Um, just to let you know, so, the Journal of Pediatric Surgery has been very kind in letting us share, um, um, key charts from articles through both social media, through, um, through the, uh, Stay Current app, and so, uh, we, we really appreciate their Involvement in, in education and um those, as you noticed, that video made by the fellows was, was, was put on in, in part with the Journal of Pediatric Surgery to highlight what they have felt have been the high, uh, the key articles. Um, and, uh, let's see, I don't know if, if I see wit, but, um, is he, yeah, there's Witt. Witt, do you wanna make a comment about the JPS? Yeah, the JPS has been very fortunate to team uh with stay current. Globalcast and um I'm glad to do that and, and really, uh JPS is trying to improve the care of our patients uh through peer review articles. So we're, we're glad to be part of this process. Uh, I congratulate you, Todd, uh, and, uh, uh, the others for, uh, uh, another wonderful, um, uh, webinar and, uh, we're just glad to be part of it. Thanks. Thank you, Witt. And uh we'll continue to work together and, and help provide people the most uh important information. Um, so we're gonna move on to then the final session and hopefully get this, uh, closed out on time cause I know we, we always try to end this on time. And this final session is a complication session, always the hardest thing to discuss. Uh, and so we've, uh, asked, uh, Doctor Jason Fraser and, and Doctor Miguel Gilfan. To take all these faculty, and you know what's fun? Now we've got a, a lot of faculty in here now in the Zoom room and also in the chat. So, uh, Jason, why don't you start off, take us through some of these cases. And I know, by the way, um, if we have time, which, uh, that, that has never happened in history, but if we actually have time at the end, Then feel free to present your own complication on here. You don't need slides. I know, Sean, you have a complication you may present that doesn't have slides. So, uh, Jason, you and, and Miguel go and then, um, we'll, we'll, we'll let uh anyone talk open forum. Sounds great. Thanks, Todd for giving us this opportunity here. I'm gonna share my screen. All right. Well, hopefully this will at least start uh some interactive here. Um, our first case, uh, is a newborn baby. uh, did have a prenatally diagnosed lung lesion, uh, and was born, uh, and, uh, brought to your NICU uh asymptomatic. Um, NICU, of course, calls you, uh, and says, hey, what, uh, imaging do you want to do for this asymptomatic baby with a prenatally diagnosed, uh, congenital lung lesion. So I pose that to the group and then uh ask our experts, uh, what, what is your practice, uh, at your facility to do. That's right. All right, who wants to start? You want me to start calling on people or does someone want to go? Hey Mac. Chest X-ray. Chest X-ray. I agree. chest X-ray. chest X-ray. Does anybody do nothing? Does anybody just follow these symptomatically and uh wait until they're older. I'm curious if there's anyone here from Canada. Uh, let's see, Eric, is Eric still on here? Um, Mary Brindle, I don't know if they're still on here because I know it's not always the same in the US or Let's see if anyone from another country has a different thing, but I think most people in the US would get a chest X-ray. Oh, Tara says nothing. Uh, so, I'm curious. OK, so there are some people that say nothing, but let's keep going. All right, so, uh, of course, patient got a chest X-ray. Uh, I can see a little lucency there. Um, so then comes in, uh, a couple of months later, uh, sees, sees you and, sees me in clinic, uh, and gets the CT scan. So I can see a lucency here. I'm sorry. So the, the CT scan was done, uh, just after birth. So a CT scan, um, I, in my practice and here usually we don't not, do not necessarily routinely CT scan patients, uh, in the NICU. I'll usually have them come back at 3 to 6 months in clinic, uh, for a CT scan at that time with the CT angio, uh, and that's what happened with this patient. Um. I think the symptomatic patients is a different, uh, a little different workup and algorithm, and I think that's where you'd probably recommend CT at least I would, uh, in the NICU, um, but in this case, an asymptomatic baby, uh, I would usually see them back in clinic at 3 to 6 months with the CT angio. All right, let me stop you. So, uh, Tara, by the way, correct me if I'm, I'm calling you Tara Lou. I, I'm assuming that's how I'm pronouncing your last name correctly. Um, but Tara just provoked an interesting question that I'm sure someone here has studied and I'm just not knowledgeable of it. So, you get a chest X-ray and I agree with you, I would get a CT scan prior to surgery, which should be around 3 months. Um, but Tara's, Tara says she would get nothing and just go ahead and get a CT at 3 months. So the question is, how many babies with a prenatally diagnosed lesion. End up having a negative chest X-ray that never end up getting a CAT scan. Because if 99% of them end up getting a CT then maybe you don't need a chest X-ray. Sean, do you have data on that? You have data on everything. Mm. No data on that, but um. I think it would be more heroic to keep neonatology from getting a chest X-ray than it was for Kurt Heist to get them to get anesthesia to back off from their NPO rules, which I have to just say, Kurt, is the most amazing thing I've heard a pediatric surgeon accomplish ever. But having said that, you make a good point. If, if you're gonna, if you're gonna get a CT before you operate, the chest X-ray is going to offer nothing in the asymptomatic patient. The only thing it may do is give you a baseline if the kid comes in with a potential respiratory issue and you get a chest X-ray and they have, and uh they have a consolidation or something, you, you don't have any baseline to compare that to. That's the only reason I would get it. So, so I have a question for everybody. If, uh, you get a chest X-ray and it's normal, which does happen. Do you then still get a CT scan at 3 months, or I've, I've followed always chest X-ray in 3 months. Absolutely get a CT scan at some point because, always, yeah, but I'm saying some of these kids totally like say they're born totally normal 3 months X-ray, yeah, you can get another X-ray and it's still totally normal. On that, but that doesn't mean it's it's a real normal baby. The X-ray is normal. No, but so, so it, I guess that goes to Dan von Almen's point that maybe it's a baseline, but if you're using it, if you're gonna get a CAT scan on everyone anyways, that supports Tara's point that Unless you're using the X-ray for some other reason like a baseline, you just go ahead and get your CAT scan in 3 months. I, I, I think to Dan's point, you, there's no way that the neonatologists would not get a. Because Yeah, and most of the time they're gonna, they're gonna call you and say, hey, the baby's here and it's already had a chest x-ray, so that's gonna happen before you even probably know about the baby, so. We're not gonna change this. We're not gonna change this. Keep going. Yeah. So, the another great question which I don't know if we're gonna have an answer to and it's probably a very personal preference is when, when are you gonna operate on this baby? Yeah Mark, when do you operate on these kids? Around 3 months. OK, yeah, I think, I think you wait longer. It starts, you know, I've had some kids that have been further out for one reason or another, and there's a little, it's, it's always a little bit more inflamed. It's always a little bit harder. I think 3 months is the sweet spot. Todd, I can't see the chat, but is there anybody out there gonna say they're not gonna operate on these babies? Uh, well, that's, that's what I was actually, uh, there's a million responses about different ways that they work them up when they're born. Like, no one's saying that they're not gonna operate yet. I think they just, they're just now getting that question again because of our lag. But there are some people, like we were talking about before, there's a lot of discussion about, do you even get this CT? Do we wanna wait till they get symptoms? Does, if the chest X-ray is negative, you know, are you gonna go with the CT anyway? So why not just go for a lot of the discussion we had previously. But as these results are coming in now, it looks like the, the poll results, at least, it looks like a lot of people are saying operate somewhere around 3 to 6 months. Todd, a few years ago we had an entire IPEG session on whether it should be less than 6 months or over 6 months. Yeah. So I think, I think, uh, I don't know, do you wanna get into that now? Cause I, I, I, I can give you my opinion. I think a lot of us on this panel agree, but, um, we have, uh, Marion says 6 months. Uh, we got 3 months, we got 3 and 6. I don't see anyone, let's see, Rod, you said no one answered never, um, and it's changing, but most are 3 to 6 months. I think that's probably pretty standard for most people. Hey Todd, I think you ought to get a CT at 3 months and act on it accordingly. Wait, so that means if there's something there, you take it out at around 3 to 3, a little over 3 months. Yeah, yeah, yeah, there's a lot of, go ahead, you don't get another CT at 6 months. I mean, you, you know, OK. OK. Well, it's all been great discussion. It's nice to hear that everyone's got, you know, similar but different interactions with their ideas with this, so, all right, so I guess this, I would probably know the answer to this mostly, but uh Is there anybody that would approach these open? I guess might be the easier option from this, the question from this. Well, while we're waiting for the faculty to answer, there's a, uh, from Nigeria, um, Doctor Ajayi says in a facility without laparoscopic capacity, uh, when you do open? And so obviously, not everyone has laparoscopic capacity. Um, Well, and if you don't have a laparoscopic capacity, would that more force you to wait until the patient are older or just observe these? That's what or, or thoracoscopic because these are hard to get through the abdomen. It's doable, but you need the long instruments. Maybe you can do that, Sean.gmatic. All right, there's a lot of people answering that they do open thoracotomies for this. That is an issue. I, I don't think that whether you do it open or thoracoscopic would change when you go after it because I think the reason for the timing has nothing to do with the scope or the technique. It has to do with the lesion and whether there's gonna be inflammation or infection there. Yeah, cause I know the ones that I've done that have been either later diagnosed or diagnosed after pneumonia, those are, can be pretty darn difficult and kind of hair raising, uh, what, what little hair that I have, but Mark. Bye Yeah. Yeah, definitely, if you're going to do a 3 month old baby, it's much easier doing terragoscopically that open in terms of visibility. Definitely. I, I think it's better to do it thoracoscopically in terms of visibility and everything else at any age. I know, but no, but if you don't, the question is, if you don't have laparoscopic capabilities, am I asking I have to do it an older, I would do it in an older child rather than a 3 month. That's the question, right? Yeah, I, I would do the same. I would do it. I'll still do it at 3 months. All right. All right. So this kinda gets into the crux of the uh next complication section here. Um, so you're doing a, a lobectomy thoracoscopically. What, how do you secure vessels? Are you gonna use clips, ties, energy devices, staplers, combination thereof? Uh, in the US we have multiple different, uh, techno technological, uh, pieces of machinery that we can use, uh, and obviously different things like that, but, uh, does anyone have anything that they would or would not for sure use? We're taking, doing lobectomies. So I would argue you should be able to, you should at least know how to use all of these. Um, you know, but in general, we use an energy device, uh, you know, in, in, in the small babies, it works really well. But even in the bigger kids, you can use the bigger energy devices. Yeah, I would say to use whatever you use best. Yeah, that's a very good point. Um. So go ahead, Mark. Yeah, I was gonna say, I mean, I, I, I don't know, maybe some of the younger people haven't seen it, but everyone's seen my, uh, you know, my worst nightmare session from IPEG where I had a stapler fail on one of these older kids that had a, uh, That had a lobectomy for uh a CPAP that wasn't diagnosed until they were 8 or 9 with having recurrent pneumonia. But you know that staplers do fail and they're not perfect, so I think you need to be really careful with that and uh there's ways to do it that you have control. OK I think that leads us into a good segue into, into this complication here. Uh, thank you, Doctor Wilkin. That's a good plan. So, so you're, you're doing your resection here. You just have the, pretty much the vein left. Uh, you fire a stapler across and then you can see bleeding kinda slowly starting here. Um, and then it becomes a little bit more rapid and a little more bleeding here. So now what do you do? So the question that will beg is what do you do now and then why do we get there? So you're gonna open, you're gonna clip, we're gonna tie, you're gonna staple. So that's right now you just see you, you can't tell what what's happening where it's coming from, uh, you just see a little take a look at the 11 o'clock position. No, there's a, there's a right, yeah, yeah, yeah, OK. He's coming. It's coming stream of blood coming from the pulmonary vein there. Yeah, so, I, I mean, I'm assuming you tried to grab it with a grasper or something. Were you able to just grasp it and control it in there? Again, good, good, good, good thinking, Doctor Wilkin. It's always good to have that ready, you know, unfortunately, I'm, uh, I, I, my knowledge is all from experience. So that little, that little bleed actually, that wasn't ferocious yet, but significant, gives you a few, uh, a minute or at least 1020 seconds to get your stuff together, get the right instruments together, get suction before going after it. I mean, if it's really going, But sometimes going after it, it can make it substantially worse. So I would get my suction ready, be prepared, and then go and, and do the grab and try to maintain it, get, get your prolees ready if you need it or whatever. Yeah, and I think that's, that's the, the very valuable point of this is now that you have a little bit of time to catch, you can talk to your anesthesia, you can talk to your circulating team. You can get what you need to get to be able to have the multiple next steps ready and available for when and if you do have problems that if you, you, you let this go and, uh, you know, the, the whole thing opens up, you can be ready. Put in another cho car. Yes. And that's the part of the next video that I just cut out, is walking around the other side of the table, putting another tro car in, and then thankfully, um, Thankfully being able to put a 5 millimeter tropher and taking that that Maryland off and just putting a clip on that. But having that extra step, extra, extra equipment there ready, ready and ready to go is the, is the important thing. But I think the most, one of the most important things is realizing how, how you get to this place, how you get to this place of having, having here, but then also how you get out of it. So, um, The tips for using energy devices and everyone please uh interject uh as we go. Um, and obviously this was uh an issue with the stapler which we'll get to next, but, uh, I know Doctor Rothenberg, uh, has talked, talks extensively about this, uh, and all of his talks that he gives too, but, um, you know, You wanna be able to leave yourself with enough of a remnant that if you do have an issue with that energy device, it doesn't suck back. You're able to get a good purchase on, um, on the vessel that you're sealing. Now you get proximal control so that, or, or you partially cut across, so when you have, if you do have an issue there, you know about it before you go ahead and, and fire completely. And the same thing with the stapler, uh, you wanna make sure that you see the end of your stapler. You use, uh, appropriate size of your staple and appropriate size staple load for your tissue, and then, uh, if you need to leave an extra little pieces of tissue around the the edge of the stapler, uh, so that you do, uh, have an appropriate tissue coaptation. And then of course with all these things, uh, like Doctor Wilkin alluded to is be ready for the next, and, and Mac alluded to, too, Doctor Harman alluded to is be ready for the next two things that can happen, uh, if your device or your stapler or whatever fails, and those are very important things. And that's something to think about before you fire the stapler every time. Yeah, or, or the ligature before you deploy any of these technologies. That's why I've become a fan of placing a silk suture before doing that. On the vein. Once you get the dissection complete, lay a silk suture down and tie it right against the mediastinum. So now whatever happens, you're, you've got the electricity off and you may lose visibility, but the patient's not going to die. And then likewise, the, the main branch of the artery on a lower lobe, let's say, passing a tie on that. And in one case, we put the tie on there and then took all the distal branches with ligature. But you know that posterior superior branch comes off before you have that, that, that main trunk. And so we fired the ligature on that and it opened up, but because we had the silk in place, we had something that we could grab, roll it over, get easy visibility, and put the clip on there. Um, also gives you the ability to manipulate the vessel a little bit better. And I think too, understanding the device or the stapler that you're using, understanding the mechanics of it, you know, what button sequence you need to do to push, uh, what comes next? Does your device fire on the way out or on the way back? Things like that, that, you know, when you know the, you know, the instrument before you're cutting across the pulmonary artery, I think it's an important thing too. Yeah, like, like was pointed out in your case, Jason, um, at IPEG that you had dissected the vessel so cleanly. That it was no longer probably a staplable vessel as opposed to had there still been some adventitia on it. Yup. OK. That's it for this one. Does anyone else have anything else? If not, we'll move on to our next case. Uh, just wanna bring up, uh, uh, some comments here. So, um, the question that, uh, Doctor Shia brought up back to the very beginning of this discussion that we've had debates on here is that, uh, until we know the real risk of malignancy, we, we really won't have a good answer on the Canadian versus US debate of leaving these versus taking these out. Um, and so, you know, it's just a, it's an interesting point. I don't know if the data is any better now than it was a few years ago. Um, so that's, that's one point, and Yeah, I, I agree that when you have that, I, I've always been hoping for creating a great trick for when you have a, now a flat surface with bleeding, nothing to really staple on, but it's a flat surface and there's blood coming out from a flat surface. How do you best get control? And all I know reliably is a stitch, um, because a clip won't really work. It can make it worse. A stapler won't really work. It can make it worse. Um, and so, uh, you just have to, I think if you're gonna be doing a thoracoscopic lobe, it's back to what Mark's point is, that's something you should go in the, in the models and really make sure that you can quickly throw in at least even a basic tie. Uh, and this is not one you wanna have tension while you're pulling up to tie it. I mean, this would be a good one for a controlled, um, a controlled tie, either intracorporeal or, but This is exactly the reason why you need to know how to suture and tie before you do a thoracoscopic lobe. We All right. Next case. Jason? You go, OK, so this is the 2nd case. I'm sure Mark has a couple of those. I never had one, so we need Mark, you know. Uh, thoughts. This a young patient had a Nissen funoculation a couple of years ago as a child and now present as a later and found a parasophageal hernia that is completely symptomatic. Next one. So what do you do? How's your approach? Just observation, primary repair, repair with patch, other like medication? Some thoughts, Sean, Mark, Wit, Mac, the others. What's your first approach on this? You said completely symptomatic. Yeah, what do you a lot of symptoms. He's, he's vomiting and some wretching, and he's not happy with this, so somebody's got to do something. Meaning Well, so observation is not a good choice. OK. Medication is some doing something or just go straight to surgery? Well, you can start in. Go ahead, Mark. I'm gonna say, I'm, I'm probably gonna say the same thing where I'd do a trial of medication. Uh, unfortunately, I don't think it's gonna work, but it may give you a month or so of reprieve before you gotta go in there and fix this. So we do a month of trial of medication and see how it goes first? Yeah. Sean with. I'll let Witt talk about this. I think he's probably seen as many of these as anybody on the phone. Not, not his fault, just the error. Right. And what do you do, Sean? So, if, if they've got a substantial herniation, um, that they're going to need a repair at some point. And so they're currently symptomatic. Even if you suppress the acid, that's not going to be a lifelong answer for somebody who's got a hiatal hernia. And we've had the small ones that we've followed back in the dissection era when we took down the frontalesophageal membrane during a fundal placation, and invariably, they just continue to progress. They continue to go further up into the chest and create a bigger defect. Is there any difference between uh sorry who's going to say something? This is definitely a maximal mobilization patient. As opposed to men mode. There's any difference between a, you know, a, a, a 34 month old baby or a 56 year old boy with a perisophi uh uh hernia approach. We do exactly the same. I think if they're symptomatic and they have a significant paraesophageal hernia, you just have to fix it. I don't think medical therapy is gonna do anything. And to Sean's point, it'll just continue to get worse. And it looks like our respondents for the, for those who are, uh, hardly anyone said observations, so almost everyone wants to repair this, and more than half of the respondents said they want to repair it with a primary repair. OK. Next one. OK, so you go straight to surgery. What do you do? A laparoscopic redo the hiatal hernia repair, put uh some biological mesh reinforcement or on a gentle closure. What would you do if you see this peresophageal hernia? You just bring it down and close the hernia or do something else? Done. I think I, I would bring it down, redo the wrap, and if the, if the cura come together easily, I would just primarily close the cura and not put a mesh in there. If, if it was tight or I thought, um, it, it was not hold the stitches, then I would probably lay a piece of mesh in there, but I prefer, prefer to avoid that if I can. And you put only just stitches or do some pledges or just stitches. Uh, I would do it laparoscopically and I would probably do just stitches and not pledges. What else would you use? I'm sorry, what was the question? What, what kind of mesh would you use? Yeah, that's um. Uh, I Uh, would probably use a biologic mesh. OK. Anybody else, and that's my kids. Well, that's, you know, that's a controversial area and adults seem to have different results than kids. But if you had to reinforce in a kid, a biological mesh makes more sense. Unfortunately, I've had the pleasure of picking out a non-biological mesh from the lumen of the esophagus on endoscopy because it will erode into the lumen. So even though the biological may have some downsides, it's probably safer in a child than. Non-absorbable mesh. We found one in the diaper. There you go. That's better. That's efficient. I've had the same experience as Mac pulling a piece of cortex out of the esophagus, um, but, uh, I, I would do a biologic mesh reinforcement, and I'd have a really low threshold to put it there just based on the adult data that if you don't put a mesh on that the risk of recurrence is higher. That being said, you know, if you reduce it, some of these for some reason, maybe it was just a technical issue with the first operation. And you just, you know, it really does just come together pretty easily without any, uh, without any tension. So, Rothenberg talks about something that I've never done, and I, I don't know if anyone here has done it, but because of the risk of the mesh eroding through the esophagus, he makes a relaxing incision on the diaphragm, puts the mesh out laterally to be able to close. I've never done that. I don't know if anyone has. Not me. So have you not heard of erosion being a problem with the absorbable meshes, but the problem with what the adults would tell you is the absorbable mesh isn't going to do much. Right. So we, we actually did find data. I mean, we produced data back when we were doing lots of redo hernias that um our risk of a redo redo went down when we started doing an overlay mesh, and that was with the SIS era. And now we use Permacol, and I don't, I don't know how that will fare, but fortunately, I, I think we're not going to see the herniation problem very frequently anymore that we don't do dissection. Now it's more the fundus, uh, the fundallication comes undone, which is a much easier operation. Can I ask you, how do you put the mesh? Where and how, yep, exactly like that. OK, so that this one crossing or not crossing. With a cut right up the middle and a circle in the middle so that you bring it down and then it just naturally sits like so and you don't, you don't cross on, on, on the lower side. It depends on what your posterior cruise looks like. If that, if that was wide open, then you're, you're going to want to cover that. Everybody does the same. Yeah. Yeah, I think the, the problem is posterior usually. So I think if you're, you know, you pull the Kura together, that you need to, the idea is to cover that repair. I, I always cross the, the limbs of, of that thing, Mark. I, I do a horseshoe from underneath. I don't know, I don't cross it up above, but I, I leave the bottom part underneath. You do that this way. That's what I do, and I try to make sure, and, and I'm trying to make sure it's wide on the good tissue on either side down below because I think that's, that's where the problem is. That's where it's gonna recur, Mac. Yeah, that's what I'm doing. That's, that should be a U instead of a V, but that's the way I put the patch on. Do you stitch the, the mesh or just leave it there? I put a few stitches in. I stitch 4 tacking stitches in. OK, OK. Next, next slide, Jason, please. So, we did the surgery as everybody said, we did a fantastic surgery and the baby, the child starts with severe dysphagia and can tolerate even water. Next slide. So what do you do next? Anyone continue to observe only more medication, go straight to surgery, contrast, dilation. Did a contrast study. Contrast study first contrast study. Everybody agree Sean Mark. This is, this is immediately post-op 2 weeks. What do you do, Todd? We have to start with a study, but it's gonna show a narrowing. But then the question is, what are you gonna do next? OK, let's, let's have a look, Jason. There you are. So the reflux is fixed. It's all those screws. Well, that, that, that, that went very well. That, that surgery went very well. No problem with that surgery, Dan. Don't worry. The neck is fixed, really fixed. So I, I seeing that, who would do what? Miguel, did you put mesh in? Of course we don't know. But we'll see, we'll see in the redo. They send the patient without the records. So Mark, well, Eventually, eventually I would scope and, and probably dilate because I couldn't resist it, but, uh, it doesn't have to be stat. And how with what Mac? how do you delight delay uh what would you the relation with Well, you know, anytime you're dilating a fundo, there's a risk of hurting the fundo, but if the patient stays like that for months and months, that won't do. You're gonna have to do something, and I'd certainly start with a dilation. With like Sabari or balloon. Blue OK, anybody else? Miguel, could you put in a feeding tube and give it a little time after you did the dilation to see if that would help? Thinking about the, some, some edema or something like that. A small, yes, Dobhoff or something like that where you could feel it in the stomach or feed distally and give it some time for the swelling to go away. I, I think you, you, you can, you can do that. Everybody agree with, you can do that maybe stop with 21 weeks with an NG tube. If you're gonna go that route, I, I think it may be reasonable to do that for, you know, 4 weeks or so, get about 6 weeks out when the swelling would really start to go down if it's just swelling. I'd be a little anxious dilating it that early because you're gonna end up with recurrent reflux. So I, I, I just, uh, I, I think Kurt's approach is pretty reasonable. Yeah, I, I, I'm very scared to, to do a dilation, you know, two weeks after I read an essay done. I agree. Uh, if you can get a feeding tube in, that would be great. I would wait, but I agree with also with if you're gonna wait, you should wait for 6 weeks. A, because it takes a while for the swelling to go down, and B, because you don't want to go back in there at 3 or 4 weeks with the maximal inflammation, even though it's presumably laparoscopic. Well, I'm probably the only person on this call who's had a Nissan fundal placation. It was day number 18 when my swallowing became normal and the swelling went away. So beat that, that, that. That's very, that's a very good, very good point. Thank you. Hey, Miguel, quick Miguel, quick question. So I had to step away for a second, but did you, was a bougie used when the fundo was done? And yes. You know, happen to know what size that was? No, no, it was marked. It was marked case, so I, I wasn't there, OK. No, it's, it's, it's, that's not true. So let's see the next one. Jason, please. So we balloon, they, they, they had a balloon dilation uh episode. See the next one, please. And no improvement in the symptoms. So that, you have one dilation supposedly went well during the dilatation but no improvement at all. Again. What do you do? Repeat it again. Observe an NG tube. Sorry, how far out now. 2 weeks. Be patient. Right. I mean, but this patient, this patient, um, so they, they have, they're completely obstructed almost from their esophagus, so we can be patient, but we need to have some temporizing measure. I mean this patient, the feeding tube or a G tube even, right? Can they handle their secretions? Yes OK. So they handle the secretions, you feed them. I agree. You feed him an NG wise, yeah, if you can get it in. So, everybody will agree to just put an NG even if he has any other thing besides secretion, he can't get in. To put a surgical gastrostomy in. And wait. And wait a bit longer. It's too soon after the last operation. You're 2 weeks out. You're right in the mess of it. Wait. So what if it was 6 weeks and you dilated and they didn't get better? I would operate. What do you think the problem's gonna be? At the GE surgery, it's too tight. This patient's never gonna be normal because you're gonna keep going back and forth, then they're gonna have reflux, then they're, and they're gonna need to disconnect eventually. So you, you think it'll be that the bundo's too tight. I agree with that. He must have used mesh and it's just a, yeah. No, I think, well, it depends how they did the repair. You're going to find out when you go in there. He didn't do the surgery. So, the, the, the problem that I've seen in this situation, and this was an older patient, but literally couldn't get anything down exactly as described here, it was the, it was the posterior curral suture. So, in repairing the posterior cruise, instead of just placing a single stitch back there and making sure that it's quite posterior, there were two stitches, and that next one was a little bit more anterior. But the course of the esophagus goes anterior to posterior as it crosses the diaphragm there, and that posterior crural suture makes a pinch. That's why the bougie always gets, yeah, that's why the bougie always gets stuck there, and you kind of have to manually straighten that out to get the bougie through. And I took the top stitch out first, did some contrast on the table, still a complete obstruction. Then I went and cut that top posterior stitch, injected contrast again on the table, and contrast went through. And so then I actually replaced the top stitch to redo the fundo back how it was. And then the patient did fine. So it was literally a single stitch mechanical failure. I'm not saying that it's, if you don't know who did the operation. But that guy stretches. So, so, but, but Sean is, is, is completely right, I mean. Usually if you do a, a Nissan with a Bugi, uh, usually the problem is not the Nissan, it's, it's, it's the, it's the Crua, and usually what we do actually is after doing everything, we get the Bugi into the Thorax and then again to the, to the Nissan to see how it goes, if it goes smoothly or not, just to prevent that step in the Kura repair. So that, that's my question. So that was one example. It could have been very easily that they put in a top. stitch that was causing the problem. It could have been the fundo. I think Sean brings a great point that you got to think of it that way. It could be, uh, it could be the mesh that was causing a problem if they used it. It could be the top stitch, the bottom stitch, or the fundus. You have like 4 possibilities of what it could be. So my question is for Sean, or for anyone here, how do you determine that in the operating room? Uh, you use contrast. Could you put an endoscope down the whole case and, and do one thing at a time and see what happens, Sean? Yeah, I would think if you're more facile with EGD, then that would be a good way to follow your case. I agree. But you're gonna eventually have to, if you operate, just take down the fundus, the fundal application, and then uh assess the esophagus and There's a high likelihood you're gonna have to redo the curl, uh, the curl wrap anyway. And so, if you take that down, then you've essentially got a, um, a hiatus and a fund application that needs to be redone. So then you just redo it correctly, so to speak. OK, I guess the next one, Jason. Yeah, there you are, Mark. You want to say something. Yeah, no, no, I was just gonna say the, the other point is, you know, what, if it's not all stuck together, you, you probably, you know, you might be able to just go in there and just do what looks like, uh, Miguel did here, just fix the, you know, fix what was obstructing in the crew and leave the wrap alone. Yeah, a lot of that depends on how far out after the first operation you go. I mean, if you're a year or longer, it's likely scarred in, but if you're, you know, soon relatively soon after the operation. Then, you know, you might be able to just cut it. Well, here's the answer. Uh, uh, uh, they did an EGD. They were unable to pass the scope and laparoscopically, they were, uh, obstructing suture that would release uh by cutting it, and the scope were able to pass through easily. I think we have a next slide, Jason, or not? There you are. And this is what we're discussing basically. Again, watch tightness of mesh around the GEG, not only the mesh, but, you know, the, the, the repair of the cruel as well. And again, even with using the boujie, again, watch the repair of the cruel culture and the tip is putting the bougie inside the thorax and again to the stomach even after doing everything. And what Todd said about the other stuff is going to technical, see every 3 or 4 points that you be sure that your Nissan is not too tight or recruiter repair is not too tight. Any thoughts? Any other points? So, I, I think though, Miguel, two points. Uh, one is I think you need to make sure your bougie is big enough, you know, and we, we wrote a paper about 20 years ago that has a chart, and we used to always use the chart, and it's a good guide for, you know, the based on the patient's age and weight. Um, and the other one is you have to pay particular attention when the anesthesiologist is passing the bougie, what it actually looks like when it goes into the GE junction. Cause if there's any hang up, and it's, it occasionally will go posteriorly, then you know that, that, um, that curl stitch is too tight and you need to uh loosen it up. You need to cut it and then, and then either leave it alone or redo it. I guess the last technical point is we, we've gotten rid of the posterior crural sutures, so with the minimal dissection, we create that retroesophageal window and then, and then leave the posterior cruises alone. Wow, really? That's a good point. We just finished up our, our prospective observational experience and um uh submitted the paper to the IPEG Publication Committee. So it maybe it's just that you gotta pick one, you know, like when you do a Nissan, you do posterior. Uh, when you do a paraesophageal, you're mostly worrying about anterior. Maybe the issue is just to pick one side or the other. The problem is when you get it from both sides. No, there shouldn't be any anterior suturing, I would think. And uh most of the time, most of, most of the time there does not need to be anterior sutures most of the time unless you have a, unless you have a huge, uh, in a big paraeso. We're talking about our baby Nissan, but in a big paraesophageal. The question is how do you best close this huge Grand Canyon and a lot of mainly from posterior, interior, yeah, all right, Dan, oh, go ahead and Sean, Sean, Sean, I did wanna ask, uh. Uh, Kansas City is not doing the collar stitches anymore, is that right? Correct. Yeah, there's just, just 3 stitches now. All on the fun though. That's great. Miguel, is this the last 5 days because I have a question. It's the last one from the 2nd case. Yeah, OK, so Dan, uh, von Olmen, so you now have this patient. You go back in and it, it, uh, you, you find that actually the cura were not the problem, and it's the fundus. It's the fundo. You have a bougie down and so you take it down and you redo it a little bit looser. Now the patient has reflux. Uh, and you keep going back and forth between reflux and tight, and reflux and tight. You know, these two things battle each other and, and, and, and I feel like these patients never get perfect. They're always gonna have a little bit of an issue or if they don't immediately, they may in the future. Maybe I'm being overly dramatic, but that seems to me to be the case. How do you I, I agree, and I, the residents will tell you my standard quote is, I hate this operation, whether it's open or laparoscopic, because you're trying to do a mechanical fix to a physiologic problem, and it's uh miserable. I anticipate this patient will have trouble even when you're done. Miguel, have you operated yet? No, no, I anticipate it's gonna be, not again, right, I anticipate the patient will, will have trouble, and then I wonder if a patient who's gone through this more and more and more, if, if doing a disconnect would be the only way to get this patient out of trouble. And that would be, you know, and we're learning from people who have done these a lot. I know Dan's done some people on here. I've only done one or two, I don't remember if I think one. So, uh, and I did it open, um, but I know that I, I, I know that people like, um, from, from, uh, where is it, West Virg or from, uh, East, from Virginia, Commonwealth, they're saying that they do them in totally normal patients, totally cognitively normal patients, and they do OK. Dan, doing gastric disconnects, I assume you're talking about, yeah. Yeah, I think it's a, personally, I think it's a great operation in the right patient. The ones I've used it in are people, are patients who typically don't take a lot, you know, uh, uh, patients with multiple issues, um, who don't take a lot by mouth, who have problems with their current reflux, or they've had 5 or 6 attempts at a Nissan. A gastric disconnect is a, is a great operation. Yeah, OK, one thing about that is that, uh, you know, we, we've got a reasonable series of those, and it's some, you know, I, I try to choose the patients upfront and the kids that are cognitive, usually kids that are cognitively impaired. I've not done it in cognitively normal kids and the operation, at least in our hands, is, you know, you do it, if you do it as an initial or maybe after one failed fundo, they sail on through. Uh, you can do it with a scope. Uh, the ones that have had multiple fundos, um, have Yeah, take a while to take a while to recover. My, my end of one was spectacular recovery, but and changed their life. So I'm a total convert and it was after watching it on the update course. I'm converted to this. I thought it was crazy and now I love it because of my end of one. A great operation in the right patient. I think that's level 5 evidence, Todd. I'll take it. Let's go. Do we go to the next one with Jason Todd? Yeah, go. OK. So this is our, our last case. Um, so this is a newborn baby. Uh, you're called to the bedside, uh, they're unable to place, uh, a newborn baby, uh, intubate in the delivery room for some instability. Uh, they did this chest x-ray. That you see here. And then I'll go to the next slide too. And they also are unable to place an OG tube immediately after placing the NG tube or the uh uh ET tube. And this is the chest x-ray that they have, they, that they give you. So, baby's intubated. OG tube is, uh, you can see there, uh, high up. Um, Based on this, does anyone have any specific thoughts, uh, besides, uh, esophageal atresia, and tracheoesophageal fistula? Obviously the baby was fairly unstable at birth, which doesn't necessarily speak to normal esophageal atresia with the tracheoesophageal fistula baby. The heart is in the wrong place. Yeah, I was gonna say, who, who put the uh tube and how hard was it for them to pass that tube or how'd that go? Yeah, so the OG tube just stops. That was apparently was repla replaced by a surgery fellow. ET tube uh was placed easy. um. They did get an echocardiogram that showed mesocardia and then some hypoplastic pulmonary arteries, uh, SVC, uh, that's, uh, persistent on the left and then a mildly dilated right ventricle. Uh, day of life too though, uh, baby starts to rapidly decompensate. So this, uh, how old is this patient? I mean, how premie is this patient or full term? 35. 35 weeks. So, but 35 weeks and 2 kg. You compensate in what way? Respiratory wise or respiratory wise, increasing settings, abdominal distention, acidosis, uh, respiratory and metabolic. So Next step, yeah, next step after that with the baby who's getting worse, systemic, systemically. So, you gotta do something, obviously, right? Gotta do something to control that fistula. You're gonna go to the OR with a thoracotomy. You're gonna go with a thoracoscopy to try to ligate the fistula. You're gonna put a G tube in at the bedside or in the OR. I personally, I think with the dextrocardia, that's gonna be a challenging thing to see. Um, Uh, thoracoscopically. To get, uh, uh, uh, you know, it all depends on the baby's physiologic status. Another option would be to do a laparotomy, mini laparotomy, do a G tube and put a, uh, vessel loop or something around the GE junction so you can control that, ventilate the child, and then address the, something in the thorax when the child would actually tolerate it because you can ventilate them. I, I, I agree with, with Dan completely depending on how the, the child will tolerate the, uh, anesthesia basically I, I agree. I agree with, I agree as well. Some comments from the, from the audience, just so you guys can be aware, if you can look at the chat, there's a lot of discussion throughout this whole thing. Um, one person says gastric distention causing respiratory compromise. Is there, someone's wondering if that's free air. Um, uh, and, uh, that's, uh, Mukul who says that I, my comment on that is, I don't think oesophageal perforation high up in the pouch or high up in the esophagus would give you intraperitoneal free air. But that is a common misleading thing when you have a preemie and you have a perforation that can look like it's behaving like an esophageal atresia. That's why I was asking the age, but uh, it shouldn't give you freer. We have someone says bronchoscopy first. Someone says, advance the ET tube into the bronchus beyond the fistula to temporize. Is this an esophageal lung, um, repeat an echo, um, The baby has an extremely poor prognosis due to severe heart disease, ultrasound, so, a lot of different thoughts. A lot, a lot of different thoughts, yeah. All right, so a few minutes later. Worsen, apparently worsening decompensation, went to the OR, uh, too unstable to do a bron bronchoscopy, apparently, uh, and then, uh, got a G tube placed, uh, stabilized out a little bit after the gastrostomy was placed and put under water seal. Um, uh, but then, uh, I guess during attempted, uh, fistula ligation, the patient decompensated further and then emergently had to go on ECMO, uh, at that point. Jason, sorry, how did they put the gastrostomy open or how? So This patient was put with a laparoscopic gastrostomy. So would anyone have done that? Uh, I mean, if you have time to do a gastrostomy laparoscopy, you have time to, you know, do something on the esophagus as well. Yep, yeah, I think you have to occlude the esophagus either if the baby's stable at the trachea and if not at the GE junction because that's really the problem is you can't ventilate. You put, uh, you put up a clamp, even a clamp, something for a couple of minutes, it will get better, and then you can do anything, right. I think when they get unstable enough from gastric distention, if they're unstable enough from that, that you're rushing to the operating room, their second highest risk is that, that when you decompress them, they're gonna have just as bad of a problem. So for that kid, if I'm going to the operating emergently for that reason, I'm assuming that I'm gonna be prepared to just do an open gastrostomy so that I can go and get control of the esophagus. I agree. And you can do it, you know, I put a vessel loop around there, brought it, actually remelded around the esophagus and brought it out through the skin, closed everything. And then when you get everything organized, you just undo it and pull the uh vessel loop out. No, I think at this time, yeah, at this time you're, you're not necessarily worried about incision size, incision site, you're worried about temporizing the baby, saving the baby's life, yeah. When, when Matt was a fellow, he and I did that as his very first case as a fellow. He got initiated. The, the thing, the thing if you have time to do something, you, you, you can put a tie but as high as you can in the sofa was from the abdomen and then you can take it out during the surgery thoraoscopically after. I'm just gonna say it again though. If a patient is decompress, decompensating from gastric, do it, I mean, your fastest way is to go in the belly and get control within seconds. So, if you're, that's a good indicator that when you release them, they're gonna get sick again. Yeah, that's, that's an extremely valuable thing to know and everyone out there. So this baby now is, was stabilized on ECMO, so there's, you know, more time to try to attempt to figure things out and so, um, chest was open and fistula was ligate the trachea, but then there's a second fistula interestingly seen at the distal esophagus just above the GE junction, and that one went right to the level, right to the lung, right directly into the right lung at that point. That's why you got a bronch all these kids. Yeah, I agree. Everybody. Yeah, so this is what, this is what they saw in the OR, your trachea, your distal esophagus going into the trachea, your right lung, and then an esophageal lung fistula at that point. So, Baby is still the same on ECMO after a couple of days. Hasn't shown any improvement. Lung is still white, both lungs are still whited out. Uh, clip is on the distal esophagus that was tacked to the vertebral column. Now starts developing some clots in your arterial canal. Based on that, trying to help the family understand and a bronchoscopy is done. So you can, you can see then a, a fistula, uh, the fistula site that was seen, uh, but there was no carina. There's no right main stem bronchus. Uh, there was just the one fistula, uh, site, uh, seen in the bronchus at that, or in the trachea at that time. Uh, and then at that point too, trying to get more distal showed just there was no observable left segmental bronchi, uh, seen, uh, and it looked, the left bronchuss looks stenotic. So further imaging at that point was a CT scan. You can see the ET tube in the trachea. There's a clip. You can see a large clotted non-aerated right lung. And no observable, right? Bred main stem bronchus. So if you had the CT scan first before you had the bronchoscopy. My initial thought would be, did the clip or did the division come across the right main stem bronchus as opposed to the, the, the, the fistula. But you have a bronchoscopy now that shows that There's actually no right mainstream Bronca. So would anybody offer anything next? Based on this, based on you have a somewhat or completely, you know, very stenotic left. Left main stem, no apparent right mainstem. Cloud Sitiro cannula. But the right main stem was there, I mean, the right lung was aerated at some point. Right, right, right lung was aerated during the initial operation. And on the bronchoscopy, there was a small orifice going to the right. There was no orifice going to the right on the bronchoscopy. So there, there's, there's the trachea here without a carina that just cones down to the left, and then there's a fistula, the the other, the fistula that was ligated. But there was no secondary fistula or no actual carina with the right main stem bronchus. The right lung was being aerated through the fistula. Yes. Right, but there is some, there is, there is relat, there's some sort of lung morphology with bronchi in it. Uh, I guess the, the issue I'm trying to get at is, is, is the right lung salvageable or not? Is there a way to reconstruct the trachea? We had a case just like this a month ago. Uh, and there was just a very small, very stenotic right main stem, um, that was essentially not there. We did a median stenotomy. And uh reconstructed the trachea. And then pulled the esophagus together behind it. How old was that child? Uh She was about 1 month old, 4 weeks, maybe 6 weeks. How did you reconstruct the trachea? Uh, this was done with our, I won't take credit for it. We have this great airway group here. Uh, Mike Rutter, one of our ENT surgeons, uh, we did the median sternotomy, and he basically just cut off the, uh, this abnormal connection to the trachea. Uh, then, um, With, uh, in fact, divided the trachea, with the trachea out of the way, I pulled the esophagus together behind it. Um, and then he just reconstructed the trachea and fish mouthed open this, this very abnormal right main stem to create a connection to the right lung. What did the left side look like? Uh, the left side was very kinked and very stenotic at the, at the orifice to the trachea, but once you cut it off, it was fine. The biggest problem was that, um, the, uh, a significant segment, the initial treatment was much like this where the, the fistula was ligated. Unfortunately, it was ligated like 2 centimeters away from the trachea, so there was a large amount of esophagus that was lost. And so I couldn't get the two ends together. Primarily, we just, I just tacked them together and we're actually gonna stick magnets in that kid. Mac will probably have a heart attack, but uh gonna put magnets in, because the two ends are now end to end, but there's no anastomosis. It That's great. That's an awesome, awesome save. It'll be great if it works. Yeah, it, it's great that you're able to at least approach that. I think that's, that's fantastic. So this, this baby continued to, to compensate and have continued clots in their arterial cannula and so um there was a multidisciplinary discussion about doing a similar uh tracheal reconstruction operation, uh, as well, um, but the baby continued to have issues with clotting and arterial cannula. Um, and so there was also a thought that with the abnormal bronchus on the left, that some of that abnormality and stenosis was coming from this large, uh, non-functional, non-aerated, clotted lung on that right side. And so the decision at that point was to, to do a pneumonectomy, uh, to try to salvage, uh, whatever functional left lung and open that would be. And so, um, that happened and then, uh, Left, uh, then the next day they did a bronchoscopy looking at the, at the left side and it was still really, really narrowed. Um, and so this would be the same question I guess then for Doctor von Alman at this point too, with the exceedingly narrowed left side, would you try to operate, you know, try to, uh, do a sternotomy and operate on this at this point? Would you try a, a slide? Would you try to reconstruct still at this point? Yeah, I'm, I'm not sure. It's, uh, it's certainly not a classic slide tracheoplasty, which we do a lot of. But, but I think, you know, exactly what I described for this other case, you can, uh, divide the bronchus at the trachea where it's abnormal, fish mouth it open, and then reimplant it, uh, reimplant it into the uh main stem trachea. It's not always perfect, but it's enough to ventilate and it's stable. It, it depends on also how long is the stenosis. Exactly. Do you do that on, on bypass or on ECMO? We did that on bypass, bypass. OK. Well, unfortunately, uh, really quick, the chat is, is loving the discussions, and a couple of questions that came up since we were talking about the clots coming up in the cannula, uh, Doctor Liu brought up, you know, maybe we could readdress what happened with the cardiac workup. How is this, this baby's heart? And then Doctor, uh, Kirstenbaum was wondering, you know, with these clots in the cannula, how is the patient hemodynamically? Is that gonna guide your management one way or the other? Yeah, I think those are all, all great things. Even too with the hemo, the, the clots and the canna, trying different, uh, heparinization strategies, going to bivalve Rudin, uh, things like that, maximizing your ACT, uh, while men trying to minimize your bleeding risk, uh, is important things that, uh, you know, and this patient kind of were tried, um, and there was even discussion about, uh, you know, removing and replacing an arterial canal, um. Uh, too, I don't know if anyone has ever had that experience, uh, of a patient that's currently cannulated on VA, uh, removing an arterial cannule and placing a new one. A 2 kg baby. 6 Exciting Mark, you, you're smiling about that. Would you have something you would offer? Taken. Um, I think, I mean, I replaced the cannula on a kid, you know, for it's, it's not fun. Vacation. Yeah, that's a great idea. Yeah, for this particular kid, uh, uh, the, the outcome was not as good as, uh, hopefully the one that Doctor von Oman, uh, was gonna report with his case, but, um, the, you know, the bleeding, this patient had significant bleeding des despite whatever was happening and so eventually they were able to optimize things to get the baby off ECMO, uh, after a couple of days, um, but then continued to have significant, uh, Uh, hemodynamic instability that even continued while on ECMO, um, and then, uh, parents decided, uh, to withdraw at that point. Um, but, um, I think the important thing is to realize that, uh, like Doctor von Oman had said, there's still options, uh, there's options for these, these babies, um, and it's an aggressive thing, but this patient did have what someone had said in the chat was an esophageal lung, and that's what it, what it was. There's, it's very rare, it's about 30 or so cases apparently reported. Um, but it's where your bronchus from the, to the goes right off from your esophagus to your bronchus, but there are, you can reimplant it and, uh, you know, reconstruct the entire trachea or pneumonectomy is with the hand was kind of forced in this case for that, but, um, there are options. Jason, when I was in um The UK, like a few months ago, I had to figure out what group it was. They have a series of these esophageal lungs, and they're looking to meet up with other institutions that have seen it. Um, I'm blanking on what city it was, um, but they, I can connect you with them because I think, uh, there's a, there's a sporadic number of these, and I think we need to better understand this group. Yeah. Nottingham, that's where they were from. Anyways, this is a tough case. You know, I, the, the mortality is so high. Um, we had another variant of this, uh, Daniel, remember where, uh, the fistula went straight to the, it was a bronchioesophageal fistula, uh, but it, it, it was not, it's like this situation. Um. Any other thoughts, comments from the audience? These are tough cases and I appreciate you guys, uh, um. I appreciate you guys presenting these. There's a lot of comments in the chat, um, and we can continue this. Now, let me just, um, I conclude here. I think we can, uh, finish here at 3 o'clock. Um, uh, Sean, unless you wanted to present your case. Um, no, I'm good. OK. I, I appreciate everyone coming on from all over the world here. Um, I know that we have a, um, several 100 that have stuck with us, probably, well, it's a lot of, a lot of you, uh, more than several 100. Um, but, uh, thanks for sticking around all day, all, all night, all morning. Um, and, uh, we will, uh, hopefully be able to do this again next year, um, and I, I really appreciate, um, everyone taking time all day. So, uh, with that, uh, good morning, good afternoon, good evening, and we will see you next time. Thank you. Bye-bye. Thank you. Thanks, Todd. Hey, Todd. Thank you all. Thanks, everyone, you guys.
