Greetings:
The National Interns and Residents Match is complete and we are very pleased to have a terrific group of new residents, six in Pediatrics and four in the Med/Peds program:
Since our last newsletter, a second pediatric surgeon has joined KUMC. Kurt Schropp, MD received his surgery training at Ohio State University Hospitals and was most recently on the staff at St. Jude's Hospital, Memphis, TN. [See Dr. Schropp's article on "Minimally Invasive Surgery" in this issue. -ed.] He joins Dr. Roberta Sonnino in the pediatric surgery division. Their office number is (913) 588-2437.
The "Annual Spring Symposium on Adolescent Medicine and Updates on Vaccines, Autism, and Gun Safety", held in May, drew a substantial attendance. The KAAP dinner, which was held the previous evening, featured Steve Berman, MD, immediate past president of the AAP. Dr. Berman was delighted to come to Kansas City and reconnect with the pediatricians in this area.
Professor and Chair.
We all know that we need different amounts to drink from day to day, depending on what is going on in our lives. For example, we need greater hydration when we take part in an outdoor baseball game in July than we do when we spend the day in front of the television. So why should we, as clinicians, think this is any less true for the hospitalized patient?
The need for thoughtfully individualized IV therapy is clearly much more important than how much Gatorade to give your sports stars. Unfortunately, conventional wisdom for our hospitalized patients (guided by the Harriet Lane Handbook and other publications) is to run a set amount of fluid, with a set amount of electrolytes, to patients in a wide variety of situations. Current standards typically end up with a patient who is volume overloaded, with undue stress placed upon her kidneys. It is similar to giving the television watcher enough fluid to cover the baseball game -- and doing it at a time when her physiologic status is already compromised.
We challenge this traditional but mistaken practice (a misinterpretation of data from over 50 years ago) by offering an evidence-based, individually tailored approach to IV fluid management in the hospitalized Pediatric patient. To learn about our approach, go to http://classes.kumc.edu/som/fluid_electrolytes/. This interactive website explains our method in detail, and allows you to rapidly enter data get the results immediately, and send it to us. We will quickly get back to you with our suggestions, working to ensure the best care possible for your patients.
You can also locate this resource by going to the KU Children's Center site (http://www2.kumc.edu/kids/). Find "Jon Scheinman, MD" under the list of providers and click on the link to "Fluids and Electrolytes Clinical Pathway."
Professor and Division Chief Pediatric Nephrology
No topic has created more controversy in the pediatric surgical community over the last decade than minimally invasive surgery (MIS, laparoscopy, and thoracoscopy). As pediatric instrumentation has improved, avid proponents of MIS have come to believe that any abdominal or chest operation should be done "closed." Opponents, at the opposite extreme, claim that MIS should not be performed in children because of its greater cost, operative complication rate, and decreased benefits vs. adults. Certainly, the standard of care falls somewhere between these two extremes and slowly is shifting toward the MIS "side." This review presents a conservative review of today's standard of care for children with regards to MIS.
In this review, major pediatric operations that can be performed with MIS have been assigned to 3 categories. MIS procedures are listed as "indicated," "probably indicated," and "possible but controversial." Most pediatric surgeons at this time do not feel this last group of operations should be performed with MIS. The assignment of operations to these categories is subjective and may change depending on extenuating circumstances, size of child, illness of the patient, and improvement in technique and instrumentation.
"Indicated" MIS procedures in children include cholecystectomy in any age group and splenectomy in any size child as long as the spleen is not extremely large. Fundoplication with concomitant gastrostomy can be done in about any size child but is increasingly difficult in babies less than 1.5 kg. Laparoscopic exploration of the abdomen for pain or tumor can be performed in any size child, limited only be the number of previous operations or size of tumor. Lymph node biopsy for tumor or infection is done using MIS in all size children and in most areas of the abdomen.
One procedure that most pediatric surgeons agree is safe and worthwhile is placing a telescope<<question from editor: Did Dr. Scheinman mean 'telescope' or 'laparoscope'?>> through an ipsilateral hernia sac to explore the contralateral side in indirect inguinal hernias. This procedure has almost no morbidity and may avert an open exploration on the other side. The other extremely popular indication is using a laparoscope to look for a nonpalpable undescended testicle.
"Indicated" chest procedures include thoracoscopy for debridement of loculated empyema in any age child. Directed lung biopsy in children greater than 2 years and removal of bronchogenic cysts are now commonly and safely performed.
Procedures that are frequently performed but have not been proven the safest or the most effective operation are classified here as "probably indicated." These include appendectomy, either acute non-ruptured or interval. Data seems to be increasing that laparoscopy for ruptured appendicitis may lead to increased intra-abdominal infection with no decrease in hospital stay. MIS operations for Meckel's Diverticulum as well as some types of penetrating trauma are probably indicated. Repair of imperforate anus with MIS is gaining popularity, but long-term follow-up is lacking. Pull-through for Hirschsprung's disease is a relatively simple laparoscopic operation but not always indicated. In the chest, thymectomy and lobectomy fall into this category.
The last group is controversial even among trained MIS surgeons and there are strong opinions as to whether these will ever be in the "indicated" category. They can be done with MIS but may be dangerous or offer no significant benefit to the child and often cost more. Examples include pyloromyotomy (increased perforation rate, longer duration to full feeds), intussusception reduction (bad technique), G-tube placement (site problems), tracheoesophageal fistula repair (increased leaks and strictures), and lastly laparoscopic repair of indirect inguinal hernia (minimal improvement in pain, scar, and return to school with increased risk of recurrence).
These categories are not all-inclusive and opinions as to where each procedure belongs vary drastically among pediatric surgeons. But, as in adults, the indications for MIS in children are certain to expand as experience increases and instrumentation improves.
Associate Professor, Pediatric Surgery
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The University of Kansas Medical Center