Update Course 2013: EA & TEF

Bob, thanks, Todd. Um, this one will be a different approach. Obviously, I, I got the, uh, maybe unenviable task of doing a 7 hour or 2-day global cast presentation in 40 minutes, which we clearly will not get to. Um, we're going to try to move through oesophageal atresia and tracheoesophageal fistula a bit as the audience takes us. We'll be a little bit different. We'll certainly shoot some, uh, polls out there and kind of jump to controversial spots perhaps. And if we stick on one for a while, that's where we'll stick. Todd, blow the whistle when the time comes and we'll just kind of see where we're at with it. I thought we'd start though with just our standard kind of, uh, uh, you know, a clinical beginning. Of how we meet these patients most of the time, I believe you recall the NICU we see a term newborn. Um, we can't pass an NG and the call comes out there's uh some form of background if we step or, uh, if we, Jonah could put on that first poll question. Um, just so that's kind of working in the background while we go through this. But we find, you know, antenatally we have a chance of figuring out if the esophageal atresia is there, but it's one of the ones we're really not that great at. If you get the small stomach polyhydramnios, we're looking that way, but less than half of them we know about beforehand. Um, we worry about other things that are coming up, bacterial possibilities and potentially other prenatal information. But we're gonna basically press on and Mark, maybe you can help me a little bit about thinking when you get that call to this type of kid, what's the thing you're gonna be looking for as the audience answer some of these uh poll questions. I think this is, these are great cases and they're exciting cases. They're they're fun. There's a lot to them. They can be complicated and it surprises me that the workup is so simple, you know, it's almost disconcerting to go in and see a chest X-ray with an NG tube with the proximal pouch and say, hey, here's the diagnosis. I'm going to the OR. And I remember the first time I did it, it was, it was, uh, it was a little disconcerting. So here's our X-ray, which is the one we look at. So, yeah, that, I mean, that's a diagnostic x-ray. Then you have to decide safely how to get to the kid to the OR and, and the way I proceed is, in addition to a Vactral workup, which I think is for the most part, an elective workup, I do want, uh, I, I do want an echocardiogram, um, to rule out an associated congenital heart defect as well as to decide whether it's a right or left aortic arch. Although I approach those the same either way. So, so, uh, that's my initial workup. Then I'll complete the workup on a more elective basis as far as renal ultrasound, x-rays to look for vertebral anomalies and or limb anomalies, uh, and then, uh, evaluation for perip anus and sometimes corrino's triad if, uh, if, if there is a veal association. Good, good. Did we, uh, I don't know if that pole got out or not. Um, Anyone know if we, I don't, see if we've got it up or something. Um, we're just waiting on results. OK, cool. I keep jumping a little on the, uh, my, And then there's, uh, you know, preoperative workup and then there's intraoperative workup as well. There's one other, you know, I'm a, I'm a fan of bronchoscopy. Perfect. So, we'll, and that would be a, a second pull that coming up. I don't know if any of the group over on the table have any burning things that they like to get on these routine. Thanks. Um, patients that are coming in, uh, with looking like a typical TEF that we would see. Uh, we have our x-ray. We look at that. Are there further things? Does everybody, uh, in the group here get an echo before they go, want that before that happens? Anesthesia will insist on it. Yeah. Yeah, I think, I think knowing which side the aortic arch is on is important as for the surgeon. Now, at the granted, there's a very small number on, uh, you know, the, um, right side, uh, uh, but I think it's important to know. I agree. And the question would be, of course, what, what follows from that. If you get the right sided arch, Where does that take you? Do you change your approach? Do you go to the other side? That's, I'd love to hear what each group's as, as, as everyone encountered that and found that. Well, Tim, I know that I remember at the DC course a couple few weeks ago, uh, Alfred Shaheen or someone I think presented that. There, there is no benefit. Or what was the, the, do you remember about getting an echo and there was a lot of debate about that? Yeah, but I, yeah, I, I would get an echo absolutely. But I think since they, they often, uh, mis, you know, misrepresent what side the arch is on sometimes doesn't, doesn't help you. My, my first one out of fellowship, they said it was a right sided arch, so I went in the left side and found an arch. So I went to the other side and found an arch there. It was a double arch, you know, and you just kind of have to. That is bad luck. When out, Todd, where was it you or when we were at Rainbow or whatever, we had a called on the opposite side, but we went in on the side and the arch was right sided. The technical difficulty of the case. It was a little harder but quite doable. Um, so I guess my question is, has anyone done it on that side and feel comfortable pressing on? Do you, do you really change? We are taught to if we have the right side arch, we go to the left side. I think if in looking at anecdotal stuff, talking to people that have, have done it, including myself, it isn't. Super difficult to do, um, and it may not change things because it's not simple to do actually always from the left side. So rapid global thoughts. So, so you want to say rapid fire if you have a uh uh a right sided arch. Will you go in the left side or right side, right sided arch, left, will you go on the left or the right? I'd stay on the right. I'd stay on the right and it depends on the proximal pouch. If you can get it down, uh, it's usually under the arch. If you can get it down enough, you'd stay there. OK, Dan. Yeah, my experience is the same as yours. I've had one where it was called on the, on the left, found it on the right and did the repair anyway. On the right. Danielle, stay right. Stay right, Peter. I'd probably go left. my end of one. OK. And it worked out. It worked out. OK. Let's stay right. That's where my experience is and my confidence, and, uh, it's important. Yeah, I think that also the. So, these are fun cause, you know, we're all said go left and. Well, I can tell you right. A lot of you guys have a lot more experience with this, the right marches than I do. I'd go left. Hey, how about a poll though on bronchoscopy for, uh, preoperatively before you start. Uh, can we pop that one up? Yeah. Uh, it's, it's up. It's actually. Where are we at on the number on that? It'll probably take a minute to get Almost everyone says no. Almost everyone says no. Wow. Very interesting. How about a, let's do a shot through the crowd here on that one. Can you guys is the question. Do a loop. Um, bronchoscopy, yes or no? Uh, yes, uh, in part for training of fellows. Yes, same reason also I want to know where the fistula is. We brought them all. I brought them and I have picked up a double fistula. Um-hum. I brought them all as well. I brought it. Yeah. Uh uh Interesting. I think, uh, I, I think you ought to do a bronchoscopy if you're going to do a thoracoscopic operation because I think it allows you as the surgeon to try to have a better understanding of where the fistula is going to be. I don't do it as much to see if there's a double fistula as much as, uh, if the fistula's in the, uh, mid trachea, you feel fairly confident that the ends are going to be closer together. If it's more at the corona, you ought to realize it's gonna be farther apart and it might be more difficult, uh, and I think that in our country there's a lot of, um, uh, resident training involved and so I think that's a good reason too. But for me it helps me as a surgeon think about where the fistula is gonna be. I feel much comfortable doing it. Do we have, um, actually, well, I'm gonna look at the counts for a second, but then Yama, are you there? Yama. We'll get him in a minute. He's on the phone. All right, here he comes, Yama. Yes, can you hear me? Yeah, we can hear you. What time is it there in Japan? Yeah, what time, uh, good question, 11:30 p.m. Thanks for staying up with us. What do you do? Do you routinely bronc? Yeah, I do a bronchoscopy because in, I feel intronchoscopic era, bronchoscopy, bronchoscopy is very important to check the gap. For example, if the fistula orifice between the right and left bronchus, I may not do a thoracoscopic approach because the gap can be very long. Depend on the, you know, position of the proximal pouch. Hmm. OK. All right. Let's move on, Bob. Perfect. So, um, again, that kind of brings us on this to the, uh, another fork in the road, of course, which we alluded to a little bit a minute ago, between going with the, the open procedure versus minimally invasive procedure. And certainly putting up on the, um, screen, uh, uh, a pole for this would be great. So, I think that's number, uh, number 3. Um, I'd like to, uh, as that poll runs and, and, uh, with, I'll be with you at some point. We're talking about your thoughts, minimally invasive repair, how you kind of structure that. Um, but with the open procedure, um, we, we talked a few pieces about it. Mark, maybe you could just, Pop through some of these bullets and then I'll probably go to the table just to see if there's any parts of these that you guys agree with or disagree with looking at this as kind of the standard approach and what do we do. Sure, I think we talked about the 1st 11 side with the arch. Uh, yes, muscle sparing, right posterior lateral tracotomy in most cases, uh, extra pleural approach, uh, carried down to the vertebral bodies. Uh, identification of landmarks, it's important with the zygous coming across. Uh, that gives me a pretty good indication where my fistula is in most cases, and that's where I'll have anesthesia advance a regal tube to try to visualize that, that, uh, bulging proximal pouch. Uh, after division of the zygous and mobilization of the, of the, uh, the fistula and division, uh, I'll usually use a PDS suture, a fine PDS, uh, for hopefully a tension free anastomosis. Generally on an, on an uncomplicated, um. esophageal res, I do not put tissue in her position. I never can really find a lot of tissue to put there. I do put a small chest tube in that I tack with a chromic in that extra pleural space that I leave to. Water seal, not to direct suction. Great. Um, pull up, did that come up? Jonah, do we have those results? I don't see the results. Can you put the result? The results? Yeah, um. Yeah, 14 of 19 people said open. So the majority are saying open, not tho arthroscopic. OK. And, uh, the majority of people will go in the right side. All right, great. Um, I'd love to just out of curiosity, do, uh, number 5 if you could, which is the suture material. Uh, I know. So Mark, if you could just send me the poll results, then I can read them off. That'd be great in a percentage instead of, uh, direct numbers. So it sounds like, uh, uh, the majority of people still do open, um, TEF repairs. And then if we look at the, uh, suture material, there's a pull out for that if we could, and I'll, uh, and looking at it, there's three types of things. Is it someone using just Vicro? Do they use kind of a medium, uh, the Maxon in the US PDS type things or a permanent suture? And, and let's do a kind of a, again, a room walk of what are people thinking, what they use. I use like a Ivo Vicryl TF. BDS? Vicryl. Monocryl and I've used Vicryl as well. PDS. I'm a PDS. I actually use silk. Yeah. But I will tell you that we had a, we had a, we had a, uh, uh, but, uh, cause in many ways if you're doing it thoracoscopically, the silk, at least for me, is a lot easier to tie. Um. But we did a study a few years ago, retrospective study around 100 patients, uh, looking at complications with Viryl versus silk, and the, uh, the results were there was no difference in complications whichever suture material you use. So, it's a surgeon preference. So, uh, so, thoracoscopically, it depends on, I'll use either a Vicro or a PDS, but it depends on how I'm doing my stitch. So, the first stitch that I do, I do with a knot pusher, so I can watch the two ends come together. You have to use a PDS when doing that. If you use a Vicro when doing that, you'll likely saw right through the tissue. So the first stitch, I'll use a PDS if I'm, if I'm not pushing it. If I just do it all intracorporeal, I'll use Vicro the whole way through. Excellent. And anything up on the, from around the world? Do we hear, uh, any thoughts of what people are using? I'm still waiting for results on that, so. Good. Keep going. Yeah. Um, we can try, as we get the results, we, you know, if we need to, um, keep, uh, uh, going, we, we don't have to hit all these, uh, um, particular poles. But, uh, clearly the ones that are, the other pieces that, is the chest tube question are people putting those in, uh, uh, routinely on all of their, on all of their cases. Let's do a quick walk around. Yes. Yes. Yep. Yes. Yes. And I take it those come out to you guys, do a post op contrast study universally? Yes, yes. And we're still doing that and pull the tube following that? So, still kind of our traditional teaching seems to be hanging in there with, uh, with, uh, most of this stuff. I guess the only thing we've really bounced onto was that the right sided arch doesn't immediately push you to the left from the kind of classic teaching scenario that we get. So, if we, if we, Move from that then on to the minimally invasive type repair. And, um, wait here, I'll probably defer to you to kind of look at these questions here and see what are the things that you are in your work and, and, uh, and, and data that you feel, you know, address these types of issues. Well, I think it's certainly, uh, safe, uh, in experienced surgeon's hands. Uh, I, I personally think there's, is, uh, a fair bit of efficacy, uh, and advantages of using it if you can do it. Um, uh, I think that, uh, I don't think every patient's a candidate for it. Um, you've got down here heart disease. It sort of depends on what the heart disease is, but a complicated heart disease may not be a good case for, uh, a thoracoscopic repair. As a general statement, they take longer to do and I think they're, you, you need to make sure the patient is stable enough, uh, uh, cardiovascularly, you know, to, uh, undergo the operation. Um, it, um, I, I think, um, uh, we'll go over the port locations at, uh, at, uh, some point. But I, I do think about 75% of the patients end up being a good candidate. But I would be the first to tell you if you can't get the two ends together, if you're having any trouble, then you ought to, uh, convert to the, uh, open operation. There's nothing wrong with that. I think, As a general statement, we get one shot at doing this operation, so we ought to do it in the best way that the surgeon can. I think it's a great point. Uh, it really is a one shot operation. We should look at it that way cause the issues of complications are significant. So, Uh, I think the data, there's a list here, and I should put a plug in for the European Journal of Pediatric Surgery, I think it was Volume 23, May or something, had a wonderful, uh, whole sequence of articles regarding oesophageal resia and TF repair, looking at the literature over the past half, you know, a dozen or more years. The data that's shown up here is looking at the more, most, more recent studies. And even as we get closer and closer to today's date, uh, there's very little, uh, difference between the open and, uh, and repair, uh, and the thoracoscopic repair when we look at these studies. But you've been garnering lots of experience over time and it's, you know, what's your gut sense? When do you, uh, know, say 75% of the time you're gonna be able to do it preoperatively, perhaps it's the cardiac stuff, the flags that make you go, mm. Uh, this isn't where we want to be. We need, we need to get out. Yeah, it's kind of interesting. Early in our experience, we started doing these in 2001 and we had a lot of good success early on. Um, and it seems like lately we've had a lot of complicated problem. It went that way cause then you, yeah. Well, it seems like the gaps have been longer. Uh, to me it's, uh, it's the gap distance. Uh, and, um, if you just, you know, if you, uh, if you've done enough of them, you can, after you divide the fistula, you can figure out if you're going to be able to get the two ends together. Uh, but even if you think you're going to be able to get the two ends together thoracoscopically and you can't, then I would open and try to, uh, manage it open. Um, Uh, somebody like, you know, Steve Rothenberg's a very good friend of mine and he's a master surgeon. He may be able to get, uh, longer gaps together, but I think most pediatric surgeons will have difficulty with it. And so, I, I would, uh, uh, caution you to go on and convert if you're having trouble getting the two ends together. It is interesting on some of the data and the, uh, particular studies more in the 2008, 2010 frame showed a better strict, Your rate actually with the thoracoscopic approach, then it's, it's evened out in the more recent ones. Anyone else on the panel have a, have flags that just say, I'm doing this open? Or even as you start a case, what are the things that push you to, to shift over? Yeah, I would say the size of the baby. If the baby's small, it's going to be a little more difficult, um, to get the lung out of the way. And, and, and what's right, when you first look in there, it's that proximal pouch. That's the difficulty in getting that down. And size is like. If they're under 2 kg. You can do it, but it, those are a little more difficult because if you don't do a lot of incorporeal sewing, that's, that could be a lot harder cause there's not as much space. I think one of the issues in our country is how do we train surgeons to do this, uh, operation. Internationally in some travels that I've, Done, it seems to be that most of the attendees are actually doing these operations and having a good success with it, but in our, uh, centers we're trying to train, uh, fellows to do the operations and so, you know, you have 2 or 3 fellows that you're training and, you know, a typical center might have 8 or 10 or 12 esophageal atresias and so it may, it may divide up to 4 or 5 or maybe 6, sometimes 8 for a fellow when they finish. Is that a. Is that a good number to train them thoracoscopically and also you're training fellows every other year and so there's no continuity. The staff is the continuity. uh, so anyway, I think there are a lot of factors involved with training the residents and the fellows and doing these operations. I think you could, you could apply that same argument to the attendings because, you know, Maury Ziegler's data is that the average attending does 1 or 2 TEFs a year. And, and I think it's a, it's a challenge if you say you get one good shot at doing the operation to to learn these kinds of techniques that are really advanced laparothoracoscopic techniques and not do it at the expense of the patients. No, I agree that in our country, I think each attending has a very limited experience with it compared to our colleagues in South America or in Europe who are primarily doing them themselves and. And uh they might be be uh seeing a lot more uh of the so I think it's a very valid point. I don't have a good answer for it, but it's a very good point. How about the other pieces here on, uh, just for you, I guess, the port locations and all, when you're going in. Yeah, you try to get the ports, uh, spaced as widely as you can. Uh, in a small baby, it can be, be very difficult. I try to stagger them, uh, a little bit so they're not in the same line. You want to make sure that the baby is more prone than lateral, uh, because the esophagus as opposed to your mediastinal structure. Uh, and so you just try to space them out and get, um, Uh, space them so that you have ergonomically, it's easier to sew. Excellent. I, I actually generally oftentimes need 4 ports. The standard port loca the standard number of ports is 31 thing I'll mention is that we've, uh, we're a training center not only for pediatric surgery but for, uh, anesthesiologists as well. And so, you know, they're trying to train their anesthesia residents and so we've had, uh, some trouble with that with the lung becoming inflated. And problems and so we have gone to, uh, using the high frequency oscillating ventilator, uh, in the operating room. The disadvantage is the baby shaking. The advantage is the lung stays collapsed. And so once you get used to the shaking, um, the operation actually is a lot, a lot easier to do because you're not worried about hypercarpy and, and problems like that now as a general statement, yeah, we are, we're bringing the oscillator down to the, uh, operating room. Todd, how are we with the, the, the international faculty that we have? Are they all online or something? So that's who's online on the phone right now. I'd love to have, uh, I'm thinking on the thoracoscopic looking down South America. Maybe Marcello, you know, chip in any thoughts on this, this particular slide and your feelings. Marcello's a master surgeon, so, uh, so is Yama, and I'd be interested to know, yeah, if each of you guys could toss in your thoughts, we'd love to hear it out here. Marcello. Well, I think that today one of the big advantages that we have is that we have all these training models that I saw just last IPEC meeting in Beijing. There was a doctor from Argentina who actually brought an amazing, very low cost training model, and then you have the different models from other surgeons from the United States and from Europe that you can train your surgeons with. So that will help if you have low volume, and I think that is a big advantage, one of the big advantages of having a society as IPEC, which is always a society that is always looking for a way to train the surgeons. Then on the other hand, I can't tell what is to open esophiatricia because it's more than 10 years now that I've been doing them thoracoscopically and and so I think it's the way to go and And, uh, I feel so comfortable when, when I'm, when I'm in the thorax of a, of a neonate. And I, I don't see any, any other way of doing it, uh, but again, uh, I, before I started doing thoracoscopic esophageal, I already had, like, almost 150 done open. So for me it was almost natural to start doing it thoracoscopically. Then, besides the technical details, I think that you've you've said most of the things. I think we are almost all, everybody's doing. The same things, maybe some different ways of just clipping the fistula. I use wet clips that are very fast and reliable, but besides that, I think that we are almost all doing the same things. Marcello, do you have um any time you tend to go open at all now, or are you doing all of them thoracoscopically? No, we are doing them all sarcoscopically. It's where we feel so comfortable. Uh, I, I, I, I don't remember doing any other, any, maybe just when, for example, some very, very difficult cases where you have to, uh, come back by third time because of, and then you find many additions of the lung to the wall, and then you can't find, uh, The, the, the correct place where to put your CO2 or your truckers, then you may have to open, but those are extreme cases, like maybe some patients that we already, that they, they, after anastomosis, you have like a leak in a in a fistula between the esophagus and the bronchi or a red fistulization, maybe those cases, but, but the regular cases we do them all open. That's scopic and, uh, just 222 comments. First of all, just some follow up on your polling. Um, what's your guess on what percentage of the population of our viewing audience does thoracoscopic TEF repairs? I think it's like, I'm guessing it's more US centric and would be more 60% open versus thoracoscopic. So it's 35% thoracoscopic, 60% open. Good guess. Good, very good. I didn't even see it. And then, um, but I think it'll be different if we. Did it if we talked to Marcel, obviously. And actually to Dan, it goes back to your point of, you know, 10 years, you know, hundreds of TE apps, it's, it's, it's just like us, it sounds silly with the yay, but anything we do and you realize you've done it a while, it's a different operation. That far out and it's how do we get the skill set to that point and uh, can I just add, you know, one of, one of the things just for our, the US based folks is, um, Cathy Barsson at Northwestern has really developed a, a very nice model of the TEF that's in, um, uh, does not rely on a living, um, uh, tissue, it's a bovine, uh, uh, fetal tissue, and so we, we just, uh, some of us from this group were gathered two weeks ago to teach the fellows from the United States and Canada. And uh that model's being going to be rolled out and applied at ABSA and and perhaps at IPEG and other meetings going forwards as well. Did you use it at the, and we did, we used it to train the uh 30 or something, so, uh, senior fellows from around the, around the country, and, uh, the feedback's been very good and so I think that increasingly we as a field will need to continue to support and develop these models to account for the rare, and that's perhaps the future of our training for, for this. Yama, maybe uh, any, uh, any thoughts on your, your side of the problem. Yeah, my, my, my comment is that, uh, you know, when we use the thoracoscopic treatment for treasure, you know, I feel that approach is very, very gentle for lungs, so postoperative management easier because of probably, uh, you know. Very gentle for lungs intraoperatively. Also less pain, so extubation is smooth, and that's why, you know, I like thrust approach for such a treasure. But my question is, where do you start the first suture suture? The lateral or midline, I want to ask all of you. Uh, where do you start suturing? The far, far suturing. You want to walk through the crowd? You want to come up, come up the table, uh, lateral. Yeah, I start lateral or the middle stitch, whichever one comes easy. Same. Same. Same. Open lateral. OK, so another question is, I, I, I, I'll put in the back row in the middle, the, the back row stitch, the middle, exactly the middle one, the back row, and then that, that knot I will tie it inside. All the back row, I, I tie the knots inside, and then, and then I pass the trans anastomotic feeding tube because it will help me to give volume to the suture. And so all the, all the front row, I will tie it, the, the knots will be out of, of the lumen of the esophagus. And because I have the trans anastomotic feeding tube, that will help me to pass the, the, the, when I pass the, the, the needle, it's easier. I can, I can use the wall of the, of the, Of the tube to help my needle to go exactly where I want, is that what you wanted to know, Jama Mariel, another question is what kind of, what size of the needle do you use? What size of because needles are very, very, especially for, you know, small babies. Yes, that's a very important question. The needle is very important and the suture too. We use PDS 50 PDS, but the needle has to be a C1, C1. Yes, I agree. Yes, that's, that's a very good needle because it has a very good curve and also will get through the 5. Actually, I use a 6 millimeter trucker in my right hand, so it will go through the trucker without any problem and without damaging the tip of the needle. Marcello, can I very well, can I ask you, I just want to clarify because I use a TF needle and I want to understand, is a C1, the CF is also very good. It's smaller. It's very good. OK, I just don't know because at different companies the names of the needles are different, so we just want, I wanted to clarify that. Um, the other thing is that the first stitch, um, that I'll put in doesn't necessarily need to be a tight stitch. Um, I'll put it in, I'll stop when it looks like it's under stretch, and then my subsequent stitches are the ones that I tie down tight, and, and, uh. Um, you know, it depends. If they're coming in together easily, that first stitch will be tight, but not always. Always. One thing we did in our early experience was put the first stitch in and then exteriorize that stitch to help bring the gap closer and then put in the next stitch and tied that down. So, that's a technique that you can, uh, sometimes, through a trochar or through the chest wall? Chest wall, yeah. And you had a, you had a hemostat on it that you could make it, try to bring the edges tighter if you wanted to. Yeah. What's that, Marcello? I think that Jama just published that and he said it's a very good trick. He calls them stay sutures. Jama, I thought it was your idea. That was Mark Walken, I think. No, Todd, yes, yes, I have a question. Yeah, when you, when you divide the fistula, do you divide all all? Because I don't divide, you know, fishes completely when I studied anastomos. I divide 3/4. To keep the that's interesting. Yeah, I've never tried that. It is easier. It's a great easier for. So why don't you make a video and send it in? We want to see that. That is a kind of secret so. Another question, another question for long gap. How far do you, all of you dissect the distal esophagus? Do you dissect very, very distally or just a minimal dissection? Even for long gaps. Let me I don't, I, I, I, I don't want to dissect the distal tissue of, you know, you know, entirely because, uh, less, uh, you know, traumatic and less blood supply. I want to keep a distal, I want to keep the blood supply of the distal. Very good. Yeah, we'll take that. I'm going to jump us too long gap now. And just hang on that because we're we'll bring that up as we walk through it and so just so you know, yeah, the poll, yeah, we're already 10 minutes over, so I, I knew this would happen to esophageal resia and just so everyone knows we're going to be doing multiple of these events and we'll probably do part 2, part 3, part 4 of oesophageal atresia, but we'll get as much as we can in the next couple of minutes. Do you want to jump to the long gap then, see where we're why don't you, you have probably 3 minutes left. We can cover all those the esophageal replacements and I think the MOC questions you're just going to have to guess because we're probably the, the, um, you'll be pretty good figuring those out. What are the key points that you think are going to be most debated. Let's fly through bam, bam, bam, and let's see what people say. I think it's the, with the, the, the long gap. Piece things are, you know, what do you do to work these, uh, patients up? How do you determine, how do you even define what a long gap is and what do you do to figure out what they are preoperatively? Are there any tricks, uh, uh, uh, that you use or what do you, uh, make to make that, make that definition? Um, anyone want to jump in on something when they're looking at a long gap? Dan, Dan's got a lot of experience. I would love to hear it. Dan, thank you, you see a kid, we see our, our kid is gonna be, um, this X-ray. You know, our gasless abdomen, little thing up at the, up at the top, and, uh, we're thinking it's a long ga atresia, you know, what do we do with this lineup of questions here. We still take a pretty standard approach to that, and, uh, we would assess the gap, uh, with the, with the G tube in place. You can assess the gap and typically if it's within two vertebral bodies, we would go, we would do a primary closure. So, the trick basically then would be, you're, you're assuming it's a, it's a long gap with seeing your x-ray like that. You'll go get a G tube in, and that's the first sequence and then study from having the G tube in place. Correct. And Contrast only or you put a scope through your stomy site? We actually do them in our, uh, we have really good interventional radiologists and we do it there with their assistance with both of us in the room, and we can pass catheter, a wire up to make sure you're up the distal esophagus and then, uh, uh, wire, um, catheters over the wire and then an injection to make sure that you know what's, uh, uh, where the GE junction is and how, because you can push on them. You know, you get different answers depending on how hard I mean that's what you put in there and how hard you push it to find it. Exactly. Right. So, the issue is, at what point are you, do you think you're going to be able to take that child to the operating room and get the two ends together so that they'll stay together. Yeah, I find it's, you can get most, uh, even the, even the pretty, uh, the 160 scopes off through the 12, a little slightly dilated 12 G tube, you can get right up and take yourself right up the lower esophagus and try to push that a little. Or then try to bring something down from the top, perhaps. The cervical esophagostomy issue, anybody do those? Is that still I think you, uh, I think unless if you do that you're committed really to a replacement, uh, or a substitution. So I think we have a couple, I think most, most people today would try to get the two ends together within a, you know, reasonable, um, attempts and then you might go to the cervical esophagoscopy. I think that would be the modern thinking about, uh, About management of the long gap. Yeah, and anyone routinely going to cervical esophagostomy, uh, most probably would not. Want to hit on, um, management of recurrent TDFs, maybe? We sure can. Let's just do that as the ending thing. Only on the sense of that just before we drop the long after there are the, the, the, the split trees are, is the whole definition between primary anastomosis attempts, you know, which when we're looking at are the, you know, the focal or delayed primary anastomosis kind of things, which is certainly something we could, um, spend time on in another thing or you make that shift of going to esophageal replacements and whether you're going to make that decision. Um, just curious before we make that jump, who here? I guess your initial, you know, your gut sense is, are you thinking replacement when you see a long gap atresia when I say, you know, a long gap atresia, I mean, uh, kids that will have, um, you know, uh, X-rays, and I don't know if you have the XR one here where you have a very small, um. Uh, Distal thing. I'm trying to see if I got the thing in here somewhere. The next one, you know, a very small distal esophagus. Uh, like this. Are you, are in a shot like this, is this a kid that's getting a replacement? Or do you feel you can do some form of a primary anastomosis, looking around the table? Start from the, you always get stuck, Jose. Uh, I, I ask the most junior person. Uh, this would probably be a, a replacement, I would be thinking. Yeah, my hands, I, I, this way I wouldn't get together. I'd do a replacement. We, I would always wait and try to see if I could get that to grow and get it. So, you'll do the concept of three months, say, up to three months. Yep. And. Uh delay, and then look for a delayed primary, see what you can do. I, I don't necessarily believe that if you bougie it once a week or something, that that's actually going to make it grow. I think it grows on its own and you wait and we would wait and see if we could get it together. And to clarify before we get to Danielle, also, you would not do a Folker? Before. Not up front, no. OK. Yeah. This kid, I, this small of a, an esophagus, I would try and get them up onto bolus G2 feeds and hope I get a little there. And I also would give time. I'd give several months, and I, I don't bougie the, uh, proximal esophagus either. But my hope is that they'll grow and, and some of them do and some of them don't. Yeah. Yeah, I, I think until we have a, a, a much better replacement, uh, for the esophagus, I, I, I would try everything I can, even waiting a long time, as long as the parents can bear with us, uh, to try to get it together somehow, and, um, uh, but, you know, obviously you'll always want to prepare them for that possibility that a replacement will event might eventually need to be done, but so and then you, but this was actually a kit I did a poker on and came together, but it required. Uh, you know, fundal placation had a strictureplasty. I mean, it was a long ride, but it's a long ride, plus or minus. Sometimes they work great. Actually, in your hands, I've seen better results than I've seen other times. So it may depend on technique. But certainly I've seen good results, some not perfect, but good. So let me try to summarize what we've done in esophageal resia so far. I think we've learned that what are the key points that we've learned, I, I, the first point I remember is Yama's point about maybe leaving it mostly somewhat still attached to the fistula as a little traction point to do your first stitch. I like that. It seems like it's divided. People use, um, uh, early absorbable versus delayed absorbable, PDS versus, uh, vicro. It seems that the majority of people still do open, about 60%, um. Uh, it seems that the majority of people don't do a folker, at least that we've asked in this studio. We could certainly pull the audience, uh, Jonah, uh, put that out there. Um, what are the other key points that we've walked away with? I know we're not gonna get to everything. Was there anything else I left out? Not that we still, we tend to always go through the right side, where, where. Oh, yeah the arch is. So, you don't always have to go through the left side if you have a right sided arch. Um, and so, I think if there's any other, just my good plug for a nice long global cast on esophageal atresia management so. Yeah. Well, you know, we've done one already.