uniku tanoan ni copies hanoan caro odro fine are monitoring everyone and welcome to ground world it's my pleasure to introduce daughter Tamotiation còn井 spirtually from the ira city he was born in Tokyo and did his medical school and surgical residency in Japan y mad m multissa memorial hospital Transplant Surgery Fellowship. He stayed on his faculty there until 2008, when he came to New York Presbyterian Columbia University Medical Center as the surgical director of adult and pediatric liver and intestinal transplant. In 2010, he became the chief of the Division of Abdominal Organ Transplantation and as a professor of surgery at Columbia University, College of Physicians and Surgeons. Throughout his career, he has been known to be a pioneer and innovator in pediatric and adult transplant, including Multivistral Transplant and X vivo Resection and Auto Transplantation. Earlier this year, he faced a very different and unexpected challenge. Many of you know I did my residency at Columbia and things became, things certainly became very real for my Columbia family when Dr. Cato got COVID and survived after an ECMO run. He'll be sharing his story and unique perspective on COVID as well as his experience with X vivo surgery. Dr. Cato, thank you so much for being here with us today. Thank you. We have a personal collaboration with Boston Children a little bit and it goes back a long way when Humbay came in a team wanted to start in Testinal Transplant Day visited Miami and then it was probably like 15 years ago or more and since then, we've known each other and have a collaborative relationship for a while and then we also share a lot of patience in an exchange and then discuss about the cases for a long time. So it is really an honor to be here to present to this group on the ground now. Humbay gave me a very difficult task to put two things in one lecture and it's a very different things and I was wondering how I can put it together or maybe it's not possible but I will try. I will try and I think the more of your interest maybe half and half or maybe more towards the COVID so I'm gonna start with my COVID experience. Okay, so this is the piece of paper on a scribble of something is in there, you can see it. So what it is is this is when I started to do practice writing after I woke up from the intensive care ventilator and so forth. So I still remember that very well that first line was something I tried in the first day as you can see those, I'm trying to write poem there and you can see as you go down things get a little bit better and in final one is really recognizable. And I still remember that when I woke up I wasn't able to really move in the bed even and trying to reach the rail of the bed was really hard. So there's a control of the bed and a rail that you can go move the bed up and down. I was able to reach my hand to the button but I couldn't push the button. So that's how weak I was at that time. I had a rectal tube and had a feeding tube and pretty much full support I think at that time I was still on CVVH. So the beginning of March as COVID is coming to the US and North Eastern area that we knew that was coming and we know that it's coming in some way that is going to be overwhelming but we had no idea and I guess you guys didn't either how fast and how big that the wave is gonna be. So the beginning of March and March first there was an index patient in New York City infected with COVID-19. This patient was from Westchester County it's about a little bit north of New York City in a new Rochelle area and then the patient had a lot of contact with others. So there was people, about 1000 people are quarantined at that time. So when we heard that, oh okay that's a big number and then we saw that maybe something is coming we have to be prepared. That's what we are talking in that time and the index patient came to Columbia he was admitted in Columbia and medical ICU so we knew some of the illness how serious it's gonna be but we still have no idea what that was about. That time we heard that 1000 people quarantined so it's something like this is something happened in one local area of New York and we just have to make sure that we don't get contact with people who are quarantined. The reality was not. At that time already the disease was spread through the city and then a lot more people are infected than we knew of that time but back then we have not done any extra precaution to protect ourselves. We are doing surgery as usual up to the second week of March and then during that time I did a surgery and some of them turn out to be COVID positive later but we didn't check any COVID pre-surgically or we did not wear a 95 mask during the surgery and as you know that the you know fume of the electrocordory can also make the virus up in the air and also the intubation time. So we stopped the elective surgery in the second week of March I think I believe as March 14. I was still doing a living donor transplant in March 16 or something like a couple days into elective surgery with hold because that case was scheduled for a while and a very sick child was a profound jaundice in a poor hypertension so we didn't want to cancel the case so that was the last surgery I did before I was done with COVID. There is not only me that several other people are getting infected in healthcare workers including doctors and nurses but most people who get serious are the ill who was around the time. Same time I got sick. Probably that was because that we really didn't have much protection to ourselves even with the shortage of PPE later it wasn't much of a huge problem in our hospital. However though around the time people got infected someone then got really sick like me and then some of them died around that time through the operating room, order and doscape sweet. So I finished my last surgery as a last surgery living donor liver transplant I was still not necessarily thinking about stopping transplant process because transplant could be considered as an emergency situation. We have several patients was on the waiting list for a multivisceral transplant. I started to get sick about a week after the living donor transplant started in fever. The first symptom was I should not the fever it was an extreme backache. It was like a muscle ache but it was some muscle ache that I never experienced. So I kind of immediately knew that this was not something that I know of but I was kind of in denial that didn't think it was a COVID and also that time the hospital did not recommend the healthcare workers to get tested. The test was preserved for the patient. So we were told to stay home and I was staying home and then I started in fever about 37.5 to 38 degree Celsius. Then I was still working from home and then as a matter of fact there was a one multivisceral transplant got an offer for the organ that's a child who needed the transplant and I made a phone call to an email to Italian and French who has already overwhelmed that COVID that time and how they are going, how they are handling those urgent transplant cases. And then some of them said that we are still doing it. Some of them said we stopped it and you were just doing an online chat about how multivisceral or intestinal transplant should be handled during the time it COVID with the people from France and Italy. Then my symptom started to get worse and then I finally decided to get tested. Again, the test was still very limited but my very close friend of infectious disease he actually was running the COVID pretty much infectious disease frontline. He asked me to come in and get tested and I was tested positive. I still stayed home and then taking hydroxychloroquine and adysceramizing combination, those combination that turned out to be not effective but that was the only thing available back then. I had a pulse oximeter at home I was checking my saturation and at that time my saturation was actually not normal. It was about 94 to 95 but it wasn't really go down less than 90. And then again, this is something like more of a denial plus the things that the fact that more than 80% of people don't go serious stage of the COVID. So I was not really that concerned of that 94 of saturation. In retrospect, the saturation below 95 is actually indication to get tested for all the CT scan to see the pneumonitis. But I was still home and then trying to go through it. And then one day I was taking a shower and then suddenly got really difficult to breathe probably because of the humidity in the shower room. And it was coughing a lot. And then the saturation went down below 90 and I thought that this is the time I have to go to the hospital. So I went to the hospital and then the through the emergency room but get admitted to a medical floor and then got oxygen. It didn't really, I didn't still get much symptom. And then the saturation went up to 100%. And I was still not really thinking that anything that happened to me would have happened at that time. So you know, you heard about happy hypoxia, right? Happy hypoxia is the name coined for the state of the patient who has profoundly hypoxic but still able to do anything, you know, everything. As a matter of fact, the day I was intubated, it was the next day I went to the hospital. I got 100% by the oxygen, but overnight I got deteriorated. So they wanted me to want to intubate me in the morning. So I was moved to the intensification unit. But still I was not really thinking that how serious it was. They are telling me that you need an intubation and then I was still texting my friends. Oh, okay, I'm gonna be intubated. And I was texting one of my close friend, Transparen and a state of theologist and I asked, okay, if I'm gonna be intubated, I would rather you do my intubation. And a state of theologist run up to me and then he did an intubation. The last text I sent it was just a 15 minutes before I was intubated. So how profound hypoxic I was, but I was able to speak and then communicate like that. That was very unusual. That is actually very unusual phenomenon. I don't think it's everybody figured it out why that happened in COVID, but that was one of the characteristics of the COVID pneumonia. I was intubated in end of March and then from there on, things are okay for about a week. Then suddenly got turned towards with the bacterial sepsis. So that time that I was on the maxed out pressure, they started me on ECMO. Not about the ECMO for about a week. We don't really know exactly where that bacterial infection came from, they suspected it might be from gobladder because they were ghost on. So they call the sepsis to me too. And then managed that bacterial infection as well as the COVID pneumonia. The things was really critical about a week, but it's good that I was still in a full support that time because soon after I was intubated and get on, put on those support, we didn't have a shortage of the ventilator, we did have a shortage of the CVVH machine. It's much less of an instance now with a multi-organ failure immediately after the COVID pneumonia, but back then pretty much everybody who was intubated goes on dialysis very quickly. So I was put on CVVH and ventilator and then ECMO. I think they were probably doing my CVVH also shared by someone, so they have their shortage of machines, so they have to put one patient for 24 hours then put it off and then put it to the CVVH machine for another patient, so alternating use of CVVH machine. So I might have been on that situation too. But thank God to my colleague and also I got to a CSMAB and all those, the Remdesibio and pretty much whole. And then they're also preparing for me the plasma therapy, but I didn't really need a plasma after Toselisma and the Remdesibio things started to get better. And a total about three weeks of intubation I was extubated. And then go back to that scribble time, but I was really sick and it was so weak, so that it was really hard from recovery. And then the first thing I noticed was that when I work up, I couldn't talk, then I lost my voice. There was a very, very sick secretion on back of my throat and it was very difficult to clear. But I couldn't talk, I couldn't write. And I was trying to communicate what I have, I've had nobody understood me. So that was really hard time that until one nurse or maybe one doctor found out and put her finger into my mouth and then found there was almost like a gum type material that was covering my vocal cord. So and then after that, you know, I started to talk a little bit and then I started to recover. But in a swallow function didn't come back for a while. You know, in my mind I was able to swallow, I wanted to swallow, but it was completely, I was not able to swallow at all. And when you don't have any garrick function, the feeding tube tends to go to windpipe much easier than into the softwares. You notice a typical maneuver of letting patients swallow and push the nasal tube in. It doesn't work for somebody who doesn't have a function. That was a good way to learn. So you know, the nurse trying to put the feeding tube into the lung and then I said that was somebody who didn't really have a skill. Then one of my resin was supposed to be really good at everything was trying to pull it, he went into lung again and I was just, you know, cursing at everybody, this is not something I can take. But reality was, it was really not that because of the technical skill, there was really my vocal cord function. But somehow I was able to put it in and one of the intensive care doctor was able to put it in. And then I had a feeding tube. And then coming over to feed in tube and doing all this swallow evaluation was painful. And I don't know if you guys have ever tasted this phagia diet. You know, this phagia diet is terrible. That's just so terrible. You know, I don't know if you have a thickened milk, drink yourself, how hot it is to drink thick milk and thick water. You know, I have many of my patients win through that. But I didn't really realize how hot that is. And another thing that I sort of thought that time was that if I got any setback with this level of weakness I'm not gonna make it. You know, from my experience, I know it, the condition patient like my situation, whether another pneumonia or intubation or some kind of setback, it'll be really hot for me to come back. So I was on some kind of, you know, fear and maybe a PTSD. I was trying to stay up all night and not to get choke myself. There was ridiculous in some way, but that's what I how I felt. So that was really hard time and a lot of people helped me through that time. And then now I'm back in the operating room and I can do pretty much everything. So that was good. I had a policy in my nerve, the cranial nerve. They were one of the, the right side of the accessory nerve was pretty much damaged. So I wasn't able to move any of my back muscle to the right side. So I wasn't able to raise my hand for a while. But thank God it also came back. It came back in about a couple of months. When I first went back to the operating room, I was doing aesthetic taping to do like an athlete, but that's no longer necessary. I still have some numbness of my finger, but functionally I'm pretty much normal. When I was recovering in my bed, I was thinking a lot of things. If you face with near desk experience, you started to think things differently. I saw a white light. I saw a white light while I was intubated. And I saw that white light that people talks about and was coming from far and then surrounded me completely. I really saw that I died. I really saw that I died at that time. I didn't see anybody waving at me from a distance, but there was an experience. So that experience sort of made me think that you may not have your tomorrow. You may not have tomorrow. It's not all the time it's guaranteed that tomorrow is always come. And I was thinking a lot of things through that time. We have a lot of time in the hospital. So I was thinking many things. And one of the things that I was thinking is about my work on this XIVA surgery. The XIVA surgery is something that I started in the developed and I've done it for more than 10 years now and then getting a lot of long-term outcomes. But those outcomes are not necessarily put together and presented and published in a big series. I had a send a paper to European and surgical association, which is the biggest surgical meeting in Europe. I was supposed to make a presentation in colon Germany and May. So I wonder what happened to the meeting. Meeting was canceled, but it still accepted my paper. So I was able to publish. I finished paper for analysis surgery while I'm in the hospital with a lot of help on the colleague. So the important thing I really thought that was that this is something that I really have to pass on to everyone, other people. Because I may not be here tomorrow. Then somebody else needs to continue because I really think it is an important surgical technique. And it's a surgical technique developed by the trans-trans-surgeon and a photo-trans-trans-surgeon. So if whoever has a skillful to trans-trans, whether that is a liver trans-barn or intestinal trans-barn or any trans-barn, as natural skill sets to do this procedure. So this is how we connect these two talks into one. And I'm gonna present maybe a very short time so that I can take enough questions for my talk today, but I'm just gonna present very quickly about this talk. Because the talk itself has a pretty much 30 minutes content. I don't want to spend everything. So this is a paper that I published this year in Annals Obsergery about XVW Experience. Again, I said that was a paper supposedly presented in Germany. This is an experience in Columbia University Medical Center between 2019, including 46 cases. Most of them are adults, but some of them are children. XVW's surgery is essentially for the vascular involved tumor. So instead of taking the tumor out, you take the tumor and organs out, put them in a back table to a cold preservation solution and put the organ back so the organ can be preserved and resection can be done effectively. So I'm gonna go over some of the cases. This is a vout case, but there's a collaggio cancer right in the middle of the liver, involving multiple blood vessels, including photo vein and the three hepatic vein orifices. So in usual sense, this is unresectable, but if you take the liver out completely and chop, cut this left lateral segment and then connect the vein inside of this liver to the goatex that can be resectable. So this is the surgery of the vinaigivers replaced by the goatex. There's the back table surgery and then left lateral segment was placed back as if we do a live endona liver trans. Sorry, this is another case of a adult case with a huge tumor in the middle of the body. It's not just a liver, also involving pancreas head, but just by looking at this image, most people won't think this is resectable, but X-Vivo technique, you can resect it. So this particular case, we have to do a pancus head resection as well as the X-Vivo and liver is out of the body and then replaced by the kevavus replaced by goatex and liver was put back in. This is another form of X-Vivo for intestine. So SMA is involved in this tumor and in order to remove this, if you just remove the tumor, a patient will become short gut, but if you take it out and cut the intestine, small piece of intestine and put it back, we were able to rescue about one third of intestine. This is a tumor. It looks like there's almost no intestine left, but behind here the tumor, there was some intestine length, about one third of the intestine was one back in and this lady did not need any TPN and recovering really well. This is a 7-year-old girl with inframarine, myophybergastic tumor. The tumor is right in the middle of the body right here and then this is a SMA involvement. Sorry, the Ciliac artery, this is SMA. So it's both arteries are involved and then she had a poor hypertension because SMA and porovine, and SMA, SMA, porovine and spenic vein, they're all clotted. So you know that to take this out, we have to take entire abdominal viscera out and then put it back in. I have a three-minute video, so maybe I just shared this. Maybe this is, we still have some time. So this is like a little while ago, so the video is not really that good quality but we are dissecting everything to put everything up in the air from retropectonium. This patient has a previous deutanectomy, so this was like a recurrence of the tumor dividing the large bowel, dividing the esophago gastric junction. And then just take all the retropectonial deutanectomy out and then put in the clamp on the SMA and the cellular gallery and then top cave bottom cave below the liver and top cave above the liver. And then we're just cutting it and take a entire organs out of the body. So this is a full set of organs. You can see how swollen it is and it's flowing as large and it goes out and then go to the back table for flash. And then it is my colleagues, Dr. Imon was there and flashing the liver and intestine and then cutting out the tumor, the liver of the tumor. This particular case, we have to sacrifice pancreas and entire stomach. This is reconstructing the artery of the hepatic artery, finding small vessel graft from somewhere in the intestine. This is a microsurgical reconstruction of the hepatic artery and then small bowel is also separated from the tumor. We used to use goatex for the arterial reconstruction. Now I'm using the softenest vein because goatex tend to have an issue in the longer term. But this is like three things working together and now we are putting the liver back in. The process is almost like a liver transplant. This is like a more like a caraviric liver transplant just putting it back in as we normally do in transplant. This particular case, entire abdominal visceral without there's no porovine. So we used the renal vein for the porovine reconstruction and then putting the artery with the conduit and the liver. And after we're perfusing the liver, we're putting intestine back. So this is after the intestine is some back in. This is almost as if we are doing intestinal transplant. So the SMA conduit was anastomosis SMA and SMA was anastomosis to the porovine conduit between renal vein and the liver. So essentially the entire intestinal flow is going back to the liver at this point. So in this case, patient lost the stomach and the pancreas that she's on an insulin pump but now she's in college living in a bone re-productive life. We also did another case like that around the time in also a child and doing really well. And lately after I actually come back from call with really the two cases of fibromeda extensive cases on the teenager. So this is a technique that not necessarily available for small little babies but can be available for teenage cases. So just to summarize what we have done with the 20 cases about the no-calcinoma, 20 of sarcoma, six cases of benign to low grade tumor. And a neuroblastoma was one of the cases that is included in benign to low grade. It's not really benign but because of the chemo response we consider that is a low grade in this series. The procedures are exhibit hepatectomy. There's a liver only procedure, exhibit resection in test node or transplant in 12 with poor procedure and exhibit liver and multivisory exhibit. The case that I showed you in a video is in about seven cases. In three cases open heart procedure under cardiopulmonary bypass was added. Neuroblastoma case was one of them. That she had a tumor in the rate of HM, really big one. So we have to remove that under the open heart surgery. Patient survival, 50% of a coronary alive with median follow up of four years, one, three and five years survival. But it been nine to low grade is 100%. So coma and other noctal cinema are much lower but it's about 50 to 40% and long term survival. I don't have a curve here but a curve seems really flat after five years. So once the five years, landmark is reached, there seems to do really well. Margin status and recurrent free survival, 91% had a margin free and then 20 developed recurrence. It's a very advanced cancer. The XIVO technique doesn't really change the nature of biology of the biology of the malignancy. So recurrence would still happen. But in good news is about this, been nine to low grade tumor that's really 100%. The actually recurrent free survival of low grade was 83 because the neuroblastoma case had a recurrence in a brain but the tumor is removed and she's still fine doing really well. So the currently alive is no recurrence 7.8 years in a 16 patient going into more than 10 years survival. Okay, so here's the graph. So this is the graph of overall survival by pathology. So been nine to low grade is really cure for the disease and other noctal cinema, sarcoma are much lower but it's actually not as bad. And recurrence free survival is in long term is like 30%. Those are including, you know, pancus, adenine and colangio. And just comparing worst case and better cases, maybe I'll just skip this slide. And perioperative mortality, we have two patients died within 30 days and then another two patient died between 30 and 90 days. But most recent case, last 23 cases, there's only one patient, no 30 days mortality and one patient between 30 and 90 days. So the things are getting better on that. There's a lot of complication and still many and links of stay is extremely long. I skipped that length of surgery but median length of surgery, a mean length of surgery is about 17 hours. And I can skip those two. The vascular complication is one of the concern because we do exevo surgery because the organ goes out of the body. So you have to do some vascular and as most as like we do in transplant. So that's the difference between inside two surgery and exevo surgery. So there's a concern on the arterial complication, venous complication, but rate is actually not high. We have had one hepatic artery tombosis and development of partial trombus in hepatic artery. And that was the case that we discovered partial trombus at the time of take back with a closure. So the patient didn't have any consequence so we didn't consider that as a arterial trombosis case because patient didn't have any big problem in the long run as well. So it was not that high. In a mesentric vascular trombosis rate, so it was not that high either. We have lost one case of a semi and a semi trombosis in long term like three years after the transplant case after the exevo case. The patient lost the bowel. We offered a bowel transplant but she decided not to take the bowel transplant and die. So that was caused the mortality and also early hepatic artery trombosis also caused the mortality. So this is serious complication, but rate is still really low and it's not necessarily considered extremely high risk in that sense. So in conclusion, exevo surgery and auto transplantation offer effective removal of otherwise unresectable tumors in our experience. Large malignant tumors with vascular involvement are usually advanced in stage with high rate of recurrence despite our their resection. Long term survival of adenocarcinoma, stochoma, or both 40% or greater, you know, I call it suggesting viability of this approach in selected patients. Furthermore, for benign to low grade malignancy, those are the cases we did it for auto hypertension and the site is mostly because of the vascular trombosis. It appears to offer a cure of the disease and could not otherwise be achieved. So despite the extreme complexity of exevo procedure, this single center series demonstrated that with the appropriate experience, exevo tumor resection and auto transplant can be performed with reasonably low parioperative mortality and say a satisfactory long term survival in selected cases. So I do think this is the case that is, should be in everybody's toolbox, whoever do a liver transplant or intestine transplant, it is still extreme case to be considered extreme case, but I do think the things are already getting better and a more people join at exevo surgery approach, I think so, even further improve, I hope. So I believe this is the end of my talk. I did really go very quick on the exevo talk portion. So I still have some time for question. Hi, Tom, it's a Hongbei. How are you? Hi, great to see you. I wanted everyone to know that Dr. Kato was really, I consider him one of the founding members of our Ritesimal Transplant Program here. He mentioned at the beginning that we visited him in Miami, it was in 2004, by the way. And when we went to visit him, we watched him and Dr. Susakis and their very large team and do a multivistral plus kidneys on an infant. A couple weeks later when I got home, I saw that child on CNN as they were recovering from the operation. But he was not only very gracious during our visit and taught us everything that he could teach us in such a short time, but he also became a mentor, a colleague and friend over the years. And I called him many a night when I had organ offers early in my experience because this is a very unusual program to start and you really need help. And he always picked up the phone and I recall one night we spoke for over an hour in the middle of the night about a donor. So I can say without doubt that we would not have been successful starting our program without his help. So I just wanted to thank you on behalf of our hospital. And I want to tell you another story because when you were sick, during that time, I was actually down in the New York area twice to split livers with Columbia. And the fellow from Columbia was on those procurements. And so we were hearing about what was going on while you were on EGMO in real time, quite scary. And I'm so happy to see you fully recovered and back to work. Sounds like you weren't out of work very long since you were writing manuscripts from your hospital bed. But it's great to see you back to work. Look forward to maybe seeing you sometime at a meeting if we ever get back to meetings. And so I just want everyone to know so how closely linked we are in the intestinal transplant world. I do have one sort of geeky question from the multivisceral transplant and exeval perspective. How do you decide when yet to view our reception is better than doing just a multivisceral transplant? Because as you showed halfway through that operation, you have all the organs out. And if you had a multivisceral graft, you could just put that in. Yeah, that's a good question. I think in a long term, if it's successful, if it is successful, it's better than multivisceral transplant because you don't need immunosuppression. Although this particular patient in some others lost pancreas in a long-term, so is this really better than multivisceral? It's a little questionable, but now is the insulin pump and the technology is actually not that bad. It's a pancreas, is different from a different from a usual diabetes. It's a more profound issue because of the glucagon and all these are missing as well. So they have a tendency to go very brittle and hypoglycemia attack on episode is more frequent. So it's not easy to manage. So maybe that's one developed area, but I don't know how many inflammatory myocipal brastic tumor you've done, but we've seen some regards after transplant in liver transplant cases. And these are really problematic and difficult to handle. So I think not having immunosuppression is definitely better. So in usual sense, in general sense, in long term, it is better. However, to decide on technical feasibility is hard because those are already, you know, vascular involved and technically challenging cases. So in this particular video case, we prepared a farther for potential liver donor in case it fails. And also we've done putting the patient on the multivisceral weighting list before to do surgery. One of the ganglion neuroma cases we've done that approach, how practical it is I don't know though, because if you're just taking it out and making patient into an organ, an hepatic, it's probably impossible to find the organ. But you know, in case that we find something in the middle and like a bleeding, we have to suture it, but it can be rescued by a multivisceral. So some of the cases we do. But in malignant cases, there's no doubt that multivisceral is not gonna work. So as in this is the only solution. Thank you. Tom, this is Steve Fishman. And although we don't have the kind of relationships you and Hungve do, we actually met earlier than you and Hungve do. You may not remember this very early in the experience. When you and Andrea Salkisquake were starting XVV surgery, I had a patient, my career was focused in Vascular Malformation and Vascular tumors. And I had a young boy who lived in, I think back to you, who lived in Dallas actually and had come up for several kind of crazy procedures and he had a very extensive venous malformation of the porta and the dodenum and had the pancreas and all of the central root of the mesentery. And we had done tips procedures and I had, I had caught it and I had done a spleen of renal shunt in the very, very distal part of the splint of fein that was not any of his mom. And when that trauma was predictably a couple years later and the family called me and he was bleeding quite a lot from the duty to him. We had a crazy plan and the dogs and Dallas have contacted you guys and I got a call from Dr. Salkis and he explained to me what you were contemplating. And of course this wasn't a publicly described operation yet. And I said, while that sounds really crazy but it's less crazy than what I was planning to do which I wouldn't even admit to anymore, publicly. And he said to me, well the problem is the family trusts you so much that they will not let me operate unless you agree and come down. And so I said, okay, if you quote them, when you told me that there's a 50% chance of dying on the table because he called me, so it was a thing I looked like because I operated on these meltmases until the time he didn't know what it looked like except he had the scan. So I sent photos of my prior operations and he said, okay, I'll tell them it's a fifth set mortality phase to phase if you'll come down. So I flew down the next day and I had the great honor of watching the two of you do an incredible operation. And I give lots and lots of talks around the world but the picture of you doing the operations always included in my talk, even though it says many years ago. And it sort of goes along with some of the things that we have been taught in our department here that when the problem is too tough and you haven't seen the solution or you haven't seen the problem, you roll up your sleeves and you find the solution. And I watched you do that operation. It was one of the most masterful things I've ever seen because it wasn't just the SMA and the SMV. This means meltformation included all of the proximal branches of the SMV. So you had to on the back table take all those mass out and then so multiple segmental branches of the SMV together to make a single site and then implanted. And it was just extraordinary. And it was one of the most enjoyable and amazing learning experiences I've had in my career to date. So I also thank you for helping us advance our program and ask them out for missions. And when I heard from Humbay initially after he had come back from these experiences doing the liver harvest that you were ill, I was sick of. This is when we were all watching what's happening in New York. And then much later when we heard you were well and then you wrote very publicly about your experience. And for a very, very private, the most private of experiences you made very public. And one of the things you wrote about was experience of having your own colleagues, friends, and trainees care for you when you were in the most compromised situations. Can you talk about a little bit about how that's changed your relationship with those professional colleagues who kept you alive? Yeah. Yeah, thank you very much for sharing that story of that, you know, Vaskamon, my formation, a child, you know. Yeah, that was really incredible sort of the story that you even come down, you know, to do this. I was really nice of you to do that. And the relationship with my colleagues is changed. You know, I'm really eternally grateful to everybody. So, you know, I'm saying to the other time, you know, sometimes I get frustrated and something, but I can't really raise my voice, you know. That's one. And the other thing is though, I just had an incredible, incredible support from my colleagues. And I wrote one of the things that, you know, one of my younger surgeons, attending surgeons and a fellow, they really stayed in my room, you know, spend the night. You know, they were mostly deployed for the COVID assignment. So, they are, you know, in the hospital taking care of the COVID unit. And during the time that they were taking COVID unit, you know, if they're not busy in the unit, they come to my room and then just stay there. And then just slept in the couch, you know, pretty much with me while that time I wasn't able to really sleep at all, like I'm fighting that I may get choked that time. Because if I don't get any like ice chips in my mouth, I feel like I'm going to be choked. So, that was something that it's really incredible. You know, I think that kind of friendship, and I think that it's a great opportunity to be able to do it. And I think that, you know, I think that I really have to replicate, I have to, you know, reciprocate to me to my colleagues. I don't know if anybody was listening in from New York, probably not. But, you know, I really think so that I have to give back to them. You know, I owe a lot to everybody. I think that I was in the hospital, pretty much very know me, but they probably know how bad I was at some point. I was probably fighting and combative. I don't really remember, but those hallucinations, you know, in my dream that I wrote in some of them, probably makes me very combative to the nurses around. I still haven't gone down and asked yet how bad I was. I don't want to do that in some way. But, you know, the people, health care workers are amazing, amazing. You know, they have to take care of the people like that, you know, hallucinating and saying that you may be, you know, killing me. I probably might have done it, might have done it to think that people around me are killing me, I think, because I was in a, you remember, I wrote about the water lubarol. I don't know how it came out to my mind, but where I was in my hallucination. I was in a water lubarol watching Napoleon, you know, defeated. And then for some reason, you know, I'm not really like a, you know, history fan. And the last time I ever come across with water lub is probably when I was high school. And I don't know, somehow it came to me. And the solution that I got arrested by the, you know, coalition army was suspected to be a supporter of Napoleon. I have to gather myself out by calling my lawyer in New York. It's like something really unrealistic in the end. But, you know, during those times, I'm almost sure I was fighting with nurses in the unit, you know, thinking that I was arrested by, you know, these people. I think those, those other things may be uncovered later. But I feel though, you know, I owe a lot. And but the same thing that, you know, we really have to give back. And I have to give back to my patient, as well as to my colleague. Well, you're willing this to share your experience so publicly. It has really touched us all. I've realized it could have been or could be us. And as the entire world has faced this horrible scourge, we've seen so many people, not so many theatrics, but around the world who experience what you do. But to have one of our own world class healthcare providers go through the experience and share it with us has been incredibly powerful. We really owe you a dedicated three-will and this to share the tour of. Thank you. Other questions or comments? I think you're experiencing so moving the personal best. Other than hungmays, single technical questions, difficult for people to ask you specific questions. Obviously, had you given this lecture to us without having had COVID and just on the, you know, ex-fuel surgery experience, we all have our miles dropped open. We want to extraordinary, extraordinary topics. One of your personal fight with COVID and one of your personal sort of life mission to change the way that patients with unsolvable problems can be saved. Much as you were, is to go online to do this really a very special talk. So we thank you for on behalf of our entire hospital. Thank you. And I may want to mention one thing that, you know, the new spread of all so quickly, you know. So the humbe has his first and experience hearing from my colleague, but some other has a different way. So I can, you know, when I woke up, I saw a lot of text messages and emails from all over the world, you know, just really routing me. That was really, really nice and overwhelming the way that, you know, I kind of, you know, sometimes you imagine, you know, when you die, what happened, right? You know, who comes to my funeral, right? It was somebody who was thinking about me when I died and I have to die. And I kind of experienced a little bit about, you know, what happened when I died. So that was really good and a very positive thing that I learned. And it was an incredible, incredible feeling that, you know, people around the world is thinking of me. So I think that's a very, very positive and I really thankful to everybody was that. I don't think maybe I can share a little bit what I wrote and, you know, some of the things I didn't write either, but hallucinations, there's so many things that I remember. You know, the things don't disappear. It's not a dream. A hallucination is something very different from dream. So it's just to stay in you forever and to the detail, you know, to the little, you know, in my mind, I was in the airplane when I got sick, I was coming from some country. We didn't, I didn't name the country name because there was something that I didn't want to, but you can probably imagine what country I was coming from. And then I get sick in the airplane and I got to integrate it in the airplane. But what happened was that I was getting hypoxic and I couldn't really breathe, but nobody in the airplane has a knowledge to interpret. There's no doctors, no nurses. And then finally one girl, in the young girl step up and then, you know, interpret me, but, you know, she was not a nurse. She was not a doctor. She just know how to integrate people from her ex, you know, engagement to this underground world that is infecting those passengers to people in that country. She was one of that group and you know, she interpreted me and then I was having the tube in the end of the trachea tube landing into JFK. And I was moved to area of a quarantine, somehow there's no ventilator. I was having the tube in my mouth, sitting in that tent outside of the colonel hospital. For some reason it was colonel in Columbia. And then one of the colleagues came out and said, hi to me. And I was looking around, there was a lot of sick people around. And I was just telling me that I have to get out of here having in the trachea tube in my mouth. So that's, you know, very interesting hallucination. But there's so many other things that is unreal. And then, you know, it's interesting to remember. But it's, you know, and I asked about other people who got sick and COVID. And a lot of people have the similar idea, similar hallucination. How since it's always like directly, you have been chased or you almost died or you've been killed and that that was nation that happened. So there might be something that direct effect of the COVID to the brain may trigger that type of hallucination obsession. Well, I think the hour is near and people are going to have to drop off. But I think I can say, on behalf of all of us, we are so thrilled that you did not have a funeral. And hopefully your funeral will be many decades from now. But very few of us, I have the opportunity to know. I have that experience that you have had to know how many people care about us and love us. And so I am glad that something good of this came for you personally, as well as all the good you've done for all of your patients and the way you've educated the world about, from a personal and medical perspective, about going through COVID in the most extreme of cases. So thanks for taking your time to join us. And we wish you all the professional success that you've already had to continue exponentially and that your health remain perfect for decades. Thank you again. Thank you. Thank you.
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