Speaker: Farokh R. Demehri
Thank you. Uh, so today I have the distinct honor to introduce today's speaker, Doctor Faro Demari. Um, I will tell you all things that you already know about Doctor Demy. He's an accomplished pediatric surgeon, innovator, and educator, um, and he, uh, we've all learned that since his time here with us for a number of years, and I started to learn it when he was my chief resident when I was an intern at the University of Michigan. His impressive journey, uh, began, uh, with a biomedical engineering degree from Duke, um, and followed by his medical degree at the University of Florida. He completed his general surgery residency at Michigan and pursued, uh, later on fellowship training in pediatric surgery, as well as a pediatric critical care, uh, surgical critical care here at Boston Children's. Since being on faculty here, I don't think that there's a subspecialty group in this institution that he hasn't worked with. Uh, currently, this is just the current state, this may change by the end of this presentation, but his current clinical practice spans from oesophageal atresia to CDH, ECMO, fetal surgery, and he's also the director of the pectus and chest wall treatment program, which he's done a great job, uh, expanding and growing. In addition to his clinical expertise, Doctor Demy is a leader in surgical innovation, surging serving as the co-director of the Surgical Innovation Fellowship. He, his research touches on novel device development, surgical education, as well as optimizing surgical outcomes. From the perspective of us fellows, uh, Doctor Demy is always known as someone who's willing to try just about anything with us that we can, uh, pitch to him as an innovation. Um, I'm certain that he has been burned by that approach in the past, but we appreciate it as it, as it encourages us to keep thinking creatively about some of the problems that we all face. Uh, and he's always open to any of our, uh, sometimes smart, sometimes not so smart ideas. And for that, we're grateful for him. We really appreciate working with him here as faculty, and I appreciate him, uh, giving us ground rounds today. I look forward to hearing from him. Please join me in welcoming Doctor Demy. Well, thank you, Brian. Um, We go way back. So, thank you. That means a lot. And, um, and uh you'll, uh, I'll address some of those points actually during this talk. Um. So I have no disclosures today. I'm gonna maybe show some pictures of some devices, but I have no financial relationship with any of them. But, um, to pick up where Brian left off, why am I here? Well, I got an early morning text from Brian a few weeks ago. Any chance I'm willing, willing to give a grand rounds. We have a scheduling snafu, so, um, I'm willing to try, try anything. So, would you, it'd be great to hear about pectus or fetal stuff. Um, so I'm like, uh, not thinking straight, early morning, text back, sure. And then later that day, crap. What I'm gonna talk about? Pectus and fetus. What do these have in common? Ah, they both end with us. It ends with us. I'll call it that. I think there's a movie called that where everyone's getting sued, so I'm not gonna do that. All right. Um. OK, so, it's not just pectus and fetal though. I mean, I thought about actually a quote that I've personally encountered when I was in high school, um, how we spend our days is, of course, how we spend our lives. And, um, you know, professionally, I spend my days doing some work with pectus, fetal, ET, surgical innovation lab, ICU, CDH ECMO. What's the link between all these and how did I get here? Well, I'm gonna call it Confessions of an ADHD surgeon. Um, which I would love to give this talk one day, but I need to do more research on this. I think there's actually a lot of meat here, but I'm not gonna quite make that the talk today. Instead, I tried to find another link besides just being ADHD. And I put myself in the shoes of the trainees, mostly, um, and wonder, gosh, if I was in your shoes and I saw an attending up there saying this is what I do, um, it would be a little bit different from a lot of the mentorship I would have gotten at that point, you know, a lot of mentorship is pick a thing, pick one problem, double down, dig in, do that thing. And I think for a lot of people that is the right answer. Um, but I found myself here and honestly, I'm pretty happy. Um. And so was this my goal? Uh, no, actually, when I was in your shoes, it wasn't, but again, here I am and I'm happy. And so, I thought back to the incremental decisions that I made and how I got here and made the decisions to be doing what I do. And so, what is the link? Well, for me, the link is joy, and I think all of us. Actually use that as our link when we make our incremental decisions in our careers. And we gotta find what our own joy is, and I'm gonna talk a little bit about that and I'll tell you what I think my Version of joy is that led me to these things. So, we'll spend a few minutes talking about professional joy because as I was telling some of you earlier, as an attending one of your grand rounds, you can talk about whatever you want, even if you're not an expert on it. Um, and so I'm gonna bloviate for a bit and then show you some, uh, hopefully some cool projects I've been, uh, lucky to be a part of. Um, and also along the way, let you know a bit more about me, uh, sort of a self roast, if you will. Um. So we'll talk about what is professional joy, why is it important, and what are some of my professional joys right now. So, I wanna focus on professional joy, not the big joy, OK? Obviously, we live more than our professional lives, right? This is my big joy. This is my family, my, uh, uh, my kids, my wife, my extended family on my side, Angela's side. Mainly, I want to point out this guy right here, that's Barley. He's a 230 pound mastiff, and this Chuy, she is an incontinent bulldog. And uh I want to point out my 2 year old niece here who's very afraid of them. Look at her face. Um, so, In the words of Chris Weldon, and I keep this quote to heart, he told me this when I was a fellow, your kids will never read your resume, right? A lot of things I'm gonna talk about are professional things, OK. My kids, other than the fact that I, if I come home happy, that's the only part of it they notice. So, as I thought about this, I thought about a quote that I also encountered in college actually um by Leo Tolstoy. The first line of Anna Karenina, All happy families are alike. Each unhappy family is unhappy in its own way. And um it's actually called in philosophy the Anna Karenina principle. There's one way to be happy, there are many ways to be unhappy. And that can apply to any endeavor. In this case, talking about families, but it can be a business, it can be a research endeavor or any sort of group with um uh well, um, a, a mission. And the idea is that a deficiency in any one of a number of core requirements dooms an endeavor to failure. If you're a family means, you know, health, financial security, mutual affection, um, as pediatric academic surgeons, those criteria are different. And so, One of the things that, you know, we need, we think about, and I'm I know, you know, good leaders think about is what are the core requirements of being a successful academic pediatric surgeon. And to be honest, we, we have those core requirements. I, I feel like I have that, but Is being successful the same thing as having joy? And that's something that we can only answer for ourselves, um, in that what is our goal? Is it success? Is it joy? Is it both? And what are the criteria for those? So This is the scary thing about finishing training. And uh for some of us, this, for many of us, it feels like very recently we're still in that, and for the rest of you, it'll be very soon. All right. The horrifying moment when you realize you're an attending, but you realize you need to look for a smarter attending, someone actually the attendee attending. But then you figure it out. And you're like, I'm doing this, I got this, and you know what, I'm doing all right. But am I happy? And then, you know, you do all this training and you're there and you're doing the thing and the thing is, and this, almost everyone I've talked to when you start training or you start your attending hood had gone through a similar sort of deceleration injury and then existential crisis. We're like, whoa, is this it? Cause it's awesome. But whenever there's a light at the end of the tunnel for that long, it's never exactly what you think it is. So, there comes a point where you have to reinvent what that light is. And so, where is the joy? What, how do we define that? Well, this is a concept that, that comes up in uh uh non frequently, which is this tripartite description of drive or motivation. It comes from Daniel Pink in, in, in a, in a popular book about a decade ago. Um, so it's 3 pieces that basically, so people don't quit their jobs. OK, this is where it comes from. All right. Autonomy, means the desire to control our lives, right? We should have autonomy, no matter what industry you're in. Mastery, the desire to become better at something that matters, and purpose, desire to do something important. Now, as surgeons, we're really lucky. Like mastery and purpose, those are built in, right? We spend 10,000 hours, better be masters by the end of it, and purpose, pediatric surgeons, I mean, amazing. Autonomy can sometimes be the hard one, right? That's where leadership and, and a good organization comes in. But this Is motivation But is that enough? Because you can be motivated and you can feel like I should do this, but that's different from saying, I really, really want to do this. So, that's where joy comes in. And again, for each of us, it's our own thing, but if you can get motivation, plus whatever your X factor is, that joy, then power up, baby, cause it gets fun. So, what brings you professional joy? Well, joy doesn't mean happy all the time. It's not the existence, the feeling of joy, but it's that X factor. You can call it joy, you can call it fun, you can call it, you know, the thing that gets you up out of bed in the morning, and the thing that is related to, but not exactly your job description. We all have our own joys, whether it's um uh that that inkling of, of I invented something, that inkling of I taught someone, that inkling of I'm holding a baby in the NICU that I just operated on, whatever it is, but holding on to those things, even if they're transient, it's super important because there's a lot of down days and weeks, etc. and holding on to those joys are super important. We can have more than one joy. I just described a few. And joy can change. Remember when I was a resident, when my co-residents said, I'm gonna be a vascular surgeon because I love sewing vascular anastomosis. There's nothing I love more in the world than the act of putting needles in vessels. And then I remember later on, it's like, I don't want to be a vascular surgeon. It's like, why? So, well, I realized if I, when I'm attending, I'll be watching someone else do that. And he's actually an amazing researcher now, um, but still, like, Um, uh, that can change, and it's having that idea of, well, it may be different at different stages of my life. So, what's my professional joy? What links all these together as I did my soul searching and thought about it? Well, it's all these people. The truth is, like, especially after COVID, you know, uh, you know, we got lonely and I came back like, holy crap, this is awesome. I still get to work with all these amazing people and what they represent are creative teams. Not just teams, but creative teams, and that's important. So, creativity and teamwork, that's what drives me, that's what gets me excited, among other things, but I wanna talk about that today. So, I'll start with a quick confession. I'm a band nerd, right? That is me in, I think 7th grade. All right, playing the trombone, that's, I'm also a theater nerd. All right, so this is, this is college, this is the cast of West Side Story. This is me as the lion in The Wiz. And so, those were things that I loved and I still have that part of me that I really just enjoy is creating things and not by myself, but being on a mission with a group of open-minded, talented, hardworking people so we can create things that I can never create on my own. Um, Think of being in an improv group, right? There's nothing more fun than having a group of people and just making stuff up, and it is exciting and it's addictive. And you get to do this every day at work. It's awesome. Plus, you know, all the other cool stuff we get to do with this job. Um, so, This version of creative teamwork is team surgery, and that's what, you know, all I'm involved with all these things, but they're all teams. Um, and uh I'd like to look at it, but I think I probably hold the record for most second, secondary surgeons in the, in cases in the group. Like I operate a lot with my partners, which I actually really, really love, and it leads to creativity, which I'll spend the rest of the time talking about. So, we'll go through each of these and why they link in with this idea of team surgery. So, we'll start with ICU, CDH and ECMO, um, So When I was going through that existential crisis section early attending, Chris Weldon who's in the back there, he pulled me aside and, and we talked for a while and he got, and, you know, he's known me for a while. And through his mentorship and, and Jill and Belinda and, and led me to To doing another fellowship in critical care. Um, and that led me to a very, very important part of my life, which is this idea of clinical team surgery. Not just surgery, but the whole ICU like environment where every day you're working with a whole bunch of people who are more talented than you in different ways and you do it all together and you do something you no way you could ever do by yourself. And CDH is definitely one of those things. I'm not gonna get too much into the science of things, but CDH, as we know, is a real challenge. One of the hardest things we do in medicine as far as getting the sickest CDHs to live. Um, and it definitely takes a, a team. And, you know, one of the things that, you know, I'm gonna talk about a few examples of creative endeavors that we've had and how this came from a team. So, you know, we, speaking of joy not always being happy, um, you know, we've definitely hit our heads against the wall a lot, you know, um. Among many, many great experiences, but, you know, we'd hit against the wall with some kids who just wouldn't come off ECMO. We'd canulate them and, and they, they wouldn't live. And, you know, anecdotally, there we go, though, that that's that corner group back there with, with me. We'd we'd We'd say, well, you know, we'd noticed that the ones that seem to do better had a shift of their mediastinum, and some of us thought about that, you know, that it made sense. And then we had our ECMO specials at the bedside and RT's at the bedside that doesn't matter, does it not? And then we sat down with one of our specialists and research fellows and said, well, why don't we study that and see if this matters, right? And I'll show you what we found. So, um, We ask this question, does the media sound position matter? You put a baby on ECMO. Right after birth, unrepaired CDH and their cannulas, look at these emo cannula, arterial ven, it's way shifted in the right side of the chest. If you can get them while they're on ECMO to shift over, will that actually improve outcomes? Does, does, if they're coming in already shifted this far over, are they worse? And we would start pruning these babies to actually see if it helped. And anecdotally, we saw, yeah, their PO2 is coming up, their vent settings are getting better. So Nicole Simbach. Um, and, uh, Andre Badoya, one of our radiologists, and I went through basically all of our ECMOCDH patients for the past decade, um, and The two things. One, we worked together to figure out a way to measure this objectively using the venous cannula. So basically, we'd measure the distance from the venous cannula to the contralateral chest wall of the CDH, basically saying how far you're shifted into the contralateral chest divided by the actual size of that chest. So basically, the lower this number, which we call the mediastinal shift index, the more you're shifted into the other side. So the more guts that are in your chest, the worse your CDH is. Makes sense. Um, the challenge, the, the reason it's helpful is because some of these kids don't have good numbers prenatally or you're misled by prenatal numbers. At this point, postnatally, you're on ECMO, now the proof is in the pudding. What can they do physiologically? And what we found was, yeah, you know, if, if you take repair the CDH, generally they would move over. The MSI would get bigger, so the cannulay is closer to the midline, and this is right before coming off ECMO and living. MSI gets higher, and here we're across the midline. And so, lower MSI, more media sign of compressing good lung, worse outcome. And what we found is that this correlated very well. With predicting survival. And so baby on ECMO, the further that venous candle is shifting the other side of the chest, the more likely they are to die or vice versa. And interestingly, if the MSI is greater than one, meaning the cannula shifts over into the other side of the chest for a left-sided CDH it's actually, this is not true for right-sided, um, the shorter demo run and a trend toward higher survival, although our numbers weren't high enough. So That was cool. That was a fun experience because we're, we're in a situation where we're dealing with a real challenge, but we all work together and get to create something, which is like, kind of a fun thing to be part of. Well, speaking of creating things, when I first started as an attending, I joined Hong Bai Kim, who had just started Surgical Innovation Lab, and, uh, and got to work on really fun projects with, with him. And basically, there was like, I'm starting off, I don't know what I'm gonna do. And he's like, hey, you wanna hang out with some really smart uh uh driven residents and make stuff up all the time? Sure, that sounds fun. I can do that. And so, um, I joined them to co-direct the surgical innovation lab and had the joy of mentoring several uh fellows over the years. Including uh Sarah and Megan, who are current fellows. And so, some of you have seen this in various forms already, but I wanna talk about it from a little different angle and how looking at this problem from having a group of people looking at it has helped it move forward. So, the pruning device. So, we've been working on this for a few years, basically since COVID, and the idea is that we know that prone positioning improves clinical outcomes in patients with ARDS and respiratory failure, um, ventilated patients, um, Especially adults. Uh, many of you during COVID may have seen this or been part of it. Have patients intubated on high settings. What do you do? Call the pruning team proneum. This was new during COVID. In fact, this idea came before pruning was widely used in the US. We started working on this because it was used in Europe and in the US no one wanted to do it because it's a pain in the butt. You take 6 nurses who have no interest in doing this and you say prone that patient, they're like, no thanks. And in Europe, they were doing it and showing better outcomes. And so that's where this idea came. I, you know, I'm driving home, I get home and I send a quick, you know, message to Steve Fisherman in Hung Bay like we, we, can we work, can we do this? Can we, this is something that we could be able to create a better way to prone patients because if it's gonna help outcome, there's no reason we shouldn't do that in the US and the truth was it took years, well, it took a long time before people started doing in the US because of how hard it was. And so, this is the initial idea actually. I was like, well, why don't we just strap two hover mats together and see if we could flip someone. And, um, uh, research fellows, this is your main job is to be the person that we flip. So, this is Rob Crumb, um, who we flipped in our first version of this, and here's two hover mats. Here's Bree and Kyle and flipped them pretty, pretty well. And we took what takes about 8 caregivers and did it with 2 flippers and 1 holy airway person. Um, well, there's a lot of lessons in innovation, but it turns out it's hard to make a device that's already FDA approved for another device, um, for another use, um, uh, and retrofitted for a lot of reasons. But regardless, it wasn't a perfect design, mainly because it was hard to control whether you could breathe. But it kind of stuck after that. We were like not doing much. With it, and then our fellows come in and the fun thing about having a team is the team keeps you, gets you back to different ideas. So we, we let some time pass and then new fellows come in and say, well, that looks cool, let's work on that some more, and they keep an idea going. So, we worked on a few other prototypes. Here's one. And you'll see basically I'll just click through this, but um it's here's the next version, right, so here we've gotten rid of one of the issues with covered matter is just spraying particular matter everywhere, which no one wants to do in COVID, um, so. We have another device that's a sealed round device, very easy to turn, but, um, Heng Bei uh almost passed out during that, so, could not breathe, that's a problem. We have another version, and here you can see my role in the lab was mainly dead weight. Um, is, uh, how do you feel multiple bladders, and here we start taking to the ICU. We have some familiar faces here, ICU nurses, respiratory therapists. Drive them by saying and then you take the top off. I love that and this is better. And here's our uh, not our latest. We don't have a video of our latest one yet, but this is our second latest prototype. Spicer. Yeah, I mean, that's the question, right? Um, jumps in here. Now we start getting real buy-in to get full ICU teams flipping patients or fake patients and assessing the ease of it, perceived safety lines, tubes, etc. So easy, so easy to flip me. There we go. And so, we were able to survey um ICU teams here. Actually, Oren's wife um helped us with the team from Brigham, um, and uh we were able to, at least so subjectively by caregivers that it required less force, perceived safety was improvement and people wanted to use it. So, we're still working on that and it's super fun because, you know, once we get to meet and and create something. All right, so now back to team surgery, so pectus. Um, Brian mentioned, you know, we now have a practice, chest wall and practice treatment program. Um, really, I think if there's one innovation here, it's, it's actually taking something that I learned through other teams like the E Team, which is if you get a bunch of people and do things together. You can share your experience and rapidly innovate and rapidly to improvement in care, even if you're not necessarily inventing something new, but making it so you're all doing it the same way and, and, and getting better, better outcomes. Um, and so when, when I started as an attending, honestly, practice kind of scared me because I, I, I was like, I don't, there were so many different ways of doing things and, um, and, um, and it was perceived as kind of, you know, some potentially dangerous thing for like a thing that didn't really, you know, Wasn't really life threatening for a child in the first place. But with a team was able to feel more comfortable doing something that kind of seemed scary initially and make it now where it's kind of a fun, boring operation in a way, you know, we're not scared, but we're just having fun. Um, and so, this is the initial version of the NUS procedure, which we're not doing a whole pectus talk today, but, um, As Dr. Lilihi, um, you know, taught me when we first started doing the first one of these with him. It's like, imagine when we first, Dr. Nuss first did this, there was no thoracoscopy. So he did 10 years' worth of patients before, before publishing or sharing the data. So imagine that doing 10 years of operations, not sharing with anyone, and then after 10 years presenting it. I wasn't. for that, but y'all were, and, and I've heard the stories about how big a deal that was. It's like, whoa, this is completely different than the open operations that were being done before. And honestly, appropriately, a lot of raised eyebrows. So you're taking a child who's otherwise healthy, and you're kind of blindly shoving a rod behind their sternum in front of their heart, flipping it over. And saying, all right, And their anesthesiologist and now, you know, has stopped sweating and changes their pants, right? Um, and so, uh, But it caught on cause it made sense. But as You know, when, when you think about innovating something, and I think about this lesson as I think about, you know, potential future innovations and things, technical or otherwise, like when you, if you create something or a technique and, and you publish it and share it, and then people are like, that looks cool. I watched a video, I'll try that. Um, then bad things can happen. You know, Ben and I have talked about that a lot with um tracheopexes and airway work, right? It's like, there's a certain moral responsibility that comes with, with um sharing new techniques if, if appropriate safeties and things like that aren't put into place. And, you know, if you ever get a chance to hear Doctor Neuss talk about it, it really wear on, on him because their kids died. Um, surgeons like, that looks cool, I'll do it. And the cardiac perforations. This is a picture from a case report of a right um lung, high lung perforation and deaths. And, and so, the greater practice community worked on how to make it safer and, and even the last few years since we started working together, we've worked on other things to make it safer to, like I said, now, it's a pretty fun case and, and, and, and it's, it's, it's um very safe. And so, a few things that way before I got involved in any of this, but, um, uh, thoracoscopy, that was a big deal, actually. I think it's obvious now, but actually it took time for people to realize, let's put a camera in there and actually see the bar go across. That makes sense. Sternal elevation seems obvious. Most great innovations are actually obvious when you see it in retrospect. Um, and again, years before anyone said, why don't we just like lift the sternum ahead of time so the, the tunnel is bigger. Um, and this seems very simple, but actually, you know, even just yesterday, we were struggling with how to do this effectively and it's fun, you know, because of the mechanics of it and things like that, but lift the sternum, make more space. You can see here's a picture. Actually, it's not from this um um uh source, but this is actually from one of our cases. Um, here's the heart being compressed by the sternum ahead of time and we put a little retractor in there, lift it up, and plenty of room. In fact, we're like the thymus is like begging to be taken out here, um, because we've lifted it up and we have plenty of room to pass that bar. And then it's still around the country, around the world, most people just like take the bar passage, which is a big metal thing and still kind of shove it across there. Whereas, you know, it's fun as a fellow, you like doing, you know, an actual operation, you're dissecting things. And so we started doing that and actually dissecting out the media side and peeling the heart away from the sternum, making a huge highway to put the bar so you're not worried about it and getting a critical view of safety where you never lose sight of the tip of your bar passer. And so that has made it a very low anxiety operation. And then bar stabilization. So, this is something that we continue to evolve uh together and this is the only reason we've changed this is because we've grouped our experience. So, this is the way that sort of it's still in the textbooks. This is how it is described. How do you stabilize a bar? You put a bar and you want to make sure it doesn't flip. So you put a little cross piece and you stitch it really well to the ribs and we're surgeons, we stitch things and if you stitch it real good, it's not gonna go anywhere. It doesn't quite work when it comes to high force things that are gonna have to stay in for 3 years like a bar. And the kid's gonna go, you know, play football, etc. So, this is the textbook appearance of a post-op bar. Nice bar, you got the stabilizer there, looks really good. That's how it's supposed to look. This is standard of care. And um another lesson taken from, you know, the eat experience to this is, is, you know, when you treat enough patients. Even rare complications need to be addressed. If you do like, you know, 5 practices a year, you may never see a bar flip, but once you get to like 30, 40 a year, that thing that's rare, you're gonna see a lot of, right? We talk about that in like, yeah, nerve injury. All right, I do 2 of these cases a year, it's not gonna be, maybe I'll see one in my career, right? But if you're doing it all the time, you're gonna see it over and over and it eats at your soul. So, that's what happens here is when you're doing it over and over, you see these complications altogether. And you learn. So, not so stable. By sharing experience, we all learn faster. So, this is a case that we shared um of a bar that looked really good post-op. This is a textbook answer, but came back a few months later and the bar is flipped, and a few days later before we got into the OR flipped some more. I was like, how does that flip with a stabilizer on? Well Physics, Newton's 3rd law and Every action has an equal and opposite reaction. The bar is pushing up against the sternum. The sternum's pushing equally hard against that bar. The bigger a patient is, the more rigid the sternum, that sternum's going to try to make that bar move. So the older the patient, the more active they are, of course, is going to make that bar move, and the position of the stabilizer matters. So a stabilizer on the side for, you know, again, great innovations are obvious in hindsight. If it's on the side, it's not gonna work because it doesn't actually prevent the bar from flipping as a bucket handle. You put it in the front, and now the vectors completely oppose the rotation of the bar. So, move the stabilizer immediately, and there you go, one stabilizer on one side, you're good to go. And we felt good about that. We actually did about 3 years of cases just doing this for for most cases. We did some 2 bars, things like that. And then shared experience, we had an intrathoracic bar erosion, another shared patient of ours. Patient comes in, it's like, I feel a bump over here and basically the bar on the side without the stabilizer had completely eroded between the intercostal muscles, um, and, uh, and like it's bony callous into the chest. And, I mean, he was complaining of a, of, of a bump, luckily, nothing more, but that was scary. We took him to the OR, of course, fixed it and put another stabilizer on. And, and now, we, we have actually something that seems Very, very stable, which is basically 2 bar, uh, 2 bars for bigger patients linked together and then 1 bar with bilateral medial stabilizers. And I. I'm pretty certain that if we had not joined each other for these cases, thought about them together in the operating room and with the complications. The evolution would have been much slower than. Hanging our heads down, you know, oh, I had a complication. I like the fellow's gonna present at Eminem, and then a month later, we talk about Eminem, and then you do your mea culpa, and then you go away, and you don't actually innovate quickly. And that's where this is where the team-based surgery model really, really helped because you force each other to think on the fly and innovate together because each complication is everyone's complication. And uh this is Oren's case, we did 3 bars once. I'll throw that in there. Thanks, man. All right, so anyways, post-op appearance of us, um, but the other innovations impact us. So, I'm gonna fly through this cause I want to show a couple of videos. Oh, I have a little more time than I thought. OK. Um, so, postoperative pain. So, um, as, uh, as our, our inpatient team knows, um, uh, the NUS procedure in minimum invasive practice repair is like really painful. Um, one of the analogies, um, is, uh, you know, it's like putting braces on. Dr. Lila taught me this, putting braces on and cranking them on the whole way when you wake up, like that's really painful, and that's what they used to be like. They'd be in the hospital for at least for about a week, go home on a, you know, boatload of narcotics. One of the actually interesting in literature, one of the main, one of the known complications from pectus repair was perforated duodenal ulcer because of how many NSAIDs kids are taking. Um, and so it's a, it's a very painful operation, which hopefully now you guys aren't seeing. And, and, um, another fun thing about, you know, fixing problems is that as new generations come in, you don't realize how it used to be. I always tell the story of how the new generation doesn't really understand how PNALD, um, how painful that used to be for our patients and, and, and everything nowadays, like, this is an example of like things are different now, but it used to really suck. In fact, it's still noted as one of the highest per case average opiate requirements in surgery. There's an initiated by the ACS. Now, you know, I'm trying to figure out how to reduce opiates in, in pectus, but the, the, the bar has already shifted. Um. So, this wasn't anything we did. The people have been using um cryoablation uh for a few years. This is actually a device that had been used initially to um uh ablate Afib in the atrium. Um, uh, and that's why, uh, so anyways, they, they've taken this and said, why don't we ablate radio frequency ablate the nerves? And, um, people have been using it for some years in, in chest surgery. And then, um, And it showed a significant reduction in length of stay. Um, people in literature showed a reduction of about on average, an average of 2 days reduction. So, really, just by adding cryo, you went from about 5 to 6 days in literature to about 3 days in literature. In our experience, we saw that too, went from about 5 to 9 days to about 2 to 3 days. Um. But again, together, we're like, can we get this better? Can we get this better? And so, with anesthesia, etc. fellows over the years who said, why don't we do other things so we can bridge the gap? Because the problem with cryo is it takes about 12 hours for it to totally kick in, 24 hours sometimes. And in that time, a child may have already gone down a pain spiral and then they're stuck. And so, in the last couple of years, uh, we've added intercostal nerve blocks with clonidine at the time of cryoablation. And this has been a game changer. So now, basically we do the cryo of each nerve, so we go freeze each nerve to the chest wall 3 through 7 on each side. Adds about 40 minutes to the case. Well worth it. And then we go and inject cortisone bupivacaine uh with epi and clonidine, and that lasts just long enough for when the cryo kicks in, the patients are generally doing quite well. And our average length of stay is, is, um, one day from one night for most patients unless it's done late in the day. And more importantly, um, as, um, um, uh, Megan and Sarah others looking at, um, going home without narcotics, and thanks to our inpatient team for helping make sure that happens, um, because Not needing it, which is great. Um, so One more thing, um, about creating things, which has been fun as a team is we started doing vacuum belt therapy, uh, which also came from, you know, a need as a group when we sort of recognize each other's pain. So we see patients come to the clinic and they'd either be not bad enough for surgery or really bad enough for surgery, but they really, really don't want surgery, they don't want the operation. And, you know, as a surgeon, one of the least gratifying clinic visits is patient comes in with a problem that you know you could fix. And then for one reason or another, you can't. And it's like, sorry, live your life. And that's like, that's the worst. Um, and so, we started looking at different things we could do for patients who had a fixable problem that either couldn't get surgery for insurance reasons or um the family or some reason said, you know, I don't want that right now, but the child says, I really want my chest fixed. Um, and so long story short, we started using what's called vacuum belt therapy, which came from Germany. We're not gonna get too much into it, but hadn't been used much in the US at all. We, I reached out to the, the engineer there and they started sending us some samples and, and now we're, we're treating, uh, lots of patients with it. Um, I think we're up to like 270 patients, something like that with vacuum belt therapy. Um, But then came the question is, how do you track progress? This is, this is uncharted for us because we're just like, you get your CT scan, you get your surgery, come back, you say it looks good. But, but now we have patients we're longitudinally following for a morphologic issue that we didn't really have a great way to track objectively other than um trying to, you know, put a ruler in there and things like that. So here's a vacuum bell, um, and this is the Haller index, which is a radiologic, a radiological way of measuring depth of pectus exava, but we don't want to scan a child every time they come to the clinic. The way the vacuum belt works briefly is you put the suction cup on, you crank it up, it actually sucks the chest forward, um, and it, it moves and we, we do it in the OR. You can, you can see the sternum move forward, um, but, uh, but it also pulls soft tissues, etc. So it's not as efficient as putting a bar behind there and it requires a child to wear it 2 hours twice a day. So that's 4 hours a day. And, um, as, um, some of the innovation fellows have looked at before, definitely compliance matters. You gotta wear it 7 days a week or it really doesn't work that well. Um. But this is the way that we were measuring before is take rulers and we're gonna measure it like that. And the problem is it's very subjective and it wasn't that, that precise, and we get numbers that were all over the place. So, actually, um, an insight from, uh, from one of our nurses was, you know, there's this thing they're using in um in the craniofacial uh plastics clinic. Uh, for kids who need helmets, pleiocephaly helmets, which is this little white light scanner. They go and they measure the head, and they can, they can get the, the helmet size with it. So, so we called down there and said, where did you get that thing? And then we bought one, thank you. And, uh, and now we have one in clinic and we measure every kid that comes in with it. And Sarah, thanks for the slides, uh, for doing this research, um, but basically, um, Sarah and Nina and others looked at this as a non-invasive, non-rating way to measure. And basically, this is what it looks like. And this is, this is, these are the pictures that we get. So it's really nice. And we, we are able to track consistently how the pectus changes over time. It's not a perfect treatment and we'll, another talk, we'll talk about the pros and cons of, of vacuum valve, but for those who respond, we're able to reliably see the improvement in the, in, in the pectus. And it's nice, you can show them at the clinic visit. This is the last time, this is this time, this is where you're at. Is it working? Is it not? And that can guide you're gonna go to surgery or not. Great. All right. So for the last bit of time, I want to show you two videos about Team surgery and the overall concept of when you're going somewhere new, don't go alone. When you're doing something that hasn't been done before, um, it's best to do it with a group of people with individually amazing skills all working together. Um, and, uh, and so this is an example from, from my time, uh, the E team. And so here, so we've been working for, uh, a couple of years, um. On a new way of doing a tracheal tracheopexy of tracheal malaciia treatment called a membrane reduction tracheoplasty, which I'm gonna show you. Um. Ben and I and others, we, we'd, we'd been saying, we could, if we had a patient, just the right patient, we could do this minimally invasively. Um, we could do it robotically. And then we had a patient come in who had severe tracheomalacia and And, you know, I text Ben, like, hey, man, I found our patient. Um, and I'm gonna show you a video. And Sean made this, this, um, this nice video. But the key thing with this video is I put these other people up here because, um, We end up doing this case robotically and we've done robotic cases, but again, tapping into all the resources we have is really important. So, so we don't do that many robotic cases and Pratima is a um jumped in and said, I'm the robotic surgeon, so she joined us and helped us we basically devise this operation from beginning to end. Even though she doesn't do tracheal surgery all the time, we did this robotically because of Prehema. And then um this is uh Chiche Ebure. She's an anesthesiologist and intensivist. And so when you're doing something a little bit unusual, it's always have someone who's on the other side of the, of the curtains who's willing to, to create with you. And I'll show you some of the techniques she figured out for this. And Patrick was a, a senior fellow at the time, um, Dela Plane, uh, who rocked it. So, um, anyways, let me, let me escape from here and share the video elsewhere. Here it is. All right. I'm gonna skip through a little bit quickly for time, but, um, tracheomalacia is characterized by excessive dynamic collapse of the posterior membrane of the trachea. This in pediatric patients is often due to congenitally malformed tracheal cartilages with an associated widened membranous trachea. In adults, some have used mesh to placate the wide posterior membrane and recreate arch-shaped tracheal cartilages, but mesh erosions are a concern, particularly due to the life expectancy of the pediatric patient. Although the open tapering membrane reduction tracheal bronchoplasty has been utilized to resolve this redundant membrane and recreate stable tracheal cartilage architecture, the use of a minimally invasive approach to achieve these goals has not been reported. Here we report the first case of a robotic tapering membrane reduction tracheal bronchoplasty. An 18-year-old male with no prior history of thoracic surgery presented with a history of shortness of breath and worsening exercise intolerance and with an increasingly obstructive picture on serial pulmonary function tests. Preoperative bronchoscopy demonstrated severe tracheobronchoalacia with a near complete collapse of the mid to lower trachea and proximal right and left main stem bronchi associated with broad-based bow-shaped cartilages with redundant and dynamic collapse of the posterior membrane. The patient was anesthetized and underwent placement of a 9 French right bronchial blocker for right lung isolation. A double lumen tube was avoided to allow intraoperative flexible bronchoscopy to guide surgical manipulation of the trachea. He was then placed in the left lateral decubitus position, exposing his right chest. 48 millimeter trocars for the da Vinci XI robot were placed starting at the seventh inner space below the scapular tip and working anteriorly spacing them about 6 centimeters apart. Two active assist ports, a 12 millimeter and 8.5 millimeter air seal, were placed inferiorly just above the costal margin. Intrathoracic access was attained and lung isolation was confirmed. At this point, the chest was explored and the esophagus was fully mobilized, exposing the back wall of the trachea and making sure to preserve the vagus nerve. Then a partial lymphadenectomy was performed at the back of the trachea and the subcarinal area, clearing off the back of the trachea along its full length into the neck and then down along the left and right main stem bronchi. For this, it was helpful to place dental rolls into the chest and use these with robotic arm 4 and with the active assist to push the right main stem bronchus anteriorly, thereby exposing the left main stem bronchus. With the esophagus mobilized, the back of the trachea and the right and left main stem bronchi were properly visualized. Full thickness marking sutures were placed in the midline of the posterior tracheal membrane from the thoracic inlet to the carina and exteriorized, being held on traction by the bedside assist. Bronchoscopic guidance was utilized to ensure proper suture positioning. The picture in picture feature of the robot uniquely allows the surgeon to bronchoscopically guide suture placement without looking up from the console. Starting caudally and working cephalad, the muscular layer of the trachealis, or posterior membrane was incised, exposing the submucosa. Following this, the mucosa is incised, and the full thickness strip of membrane was resected roughly 1 centimeter at a time with concurrent longitudinal closure with a running horizontal mattress PDS barbed suture. It should be noted that coordination took place with the anesthesia team to ensure that the peep and intrathoracic pressure created by insufflation was approximately equal, made more consistent with use of the air seal pneumatic system, and in this case, close to 5 millimeters of mercury in order to minimize a pressure gradient with an open airway. Rehearsing ahead of time mentally, talking through it, figuring out the tracheal bronchoplasty was performed with the first layer of running horizontal mattress and a second layer of running stratifix barbed PDS suture. And if only one of us were trying to anticipate all those problems. Higher likelihood we would have missed something ahead of time, but each of us sort of came to the table with this process was repeated for affected bronchi, in this case, both right and left main stems. In this case, the membrane reduction tracheoplasty was sufficient alone, as evidenced by a completion bronchoscopy with suction applied to the airway and demonstration of a stable, open airway even with suction to a level of -40 centimeters of water. If such stability and patency cannot be achieved with tracheoplasty alone, the addition of a posterior tracheopexy is an option. Postoperative bronchoscopy is performed to view and confirm the tapered posterior membrane. A before and after photo demonstrates our results. So, uh, I just want to share that as an example of, of what team-based surgery can do cause, um, again, we all got to be creative together, um, to make this happen and share that burden. Um. And actually, that patient just had, there we are. They're one year post-op bronc. We did this a couple of weeks ago, um, from slide and um looks really good. This is actually him coughing, um, and uh it didn't really recognize him in the recovery room because he had gained 15 pounds of muscle since, since the operation because now he can actually exercise without being short of breath. Um, and actually at PFT since then, this FEV1 showed a less obstructive picture. So, um, at least, you know, and of 2 so far. This is the only one we have 1 year um follow up with, but, um, seems to, seems to be uh durable. Um, but, um, uh, it's fun learning together as, uh, say every day is a school day and we definitely learned a lot with this case. All right, with the rest of the time, whatever, 5 minutes left, good. I have 3 minutes for this. Um, so fetal. Whole other talk and uh uh Shammy and and uh AL asked me to like save a lot of this for, I think we're gonna do like some other talk down the road about this, but I just want to show you a quick video because Brian did ask me to talk about fetal. Um, but to be, I want to be clear, like my role in fetal is, is as a pediatric surgeon, as a minimally invasive surgeon. Um, and, but it's still been a really great lesson and reminder of how team-based surgery is so important. So, how did I get involved was, honestly, um, they asked me, can you teach, can you teach us how to sew incorporeally? Um, I'm like, sure. So I go to the lab and there's like this little simulator, which um I can show you another time. It's really good actually. Um, but, and hopefully I can get you guys, the fellows in there, um, later talking to with them about doing some sessions with you guys to get to practice. But anyways, there I'm like, sure, I'll teach you inpoally. So, and then first day in the lab, realized that the the setup for fetal NTD is you're basically sewing half of the time backwards against the camera. With little tiny space and um oh, and you can't touch the needle to anything else in the field because that's all um amniotic membrane. And you have a team who is very, very technically gifted, but does not do anything complex laparoscopically, right? And so, as far as sewing, it's like, all right, teach us, which is like, I mean, I feel for those, I mean, but like, you know, movie stars are like, teach me how to box and like, all right, well, you know, um, and so I, We, we'd worked on it for a while and these guys are amazing. Um, but they're also really smart because pretty quickly he said, well, actually, why don't you just do that part, um, because it's really hard. And the truth is, you know, I mean, as you guys see, it's like for what we do in our SIM lab and our neonatal MIS cases, it's, it's a variation on a theme. It's not that big, but it's, you know, it takes a lot of training to get to that point, a lot of reps to get to the point where we can do these sort of things. Um, and It was fun though, because what we started doing is going in the lab over and over and over. It took a few rehearsals for us to get to that conclusion and it reminded me of when I used to be in a band, um, a few bands, high school, college, and, um, it, the analogy that we sort of used was like, it's like you're in a band, you're in a garage band, you're practicing in your garage, and, you know, one guy's like, I'm gonna learn the guitar, and another guy's, I'm gonna learn the drums, other guys's singing. And at a certain point, you're like, I can't play the guitar and sing and play the drums. Why don't I just focus on playing the guitar, right? And so that's the kind of analogy we use, kind of another lesson from, from the experience with the adrenal interpositions, right? Bring in the expert, bring the plastics guy, do the microvascular thing. And so, that's what we said, we did. So, we decided that, you know, we'd have the team taking care of the mom, putting the troll cars in, getting access safely to the intra amniotic space. The neurosurgeon who will be the lifelong doctor of this patient with spina bifida, that's what we're taking care of. In these cases, neural tube defects, Doctor, um uh uh West Northam there to actually do the dissection of the spinal elements, like, I don't want to be anywhere near the spinal cord. Um, and then, uh, and then, you know, I'll come in and do the, the sewing, um, and, and that's it. We're just a band and I'm, I'm this, I'm the guitarist, you know, he's the drummer and he's, he's, he's the keyboard player. And, um, we did that for a few months until finally, A patient came along and uh oh crap, we have a concert. We've been practicing all the time. I remember our first show. So, another team-based crap your pants moment where we're all gonna do this together and do it, do something kind of scary that none of us have quite done before. Someone has been there before uh in a different way. So, uh, Shammy had done these sort of cases. through a different technique, but we did it, as I, as I'll show you, transabdominally sort of a hybrid percutaneous approach. And so, um, another thing that came to mind is doing this kind of like, I never operated in a, in a uterus before and a fetus, like it's kind of like going to space, you know, and if you go to space, it's nice to have someone who's been to space before. And so, you know, he, he'd been there before. I say, it's gonna be all right. We can, we can do this, we'll get through it. So, um, here is a quick video of our first fetoscopic neural tube defect repair. It's only 3 minutes and it's sped up. Trust me, this is, this is not how fast it went. Um, But Some of the fetal fellow um research folks had had made this video, so I figured outsource the rest of my grand talks, grand rounds talk. So they administer fetal anesthesia, um, and this is the technique that was uh very um useful and we've, we've done about, we've done 7 cases so far and 4 of them we've done with this technique, 3 of them we've done through a Uh, exteriorizing the uterus, but the idea is you put your first trochar through the umbilicus and then the other two percutaneously through the maternal abdominal wall to reduce maternal morbidity. And here is Doctor Northam doing the neural placode release, and it was very quick. Um, let me show you that one second back here. All right, this glimpse, I'm gonna show you for a second of the neural tube defect right there. This is the neural tube defect. So it's a big gelatinous covered thing, um, that basically, that, that is dysplastic skin on top of the neural placode, which is basically Beyond the end of the spinal cord where the, the roots come up and then you have this neural plaqueco on top, and the idea is to take those spinal roots and deliver them back into the spinal canal and then close in layers. And so, that's a 26 week fetus. Here's Doctor Northam releasing that neural plaqueco, so basically excising that dysplastic skin, and now this stuff right here. Here is the open spina bifida defect. So this is actually the vertebral bodies and the fascia over it. This is the spinal canal. Here are the spinal roots coming down now dunked into the spinal canal, and now he's excising that skin. You know, creating flaps above the. Meninges and underneath the skin, dropping the dura. Down into the spinal canal. And Here we are sewing in. A patch Circumferentially to cover that dural canal. And this, do your very best to make this as watertight as you can to keep the CSF in cause uh for a whole of talk we'll talk about the pathophysiology of this, but um the idea is the really the benefit of this is to prevent the CSF extrusion from the fetus. And reverse a Chiari defect. To decrease the risk, the chance of needing a VP shunt and improve neural outcomes. Once you sew the patch in, then suture the skin over the patch. Oh. Like a DA repair. Right. Here we go. And so here, it's it's actually quite a bit of tension, and this is one of the challenging parts of it is people do like releasing incisions and stuff which have pros and cons. But basically, to get this closed, you dissect from the back all the way to like the groin, so the inguinal region on the fetus, all the way to the abdominal wall from the back. You got to make this huge flaps. That's our technique, at least that we've, we, we've chosen to use this or figured this out that you can with, if you, if you're willing to be aggressive, dissect all the way around. See, that's the right there was the groin, the fetus, that's the hip, see, that's the leg. Um, and, uh, and you can get this together. Otherwise, you can put in a second patch or you can make big incisions on the side of the fetus. Um, but with this, we, we've been able to get them all closed, um, so far, knock on wood. All right, and there it is, and Again, having the experts, they're spending another 3 to 4 hours after the case monitoring the fetus, making sure they're OK, getting to Brigham or BI and um here is now we've had 34 of them uh deliver, um, but this was, that was the first case. We've, we've made some changes to the technique since then, but this is the um This is that first delivery. So, uh, the Chiari malformation started, started to reverse within weeks, um, and, uh, the fetus was born, the baby baby was born, completely healed, um, and really no postnatal intervention needed. Um, and so, um, team effort, super fun. That's the fun thing about doing this job. And it brings me joy. So thank you all. Happy to take questions. Wow, um, Thank you for bringing the joy. Um, people, Sometimes ask me. When's Fro gonna pick a life? Me too. He's getting involved in that and that and that. And You have picked a life, right? And you've just described it. It's joy, right? And, and, um, Thank you for, especially for the people sort of looking forward. I always say to people, uh, people in my office talking about careers and development, like, you know, that some of you have been there, like, where are you gonna be in 10 years? And like, It is so much easier to look back 30 years and say how you got to where you are, than look forward 10 years and have any clue where you're going to be. And you follow the path of joy. We all have this incredible privilege, uh, like you pointed out, right? Like, Wow, so there's lots of, you know, headaches and personal sacrifice in what we've chosen to do, but nobody beats us on mission, on purpose, right? And so, for you to, uh, relate to everybody how you bring the joy into all that. Acknowledging that you have your headaches and, and, and your sacrifices, uh, is, is, is really special, uh, to put this talk together. Um, so, I'm, I wanna thank Brian for, um, having his, um, whatever snafu that caused, caused him to, to lean on, on his old chief resident to help him out because this is a, a really different kind of, kind of grand rounds, uh, and, uh, um, to, to highlight the fact that It's not about you. Right? It is about you, because all those teams asked you to be part of them. But for you, it's about working with them, uh, and giving them credit, uh, and that, and that's what it's about those patience, those innovations, um, you may forget them individually. But they will never forget you, right? One of the joys we have that some of our colleagues don't, right? Like, so the anesthesiologists, the nurses, In the OR on the floor, the nurse practitioner is like. They don't get The birthday pictures. Right? The thank you notes, um. A year later, 10 years later. 25 years later, Um And that brings a whole different level of joy. Um, so, Um, I wanna open up to, to questions, but I just wanna thank you for, for instilling joy throughout, throughout the institution. Um, and, uh, open up for questions and comments for others. Uh, for Uh, uh, that's really a remarkable talk, and you're a remarkable individual, and it brought me back to being 12 years old. I thought, you know, what is sort of the best a human can do, and I thought about it, and I hit my peak intellectually at age 12, parenthetically, and it really is to be a Renaissance person, and you are a Renaissance surgeon. And uh it's amazing how you brought all of these teams together, and you certainly lead the practice uh team, and uh we're very grateful to have you here. You know, Verroc, you leave us all kind of spellbound and, and, uh, thank you for sharing this, the journey with us and kind of showing us that, that light. I, I think the only thing that I'd, I'd add to your joy which is manifest for all of us to see is also your innate curiosity that you. You wanna understand how things work to dissect into that and, and that's infectious, uh, it infects your, your colleagues, it infects your trainees and whatnot, and, and it's a, a wonderful way to, to open the window of a career in surgery. So thank you. I think The people who, who Doctor Murray is speaking to most, uh, will, will look back and, and, and appreciate the lessons he just gave you. Um, thank you for, for the talk and for all you do and for all the teams that, that you support. Thank you. Thanks, everybody.
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