Gastroesophageal Reflux: Contemporary Management Pediatric Surgery Update...

Tim's gonna talk to us about gastroesophageal reflux. We already know his bias towards the operation. Uh, so let's address some of these issues. Right. So, uh, I'm just gonna start with a fastball down the middle here. Basically, most of the literature now supports, uh, studies for gastroesophageal reflux, but the most, uh, the best test for quantifying the presence and severity of non-acid reflux over time, um, is one of the following multiple-channel interuminal impedance probes, EGD with biopsies. Uh, esophageal manometry, PH probes, or upper GI series. on as much You certainly helped us there when you said non-accid reflux that that eliminates that eliminates, uh, I guess the issue is that I don't know that, um, impedance probes are readily available to everyone out, uh, especially out in the world I would imagine, but, uh, even within our country I'm not sure that all the gastroenterologists, pediatric gastroenterologists are, are doing that. Um, and PH probe is a little more readily available and, and willing to be, uh, evaluated, right? And the challenging thing is neonates too. So our gastroenterologist says he can do these in the neonates, although they never asked for them. Um, we typically, you know, based our decision to operate based on clinical symptoms, but, um, as a board question, this is what you're gonna see. OK, fair enough. So, um, I guess my only thing I would say he can do them. But how well do they correlate? We're gonna study that. We're gonna study that. Look at kids who, uh, you know, did or did not have subsequent surgery. Let's see here. OK. This 3 year old boy has been vomiting since infancy. Uh, his weighs in the 10th percentile. He'd get a barium swallow, which shows uh free gastroesophageal reflux to the pharynx, as well as a sliding hiatal hernia, um, with 4 centimeters of fundus, gastric fundus above the diaphragm, um, with the GE junction also herniated up. So, the most appropriate management would be which of the following. And would anybody get any other studies on this, this kid? Sorry, I was half listening because we have to make sure, we have to make sure you, that's right, I know, we have to make sure you don't say, uh, bored questions. Cut that delay, sorry, sorry, uh, I'll jump in. I, I mean, I, I think, um, I don't think I would need any additional tests with the, based on this clinical scenario, um, and, um, and I would certainly not wanna delay more time given that the child is already, um, at a suffering from a weight loss and, uh, and growth, uh, perspective, so that would, that would push me, uh, to towards the operating room, and I, I, I have not found it necessary to perform a coli, uh, uh, gastroplasty. Uh, from the outset, so my anticipation would be that I could, uh, fix the hernia, pull down, um, the stomach, and, and perform a fundoplication. You know, I wanna echo that, um, everything that you just said. I don't do, I, uh, so quick answers, I would not need any other studies on the child except for an upper GI. Which, which we have to make sure there's no malrotation after that, I do not need any other thing to prove that they have gastroesophageal reflux, um, a, um, a, except that if they do an NG tube and they do. Uh, great, with an NG tube, you could make the argument that all they need is a G tube. Um, that's my test. If they, if a patient is vomiting, I put an NG tube down. If they do great with an NG tube and they don't vomit anymore, then they can get a G tube. If they still vomit, then they're going to get a Nissan. I don't need a PH probe or anything else. I don't think you need a callus. I don't do pyloroplasties. Um, OK, so I left this out purposely. I didn't put G tube in, in either D or E or even C. Because who, who would, who would routinely do a G tube on this kid? Oh, he's a 3 year old, 3 year old, yeah, I would. That's the point. So a 3 year old's eating. It's gonna be hard to get the 3 year old to keep a, yeah, I would not do, I would not do a G tube. He's what we call an eater, so you can just fix his height. Yes, and I think the free reflux to me means everything comes up, but I think most upper GIs and the kids with reflux are not that dramatic. And so you have to have some other way, I think, to figure out who needs it. But this kid child clearly needs a fundo. Yes, so we did a study out of our, uh, institution a couple 3 years ago, looked at a large number of fundal placations, upper GIs, correlating with PH studies. Anyway, the gist of the study was that 4% of the time, uh, the upper GI influenced your management. So you could interpret it one of two ways, and, and 80% of that 4% was malrotation. So you could use it one of two ways. Either 4%'s a lot and you wanna know if they have malrotation ahead of time, or 4%'s a little, and you can go look and see if they have malrotation. At the time of doing your, uh, fundoplication. So, what have you done since the study? Have you changed your practice? Uh, well, I think it's surgeon dependent. How they view the 4%. Uh, and, personally, I'd like to know if they had malrotation or not. Right. Cause it would influence how long I'd scheduled the case and. Sure. And counseling the family and stuff like that. Others may say that's not going to influence me at all, and they would evaluate that at the time of the, uh. Not only that. Uh, fundal placation. I mean, of, you know, Tim, but what we talked about, Before is if you got that upper GI and it did show malrotation and this kid that you were about to do a Nissan on, it's just a pre-op study for the Nissan and they got morrow. Now you're not going to do a Nissan. You're gonna do a lads and PPIs or something. So, OK, yeah, I, I've used your data that way, that 5% to say it's, it's worth it to get the upper GI so that I treat it differently upfront. Yeah, it can be interpreted either way, yeah, or duodenal web or duodenal stenosis, 3 year old, yeah, although mal rotation rate was the most common reason that it changed your. Formal and are we not, it seems like we're using it interchangeably now. Maybe it's an old fashioned sort of academic and not, not, uh, critically important distinction anymore, but it seems like we're using vomiting, which is for traditionally considered a forceful thing versus reflux, which is an effortless thing and. I don't know. I'm probably wrong, but I think I can distinguish the two clinically, and so that might steer me in one direction or another, whether it's true reflux versus maybe there's something else causing the the actual vomiting like malrotation or something else. I mean, is that, is that a distinction without a difference anymore, or is it, what what do people think? I think it's probably too hard to quantify. Yeah, I mean, the families that have spitters know the difference, and they can tell you and you understand it, but. I think it's a little hard to know. Well, we have a lot of kids with projectile reflux, so I don't know what that means for the nose. Yeah, so everyone's pretty. So 80, 81% went for the, uh, D. They've been online, yeah. Yeah, exactly. It's always projectile. And D was supposed to be laparoscopic, correct? Yeah, correct. Of course, of course. Oh, I didn't. They didn't want to bias anybody. Although I think in 2013, if you're doing an open distance a priori, you probably shouldn't be doing a. You need help convincing it? Yeah. Oh, sorry, here. OK, this is a 25 year old that we all take care of in our hospitals who are chronic patients with uh CP, uh, had a spinal fusion 33 weeks prior. Never had any abdominal surgeries in the past, weighs 30 kg. He's unable to take an oral diet, um, and he had this upper GI study. He also had pancreatitis post spinal fusion, which resolved. So how are you gonna treat this patient? NJ feeds, a GJ tube peg. Lap hiatal hernia repair and uh anti-reflex procedure. Lap hiatal hernia repair anti-reflex procedure with G tube. Would you show the one thing I was, yeah, absolutely. Here it is. I was a little, this kind of patient's a typical SMA syndrome kind of patient, so I'd want to make sure that on the study they didn't, they didn't rule out a distal duodenal obstruction from, you know, recovering in recovering spinal syndrome, correct, correct. No, he did not have that. So he had free flow contrast past the, uh, because that would change your management, I think, right up front. Would you worry about cast syndrome or something where severe weight loss. He just, he's 25, he never, and he's 30 kg, so he just never progressed. But I should note that he's never, he's, he, he ate everything orally prior to his, his spine surgery, not that he was eating gangbusters, but he's 25 years old and never had a G tube. He probably needed it before he had the spinal surgery, right. So now you got this finding, so. Is there a concern about how he, how well or poorly he protects his airway? No, he does that, does that factor into the calculus or not? You know, he seemed to protect his airway fine, so he's, um, a fairly high functioning. Tim, I would actually, uh, choose. A. I would put a nasodenal tube in its child, feed him for certainly several weeks, uh, beef him up, and then if he does come to a fundal placation, at least he's a better candidate. I agree with what. That's exactly what I was going to say. We would, I would advocate nutritional rehab for this patient for a while before you operate on him. Yeah, and he, he may, I mean, nasal general is easy, but he also may do fine with just nasal gastric feats. We have no reason to believe that he's gonna be. Um, vomiting everything. But that'll be a difficult operation. It was not, not easy. It was not easy. Uh, no, it was not difficult. Oh, it wasn't difficult. No. So, I mean, I, my, my feeling is that, the kids, it's been a long time. So, I mean, I, I didn't know that beefing him up for a period of time was going to help. So, that, that's the type of kid that I would just, needs to get out of the hospital. So, um, do the surgery, use his G tube and, On his way again, so I think with a laparoscopic approach you're not really, I mean he had a spine fusion, you know, which is maximally invasive, and I think doing a, you know, 50 minute missing, but why does he need an anti-reflux operation? Well, he's got a hiatal hernia with, uh, that's his fundus hernia. He's got a point he required a 66 stitch, yeah, he had a 6 stitch coral repair. You know, um, well, I see. What would you have done? And I'm sorry, I didn't see that if he had no hiatal hernia on upper GI, Oh, that would have been different. So no hiatal hernia and upper GI had been eating normally. I may just do a G tube in that kid. That's what I would do it, yeah. So this is a different situation. This kid has an anatomical problem, something that needs to be dealt with eventually. So I opted to do it at that time, uh, but no, if he had, you know, normal upper anatomy, this is basically to assess him for a G tube, so. Had that been normal, I would have put a G tube in. Got it. OK. So it's a 10 month old who uh presented with a chest X-ray showing a right lower uh chest opacity and then uh got an upper GI which shows this. So do you have a lateral on that? Um. We're not. I don't, but I can tell you that this is in the right chest and it's posterior. OK, so it's not anterior. Correct. Otherwise, the kid is, you know, otherwise healthy. Presented really with a cough in the ER and that's why they got this x-ray. So how do you manage this? So it's a dynamic film. Um, so the, the contrast basically goes down. I mean, does this child have. Did it look like it was a hiatal hernia when they, when they, it's hard to tell from this, yeah, so this is, this is dynamic and moving, so this is stomach. Contrast outlining the stomach there but it's paraesophageal, right? Yes, OK, yeah, not hiatal. Oh, well. Type 2. Type 2 hiatal. Yeah. Not a slider, right? Yeah. I'm trying to move the arrow to point a little bit. So how would you treat this 10 month old who comes, he's on the peak surface now. Taji's still going to put an NG in, see if they tolerate it. No, no, this patient needs an operation. I, I, I would do, um, the question is, do I do, um, a PEXI or not? So, I would do a laparoscopic hiatal anti-reflux procedure and, That's all I would do. Did you think there was a gastric volvulus there? Um, Not really, because the, the kid wasn't, uh, you know, wasn't in distress, wasn't vomiting. Has anyone seen a gastric valvulus and a neonate with a big congenital hiatal hernia? I've not seen one in a, in a, not a neon, but a child, a, a toddler. Sorry, I, and I think the data if you do a Nissan alone. I don't think you need to do uh a PEXI or a G tube. I think that that should be adequate, and I'm, I'm trying to remember from the adult literature. Our, our literature is so scant with this, but it is, I, I think, um, the conservative, uh, approach is to do a PEXI or a gas gastrostomy because you don't want the stomach to volulize. But once you reduce everything and you do your Nissan, it doesn't seem necessary. I've stopped doing it, but I used to do it, uh, uh, gastrostomy and then PEI, and then now nothing, so. OK, is that what the audience, uh, yeah, the audience was. They, they do not do the Pexi. Well, a third of them did a Pepsi. Yeah, yeah, that's true. 30% did a Pepsi. The majority did the, yeah. OK. 6 month old, uh, girl previously, uh, treated for gastrosthesis has been vomiting with increasing frequency over 2 months despite, uh, thickening feeds, positional therapy, proton pump inhibitors, and an upper GI series, which is normal. Most appropriate management is. Additional therapy with Reglan, repeat barium at 3 months. Anti-reflex procedure with G tube. PEG with trans pyloric J tube. G tube alone. So anti-reflex procedure alone. The upper GI, did they do a small bowel follow through? Yes, uh, no distal obstruction. Everything goes through, no dilated loops. No reason to believe there's motility problems for small bowel, vomiting, stooling normally for a 6 month old. Well, I think it depends on whether or not you feel like there's been good medical management or not. If you don't necessarily think there has been, you might, uh, try some, uh, Reglan. If you do, then I think proceeding with an operation is very reasonable. Yeah, and this, this. This child had had maximum medical therapy, you know, extended period of time, um. So, I would. Uh, I, I would probably do would be in this patient. Laparoscopically, yeah, so I would, I think you can be surprised sometimes. I would probably try, um, it depends, um, you know, the question is, would I start with an alternate site entry port, uh, rather than the umbilicus, um, and I would, I would probably consider doing a left upper quadrant initial, uh, mini cut down there instead of starting at the umbilicus, um. You know, the other option is I usually use a varis needle in this patient I would not. I would probably either start with a little cut down at the umbilicus or cut down in the left upper quadrant. Yeah. We've done several of these, and you, you can get in the left upper quadrant pretty readily or, or even with a transverse abdominal incision in kids who've had stomas for neck or meconium ileus, you can get into the upper abdomen pretty easily once through an open incision, yeah, open and then Hassan put a little 4 millimeter port in. Oftentimes if you re-operate on a gastroschisis baby at 6 months, there's not very many adhesions, um, and, um. So, doing a laparoscopic approach is not unreasonable at all. Or at least trying it. But where would you gain your excess weight? It would, it would depend. If it was an easy gastroschisis approach, uh, you've maybe reduced it, um, or, uh, I don't think there's anything wrong with trying to go back to the umbilicus. If on the other hand, you don't feel comfortable doing that, then a left, uh, uh, left abdominal approach is fine. OK. Uh, our audience. Well, we didn't address that with the audience, but Anti-reflux. Most, most would, yeah, would not operate right away. Yeah, I, I had some, it depends on if I knew this patient, I might wait longer. If it's a normal kid and it's 6 months, it's still kind of under that age where they could outgrow reflux and, Uh, I don't know that I would do it a fundo. I tend to drag my feet a little more and what I think is a neurologically normal child. Um-hum. So, I think that's a reasonable option. The other thing I would say is I've really, my own practice has evolved a lot. I, I really try laparoscopically on almost everything. Even with previous operations, cause I find you can get in there and most of the time you can get, accomplish what you need just by some patience. So because you and Jose and Witt have to catch a flight, you know, OK, your car's here in 6 minutes. OK, let's go, uh, next one. Uh, here, let me help you. How's that? And It seems to be frozen here. Mark, can you advance to the next case? I got it. OK. Here's an 8-year-old neurologically impaired boy feeding intolerance of emesis. He had a, a laps at the age of 3 with a G tube. And he has that study. So He is symptomatic. Did you need to leave that up longer? Yeah, you go, OK, good. I can do it from here. Great to see you. Take care. So symptomatic in terms of not gaining weight, emesis failing to thrive so similar, so I guess the, the kicker here would, you know. With someone in, in a patient who had a, a prior laparoscopic. Nissan just automatically go in laparoscopically. I think most people would, but I don't know. Uh, surely, yes, like what I just said, I think I've done that more and more and would always try it laparoscopically. I've even taken a couple of Nissans down and like teenagers who had Nissans open and, and still try it laparoscopically because you most of the time you can see better and you can really work well up in there better than open. So 67% do it, would do it laparoscopically. That's great. All right, next question. This conference is being ended due to inactivity. OK, again, 4 month old MSis failure to thrive chest X-ray with a right lower chest opacity, similar to the last kid, um, so you have an opacity here. The pediatrician ordered a CT. So this is, that's the information you have in your CT. So I was just like the last kid, a little younger. Would you get any other studies? You get any other studies? Uh, yeah, I, I would do an upper GI. No, it was, uh. Emesis and failure to thrive. 4 month old. OK. Never had innocent. Never had any procedures. Small for age, just not thriving. So I think that it's an operative lesion, but I think you need to know what part of the bowel that is. It's probably stomach or you just want a little more anatomy, I think. So he's on the pediatric service. They decided to put an NJ tube in. I can tell you they did do an upper GI through this. It doesn't tell you anything. You have no more information than you had than this stomach, that's all, yeah, so this is all you have. Hm, so you can see how the tube does go out into the jejunum. So they won't do the upper GI. Let's say they won't do it because the kid's, you know, bombing. Now what are you gonna do? So, So this she tolerating the NJ feeds at all? Yeah, tolerating the NJ feeds. So would you force, force the hand, say that we need an upper GI? Just Continue NJ feeds for whatever uh prescribed period and then. Uh, decide then or just plan your operation. I would do, I would do B and C and try to do A. OK. A straight out. It's not getting done. Uh. Anybody having strong feelings different from what you would have done in the last kid, so it's a similar case. So this kid did get NJ feeds for a period, uh, for a period of just a week. Um, basically the family situation precluded a discharge to home, so it was done as an inpatient, uh, and again, hiatal hernia repair. with Nissan no G2. So, uh, this, this question is in terms of, uh, you know, operative, um, uh. Operations and re-operations for Laparoscopic versus open and and uh for for GERD, which of the following is true? Laparoscopic anti-reflux operations are tolerated by infants with cardiac anomalies. Wrap herniation above the diaphragm is more common in the open group. Disrupted or open wrap is more common in the laparoscopic group. There are equivalent rates of postoperative bowel obstruction in both groups, or there's an equal incidence of esophageal shortening in children compared to adults. Uh, hold on. Yeah, well, laparoscopic anti-reflux operations are tolerated by infants with cardiac analysis I think that's true. Yes, that's true. And all the others are, are, are not correct. So it's, it's pretty, uh, just the opposite. Wrap herniation above the diaphragm is more common than in fact, it's remarkable, I think, how. Much more infrequent the bowel obstructions are. I mean, as the data is out there, I think it's, uh, traditionally we would say it was a 5 to 10% of the open groups, um. And I don't know what you would quote a family now for the laparoscopic, but probably 1 or 1 or 2% maybe. I've not seen one. I, I mean, I haven't really seen them, but I, I, I give some percentage just for any surgery you're saying though. Yeah, I can't, but this is upper abdominal, so I, and, and our ports are all higher up. So I wonder if it's even less than that general quote. It's probably less than that for another reason is that most of the laparoscopic cases we do in childhood are for appendicitis, and, uh, they have other reasons to have postoperative adhesion inflammation. So it's hard to know what's from the operation. And, and that's a dangerous situation when they get an adhesive obstruction and they have, uh, an obstruction to vomiting, loop. They, they have a closed loop, so they come in late, sometimes very ill, and I think that's one of the biggest advantages to laparoscopic for the patient. Neurologic impairment is also a, a kicker for those kids that come in and they're sick and yeah, nobody, nobody picks it up, probably from the high pressure in the stomach. Yeah, right, unfortunately I've seen that. OK. A 6 week old male with hypoplastic left heart is status post stage one repair of his uh lesion. He has documented feeds in his mouth, and recurrent desaturation events. The events ceased with NJ feeds, and he's on maximum medical therapy for GEERD, and upper GI reveals, uh, reflux up to the thoracic inlet. So I think this is a great case because it, it's exactly how I work up my patients. Um, NG tube is very diagnostic. NJ tube isn't always necessary, but it's even more helpful in the, in the workup because if they do well, that's a good diagnostic test that they'll do well with in this and. Um, so, I, I, for this patient, I would do, uh, a Nissan on him without anything else. Yeah. Anybody anything different? What, what's the indication for fundoplication in that? OK, what did I miss? No, that's a good question. So let me go back to that. So 6 weeks, I think, I think all 6 week olds are gonna have reflux. So this is what we talked about earlier. Uh, let me rephrase that. So if this patient had an indication, either recurrent aspirations or A's, B's, and D's or failure to thrive, that's when I would operate on the patient. I personally would not operate, would not operate based on the fact that he has a cardiac anomaly, but I think you would. Yeah, I'm a little more aggressive about it because I think that the, the typical patient that gets referred is the one that is failing to thrive, um, and they want a G tube on. And if I think, uh, rather than creating an aspiration prep with just a G tube, specifically, if you're doing a peg too that sticks straight out and they're gonna have sternal wires and atrial leads and all that stuff, it's kind of cumbersome to, to have that going on. The, the pegs, I don't think are very, very appropriate for, for babies. Um, I think, you know, you're not adding too much time to the operation if you can handle the reflux at the same time. Um, they're not gonna tolerate aspiration events as, as, as another, you know, NICU baby will that, you know, just can do better with an NJ, uh, and these kids don't go home and they pull their tubes out and they come back because the kid turns blue. They have lots of different reasons for bringing the kids back, so. We're, you know, a little more aggressive about it. Yeah, our cardiologists and pulmonologists for that matter, are pretty aggressive about the kids with pulmonary hypertension or cardiac anomalies who are, you know, borderline feeders that they push us to do Nissan's, um, especially if the child needs a G tube as well. And if they're too sick for that, we've even put a couple primary GJ's in, put the tube in and put the GJ in right on the, you know, right on the field and, um, and feed them through it if they're hospitalized and they don't think they can really go through and miss one. Yeah, we've had a couple like that. OK, next question, which of the following is true when considering a fundal placation in a five year old with developmental delay in regarding gastric emptying? You should obtain a gastric emptying study. Uh, delayed gastric emptying is defined when more than 20% of labeled agents are retained after 120 minutes. Pyloroplasty should be performed on all infants in addition to fundoplication, or fundoplication alone improves gastric emptying. So, um, I'll, I'll start off, the idea would be my answer. Um, uh, fundoplication is usually adequate. I don't do pyloroplasties, but I wanna give one plug. Um, a problem with a lot of kids that have severe gastroparesis, I don't know if John knows what I'm gonna say, but a lot of them after, uh, after doing a Nissin in a patient with severe gastroparesis will have wretching, especially the neurologically impaired children. And the wretching, I believe, uh, can, um, can first of all, undo or at least loosen your nissin, um, but I, I think the best, there is something that I do for those patients is I do gastric stimulation, uh, gastric electrical stimulation, and after I've done a nissin will shut off the wretching, um. And very, very, uh, impressive immediate, uh, cessation of wretching if you do gastric electrical stimulation in these patients. But I won't do a pyloroplasty in them, and I don't know, um. Well, I grew up, uh, a, a while back and in my 1st 10 years when we did openisc, we did check gastric emptying and we did, Pyloroplasty's on, he's neurologically impaired, but when I switched to the, the laparoscopic Nissin and then the, the statistics came out that it helps with gastric emptying, I don't do it any longer. I would, I would qualify to say in many or most patients it helps. There still is a segment, I think that has poor gastric emptying. So, here's a question I have for the group. Um, in kids you're doing a, a gastric pull up on. Do you do pyloromyotomy or pyloroplasty? For gastric. Whether it's a, for a, a lie, lie stricture or for oesophageal resia. Damn. Uh, we don't usually do gastric pull-ups. We usually do colon interpositions, OK. And yes, we do a pyloroplasty. OK. I've done a couple of pull-ups and I've done pyloroplasties just because. Yeah. Those with more experience seem to promote it, but I don't know if it's the right thing. It's interesting. So, I, I. We, we, we've done reverse gastric tubes here, actually in the neonatal period for some of those pyresia, and we've not done poloplasty with a gastric tube. So, so for a gastric, which I, I prefer the stomach, but, um, You know, initially a pyloroyotomy, I don't think it really relieves your outlet if you're gonna, if you're gonna open the, the stomach outlet, you got to do a pyloroplasty. But, but from our adult thoracic surgeons who do gastric pull-ups for esophageal cancer, uh, Jim Lucaitz in Pittsburgh did them all minimally invasively. They stopped doing pylorootomies or pyloroplasties, and if the patients had trouble emptying, they'd do Botox injections and found over time, even though their vagus nerves are out, they would empty, and they had more problems when they did the pyloroplasty of reflux and stricture, uh, strictures with their esophagogastric anastomosis. So the last, I think, 4 pull-ups I've done, I haven't done. Any myotomy on, I found a lower, maybe I just got better at it, but I just found a lower rate of stricture because when you, when you scope these kids, you see bile in their stomach. Interesting, and it's, it's very close. It's a short distance. So I don't know. I think it's, it's evolving. You could always, you could always go do your pyloroplasty if you need to. You can go back in later. You can't undo it. But, but I will say we had to do that, having decided not to do a pyloroplasty and was sorry when I had to go back and do it because it's not very much fun right after. There you go. All right. OK. Let's see. Although Oliver just left, but, uh, I, I, um, yeah, I think that's it. He does a, uh, a mucosal sparing pyloroplasty, which is essentially a pyloomyotomy. Oh, yeah. Uh, that's how he does his pyloroplasties. He does, uh, Heineken Mulliz. Uh-huh. But he doesn't open the mucosa. The mucosa and, uh, and then I've talked to a few other people that do the same thing. Um, do you, what's that? No, it's like a pylomyotomy, but, but he sutures, but he closes it transversely, transversely. He does a pyloroyotomy and then closes it, yeah, so I do it. I do full thickness. OK. So that previous slide just showed types of, uh, uh, hiatal hernias. So yeah, operative intervention for type hernias 1 through 4 is pictured here. When would you intervene operatively? In symptomatic patients with type one or other paraisophageal hernias, for all type one hernias, recurrent or primary, um, only by open approach and redo hiatal hernia repair patients via the open or laparoscopic approach with equivalent perioperative morbidity or in all patients, even if asymptomatic. This is something we learned more from our adult colleagues who deal with this, uh, as well, but based on the most recent SAGs, uh, uh, literature on management of hiatal hernias, that's where this data comes from. Well, I, I mean, I can jump in. I, I think for the, for the type one, I think if they're not symptomatic, I wouldn't do anything about that, um, but the others I, I would, I would go back and, and fix. So I, I think for me it would be an A, um, if symptomatic and type one and the other paraesophageal hernias, yeah, and I'd agree. And even some of my, sometimes those kids have had Nissan's either by myself or other people get a little bit of a, a hernia, and if they're not symptomatic, most of the time these are developmentally delayed, it's pretty high risk. I just watch it, right. Interesting, we have about 25% of the audience that's saying they'd fix all patients even asymptomatic. I wonder if that's because they're worried of a perisopal hernia, but I, I'd agree unless they're symptomatic, you don't touch them, you know. Yeah, I'm sure I have a hiatal hernia cause I on medication. You're walking around. Yeah. But, uh, OK. Well, uh, actually, Mark, we recovered pretty well.