Esophageal Disconnect for Severe GERD in Neurologically-Impaired Children:...

So first we'll start with a couple of cases. You have a 4-year-old neurologically impaired boy that's had, uh, 6 months of vomiting and respiratory difficulty. He actually had a Nissan fun implication laparoscopically as well as a hiatal hernia repair, uh, really as a, as a, a young, uh, child, 6 months of age, also had a gastrostomy tube. Um, in addition to the symptoms, uh, they tried a trial of GJ feeds that were unsuccessful. The tube continues to fall out in, uh, frustration for the family. Clearly he's got severe uh recurrent reflux on upper jaw and appears to be a recurrent hiatal hernia on the study as well. Interestingly, he also has Lee syndrome, which is a genetic problem that's, uh, associated with, uh, some degree of, uh, shortened life expectancy. Um, and so in actually consultation with the family about redo fundlication versus a dissociation, the family actually leaned towards, um, uh, dissociation, but in, in discussion with a neurologist because of the child's shortened life expectancy and. The decision was made to move forward with um a redefundification. Actually this is a, a case from a couple of weeks ago. Well, let me, I guess, pull the audience, I guess what, what would, uh, their next step be? Uh, continued maximum medical therapy, continue trying to do GJ feeds with the different tubes and so forth, redo fundlication and repairing the hiatal hernia, possibly with some, uh, placing of some mesh. Or maybe just a surgically placed J tube with a G tube to gravity, dissociation or disconnection, or even to some degree of TPN in addition to enteral reduced enteral feeds. Does the child eat? No. Nothing by mouth. Well, I would do B, personally, you know, they, they having done a few of those, I think that the red flag here is a chronic respiratory problems. No, this patient has a respiratory issues even after an incident, you know, the, so, but I'm not sure that B is the right answer. Well, interestingly, when we presented our stuff at IPEG, the morning session, actually there was, uh, someone quoted Albert Einstein, and that one his quote is, you know, the definition of insanity is, uh, continued. You're trying to redo the same applying the same solution to the same problem and expecting a different outcome. So again, it's, you know, certainly, uh, you could argue, well, maybe the first operation wasn't done well and certainly could play some mesh. But again, a child, particularly, as we know what the risk is of hiatal hernia, um, with, uh, their chance of failure, so the child has a recurrent hiatal hernia as well as recurrent reflux by mouth, right? Correct, yeah, I mean I. You know, I know, I know we've talked about this before. I mean, I'd go with, I'd, I'd go with Dee. I'm sure Dan would too, um, you know, I think, uh, I don't know, Steve, what would you do? Well, it depends whether I did the first procedure. No, seriously, so you're saying that, well, I think then I would absolutely. No, it's, I mean, I think like anything else, the operation, the success of the operation is somewhat surgeon dependent. And so I would want to know if, if I did the operation, I would want to know if he had a hiatal hernia the first time I did the operation or did he develop it after I did the operation. I would, you know, I would probably evaluate him. I, I, I think moving towards a dissociation is. As this talk is a reasonable thing to go, but you know, a redo fundo with a hiatal hernia repair is a 30 minute operation without cutting open. The stomach or disassociating the esophagus, all things which can have significant morbidity. The morbidity of a redo this and fundoplication, again depending on who's doing it, how the first operation was done, and what your results are, is pretty low other than long term complications. So you're changing, you're changing the potential morbidity of the operation based on what you're doing significantly. And so I, it would be very dependent on what I did based on what the history of. That procedure is um and my involvement. This child did have a hiatal hernia from the start and I would argue that parenthetically to me that's very unusual. I mean, at least for me, I don't see many true hiatal hernias in six month olds. I mean occasionally you see it, but to me it's not, it's not very common. So my, my first redo procedure would be I would do redoing this and then I would repair the hiatus with pledgeted sutures. To buttress what is going to be a weak musculature because of his neurologic impairment, would you put mesh in his in the camera. I never put mesh in. David, David, did you have a comment? Yeah, so, um, and just adding to, to Steve's comments about how the first operation was done, you know, uh, the, if you have a A large hiatal hernia and you're thinking about doing esophagogastric disconnect, that's actually going to impact your operation as well because you, you may potentially end up with small bowel up in up in the chest that that makes things more complicated. If you did the Kansas technique where you're not, you know, mobilizing all of that esophagophrenic ligament. And you're leaving a lot of that stuff intact. I think you're you're probably leaving yourself your options open better for for your esophagogastric disconnect. If you had a hiatal hernia at the first operation, they probably opened it wide, and I think that that's going to put your disconnect at a little bit more risk of getting bowel up into the chest. Uh, Certainly some redos in my experience have been pretty straightforward. Others can be pretty challenging, certainly for the hiatal hernia from the beginning and a lot of dissection. And so going along with, uh, the neurologist, we decided just to move forward with a, a, a redo lap fundation, hiatal hernia repair. Again, this is just a couple of weeks ago, um, some adhesions up by the hiatus, and as you really dissect up more, you find that again it's things are fairly stuck in. Um, get to the hiatus. Certainly see a pretty sizable recurrent hiatal hernia. This is, uh, closing the hiatus posteriorly, mobilizing the GE junction down, uh, fairly well closed, uh, here and tacking the esophagus down, and here's the redo of the wrap. I like to actually put a prolean suture in, almost like a baseball stitch to reinforce my silk sutures, just anecdotal experience. Uh, so this is a different case. Case number two, what was the poll? Did the, did we respond to the first? Yeah, let's see, uh, so 50, 61.1% did redo lapnusin and hernia repair. The second most common was D, uh, which was the disconnect, 22%. So a little bit of a different twist. Uh, a nine year old child neurologically impaired again, um, 12 months of bloody amesis with, uh, several episodes of admission for aspiration pneumonia. Uh, had an openness in, uh, a number of years ago, a hiatal hernia repair at that time, and a gastrostomy tube placement. EGD shows erosive esophagitis despite persistent, uh, maximal PPIs, and really they've had to switch to continuous feeds for her G tube because of the emesis. So again I'd pose the same question in this patient, would we consider, would people be more inclined to consider a dissociation as opposed to redoing the phone back to that scenario again. I think one thing to point out too is that sometimes these patients will come in and on continuous feeds and they're they they'll say, well, we're not vomiting and the patient's not vomiting anymore. Well, they still may have bad reflux, and again, as this patient had erosive esophagitis, yes, you may not have it vomiting out or you may be even having respiratory problems, but you continue to have a lot of discomfort and, and, uh, irritation of the, of the esophagus. So this is broken down, um, yes, it looked like there was obvious reflux and well I guess my bias today and that's just this is just my own experience is that I would do a sec or a first redo or a second fundo quote always uh but after that. Uh, and having never done a disconnection, uh, I think it's a very attractive third option or option for a third time, and I, I would agree with that, and I would, I would suggest that as an advocate of the dissociation procedure we've mostly used it in kids who come to us and they've had 4 Nissans or 3 Nissans and that gets to the. Einstein quote of expect a different result if you do this again, we know the failure rate of that's fairly high, but the question is, you really, how many of these kids will fail beyond that 234 year period. And again, many of these will have a life expectancy that's 2030, 40 years. And you know, our adult colleagues are probably not going to be very excited to inherit some of these patients as 25-year-olds that have, you know. The 4th redo operation, but they're not here so I think I think I told you about, you know, I, I have this family. There's this, there's a saint in Atlanta who keeps adopting these neurologically impaired kids and, uh, you know, I had one of his kids that I that I did this on after 2 or 3 fundos or something. And it went fine and everything, but then the next, you know, then he had a couple more of these kids that were this patient more or less or had bad reflux had never had a fundo, and he was begging for a primary disconnect, and I did them and those kids flew. The difference between a primary disconnect, you know, and then also, you know, again, you know, I, I do these laparoscopically. It's basically a gastric bypass with a G tube, right? And if they're big enough, you can even get that EEA through from above with the one that you can put through the mouth and the little kids, you still have to hand sew it. I don't know if there may be anybody in the virtual audience from the UK, but when I first saw this presented a number of years ago, that was exactly the presentation was doing this as a primary operation. And and what I've seen is in the kids that you've done redo redos, they seem to have a much bumpier, and this is anecdotal, I don't have enough power to even say anything about it, but those kids just seem to have a bumpier postoperative course. So what's going to change the thinking on this and I have, I, I think that you all may be exactly right. What's gonna change thinking though is some longer term uh outcomes and and you know say you say you can have you can get 30 kids out 10 years and none of them have had a problem and none of them had had another operation well that's gonna sway people but because we know what's gonna likely happen if you do a redo fund or what may happen if you do redo fund. So anyway, I think that I think that long term surveillance of this patient populations could be really important my question. So briefly on quick background, uh, you know, obviously we know that um it's controversial, but, but many do believe that neurologically impaired children have a higher incidence of, um, reflux disease, and then certainly that, uh, when treated with a fundlication there's a somewhat of a high failure rate. Unfortunately, a lot of these kids are, uh, once they fail, placed on PPIs and instead of, you know, given GJ feeds, which is pointed out earlier, continuous Ggenoscopy feeds is just a, uh, not a great long term solution. And a lot of these kids are quite miserable, as are their care providers. Some of the surgical options, uh, redo fundification, we've touched on that. Concern about the failure rate of this operation, um, I think, uh, some would advocate for a jejunostomy tube again fraught with continued problems and, and really not ideal for the, for the patient or the care providers. Certainly Bianchi uh introduced the idea, the concept in a, in a paper in '97. Um, that, uh, really is, uh, proposed as a rescue operation for these children who have had a, a fundlication and have recurrent disease. So again, what we're talking about is, uh, really dividing the jejunum, uh, bringing up a roe limb. This shows it being, um, you know, retrogastric, retrocolic, uh, we often now try to do an anti-colic and anti-gastric. But we do try to preserve the um the vagus nerves, one if not both if possible and do an end to side esophago jejunostomy and then a jejuno jejunoscopy. We do all laparoscopically as well. Uh, in terms of some results, just briefly, uh, European results, a lot of this is out of Manchester, of course, where Bianchi was, and, and, uh, continued, um, publications from them. So it really does, uh, effectively, uh, cure, treat the reflux disease, and also the respiratory complications associated with the reflux. Uh, their nutrition often improves because now you can reliably give these, uh, children feeds, usually in a bolus manner. And um you know, I think to touch on Mark's point too, um, quality of life, and not only have they shown some studies, and we have some preliminary results showing that the care providers of these patients really feel as though it's a dramatic, it's a game changer for these kids and for them as well, caring for them. Um, there has been a little bit of, uh, evidence looking at, uh, dissociation versus complication, sort of in a retrospective manner. Uh, it does show that dissociation is associated with increased OR time as expected, increased length of stay and time to full feeds, but, um, improved reflux results and lower failure rates. Um, just a few studies out of the United States, um, uh, Danielson out of Rochester, New York looked at 27 patients. Um, these are a mix of kids and adults, um, neurologically impaired patients. Um, they, uh, really determined there was a definitive treatment and, um, for these patients, and, uh, but only 3 of them had prior frontal patients, so really they had 24 patients as a, as a de novo procedure, did have some minor major complications, but really, uh, pointed out that it really cures the reflux and allows for bolus oral feeds. And suggests it's a great operation for knowledge impaired patients. Interestingly, and this was presented in '98 at ABSA, Witt, you were one of the people who commented on the paper and that, that's an interesting. Oh yeah, I remember that. Um, so 10 back then, right, yeah, just a few years later, um, a, a paper out of San Diego looked at their experience, just a handful of patients, 7 patients, a fair number of minor and major complications. However, they still felt it should be considered for neurologically impaired patients with a current reflux disease, um, and, but they did say that they would suggest, um, that it really be after a more conservative procedures have failed, not so much as a, as a de novo procedure. Then lastly, the only really other paper, uh, from the United States is, um, from, uh, um, uh, in Michigan, yeah, um, and that, uh, again in 2004 just a handful of patients, 10 patients, they had, um, um, one, they'd all failed at least one fund application. Some, uh, had failed up to 3. I think half of their 10 had at least two fund implications. Uh, did have some, uh, complications. All these, uh, the studies really were, um, of open operations, so some of them had some wound complications. There's some other reports of adhescences of the wounds and other, um, studies, uh, but they did stress the value of being able to do these feeds in a bolus manner after the operation as opposed to continuous feeds, um, and they, uh, thought it really should be considered for neurologically impaired patients with a recurrent, uh, disease. So our series started just uh in 2013. We've had 24 patients. Almost all of them had at least one, if not more, uh, fun implications. Uh, when I came back to Richmond 13 years ago, um, they were all pretty much done open before that. So a lot of these patients, some of these patients have been from open ones, uh, part of my arrival. Uh, all neurologically impaired severe reflux disease is determined by, um, gastroenterologists. The first one interestingly was, um, trying to do a uh maybe a third redo on a young child. Got into the esophagus. It was really stuck in. I think I'd placed some mesh before, so it was really was a bailout operation, um, as an open operation. Worked great. She did great. So that really kind of stimulated me to thinking about doing them, um, in some of these other patients and, um, thus the rest of the 20 of the other 23 patients. Just some brief, uh, technical details. Lots of these patients, uh, particularly the open ones, have lots of adhesions. We'll take that down with Hulk, if not, uh, and also the hormonic scalpels really helpful. Uh, we like to really use the Nathan Sutra to really get up to the hiatus and, and get exposure there. We've been able to preserve all the gastrostomy tubes, uh, that have been placed, uh, previously. Um, all of them seem to have hiatal hernias that are repaired after we immobilize the esophagus down into the abdomen. We do anchor the esophagus to the crew. Um, we transect the esophagus, um, really at the lowest, healthiest point for the esophagojedennostomy. The only additional or new trucker place is, um, beyond what you do for a redoni and is a 12 millimeter trochar in the right lower quadrant here the. Um, you see the trochar sites here, the, the liver tractors in the epigastric area, and the G tube again, we've been able to preserve all of our, our sites. Uh, most of the time we'll use 5 millimeter instruments, a couple small kids will use some 3 millimeter instruments, and then the 12 in the right lower quadrant. We've been able to preserve one if on all, uh, uh, both vagus nerves and have not done any pyloroplasties and have found, uh, not have found any emptying problems. Our limbs are about 25 to 30 centimeters. Um, we've really tried to switch more to an anti-colic, uh, placement of the rear limb in some effort to save some time, but also there's some evidence in the gastric, um, the, um, bariatric literature suggests there's less complications with anticholic limbs. We, uh, we've done some staple anastomosis. We did, uh, 5 or 6 robotic esophagoginoscopies. We've really just kind of gone back to hand sewn esophagoginoscopies. We feel that that's nice and secure and, and, uh, no benefit to the other techniques, particularly in smaller children. Um, can I just interrupt for one second to say. You have to be careful, I think, with the length of the rue limb, and I did one of these a number of years ago, and post-op kid initially did well. Mom came back and said he's refluxing, and I get it again, and I said that's impossible. It can't happen. We did a contrast study and she was absolutely right. You feel stuff in the stomach and it would reflux. We'll er more towards 30 centimeters for the rear limb. There have been reports of, uh, bowel refluxing with her tissue. No question. So does that matter how old the child is? I mean, it's 3030 centimeters and a 1 year old is different than 30 centimeters in an 8 year old. So older kids, you may do 35. Younger kids, you probably do fine with 25. So, so, uh, we've talked about this in London. Can you, can you leave a little gastric. Well, there was one he's asked about if can you leave a little gastrogram, a little rim of the cardia to sew, to sew to because there's no cirrhosa on the esophagus to sew to a better. Well, one paper does suggest doing that. I, I've found that really because they have one if sometimes two fundlications, the cardia is really easy to scarred in, and it's, I think there's not much added value to that. And in fact, if you can get healthy, fresh esophagus, it always has great blood supply, and then someone raised a question about that. So I would do an esophago. You agree, Dan? You said I agree. OK. Um, it's very important to close the, um, mesenteric defects, particularly the Peterson defect. We've had a couple kids, as reported in the, in the weight loss, uh, surgical literature. He will have, uh, internal hernias if these, uh, sites aren't paid attention to. Place a couple round drains, uh, channel drains by the anastomosis. We've actually switched to, to adding, um, you know, brospect of antibiotics for several days, particularly those kids that have dissection often into the liver capsule. You know, you're coming across the esophagus, it's theoretically contaminated when you've got the liver, uh, parenchyma, I think sometimes sitting right there. So we'll treat it with antibiotics like a perforated appendicitis per se for, for a few days. Most of the kids get a study in about 3 days. We have a couple of kids that have gone very well, the, the de novo patients. We've been confident and not done contrast studies and just started feeding them. Um, but we have a low threshold again like, um, weight loss surgical patients for going not only for reimaging them but even going back to the OR if we're concerned. One patient, we had some air in the drains, um, and I took him back to the OR, tested things, looked fine, and, uh, it was a, you know, 20 minute look, and the kid went home, I think, in, uh, 36 hours. Why not just do a contrast study? Well, sometimes you'll miss them. So again, I think if you have any concerns. Um, and, uh, we found that some of those channel drains will actually leak some air or this residual air that's left inside that's coming off. So David, have you thought about not leaving a drain at all? I don't drain mine. Yeah, I mean, there's certainly evidence in the, in the weight loss surgical literature not to leave drains, but, um, because, because I, you know, again, you know, we talked about a little bit earlier, uh, in the esophagus is drains may actually cause leaks or cause problems. Yeah, great point. Um, and then some of these patients we've even considered starting feeds on again because it's gonna go in the stomach and downstream and not even really go past the esophageagenostomy, um, and Trocar, well, this is actually the video, hit the button and see if it plays. Oh, there she'll do it. OK, perfect. Thanks, Sophia. So again, uh, historical, so again, you have a, we found there's a lot of patients that have a fair number of adhesions right up by the hiatus, particularly they've had open repairs before. Uh, we found the harmonic is very helpful, um, not only to do some of the dissection of the, of the adhesions, but even to come across, um, the esophagus. So here you can see the hiatal hernia, um, um, closing the hiatal defect. We actually will Place the vagus nerves um uh away from the esophagus as we close the hiatus to kind of keep them out of the way. Here we are anchoring the posterior esophagus to the cur. And the purpose of that is what so it doesn't retract back right, yeah, when you cut it, it'll shoot back up. Oh, I'm sorry, I was one comment somehow I was thinking you were anchoring the, so David, one comment I noticed is I do the same thing. It looks like, so you're operating from the patient's right side just like you would in bariatric surgery, not between the legs like we would some people do on a fundo. Oh, interesting, yeah, so I've actually started doing my fundos this way too, because you can actually, because bariatric surgery, there's no way you can get. Uh, you know, you don't want to put those patients in the lithotomy position. So you learn to do everything from the right side with, well, this is roars. This is, this Penrose really is kind of helpful because sometimes the stomach tacked up still, it kind of gets in your way. You can use that to pull up this, the colon and the stomach together to help you pass your ru limb underneath when you go retrocolon or gastric. Oh, I missed that. That's just the, um, re limb, OK, OK, I mean the I see you're doing now, and this kind of, uh, helps us either, you know, guide and or sometimes we can retract the colon up to pass our our ru limb. And we do an end to side, um, esophago jejunostomy and actually again the harmonic scalpel is really nice to transsect the esophagus just above the staple line and, and, and as well as make your uh enterotomy in the, uh, jejunum. One of the things we've also transitioned from is you really don't need a big hole in the jejunum in this video, which was done probably a year or so ago, you can see that the degenital hole is pretty, pretty generous. Seemed like it does you went retrocolic there, but sometimes you go into college, right? OK, so we've done a number of those 5 or 6. It's, uh, I think Mark mentioned it's really tough on smaller kids, and we just feel much more secure, hand sewn, big nice bites, and, uh. You know, really the, the anvil, even the smaller ones will stretch out the degenerum a lot. You, you know, it's just you feel more confident with a handsome anastomosis, and, and I've actually, I do this running. I don't, I don't you know, interrupt it. I do this with my partner, uh, see, and we talk about every case, you know, I wanna do in 4 quadrants, and he's, uh, follow his advice. He says, no, do it, do it, interrupt. It does take some time, but again, it's, I would interrupt it too. Yeah. What kind of suture is this, uh, 4040 viral. You could certainly use, uh, probably PDS or even silks if you wanted probably yeah, magnemosis would be perfect. Yeah, a bunch of people back here are saying magnomosis would be, uh, perfect. I, you know, I almost talked to Mike Harrison in in London about that. I think it's great. So here's the the complete anastomosis again. You can see the vagus nerves. We've saved the posterior and antepi nerves. Sometimes the tip of the rue looks a little ischemic, but it always pinks up. You can see we put a little air in there, and, uh, we do actually anchor the rumb2 to the posterior. Uh, hiatus just to sort of give it take a little attention off the estimate. David, I had one complication on one of these kids that actually I, I went anti-colic. But you know, a lot of these kids are neurologically impaired with global motility problems. I had a huge colon and it looked all fine when I was done, but the colon had sort of flipped, had slid around to the other side of the rue limb and had been obstructing. And so I actually ended up taking, it was like, oh my gosh, what am I gonna do? And then to convert it to a retro, do I divide the jejunum, go under? Yeah, what do I do? I ended up pulling the colon back over to the patient's left side because it had gone over to the right side and I pulled it to the left side and then I tacked the colon to the rear limb to keep it from sliding back and that seemed to work, but I, but I, you know, the next one I did retrocolic again. The last one interesting we did retrocolic anti-gastric. You know, and, uh, yeah, I usually go anti-gastric, but I, but the, so, so can I ask you a question? You, yeah, what about a neurologically normal patient, because this is, you're doing this in neurologic, great question. Um, there's been a, uh, I think one report that suggested that was a, a good option. And again, I, I think like this time will tell, you know, I think certainly, um, the indications may expand some. I, I think it's really has a role for those that are neurologically impaired that have. I actually have a neurologically normal patient who is begging me to do this, but, OK, so my question to you is this is what I was talking about with, uh, and, uh, if you're doing a gastric bypass in a normal patient who wants to eat by mouth. How are they going to maintain their weight unless you're going to what I told the patient is you will be able to eat by mouth, but you probably won't be able to maintain your weight, so you will also need supplemental feeds at night or whatever to to maintain your nutritional status, but you will still be able to not be able to eat steak and potatoes, but certainly probably smaller or you could, I mean you could eat, we have, I have patients who I've done total gastrectomies for malignancies. And done this operation and they still eat by mouth. They can't maintain their weight, so you have to supplement supplement them. OK, so our series, um, averaged about 9. We've done children as small as 14 months and as small as 8 kg up to 17 years of age and 57 kg. Length of stay is a bit long, 12 days, um, and why is that? You know, usually it's a pretty complex group of patients, you know, sometimes they have respiratory issues, a lot of pulmonary toilet, getting immobilized, um, uh, so we certainly, um, so it's not related to the actual operation. It's related, it's a lot of things. I mean, certainly some patients have the extensive license of adhesions, and it is a long operation. You can see durations up, you know, average about 474 minutes. Quick question about the noble ones is quicker, but yeah, quick question about the duration, I guess you're talking through it. Um, that's the real, uh, everything about this operation, especially the laparoscopic approach, is appealing, and I want to put this in my toolbox. But to add an 8 hour operation into my toolbox, it's just, uh, for this problem, I wonder if there's ways to figure out how to turn this into a shorter operation as complex as it is. Yeah, I mean, we've certainly tried to started to do things that I think, um, will save us some time, uh, again, an anti, uh, colic. Um, Rue Lamb still have to close some of the defects, uh, Peterson's defect, but, but a little bit less time there, um. Uh, you know, certainly, um, how we do the anastomosis, you could make an argument to run, maybe do it in quarters, um, and, um, certainly you're not placing drains, maybe prepping their bowel a little bit ahead of time or just give them some MiraLax at home so the colon's not so big and in your way, uh, taking down the G tube site. You know, maybe a bit quicker, but again, the families really love to be able to have the same old G tube site. So there are things that we've done that have decreased the time some. But again, a lot of these patients, even if you did a redo this and, sometimes you spend 2 hours slicing adhesions to get to the highest, and particularly had an open operation in the past. So, um, our follow-up is a bit more than a year. Um, results again we've actually found great results in terms of wretching and vomiting. It really is minimal, um, uh, in our, our patients we have done 4 as primary operations. And uh again what's really I think uh telling is how these parents, these care providers come back. I've had lots of moms in tears in my office just saying, uh, you know, you've you've given me my child back. So I think I think it's telling in terms of how significant the reflux is in some of these patients and you've seen we've got pretty good again this is uh some uh polls from our, uh, questionnaires from the, from the, uh, care providers about their kids as well as, you know, from themselves as well, very high results, um. And also we found that none of these patients have actually come back and been readmitted for aspiration, uh, related events or respiratory problems, uh, related to reflux. Uh, again, no reflux rate admissions. Um, interestingly too, uh, maybe there's another telling sign. Um, the GI providers in our, uh, in our region have all been sending us patients. I mean they see it's a game changer as well. Um, it does come with a price. There have been some complications, some things we've learned from this, uh, internal hernias, can happen. We have a child that had an internal hernia that had an outside institution and delayed coming in. We had to do a bowel resection and is doing better now. We did have one death, a child with gram-negative sepsis. The contrast studies and the post did not show a leak, but that's again stimulated us to put antibiotics through that peroperative period. Had a few readmissions, but again, um, really I think, um, very few related to, um, the operation itself. So in, in closing, I really think it's a, it's a very reasonable option for these neurologically impaired patients that have failed fund implication, have recurrent disease. Um, it can be really a difficult long operation, um, with some risk for uh minor and major complications, but in this particular patient population, it really may be the best long term result, maybe the only definitive cure for these patients. Um, and as pointed out earlier, you still can take things by mouth. A lot of these patients are strictly tube fed, but many take things by mouth, for pleasure, and they continue to take ice cream and supplemental feeds. It doesn't restrict that from happening. Um, as mentioned, can be used as a primary operation. So our retrospective study results are, uh, encouraging, but no question a prospective study, as alluded to, would be very important to look at these patients long term. Thank you. Great talk. Uh, this is, I love it. This is, uh, exciting stuff. I think I certainly need to be, we've talked about it after I saw his and also now that I see that help with wretching, yeah, because that was one of the things that I was afraid that the patient continued with wretching after the surgery, you know, and that was actually a question from, uh, the audience is uh what is the incidence of non-acid reflux after you do the disconnect and symptomatically they're better, they're not vomiting, um, you know, they, they don't, uh. We haven't really studied them, yeah, because you won't get it because you're far down in the jejunum, so I mean you have a 30 centimeter limb unless they're obstructed distally. It really is a shit, but you need to continue on PPI, this patient. No, no, they don't develop ulcers in the stomach. That would be bad. Are you gonna scope this kid through the jit? Why would they develop ulcers in the stomach, and the stomach's, I mean, it's, it's the reflux of the stomach acid in the esophagus is the problem, but that's disconnected, you know. But if you disconnect that, I don't know, like anybody, anybody else will develop ulcers. Well, if you have a specopeptic ulcer disease, he's saying his point is they're not at any higher risk than anyone else, but you will never know. Unless they get a lower GI bleed, I guess, because you can't scope them, so he's, he's worried about the risk of if they scope them through, through the G tube site. Yeah, no, you just, but you just look through the G tube scope. I mean, the only thing I would say about this is I think I would be, I mean, I think this is a great option, but I think we need to recognize. Well, I mean, and, and, and it varies, but you know these are complex operations, take extensive amount of time, has a significant complication rate, 2 out of 20. You know, or 3 out of 20 went back to our bowel obstructions, major problems long, so it's not something to just say when you compare that to doing a redo Nissan in a kid, you know, a, a standard neurologically impaired kid, a redo Nissan who in, in most of our hands would be a couple hour operation, would be discharged from the hospital the next day or within 48 hours. I mean there's a lot of issues that go beyond and and having a rue limb is not necessarily a benign thing to have in your body for a long period of time. There's significant complications so I think it's a good option and should be considered, especially in those patients who fail a couple procedures but I would be, I would be a little hesitant to go straight there, um. As as a primary procedure because there is significant more morbidity with this procedure and that's why I think the long term follow up days is gonna be really important for you. For you and your group and Dan and his group, because I think that what we wanna know is, you know, what are the results 10 years and over the next 10 or 15 years after having because we all sort of know what our results are now with the redo fundo, uh, so anyway, I think it's really important. I would point out though, sometimes we don't know necessarily you know, sometimes you'll patients will be getting a GJ tube. In 4 or 5 years and the GFI folks may not necessarily let you know and a lot of these patients, I think, don't come back to us once they fail because they don't wanna have a redo operation and, and so, uh, it's following them closely over years over a few years will really tell. Uh, this is great, Khalid, uh, your question about oral feeding, it sounds like we can, you can use oral feeding, as you said, uh, if they were doing it, uh, preoperatively. So, uh, I, I, I know that we are running a half an hour behind. I will tell you that I let that happen a little bit because we canceled one of our half an hour lectures. Karen Diefenbach's lecture is no longer happening. So we let it run a little over, but we are going to try to stay on time for the 2nd, uh, for the 3rd session. We are going to take. Uh, a 20-minute break. We're going to lower it to 20 minutes from 30 minutes. Uh, so we're gonna all have to eat fast here. So, a 20-minute break. We will be back for the 3rd session. David, great talk, great panel session. Thank you guys very much. We'll see you in 20 minutes.