Case Based Journal Review: Esophageal Atresia in 2022

Published: 2022-08-02

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Ellen — host
Em — host
Rod Gerardo — guest
Todd — guest
Jose Campos — guest
Speaker 6

Chapters

0:00Introduction and Azygous Vein Decision — Podcast introduction and first clinical scenario: whether to divide the azygous vein during esophageal atresia repair
2:27Azygous Vein Preservation Evidence — Review of systematic review showing preserved azygous vein associated with lower pneumonitis rates but no difference in leak or stricture rates
5:32Transanastomotic Feeding Tube Discussion — Clinical scenario and evidence review showing transanastomotic tubes increase stricture rates 2.72-fold without reducing TPN duration or hospital stay
9:18Congenital Esophageal Stenosis Detection — Discussion of using feeding tube passage to detect congenital esophageal stenosis intraoperatively
10:29Chest Drain Placement Evidence — Review of meta-analysis showing routine chest drains do not prevent leaks or pneumothorax but are associated with higher reoperation rates
13:24Antibiotics and Acid Suppression — Discussion of postoperative antibiotics beyond 24 hours and acid suppression, with evidence showing no benefit for stricture or leak prevention
16:52Summary and Closing — Recap of "less is more" theme and podcast closing remarks

Key claims

3:25The azygous vein drains the bronchi, trachea, and esophagus — Jose Campos
3:30Dividing the azygous vein may lead to impaired clearance of mucus and debris from the tracheobronchial tree postoperatively — Jose Campos
3:02In a systematic review of almost 700 neonates, preserving the azygous vein resulted in significantly lower postoperative pneumonitis — Ellen
3:11There was no significant difference in anastomotic leak rate between preserved and divided azygous vein groups — Ellen
3:11There was no significant difference in stricture rate between preserved and divided azygous vein groups — Ellen
4:54The endpoint of chest infection was not clearly defined across studies in the azygous vein meta-analysis, with some using pneumonitis, some pneumonia, and some just chest infection — Jose Campos
6:43In a Quebec study of 244 patients, the overall anastomotic stricture rate at one year was 30% — Ellen
6:50Transanastomotic tubes were placed in 61% of patients in the Quebec study — Ellen
6:5036% of patients with transanastomotic tubes developed strictures compared to 19% without tubes — Ellen
7:06After multivariable analysis adjusting for gestational age, leak, gap length, and tension, patients with transanastomotic tubes had 2.72 times higher odds of developing strictures — Ellen
7:54Patients with transanastomotic tubes started feeding on day 2 versus day 10 for those without tubes — Em
7:58Despite earlier feeding with transanastomotic tubes, TPN duration was identical at 9 days in both groups — Em
8:09Early feeding with transanastomotic tubes did not result in earlier hospital discharge — Em
8:48Having a foreign body (transanastomotic tube) in the anastomosis does not stent it open and in fact makes it stricture — Todd
9:44Congenital esophageal stenosis is associated with esophageal atresia in 7% to 10% of cases — Jose Campos
9:54Most cases of congenital esophageal stenosis are diagnosed really late, some after the anastomosis fails — Jose Campos
9:58Passing a tube through the anastomosis and checking for resistance can detect distal esophageal stenosis intraoperatively — Jose Campos
12:20In a meta-analysis of about 500 newborns, there was no significant difference in leak occurrence, pneumothorax, or mortality based on chest drain placement — Em
12:31The group that received routine chest drains had significantly higher rates of return to the operating room — Em
11:23If a leak occurs, it doesn't always drain through the chest tube — Todd
11:30Chest tubes may injure, suck on, or increase the chance of anastomotic disruption — Todd
11:39Chest tubes are painful for patients — Todd
13:14If you place a prophylactic chest drain, the chances of needing another one later are the same as if you didn't place one initially — Jose Campos
13:53Giving acid suppression to neonates increases the risk of necrotizing enterocolitis according to neonatologists — Todd
14:24Giving PPIs to neonates can increase pneumonia in different populations, but the risk is very minimal — Jose Campos
14:54Antibiotics for more than 24 hours and acid suppression showed no difference in strictures or leaks in the Midwest Pediatric Surgery Consortium study — Ellen
15:58The theme emerging from recent esophageal atresia literature is that less is more, with studies showing things we don't need to do anymore — Todd

Points of disagreement

13:37Postoperative acid suppression use
- Todd: Has moved away from routine acid suppression due to neonatologist concerns about NEC risk
- Jose Campos: Still gives acid suppression routinely, believes the pneumonia risk is minimal
10:41Chest drain placement
- Todd: Routinely places 12 French chest tube, though could be convinced to stop
- Jose Campos: Does not routinely place chest drains, only selectively in high-tension or long-gap cases

Open questions

Why does routine chest drain placement lead to higher reoperation rates in esophageal atresia repair?
What is the optimal approach to acid suppression in neonates with esophageal atresia, balancing reflux concerns against NEC and pneumonia risks?
Should azygous vein preservation become standard practice, and if so, what is the mechanism by which it reduces pneumonitis?
What are the specific indications for selective chest drain placement in esophageal atresia repair (high tension, long gap)?
How can congenital esophageal stenosis be reliably detected preoperatively or intraoperatively before anastomotic failure occurs?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Chest Drains and Acid Suppression After Esophageal Atresia Repair: Two Unresolved Questions

The points where the speakers disagreed, with each position presented side by side. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Points of disagreement · AI-written, human-reviewed

The chest drain question

Should a chest tube be placed routinely at the end of esophageal atresia repair? Two experienced surgeons working from the same evidence reach different answers.

Todd routinely places a 12 French chest tube 12:20. His stated rationale: if a leak occurs, the tube could drain it 11:23. Jose does not place drains routinely, reserving them for cases with high anastomotic tension or long-gap anatomy 12:20. His position rests on the meta-analysis of approximately 500 neonates showing no significant difference in leak occurrence, pneumothorax, or mortality based on chest drain placement 12:20.

Todd acknowledges three concerns that could move him away from routine drainage. First, when leaks occur, they do not reliably drain through the chest tube 11:23. Second, the tube itself may injure the anastomosis, create suction on the repair, or increase the risk of disruption 11:30. Third, chest tubes cause pain 11:39. He describes himself as open to stopping the practice but not yet convinced [q10].

Jose points to an additional finding from the meta-analysis: the group receiving routine chest drains had significantly higher rates of return to the operating room 12:31. He adds that placing a prophylactic drain does not reduce the chance of needing another one later — the risk remains identical 13:14.

Both surgeons were trained to place drains. Both could articulate the opposing position. Neither disputes the meta-analysis data. The disagreement is not about evidence quality but about the threshold for changing practice when the evidence shows no benefit but also no clear harm from the intervention you were taught to perform.

The acid suppression question

Should neonates receive proton pump inhibitors or H2 blockers after esophageal atresia repair? Here the positions diverge more sharply.

Todd has stopped giving acid suppression postoperatively. His neonatology colleagues have raised concerns that acid suppression in neonates increases the risk of necrotizing enterocolitis 13:53. He acknowledges this remains debated but has moved away from routine use.

Jose continues to give acid suppression routinely. He is aware that PPIs can increase pneumonia risk in neonatal populations but considers that risk very minimal 14:24. When asked directly whether he would change his practice, he stated he is not ready to give up acid suppression [q7].

The Midwest Pediatric Surgery Consortium study showed no difference in stricture or leak rates based on acid suppression use 14:54. Unlike the chest drain question, where both surgeons could see a path toward the same practice, Jose explicitly declined to move on this one despite the absence of demonstrated benefit.

The disagreement here is not technical. It reflects different weightings of three considerations: the theoretical benefit of reducing acid exposure at the anastomosis, the neonatologists' concern about NEC risk, and the pneumonia signal in other populations. The evidence shows the intervention does not prevent the complications it is meant to prevent, but one surgeon finds that sufficient to stop and the other does not.

Where they agree

Both surgeons agree on the broader pattern. Recent esophageal atresia literature consistently shows that interventions once considered standard — transanastomotic tubes, prolonged antibiotics, routine azygous vein division — provide no benefit and in some cases cause harm 15:58. Todd summarized the theme as "less is more" [q12]. Jose agreed, describing the evidence as strong enough to "respectfully challenge" the surgeons who taught the original practices [q11].

Neither surgeon is dogmatic. Both described their training, their current practice, and the conditions under which they would change. The disagreements are not about whether evidence should guide practice but about how much evidence, and of what kind, is required to abandon an intervention that feels like a safety measure even when the data show it provides no safety.

What would resolve it

The discussants did not propose a specific study design that would settle either question. For chest drains, a randomized trial with leak as the primary outcome and reintervention as secondary would directly test whether the theoretical benefit Todd describes occurs in practice. For acid suppression, a trial powered to detect differences in both anastomotic complications and NEC would address both the hoped-for benefit and the feared harm. Neither study was mentioned as planned or underway. Both questions remain unresolved in practice, even as the evidence against routine use accumulates.

Takeaways from this story

Routine chest drains after EA repair show no reduction in leaks, pneumothorax, or mortality but increase return to OR
Postoperative acid suppression shows no difference in stricture or leak rates in EA patients
When anastomotic leaks occur, they do not reliably drain through prophylactic chest tubes
Placing a prophylactic chest drain does not reduce the chance of needing another drain later

Topic overview

A case-based literature review of esophageal atresia repair in neonates, examining five surgical decisions through recent evidence: azygous vein preservation, transanastomotic feeding tube placement, chest drain insertion, and postoperative antibiotic and acid suppression use. The discussion reveals a consistent theme of "less is more," with multiple studies showing that traditional interventions—transanastomotic tubes, routine chest drains, extended antibiotics, and acid suppression—provide no benefit and may cause harm. Transanastomotic tubes increase stricture rates nearly threefold without reducing TPN duration or hospital stay, while routine chest drains do not prevent leaks or pneumothorax but are associated with higher reoperation rates.

Key takeaways

Transanastomotic tubes increase stricture risk 2.72-fold without reducing TPN duration or hospital stay—avoid routine use. (7:06)
Preserving the azygous vein reduces postoperative pneumonitis without increasing leak or stricture rates. (3:02)
Routine chest drains don't prevent leaks or pneumothorax but increase reoperation rates—place selectively, not prophylactically. (12:20)
Extended antibiotics beyond 24 hours and routine acid suppression provide no benefit in preventing strictures or leaks. (14:54)
Pass a tube intraoperatively to detect distal esophageal stenosis, present in 7-10% of EA cases, before it causes late failure. (9:44)

Keywords

esophageal atresia tracheoesophageal fistula type C esophageal atresia type D esophageal atresia anastomotic stricture anastomotic leak pneumonitis pneumonia pneumothorax congenital esophageal stenosis necrotizing enterocolitis right thoracotomy extrapleural dissection azygous vein division primary esophageal repair

Hashtags

#EsophagealAtresia #PediatricSurgery #NeonatalSurgery #SurgicalTechnique

Transcript

Click "Show Transcript" to view the full text (18232 characters)

Hi everyone. Welcome back to the Stay Current podcast. I'm Ellen Ancisco and I'm Anton Bash. We're research fellows at Cincinnati Children's Hospital Medical Center. We're back doing a format we've done before. This is a case-based literature review and we're joined by our friend, Dr. Jose Campos from Chile. So in this format, we have a bunch of articles about a particular condition. And we're going to review them by going through a case. And we're going to do so with Todd and Jose. We're going to take them through some scenarios. We're going to grill Todd, get their opinions on how they would manage a patient, and then we're going to review articles from the last few years that can help answer some of these clinical questions. And we're going to take you, the listener, along with us. And this is Stay Cured in Pediatric Surgery podcast. Also here in this podcast, we're featuring Rod Gerardo. We recorded this episode just before he left to go back to general surgery residency, so we're excited to have him here with us. And today, spoiler alert, we're talking about esophageal atresia. If you're listening or watching us on YouTube, you can scroll down on the media player, click on the link and open it and you could read along with us while you're listening. If you have ideas for other articles that may answer some of Todd's questions, you can leave those in a comment if you're listening on the state current pediatric surgery app. So here's the situation, Todd. You're taking a trainee through their first oesophageal atresia case. You have a neonate with an antenatal diagnosis of oesophageal atresia. They weigh 3 kg. They're Completely stable, no other anomalies. We already did the workup. They have a type C esophageal atresia. Let's say we start through our right thoracotomy, and we've developed the extra pleural plane. The azygous vein is right in my face here. And then I look at you across the table and I say, do you want me to divide this? What are you gonna tell me? So I would divide the azyous, but that's purely because that's how I was trained. It's usually right there in the way of where the anastomosis is gonna be. That's why I divide it, but I could be convinced to not do it. Jose, what are you gonna say if Rob looked across the table and ask you, hey, do you want me to take this? I would divide it as well, the same reasons I was told to divide it. It's just kind of the classical approach to it, especially if I'm taking a trainee. So both of you have been trained to just take the ass against Spain. Well, that leads us to our first article that Jose has brought to us. This is called the Impact of Preservation of the azygous vein during surgical repair of esophageal resia, tracheoesophageal fistula. Systematic review and meta-analysis. This came out of Pediatric Surgery International in last year, almost a year ago, 2021. And they systematically looked back through the database from December 2020. And they looked at anestematic complications, thoracic infections between neonates who either had their azyous vein preserved or not preserved, and then they looked at the outcome postoperatively. So almost 700 neonates were included in the study, and the significant finding was that if they preserved the azyous vein, meaning they left it alone. There was a significantly lower chance of postoperative pneumonitis in that group of patients, but there was no significant difference in the leak rate for the anastomosis, nor was there a difference in the rate of stricture postoperatively. The theory behind this is that the azygous vein will drain the bronchi and the trachea. Uh, as well as the esophagus, which would lead to an impaired function postoperatively and impaired clearance of mucus and debris from the tracheobronchial tree. But it seems like preserving or not preserving the esophagus doesn't really affect that. I'm not sure if I'm gonna change my management right away after reading this, but I would be very interested in seeing more prospective data on this, on, on people who have preserved the ASIOs and see how they're doing. What, what do you think, Todd? So, a few things. Let me start off by saying, I could definitely be convinced to stop dividing it. I Never like dividing it. You're in this tiny little space and you're cauterizing a vein that you kind of know you don't need to be doing because you could probably still do the operation without doing it. There's a definitely a chance that you could cause bleeding. So for all of those reasons, I think it's great to know that maybe we shouldn't be dividing. Now, I'll tell you what's not convincing me, this paper. Oh why not? They took a bunch of papers and compare the outcomes. Were those papers designed to look at the difference. Between division and non-division of the Azagis, or were they taking papers that had different endpoints and they, they looked at that coexistingly to see because there's so many other factors. The articles were made to pick up a difference between divided and undivided, but the endpoint of chest infection, it's not clearly defined in all of these papers, so some of them just said chest infection, some of them said. Pneumonitis, some of them said pneumonia, so that's not a very homogeneous endpoint. That's not a metric. They have to look and figure out why they're having chest infections. That's a bigger question. OK, that's a good point. I am willing to explore this possibility of not dividing it. I don't need someone to prove to me that dividing it hurts the patient. I need someone to prove to me that you don't need to divide it. It's worth to continue to look into this, and I would look forward to more prospective data. All right, next question. So we finished the posterior part of the anastomosis, and the trainee asks for a 6 French feeding tube to put down. What would you say to that? I would say absolutely put it down, but then take it out at the end of the case. It's good to have it in there when you're doing the interior wall, so you don't get the back wall, but then take it out. And what about you, Jose? So, I would put one in, yeah, I would leave it at the end of the case. We'll see if I change my my opinion after listening to the article. OK, so the article that Jose helped us find to address this question is called Effect of Trans-astomotic Feeding Tubes on Anastomotic Strictures in Patients with esophageal atresia and tracheoesophageal fistula, The Quebec Experience. And this is published in JPS this year, actually, 2022. This is a retrospective review from three hospitals in Quebec. They looked at type C and type D esophageal atresias undergoing primary repair between 1993 and 2018. They divided patients between two groups, those who have a trans anastomatic tube placed and those who does not. Now the primary outcome was whether or not they developed a stricture within a year, and the secondary outcome was the duration of the post-operative TPN use for the patients. OK, so here they looked at 244. Patients. The anastomotic stricture rate overall for all the patients at one year was 30%. They put transastomotic tubes down in 61% of patients, and 36% of those who had the transastomotic tubes in developed a stricture compared to 19% of patients without a trans anastomotic tube, and that was even true after multivariable analysis. Patients with the transastomotic tubes had a 2.72 times higher odds of developing a stricture compared to those without transastomotic tubes. And their conclusion was trans anastomatic tubes are not recommended from their perspective rate. So what do you all think about that? Well, I would like to change my management. So far I've been leaving transana automatic tube, but I'll be very happy to change that management based on this article. I think this article is well done. They actually adjusted for gestational earthquake leak the. Length of the gap, the tension, everything. After adjusting for everything else, they still got almost 3 more stricture rates. The other thing that is I was leaving this tube in my hope to feed the child early, so I'm a big fan of ERAS protocols on early feeds. Patients with the transcendastomatic tubes started feeding on day 2. Versus the other newborns started on day 10, but early feeding did not lead to less TPN. The duration of TPN on both groups were exactly the same, 9 days. And did we get them home earlier? No. So even if you don't believe that the trans anastomatic tube is giving you more strictures, there's no benefit at all in leaving one. I think we should get rid of it, and it's going to take a while for people to be brave and change their practice, but I think this one's a no-brainer for me. Todd, you said you already take the tube out before you leave the operating room. Is this kind of in line with what your thoughts were? Yeah, we're finally getting good data in pediatric surgery. I historically always left tubes. In fact, I went the opposite direction. I used to theorize that you should leave a huge tube across the anastomosis, and that would keep it stented open and it would heal wide open. Boy was I wrong. This is clearly showing that Having a foreign body in there does not stent it open, and in fact makes it stricture. So once I read the Midwest Pediatric Surgical Consortium article, he stopped using trans anastomotic tubes. And for anyone out there listening, it's hard to do. That's been your safety line, and to let go of it is a little scary, but it certainly did not impact. Uh, any of our outcomes. In fact, it's probably been better, and now this is just another paper to support that. And both you and Jose said that you were trained by people who were like, you place a tube, you leave it, that way you could feed them afterwards. There were 3 reasons to have a tube. One is it helps with your anterior anastomosis. 2 is people believed that it was like safe to have a stent across an anastomosis in case there was a leak. To maintain some continuity. And then the third thing is that you could feed after surgery. Esophageal stenosis is associated with esophageal atricia from 7% to 10% of cases, and most of them are diagnosed really late. Some of them are diagnosed after your anastomosis blows up. So one of the maneuvers you can do is just pass this tube and see if there's any resistance in passing into the stomach, and that will give you some idea if the distal esophagus is. Tight or not. That's a great idea. Push it through, make sure it passes. That's happened to me before where I found that it didn't pass into the stomach and there was an esophageal stenosis. In fact, that was one of our previous articles we talked about. As I say, congenital oesophageal stenosis. If you guys wanna listen to that, then you can scroll back a few episodes. Let's say you're gonna close the chest here, and we're getting done, and then suddenly then Rod's across the table and he asks for a chest tube. It's gonna help in the post-op management. What size chest tube should I live in, Todd? Yeah, I look across the table, I say, hey, Tosh, what size chest tube do you want me to put in here? What are you gonna say? Usually I put in like a 12 French chest tube. Oh, you do, Jose, what do you do? Yeah, I was told to leave a, a chest drain in. A few of my first cases, I did it routinely. We tend to be dogmatic. I'm, I was just trying to be safe at the beginning, like being an inexperienced surgeon, doing whatever they gave the baby security, but I quickly moved away from it. If there's a lot of tension, difficulty on the anastomosis, or if it's a long gap, I think I would be more convinced to leave a chest drain, but I do not do it routinely. Todd, do you leave a chest tube every time? I do, that if there's a leak, it could drain the leak, right? I could be very much convinced to stop doing it because number 1, if there's a leak, it doesn't always just come right out through the chest tube. Number 2 is I believe that the chest tube. May injure or suck on or even increase your chance of disruption of your anastomosis. And number 3, they're painful. So I could absolutely be convinced to stop leaving them. The journal article we're gonna talk about here to address this question is from last year actually, from 2021. This is again out of JPS and this is called Weather. Prophylactic intraoperative chest drain insertion in esophageal resia, tracheoesophageal fistula is an evidence-based practice or just a prejudice, a systematic review and meta-analysis. The authors here out of India, they looked at patients who were either received a chest drain for the post-operative period or did not get one. And then they looked back retrospectively on the, the outcomes of them perioperatively. So it ended up with about 500 newborns. They didn't have any significant difference in the occurrence of the leak, or the pneumothorax or the mortality rate based on whether or not they placed a drain. But there was a significantly higher chance that the group that got a chest drain would have to go back to the operating room. Basically suggesting that you may not need a routine chest drain every time because it doesn't appear to prevent complications. And probably for a lot of things that you and Todd are mentioning, it's not necessarily gonna drain the leak. I'm a bit conflicted by this evidence because the authors don't mention an explanation on why the group that had a routine chest drain insertion had higher re-operation rates. They don't mention the indications for those operations, but here's one thing that is convincing me not to leave a chest drain, at least routinely. If you put a chest drain. The chances that you're gonna get another one is just the same. OK, final question. So we're finishing up the case and Rod asks if postoperatively, we should continue perioperative antibiotics for more than 24 hours. And should we put the patient on an acid suppressor, like a PPI or an H2 blocker? I have moved away from both of those. I used to do both on everybody. Regarding the antibiotics, I just don't give it after a 24 hour perioperative dose, and our neonatologists are concerned that giving acid suppression. To a neonate increases the risk of necrotizing entercolitis. In the neonatal period, we try to uh give less of it, although this is debated. And Jose, same thing. Is this what you were taught? How does it changed over time and where are you at now? No, I don't. Don't do antibiotics post-operatively. One of the reasons it's not indicated. I want to detect a complication early. I don't want to have them on antibiotics kind of covering a complication, and acid suppression is a difficult one for me because I do give acid suppression. Giving PPIs to neonates also can increase pneumonia in different populations, but I think that risk is pretty, pretty low. It's very, very minimal. All right, so what did the article show? OK, so the article we're looking at here looks at a bunch of different things related to esophageal atresia, and the title of the article is Challenging Surgical Dogma and the Management of Proximal esophageal atresia with distal tracheoesophageal fistula. Outcomes from the Midwest Pediatric Surgery Consortium. This article is published in JPS in 2017. As far as the questions about postoperative antibiotics and postoperative Acid suppression. The paper outlines that antibiotics for more than 24 hours and acid suppression essentially showed no difference in strictures or leaks. It's an important article. It's a good article. Yeah, it's a great summary article looking at a bunch of different outcomes in esophageal atresia. I feel like we covered a lot today. To summarize then, so we decided that when you're doing esophageal treatsia, tracheoesophageal fistula repair on the neonate, you guys are still on the fence about taking the azyous vein or not, but you could be convinced. As far as a feeding tube, you guys are both thinking maybe more people should stop leaving feeding tubes postoperatively, right? And then as far as the chest tube goes, Todd, you leave one, Jose, you selectively, OK. And then the last question we were saying, antibiotics and acid suppression. So Todd doesn't do that postoperatively, but Jose, you're still kind of maybe holding on to the acid suppression part. I'm not ready to give up acid suppression. Sorry. If I were to give a summary of today's selection of articles, the theme is less is more. It keeps seeming that articles that are coming out more and more are showing us things we don't need to do anymore. And so, I think I agree with that concept and If I felt like chest tubes hurt the operation or the anastomosis or a patient, I could be convinced to stop using them. It's a little scary, but I think it's probably heading in that direction. I think it's difficult as a trainee or as a young surgeon to challenge the very same people who has taught you to do something. But with this new evidence, I feel that we can find common ground. It's not uh a crazy idea, less is more, it's something that it's been proven and it's been safe so that's how you can respectfully challenge. What you've been taught to and to improve the outcome for your patients. Yeah, definitely. OK. Awesome discussion. Thanks so much to Todd, Jose, and Rod for joining us. If you like this podcast, if you like this content, leave us a review on Apple. Podcasts or Spotify, wherever you're listening. Subscribe to our YouTube channel. Let us know what you think there. And don't forget to download the Stay Current in Pediatric Surgery app where we have a lot more content like this with podcasts, videos, articles. Take a look and download it. And as a reminder, don't forget, we have another virtual event coming up soon in the end of August. What's the virtual event, M? It's 10th annual pediatric surgery update course. Todd's been doing this for 10 years now. It's a huge milestone. We'll have it in person in Cleveland with some of our experts, and anyone can watch virtually. It's happening on Tuesday, August 30th, starting at 9:00 a.m. Eastern Standard Time. Check out the link in the description below. Until next time, I'm Ellen. I'm Em. And remember, knowledge should be free.

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