Ulcerative Colitis and Familial Adenomatous Polyposis: Update Course 2016

Um, ulcerative colitis and FAP, thyroid disease, and enhanced recovery after surgery. And to start it off, we're going to Doctor Jason Frischer, uh, who is the director of the, uh, Pena Colorectal Center and also, uh, director of the ECMO, uh, Center at, uh, Cincinnati Children's Hospital. So, uh, today, he's gonna be talking to us about considerations with ulcerative colitis and familial adenomatous polyposis. So, Jason, great, thanks for joining us. I appreciate it. I look forward to going over the adventures of J pouches that we all have, uh, endured during our times and maybe we could share some tricks, uh, throughout this short session. I start with a case of a 12-year-old male in our hospital who was diagnosed with ulcerative colitis. He presented with abdominal pain, vomiting, and dehydration and weight loss. He had fevers, bloody diarrhea, required 3 blood transfusions over the course of his two week hospitalization. During the hospitalization, he also had a PICC line placed and was started on hyper alimentation. He had a pretty benign abdominal exam, elevated inflammatory markers, and was hypo albumin anemic and anemic. He was started on infliximab and, uh, dosed with, uh, IV, uh, steroids. So in this type of situation when the surgery team is consulted, there are a number of, uh, of considerations that one must undertake. I've listed some of them here and so. Uh, one has to consider, uh, the nutritional status of this patient. Would you start TPN or delay surgery? What's your feelings about the albumin in this patient? Uh, the steroids, would you want to wait or taper the steroids? Uh, would you give stress dose steroids? I think thromboprophylaxis is a very important consideration in this patient population and then of course the surgical interventions that, uh, for consideration. So there's a very good paper out of the Cleveland Clinic a few years ago, uh, again an adult sample, but looking at albumin levels and adverse effects after pouch surgery, and I've highlighted the upper part of this table, uh, demonstrating that, uh, there are two real highlights of this that I think one should look at. One, they looked at albumin levels of greater than 4, 3.5 to 4, and less than 3.5. And then it also looked at the complication rate. Anastomotic leak was significantly different in the hypo hypoalbumic patients compared to those with a more normal albumin level. I could tell you I reviewed our data in Cincinnati and of the last 50 patients that we did. Uh, Jay Pouchon, none had an albumin level of greater than 3.5 at the time of surgery, and so I think the patient population that we see as pediatric surgeons are different than the patient population in the adult, uh, literature. I think some of that stems from the adults often do a reconstructive surgery for dysplasia. Extremely rare in our patient population to see dysplasia on. Uh, on surveillance biopsies, amongst other reasons, so I think that's something to consider when approaching these patients. I wanted to touch on thrombo thromboembolic prophylaxis, so I don't know if this is a survey question out yet, but, uh, if we could answer, would you use compression boots on a 12 year old patient, subcu heparin, Lovenox, or a combination of compression boots and heparin or Lovenox, and we'll get back to those answers a little later. Everyone here could try to answer that as well on their phone. There was a consensus statement that came out a few years ago, that is followed, and there are two surgeons on this panel of experts that gave us a review of what to do in patients with acute flares of ulcerative colitis, and these were the take home messages. One, delay in surgical intervention to enhance nutrition is not recommended. Children undergoing colorectal surgery should be treated with antibiotics of appropriate spectrum starting 24 hours, uh, starting before surgery and terminating 24 hours after surgery, and pre-op steroid administration is associated with increased risk of anastomotic leak and infectious complications. Some practice points lower down include a low serum albumin marker is associated with increased risk of post-op infections, and they suggest prophylaxis against venous thromboembolism is best considered, but they don't go any further into giving specific recommendations. So in this patient that I presented this 12 year old with an acute flare, uh, sitting in the hospital, what operation would you consider performing? Would it be a subtotal colectomy, an ileostomy, uh, total procto colectomy, reconstruction with diversion? To, uh, reconstruction without diversion, just an ileostomy or continue medical therapy. Jason, you're gonna come back to the previous questions. We'll come back to these as we go along. So like the TE, you'll get back to the TE prophylaxis thing, yep, OK. So as you answer, we'll continue. I also ask, do you do a hand sewn anastomosis with a mucosectomy, or are you performing a double staple technique, and we'll go into those techniques a little in a little while. And I think this question, uh, will get some attention. Where do you make your anastomosis for ulcerative colitis? Right at the dentate line, 1 centimeter above, 2 centimeters above the top of the columns, or somewhere else? W And is your anastomosis different if you're talking about FAP or familial adenomatous polyposis again, same levels, but is it different based on the disease process? So let's talk about where we make our anastomosis first and tackle the the last questions first. So this, uh, topic obviously remains a debate. I don't know, Todd, where do you do your anastomosis for these, for an ulcerative colitic? Um, so I, I do a stapled anastomosis and so I leave a little bit of a cuff, but do you do it at the dente line, 1 centimeter above the centimeter above the dent 1 centimeter above the dente line, Kurt, 2 centimeters above the dente line. Does it make a difference in a 4 year old versus a 1 fourteen-year old? Well, it's, um, the 4 year olds are a lot less attentive to their, um, continent and nocturnal soiling, but for a teenager, uh, the slightly enhanced continence is a huge deal for them, I think. And, and so we have a pre-op conversation. I say I can do this slow or I can do it a little bit longer. You're gonna get monitored anyway for the rest of your life. And would you rather be. Intensely continent right now and uh and not have a transition period of soiling or would you have me go lower and and then and I think that's patient centered care. I let them participate in the conversation. They they uniformly want immediate continence. It's a really big deal for them so. I agree and I think the next slide, if I can get my slides back, Max, yeah, I think it depends and uh, it depends on the age of the patient. Can you ask that question again in the microphone so that everyone could hear that? Can you show my slide because that's a great question. I was asking the difference between 1 centimeter above the dentate line and the tops of the columns. Usually I. Find that that to be about the same so I do the operation 1 centimeter above the tops of the columns, which I think is the same thing as Kurt's 2 centimeters above the dentate line in general, in general, mine's a little bit longer than that. So here, here's a schematic, uh, looking at it, and it comes from one of the papers discussing this topic. Um, the top of the columns is where the letter B is denoted in this, uh, drawing. C would be even a little bit higher than that, and A would be at the dentate line, probably associated with more issues with continent than B or C. And so again, it remains a matter of debate. I think in our adult when we have taken care of adult patients I've taken care of 2 or 3 patients who've developed rectal cancer following a J pouch. They're obviously diagnosed extremely late because that was during the time of doing all mucosectomies, extremely hard to diagnose, and so by the time of diagnosis it was very late in a stage of disease. So I agree with Kurt and say. If we leave, you know, 0.5 centimeter, 1 centimeter, 2 centimeters, they're all at risk for developing cancer, all need surveillance and screening, and so I'm not sure what the difference is, and time will tell because we need longer, uh, prospective. So when you think about this, these colons are 10 ft long when we stretch them out, and we're adding 1 centimeter to this. And so it seems like the, the cancer risk is gonna be. Very, very minimally changed by, by changing it that much. That's what I agree. And when I have those conversations with the family, that's what I say. If I leave, you know, 1000 cells or a million cells, you're still at risk and need, need this type of surveillance. And so we could go back to the slides, I'll touch on the cancer risks right here. So studies have shown basically after restorative procto colectomy it does not completely abolish the risk of cancer and so the cumulative risk about 25 years after surgery is still about 3.5%. So, um, main risk is preoperative diagnosis of ulcerative colitis associated with dysplasia or cancer which typically is not our patient population. In the older patient populations, but it's something to consider, um, and there's obviously a high mortality associated with these cancers when they're diagnosed so late. So this leads me to the next slide which again goes into the preoperative counseling and that's what I really stressed in this talk over the next 30 minutes is what we talk about with the family. Um, and I really stress because we're, we're meeting adolescents and young adults in our clinic and they go off to college or, or jobs and leave our, our jurisdiction and. They really need surveillance over a long period of time and so this graph, uh, or chart out of, uh, cancer in 2011 sort of describes what the follow up and surveillance should be. And most of our patients fall under the average risk patients, which means they should be undergoing pouchoscopy and biopsy three year every 3 years, 10 years following their diagnosis of ulcerative colitis. So this is a video, a little schematic of. How I perform or uh how I perform the total proctor colectomy and pouch. You're gonna have to run it, so this starts with our port placement. I typically place 4 ports, one in the umbilicus, a 5 millimeter port, one in the left lower quadrant, one in the epigastrium, and a larger 12 millimeter port in the right lower quadrant. I do a lateral to medial exposure. Some do medial to lateral, and Kurle adds some insight into his techniques too. I then do the subtotal colectomy portion of the procedure, um. And staple at at the. Rectosigmoid junction remove the entire colon out through that right lower quadrant port and then continue on to perform my proctectomy. I typically then after completing the proctectomy invert the rectum out the anus which we then identify the uh the dentate line in the top of the columns and I'll show you live pictures of this in a few minutes. Do my proctectomy and then put the rectum, the rectal stump back intracorporally. Then if we could just go to the end of the um we make our J pouch extra corporally through that right lower quadrant um port site put our EEA stapler in and one little trick I've found because I've had some issues with this is using electric cautery when the anvil of the stapling device is coming through the rectal, uh pouch to cauterize it to make it a little bit easier for that, um. For that, that, uh, the, the device to, uh, meet up with the anvil and perform our anastomosis and so that's how I do our double staple technique we converted from hand sewn and mucosectomy to mostly double staple techniques, um, and around, around 5 or 6 years ago we've converted our technique. And so if we could keep going, I just, if you're. The standard non-double staple, the inversion. I actually learned that from my partner as well, Oliver sold us. Before I was just doing a regular EEA staple, uh, I divided as low as I could. And then stapled and I think that whole discussion about how far above you get the dente line is not as relevant because it's hard to be as precise. You can't see when you're when you're doing it in in intrapoally with this, then that question of the centimeters becomes very relevant because you actually can get that precise. You could see, and I'll show you pictures of seeing the tops of the column, but I have a question for you. So if you're doing this on a. And uh. Pre-pubescent person, OK, what happens to the cuff over time? That's a great question. I, uh, my guess is it grows over time just as it does. It lengthens just as it does, I think, in Hirschberg's disease when we go 0.5 centimeter above the dentate line and they're a teenager and theastomosis is, but it's more, it's a different situation for, for, for these kids because although we talk about proctoscopy and sigmoidoscopy for evaluation. Um, the rectal exam is gonna be really important and, uh, for their annual physicals and if it's getting above the length of your finger, then that's gonna be a problem. So that extra 1 centimeter or 2, which is not a big deal when they're little, could become a lot more than just 1 centimeter or 2 when they're older. Could, and I mean, I don't know if anyone's, I, I don't think I've all my anastomosis, at least to this time I've been able to even after they've grown. Over the last decade you've been able to palpate, but it definitely gets higher. Got it. That's good. So, so, so 2 centimeters you'll still be able to still been able to, OK, I don't think it grows 8 centimeters. No, but their buttocks does, and yes, it becomes a harder exam, no question about it. So Jason, when you, uh, when you're making that pouch, um, I'm sure in a referral center you on occasion get preschool age children, and, uh, so can you talk for just a minute about how you graduate that pouch from a 4 year old to a 9-year-old to a fifteen-year-old? I think the basic rule of thumb is you want to make a pouch that lies within the pelvis and not halfway up the abdomen and, and, and takes up space in the abdomen. My typical rule of thumb, and it sort of works, is age of patient maybe +1, so a 5 year old I'd make about a 6 centimeter pouch, a 10 year old I make about an 11 centimeter pouch that typically works for an and for the. Postpubertal patient of 15 or or you know a teenager or a young adult, about a 15 centimeter pouch is my maximum, but usually you want the pouch to lie within the pelvis. So the preschoolers, I've made the pouch about 6 centimeters in school age, maybe closer to 8 to 9, and then I've never made one since, uh, years ago that was more than 12 because I had a couple of 15 centimeter ones which came back later and they were so dilated that I had to kind of cut them back and so I. Made 12 the kind of the maximal power size. One of the others. Tips I do and I don't, I don't think I have a slide. I now fire an extra staple line after I make my pouch. The short end of the J, you never get your septum exactly lined up, and I've been cutting off that short end of the J to sort of line up with the. Anastomos loop of bowel so that you don't have a blind, uh, uh, or at least I have a shorter blind end on my short limit of J pouch. No hanging chads, no hanging chads. For those from Florida. Can you get the slides back. So I wanted to mention I use in the right lower quadrant port site sometimes I use this gel point mini um it's a great device that uh takes this allows me to add add multiple ports if needed and it's great for when if I'm doing a multiple stage procedure so they already had, they had a subtotal colectomy and ileostomy. I take down the ileostomy, use this device which is also acts as a wound protector, um, and allows for, um. Allows me to complete my proctectomy and J pouch that way. You could put the second one of those in the umbilicus and do the whole thing with just those two trocars. I could, or I add two more 5s in them. We could single site, yeah. Yeah. types. These slides are a courtesy of Kurt who wanted to discuss. I again, I take my mesentery intracorporally. It's a long, painstaking technique, but Kurt had some comments about doing it a little bit differently. So one of the things that's proved valuable to us over the last couple of years is by, by using a single site port in the navel, uh, and. This requires a lot of self-control because when you're working with a fellow, you always want to put your own 4th port in there so you can, but if you stay out and just use that gel point with 3 ports, I drive the scope and they do the dissection, um, then we mobilize lateral to medial just as Jason said on both sides and take the rectum and then pull it out through the. The larger gel point and then take the mesentery extracorporeally, which took a solid hour off the time of the procedure and so it's instead of being a longer case now it's really kind of a 2 to 2.5 hour case which has made a big difference for us and so using the ligature outside extracorporeally made this a lot easier operation. Thanks Jason. Jason, you don't do that. I've, I've done that for the smaller patients where. I needed space and maybe it was a little bit more difficult, but typically I take the mesentery completely intricapoly using so just to clarify because that's intriguing to me so you, you free up you free it up laterally. And what point do you bring it out? So, um, right colon first and then use the right colon just laterally. You haven't done the mesentery yet. Are you, right? Just, uh, all we're doing is taking down the white line of total, just bringing it medial, then, uh, mobilize left colon, go up the splenic flexure, which is really the hardest part of the case, and then. And then once that's down and we've got it medialized on both sides, you go to the rectum, divide the mesenteria a little bit, staple it, and then bring the stump out through the gel point, and then we can do the whole mesentery extracorporeally. It really, really changes the operator. This is demonstrating, uh, the making of a pouch. I've converted from using the open stapling device to the endoscopic stapling device. The limbs are a little smaller, which then makes your common enterotomy a little smaller and just I think it's a little bit of a cleaner operation. Um, we could talk about open versus laparoscopic. I'm going to venture to guess everyone at this table is using a scope for some portion, if not the entire portion of this procedure. And we could talk about hand sewn versus staple denastomosis. This is demonstrating a mucosectomy and setting it up any way you like. People use silk sutures or a Lone Star device in order to, uh, start your mucosectomy. As pediatric surgeons, I think we're all pretty well versed in doing a mucosectomy, and this is a schematic of the double stapled, uh, technique. I think our adult colleagues have led the way in this and have been doing this for over a decade now, the double staple technique. Um, and haven't shown much difference as far as cancer risk, um, to this stage with any definitive results. I think we need more time to tell as my previous slide showed, it takes 20 plus years to really see the cancer risk, uh, demonstrate itself. And this is the schematic of uh bringing the rectum out extra corporally, uh, from the bottom and then I have a couple, uh, OR pictures from this showing I just use a big Kelly clamp, put it up the anal canal and into the rectum and avert the rectum. Uh, this is a patient with FAP doing that same way and then you'll see the next photograph shows us demonstrating at the top of the columns and using a. Uh, stapling device to, uh, transect the rectum. Making the J pouch, we talked, this was my cue to talk about the size of the J pouch, but we've hit that already. And then I guess the next question is, do you perform a diverting ileostomy or not in the in these patients, and I think that's a pretty broad question because I think it depends on the patient population, uh, if you're going to do that or not. Maybe we could bring up some of the poll questions and see, Todd, if any of, uh, so, um, also the third option would be who is anyone still doing 3 stages. In the just because you know, just do the make that comment the um. Earlier you had brought the issue about um how our population is different and my impression is that the pediatric gastroenterologists are so committed to helping the patient that sometimes they keep these patients longer and we end up with, I think our population has a lot more children who are bleeding on TPN getting steroids and Remicade in the hospital and so. Uh, I'm, I'm very generous with 3 stage operations because um some of these kids are super sick and I think that a simple colectomy changes the course of things for them so dramatically that they go home. Some of my patients have chosen to wait a year or more to have their 2nd and 3rd stage because. They feel so much better and so I don't, I, I don't feel like I'm a troglodyte because I'm using a 3 stage procedure and someone woken thinks I'm a troglodyte, but most of the people recognize that, uh, you know, in a really sick patient like that, I think we're, we're giving ourselves an immunocompetent patient for that 2nd and 3rd procedure just in the way of looking at it. I, I agree with you, Mark. You, I, I, I agree. No, I, I, I, I, I agree because it's, it's, it's interesting to me. That these are really two different patient populations when you look at the pediatric literature versus the adult literature. The adult literature has a lot of elective colectomies, and it seems like, and I, I used to do more of these before, you know, Kurt stole them all from me, but, uh, but it's, it would always impress me how every one of these patients is, I mean they're sick kids that we're being consulted on in the hospital to do this operation. It was really rare to get somebody who you could do a two-stage operation on. Pretty much it would be FAP. I mean, the FAP is a different. Yeah. Oh yeah, we love those. I told you I looked at our last 50 J pouches. Not one had an albumin level greater than 3.0 g per deciliter. I, I believe it because I think the GI doctor. Now they have such a strong armamentarium that they can get a lot of patients through this stuff, so they try and so I think they're hanging on to the patients longer and ultimately, you know, whether it's we need someone like someone smart like Sean to figure out whether it's the right thing to do or they should be sending them earlier to us, but I think that's just the patient population we have now. So it might be 60 seconds. I made a deal with the devil several years ago and Mark and I agreed that we would. Um, trim our patient population a little bit, so I took the thyroids and the IBD patients, and it's a bit of a sacrifice, but I've given him all my lung lesions, and what that does is it allows. Uh, us to have a team of colorectal people who are. Using that kind of 10,000 hours thing and, and we just keep working these segments of the operation to the point that it's allowed us to make a lot of progress and instead of making them all day long cases, they're, they become much shorter so. I made a deal with the devil. Yeah, the question is, does this belong in a group of, of operations that should be done by someone who, a specialist, you know, that's the question. Is this like, you know, people talked about that with cassa and, uh, pancreatic surgery, you know, is this, or anorectal malformations? Do, do, do colectomies for ulcerative colitis belong in a specialized. Yeah. Well, our, our, I think our, our GI colleagues had a chance to vote. They really like having, you know, one or two people on. It might just be they like you more than Mark is that's besides, besides that, I just have his cell phone number. We're accessible. I, I, I think it's an operation that the more you do you get a little bit slicker at it or you, I know a lot of centers incorporate their adult colorectal surgeons in on some of these cases. There are some centers we average in the last few years about 10 to 18. J pouches a year. There are others that do one a year, and I think it just depends on volume just like many of the operations just hasn't been studied yet in detail, right? And, and then if you have a group like yours that has 23 surgeons or 22 surgeons or, or ours in our system where we have 16 surgeons, you know, when if you're doing 10 to 12 a year, that means that if, if you divided it up evenly, there'd be some someone's doing none, right? So I mean, I think there is something to be said for. Having a point person and in our, in our institution, it doesn't mean that nobody else can do it, but if they did, they would get, they would get Kurt or uh you know, Matt does some of these as well, um, involved so that we could, you know, so that you maintain that expertise. We go back to the slides. So I just wanted to wrap up a little bit with the risks, how, what I talked to the families about, and then the outcomes for a moment and then we could, if we have time, we could talk about some of the questions. So leak rate's about, I, I quote, somewhere between 5 and 15%, and that that correlates with pelvic infections. Uh, it's rare to have a pouch fistula, but careful dissection could avoid that, and I, I'll talk about incontinence and number of stools out of a couple studies in a moment. What I do find that I've discussed with my female patients that I think they get shocked when they come to my office so I sort of brace them and bring the tissue box out before is especially with the parents and the mothers is talking about infertility, uh, with this patient population because, um, I guess my first question is does doing a a pouch affect infertility. Uh, and you can answer yes or no. I didn't ask for percentages, but we'll talk about it. And then my second question is, does a pouch affect fecundity? Probably many in the audience don't know what fecundity is. I didn't know what fecundity was until I looked it up and was doing some research on this subject, but we'll go over that in a moment. So do you want people to answer that question if they don't even know what fecundity? We could fecundity is the ability to carry a pregnancy, whereas infertility is the good old fashioned way of doing that. So you can as you answer those questions we'll talk about it for a moment. So infertility rates, uh, after a pouch is somewhere between 43% and 63%, about two years ago, a number of meta-analysis were reviewed, um, but it's difficult to measure accurately, obviously, uh, based on when the pouches were made, how long and how often they were trying, but infertility is typically measured as 1 year of attempting pregnancy and not becoming pregnant. So, your infertility rate is only after 1 year. If you're trying more than 1 year and then become pregnant, you're still deemed by definition as infertile. Um, the North American infertility rates approximately 8%. That's down. It used to be about 10%. And then where does laparoscopy play a role? Well, I can tell you a number of papers were written on infertility, and papers went as high as 90+% infertility rates when during open operations. There are now some more recent papers following laparoscopy, which has been done for now over a decade in this patient population, and infertility rates seem to be going lower and probably more in the 20 to 30% range, uh, following laparoscopic J pouch creations. Then you also have to talk about pregnancy and delivery. There's no literature to support or, uh, whether a C-section versus a vaginal delivery is safer in this patient population. But when you ask a number of colorectal surgeons how would you prefer your patients to be delivered, they unanimously, um, suggest getting a C-section and this patient population. The C-section rate is between 38 and 78% versus 22% in the general population. Jason, is that because they're anxious about, uh, tear or episiotomy going into? This is a patient population that in the next couple of slides we'll talk about incontinence. We know incontinence is associated with vaginal delivery. And now you're adding to that stress and, and no one knows the real answer and there's no literature to confirm or deny which is safer, but I think counseling, many counsel for a, um, for a C-section and sexual function has been demonstrated to be greater, um, following surgery for a number of reasons, so, um. I'm gonna skip this question just to move things forward a little bit and just talk about results. So, um, the Helsinki Group published about 6 or 7 years ago their outcomes of a number of patients in pouch versus straight, uh, and I cir highlighted some numbers, uh, daytime stooling frequency about 5. To 5 to 6 bowel movements per day in the pouch group, 7 in the straight group, but I thought what was more interesting is looking at their incontinence rate, the daytime and nighttime soiling, 22% during the daytime and, and 56%. The nighttime was their soiling outcomes and then we just recently published just this month actually our outcomes uh looking at our J pouches over the last decade or so uh and my premise or hypothesis when writing this paper was I thought and I didn't demonstrate this here but I was under the assumption or feeling that if I was doing these J pouches in the younger patients that the more we're converting to Crohn's disease. Later on and so I was concerned that that was the case and not demonstrated here but the rate of conversion was approximately 10 to 12% both in the younger patient population and the older patient population so there was no difference but here we demonstrated our data. Time and nighttime in uh soiling rate was about 5% during the daytime and the younger patient population, about a little under a third of patients had soiling and about 18% in our older patient population that wasn't statistically different, um, so. As far as doing this this case in younger patients versus older patients and the mean age was 7 versus 14 years of age in the two groups, uh, there was no real outcomes differences between these two groups and so I'm not sure of my time, but if we wanted to go over questions or let's go, let's, so we move along, yeah, we're good, we're good. So I guess the question goes back to this patient that I presented at the beginning. Um, first, the 12 year old who was hospitalized for a few weeks had a PICC line in place. I took him to the operating room. I chose to do a subtotal. He was getting blood transfusions, pretty sick on TPN, on steroids and immunosuppressive agents, and so I did a subtotal colectomy and ileostomy. And then, um, I put compression boots on him for thromboprophylaxis. 3 hours after surgery in, in his, uh, in his on the floor, he developed chest pain. And so we got an X-ray and then some imaging and found a golf ball thrombus in his right atrium. He then quickly went to a different room in the intensive care unit, um, and so that was my wake up call. This case is about 5 or 6 years old now. Uh, wake up call for what is the proper thromboprophylaxis for this patient. So Mark or Helen, um. The first polls that kind of disappeared. I don't know if we can find it, the one on TE prophylaxis. Can you bring that up and show the results here, or did it get deleted? OK. So, so Jason, what do you need all the polls from this whole session that we're going back to review them now. We've just used, uh, um, SCDs as, uh, uh, but maybe, maybe, maybe we should do. I could tell you the adult literature, and this kid was pubertal at the time of this operation, the adult literature is very strong in using. Heparin or Lovenox low molecular weight heparin in combination with compression boots, a number of studies showing that there is no increased bleeding risk, which is all our fears in this patient population or outcome risks, uh, associated with it. So this was my wake up call for. Being more aggressive with thromboprophylaxis, I do this case. This case happened to be a subtotal colectomy, so it's supine on an operating table, but if I'm doing a J pouch, they're in stirrups or in yellow fins, and so they theoretically the risk could even be higher for, uh, venous thrombosis. And so I highly suggest reconsidering your. Your approach. So one of the, uh, I got assigned a PSA question about 5 years ago on, uh, on something like this, and the, the compartment syndrome rate in people who have elevated legs for a period of time is surprisingly high. And so I've made a point about keeping the legs down. In in the stirrups until we actually have to go to the anus, in which case we lift them up, do our business, and then put them back down, and that at least that makes me sleep better at night because that's one of those things we don't talk about very much, but STDs when the legs are up in the air for. A couple of hours could could be a problem for him. I, I, I was gonna make a quick comment about uh TE prophylaxis because I think that we, we are not attuned to it and we don't think about it and I know that in my bariatric practice. All of a sudden we do all these things for these patients that are high risk for thromboembolism, but we take that same patient and we're doing a different operation or you're doing a different operation such as a colectomy that has high risk of thromboembolism or any pelvic surgery in these teenagers, and you know we really know the risk of thromboembolism is based on the patient, not the operation you're doing. And all these kids are at high risk, and I think it's something that our institutions or we as Uh, you know, representatives in our institution ought to work with our hematologists, the ICU docs, and others to make sure that we do this, and I think we've gotten a lot better about it, but I don't think that we are where we need to be. Alright. And just to piggytail on that, uh, with two comments. One, all IBD patients are at higher risk for thromboembolus, so that puts our patient population at risk. The other thing to consider is that. We now at Cincinnati Children's anyway have a bundle at the beginning of every operation trying to stratify what your patient risk is to try to sort of bring to the attention to the surgeon what type of thromboprophylaxis should be required so a way to intervene would be when you're putting in your order sets for. Antibiotics and and other things, that's a way to sort of bring to attention this situation. Yeah, the, the other point to make is that if you don't start your prophylaxis before induction, you almost, I'm not gonna say you might as well not do it, but you almost might as well not do it. The efficacy is much better if you do it before induction of anesthesia. So that's a big issue I have is that they always decide to, they, you know, by the time they go find everything, the patient's already intubated or I haven't thought of it till after it. Is that true? And how do we know that? Because I've always quoted everyone in the room, oh, if we didn't give it before they're induced, we know that they get, do they get Dopplers before and after induction? Or, I mean, I, I, I, I, I, I think the data, and I'm not, I'm not, uh, we reviewed this, uh, it was a couple years. Years ago when we came up with our pathways, but I, I think that the patients who get thromboprophylaxis prior versus those who get it with or after have a lower incidence of thromboembolic events. OK, well, that's the other thing, yep, so. The other thing that was just brought to my attention and actually written about from our institution is PICC line in this patient population is a huge risk factor. And so if you have a PICC line and IBD, you're at your odds ratio of getting a thromboembolus is, is much greater. And so this patient was ripe for it. I missed it. I got a little lucky. We just heronized and. Multiple echoes and a and a sternal saw in the room in the PICU uh allowed for this to go away. So, so if you do a, um, a 16 year old lap app, do you give. Do you give no, because they, there, there's different risk factors. So shorter operation, shorter time on the operating room table, and they're gonna be ambulatory in a few hours. But, but a and doesn't have a PICC line, so there's a number of different risk factors. But, but if that patient was morbidly obese or had other risk factors for you do. OK. I think there's a large literature in the adult population allaying our fears of bleeding associated with the administration of these agents. Let's fly through these questions if there's any points you wanna make, uh, let's look at the results and see, um, so I, I'm not sure these are, they're actually probably not in order anymore, but we can try. I think lap versus open, uh, 77%, 73% again, I think that's skewed. In this group, uh, do you hand sew or staple, uh, 81% staple. Uh, and, uh, it's funny because a lot of pediatric surgeons are used to doing their hands-on anastomosis. So it's, uh, uh, I do that as well. Uh, diverting loop ileostomy, 90% I'll go, although we didn't really address, would you do a three-stage or a two-stage, um, but, uh, but most people here would do it at least as a two-stage. Contrast study prior to the ileostomy closure, um, 62%, um, say they would, um. So I, I wrote a paper on this moons ago, uh, looking at this because we were getting contrast studies. It's an invasive procedure, um, and I found none demonstrated anything that I wouldn't didn't know already. If a patient had pain and fevers and you knew there was a problem. With your pouch, they had a problem with their pouch. If they weren't symptomatic, there was never a problem with their pouch. So we talked earlier, uh, about this study that I'm gonna actually, uh, paste here in the chat which said that for neck you don't need to get a contrast enema, and I think it was Dan or some Mac or Wit Witt, it was Witt that said that that that that he found a second lesion. This is different though. This is different because I can do before I go to close their ileostomy. I do an exam in the office and or in the operating room and if there's a problem at that time I could try to correct it. How, how would you know in the operating room before you closed your ileostomy whether you had, uh, a contained leak or would that matter to you because that's really, I, I do contrast studies and really and in the situation where I've seen a contained leak I just wait a couple weeks and it goes away, but it would, it would cause me to delay my um. Ileostomy closure if there was a contained leak, it would or wouldn't. It would, yeah, but it contained leak, you're gonna have symptoms. I assume you had a contained leak because you knew the patient was febrile for an extended period of time just it's just been kind of like, you know, I mean, we have esophageal anastomoses that have contained leaks and they're not febrile and, and so I, but you also don't do. I mean, I stopped doing these studies a long time ago and as, as, uh, Jason mentioned, if they're not symptomatic, you, and you don't, and you go ahead and you close the ostomy, they do fine. So if you had patients who came back after closing the ostomy with a problem, then it's suggesting you'd missed a contained leak that became clinically significant, that would be different. But I think the, the data that Jason's quoting is that. Unless they're clinically symptomatic before you close the ostomy, they're unlikely, or I don't know that we have any cases, do we, Jason, who that became them symptomatic with a leak after the ostomy was closed. Um, So I think for this, I think what we're gonna and any last points well I guess the only last question is to bring up FAP, um, and timing of surgery for FAP. I think that's a question that I often get asked and Practice differently and and colleagues here practice differently than our European colleagues I think because in Europe many patients will undergo a subtotal colectomy and ileorectal anastomosis for an FAP patient, especially in a female until their family they make their families and they're done with um. Done with their, you know, 20s and 30s and done making their families and then go on to doing that completion, uh, proctectomy and, and reconstruction and so when do you do it? I, I've been doing the entire procedure when so my indications are if they're symptomatic, having bleeding, pain issues that are associated with the polyposis. Uh, colonoscopy that demonstrates greater than 100 polyps and increasing polyp burden or if there's dysplasia, which is extremely rare in our patient population, when did they get their colonoscopy? So that depends on if there's a family history, they'll get a family history of. That's what we're talking about because otherwise they're symptomatic. So, right, so either symptomatic or and and they could be mild symptoms and they're getting colonoscopies. But if they're, if they're, if there's a family history, they're typically getting colonoscopies at least 10 years prior to the age of when their, their parent was getting. Having colonoscopies and, and diagnosed um with a heavy polyp burden. So if they were, if the family member had a colectomy at age 20 for a heavy polyp burden, usually about 10 years before that, they're going to start scoping and looking for that. Would anyone do it differently? Anyone have a, a feeling about what timing of FAP surgery? OK, um, any other things we didn't hit on? I have a question. How did you get that animation? My boss, I was looking at your boss when I saw that. All right, uh, I, I have to say I, I know those are so expensive, but they're, they're so valuable, and they're on our website, you know, to use as teaching tools. Anyone could use it as a teaching tool. Can you, I sort of made it halfway. Because I, he, my boss only gave me one budget for it, so I had to make it somewhat for teaching and some for patient and family education. And so I sort of scroll through it quickly in some areas where the details aren't needed, but it, the families love it because they can't conceptualize it from a two-dimensional drawing on, on a piece of paper in the office. And Todd, as you pointed out, this is our population has changed, right? I mean, our parents might read stuff. The young families where they need visual have right now or multimedia. They want videos so they can watch the probably operation on, I'm sure YouTube, yeah, but I think a lot of us have patients who come in having watched, you know, the operation on YouTube, right, right. But this is different because it's, it's YouTube. They just see red. They don't know what they're looking at. Um, can you, can you, uh, or maybe Dan if he has a phone, type in through the chat the website where they, where people can go look at these. That would be great.