on dialysis outcomes for infants undergoing congenital heart surgery. It highlights that about 1% of these infants develop severe acute kidney injury requiring dialysis, with a one-year survival rate of 46% compared to 94% for those who don't need dialysis. The most significant finding is that infants treated at hospitals with more frequent dialysis use experienced significantly higher hospital and one-year survival rates, suggesting the importance of specialized center experience in improving outcomes.

Grant Chappell, Darren Turner, Amir Mehdizadeh-Shrifi, David Lehenbauer, Marco Ricci, Meghan M Chlebowski, Stuart L Goldstein, Awais Ashfaq, David L S Morales

Hemodialysis after infant congenital heart surgery (CHS) for acute kidney injury (AKI) presents a major challenge due to relatively low utilization, difficult vascular access and small patient size. Therefore, we performed a multi-institutional analysis for infants requiring hemodialysis post-CHS. The Pediatric Health Information System (PHIS) was queried for infants undergoing CHS from 2004 to 2024. Intermittent hemodialysis (iHD) and continuous renal replacement therapy (CRRT) were included, patients undergoing pre-CHS dialysis or post-CHS peritoneal dialysis during admission were excluded. High HD use centers were in the top 10% of HD usage while low HD use centers were all other centers. After CHS, 1% (332/31,634) of infants received a form of hemodialysis (HD); 61% (204/332) received CRRT, 11% (37/332) received iHD, 11% (36/332) received both, and 17% (55/332) had an unknown type. HD was provided in 2% (220/12,898) of neonates (‹ 31days-old at CHS) vs. 1% (112/18,736) of infants 31-365 days old (p ‹ 0.001). One-year survival was lower in the dialysis vs. non-dialysis cohort (46% vs. 94%, p ‹ 0.0001). CRRT patients had higher one-year survival vs. iHD (50% vs. 25%, weighted log-rank; p = 0.01), although there was no difference after adjustment upon multivariate analysis. HD infants at high HD use centers had improved hospital and 1-year survival vs. low HD use (66% vs. 23%; 67% vs. 28%, p ‹ 0.0001). Infants requiring hemodialysis (iHD or CRRT) post-CHS suffer from poor outcomes with ‹ 50% 1-year survival, with high HD use centers having triple the hospital survival and double the 1-year survival, suggesting modifiable factors may mitigate poor outcomes.