Bariatric Partial Gastrectomy Technique: Adolescent Obesity 2013

Perfect. I'm here and Evan, we're going to turn, we're going to turn on the screen there. We see you and we're going to, if it's, we're going to let you sort of lead the discussion, but we have Mac, Tom, Ayed, Mark, and Mark who are going to be sort of moderating the case and asking questions, making comments about how maybe they do things differently as the case goes. Is that OK? Yes, we're just getting our truck cards in and getting things set up, so. Perfect. Now talk to us about, I, I, I missed the part that I'm most anxious about and um interrupt me if there's something you want to say. I'm not doing much bariatrics at all. I'm always very nervous about getting access in an obese patient, and, and it seems that all of you guys are very comfortable with it. Can you tell me how you got your first port in? Do you use the Visi port? So yeah, this is the patient's left upper quadrant, and I use an OptiView Trocar uh with a 5 millimeter. Uh, zero degree scope to get in in the left upper quadrant, and I actually use the same access for any obese patient who's undergoing cholecystectomy, appendectomy, or any intraabdominal surgery. I, I don't, I no longer enter through the umbilicus or, uh, perambilical for any of these, any of these cases. I, I always get it up here. And then go from there. And then I'm sorry, um, Stefan, can you remove that picture at the bottom of the screen? For those of you watching, you can watch this either in Adobe like you're watching it now, or if you enter in that that website at the bottom, Ustream.tv/globalcastMD, you can watch this in high definition. Um, so you can watch it either here or in high definition. I have both tabs open so I can switch back and forth because you will not see the comments being made on the chat box. So talk to us now, Evan. What's going on? I'm actually going to switch out to a better scope so you get a better feed for your, for your uh. Video, but we're just about to start our uh resection of the greater curvature, the good of the greater curvature. We start about 5 centimeters from the pylorus so that we spare atrium, so there's no intrinsic factor issue or uh anemia issue from that and then uh it's basically the start of the procedure is just like a missing fun application for all the pediatric surgeons who are out there, uh, just for a second, we still do a big mobilization there. That would be a better inoperative feed for you guys. And you're, you're standing to the patient's, uh, left side. I'm studying with the patient's left side and Miller Hamrick, who's my fellow, is doing this case and he's staring at the patient's right side. However, for bigger patients, this patient's BMI is 41, for bigger patients, I do them in, in. For bigger patients I do them in in in between from in between the legs, so our earlier patient today had a BMI of 60, so uh we did her Miller was between her legs for that case and I was still to the patient's leg believe it. So, so, uh, Evan, you know, and I'm curious what the other guys do. I mean, I, I tend to stand on the patient's right side, uh, and I, I've actually come to do it no matter how big they are, just cause I, uh, we don't have a split table and, you know, I don't like putting these kids into stirrups, uh, because of the risk of, uh, VTE. So, you, you stand on the right side when you're the operating surgeon? Yeah, operating surgeon stands on the patient's right side. Yeah, so that's what we're doing here. That's what we're doing here. All my fellows doing the case. I'm just, uh, on this, on this, uh, left, or this right hand over here to the left screen left for you guys, and, uh, so yeah, I do it the same way, but for my big, big patients, they're so wide that it's really uncomfortable for the surgeon. The operating surgeon to be to the patient's right and also my ports, I don't know where you guys put your ports through your sleeves, but 3 of my 4 ports are to the left of the patient's midline, with only 1 port on the right of the patient's midline, so it's really being on the patient's right. Uh, only works when the patient's fairly narrow. You know that works, but it's more comfortable. Yeah, your, your poor placement is a little different than than mine. I don't know if you could comment on that. Ay, I, I, uh, so Ayed, Tom, and Mark, we, we, and, and, uh, Mac, we still have you on the phone, but I'm closing out your camera because we want to make the screen bigger so they can see the operation. After he's done, we're going to open up all of the other cameras. So just for the purpose of making the image larger, let's keep the cameras off for now. We'll reopen. Ay, talk to us. Would you, do you do anything different here? Yes, uh, the position, yes, I prefer, uh, split legs, and, uh, definitely you don't need, I, I don't think there is any study scientific evidence that, uh, DBT will increase if we put them in a repair. Where did you take all precaution of, uh, DPT prophylaxis. Uh, the second, uh, I use, I don't know, I, I didn't see the two on the right side. Are they, how many 12 and how many 10 because I use only the camera 10, and then the left side is 12, and the others are 5. The other, uh, 5 in each, uh, so 35 and 10 and 12, and this kind of, uh, position of the roer, uh, location in the abdomen are the same. So, uh, I had, I use a 15. Uh, for the camera and to remove the stomach and everything else is a 5, so just like you. Um, and, uh. You know, with, with the with the uh echelon Flex stapler, you can basically. Get all the angles you need from 115 millimeter port or 12 millimeter port. So I've gone away from using anything more than just one. And as far as energy devices, you found this is the, what, what have you found, have you ever had any thermal injury? I guess it doesn't really matter because you're going to be removing the edge, uh, anyways. You know, what, did you want to make a comment? Well, I was, what I was going to make, I was going to try to get the discussion going, uh, because, you know, uh, right here you can see Evan taking down the greater momentum. I guess that's, I guess that's Miller, but one of the, you know, one of the questions that came up on the chat was if you could, uh, give us the patient's BMI and age and, uh, maybe a little bit of history and what the indications are for surgery so we can launch into a discussion of that. Sure, so this girl's going to be 18 in April, so she's 17 and 3/4. Her BMI is 41. She has polycystic ovarian syndrome and insulin resistance. She's on metformin. And she's been in our multidisciplinary weight management clinic for I think a year or so now, and, uh, you know, the family was initially resistant to surgery, but the medical team really felt that she had made all the necessary behavioral changes. She's actually a uh a catcher on the softball team, so she's physically very active, captain of the of the softball team actually. And so she exercises and she eats right. And still is stricken with this disease, so, uh, eventually the family warmed up to the idea of surgery and here we are, uh. Doing a sleeve gastrectomy for? So, um, what, what are you, so, uh, I'm going to go around, I'm going to poll the, uh, the experts here. We'll start with Tom since, uh, you, you basically authored the paper that established this, but Tom, uh, what are the indications for adolescent bariatric surgery? Or I guess since Ied's in the audience, we should say pediatric bariatric surgery. Um, question mark. Can you hear me? Yeah, I got you. Yeah, so what we do nowadays, and I think it's been an evolution over the years, um, is, uh, is really use guidelines. But more similar to the adults than they were in '04 when we first thought about this. Um, BMIs of 35 or greater, um, with major comorbidities of obesity, like diabetes, sleep apnea, Um, you know, significant sciato hepatitis, um, and, um, and pseudotumor we use as indications of BMI of 35. For those who, uh, meet, uh, the BMI criterion of 40, uh, we do still look for comorbidities, uh, to medically justify surgery, uh, but those comorbidities can be, uh, any one of a number of, um, of less severe comorbidities, uh, that are believed to be weight responsive. Good and And what's your, what's your age, Tom? Do you wanna, do you wanna state your age, indicate, you know, in other words, what age do you start doing this, or are you Tom? We want to know your age. About me almost turning 50 here. Um, so, you know, we never really, we never really had a, a BMI, sorry, an age criterion, um, you know, in our program, and, uh, I know that, that, you know, the teenage years are the, the years that, um, are most likely to result in comorbidities developing when there is severe obesity. But the fact that, you know, um, there are a number of preteens that, um, you know, that, that act more like, um, you know, teenagers or, uh, you know, can be, Uh, mature of thought and behavior enough to consider surgery. The fact that preteens can develop, um, can develop comorbidities, which are compelling reasons to get the BMI down, uh, means that it's, it's probably wise not to promulgate guidelines that state, lower, lower ends of eligibility. So would there be a level of, you know, would there be an objective measure of maturity? I mean, some people say 90% of skeletal maturity or something like that, or 10 or stage 4, or do you just take every patient individually? Yeah, I think that there's a risk to, uh, really trying to make it, um, you know, so cut and dried, and I I really do believe this is a problem that we're still learning, um, about the outcomes. We're learning about indications, and, uh, we really do we really do need to be more, um, uh, less prescriptive and really study our outcomes, uh, based on individual assessments. Matt, do you, do you have any comments? I agree with Tom's comments on, on indications. Uh, the youngest patient we've done in Birmingham was 13, uh, and so we've not gone, uh, below that in terms of age. Yeah, I mean my youngest patient was 12. Uh, but, uh, I, I, do you, do you wanna, do you wanna comment about assessments of maturity or, you know, because you, you. Uh, I'll say it's a little bit controversial. Uh, you have some younger patients that you do, and I'm gonna, I want to hear what you have to say, and then I'm going to let some of the pediatricians comment on it. I'm sorry, I, I, uh, I had, before you answer, um, Evan, can you explain what, it looks like you're going, you started off looking like a Nissan, but you're going down, are you going all the way to the Pyloris now? No, but, so, here's the. Just don't burn it with that. So the fellow just marked the pylorus with the active blade of the harmonic for all of you who need to see that. I asked him not to do that again. Here's the pylorus over here and we're trying to get to 5 centimeters, uh, and you know it's, it's the adult guys are doing 3 centimeters. I think it frankly makes no difference as long as you leave enough antrum so that you don't have, um, intrinsic factor problems and obviously. Uh, at the incisura here, that's where you get your obstruction if you're too narrow. So you want to have a nice sort of, uh, gradual angulation towards the uh incisura from a starting spot. And there's a the gastro a blow it almost always bleeds over here when your first taper fire occurs if you don't pay attention to it. So because we're on video, I'm going to try, he's being a little more aggressive in terms of making sure that that thing doesn't bleed right there so that I don't have to explain the bleeding during the uh crisscrossing, crisscrossing on the other hand. So Evan, exactly what dose of Antrim prevents uh intrinsic factor deficiency? I was like what's that? What dose of Antrim prevents a deficiency of intrinsic factor? What dose, just the right amount, just the right amount. So, I mean, you know, this is an important point for our pediatrics colleagues who are going to be helping us follow these patients postoperatively. Uh, you know, so you can see, and this is a controversial point, how much Antrim to leave, and we talk about this at surgery, you know, bariatric surgical meetings. You know, I, I'm pretty conservative with the kids and I still leave 6 centimeters. I had, I know we were, we were just in, uh, just in Aspen actually with Todd was there too, and now we're in lovely Akron, Ohio. Um, but we, uh, you know, where, when we were in Aspen, you show, or Vail, you showed a, uh, see what day it is, know where I am, uh, we were in Vail. I had, you showed me a video and you left about 2 or 3 centimeters of Antrim. Mac Yeah. So on a sleeve, Mac, how much Antrim do you leave? I'd say in the 4 to 5 range. Yeah, so we're sort of all over the place. I, I, I do 5 to 6. I, I do, I, I measure 6 and then I sort of err towards the pile. You, you take a silk and I take a silk and measure it. Uh-huh. And then go down. But you can almost make it whatever you want when you stre you can stretch the stomach, but I sort of do it at rest. Well, have any of you had problems with, uh, B12 deficiency or? After this operation? For us, um, no, B12's been OK when we've checked it for the most part, but we put them on B vitamins ahead of time and, you know, that's part of what they have to show us they can do and that's take their vitamins regularly, so. We don't actually check it prior to surgery. We check it a month after. We, we regularly measure it and we're finding the B12s at the low end of normal, typically, but there have been some that have into the, um, abnormal range, and whether this is just a, A measurement, um, or whether it's disease, I think, will, will take a number of years to figure out. We haven't had anyone develop megalloblastic anemia, uh, but then again, the problem there is that we've got a, um, they have a risk factor for microcytic anemia as well as megalloblastic anemia. So, it's, uh, they're counterbalancing, probably, um, but we haven't seen either. And Mark, I'm going to leave this up to you. There's a question from Robbie regarding bands and sleeves, and, uh, so do you want to wait for later on that? Let's wait for later because we are going to have, uh, uh, and, and we may, and Evan, we may cut back and forth to and from surgery, but, uh, Mack Harmon from UAB. He's going to talk about bypass, uh, Tom Inge, uh, he is gonna talk about the sleeve a little bit, and then Mark Mowski is going to talk about the band and then in the discussion, I think we can talk about where people are going, uh, when, you know, when do you perform what operation or if we even know, uh. If that sounds good, I think Evan, are you getting ready to fire your first stapler there? I didn't, uh, we're about to load. I had to switch cameras because when you only one. Port, you'd have to use the 5 scope, the whole case, which I normally would do, but I went to a bigger scope to give you guys a little bit of a better view. And now we're using the 5 scope. So you have a bougie in right now? No, I did my first fire without a bougie. OK. Um, that's probably something to discuss with the different surgeons, but I do my first one without a bougie and I make sure that I'm outside of the, uh, The vessels that are from the lesser curve, so he's going to move that over a little bit so you can see where the vessels end. Um, and then we always check the underside after he closes it to make sure that there's uh. You know, enough stomach, uh, for for safe passage and then actually after this fire, I put my second stapler load on and then don't fire it, but I put it like in this direction and then I pass the bougie at that point and I find that that saves the 30 minutes of hassle. Getting the bougie to that point. So I, I had, I had, do you wanna comment on that because you, you have a nice technique where you, you always put the bougie into the pylorus. Yes, I will comment on this. Yes, uh, definitely, uh, the movie for those below 12 I use, uh, do you hear me? Yes. OK, I use below 1234. I use those who are more than 30, 12 years, 36. I don't use reinforcement of be strip as in this, uh, as shown in the in the film. There are a lot of studies with anagonist, but I don't use them myself. One thing also about B12 that was raised a question we have done our evaluation for 108 sleeve gastrectomy in children and adolescents at 6 and 12 and maximum 2 years follow up, and we found 30% of them, they have vitamin B12 deficiency, but some of them are, to start with, they are deficient, corrected. Those 30% are developing while they are in their post-op follow-ups. Um, I think the anum, one comment about the anteum, I believe 2 to 3 centimeters, and there are other studies, volume studies, and shows the part that expands more from the stomach is really the anterum, not the sleeve itself, not the tube. But I think, I don't think we should leave good size, otherwise we will not be benefiting as long term much. It will come back and they will regain. Weight within maybe a few years. Uh, indication, it has been raised, if I allow you to comment. I am going with adults exactly criteria, uh, 35 with comorbidities, and must be a little bit with comorbidities, sleep apnea or uh diabetes, hypertension, 40, uh, without comorbidities or minor comorbidities as usual. And for the age, as I said in different meetings, I don't think we should deprive the patient based on age only. If somebody has severe, severe comorbidities with life-threatening conditions, I think we should not deprive them from care based on age only. Very good. So. Go ahead. Uh, go ahead. Go ahead, Tom. Yeah. So, um, a lot of people do read that article and ask questions about, you know, what would justify surgery in a 5 or 6 year old. So, what is it that you're seeing there in the Gulf, you know, in the Gulf states that are, um, so worrisome at those very, very young ages that would, um, you know, put you, uh, towards thinking of surgery? I would say, Tom, uh, we are seeing the patient with severe sleep apnea with, uh, life-threatening condition either going to hypoxic, going through while sleeping, and the family will mention it to you. You go and do a sleep study and you'll find in sleep apnea study you'll find hyboxia up to 50% while they are sleeping. And then you do their echo and you find pulmonary pulmonar or the severe pulmonary hypertension also these absolutely we should not wait on them because they will lose their life. I have some cases I mentioned it also in the article that they go and a risk, cardiac arrest because of hypo, and this is one condition. The other condition, you have somebody who's, uh, diagnosed diabetes, and, and one of the cases is 5 years old with diabetes and, and other condition, but if you follow them and they already, uh, BMI is 40 or so and they are newly diagnosed diabetic patients, yes, I can offer them, and I think we should not deprive them if you can't cure. I mean, What up to 90% or 80% in the in the studies that you can cure in our experience, the cure of that is that 90% of those who are diabetic and underwent bariatric surgery. So I think uh the age itself is important. However, it should not be the only reason we deprive the patients of care based on their age. So Steven, uh, Pont, are you still on the, on the call? Steven. Sean, I guess he's not there. Stephanie, do you wanna, do you wanna comment on that? Well, I, I think our, when we do, you know, the bariatric programs over here, we're really looking at, you know, is it sustainable and are these kids actually making behavior change so that they can live. A healthy life afterwards. I don't know that children that young have the ability to make any of those decisions or understand even less so than teenagers understand the long term effects of that or the importance of regulating their diet because their stomach is smaller. I mean, how much, I mean, I know from your what you stated about your program earlier, you have a lot of, uh, family involvement. So are the families the one in charge of their diets then, or are they? And how do they do afterwards? You're talking about right now? Yeah. I had, did you get that? I had? Uh, I got a question, and in our cases, we are always worried of something that we don't know, and this is very important. We always say that patients, pediatric patients will not listen to us. We have done our evaluation. 71% of those cases underwent bariatric surgery. They are compliant, they listen, they follow their protocol. They come to their visit. They are even better than others in compliance. So nobody has done this. And we are always saying we are worried about this and worried about that. Similarly for micronutrient deficiency in gastrectomy, we are always saying they might get this, they might get micronutrient deficiency or a problem with their nutrition, and when we evaluated it, it is not there and fears fall out. They are living normal life in terms of their growth. We have evaluated it by their growth parameters and like. and hormones and also, uh, bone age and others, and they are really growing well and metabolic response is very well in these patients. So we are always, uh, speculating about the future that we don't have evidence on it, while at the same time, we have somebody with diagnosed disease, life threatening conditions sometimes, or organ threatening in other times like diabetes and others, and we are depriving them from the care, so. Evan, um, can I ask you a question here? Can you hear me, Evan? Yes, I have a question, two questions for you. Number one, you mentioned about bleeding from the gastropoloque. What are the other pitfalls? It seems the part that you're at now, which is you're stapling, I think it looks like you're heading up towards the angle of his. Is this, is this, this seems like this could be a challenging part is to really make sure you get the staple in the right place at this point. Can you? There are a lot of, uh, so you see this pooch here, if you don't pay attention to pulling it laterally, you can leave. Uh, fair, a fairly big remnant up here which can then actually regrow and actually even twist, or, or, you know, it certainly impacts weight regain if you have a big pouch up here. So one of the things you definitely need to do is make sure you get this part and retract it laterally. OK. Um, obviously if you narrow the GE junction here, you'll have dysphagia. So all the teaching is that you come just to the, uh, patient's left of the angle of his. You don't wanna be right at the angle, so you want a small little uh remnant up there, but nothing too large, um, you know, we didn't go over it when we were doing the gastric, the greater curvature mobilization. But just like admission, the uppermost short gastric can be a, a difficult area and you can get into bleeding in the spleen, uh, especially depending on which energy source you use if you're not paying attention. And, you know, this is where they leak in all the adult studies, they all leak at this, uh. Uppermost portion of the sleeve, so you really got to pay attention to what you're doing is that. Is it a hard angle to get to? Is it technically challenging to get that, that angle? You know, I think the theories and the science is minimal, but I think that the um I think the, you know, if, if you, if you're on esophagus where there's no cirrhosa, that could be an issue, um, I think if you're, uh. If you're, uh, can't visualize and you do something suboptimal, then obviously that would be a risk factor, uh, yeah, if you have a seam guard malfunction that we just had there, that could be a problem, um, you know, I think it is technically challenging to operate at the GE junction. It just requires more attention maybe than the, uh. Than the than the rest of the procedure which should all have your utmost attention anyway. But you can see we're just trying to hit this little last bit up here. Uh, so, may I comment on this, uh, steps which is very important. I think it's very important to, and we know the leaks is mostly at the gastroradal junction, and I think if you see if the fire was applied as such, as you can see that part of the stomach in the upper part is really folding behind. If you fire in that level, you have a leak because you are firing on double stomach, and now you see that there are some. Straightening, and this is very important, but the thing that will help in this stretch and straightening of the stomach is bringing the crust on the left side completely all the way until you see the angle of his completely free to the letter. Then by that time we'll be able to stretch the stomach and straighten it. So, so. Yeah, yeah. Clarify that for me. So, you're saying like a Nissin, like when you totally clear it off or what. So, I had, what you're saying is that, that, uh, you need to clear the, the left side of the cruise. Yeah. Just so that you can see that completely and make sure that you don't leave that gastric remnant. Cause I've, you know, I mean, fortunately, I've not experienced it, but, uh, you can see how people can do it. Uh, is leaving a pretty big remnant up there which is going to sabotage your weight loss. So, so as if when you're finishing the short gastrics, you come across the top, you continue on to make sure you've cleaned off the the left side. Yeah, and I think, uh, Evan did some of, did that. So you, you pull the, you pull the fundus down and then you just clean off the greater curve, OK, or I mean, sorry, clean off the left side of the cruise cruise. So you know what is in vogue now in some of the higher volume adults. Surgeons actually prophylaxis a stitch up there and um either dunk that corner or just, you know, actually put a reinforcement stitch. So Greg Jossart um uh in San Francisco was talking at the at the ASMBS fall course a couple of years ago, and he does that and he also suspends it to the crews. In an effort to recreate the angle of his there theorizing that that might reduce some of the um the reflux that we see in these in these folks. Oh, is that, do you see quite a bit of reflux in the in this? Yeah, that's one of the, the emerging problems that that's being reported in up to a third of them in the longer term follow-up. You know what's Matt, do you have any comments about this technique? Is it the same exact way you do it? Yeah, uh, but I, I, uh, uh, if Evan could show us the GE junction one more time, that'd be great. The GE junction up here or underneath. So this is a little, this is like the angle of hits here and then the G junction is basically there but you try to leave a little bit toward the tip. We leave a little dog here at the. At the top there for in theory to reduce the leak rate, although who knows if that really does anything. Now I just now I just noticed you changed cartridges. You were using a green load, I think our guard. Actually goes past the stomach. And that I don't think we actually are dividing anything up here other than Team guard, but I can't be 100% sure, so I'm gonna fire it with the. Hold on, give me one second so I get this set up. Sure, Miller, help him. So I think he's he's telling me what to do because he's like I'm paying too much attention to the video. He's a good guy exactly. I think we have seam guard stomach on stomach all the way past where we need to reset. So I'm using a thinner load which is gold, and I'm not using Semguard just to divide it up here and I think so, I can't remember if Tom was who was saying it, but if there's an issue, but if there's an issue up there, I'll just put a stitch in, uh. Uh, dunk it or oversell it or do something. Unfortunately, I've already taught Miller how to sew, so you're in good shape. You taught him how to do it, is that what you said? I taught him how to sew. Oh, you taught him how to sew. Yeah, that's why we're, that's why, that's why we're not doing any sewing in this case. So did you guys already mention it when I wasn't, is that a power that's a, is that one of that, uh, what's it called, med, it's the echelon is what he's using, the stapler. It's a powered stapler, yeah, huh, yeah, it's a power stapler. We're a little lazy here. Yes, they have delicate hands. I have a, I have a thing called the Bowflex. It's really good and I work out with it at home. So as you can see, here's the, here's the remnant over here. And so this is gonna be another, I'm sure everybody has their own way of doing it, but what I do now, you take the bougie out, is I take the bougie out, I put an OG in and I inflate with 60 cc's of methylene blue stained saline and assess the stable line all the way up for a leak while we hold off the duodenum down here. And, and, uh, Evan, have you ever um seen a leak by doing that methylene blue technique? No, but I wish I had no other child. And uh I just haven't. No, no, I, I mean, I guess my question is, have you ever had a leak that, that even, I mean, how accurate is the methylene blue test, I guess. So some people, and I'm sure I don't, I don't know how does it, I don't know how Tom does it, but some people do endoscopy and and insulate air to look for the leak. Some people do methylene blue, some people don't do anything and just do a radiographic test, uh, one day post-op. You know, I think as pediatric. Uh, bariatric surgeons, we have to be extra sort of belts and suspenders, you have to be extra careful, so I do a leak test here and then I do another one in the morning before I feed, and I've never seen a leak on either study, but it sure makes me feel better. Uh, doing it, I mean, if you're going to do air, if you're going to blow air, you then, then why not? Can you put a flexible endoscope down instead of a bougie, and then you could get it down to the pylorus and use it even for your first stapler and then test with air. So that's what, that's what our adult guys do. Yeah, there are people that do that. OK. I have a couple of comments to make about that, um, and about endoscopy in general. We do endoscopy. We do an air test, um. And I, I would caution people about sending a $16,000 fiber optic scope down as your bougie, because you might be surprised when you pull it out. You know, we don't have spare ones here at this hospital. But the other comment I would like to make, Evan commented about doing a postoperative contrast study, and we used to do that. We no longer do. And actually, if you look at leaks and the predictability of a leak based on a negative contrast study, most leaks don't actually happen during the initial hospitalization. And, in fact, actually, many people report that leaks happen somewhere usually between 7 and 10 days afterwards. We've had a couple of leaks. And if you look back, they've all had normal studies, so I don't really find that much reassurance from a negative study, which is why we basically just stopped doing them. Mark, what is the, what is the general accepted leak leak rate across the country with this operation? Uh, you know, I don't exactly know what the, uh, what the adult number is, but I would expect it to be, uh, you know, uh, in, in the low, you know, less than 5%, less than 5%, OK. Yeah, I would agree, uh, with Mark, you know, we abandoned that after probably our 75th case or something because we just couldn't, uh, we, we didn't really see a need to do the postoperative studies. They weren't predictive of leaks, um, uh, that happen typically in on days 3 to 7. So, um, we actually never have challenged the staple line with an intraoperative, uh, test either, um, uh, only because again, it's a, it is a challenge to the staple line and, um. And we've not, uh, you know, we've not seen a leak, uh, fortunately, but we look at every staple firing that goes down for any signs of, of a problem. Hey Tom, do you guys do, um, do you do, do you do it at any time post-op to size it so that when they come back with weight gain at, you know, two years, you have something to compare it to, or you just get one when they, if they regain weight and if it looks big, you just assume that they need something else done. Yeah, we, we use a 34 French bougie and we've been really satisfied again in that 1st 75 or so that we got upper GIs, uh, we were very satisfied with the uniformity of the size of the, you know, resultant, um, stomach. So it's typically on that first, uh, upper GI study, typically, uh, the width of a vertebral body or even, More narrow in some places. So I, I've been really satisfied using that standardized technique. And so when, when there is a need to study them postoperatively, um, you know, we, we do that just, you know, if they're regaining weight or something of that nature. Doctor, do you guys want to switch, switch to the outside camera for a second? Can you switch to the outside camera for a second? I'll show you here, so I use a wound Alexis here, I don't know what the other guys do. This is a wound Alexis. And uh we put the trocar right through it. And then grab the stomach and then pull the stomach out through the wound Alexis instead of using an endocach bag or anything like that. Again, I don't know what other people do, but we found that there's a neat way to just get the stomach out without having to use an expensive, well, I guess the wound Alexis is less expensive than the, than the, uh, bag, the endo catch-2 bag. You know and uh. I, I, I, I have to learn the trick from you. I, I've had a hard time when I remove, uh, colonic specimens, um, with that. I put a, I put a glove around the Alexis and then put a trocar through the glove, um. Keep the insufflation. That's great there. It's coming out. So that's a 2 centimeter incision there now? 15 millimeters. Maybe 2 centimeters. We'll go 2 centimeters and that's the umbilicus. No, it's to the left and oh sorry. Left in a only on uh on TV. So, uh, that's just gastric juice in case any of the pediatricians are freaking out over there. Don't worry about that. Everything looks good on the inside. Uh Another, another fellow sabotage just when you think you haven't trained up they hold you on international TV, um. So anyway, um. What were we talking about? I, I just, I just made the comment. never mind. So one of the one of the questions asked, uh, you know, is, do you know who uses buttresses and who doesn't. I personally don't use buttresses. I started out using them, but there's not a lot of good evidence for them. Uh, they may decrease bleeding, but the question is whether that's clinically significant or not. Um, and I, I was curious, what I, I had, do you use, uh, you, you said you do not use buttresses. Tom, Mark, Mac, do you use a buttress? Uh, we do use buttresses after the first firing, the first firing, um, and, and the folks who taught us, um, felt like it was, there was not enough room because of the thicker rum, uh, not enough room with the green stapler to also accommodate the buttress, uh, thickness. So after that we use buttresses, uh, for every one of the firings. I thought. Like a running on, uh, on things, a few things. One is, uh, the extraction of the stomach is the specimen. Uh, as I said, we use only 12 on the left side, and the telescope is, uh, 10, uh, just above the umbilicus, and the others are high, so we just expand with chili. We take the expand with chili, uh, the left, the 12 millimeter, and then we extract the stomach, and it's very easy. It's not difficult, and rarely you'll be having a problem with like a spillage like what was shown. And in, in, uh, about 200 cases, we have done now only 2 cases with wound infection at that site. So I don't think, I think you don't need, if you need, we can't say at the back, what I say. Now, for the leak, uh, we don't test either also afterwards post op. We don't either. Initially we were testing intraoperatively, then we stopped testing and always we know that all, Patients who are leaking will have tachycardia and fever and another 60% predictive values for study. The studies have shown CT scans with upper and I and IV contrast are much better, 90% or more predictive predictive values for this. And if it is needed, as we say, it's very incident 1% in adult literature 1 to 5, but in our cases, pediatric 200, there was no leak. So I think it, I think it's technical. The leak leak related to technical problems. Very good. So what I'd like to do now, Evan, uh, great, uh, Evan and Miller, uh, thanks for sharing this with us. Um, what I