Dr. Robert Crum, Dr. Timothy Tirrell, and Dr. Kyle Thompson - Research Fellowship In Review

I'm going to do this for some reason. So I'm on Brent's computer. But this is Tomahla. Good morning, everybody. And thank you all for joining in on this virtual grand round. We continue our series of excellent research presentations from current research fellows who will soon be winding up their time with us and returning to their home residency program. We'll hear from Robert Crum and Tim Torell and Kyle Thompson today. Just to remind everyone this Zoom is a webinar and everyone is muted. So if you do have any questions or comments, please raise your hand and we will unmute you. To start us up this morning, we begin with Robert Crum. Rob joins us from the Department of Surgery at Columbia. Prior to that, he did his undergraduate work at Villanova and his medical degree at Rutgers, New Jersey. Our own junior fellow Hester speaks so highly of Rob from their shared days at Columbia together. In addition to always being available for our cases and working tirelessly on call, Rob has been highly productive in the surgical innovation research fellowship under the guidance of Dr. Cannon more recently, Dr. Zimari. Most of us are always curious what this group of innovative thinkers and problem solvers is up to from suction bovies and more recently, the 95 mass shortage. This group has constantly impressed us time and time again. So thank you so much, Rob, for all the work that you've done with the surgical innovation fellowship program and we look forward to hearing from you on lessons that you've learned during your time here. Take it away. That's good. How did it do it? Great. Thank you very much. Okay. Good morning, everyone. Thank you for tuning in and for the opportunity to tell you a little bit about the lessons I learned in the last two years. We don't have any financial relationships with any companies, but for complete transparency, I'm a co-inventor on a few provisional patents owned by children and a co-inventor on a technology joined owned by BCH and NGB. The surgical innovation fellowship or SIF as we call it is four years old now. I am the second graduating fellow. It's a fulfillment of what Dr. Kim and Dr. Fishman had long called the kindergarten fellowship where someone junior could come in and approach questions with a fresh set of eyes. It has turned into all these different aspects here. And we primarily focus on device development as well as novel surgical technique. Am I just muted? Can you guys hear me still? Okay, great. So what exactly makes us unique? Well, it took me a lot a while to understand because innovation is a relatively broad term. And the truth is that all of us is positioned scientists or innovators in one way or another. And we do not mean to monopolize the word. The unique aspect of what we do, however, is that we keep in mind the entire aspect of all the surgical innovation process, need finding solution, protection, and commercialization. And we start by identifying what frustrates us most and listening to the complaints of our colleagues in order to figure out what a real problem is. And once we have that problem, we come up with multiple solutions. But we keep in mind which solution has the best chance to make it to commercialization. And we do this to learn the secret sauce of what goes on here in the middle. Because for us, having solution is not the end. The end is having solved that problem. In other words, my first lesson is that it just teaches us to develop practical solutions to real world clinical needs that reach the bedside. Or as one of my esteemed mentors put it about devices, the thing about devices is until the device is approved by the FDA, manufactured by a company, and sold to a hospital or clinician, you will not help your patient. The second lesson I learned in real life, but heard on Shark Tank from investor Chris Sackel was, ideas are cheap execution is everything. At first glance, a surgical innovation fellowship may make us think of this. A surgeon has a brilliant idea. Surgeon Ben Patton's idea, then company buys a brilliant surgeon's idea for a lot of money, then the surgeon continues to get a percentage of every unit sold moving forward. And obviously this is not true. Rather, the truth is demonstrated in my experience with our most successful project, not, which is a digital case log. Not as no Patton, and it's successful solely based on execution. So in order to demonstrate lessons two through five, I want to talk through our pitch deck and our journey with not. The problem is the doctor spend way too much time on administrative tasks. One of the worst of these is case logging. And the reason is because right now there's no easy way to transmit data between multiple systems. You're all probably very familiar with this process. After I do a laparoscopic app index to me, I'll go and sit down at the computer and turn my brief off note in the orders. All this information about the procedure I did. Then I should also write this in my personal log. Same information goes in there, but now some extra notes and lessons that I learned during the case. And then lastly, when I get time, I need to copy the same information for a third time into another system. For residents, this is the accreditation system or the ACG&D website. For those of you who haven't seen it in a while, over a thousand times over the course of my five years, I'm going to log on to this website and enter all the cases I do. Soly for the purpose of the ACG&D to prove that I had done enough cases to graduate. And despite its training, spending over 2.1 million hours logging cases the data that's collected is only 71 percent accurate. And so an accurate because of the manual and retrospective nature of that data collection. And we found that this task alone contributes to the burnout of tens of thousands of residents. So the solution is not, which is a digital case log that has automated case logging through software that collects and transmits data to multiple systems. It works through three key features. The first is integration with electronic health record. Once you do an appendectomy and you're anywhere in the electronic health record, we'll find it and send it to your phone so that you can storely secure your case. From there, we'll let you add photos and notes about it. And then in the end, we'll enable transmission of that data to the required groups. Right now, that is the ACG&D for residents. And all of this is doing a great job to get back to the bedside and do what they're supposed to. Early on, we recognized the important aspects of the traditional case log. And we included those in the hot, well enabling it with the latest technology. Now, instead of having your cases just in your notebook, they're searchable, groupable, and filterable. Next, we can provide you analytics that are previously unavailable. You can see your progress and how you're doing compared to your peers across the world. And then lastly, we take the note section, enable it with photos and videos. And eventually, you'll even be able to share this with your colleagues so that you can now turn your lesson into a lesson for all of your colleagues. So that's our problem and solution. And that seems great. But again, ideas are cheap. In fact, digital case logs exist. Any surgical residents report this problem. Breit even brought it up in her interview that this would be a great opportunity for in it digital innovation. However, tens of thousands of residents still waste their time every day doing this. So we think that this is a solution that still needs to be solved. And so we sought to execute it. This is where we learned our third lesson. To grow through support from those around you and validation. We are lucky enough to be here at Boston Children's Hospital, which has an actual digital health accelerator, which can actually help to develop projects just like this. So we pitched it in October of 2018 seeking a grant. But we were turned down citing concerns that this is model. Still, Convinces was a problem we're solving. Dr. Sal Afshar told us to apply to the Harvard I-Ladd accelerator. What is an accelerator? Well, we didn't know either at the time. But these are organizations that are still in the same place and these are organizations that are set up to grow ideas and start up. They're filled with entrepreneur advisors, fellow innovators, and funding opportunities. So Harvard I-Ladd, which is over on the Business School campus, helped us learn the basics of venture formation, how to grow our team, and how to start building a business model. At this time, we also learned our fourth lesson to grow through collaboration. We teamed up with a great Brigham Surgery resident and Informatics feather fellow Heather Liu, who helped us actually get the data out of Epic, as well as some other resources from Mass General Brigham. And we put up a flyer, and we're lucky to find a former Google intern who happened to be an HMS student, Gavin Ofseck, who started writing codepress. Then I-Ladd started setting up with some local pitch competition, and we started to earn a small amount of grant money. From there, we went back to our hospitals, now with partners at the table as well. And we pitched again with the validation from iLadd, a stronger team, and we earned the tremendous grant support that would help us turn our idea into a reality. We then again went external with the support and validation from our hospitals to apply to Mass Challenge, one of the top accelerators in the nation, and continued with startups from all over the world in all different fields of business. And we were named a 2020 Top 20 startup, even though we weren't really start up. And we were very proud of it. And in total, with the support and validation from all these groups, we have over half a million dollars in grant funding to make not a reality. And this afternoon, we hope to add to that as we give our final pitch to Mass Challenge Health Tech. A little bit more about these accelerators. They are driven by venture capitalists and local business objectives, and the weakest part of our pitch was a business model. So in these competitions, we were hammered about how we were going to get somebody to pay for a solution that serves lowly residents. It was a real problem and it was a great solution, but it was not enough. However, as a doctor, there is something uncomfortable or uneasy when it comes to talking about money. And for some reason, I've heard this question mostly ingest more times than I can count. The business model does not seem like it should be part of a pure academic pursuit of a research fellowship. However, we needed to recognize the reality that if we wanted to see our problem solved and our solution commercialized, we needed to dig into the business. And that is when we learned our fifth lesson. Commercialization is not about personal wealth. It is about understanding the business side of healthcare enough to support your solution. So this is our early business model, the one that got beat up a lot. And the details are not important. But the point is, first we're going to charge residents, and then we're going to charge programs, and then we're going to charge health system, and then we're going to magically grow after that. And this model was essentially laughed at. So we set out to do some market research and figure out how else we could fund that. In our next pitch deck, which is our current one, we address it head on. Who will pay? Residents are poor and hospitals have narrow margins and a long fail cycle. However, even though residents are cash draft, they are extremely valuable to other groups, notably industry. Take for example, an ortho-reson. During their training, they will be exposed to multiple devices from various companies. And when they specialize and graduate, they will choose a primary company to work with. That company is striker. The striker, that decision will be worth over $50 million over the course of that surgeon's career. Therefore, it is worth it for striker to have exposure to trainees. And this is no secret called the medical education budget. Separate from advertising, and it supports lots of things that we like. Like virtual education, procedural courses, reps, journals, and conferences. And companies spend total of $2.7 billion on medical education annually. We propose that it is more efficient and more targeted to provide many of these learning opportunities digitally in one place. Therefore, we can disrupt budgets of medical education by having the eyes of doctors who are the decision makers. We've long said this is basically turbo tax for doctors, just like you're required to do your taxes, you're required to case log, and we help you do it better. But it's also like SIPFIT, which will passively absorb what you're doing and help you track your performance. No need to go into all the details here, but this model predicts that you can. That sorry, this model presents a $1 billion market opportunity from just the $55,000 surgical trainees. And doing some fancy math and what is very important to accelerators is at the end to provide an equation that after the equal sign you have a number with a billion after it. So why not? Lesson 5a is also used at least one pun and every pitch. Doctors spend far too much time on administrative tasks. With not in place, we can remove this burden, maximize data accuracy, improve surgical education, and support it all through responsible and collaborative relationships with industry. With less than five in mind, we had a great problem. We had a great solution for a long time, but it was not until we came up with this business model in this angle that would really start to get interest from investors and other companies. Now this summer, we're set to launch our pilot at Brigham. We have interest in partnerships from digital health companies across the country. And we are really close having serious life and then conversations with a growing company that can run with this as we return to residency while we stay on as advisors. And then another group is just about integrating not with the BCH EHR. And so a BCH pilot might be coming this year as well. Taking a step back from commercialization, the final lesson I learned is about innovation and academia. In the last few months, we've started studying and writing about the field of innovation in these three areas. In the access survey, we asked respondents to rate the value of various achievements of a candidate who is applying for the pediatric surgery fellowship match. First, we asked them about valuable innovation outcomes such as making a new procedure or device or app or holding a patent. But it wasn't too surprising to see that when compared to traditional academic output, first author, publications, and presentations at national meetings, these were more important. And during these two years, we've also observed a few key points. First, on the innovation side, over a third of the teams that we compete against are in the health and life sciences track, meaning essentially medicine. Yet we've only, after meeting hundreds of these teams, we've only come across a handful of positions. And on the academia side, we found that innovation work does not lead to traditional output, but that the active clinical positions are the ones who provide the best on that need. So on the one side, we have a bustling group of commercialization focused people with tremendous opportunities. And on the other, we have clinicians with great ideas, but no time to devote towards innovation. And this leads me to the final lesson in order to bridge this gap, innovation should be an academic endeavor. I admit this is more about hypothesis, but I think it's true and more in study. It is my opinion that the goal of this fellowship is to train people to fill this office at the end. To be members of a department and a specialty that can serve our colleagues. Just as you may go to a colorectal colleague to help with the test pelvic dissection or a plastic surgeon to help you create a flat. The SIF office will be someone who understands the full innovation process to help with your need or idea. I consider it a true privilege to spend two years here at Boston Children's. I would like to thank the department, especially Dr's Fishman, Shamburg and Faza for the opportunity to pursue something unique without any pressure, while also getting to be involved in educational clinical activities. I told people when I came up here that I came up here to work on medical devices, but the truth is that they're interviewing I came up here to look with Dr Tim and I'm very happy I did. He along with our co-director, Dr. DeMarie is our exemplary mentors and surgeons, so I'll try to emulate during my career. Thanks to Dr. Afshar for pointing in the right direction several times, Gabe for defining the framework of this fellowship, for helping take our fellowship to another level, Alex for making me good and making me look good on all things device related, a special shout out to my co-cell Kyle who has become like a brother during these last two years. And lastly, enormous thank you to my wife Julie. She moved her whole life away from her family and a friend to come up to Boston with me. We got engaged the first weekend and have been living a dream ever since. Thanks again. Thank you Rob for that fantastic presentation. We do have one question in the Q&A box from Dr Z, and I'll read it Rob. Congratulations on completing your research fellowship constantly innovating has clearly led you to new and different minds that near clinical thinking and in your life. The process of problems ideas, solutions has many essential pieces of the final puzzle. How much of the collaborative experience takes improvisation on the fly as you test out novel designs and possible applications of a surgical device? Thanks Dr. Z, and thanks for you and Steve and all the support that you guys have given us. And all these are great questions at lab meeting. I think that's one of the biggest opportunities we've had in this fellowship is to kind of work on the fly early on in prototyping stage things are low risk to be able to try things innovate. I mean, we did a lot of what would be called arts and crafts during at our lab bench. So early on, there's lots of testing on the fly and it's a lot of fun. So the new one else have any questions or comments please try to raise your hand. Hey Rob, can you hear me? This is for Oak. Can you hear me? Great. Rob, as always, fantastic presentation. Sort of quick comment. You've done an amazing job these last years and then the beauty about this sort of work is that it's totally this it's all about freedom and you have you've had the freedom to take this as far as you wanted. And driven by the passion you've had for all the different problems that we've sort of been faced with and take it as far as you can. And you've taken several of these projects very far and it's all due to your work and the collaborative work you've done. So I expect you're going to have an amazing career and I've been so glad with part of it during this time. So thank you Rob. Thanks. Hey Rob, can you hear me? Hi, I'm Bay. I just want to thank you on behalf of the department for tremendous two years of work. Just so everybody knows this whole idea of the job and really driving it was solely the work of Rob and Kyle. We've passed two years. They came to me with this idea early on and I love it. I think they really go and burst the way. I look forward to continuing collaboration with both of you in the future before to welcome you on your CEO. I'm working so I'm seeing you as well. So congratulations on your great two years to love getting back to residency. Thanks, that's good. Okay, in the interest of time, we'll move on to the next presenter. Next we have Tim Torell. Tim joins us from sunny California UC San Diego, a general surgery program where he also got his medical degree. Most of you know him best from his work as a surgical critical care fellow last year. And I know for FEMA for Oken, I are incredibly grateful for the care he provided the patients last year. While juggling the critical care fellowship, Tim began exploring his interest in research within the field of color, rectal and pelvic malformations. And he's dealt deeper with various research projects under the mentorship of Dr. Dickey and Dr. D'Merry this past year. Today he will speak to us about improving care for patients with colorectal and pelvic malformations through clinical research. Take it away Tim. Thanks, Simala. Let me just get everything set up here. So thanks for joining me on a brief reflection over my time here for the past few years. I have no disclosures. I want to start out by recognizing the time I spent on seven south and seven north last year. And thanks some of the people who helped me out along the way. You know, I started out in the NICU and it was readily apparent that I knew really nothing about babies. So I carried the palace card with me all the time because I was terrified that somebody asked me, would ask me a question like, you know, what's the normal heart rate for a six week old? But the crew was great and showed me the way. I met a lot of really smart people and met a lot of bellies that were different from anything that I'd ever really seen before. So much thanks to the sails that round over there and to the surgical fellows from last year for putting up with my basically nonstop questioning. Moving over to seven south was truly one of the most multi-disciplinary experiences I've ever had. I was surrounded by people from different backgrounds and tried to absorb as much of their knowledge as I could. I hope I was able to share with them a fraction of the knowledge that they gave to me. But the reality is when you put five guys into an enclosed space, sometimes the results are always going to be the same. So we rounded by flashlight. We made it on the hospital Instagram and we learned a lot and had a lot of fun along the way. And this California boy even made it through his first winter. Although I'm still not really sure whether or not you're supposed to use an umbrella in the snow. So the summer came around and I shifted to research. Dr. Dickie was kind enough to take me on as a trainee. She runs the colorectal and pelvic malformation center, which is a large group of experts from many fields who come together and try to optimize care for what can be a pretty challenging and complex patient population. Our work falls into several categories highlighted here and we've been working on several projects in each realm. I want to highlight a few today specifically because their lessons from our own patients here in Boston and they contain messages that I think have potential for influencing how we practice. The first project is a joint effort between surgery, urology and radiology and involves utilizing an ultrasound based technique for pre-operative evaluation of anorectal malformation patients. For these patients, I've identified the location of the fistula between the rectum and the urinary tract and the location of the coccyx is critical because these factors can influence surgical approach. This has traditionally been done with imaging that involves radiation or may require sedation or requires distension of the rectum to super physiologic pressures. Now an optimal study would provide this information without the need for radiation or anesthesia and also pose minimal risk to the patient. So for a little while now, Dr. Dickey, Dr. McNamara from urology and Dr. Chao from radiology have been working on using an ultrasound based imaging technique to define this anatomy. Ultrasound contrast agents have been used in the early 2000s for detection of vesico-irritable reflex. And so they generated some preliminary data about an experience here demonstrating the feasibility of use of this technique for imperfect anus patients. And then performed a retrospective review of the children at our institution with anorectal malformations who underwent contrast enhanced ultrasound and then compared the results of their ultrasound study with their traditional imaging, which was usually a distal colostogram. There were 14 children with anorectal malformations in the pathologies are shown here. From a technique standpoint, the ultrasound is performed very similarly to a traditional distal colostogram. The distal colon is accessed with a fully catheter through a mucus fistula and a contrast agent is instilled by gravity while performing the imaging. Florescent colostograms are often also performed with additional manual pressure applied to the contrast bag to further extend the rectum, but this was not done in any of the ultrasound studies. Our basic results are summarized here of 14 patients, 12 of them underwent the studies as described. In 10 of these patients, both traditional and contrast enhanced imaging yielded the same diagnostic information. There were two patients who had initial ultrasound studies which showed the rectal urethral fistula, but a traditional colostogram which did not. A fistula was still not seen in one of these patients despite application of high manual pressure, and the other patient ultimately underwent a repeat colostogram which did show the fistula. Over on the other side here, we find that two patients had mucus fistulas that were inaccessible because they had scarred over. One of these patients underwent, sorry, one of these patients had their fistula open in the operating room and underwent ultrasound imaging there. The other patient had a VCUG which showed the fistula but was not ultimately demonstrated on ultrasound. This is an example of a contrast enhanced ultrasound with traditional imaging on the left and contrast imaging on the right. The images obtained in the anterior sagittal plane, so the top of the images is anterior and the bottom of the images is posterior. The bony elements of the sacrum and coxics can be seen. As contrasts is instilled, the rectum can be seen filling. In the fistula fills and contrast can be seen in the urethra and in this case, refluxing into the bladder. The fistula can also be defined in a similar way on traditional colostogram. In this example, you can see contrasts fill the rectum and watch it pass into the urethra. There is no reflux into the bladder on this study but the rectal ball of our fistula is clearly defined as well as the location of the coxics. This initial colostogram was not performed under high pressure and did not demonstrate a fistula. Repeating the colostogram with high pressure ultimately did show the fistula but it also demonstrated an ultrasound without high pressures. Overall, a result of very promising. Ultimately, concordant information between ultrasound and floraoscopy was found in the majority of patients. There were some patients in whom the ultrasound picked up the fistula when the traditional colostogram did not. This technique is flexible and can be performed in multiple settings. None of the patients required excess pressure during the ultrasound to demonstrate the fistula. I'll say that rectal damage from a pressurized colostogram is quite rare but it has been reported. So we think it's important to minimize that risk if we can. Ultimately, it remains to be seen just how broadly applicable this procedure is and if our successes can be replicated. But based on these experiences, Dr. Chao and radiology had started a broader education within the radiology department for performing this procedure. So this may be something you'll be seeing more of in the near future. Switching gears a little bit, we move towards a population with more complex malformations. OEIS patients have a complex set of malformations including a fallacyl, extrafea of the cloaca, imperferidane, and spinal abnormalities. It's a pretty rare set of malformations with an instance estimated to be between one in ten per million live births. Due to the complexity of the disease and the scarcity, there's no clear standardization of optimal care. First stage surgery involves tubularization of the sequel plate and rescue of the hind gut and has been recommended to occur shortly after birth to minimize cross contamination between the GI and the urinary tracks. And to optimize intestinal function. But these babies are often born pre-term and frequently have other comorbidities which can be pretty severe. Over the past few years, we've had several babies whose repairs have been delayed beyond the immediate postnatal period. So we reviewed their records to try and determine if there was significant morbidity associated with delaying these repairs. Over the three-year period, we managed ten babies and categorized them into three groups. Undelayed repair, delayed repair, and unrepared. Those who were unrepared ultimately died of severe respiratory failure. As you can see, all were born pre-term, with a median gestational age of 33 weeks and a birth weight of 2.0 kilos. I should say up front that the group sizes are too small for any meaningful hypothesis testing, but at least by direct comparison, we can see that overall the delayed patients had longer nicoestays, longer time to discharge postoperatively, and longer amounts of PN usage. I'll caution any interpretation by stating that there's no adjusting for comorbidities here and there's significant heterogeneity between the patient population. I will also note that the delayed patients didn't seem to take any longer to achieve full-enteral feeds postoperatively. We also evaluated the growth trajectories of the delayed patients, because we know that there's significant growth morbidity in this population, and wanted to evaluate if restoring intestinal continuity help improve the growth trajectory. So represented here are the six patients with delayed repair, where the red lines represent slopes of their growth curves for 30-day intervals before and after their surgery. Overall, you can see that as a group performing the surgery doesn't appear to improve their growth trajectories. So all in all, it appears these patients did not suffer severe consequences from their delayed repairs. In fact, there seem to be benefits of delaying repair in terms of optimizing their cardiovascular status, likely reducing their perioperative risk. And further, the main recommendations behind expedient repair being concerns for infection and metabolic arrangements and benefits to growth didn't seem to be demonstrated in our population. The infections that were seen were cellulitis and essential line associated infection. Now, the delayed patients did have more PNUs and therefore increased risk of central line infection. But almost all the patients whose repairs were delayed required ongoing central access for management of their other significant comorbidities. It's also worth noting that delaying the repair does not necessarily mean that PN is required. Although the sequel because is exposed and the hind gut is defunctionalized prior to repair, there's really no intrinsic contraindication defeating these babies. Now, we have to of course, temper our interpretation within the usual limits of a retrospective study and consider the small sample size and significant homogeneity of presentation. But as care for this rare disease becomes more centralized to large centers, knowing things like this will be useful in helping to think about how to triage and how to treat the patients. How to triage and transport these complex patients. So I hope that these brief discussions have given you a little flavor of some of the work that we're doing and maybe something to think about when managing these types of patients that you might encounter in the near future. I owe a significant debt of gratitude to so many people here. I'm sure I've missed some, but I want to express my thanks. It's been a really wonderful few years and quite an opportunity to be here. So thank you and I'd be happy to take any questions. Hey, Tim. This is for a, I just wanted to say congratulations. I love that I loved how you this all fit the pattern of what you first described with the introduction to the ICUs. And I think that really highlights some of your your your talents and able to walk into something that is inherently complicated for and multi-disciplinary. Whether it's the ICU or these colorectal problems that you've tackled over your time. And by asking the right questions and by working with the right people and being a real problem solver, you're able to take things to a new level and really help help kids and get some really important research done as well. So I'm congratulations and it's been a real pleasure working with you. Thank you and thanks for all your guidance. So I'll mimic what for us that Tim came to us. He actually reached out to me prior to starting the fellowship and started looking at some of the topics and topics of interest. And he really sort of started our research here within the colorectal center both clinically and starting some database work with us. So he's laid the groundwork for us proceeding and future leading of this field. I just want to thank him for all the hard work he's done. He really integrated well into the team. He was quite the team player and I think all of us enjoyed working with them and good luck with your future endeavors. Thank you. It's very kind. Tim is Chris well and I just want to say thank you very much. You came highly recommended from Hari who was near and dear to many and all of us. And he recommended you without hesitation and reservation and was a pleasure to talk to you from my basement that very first time and after dropping the phone call a few times because of connections to reconnect and feels been more quality time with you on the phone was. Pretty much the little five the job right then and there when you came out. You essentially were exactly who you are earnest, capable, able, competent and your confidence and caring attitude came through as well. So I want to thank you for a very smooth and wonderful year. You and your colleagues made it such that the year was easy to administer and easy to run because there are simply no problems at all. So thank you very much. Good luck and your endeavors and thanks again. Thank you for the opportunity to be here. Thank you Tim. We'll move on to our next speaker last but not least we have Kyle Thompson. Most of our staff know him best from again his phenomenal work as a searchable critical care fellow last year. Kyle considers Idaho home went to program young University for undergrad before getting his medical degree from UT Houston. He's currently a resident in the general surgery program that you see Davis and hopefully you all know by now that Kyle and his wife Kina welcome to him. Another baby boy born just a week ago. We are so excited for you and your growing family. Today hopefully the kids and the newborn baby are at home quiet and then we'll let you speak. Kyle will be sharing with us his lessons learned from the critical care experience as well as his work with the EA programs research projects under the guidance of doctors and they have. Take it away Kyle. Thank you. I think we can get set up here really quick. Thank you again and I just wanted to first thank Tim. He was an excellent co-fellow and I couldn't have asked for anybody better. And I have no guarantees that my kids will be quiet. My wife is with them but we'll see. I wanted to start my presentation just by reflecting on a few things I have no financial or conflicts of interest. I just wanted to reflect on a few lessons that I learned during my critical care fellowship. The first being the ability to recognize a sick patient and what it really means to be a sick patient and then it's not always the patient who's. Intubated on pressers but it's often the patient that you don't. Don't recognize or that you don't realize is going to be sick. Next the next step was a deep understanding that I developed of the differences in the physiology between adults and kids. I think this program did an excellent job at exposing us to both where we rotated both at the Brigham and we rotated at Children's. And I got to really see the difference between those two patient populations and when to apply the differences in the populations and I think. Rotating through the NICU especially those differences become substantial. And then the next important lesson that I learned is the value of the longitudinal bedside hours that we spend with these patients. And I wanted to illustrate this in a baby that we all know well who was born with a giant in fallacy and I was in the NICU shortly after his birth. And then for a lot of us I was there for the first three of his for three of his first six months of life. And it's amazing what you learn in that time and it's something that we don't often get as. As surgical trainees. And it's something that you don't realize the value of until until you get that opportunity. I wanted to just briefly mention many of the projects that I worked on the first few were with Dr. Zeleskis who was one of my primary mentors where we worked on a few CDH related projects and all of the projects that I worked on really stemmed for my time in the ICU and interest that I saw while in the unit. And an additional set of projects that I worked on were with doctors Zeleskis, Weldon, the Agerajan and NASA. And these all dealt with my experience with ECMO and these were projects that I really enjoyed, enjoyed working on. And then the last set of projects, well, definitely last but not least were with the EAT primarily with doctors in Dejas, working as my mentor. And we reviewed our experience here at BCH of the Jijunal Honor position patients as well as the NIS and fund application patients in the EAPOPS. And these I chose really to focus on the EAPOPS because of its relevance to this crowd, but also because of I think the significant impact that it has on the field of a soft geolatresia and the soft geolore placements. I wanted to start by just discussing a brief history of the Jijunal Honor position. It's definitely not a new conduit. It's been around for a while. In fact, Dr. Foker, who helped set up our program here, our soft geolatresia program, wrote up in the early 80s and experience with a 33 year follow-up. And his first case that he reported was in 1947 and he had a pretty substantial database. There were 32 patients. They reported on really just 16 of those patients. And the most substantial thing is that they were all eating by mouth at the end. They had no graph loss. And it was a pretty remarkable result, especially for the time. And I think it's also important, excuse me, as we consider the different soft geolore placement options of looking at really the end game. And I think that the goal is a 70 year conduit, which is really the lifetime of the patient. And so as we think about the different options, that end goal needs to be the primary focus. A review was recently put out that looked at the different conduits and how common each of them were and the complications are related to each of them. And the most common was the colonic interposition followed by the gastric pull up and then pretty far at the end was the gigenol interposition. Now this didn't include some additional studies that had an additional 29 patients from two papers published since then. And it also didn't include Dr. Fokers original paper, but it still is a pretty substantial difference between each of the conduits. And the main question is, you know, why? And it's been reported very high leak and stricture rates. It also has been deemed very technically difficult. And so it's just not a common option to use because of these reasons. Now this review was primarily in long gap patients. As we look at our cohort of patients, we in our retrospective review, our patients weren't primarily long gap. In fact, most of them, although most of them were E.A. patients, most of them were actually type C patients, which I think represents really who this population was and they were failed initial repairs. And so these weren't first time patients who had an interposition done in a clean surgical field. But these were patients who had multiple re operations with multiple failed attempts at repair. And then there was also a small percentage of patients that had caustic injury as well, about 13% of them. Now our total population consisted of 55 patients. And it was over the last 10 years as we started our first one in 2010. We split for purposes of evaluation. We split them into two different cohorts, a historic cohort that was published initially by SIG in 2015. And then a contemporary cohort and there were 14 and 41 patients. And over the last four years, we significantly increased the amount of gestinal interpositions performed at the institution. Now we're upwards of about one a month or near that. I think the crux of our paper lies in the lessons that we learned over time. So from that initial cohort to this contemporary cohort, we made many changes, changes that helped prevent complications, changes that helped prevent more re operations. And that really helped us improve the surgical technique as well as the ICU care surrounding these patients. So we're going to have to be able to highlight all nine of these lessons learned. But I've chosen just a few to be able to focus on today. The first of them is the value of microvascular augmentation or what we call supercharging. Now with the leak rate and strict rate being the two most common complaints about the use of the general interposition, when we looked at those who are supercharged versus not supercharged, we had a zero percent leak rate among the supercharged versus 18% among those who were not supercharged. The anastomotic stricter resection rate, although it wasn't significant, was lower as well. The overall stricter rate was 9% among the entire cohort. And if you compare this to the review referenced earlier, these leak rates and stricter rates are significantly less than the cohorts. They less than the collotic interposition and the gastric pull up and significantly less than those general interpositions previously cited as well. I have a brief video here that will work of the microvascular portion of the case. So here you can see the dissection of the internal mammurators, the left chosen for this case, the right can be used as well. And then here is the dissection of the jajunal arcade to be used as the recipient vessel in the anastomosis. Once the determined length of jajunum is chosen, it's brought up into the chest retrocholic. And the microscope is brought in and the anastomosis is performed. The hands on an asthmosis is done for the arterial anastomosis as shown here. And you can see good blood flow, good pulsation in the vessel. And then this venous coupler is used for the venous side. The second lesson we learned was that the advantage of doing an end-to-end asthmosis. And this stemmed from multiple patients requiring conduit revisions, who had had an end to side an asthmosis. And over time we made significant changes where we increased from only 67% of the patients undergoing an end to side to now 93%. It's not 100% because there are some technical difficulties that go along with creating an end to end to anastomosis. And I have another brief video here where you can see the esophagus meeting the jajunum. And there's that distal candy cane portion that when performing an end to end to anastomosis requires a section in order to not kink the conduit. Another area of debate is the configuration of the conduit. Shown here is a picture of what we call the straight to stomach, jajunum in a position. And this is where the jajunum is literally transposed between either the two esophageal ends or brought straight to the stomach. And then this is the other configuration, which is a true and white configuration where it's brought retrocholic into the neck for a root and white conduit. And then you can see the jj and asthmosis there on the bottom right. Now this is important because of the burden of re-operations that this conduit decision provided. Our total re-operation rate was 47%, so it was very high. And most of these were because of a changing configuration after the fact. And these were mostly elective operations. And as you can see here, most of them were changing from straight to root and white. And these were because of reasons of porcandroid emptying or porcashric emptying or severe aspiration. The other main burden of re-operation was our internal hernia rate was quite high. And this led to some additional lessons for in five of that ruined white drainage. That configuration is superior. And that great care needs to be taken in closing all the potential internal hernia locations, such as the mezzanter BFIX or the hiatus. The last area of outcomes that I wanted to report in last lesson is dealing with our feeding outcomes. Highlighted here are those who were able to eat without any gastrostomy support. But if we look at those who were predominantly orally fed, these two columns here, the majority of the patients were able to take in most by mouth, but some needed still some g-tube supplementation for nutrition. But our ninth lesson stems from the pre-op feeding that can happen in these patients as they wait for their g-tube on our position, even if they have an esophagus to me through sham feedings. And this is this small portion of the patients represented here. Those who had no pre-op feeding had only 67% of them had consistent oral intake versus those who underwent pre-op feeding had 88% of the patients had consistent oral intake after. And this is in comparison to the 76% overall. So pre-op feeding, even with sham feeding, made a significant difference. Now with these lessons came multiple other improvements that we saw and improvements that were near and dear to me being in the ICU. And these were significant improvements in our days intubated in our post-op paralysis with a significant difference from five days to now no longer paralyzing the patient's post-op as we've gained confidence in the graft and in the condo. And then in addition to this significantly shorter ICU length of stay hospital length of stay and and our operating time, which all represent the interdisciplinary care that goes into taking care of these patients and not just the interoperative lessons that we learned. So in summary with this paper, the digital or position, it remains a very challenging operation and in a very complex patient population, especially those who come after a fail, the initial attempt at repair. But with that in mind, we've been able to make significant progress over time and it's reflected in our patient outcomes and the the jichunal conduit, especially when performed at a high volume center who's able to deal with a lot of the complexities that are needed, should be considered an option for a suffigil replacement. And I think in the future will be seen more and more often with the improving results seen and the different techniques that are employed. I wanted to just thank, especially those involved in the fellowship directly, Drs. Weldon's, Leskis, Rice Townsend, and then those from the from Southern South and Southern North as well. I wanted to thank my research mentors, Drs. Leskis and Zinn Dejas primarily, who've made a big contribution to my learning to my overall growth as a budding pediatric surgeon. And then it would be a miss if I didn't thank those who support the critical care fellowship, Drs. Fishman and Schamberger and Dr. Burns. And then those also for my home institution who were very supportive in me coming out here, Dr. Diana Farmer, especially, was key in supporting me in coming out here. And then I wanted to also thank the surgical fellows for Oak as a fellow last year and Samala and Pratima and now Hester. I wanted to thank them all for the significant amount of knowledge that they shared with me and help in developing me as a surgeon. Well, thank you. Be happy to take any questions. This is Chris. I just want to say thank you very much. You and Tim and your co-fellow truly made the year enjoyable, pleasant. And you're a remarkable individual. I think your echo poise and quiet nature of belive the fact that you are have a great deal of intellectual capacity and you're clearing for the patients who are fantastic. I'm very encouraged by your progress with the team and doctors in Dejas, especially mentoring you through this project. And I think there's only to be great things for you and your family ahead and best of luck and congratulations on the new addition. Thank you. Rob, Kyle and Tim, this is Steve Fishman and I just want to say how proud as an apartment we are of all three of you. We are only as good as those who push us forward and you guys are all three exemplars of what we hope to produce in the future. We hope we add just a little tiny bit to your success, really what makes you successful is your own drive, your education, your prior experiences. And we are just lucky enough to have people like you join us. I couldn't add much more praise to that to your individual mentors comments. The experiences that we had with all three of you in the clinics and the intensive carry in its in the operating room in the emergency room in the lab meetings and seeing your productivity and your growth only gives us tremendous hope for the future of our field. And we know that each of you will be successful moving forward and we are behind each one of you supporting you in your career goals. And I just want to thank all of you. Usually we have a big round of applause for everybody here. It's a little difficult in zoom, but please accept my my applause on behalf of the entire department and all of the Boston Children's surgery family. Thank you. Thank you. Thank you. I want to thank you for joining us. I want to thank you for joining us. Thank you. I think we'll call that a wrap. Great job, guys.