Introduction and Panel Discussion: EA & TEF

With, I want to get everyone's uh uh uh ideas and thoughts here on the basics of oesophageal atresia. So most of today is going to be about what do we do in the complicated situations, but before we get there. We need help from this faculty to teach us how do we avoid those situations. What are some, some tricks, some pearls, and what are the pitfalls that we can avoid when doing a very straightforward, simple, simple, uh, type C esophageal atresia. So, um, Doctor Corn, let me, let me start off by asking you, so first of all, You make a muscle sparing incision? Yes, OK, um, and is there anyone here that doesn't do a muscle sparing incision in a, in an open, if they're doing an open TE fistul repair? OK, so silence to me means that I think that probably most people do a muscle sparing incision. You get in. Um, I don't want to go too far into the operation, but if there's anything I'm passing, stop me. But let me get to the point where you're inside the chest. Let's say you've moved the pleural away. You've dissected the pleural. Do do you use Q-tips, or do you, I think the first question is, do you use, if you're doing it open, do you use a trans pleural or an extra pleural approach, and does it make any difference? And I, you know, when I was initially training, we did it trans plural, and then there was a lot of discussion about doing it extra plural, feeling that that was safer, um, because decreasing the risk of mediastinitis and other issues if you used an extra plural approach. So Doctor Corn, I just wondered. Which technique you use? Uh, I always use a retropleural approach, but I'll be, I completely agree with you that it probably, in this day and age makes no difference. You realize the first case that Cameron Haight did successfully in 1941, he actually went through the left chest, Resected a rib and we stayed uh extra plural because there were no antibiotics at that time, if there was a leak, uh, and that whole area, of course, is uh, way, way past our current uh uh knowledge and technology, so. I think it makes no difference. I just like to do it because that's the way I've always done it, but I agree with you completely. Trans plural or retro plural in this day and age are equivalent. I think the biggest thing about an extra plural approach is I think it makes it a little bit easier to get the exposure because if you're going trans plural, then you have the lobes are separate and so it's hard to have one retractor that that will keep all three lobes out of your way as you're doing the repairs. So to me that's the biggest advantage of doing an extra plural. And when people say and some of the criticisms of doing a thoracoscopic approach have been that um where you go trans plural and and and so, but that becomes a non-issue when you do it thoracoscopically because you have lung collapse and you don't need to retract the lungs. So but I I would agree. I think if you're doing it open, it probably doesn't make any difference anymore in terms of sepsis and things like that. I think it's purely a matter of exposure. It looks like 90% of the audience does it extra plural. Louis, what do you do still? I think it is more elegant to do it extra plurally, but I don't think it makes any difference, and some of the time you start extra plurally and a rent is made in the pleura. So I don't think it's 100% either way. OK, um, if anyone else wants to make a comment, otherwise, we're gonna move on to the next part, which is, um, you get into the chest, you start off by, uh, dividing the, the azygus, um, starting your dissection. Tell me about the part that always gives me the most angst. is dissecting the proximal pouch off of the membranous trachea. Um, I know that from a thoracoscopic approach, Marcelo Martinez Ferro, who will be here, he's got called to an emergency in the operating room, but he has a cool trick where he sort of Spaghetti coils up the proximal pouch to really see thoracoscopically that space between the two. Any tricks on how to avoid, how much dissection do you do, minimal, maximal? How do you avoid an injury to the trachea? Uh, what I always do with, uh, any standard repair is have a, the reploal tube in the upper pouch. I. I have the anesthesiologist push down on it so I can see the tip of it sort of beginning to shine through the tip of the upper pouch, and I put a little stitch through the tip of the upper pouch and through the tube. Um-hum. So that you use that stitch for traction, but the traction's not on the esophagus, but it's really on the plastic tube. And I think that then allows you to pull that, uh, suture laterally. And you see that plane between the membranous trachea and the uh medial wall of the upper pouch, and the name of the game is, if you're not sure where you are, err on the side of cutting a little muscle, not to, uh, don't try to get too close to the membranous trachea. And I think with that technique, 99% of the time you'll be safe. I like to dissect the whole pouch all the way up. I know there's some, uh, surgeons, especially thoracoscopic surgeons that feel if you dissect all the way up, you affect the, uh, vagal branches and that affects the contraction of the esophagus. I'm not sure I believe that. Uh, and then once I've dissected that all the way up, I go down to the lower pouch. I don't know if you want to wait. To discuss what we do with the lower pouch, but, no, go ahead. So talk to us, I think one of the misconceptions in my mind, yeah, go ahead, Jack. Yeah, so Siggy Ein, who was one of my teachers, uh, always said you have to go all the way up on the proximal pouch. But the main reason that he said that was because in case there's a proximal fistula, that's how you'll discover it. If you don't go all the way up, you may miss a proximal fistula. And I just wanted to make the point that Yeah, you started with the operation, but I think, uh, it's important to do bronchoscopy on, on every one of these kids before you start the operation to determine if there is a proximal fistula or not. Yeah, great point. Um, I'm gonna put a poll up right now. Uh, I'm writing bronchoscopy, yes, no, or depends. Uh, and I'm curious what people, uh, do here. What about the two of you? And then I'd like to ask the, uh, faculty, anyone chime in. Um, but, but Doctor Corn, do you do a bronch, I agree with Jack completely. You want to rule out, uh, an upper pouch, and I know in this day and age, most people are doing it with bronchoscopy. I have, unfortunately seen some cases where a bron bronchoscopy was done by an experienced pediatric surgeon and it was, Med. I actually still use, uh, a water soluble dye into the upper pouch done by a good pediatric radiologist because I think if it's done right, it's very, very accurate in picking up the upper pouch because not only will you see the, uh, dye going into the trachea. But if there's an upper pouch in utero, that pouch does not get as big as, when, as the case where there's no upper pouch. So, if you see an upper pouch that is sort of narrow, narrower than you expect, that should make you suspicious for an upper pouch fistula. And the upper pouch fistula, I think Jack brought this up, and it's very important, is far more common than we realize. And a number of cases that have been called pure long gap esophageal atresia are actually cases with an upper pouch fistula, and that can be a problem when you're doing the operation. OK. Steve, do you do? I don't do it routinely. I think the biggest issue I think in doing these kids is getting control of that proximal fistula before the baby decompensates. And so the number of I've seen one proximal fistula in 20 years that we've had to deal with and so. Unless I have some suspicion, we basically go straight to thoracotomy or now thoracoscopy and get control. I've seen it was in training, but I've seen periods where while screwing around with the bronchoscopy, the baby decompensates, and then the important part of the operation, the most urgent part part of the operation, which I think is getting control of the fistula, becomes more of a flail rather than a controlled process. And so I don't routinely do it. I haven't been burned yet, but. Um, you know, perhaps, uh, someday I will. Can I make one point about, uh, an upper pouch fistula and being in the chest and not knowing it? When you start dissecting, uh, the plane between the, uh, medial, uh, wall of the upper pouch, uh, of the esophagus and the membranous trachea, and you do that very carefully and very often bluntly for a good part of it, you can push the upper pouch fistula out of the way. Don't forget, they sit really in the, in the area between the cervical esophagus and the upper thoracic esophagus. Sometimes, as you're dissecting along, and I like to use a little Q-tip to dissect up there, you can actually push it out of the way and not even know it's there. And that's why, as Jack mentioned, it's so important. Thank you. To know you've got one ahead of time. I have seen at least three patients who, uh, were referred because of what was called a recurrent tracheoesophageal fistula. Uh, by very experienced pediatric surgeons, where the fistula was not a recurrent one, it was a missed upper pouch fistula. In a way, that's good because they're easier to deal with. But that can easily happen in the hands of the most experienced pediatric surgeon. Um, Holger, welcome. Can you hear us? I hear you very well. Can you guys hear me well? Yes, and welcome from your new, uh, from your new job. Congratulations. Thank you very much. What's your thoughts on this, Olga? Pardon? What are your thoughts on the whole discussion of doing Bronx? Do you guys do Bronx there? Well, I'm trained to do them, and I do understand the whole discussion that we, um, let's say if there is an incidence of an additional upper fistula of about 5 to 8%, that means that we bronk about 95% of patients without any sense and any benefit. Also, I think there are a couple of nice papers around teaching us some lessons. For example, Bach showed That the shorter the upper pouch is, the more likely it is to have a fistula, which is tagging it up there. So maybe it is wise not to bronk every patient, but to take a close look at the upper pouch, and if it is suspicious in any case, then, uh, I'll, we'll bronk. Is that, can, what do other people think about that? Short pouch, meaning you're more likely to bronk. I, I agree about the short pouch, but I still think. Uh, you should figure out whether there's a fistula. If you're worried about, as Steve said, worry about doing, uh, a bronch and having the baby decompensate while you're doing that. As I mentioned earlier on, why not just do a very simple, quick contrast study. Because I think in, in the hands of an experienced pediatric radiologist, you will pick up the upper pouch either by seeing a smaller upper pouch and you expect an upper pouch fistula, either by seeing a smaller upper pouch or actually seeing the dye going across the fistula into the trachea. Can I comment? Yeah, go ahead. Yeah. Well, you know, I enjoy this discussion because I recently wrote up the German guidelines for esophagia, and we sat down and had numerous discussions about the fact, um, shall we recommend in the German guidelines to use a contrast or not? Um, most people agree, especially the neonatologists said, well, if you generally recommend to investigate the upper pouch for an additional fistula. By contrast study, you will very much likely to find babies that have aspirated. You will find babies that received too much contrast and then spilled over. So where do we go from here? I mean, in your hands, a contrast study is fine. But can we generally recommend it worldwide? Well, I think, I think if you're going to do a contrast study, you need to make sure that you're actually the one doing it. You need to go with the baby and do the exam yourself so that only 1 cc or so of contrast be put in and then you're able to evacuate it. This isn't a case where you can send it down to radiology and expect the radiologist to do it. So if you do do a contrast study, you've got to do it yourself, and I think you need to do it under floral. I agree completely with Steve. The, the rule of thumb where we used to do these a lot when I was a resident at Boston Children's is 1.5 cc's is the maximum amount of dye you put in, and you suck it out immediately. OK. And you got to be there. Obviously, as, as Steve said, you got to be there with the baby. Please may I have a comment from Rome? Yes, uh, uh, Professor Bagulo, thank you very much for joining us. Thank you very much to you. Um, I would like to intervene in the tracho bronchoscopy reasons. I completely agree with Dr. Langer because I I think that many reasons we have. To do tracheal bronchoscopy in these children to assess the vocal cords' motility preoperatively because you know sometimes we have also some congenital vocal cord parasis or paralysis and we have to know in advance, but most of all I think that we assessed. System to measure the gap also in babies with type C esophagealresia and as you know there is a recent meta-analysis by PEPi. More than 50% of lung gaps are included in type C esophagealia. So I think that Doing this exam preoperatively to all these babies, we can, we can assess those who have a normal or short or no gap compared with those who have really a long gap. So that's quite easy and also very important to avoid unsuccessful surgery. Can I come in there? Yes, who's this? Uh, Dr. Spitz. Uh, I've been more selective in, uh, in a preoperative, uh, bronchoscopy, uh, in that the normal type of oesophageal atresia with a distal fistula, the incidence of upper pouch fistula is about 1 to 2%. So that you are, uh, endoscoping 98% unnecessarily. Whereas in the esophageal atresia without gas in the stomach, without the distal fistula, the incidence is much higher, around 13 to 15%. So in those it is mandatory to do an upper pouch, uh, study, to do a bronchoscopy. That's a very good point, Louis, very important point, yeah, and I, I, I agree totally, and that's what I'm talking about being selective. The routine patient with a type C, we don't do it because again, in, I think we've seen one in 20 years, so it's uh. Right. Uh, sorry, but how do you explain that more than 50% of those babies with, uh, within the long gap family. are included in type C and we, we can discover them only intraoperatively. That's, that's not a good, a good system today. I think that every, every assessment we can do preoperatively, we have to do it today. If the patient is in a 2nd or 1st level center and he's type Clu gap, so and you know that preoperatively, then you can avoid cervical esophagostomy and so on. So I think that's very important if you, if you look at the At the meta analysis by Premururi, you see then most of the long gap are included in the type C. That's, that's, but, but that's not really important because in the type Cs you have to ligate the fistula. You have to do a procedure to at least ligate the fistula in that newborn period so you can evaluate the upper pouch directly at the time of surgery. You can make a decision that at that point you may not want to continue with a repair, which is extremely uncommon. Um, and in fact we've only had to do that once dorcoscopically in the last 10 years. But, but so you're going to evaluate that upper pouch directly. So I don't think that doing a. A bronchoscopy, uh, helps in that evaluation at all because you have to ligate the fistula. It's not an option to not, to not, to not ligate the fistula, at least in, in our practice. I, I think also with regard to the meta-analysis, and that's a, I just read that paper recently. The trouble with all these meta-analyses, and especially in this area, and we're going to, uh, get into this when we get into the area of long gap esophage atresia. It's very difficult to talk about this when you don't know exactly what the definition of long gap is in all these various studies. I've seen some papers come through just recently, uh, as the editor of, uh, Pediatric Surgery International of babies with, uh, gaps of 2.5 centimeters, and the title of the paper was the Management of Long gap esophageal atresia. I would venture to say that everybody here at the table and everybody on the faculty would not call a 2.5 centimeter gap long gap. So we get into the big, big problem of definition. And, uh, to me, that, I don't consider that a long gap, and I think probably Steve and, uh, and the rest of us here don't either. So, uh, I don't know what that means. Uh I, I agree with Louis that you should be selective, uh, when you're dealing with the standard type C about how you study the upper pouch with bronchoscopy or with a contrast study. Uh, but I think we can't, uh, invoke, uh, These meta-analysis papers and it's as good as it can be, the paper by Prem, but we don't know what the definition of long gap was in all those studies that were reviewed. Yeah, that's the reason why Professor Coron, you're right, perfectly. That's the reason why I think that it would be of interest for everybody to have a measurement of that patients in advance and have the opportunity to judge after if it was really a long gap or not, but if we don't have a preoperative measurement, how can we judge our our surgery or our bad or good results in Of centimeters of vertebral bodies. That's the reason why I think every patient should have an objective measurement and reproducible method to measure this gap. No, no question of type of esophagia. If we want to go ahead with this problem of measurement of the gap. I want to, I want to make a comment on Wit Holcomb. And the group in uh in Saudi Arabia have just made a comment. Uh, Witt says that he feels bron bronking the patients is helpful to know where the official insert into the trachea and also helpful in training the, the fellows. You know, I, just one case, but I had a case that I had wished I had done a bronch because I went in thoracoscopically and actually the fistula inserted very, very high into the trachea and it was confusing for me. Because I wasn't expecting that and I couldn't tell, am I leaving a diverticulum? Is this where do I keep going? I don't want to get into the membranous trachea. If I had known bronchoscopically that that was 4 centimeters up from the carina, 3 centimeters up from the carina ahead of time, I would have felt more comfortable continuing the dissection of more proximal. I think you saw that video. Um, is that a reason to always do it? I don't know, but I think that Witt's point is right, and I think it, uh, I did Bronx in training more than I do now, but it was definitely good. That's where I got all my Bronx from, from my, from the officials. So it's a good point. And then, uh, Witt, I know we're working with you to try to get your phone line working, um, and hopefully we'll get that working soon. Uh, we'll give you a different number to call in on. Um, before we go on, I want, can I, can I comment a little bit on, uh, uh, I agree with Doctor Bagalan that it would be nice to get all this data and to know exactly what all the gaps are all over the world, uh, at all the children's hospitals. But from a practical point of view, as a pediatric surgeon with a baby that is a type C, uh, as Steve said, you're going to figure out what's going on cause you're going to operate on him. You're going to at least divide the fistula. And you'll be there. You'll see the anatomy directly in front of you. And I don't know how critical it is then to have, to do these studies ahead of time. Whereas, as Lewis said, with a, uh, long gap, pure esophageal atresia, you got to worry because of the much higher incidence. Let's, let's go on to the uh other fine points of the operation, uh, before, because what I, I do want to get into is once we go over all the fine points of the open, so we're talking about. Bronchoscopies. Obviously, that's a, a hot topic. We're talking about the dissection. Um, eventually, I wanna also get into the thoracoscopic approach and have comments on that as well. Um, we saw from the, before the show started that I think it was about 60% of people do it thoracoscopically, so it's worth getting into that discussion. Um, Any other fine points when you are doing your, your, your repair, you've talked to us about putting the relogo in, stitching it, using it for grabbing, helping to find that plane. What, and you talked about your distal dissection of the distal pouch. Um, let me, I didn't get to mention all I wanted to mention about the distal dissection. I think the myth, as I alluded to, uh, a little bit before, of not dissecting the distal pouch is a myth. I think the thing that causes all the problems with esophageal atresia repair is too much tension on the anastomosis, a leak. If you look at the incidence of recurrent TEFs, 70% in the paper we published a few years ago had a previous leak at the anastomosis after the first operation. So, the number one goal is to try, try to do as, as little, have as little tension as possible on the anastomosis. Therefore, that means dissect as much of the lower pouch as you do of the upper pouch. And that means even dissecting right down to the kura. And if one looks at Doctor Gross's old textbook of 1953, sometimes old things are still good, he mentions, don't hesitate if you need to, to detect as far down on the lower segment as you have to to get the two ends together. And there's been sort of a mentality, certainly in the last several years that don't dissect any more than you have to of the lower pouch. That's a good concept, but don't not dissect if you're going to end up with a tension anastomosis. Holger, you had a question. Certain point. I've got a question. Somebody has. It's, it's Louis Annie. Yeah, hi, Louis. How are you doing? OK, I, I agree with you that the section of the lower pouch should be done as far as necessary. The reason for not dissecting it in the past was the illusion. That the blood supply to the lower pouch came directly from branches from the the the aorta, and this is not true. So I think the section should be carried out as far as necessary to obtain a good anastomosis. Louis, uh, let me just respond to Steve and I were just talking off, off track here, and he said something that's absolutely true, and I bet everybody. Uh, in the audience will probably agree, he's, when you dissect the lower pouch, have you ever seen any bleeding of any significance coming from vessels that you're bluntly dissecting? I don't think you see that very much. So there's, that's a myth. I agree, a complete myth that's probably caused a lot of bad anastomosis to be done. Holger. OK, Arnie said pro dissection. Professor Spitz said pro dissection. Steve said pro. Do I really dare to say against the maximal dissection of the lower pouch? Well, I'll try. What about innovation, vagal nerve fibers, and late motility? All good. Are we responsible? Sorry, Arnie, I had to challenge you a little as a youngster. Holger, Holger, Holger, turn off your computer speakers because we're getting an echo here. Yeah, OK, OK. Yep, OK, better. Well, I, I, you know, I'm just, you know, I think, uh, and again I'm a little biased towards thoracoscopy, but you can actually see the vagus extremely well. And, but we ought to think that that the esophagus, I think you can preserve the main branches of the vagus without any problem, whether you do it open or thoracoscopically. I think it's a little easier thoracoscopically because you get such a magnified view. But the concept that we have a normally innervated esophagus that was in two parts and you put it together and it works normally, I think is crazy. So I think if you're worried about taking a few of the small branches that go into the lower esophageal pouch, it's probably not a concern, and I would be more concerned about getting the two ends together. I don't, I don't, and I, you know, I think we have a lot to learn from Doctor Corn and Doctor Spitz, but I think basically you mobilize the lower pouch as much as you need to to try and get attention-free anastomosis. Certainly I think we all are comfortable with that upper pouch mobilization and probably in some cases we don't do enough in longer gaps, but I think it's very clear that you just need to do what you need to do, and I've never seen a devascularized lower pouch from a significant. Um, significant dissection, and I also don't think that the motility is dependent on those few vagal branches that might go into the lower pouch. Uh, let me just be the advocate of the contra, and I'll try again. Um, are we, are we really sure that it's this motility, uh, later on is not a surgeon's job as well? I agree that we see no bleeding when we dissect and, um, nevertheless, we do see the nerve fibers, and we swap them off if we, um, go for the lower pouch once in a while. Um, is that not the surgical matter we should care of intraoperatively? Well, I think if you don't get the two ends together, then it's not going to matter what kind of motility they have. I mean, I, I think, again, I think even somebody who has, I think we all know that even somebody who doesn't have a long gap, who has a standard type C and that you put together, those patients still have some dysmotility and you've done very little dissection on anything because again, you've got an esophagus that is not complete. And so there aren't, there have been studies, there aren't really normal peristaltic waves as it goes down the esophagus. I mean kids who you do a beautiful TF repair on who have no stricture, no problem, will come in with meat caught because they don't have a normal peristaltic wave that goes through that esophagus. So I'm not, I'm not sure that's a significant component, but I, you know, again, I'd be interested in other people's opinions. Any other comments from the rest of the faculty on this topic? Yeah, this is Jack. Um, there was a paper many, many years ago from a Japanese group that did a manometry on the proximal and distal pouch in children who had pure esophageal atresia. They accessed the distal pouch through the gastrostomy, and this was pre-repair. They found normal peristalsis that started in the proximal pouch and then continued in the distal pouch. It was very interesting. And then post repair, that that was completely disrupted. So that Suggested that the surgical repair does interfere with the motility of the esophagus. Whether complete dissection of the distal esophagus, uh, makes that worse than partial dissection, I, I think is still unknown. Can I say something, Todd? Yeah, go ahead, Miguel. So I agree with Steve that you do the same surgery and it come out differently independently from the surgery, you have done. You strap it completely the lower pouch, exactly completely up the level of the diaphragm, and you do an eye surgery. The anasthrombosis looks good, no tension, and the outcome of that esophagus and the peristalsis are completely. Different among the different children, so I agree that I think it's not the problem that you are removing some branches of the vagus nerve. That's basically how the esophagus is, you know, working, how it comes from before the surgery. Actually it looks like 60% of the, uh, I want to get comments on what Miguel said, but 60% of the people do a minimal dissection and are afraid to do an aggressive dissection of the distal esophagus. Um, at least that's how I felt too, but I'm learning today that I may, uh, do, I will be honest with you, from the time I trained with you, um, the ends came together easier, and I wonder if it's because you do more dissection distally. I always seem like there's, uh, I get worried there's too much tension. So I bet you if I do more distal dissection, uh, the two ends will come together much easier. So I mean, I, I always dissect the upper pouch first. I mean, I always see how much length I can get and go as far up into the neck as I need to. In order to get it, I mean, a lot of times we're very fortunate and you basically don't need to do anything. You ligate the fistula, the two ends, you're sitting there and you sew them together. But, but I, I, I, I think again the concept, what I've kind of learned, and, and it's now been talking with Doctor Corn, it's, you know, clearly this is a technique that he's believed in for a long time is that you do what you need to with the distal pouch, and I don't think anybody's ever seen. A distal pouch necrosis go away. And I will tell you that thoracoscopically when you do that distal dissection, you can see in a very magnified view that there are no vessels that go into the distal pouch. So I think Kolger's point about the innovation is interesting and may have some relevance, but I think clinically probably not a lot because I think the other question we really need to ask is in these kids who we successfully get together and who don't have a stricture, so. I mean there are two issues we can talk about later, but one is the short esophagus and how do you manage that in those patients who have bad reflux, and the other is the stricture formation. Those are the problems, but rarely is it a problem that the kid, assuming those two things aren't an issue, that the kid can't eat. I mean they, they basically are able to eat and even those kids we do fundos in are able to eat. So while it's a theoretical discussion about their motility, it may not be a practical one in terms of kind of their lifelong ability to compensate for perhaps some dysmotility of that. Let's spend one more minute on this because then I want to get into the thoracoscopic. So we have a few minutes left on this topic. So can I make one comment? We don't know enough about the nerves of the esophagus in these babies to categorically say we have to preserve them. That's just a fact. And that study you mentioned, Jack, is interesting, but I wouldn't base my decision on what to do on one study like that. What we know for sure about oesophageal atresia. Is we do not want to have a very, uh, a high tension on the anastomosis. And so whatever else we have to do to make sure we can get those two ends together as, as easily as possible, we do. Now, maybe we are doing something to the motility, maybe not. What I've, I've, uh, was thinking about as this discussion was going on is if you look at any babies you've operated on the esophagus of, not for esophageal atresia, let's say for other reasons. Have you ever seen any of them show show signs of dysmotility in the esophagus when they've been studied postoperatively? I've been just thinking, uh, as we're here, whether I can recall a single patient and I can't. So I'm not really sure that dissecting that esophagus, uh, uh, distally, uh, does, does damage to the motility of it by, uh, for instance, cutting some of those small, uh, vagal branches. Can I just say a word on the tension of the anastomosis that we for the past 20 years have been doing anastomosis sometimes under extreme tension, but then we intubate and electively paralyze patients, the, the babies for about 5 days, and we've had no leaks in that group at all. So I would advocate this period of resting the anastomosis for 5 days with ventilation. I, I think that's a really good point. I've, and that's something I wanted to ask. So, in those cases where you have tension, how many people do do that? How many, um, paralyzing, leave the baby intubated, and then for how many days? Because one thing I, and I don't remember who told me, but that I've always been told, it sort of sticks in my mind that the time your anastomosis is the weakest is about 5 to 7 days. And that's the time when we routinely. Wake them up. So I just curious how many people will routinely paralyze the baby and how long will they keep them paralyzed. I think at one point I was taught, you know, if you have a really long gap to put a stitch between the chin and the chest to keep in that position. So I'm just curious if anybody. Uses those tricks. I have always, uh, done that too, Louis. I, uh, in, in the early years, we did actually put a stitch through the chin. I'm not sure if that helped. It was an ugly looking thing to see, so we stopped doing it. But I agree, I think paralyzing him is, uh, is a good idea. We've used the same sort of approach 5 days, maybe up to 7 days, but Steve's point is very valid. The anastomosis, or any wound is the weakest on the 5th or 7th day, so. Maybe we need to do it longer, but that's an impressive, uh, result with no leaks in, uh, that number of patients. Let me, let me, I want to move on because we're, we only have about 10 minutes left. Uh, but go ahead, make one last comment and then we'll go ahead and have Steve show us about the thoracoscopic approach. Well, this is John Folker on, uh, just a couple of points. Uh, the 5 to 7 days, uh, and the anastomotic strength or weakness is not the entire issue. In that 5 days, the esophagus under tension will grow substantially, and it won't be under tension at 5 days. And that's why that's effective, not that you're preserving the anastomosis under the same amount of tension. The other thing is the function of the esophagus. Um, there are a fair number of studies, and about 2/3 of the function goes down through the esophageal muscle layers, the sycitium has a peristaltic wave, and so where the anastomosis is, uh, that fibrous healing will interrupt that. Um, peristaltic wave and thereafter it'll be just sporadic contractions, but they seem to be enough to empty the esophagus in most cases. OK, um, any comments on that? Otherwise, Steve, uh, Mark, can we pull up.