State of the Union: Pediatric Surgery Today

An interview with pediatric surgeon Vincent Duron, MD, about the latest in pediatric and fetal surgery.

Last we spoke, a lot of pediatric surgery seems to be advancing because the tools have finally caught up to the ideas. Does that feel right?

For sure. A lot of what we’re doing is not necessarily new in concept, but the approach is very different now.

Fetal surgery is a good example. The idea of intervening before birth has been around for decades. People were trying some of these things in the 1980s and 1990s, but they were doing them through big incisions, and the morbidity was so high that a lot of those procedures were abandoned.

Now, with minimally invasive approaches, some of those same ideas are possible again.

FETO is such a striking example. Can you explain what is actually happening during the procedure, and why it can change outcomes for babies with congenital diaphragmatic hernia (CDH)?

Yes. In congenital diaphragmatic hernia, we can do fetoscopic endoluminal tracheal occlusion, or FETO. We place a balloon in the fetal trachea, usually around 29 to 31 weeks, and remove it around 34 weeks. What we’re doing is allowing fluid to stay in the lungs, which pushes on the lung tissue and helps the lungs grow. That has been shown to improve outcomes.

Forty years ago, people were doing this by making a huge C-section incision, making a large incision in the uterus, taking the baby’s head out, finding the trachea, and literally tying it closed or clipping it. Then they would come back later and take the clip out. You can imagine how morbid that was.

Now we do it with a small scope, a small incision, and a balloon.

So in a way, it’s redefining classic theories and applying modern technologies that make interventions possible now that were once too morbid or too risky.

The Pediatric Problem with Adult Tools

How much is robotics being integrated into pediatric surgery?

Pediatrics is lagging a little bit with the robot, mainly because the trocars are still too big for infants and because a lot of the surgeries we do are not the ones that benefit most from robotics. We’re not doing a lot of prostate surgery or pelvic work the way adult surgeons are.

But robot use is becoming more and more common in adults, partly because patients are asking for it, partly because of marketing, and partly because it really does facilitate surgery for the surgeon.

I’ve always been kind of an old-timer against the robot, to be honest. A lot of us who do laparoscopic surgery say, “Well, the robot is for people who can’t figure it out laparoscopically,” because it helps you so much. It gives you different angles and better mobility.

But even the old dogs like me are starting to think we need to get on this bandwagon, because otherwise it’s going to lift off without us and we’ll be trying to catch up.

There’s also the training environment. Our trainees are trained in adult surgery first, before they become pediatric surgeons, and they are being trained more and more on the robot. So we need to adapt to that as well.

What makes it so much harder to bring robotic surgery into pediatrics than into adult surgery?

You can’t just MacGyver something and put it in the body. You’d get a pink slip and be on the streets that day.

That’s one of the big problems with robotics in pediatrics. It is not FDA approved specifically for pediatric surgery, so getting trained and credentialed is difficult. I’m getting trained in the robot now, and there are a lot of hoops to jump through for pediatric surgeons.

Some surgeons who do pediatric cases, like transplant surgeons, are trained on the robot through their adult practice because they also do adult transplants. That is one way they’re able to bring the technology into pediatric care.

But in pediatrics, we adopt a lot of technology that was not originally meant for children. That is the world of peds. We take instruments or devices that were designed for adults or for another specialty and figure out how to safely use them for smaller patients.

Beyond robotics, are there any new tools that are changing how you operate?

One tool we’re starting to use more is ICG, indocyanine green. It’s something you can inject or, in some cases, have the patient inhale, and it lights up green with a special light to help map anatomy.

What procedures do you use that for?

In biliary surgery, you can inject it into a vein. It gets absorbed through the blood vessels and goes into the biliary system, so you can see the bile ducts light up. It helps you dissect out difficult structures.

I’m starting to incorporate it into my thoracic surgeries. We’re planning to use it in congenital lung malformations, like CPAMs, where we’re trying to remove abnormal lung tissue. When ICG is inhaled, it can help delineate normal tissue from cystic tissue, which may help us do those resections more precisely.

Seeing More and Taking Less

Across almost all specialties, we hear how much technology is changing the way a procedure is planned. How are you using any of these tools?

We have much better tools for preoperative planning. Imaging has gotten a lot better. With 3D reconstructions and AI-assisted tools, we can take a tumor and separate the vessels from the bronchi from the tumor itself, and visualize each structure. That helps us plan the operation and makes surgery safer.

Has the pediatric ICU changed in ways that affect surgical outcomes—in the way kids are cared for after surgery?

Oh, yes. The ICU has a lot more advanced monitoring now. One example is NIRS, near-infrared spectroscopy, which can noninvasively monitor oxygenation in tissues like the brain or kidneys. These are things that used to require invasive catheters or other invasive monitoring, and now we can sometimes do them noninvasively.

Another thing I’m very interested in is point-of-care ultrasound, or POCUS. That means using ultrasound bedside by someone who is not a radiologist, like a surgeon, intensivist, or research fellow.

What we’re studying specifically is intravascular volume. After surgery or trauma, patients become very inflamed. Their capillaries leak, and their intravascular volume moves into the tissues. You need to resuscitate them, but you don’t want to give so much fluid that you overwhelm their vascular system and they end up with fluid in the lungs, the GI tract, or other complications.

Is that what point-of-care ultrasound can do?

We’re studying whether point-of-care ultrasound can help us measure things like the diameter of the aorta, internal jugular vein, and inferior vena cava to understand a child’s intravascular volume earlier, before we’re waiting for tachycardia [a fast heart rate], pulmonary edema, or other signs that they are either under-resuscitated or fluid overloaded.

Talk to us about enhanced recovery pathways. What are they and how are they becoming part of pediatric surgery?

So, we’re following more enhanced recovery after surgery, or ERAS, pathways. In pediatrics, we often lag behind adults with this, but the data are helping us get patients out of the hospital sooner and prevent complications.

A good example is nasogastric tubes. Everybody used to get an NG tube after intestinal surgery. In peds, we sometimes still do that, and then we wait for patients to pass gas, which can take days.

But ERAS studies have shown that in many cases you don’t need an NG tube. It can delay recovery and prolong hospitalization. The same is true for avoiding narcotics when possible, getting patients out of bed sooner, and feeding them sooner.

Wow. That’s great.

Another example is esophageal atresia and tracheoesophageal fistula repair. When the esophagus is discontinuous and we put it back together, we used to always place an NG tube across the repair. The thinking was that it would stent the esophagus open and decompress the stomach. But recent studies have shown it may increase the risk of stricture at the repair site and does not make a difference in leaks. So we’ve stopped using it.

Ten years ago, people would have said, “How could you not put an NG tube through this repair? That’s insane.” Now, not using it is becoming standard.

That is what evidence-based medicine allows us to do. It lets us question things we thought were untouchable.

Where is better technology still lacking in pediatric surgery?

Cardiopulmonary monitoring is one area.

In kids, we try to avoid invasive monitoring when we can, and sometimes we simply cannot use the same devices adults use. Adults may have Swan-Ganz catheters or dynamic echo monitoring. Some adult patients can have a scope in the esophagus monitoring heart function continuously. For us, we often have to do repeat echocardiograms and interpret a lot of data points more indirectly.

We’re good at interpreting those things, but there are still devices and techniques that need to be developed for children.

How much of pediatric innovation depends on adapting tools from elsewhere?

A lot of it.

FETO is a perfect example. The balloon we use for fetoscopic endoluminal tracheal occlusion is actually a neurosurgical instrument. It’s an embolectomy balloon, a detachable balloon used to embolize something. It was not made to be placed in a fetus with congenital diaphragmatic hernia.

To use it that way, we needed an investigational device exception from the FDA. That took almost three years to obtain. There was a lot of back and forth.

In myelomeningocele cases, we use vascular sheaths as trocars. Instead of using a normal trocar, we use something smaller and softer because we’re putting it directly into the uterus. We need to be able to cut it, and we need it to be gentle. Those sheaths were designed for endovascular procedures, but we adapt them for fetal surgery.

That is what makes pediatric surgery interesting. You have to think of different ways to make things fit for little kids.

Recovery Is Part of the Operation

Are there examples of pediatric surgery changing adult care, instead of the other way around?

Yes. There are a few things the adult world has learned from us.

Nonoperative trauma management really came from pediatrics. Splenic salvage is a good example. In children, taking out the spleen is a much bigger deal than it is in adults because of the immunologic and infectious risks. Pediatric surgeons pushed hard to avoid removing spleens after blunt solid organ injury.

That approach translated into adult trauma care, where surgeons used to operate on spleens much more often. Now they are salvaging them more.

Some things don’t translate, though. In pediatrics, we do an interesting laparoscopic hernia repair using a little snare technique. It works because groin hernias in kids are congenital. You can close the ring without mesh.

That would be the wrong surgery in an adult. Adult hernias are often caused by weakness in the abdominal wall, so you need mesh to reinforce the area. It’s a different mechanism.

I know fetal surgery is a big passion of yours, and you’ve talked before about fetal surgery as a way to intervene earlier, while the fetus still has this extraordinary capacity to heal. Is that idea expanding?

There is huge momentum in fetal surgery, intervention, and diagnosis.

First, we are getting better at diagnosing things earlier and earlier. Second, the interventions are becoming less invasive. That includes fetoscopic repair of myelomeningocele, aspiration of cysts, placement of thoracoamniotic shunts, and other shunts used to decompress different parts of the body.

We’re gaining more experience, and the procedures are becoming less invasive.

Does the use of genetics or gene therapy impact this?

Absolutely. There is a big push toward gene therapy. Some exciting developments are coming for metabolic conditions, not just surgical issues.

For surgical conditions like spina bifida and myelomeningocele, there is a lot of research into stem cell products—microvesicles and stem cell injections used during repair to support spinal cord structure and coverings. The idea is to stimulate repair of structures like the dura and other spinal cord coverings.

As robotics becomes more sophisticated, are there places where you think pediatric surgeons may come to appreciate it differently than they do now?

The introduction of robotics is similar to laparoscopy, but also different.

Laparoscopy was introduced because it was more minimally invasive, but it was technically challenging, and there was a steep learning curve. Early on, there were higher complication rates in some procedures, like gallbladder surgery, before the field improved and it became better than open surgery in many cases.

The robot is different because, in adults, it is similarly minimally invasive to laparoscopy, but it makes surgery easier for the surgeon. It gives you extra angles, better mobility, and 3D visualization.

In pediatrics, even if we can already do a surgery laparoscopically, I don’t think we fully appreciate yet the higher level of visualization and detail the robot can give us for specific operations, like biliary surgery, pelvic surgery, and certainly thoracic surgery.

As pediatric surgeons become more comfortable with the robot, and as the robot itself miniaturizes, I think we’ll use it much more often.

Last year, you mentioned congenital lung malformations. It sounds like the question is no longer simply whether to operate, but how much lung to preserve. How is that changing?

We are trying to be less aggressive in how much lung we remove.

For a child with a congenital lung malformation, like a CPAM or bronchopulmonary sequestration, we often offer resection to prevent infection, rupture of a cyst and pneumothorax, malignant transformation, and because if you remove part of the lung during infancy, the remaining lung can grow into that space.

Historically, we have offered a lobectomy, removing the whole lobe involved. Anatomically, it makes sense. It is technically easier, there are fewer complications, and we are more used to it. But now, with better visualization, more comfort with minimally invasive surgery in small chests, and tools like ICG, there is a shift toward resecting less and preserving more lung.

There are ongoing studies looking at whether that makes sense, whether it helps, and whether it can be done without increasing complications. Segmentectomy, for example, is technically more difficult. You are going through lung tissue, and it can leak. So we have to study it carefully.

Collaboration and Expansion in Access

You’ve mentioned that pediatric surgery studies can be hard to do because the patient populations are small. How important is collaboration across different institutions?

There is much better organization now among centers to collaborate and do multicenter studies. Pediatric studies are hard to complete, especially prospective studies, so we often rely on retrospective data. A multicenter approach gives us more rigorous data than a single-site study.

In my own research, I’m focused on fluid management in postoperative and trauma patients. We have a prospective study looking at intravascular volume and fluid management strategies, and we’re interested in how noninvasive monitoring, including POCUS, can help us better manage critically ill children.

How is Columbia’s fetal program evolving, particularly for spina bifida?

Our fetal program for spina bifida has evolved quite a bit. We’ve done 20 cases now.

We’re not going to be a huge program like CHOP, because in the Northeast there are several fetal centers, but our results are very good.

The primary outcome we study for fetal repair of myelomeningocele is the need for a ventriculoperitoneal shunt. Nationally, the shunt rate after prenatal repair is about 40%. After postnatal repair, it is about 80%. That is one reason we offer fetal repair: the shunt rate is much lower.

The shunt is what causes a lot of morbidity for these kids. Shunts can get infected, kink, come out, or need to be replaced.

Our shunt rate is less than 20%. It is about 14%. So we have very good outcomes for our spina bifida program, and one of my goals is to keep improving that.

Access is really the other side of the coin here, what does access pediatric surgery look like right now?

Care is becoming more regionalized in some ways. That can be good because it gives patients access to more hospitals and care centers. But it can also dilute the experience of providers if complex care is being offered in systems that may not have the same level of experience.

We have to make sure access to complex care does not get diluted.

We also still have significant problems with access to culturally appropriate and linguistically appropriate care.

One thing I have been trying to work on is a Spanish-language clinic at Columbia. It is not ethnicity-specific. It is language-specific. The idea is to provide care with a physician who is a native speaker.

I speak Spanish, and I have found that when I speak directly to patients in Spanish, their understanding can be very different than when someone who does not speak Spanish uses an interpreter to explain the same thing. The conversation changes. The understanding changes.

So that is something I am working on: developing more language-specific care. Continuing to provide culturally and linguistically adapted care is a real challenge.

As pediatric care becomes more complex, has the team itself changed?

The teams are huge these days.

And I think that is great, because every aspect of the patient’s care is being considered. Not just the medical care or the surgical care, but social support, social work, palliative care, and other perspectives.

Palliative care is often misunderstood, especially in pediatrics. How is that specialty being brought into these conversations differently now?

Palliative care is a good example. It is being involved much earlier, not for “palliation” or end-of-life discussions, but to bring a different viewpoint. They are also getting better at incorporating themselves into discussions without being seen as the Grim Reaper. They are not there because a baby is dying. They are part of a cohesive group.

There is a better incorporation of specialties that now take on different roles because they are part of the same team.

The teams have become very big, and I think that is good. There is also a lot more acceptance of different viewpoints. It is not like what it used to be, where everything was super hierarchical and nobody really listened to each other. That is great progress.

When you think about the children you treat now, what gives you the most optimism?

The greatest optimism I have is around preventative care, gene therapy, and treating disease before it happens or at a very early stage.

There is a lot of development happening in that space. Instead of getting better at treating a condition once it is already very bad and very evolved, we are trying to prevent it from developing or worsening in the first place.

I also think people are more aware of their health. Younger generations are very health conscious, and they are becoming parents now. That is going to make the population healthier.

And what still keeps you up at night?

The same thing that always does: when things do not go the way we hope.

We deal with very sick kids, and the path to recovery is often full of hurdles and bumps. Even when you have confidence that a patient will do well, there can be a lot of doubt during those pauses in recovery.

It is especially hard when something unexpected happens. When somebody who is supposed to do well does not, that is probably the hardest thing.