Dr. Bharath Nath and Dr. Ben Zendejas-Mummert - Review of Pediatric Surgery Fellowship

Started, let these guys, uh, have the full hour. Um, keep the introduction brief. uh. These guys need no introduction, Ben and Barth, the outgoing, uh, Purdy fellows, um, they are legends, standing legends right here. Um, but, uh, Barth will go first, I think, and then Ben, um, uh, Barth, you know, um, uh, this training, uh, across the street here at, uh, BI and, uh, and Ben, um, came to us from, um, uh, Mayo Clinic, and they're both, uh, phenomenal surgeons and been, uh, like big brothers to me. And, uh, look forward to hearing what they got to say. All right. Thanks, Faro. Um, so good morning, everyone. And uh welcome to Surgery Grand Rounds. Uh, I'll just open this up here. Uh, So just under 2 years ago, I snapped a selfie at about 5:00 a.m. as Ben and I were walking into the hospital on our first day as fellows. I happen to have that photo here. Take a look at it. Tell me if you think what I think. These are the faces of two guys that have no idea what they're about to get into. When I reflect on that photo, I can't help but recall the words of our former fellow Ammer, when I had the chance to congratulate him at his and Andrew's change party. What he said to me was this, I barely remember the person that I was prior to starting this fellowship. Those words are prescient certainly for me, and I would guess true for anyone who's fortunate enough to have the opportunity to train at this institution. The past 2 years have been an incredible experience. I've learned and grown in so many ways. Some of those were in directions that I had anticipated, but of a magnitude that I would not have anticipated. Some of those have been things that I did not anticipate. All have been important into shaping me into who I have become, who I want to become, and have given, excuse me, given me a wealth of experience to draw on in the service of the surgical care of infants and children. My goal today is to share with you just a few of the experiences that have been so meaningful to me during my time at this institution, and to reflect with you a little on what those experiences might mean for me in the future. I haven't divided this talk into sections so much as, I guess you could say, organize some rambling thoughts over a bunch of photos, but I hope that'll be of interest. I wanted to start off with this photo because it captures so many things for me that are really reflective of the fellowship experience. Take a look at the elements here. Look at the pumps, at the ECMO circuit, at the constant flow of data. Look at the lights. Look at the ancillary equipment. At the center of it all, you might be able to find a tiny baby and even more poignant, the stuffed puppy at the foot of his bed. This is what makes our field so wonderful, the juxtaposition of surgical and medical complexity with the highest of emotional stakes. Another reason that I chose to photo is to highlight the degree to which the critical care experience has been central to my experience as a fellow and all of our experiences here. For the past 2 years, it's been my privilege to work alongside the critical care and NICU fellows in this environment. So this first picture I took early in my training to remind myself of the complexity of this environment and what it was like to learn how all these resources could be brought to bear on life-saving interventions for a child, but also to remember that despite the technology, despite the data, We work in a field where someone will still find a moment to place a puppy on a bed. That's how important the emotional work is to what we do. The second photo is from an experience that I was privileged to participate in many times over my training here. Perhaps too many times. You recognize the scene of emocanulation. There was a span in January to March, my first year of fellowship where it felt like I had an emocanulation almost every week, with many of those being ECLS cannulations. Uh, of course, you know, we have these ECMOS simulations, which gets a number of our, uh, staff and, uh, nursing and everyone involved. And it felt like every time I did an ECMOS simulation, I'd have a cannulation within the next 24 hours. In fact, that's what's happening in this picture. Sam Rice Townsend and I had just finished ECMOI. It was either earlier that morning or the previous day. And now here we were cannulating a CDH baby. The 3rd photo in this group is from a neonatal case. There are a few things in this photo that are very meaningful to me. First, and I think maybe most importantly, I'm operating with a good friend in this photo. And despite the fact that I've had the chance to operate with many people with whom I've grown close over the past few years, uh, it's funny how few photos I have of actual operating scenes. So I like to look at it for that. Second, this photo reminds me of how rewarding the experience is to be within the continuum of training. Uh, at once we function as teachers, as students, as trainees, as friends, and this photo reminds me of the depth of that experience. And lastly, this case was a neonatal bedside case, which is important to me again for a couple of reasons. First, as many of us do, uh, I found within fellowship a strong pull towards the NICU and conditions affecting our youngest patients. Second, this photo reminds me of my operative experience within the NICU itself. During the course of my training, I found myself in the situation of cannulating babies to ECMO on not one but 2 occasions, not to mention bedside laparotomies and other efforts at the highest level of acuity. This next photo is of a tiny infant who needed vascular access, uh, one of many such that we do as surgical fellows in the NICU. Still one of my favorite things to do. It's always a wonder for me to see these tiny infants, and when I see my hand next to them, it reminds me of the charge we have of caring for them, of how delicate and precious they are. Beyond just the technical operation. Their size and our ability to help them is truly a wonder, and it's been my privilege to participate in that. And the NICU is where I had many of my most memorable patient encounters. This is baby AG. AG was the first child with a giant and seal that I took care of uh from birth onwards. This is his uh phallocele about a week or two later after it starts to epithelialize a little bit. And this photo is particularly important to me because this baby uh tried to die on us several times. And uh this photo was from the first weekend in July, uh, when I basically spent most of the evening on both nights sitting at his bedside in the ICU ready to cannulate him, ready to call the ECMO team down, and then watching his uh TCO generally creep downwards as his gas is mysteriously normalized. And he uh escaped an encounter uh with the ECMO circuit. As it turns out, he did great. He got a He did have a tracheostomy, but uh he's grown well. Uh, he came back to us earlier this month. This shows the state of his phalocele, uh, earlier this month. Uh, we did the first stage repair. I call this the empanata stage. And the next photos show his mesh placement and rapid reduction. Within just a few weeks, um, he's, uh, actually come down a lot. Now, his case is one of the many that really let me enjoy continuity of care with my patients and their families. We experience that here as fellows through certain patients such as uh him that we care for for weeks or months at a time. We experience it through our index clinic. And as you can see from this final photo, um, he's made incredible progress, but still probably not enough to get a final closure by Friday. Now that said, I think my ID still works until July 31st. So, uh, Doctor Buck Miller, right, what do you think? Maybe we can make it work. AV was a much smaller baby with a smaller omphalocele. We were able to get her clothes within a few days of birth. She did very well, left the hospital, um, This is how her closure looked. Here she is a few months later with her family. Uh, this is when, when the parents stopped me in the hallway to say hi. It was one of those great moments where you barely recognize the baby because of how much she's grown. But one of the bigger surprises was that a couple of months after this photo was taken, she showed up in the emergency room with a new left-sided diaphragmatic hernia. Um, that was, uh, not previously recognized or evident. We repaired that on a Saturday afternoon, and later that afternoon, I can to an infant with pertussis to ECM with Brian Diffenbach, one of our ICU fellows. In many ways, a typical weekend day. Avi's case was one of the few odd late presentations of diaphragmatic hernias that I was able to take care of. I'll never forget the case of this child, uh, a 2 year old who presented with an incarcerated diaphragmatic hernia. We fixed the diaphragm, but what we did not fix was what's shown on this next image. Which is a mysterious screw that was in his belly from before the time we operated on him, was not evident in the OR. Uh, it was not palpable during the case, has never caused symptoms, but still causes some anxiety for his for his parents, understandably. Well, it doesn't seem to be causing him any issues. A few other diaphragm experiences are worth mentioning. Um, first is the 12 punch of September 28th and 29th of 2016 when I did my first two CDH repairs. One was on the right, one was on the left. As it turns out, my next two were also on the right and on the left. And so for a while, I thought that uh right-sided diaphragmatic hernia had a 50% incidence. It's not that high. But in all honesty, the experience with CDH has been another one that I cherish. This experience definitely culminated for me. First, as it always does, and seeing families go home with their babies, which is amazing. But also in the case of this family. Um, this is patient VC, and VC's mother is an old friend of mine, uh, one of a group of friends from a time in my life when I had just graduated college, really had no idea what I was doing with my life and trying to figure all that out. If I had told her or really any one of my friends back then that I had trained to become a pediatric surgeon at a children's hospitals, and one day put her firstborn child on ECMO prior to repairing his diaphragmatic hernia, they could not be faulted for pure disbelief. But there you have it. This is one of many experiences in training that have been deeply meaningful to me. For me, the fellowship experience has been two-pronged. Both learning the technical aspects of the operations and the care of the patients, but also growing as a surgeon in a field where I've derived so much satisfaction from the connections with the patients. After all, it's all about getting from this. Or this To this This particular family is one that I'll always remember as the second case of 2017. The first being an intercepted Meckel's diverticulum I did with Branna Fullerton and Doctor Rangel while saying Happy New Year to the OR staff. Looking at this belly definitely brings back a lot of uh memories for me. This is a case of patient AM. It was an important one for me, an important one, in my training. It was the first and maybe only time uh that I operated on a child with a mid-gut valvulus where we lost a really significant portion of bowel. Um, I'm talking about almost all of it. Of note, he'd had a prior G tube placed. We thought he was normally rotated, which he was. But as it turns out, he wasn't fixed, and so his colon was very mobile. He rotated his midgut. He lost most of it. This is his initial exploration. Um, he was left after this operation I did with Dr. Fishman. He was left with about 24 centimeters of small bowel, a short segment of ileum. Um, remarkably and really due to the multidisciplinary care available at this institution, care program, multiple staff members, uh, myself and Doctor Chen operated on this patient multiple times. We rehabilitated him to the point that this last photo Shows him about a month after I'd taken out his broviac, um, and he's fully independent of parenteral nutrition. Another unforgettable patient is HT, a 2 year old child with allergel syndrome. Here's when I first met him. The thing about this kid is he is an irrepressible charmer. Big smile on his face, loves a handshake. But as you can see, his inability to excrete bile normally has caused him to develop jaundice and disfiguring and pruritic xanthomas. From the first few photos in the OR here, And here We can see the excoriations and the severity of the xanthomas on his feet, face, hands, everywhere. The approach that Doctor Kim taught me was one that was new to me. It involved creating a colonic ruin Y to the gallbladder. To bypass ileal bile reabsorption. As you can see in these intraoperative photos. That's the gallbladder, that's the colon hooked up to it. This is the other end of the ruin Y. Um, and what that does is it lets the bile basically flow out of the body, decreasing its total burden and improving the pruritus and the xanthomas. We last saw him after losing him to follow up about a month ago, and I can't tell in these photos, but trust me, those xanthomas are much softer. Most importantly, his pruritus is much improved. He's no longer scratching himself to the point that he bleeds. Oh, yeah, this is a little aside. Hey, you guys, anyone remember this movie? Show of hands. Yeah. Did you know there's a sequel? It's called I'm Gonna Get You a Sucker Boy. Oh I don't know why I had thought I had time to make that slide. It just seemed like a good idea. I just couldn't resist. In all serious note, seriousness though, I wanted to use this opportunity to talk a little bit about the incredible training that I've had uh with Doctor Kim, uh, and Doctor Vakilli, their creativity in the OR. Um, I think part of that creativity, which led to that, uh, device, which is a real device in development, and I've heard that a working prototype is now available. Um, Uh, you know, their approaches incorporate creativity and technical prowess. It's a privilege as a fellow to participate in those. Uh, among the most memorable cases I've, I did with them are a few here. Uh, one of them, which is not pictured here was an aortic thrombectomy in an infant, um, with a clot, uh, basically occluding flow to the renals, and we were able to restore that child's renal flow. Uh, this is a picture of, um, one of the arterial grafts, the so-called magic graph that we use for aorta, aortic bypass. In another case, This is the setup for one of the several distal shunts I did for portal hypertension with him. Um, so essentially with, you know, several swanna renal shunts, 4 meteortic cases, and many others. Creativity though is not just restricted in the surgical department to hepatobiliary world, but really is evident everywhere. This is a case I did very recently with Doctor Smithers, um, basically, uh, with an absorbable stent that's around the airway in the neck. Um, so, here, what we've done is we've moved the esophagus from where it lay natively in the left side over to the right and sewn an absorbable stent around the trachea. Um, and this, this was a very interesting case of cervical stenosis on four sides. So we had to do the posterior tracheopexy, the lateral, and the anterior. So just when you think you've seen all the pies that there are, we'll find another one. This is another case really that uh exemplifies the creativity of approach and being able to use um the full extent of surgical tools and, uh, to come up with a solution to your problem. This was a child with a type B, um, EATF, a high cervical fistula. We mobilized the esophagus and the neck, um, put it on traction, delivered it into the chest. And we're able to put it on internal traction in the chest and ultimately completed the anastomosis in the left chest thoracoscopically. Uh, this is a highly innovative approach, um, and one that, uh, I think down the line could very well be shown to have a great deal of benefit to the patient in terms of avoiding a lot of work on the airway, um, that's necessary when you go on the ride. And of course, our very broad EA experience gives us a chance to um see a number of unique problems and know how to deal with them. For example, this recurrent fistula to the lung uh from a kid that had a prior esophageal resia repair. Here's a case I did with Dr. Weldon. This is another case that really exemplifies some of the advanced approaches that can be used at this institution. Um, and that really are the basis of our training here. This child had an osteosarcoma that had been deemed unresectable at other centers. Here's where I learned the extent of what's possible, um, of how to plan a resection like this, how, um, uh, a, uh, master surgeon thinks through, uh, this type of a case, um, how to get the patient through the operation in such a fashion that you go from this. With a huge tumor socked up way at the top of the chest. A gigantic shark bite. A tumor that's almost 15 centimeters. And managed to get them close to the Gore-Tex graph, the patient goes home, uh, and really just, uh, such a rewarding experience to participate in that. Another favorite case of mine is a case I did with uh Samurai Townsend. Uh, this is a child who had a type 3B um jujuvenile resia. We resected these uh chain of link sausages and uh put the bowel together. Uh, and actually, that kid has been able to attain al um. Full entry feeds, which is, which has been amazing. It's had some other problems, uh, has required at least one revision, but overall, it's doing very well. The range of pathology we see here is unique. This is a case I did with Doctor Modi. This is a bronchogenic cyst again, coming out from the neck. Um, and, uh, You know, it's, it's, it was uh great to do this case with an experienced thyroid surgeon and learn the uh um approach to problems, uh, again, everywhere in the body. One of the things that I think that we really excel at. A very unforgettable case, patient. Uh, yes, this is a child who was born with a sacrococcyal teratoma. This is a photo from the labor and delivery room. Again, participating in some of these births, going over, taking care of these kids from the time they're born, meeting the families in the delivery suite is an amazing privilege. This is a photo of her in the operating room. Uh, Doctor Smithers, Ben, and I all did this case together. You can see how big the tumor is. You can see that the rectum is displaced. This is a Hagar dilator showing just, uh, how odd the angle is that the, the rectum travels. This was her closure. I think it looks pretty good. And this is how she looks now. Just amazing. Actually, that's not how she looks now. That's a different baby with sacrococcygeal teratoma. That was this baby. See, it also, she also looks good, but I did this case with Doctor Liliha. Wasn't quite as good, but uh they're fine. And again, this is what we get to. Uh, this family was uh elated to be going home. And uh I'm, I'm particularly excited that they're coming back to the clinic today. Um, so I'm gonna see them after they've been out of the hospital for the first time later today. Now, along with all these learning experiences, uh, sometimes things don't go quite the way you planned. This is one example of that. So, baby LS, a small child, uh, she was under 2 kg, um, and we thought she had duodenal atresia. We took her to the operating room. We attempted to fix it laparoscopically. We really couldn't. Um, we couldn't get insufflation pressures. We couldn't see anything. Um, and she kept having desaturation episodes. So we opened up, turned out that she had multiple juvenile atresias in addition to duodenal atresia. So we fixed that by resecting. It took us multiple tries because every time we resected, we'd find another one more distally. It's a picture of the duodeno duodenos or duodeno jedenostomy, I should say. And then after she failed to failed to advance in feeds. Ultimately, we studied her and had to go back to the operating room. Uh, where I found a nice slice of humble pie hidden behind her annular pancreas, uh, that we had missed on the first time around. And um. You know, it, it, again, it's, it's cases like these that really, uh, as much as you, you hate to have those kinds of experiences at the same time, um, it teaches you a thoughtful approach uh to your patients and how to uh understand the pitfalls of, uh, of the work that we're all doing. This was another case that, um, you know, again, there is a, this is a case of malrotation with volvulus, a newborn. I, uh, took this kid to the operating room, laparoscopically, did a ladsS procedure, felt great about it. Kid ate, went home, uh, showed up with a recurrent volvulus about 2 weeks later. And, uh, again, opened up the belly to find uh, some chagrin hidden inside the recurrent volvulus, but Fixed the baby open with uh Doctor Buck Miller and uh the kid went home and he's doing great. This is a photo, uh, one of the few from this moment, which is a horrible moment, uh, in the last few moments in the life of ANA. I met baby NA as a neonate in the BAA DMC NICU where he had neck. He was transferred to our NICU for monitoring and subsequently crashed, requiring an urgent lap. This is one of many urgent neck ex-laps that I had the opportunity to do with Doctor Hamilton. But beyond his admonitions, which still ring in my head uh for suture courtesy, I know that I'm gonna think about the energy in the room when we'd bring a kid down who needed an urgent operation like this in my career going forward. This baby was so unstable that we whip stitched the belly closed and brought him back up to NICU to resuscitate. Remarkably, he pulled through, and after months of growth and care, he was discharged home with a stoma that was working and some chronic lung disease. We planned his stoma takedown over several visits uh in our index clinic. Ultimately, his operation went very smoothly. There were a few scares, including ultrasound that told us we had some non-profuse bowel. Um, but overall, he did fine. In fact, he did perfectly. He was nearing discharge home. Uh, one morning during ECMOs simulation, uh, Doctor Jacki and Froke got a page saying that ECMOS stat was happening on the 11th floor. It took them just a few moments to realize that it wasn't a simulation. I got up there and started prepping and draping to cannulate on the 11th floor, never an ideal situation. I'll never forget the feeling as I repositioned this child and realized that I knew this baby. I'll never forget that involuntary sound of grief that came from my throat as I worked to get him on Tecmo. My evenings were spent with those parents for the next several days as answers slowly trickled in and we learned that he would not be able to survive. During those moments as he realized that his care would be redirected, the parents uh had asked me to take some photos of them, and one of those photos is here. It's not the one that I find hardest to look at, but it is one that I find hard to look at. It's one that's very important to me in terms of uh Thinking about my experience here as a fellow. This was also the first time I attended the funeral of a patient. This family's loss is one that I still think about often. But you have to take the losses with the wins. Here's a photo with another patient that I had with Doctor Hamilton, um, one year after her esophageal res and tracheoesophageal fistula repair. I was fortunate to have about, uh, I think 3 or 4 type C EATFs uh with Doctor Hamilton as well as a few others with other staff. Uh, 3 tarroscopic type C's. Uh, by and large, they all did well. Some of them had the range of complications that we see in those, uh, patients, but, uh, very satisfying to have had the chance to do all of that. I won't show the Kasai photos since those are basically stage one liver transplant operations, at least in my hands. But I did have at least one unusual case with Doctor Jacki and Doctor Kim, a 4 month old child with progressive jaundice, GOLT syndrome, and extrahepatic biliary fibrosis. Here you can appreciate her balloon-like gallbladder, um, terminating in a fibrotic strand that represents her bile ducts. We were able to find decent ducts above, did a hepaticojeinostomy, and she did very well. There are some tumor cases that I just have to mention. This is one that I did with Dr. Shamberger. I think this is where I learned to appreciate the Thoorco abdominal incision. But, uh, this child uh came to us from overseas. You can see that, as is often the case, parents were in distress that, you know, his belly was so distended and Um I think one of the phrases they said was, you know, where they came from, everyone has a big belly, um, oftentimes because of malnutrition. This is an initial exposure of his abdomen showing the colonic mesentery stretched thin. This is a picture of the underside of the tail of the pancreas and the spleen. This is a picture of his tumor, which is gigantic. And this is the closure that we were able to achieve. And you know, that was again another very satisfying case. A case I did with Brent, this is a Rrhabdomyosarcoma in the pelvis, essentially a dumbbell tumor. This is an image of the iliac vessels which we were able to dissect off the tumor. I think some of these are just, you know, um, Stunning examples of the kind of anatomy that we get to see, the kind of exposures we do, uh, the operations that we're trained to do as fellows here at Boston Children's. And this is a thoracic. Neuroblastoma that we just, uh, I was able to participate in this case just last week. Um, and that kid did very well, uh, and, uh, was able to uh have his chest out, be ready to leave the hospital. OK An unforgettable case from early in my fellowship. Um, a giant hair bezoar, uh, trichobezoar I did with Doctor Chen. Um, it's hard to imagine the scope of this, but this was about an 8 year old kid and this was about that big. Um, Again, the range of pathology is incredible. And then, of course, another uh picture of the lads uh with uh malrotation and here really showing the chilo societies that you get um when these kids are malrotated and backed up. So, one of the great pleasures I've had as a fellow is being able to uh uh TA cases. Um, and, uh, of course, uh, teeing with Farro is a, uh, real pleasure because it's uh really not so much teeing it's just sort of hanging out and doing a case together. But I just want to show this so you guys know, he gets very excited about poop. Um, we pulled this plug out of this patient's colon, and it basically was a cast of the entire colon. Um, in a patient that had duodenal, uh, excuse me, duodenal atresia, uh, that we were able to fix up. And this, this kid did great, um, went home, he's on full, uh, oral feeds. So to summarize, this this slide showing my operative experience um here as a fellow. Um, I think, uh, a lot of it is hinted at at the, uh, at the previous slides, but I feel particularly, um, You know, there's a number of these aspects of this which are very, uh, I feel a great deal of satisfaction about, uh, 200 neonatal cases, 77 teachings, this case is, 82 tumors. I want to point this slide out. This is a graph. Actually, Ben showed me how to put this together. I think he has one in his presentation too, just of the distribution of uh who we did cases with. Um, and so, a special thanks to uh Doctor Smithers because I think, um, you know, he, he operates a lot. We operate with him a lot. Um, and, uh, you know, he's, he's responsible for at least The plurality of uh whatever I do well as well as the faults of mine, I think so. This was the last case, um, this is the last case I'll, I'll present this, uh, a case I did just yesterday with Doctor Fishman. It was very unusual, a large venous aneurysm that lay essentially over the patella, almost like a second cap on the patella. Uh, the patient was in IR, had undergone sclerotherapy. Um, and as we were taking it out, I was telling him I was hoping to use photos of it in my talk this morning. And he then said to me, you can't still be working on your talk, can you? I said, sadly I am still working on my talk, and he said, well, you know, he then told me the story about how the night before his fellowship talk, the power went out. He had to sort slides in the carousel in the dark using a flashlight. And then he said, that talk was the most important talk of my life. I said to him, wait to turn up the heat. But just allow me, if you will, one final thought on that moment. It's emblematic of the fellowship experience in a way. It's a special place that gathers so many talents that are able to continually create learning opportunities for us as fellows. And at least part of that is a commitment to turning up the heat whenever possible and asking us to do more than we ever thought we could do. But at the same time, I will say that I certainly hope that this is not the most important talk I ever give. I hope that the training and experience I've gained within these walls will let me find a way to bring more into the world for the surgical care of infants and children, and that someday I might find something even more important to say about it than the summary of my experience as a fellow at Boston Children's Hospital, an experience for which I'm incredibly grateful and individually indebted. Without qualification to each and every one of you. Thank you. OK. OK. So welcome, everybody. Thank you for uh sticking around and coming and joining us for this. Um, We'll go ahead and get started with my part. Uh, so this is kind of the outline of my, uh, talk, uh, similar in some degree to tora's talk, and so we're gonna go over some notable cases and spend some time on some of the lessons that I learned and what I'm looking forward to in the future and uh some special thanks to some people in the room. So, Barra showed this picture, but the, the picture he failed to show was probably a little more telling of how people were excited that we got here was this one. Obviously, when you got to recognize that Alex was a month alone in July of 2016, and so for him to see us walk through these doors, it meant a lot to, to, to him. Uh, so we always talk about this analogy about the kid in the candy store when it comes to the cases we do here, and, uh, highlighted that really nicely, uh, which I felt that way coming in. Uh, but on August 1st, uh, my first case of fellowship, uh, Alex says, hey, you wanna go help, uh, Doctor Wild's gonna do a case. Why don't you go help him? I was like, oh great, I was so excited. I was it's gonna be a great case. But it wasn't really a baby, uh, 23 year old male. With Peuts Jagger's polyposis. He was post-op day 11 already after an exposure to laparotomy, 47 polypectomies that Doctor Kim, Doctor Shamer, and Doctor Victor Fox had done, and a combination of laparotomy and endoscopic. Uh, his CT had a high-grade bowel obstruction. He was not opening up. And so, uh, Doctor Wells said, well, let's, let's take him to the OR and, and try to fix this. And I said, I got this. This is an adult. I've done plenty of these in general surgery, uh, training. Uh, how bad can it be? Well, it's pretty bad. We simply couldn't get in. We aborted. After a couple of hours of uh lice and adhesions, uh, basically, at the start, we just said it's not safe for us to proceed, let's just wait it out. Um, Dr. We, uh, said, I promise you, Ben, cases here aren't like this one. And uh he was, he was right. Uh, I see that my list, uh, looks, I'm pretty happy that it looks very similar to that of Barra in terms of just overall the distribution. I was also looking over Alex's list and also very similar, uh, in the, in the main categories. Um, and so it speaks to the, just the breadth and the volume of this place. And, you know, there's some days where we could even be 4 or 5 fellows and we would all be doing an index case. Um, although this also allows the opportunity for residents every now and then get a very, uh, nice index case. So overall, I think the, um, the variety and the, uh, depth of experience was phenomenal. So, uh, similar, uh, slide as, uh, uh Bras showed, uh, Doctor Smith probably takes the award for the fellow, uh, teaching. Um, obviously, um, I've done a lot of cases in Colorectal, Doctor Dickey and, and the spread there. This does not reflect any preference, uh, personal preference, so don't take it personal. Um, every one of you, uh, we've enjoyed, uh, working a lot with. So this is all how it started, really. I think we, Dr. Liliha uh decided to put us in a, in, in the units the first couple of months. Uh, the nurses in SSouth are pretty adamant that we learned how to handle a baby. So Ron and I had to go through this training to be able to know how to properly handle a baby. Um, it was, it was, um, serving me well. Uh, this is, um, the family we got to know very well, Doctor Ice Townsend and I was, uh, sort of like I wanna say his first lap duodenal trusia repair here as an attending and my first, uh, also as a, um, a junior fellow, and she did great. Um, it took a little time to get her out of the hospital, but ultimately, uh, she's come to see us, uh, every few months at the clinic, and she's thrived to the point where we can't even see her incisions anymore. So that's why I don't have a belly picture of her, but believe me, she, she, she was the one. Uh, this is also pretty meaningful to me in terms of this was the first bowel resection I did with Dr. Hamilton for necrotizing enterocolitis. This baby was a former 22 weeker, almost 23 weeker, who weighed 500 g at birth. This was actually his second operation for a neck. He had had already one resection. He developed a second bout of um Uh, neck, and already two surgical events in a baby of this size carries, for those of you who know, very high mortality, above 50%, and also a very high rate of neurologic disability in and of itself. So for us, it was pretty meaningful that we were able to get this picture that mom sent us. So obviously, I think he's done well and we're very happy about his outcome. Uh, malrotation of, as we all know, uh, can have very grim, uh, outcome as well, um, in terms of, uh, if we are able to get there in time or not. Um, fortunately for this little girl, we were able to, to make a big difference for her first year birthday. So, um, also one of those pictures that really brings it home to us, how, um, our care can, uh, really, uh, make a family's, um, first year birthday much different. So this picture is out of a thyroid. Uh, Dr. Schamber may get a little post-traumatic stress disorder after seeing this picture. I note that it's taken at 11 o'clock at night, uh, the day before my birthday. And you know that Doc Schandmer likes to start his thyroid. It's his first case in the morning, and so you're wondering why are we operating at 11 o'clock at night. But this was a rather unusual case. A 16-year-old girl who had basically Graves' disease since she was 3 years of age and was treated and sort of postponed the, the, um, treating endocrinologist was too fearful of, of a thyroidectomy at an early age and honestly, um, made it a little harder for us. Around 5 o'clock, we're only halfway through. Doctor Schamber. Uh, elegantly said, Ben, I think we need to take a break. Uh, we're only halfway there and so, uh, we broke for the bathroom, uh, take a drink of water and, and kept going. Uh, I, pretty much takes the record for the longest thyroidectomy I've done. It was 2.6 L of blood loss. It seems very unimpressive on that picture, but you have to believe me that those blood vessels were the size of an internal jugular vein. Each one of them, every time we, we move this thing around, it would bleed. Uh, Doctor Seefelder, um, It was uh very smart to, to, to, to use a cells saver and so fortunately, we were able to give the, a lot of this blood back to this patient. Um, I've seen a lot of constipation. My wife's a gastroenterologist, sitting right there. She's uh interested in motility. And, um, so we talked about constipation a lot at home. And so I thought I, I, I, I, I thought, I thought I'd heard all the, all the stories of constipation that I could until I met this kid. He really takes it to a whole new different level. When somebody tells you he hasn't pooped for 3 years, you sort of don't believe it at first, but he couldn't breathe. He was to the point where he couldn't breathe. So, um, I was on call with Doctor Jennings one weekend and um we're asked by uh Doctor Flores and GI to come see this kid because he, he's uh literally, everybody, he, we knew he had very bad disc motility and everybody sort of got used to just him not pooping. But when your colon gets to that size, um, you gotta wonder. And so, um, we took him to the OR, did an emergency blowhole stoma, um, Obviously, uh, Dr. Jennings' dictations are very specific, and, um, the, the fire risk was noted to be one, but once we Then, um, these, these, these canisters are 3 to 4 L each. Um, so we got more than 10 L of poop out of them. Um, really, I, I think it just speaks to the, to the variety that we see here. Fortunately, our shoes uh stayed clean. Uh, one more picture that kind of exemplifies and brings home kind of the work we do here. I think in any other, uh, institution, this is a case of a girl that, that had this pancreatic tail, uh, mass. Uh, parents or, uh, dad was a gastroenterologist. Um, in any other situation, anybody would just say, well, we'll do a distal pancreatectomy, take the mass, pancreas, and the spleen is basically an innocent bystander, so we'll be able to take out the spleen. But in kids, we really try to save the spleen. It brings them a lot of benefit. And, and so, um, Just like in the standard Doctor Kim fashion, we, we said, well, the vein's in our way and we can't peel off the tumor out of this, uh, then let's just take that portion of the vein out and put the ends back together. And initially, Doctor Liha looked at, uh, in us and I looked at each other and said, is he, is he being serious? And he was. And so we did that and she did great. She was able to save her spleen and we were able to take out the, the tumor and I'm quite happy with the outcome. Uh, we saw a lot of belly buttons. Uh, bro show a lot of belly buttons pictures. I have a lot of those too. Um, this is one of an omphalocele that had a, uh, perforated shin and a Meckel's diverticulum within that. Uh, I did this case with Doctor Jennings, and, um, we were to do it all through the belly button, so it was very nice. Um, case at the beginning of my training. So these are other examples of some belly buttons, some smaller, some bigger. You can imagine the amount of work and effort that it took to get this, uh, into that, uh, over several weeks, Doc Smithers, Doc Jennings, uh, very, um, challenging cases. Sometimes the abdominal wall is just not there. Uh, this is also a very interesting case in which uh massive gastroschisis, complete liver herniation, basically everything was out. Over several weeks to months, we were able to get this Billy to get a little bit of sense of humor. He dressed up like Dr. Smithers for Halloween, showing off, showing off his six pack, and eventually it was able to be discharged from the hospital. More recently, we were able to get him off parenteral nutrition and his probiac was taken out. He even got a circumcision. He really is the first reported survivor from a massive gastroschisis with complete liver herniation, so this was quite a pleasure to be able to experience this along with him. Did a lot of colorectal cases with Doctor Dickey and the experience was very rewarding to, to me. Uh, this is a cloica where, uh, basically everything comes in through one hole. And over the series of pictures, you'll see how we're very, um, uh, artistically we're able to recreate her anatomy, uh, to a point of, um, uh, her currently being a lot more, uh, uh, normal than she was. There's a different type of cloica. It's a cloical atrophy where things are mostly on the outside. Um, she also bolo is oh yeah is complex, a new word for Doctor Kim, um, with, uh, has a, basically, this is for those of you who don't know or haven't seen this, this is a small bowel almost like through an elephant truck through the bladder halves on each side. It involves a series of operations where we Uh, Basically able to tubularize the cecum, bring basically this kind of goes back in. You kind of fix the cecum, and then you rescue the hind gutter, bring the colon, the colon usually small, and give them a colostomy, which you can see over here. They're still left with a bladder atrophy here where the bladder plates out. Basically, this kid had a single kidney, so that's just one ureral orifice. Then the next sort of stages are the lymphalocele repair and the bladder closure, and this is kind of how he looks now. Still in the process of healing, but obviously everything's on the inside. And so he still has a little bit more work to do. You can see he also has club feet. Um, I guess not a lot of people have the opportunity to say that they've been part of, um, a small bowel transplantation. I think it's, it's, especially in kids, is something that's been done in very few centers. I was fortunate to be, uh, present for two of these that happened throughout the two years that I've been here. They happen about once a year and so I was fortunate to be the fellow on call for both of these, uh, very impressive case. Um. A couple, um, sacrococcygeal teratomas, some smaller, some bigger. Obviously, I borrow showed this one that we did together, uh, so I was very experienced, um, we're an experienced to be able to operate a co-fellow. Um, some incisions bigger, some other are smaller. This is, uh, uh, obviously the, the, did a lot of these, um, through this small incision, and, um, we'll be doing a lot more, hopefully. Obviously, a little bit resections, uh, enjoyed a lot, uh, to get to, to see how Doctor Kim. Approaches and things through these uh tumors. Uh, I've seen in the place where vascular anomalies uh sort of been developed, uh, every now and then through the emergency department, we would get a lymphatic malformation and uh actually uh know what to do with it and uh have the expert here within us to, to guide us through this uh kit's care, which he did remarkably well, just to segmental resection of this lymphatic malformation. Uh, this is, uh, just, uh, represents kind of that we operating, you kinda see some pictures of operating all over the body. This is in the, in the chest. This is a little girl had a thymic, uh, mass, uh, and you can see here the, um, uh, basically the phrenic nerve right next to it that we were, this a case of with Doctor Chamber. Here you can see the re nerve. Again, we were able to take this, uh, thoracoscopically out and unfortunately, it was a benign finding for this, uh, young girl. So with all these cases, uh, there's obviously several lessons that um I learned. I think the old adage uh that uh in general surgery you hear about eat when you can and sleep when you can still applies to pediatric surgery. Uh, actually, this is how my wife found me many times when she got home if I was able to get home before she did. Doctor Fishman, um, really was able to pioneer the do it-yourself approach. He took out his own splinter with his loops. He was able to, he was able to build his own cars. Uh, Doctor Dickey gets pretty creative with her, um, uh, with her sponges here to, to prop up the kids for the PAPs. Uh, Doctor Walden exemplifies the, uh, MD, uh, behind his name with the make-do attitude. And Dr. Jennings, uh, really brings it home when it's time to provide an informed consent to a family in terms of dumbing it down, even for the, for the children to understand how a complex, uh, stricture, uh, distal esophageal stricture, uh, could take several different strategies on how to fix this. This is, by the way, on the, on the sheet of the bed for the stretcher. Um, when you're a fellow, every paycheck, uh, counts. Uh, and so when I saw this box outside of the cafeteria, um, I was like, wow, let's get the opportunity to have Doctor Fishman, uh, pied in the face. I really thought seriously about putting my entire paycheck there. Um. Fortunately unfortunately, Doug Fisherman didn't win this, um. Barth has a wise wisdom every now and then. It looks like he showed up to CVS in a white coat, and so I think it's something not to do. More importantly, I think you gotta be very careful where you leave your coffee, uh, next to Doctor Modi. Uh, he tends to, to, to grab my coffee all the time. I, I, I don't understand. Uh, I guess I always end up with a smile. Your face is going to end up in a lot of places, and from the, you know, the building to the bottom of an IV pole. I'm not sure why that picture actually ended up there, but just smile. Uh, I guess those old headlights, we can start to retire them. I think we were able to, to convince Doctor, um, Jacki and Doctor Lohide to start wearing some uh portable headlights. I think the girls in the OR crew back there are quite happy about not having to follow Doctor Lohide behind every time he moved from one side of the table to the other. Um, but Fro here exemplifies how he's carefully prepared to run the list, uh, with some attendings, uh, near the defibrillator. Um, weekend rounds are tough. They're long. We see every single patient, and some surgeons of the week have a little more patience or stamina than others. So I've, I learned early on to, to keep them quick, uh, so that our surgeon of the week didn't look like this at the end. Um, very important to start the day with a little bit of coffee. Um, to finish up on time, I found a good strategy some fellows use to, to bribe the nurses to put up these signs, just to make it a little more efficient. Ultimately, we learned a lot of kinda important wisdom throughout our course here and Doctor Rangel is very um eager to, to improve our antibiotic stewardship. And so when I asked him about whether we needed antibiotics for this case or not, he, he made a great point that I'll never forget. And so every time I, I, I order antibiotics, I say, well, I eat off the surface I'm operating on. And so that's kind of how I go about now with my antibiotic prescription. Doctor Peter's loops are famous. I think that, uh, um, I tried to wear them once. Uh, chicks dig it, he says every time he wears them, and I just couldn't get, I, I didn't get the same response, Doctor Pete. I'm sorry. Just doesn't look good like that. Uh, but his color perception may be a little bit different than us. This is quite interesting in how this child had an incarcerated stoma. Dr. Peter said it's black. We're going to the OR. But Barth didn't agree with that. He said, we'll not call that black. Look, Dr. Rangel agreed, said it's like, it's kind of grape and cherry snow. So we got into this argument about the colors of the rainbow, right? So Barra said, well, maybe like acute care surgery, pink. And so, I thought it was maybe mulberry. Uh, Doctor Buck Miller said jam. Uh, so, I, I think ultimately we will get back to pink, although Doctor Rangelt said like magenta. So, anyway, you, you see how that goes. Um, I've learned to see every patient basically, even, uh, Curious George. Uh, so I try to instill that on our, on our junior fellow. He did well. Ultimately, you just have to be brave just like him. Uh, a couple of things I never figured out about Dr. Walden, uh, despite being here two years. One was, was, what's this thing with his shoes? He just doesn't like to wear them. Uh, but the other big thing was the rubber bands. He always has some rubber bands on his wrist. I never knew. Maybe I'll find out. Um, I'm, I'm proud of a few accomplishments here, uh, throughout my time. Uh, I guess, uh, I was able to win the, uh, fellow Jeopardy, and like Doctor Jennings says, uh, sometimes you just have to be good. Um, I was able to present, um, a case at the Boston Surgical Society and, um, get a good sized check, um, although Doctor Smithers is still asking for his commission. Um, but, um, that was fun to do. A couple of case reports that we would have published. Um, I was also able to participate in implementing, um, the strategy to hopefully, uh, get a little more feedback and learn how to give feedback and uh to, uh, uh, improve the way we do some teaching. It's not perfect, but I think it's a step in the right direction. My my most prized accomplishment throughout this time in training was obviously the birth of our second daughter, uh, Elena. Um, obviously, Doc Schamber clearly put it that we're not busy enough, so we had time to, to order, uh, our second child. Um, with, uh, so much, uh, things to look forward to, I think, um, that brings me to the next, uh, uh, stage of my talk where, um, I think I'm really looking forward to a little better sleep. My wife got me this book and, and I think it's been pretty interesting so far. So I'll try to implement some of these strategies. Um, the other book I got as part of the introduction for the esophageal and airway team, um, that I'll be joining is, is this one. So, uh, uh, I, I, I spent all night trying to find Doctor Smithers. I really didn't find, I, I wasn't able to find him. I was able to find Doctor Hamilton, so, I, I, I guess I'll, I'll, I'll practice that strategy to read my emails a little more frequently. It seems pretty comfortable. More importantly, I think I need to work on something here. Doctor Jennings has a pretty awesome motorcycle. I still need to uh fill in those shoes a little bit better. Uh, I think I need to get a better motorcycle. Doctor Jennings, you and I need to talk. Got to thank a few people here in the room just to wrap it up. It's getting close to 8 o'clock. Uh, Betty and the OR crew is sitting back there. Thank you for keeping us, Norwich. Thank you for being the spirit in the OR. Uh, you filled our drawers with snacks, uh, more than we can think of. Thank you so much. Um, Lee and the rest of the 18 nurse practitioners, we couldn't do it without you. You keep us, uh, really, uh, on our feet and really take care of the patients on the floor. Thank you so much. Uh, Terry, and, uh, obviously, Terry, uh, she does so much for us. Hillary also stepped it up, uh, a lot this year. So thank you so much, Hillary, for your help with the coordination of the fellowship. And more importantly, my wife, Joanna, my brother's here with me also. Uh, so thank you for coming. Thank you for being that inspiration for me. Ultimately, we look forward to uh Farouk's talk on Friday night. Um, I hope, uh, we didn't give you any more, uh, material for you to wanna, uh, uh, get back to us, but, um, uh, I hope you all can join us Friday night and thank you very much for all you do. Thank you. Oh. Well, Broth and, and Ben, the, uh, time is limited, but I'd like to thank both of you for the stellar, uh, presentations this morning. The, the cases are remarkable and it's, uh, rewarding to see the series of lessons that you've learned over your last two years with us. And I think one of the facts that has, has come through in your presentations is how dedicated you've been to Patients and they're obviously they're always ones that are particularly challenging that believe Messages with you or lessons with you for the rest of your life. I think one of the other lessons that has, has come through in your presentations this morning is that pediatric surgery is not just the technical component, but it's also the The cognitive uh management and knowing when to operate and when not to operate on the kids, it's so uh So valuable. Second, I'd, there'll be many more comments, uh, this Friday, uh, but I'd like to thank both of you, uh, at this point for the outstanding jobs that you've done during the last year. It's been a pleasure having you with us, and I think, uh, how you've both grown and matured during the last two years is, uh, dramatic. I don't think our incoming fellows are here, but I think if, uh, if they saw the. Presentations, they'd both uh be trembling in their shoes, but also looking forward with uh great uh Enthusiasm for the, for the coming year. I, I don't know if there are any other short comments that anybody would like to make this morning before we save most of our ammunition rounds for Friday. If not, for that we will Close this morning and thank you once more for the fantastic jobs you've done in the last year. I Great. Yeah my younger brother. Go. I