State of the Union: Pediatric Surgery in 2021
Reviewed March 2021 to maintain the latest information in treatment and research.
An interview with Steven Stylianos, MD, Chief of Pediatric Surgery.
What's new in pediatric surgical care? What fields have seen breakthroughs in the last few years?
Well, one is the ability to offer minimally invasive surgical techniques to smaller and smaller infants, so that literally we can now do full laparoscopic and thoracoscopic procedures in newborns [Laparoscopic procedures are through the belly, thoracoscopic ones are through the chest]. Whereas before we were limited by the technology, it just wasn't miniature enough, but now it is. And the access devices, the instruments themselves, the cameras, the energy sources that we use to seal tissues, even the surgical staplers, have been miniaturized. And we here [at Columbia] are at the forefront of that because we have good relationships with some of the investigators, some of the companies that make these devices, so we're really staying on the cutting edge.
The difference for these newborns is incredible. It's absolutely incredible. And they will benefit from that technique for the rest of their lives, so it's very gratifying. Families are just amazed that their child can have newborn lung surgery and go home the next day, where it used to be at least a week with days in the ICU. Very, very intense paradigm shift, and it's really wonderful.
Does that miniaturization include fetal surgery?
Yes! That segues right into the other big area, which is using minimally invasive techniques before birth, in the fetus. So, one of the main conditions now that we operate in utero and before birth is for spinal cord problems ― some of the terms used are spina bifida, meningomyelocele ― where if you wait until birth, permanent damage has been already done. Most conditions in the fetus we can monitor and then correct once the baby is born. But this particular problem, the spinal cord being uncovered, the damage is done before birth.
How far along in pregnancy would you operate in that case?
The moms are often at 24 weeks or so, in the sixth month. And there is a small window, a small range, but I would say 24 weeks is a really good time. And again, instead of opening the uterus, making a big incision like in a Caesarean section to deliver part of the baby and operate on it, now we're doing it with minimally invasive techniques. We're just poking into the uterus with instruments and a camera, and then the repair is done that way. It is absolutely amazing. And that program is run by a combination of a pediatric fetal surgeon, my partner, Dr. Vincent Duron, paired with Dr. Russ Miller from the maternal fetal medicine team, and the two of them co-direct the fetal surgical program.
Are the tools that you're using for fetal surgery the same miniaturized tools that you're using in infant surgery?
Exactly, they’re the same. Now that they're brought to that scale, not only do they help a newborn, but they help the unborn. Say you've got someone who's a three-month preemie inside of a mom at six months, you're able to use those instruments. In terms of changing how we address certain diseases, these two are examples of tremendous progress in a short amount of time.
As a pediatric surgeon, what is it like to have your primary patient be an adult? What can parents expect in that regard?
It's very critical to understand the risks that the mother is absorbing to be able to provide fetal surgery for her baby. And that's why the fetal team is co-directed by a fetal surgeon and by a maternal fetal medicine expert from the department of OB/GYN—we need those perspectives simultaneously throughout the course. And if we're putting the mother at too great a risk, then that has to be looked at and scrutinized very, very carefully.
So, for example in fetal surgeries, the anesthesiologist at the head of the table is not going to be a newborn anesthesiologist. It's going to be an obstetrical anesthesiologist because the person that they're putting to sleep is the mom. It's a very, very important point and one that families have to consider very carefully before they agree to go forward with fetal surgery. They have to understand the risks to the mom. And here, because of the quality of the care that they get, the risks are minimized, but not eliminated.
Absolutely. How has the management of pediatric diseases changed?
For the most part, we try to keep children out of the hospital. We have found ways to replace, for example, IV antibiotics that were needed for infections. They have now been largely replaced by stronger forms of oral antibiotics. So we can do, for example, an operation on a perforated appendix, which used to require a seven to 10-day hospitalization, and now we can keep them in the hospital for two days and send them home on these very strong oral antibiotics, and they complete their course that way. They get the same treatment, but 80 percent of it is at home rather than here in the hospital. And we have many other examples of how we take similar approaches to try to get children at home with their families, outside of the hospital, and leave the hospital beds for only really the sickest patients.
That’s amazing. How do genetics and early detection factor into the conditions and patients you treat?
Well, I think that it takes a senior surgeon like myself to tell you those stories, where 20, 30 years ago, we would meet families literally in the delivery room because that's the first time a condition has been detected. That really has changed. Certainly, ultrasound imaging is so spectacular, the resolution is so amazing. And now we do MRIs on moms to better characterize their conditions. We do echocardiograms on the fetus to know their heart conditions. So, we really have a really good idea of what the baby has. And also, we've had an opportunity to meet the parents, the couple that's carrying that baby. We get to meet them in a calm circumstance and in the office where a lot of different scenarios and options can be discussed, rather than meeting someone as they've just given birth. It really makes a huge difference.
Is this when parents would meet, say, the maternal medicine team, or other specialists too?
Yes, and the important part is that they meet the teams together, at the same time. The fact that we’re now able to put together multidisciplinary teams is another huge example of how care has improved. We’re able to really look at the baby not as a bunch of parts where different services are going to take care of one part. We look at the baby as a whole, and we put together a team that will focus all of their energies and expertise for the collective good of that baby. And we have many examples of that— We have a vascular malformations team, we have an esophageal atresia team, we have a congenital diaphragmatic hernia team. And these are all teams made up of many different sub-specialists who all have an interest and expertise in that particular condition, but they meet families together.
The change toward that type of multidisciplinary care seems like a gamechanger in the stress department for new or expectant parents.
It's one of the biggest patient satisfiers, to really grasp and feel the fact that this entire institution is dedicating its resources and its expertise to their baby. And they see it visually by seeing all of these different sub-specialists in the same room at the same time. It certainly gives you that feeling that this institution, this place, cares about my baby, and so do these individuals in front of me. Rather than having that family just go from office to office day to day, getting care one piece at a time. Every single one of us cares deeply.
Within that, is there new testing available we should know about? Anything with tissue engineering or stem cells?
I think it's early for those modalities to have an impact on the type of anatomical diseases that we treat. Certainly, stem cells in all of pediatric care have made an enormous, absolutely life-saving impact. But I would say still for the surgeons, it's a combination of open surgical techniques and minimally invasive techniques. Then we count heavily on our colleagues in interventional radiology who can also get to the most difficult places in the human body with small wires and catheters rather than giant incisions. So again, we're very blessed here to have a specific pediatric interventional radiology team that we work with hand in hand every day to, I like to say, do more for the patients but do less to them. And that really makes a big difference.
Tell us a little about pediatric ECMO [Extracorporeal membrane oxygenation―a machine that gives breathing and circulatory support to patients whose lungs and heart are failing]. Is there anything new in terms of applications?
Well, ECMO is a lifesaving modality done for the most critically ill patients. One of the most dangerous parts of this modality is, along with its life-saving capabilities, there are so many ways for complications to enter the equation, simply because of how intense the modality is. All the different parts of ECMO, to take all of a patient's blood out of their body, put it through a machine, and then bring it back to them. There's plenty of opportunities for things to go wrong. And so the advances in ECMO care are really to reduce, if not eliminate, some of these complications so that ECMO could run longer and save even more lives.
We now are doing ECMO, or initiating ECMO, even while a patient has a cardiac arrest, which previously was a contraindication to ECMO. But we will be called by one of the intensive care units that their patient has just had a cardiac arrest, and we literally will run there with OR instruments, with an ECMO machine. And while CPR is being performed, we will cannulate and get the patient on support. That's relatively new, and it's one that has expanded the indications for ECMO and has saved many lives.
What has changed to allow for that expansion?
Part of it is understanding the body's response to ECMO. Another is simply the courage of the people running the ECMO programs to say, "We can do this. We may not be able to save everyone, but there are lives here that can be saved if we act promptly and appropriately." And that exists here, that type of selfless courage to really push and do everything they can to ease suffering or save lives. It's really amazing to be part of that team.
Wow, that is pretty amazing. Let’s jump to trauma surgery, what should we know?
I think the key to really evaluating what we do here in trauma is that we've sought and achieved the highest designation nationally as a pediatric trauma center. It sounds simple enough, but what that means is that we have checked hundreds and hundreds of boxes, and we have resources, we have the people, we have the expertise to handle every possible injury that can happen to children.
So, by seeking those accreditations and achieving them, it means that we're at the top of our game every day. We don't want any of these things to happen to anyone's children, but they do. People call them accidents. I'm not sure they're really accidents, but nonetheless, children end up in harm's way, and if it happens, we're here. And that's the pledge that we give to the greater community, that we're here any time of day, any day of the week, holidays or whatever, it does not matter. They get the same team composition, the same team expertise.
Let’s talk cancer. What’s new in therapies and treatments?
Well, as surgeons, we're blessed to be partnered with such an innovative oncology team. And we do our parts in terms of diagnostic tests and removal of tumors when appropriate. But I would say the trend in oncology is, again, doing more for the patient, but doing less to them.
I think oncology went through a phase decades ago where the chemotherapeutic agents just got stronger and stronger, and that allowed us to treat more diseases. But the strength of those chemotherapeutic agents also brought with it toxicity and complications for the patients. So now the pendulum has swung towards targeted therapies and using tumor cells of that same child to develop targeted therapy, such that the tumor is attacked or whatever tumor is left is attacked, but not the rest of the healthy body. And that's really wonderful. As surgeons, we almost applaud the fact that we're not going to be needed as much because there are going to be other therapies rather than these giant, giant operations.
But we'll still be needed. Certain cancers are smart enough to resist radiation and resist chemo. And in those children, their only hope for cure is a complete surgical removal. There is certainly plenty for everyone to do, but again, doing it alone just doesn't work. Now you have to do it in teams. And I would say even in our division, in those key areas like newborn surgery, fetal surgery, oncology surgery, we have designated what we call a “point person.” They don't do every operation in that field, but they know about every case in that field. They go to every multidisciplinary conference, they stay up on the latest innovations, and bring those back to the remainder of the group. And we find that that model of having, quote, a point person for the big clinical entities works terrific.
Sounds like it! What’s going on in the world of research?
We have research in many areas in pediatric surgery within our division. Dr. Zitsman, who leads our bariatric program, is at the forefront nationally of weight loss surgery in adolescents. Completely different topic would be Dr. DeFazio and her work in the intestinal tract of newborns, and how the different normal microorganisms of the GI tract affect disease down the road. So, we're going from the smallest and youngest to the biggest and oldest, right in our division. Dr. Fallon has devoted her research to oncology and to tissue banking and learning as much as we can from all of the surgical specimens that we have in terms of how they can influence treatment going forward. Dr. Middlesworth helps run the esophageal atresia clinic, which is a very complex group of children that have airway and digestive problems, some of them cardiac problems, and he holds that whole team together.
And then I would say my areas are still in trauma, looking at trauma, and in a disease called biliary atresia, one that was made quite famous for this institution by my predecessor, Dr. Peter Altman [Dr. Altman brought one of the primary treatments for biliary atresia―the Kasai procedure―to the US from Japan, where it was originally developed]. And it's really an honor just to continue his work in biliary atresia. And these are diseases that link families with pediatric general surgeons, with hepatologists, and then on occasion with the liver transplant team. So again, a big team, big multidisciplinary team.
How has continuing the work of your predecessor changed over the decades?
The surgical techniques change for sure. Anesthesia and post-anesthetic care have changed tremendously. But for the most part, our understanding of the disease process at a more sophisticated level allows us to then tailor the treatments, both medically and surgically, to a finer degree. And I think that is what has happened throughout the course of medicine and must continue to happen. The one thing, though, is that the pace of change is so much faster than it used to be. It used to really take a generation for something to be obsolete. Now in five years, it's completely gone from our armamentarium. It's a technology-based phenomenon. We just have so much more technology and knowledge at our fingertips, everything goes faster.
Does this type of extensive multidisciplinary care continue over time? Are you maintaining long-term relationships with families?
Absolutely. It can be 20 years that a family is with us. And then that transition to adult care is a very difficult one, both for the doctors and for the parents and children. So, the way we influence future adult care is something that's very unique. The cardiac surgical service has a very big footprint in the adult hospital for people who have outlived their congenital heart disease. Now they're adults, but it's the congenital heart surgeons that know them best. We have a lot of examples of that.
How does that work exactly? It seems like it would be very hard to have to say goodbye to these families. Do you still check in?
It's really not even an option! The families always check in because no matter what the adult provider tells them, they always run it by us to be sure that it's okay. We enjoy the role, we enjoy linking with our adult colleagues. We don't say goodbye, we stay involved. And we're so lucky to have such an accomplished adult hospital a block away to help that transition.
What are you most optimistic about?
One of the things, and it's timely because we were recently notified who our next trainee will be through what’s called the match [the annual event that matches residents to programs], is that we keep attracting the top talent in the country. These are general surgery residents who want to be pediatric surgeons. And our program is blessed in that we just keep attracting the highest caliber trainees and they want to come here. They want to come to Morgan Stanley Children’s Hospital, they want to come to Columbia, they want to be here. And so that gives me reason for incredible optimism because these are the young people who will represent the future of pediatric surgery.
The future surely sounds bright. What are your goals for the next five to 10 years?
Well, I think we have to keep bringing all the absolute cutting-edge innovation that we can for the children right here to New York City. Because we are a children's hospital that sees the most critical, the most difficult cases, sometimes the routine solutions don't work or not enough. And we have to keep being able to offer everything and then some to these families. Cautiously, responsibly, but with that courage that I mentioned earlier.
That together with this family, together with their child, we can salvage a situation that previously would lead to just a horrible outcome for those families. I think that that's one of the keys. Along with attracting and recruiting the talent that's going to do that. The innovative, well-trained surgeons who are necessary to direct that type of cutting edge treatment. And so, that's plenty for me to do, keeping the machine going forward.
It sounds like that type of courage and integrity really stem from the top, leadership creating the culture and environment for meaningful innovation.
I certainly remember having those types of leaders when I was an up and coming surgeon, and they empower you. They absolutely empower you with the drive to find more answers and better answers. If a young surgeon is afraid of making a mistake because they think that it's going to be punitive, it's going to stifle their energy. None of us want to make mistakes. Most of us don't make mistakes, we simply don't have an answer to a problem that's before us. But if you have bosses and mentors who empower you to try things, to be thoughtful, but to be courageous, then usually you get great outcomes and you build a great team. And I'm very proud of our team here.