Biliary Atresia: Where are we now? Advanced Practice Providers Pediatric...

To speak with all of you. I would like to thank a couple of my surgeon and GI colleagues for some of the slides that you will be seeing during the presentation. And again, if you have any questions or comments along the way, please feel free to jump in. I do have a case study and some polling questions at the end, but if you have other comments, I would love to hear them. So we're gonna be talking about biliary atresia, which we all know affects the liver. So remember, back to our undergraduate and graduate pathophysiology. The liver is extremely important. We cannot live without it. Uh, one of the Functions is bile production, which is where we see the cholestasis that presents with our babies with biliary atresia. The liver has a number of other functions that you can see. And let's talk a little bit about bilirubin. Remember back to pathophysiology, it's the degradation of hemoglobin, and it's important to remember that newborns produce a lot more bilirubin than adults. In the reticuloendothelial system, heme is converted to biliverdon, and then it's reduced to unconjugated bilirubin and sent to the liver where it is sent to the liver bound to albumin. In the liver, conjugated, uh, it's conjugated with glucuronic acid, and then the bilirubin goes into the bile and is excreted into the small intestines. So, when we talk about jaundice, we have pathologic jaundice, and there are neonatal jaundice can present as an unconjugated hyperbilirubinemia and also a conjugated hyperbilirubinemia. It's very important to to dissociate the two and follow the proper pathway. Because we wanna make sure that we do not overlook a diagnosis of biliary atresia. Pathologic jaundice occurs 1 in 2500 live births. So we do see it rather frequently and primary care providers do see it a lot. When we talk about cholestasis, we can look at a physiologic definition where we see a, a decrease in the bile flow. The pathologist sees it and we'll look at some pathology slides later where we'll see biop pigment in the sections, and then for us, as we see it clinically, it's an accumulation of products in the blood and producing the yellow color. So again, we see jaundice, the yellowing of the skin, icterus, the sclera turn yellow. Some of these babies, we don't see it as commonly in biliary atresia, but they can be very itchy. When you do your blood tests, obviously, you have elevated bilirubin levels and uh elevated liver enzymes. When a baby presents with jaundice, there are a lot of diagnoses to consider. You wanna rule out the simple ones with blood tests before you go into more invasive procedures. So we won't go into these diagnoses, but there are a lot of them to consider. It's very important to obtain a very careful history from the family. I want to look at the pregnancy history as well as the family history. The neonatal course, were there, uh, admissions into the intensive care unit? Did the baby receive total parenteral nutrition? Are there any other anomalies in the baby? And importantly, you wanna note the stool color. We'll talk about that a little more. Obviously, with your lab testing, you'll be getting a fractionated bilirubin level, the liver enzyme test. You wanna rule out any kind of bacterial and viral infections. And then you want to get that baby to a pediatric hepatologist or GI doc and or a pediatric surgeon. A lot of these tests that are listed can be done as the referral is being completed. So what is biliary atresia? It's a progressive, obliterative, idiopathic cholangiopathy. There's two forms we can see it a perinatal or postnatal form. About 80% to 90% of babies present with this form versus 10 to 20% with a fetal or embryonic form. The fetal embryonic form tends to occur earlier in these babies. They'll present a lot younger, and they typically have associated anomalies, such as splenic malformations, uh, uh, heart defects, things like that. The incidence ranges from 1 in 5000 in some Asian countries like Taiwan. It's a little less in Japan, where it's about 1 in 8 to 10,000, and then 1 to 18 18,000 in the United up to that in the United States and in Europe. We do see more females than males affected. They're. Tends to be some seasonal clustering, which leads some to suspect that viruses or some sort of infectious process is a trigger for biliary atresia, and this disease is lethal if untreated. So looking at the etiology, we still haven't figured that part out. That is the $10 million question. I'd mentioned, is it an infectious process? So some have associated cytomegalovirus, rheovirus, even rotovirus, but this isn't always found in all cases. There's a lot of um. Studies looking at inflammatory processes, are those the, the reason for biliary atresia? Is it a genetic abnormality? Is there abnormal development during fetal growth? Are there environmental toxins? So a lot of these are being explored, and it's probably. A combination of factors, multifactorial. There's probably a genetic component where certain triggers, maybe an infection if you have a specific genotype. Again, we're still trying to figure out this part of the puzzle. So back to the diagnosis of biliary atresia. Once you determine that the baby has a conjugated hyperbilirubinemia, your lab may do direct or indirect bili, or it may measure conjugated and unconjugated billy. If your conjugated or direct bili is greater than or equal to 2, you need to get that child in and uh evaluated more closely. We'll see elevated GGT levels. These babies need an ultrasound. There are babies with biliary atresia whose ultrasounds are normal. We do, again, then get a HIDA scan. And if it's still questionable, they'll go on for a liver biopsy, and the gold standard is the intraoperative cholangiogram. OK. On the ultrasound, let me see if I can grab my little pointer here. In this picture you can see this is a a small shrunken gallbladder right up here. So we'll typically see that and then down here doesn't look much of a triangle, but this is a triangular chord sign. Oh, there's my arrow, thank you, that you may see. Right here is a triangular cord sign. And up here again, this is our small shrunken gallbladder. So those are some typical ultrasound findings. Again, they may be a normal, it may be a normal ultrasound. OK. The HIDA scan? This is a nuclear medicine scan at our facility. We pre-treat these babies for 5 days of phenobarbital, and then they go for the HIDA scan. Here you can see this is the liver. There is adequate uptake into the liver of the nuclear dye. But there is no excretion into the intestines. So this would be read as suspect for biliary atresia. We then do a liver biopsy depending on the age of the child. Uh, we sometimes will do, um, a radiology, an IR biopsy, and then we will also go forward with an open biopsy if we are very suspect. So with that. We can see portal inflammation. This is what the pathologist would read. We can also see some file plugs, those are those brown stains with the arrows by them. Ducular proliferation, you can see a lot of these circular areas. Those are a lot of little bile ducts. And then on this particular stain, a trichrome stain, we note cirrhosis. Hey Kat, can I, can I interrupt for a second? I'm just curious, you know, before you pass over this topic, I think I'm just wondering if there's variation. I noticed myself, uh, at my first institution, we did it one way and I thought that was the way, and then I moved to another place and they do it quite different. I'm just wondering maybe we can put a poll, Jen, of, um, I'm just wondering how many people out there do they get a, do their surgeons get a liver biopsy. Prior to going to the operating room for a changiogram, or do the surgeons do the liver biopsy at the time of chalangiogram. Uh, so I know that that not everywhere does a preoperative liver biopsy. Um, so maybe we'll do a poll. I don't know if anyone has a comment about that or do we or should we just keep going. I think, I, I think you're right. I think there is variation. I think, um, you know, if you have acholics stools and a, uh, jaundice baby, a positive HIDA and an absent gallbladder and bile ducts on ultrasound, um, I think proceeding then to a, uh, to an intra-op cholangiogram and liver biopsy, and then, you know, if you don't have a gallbladder, you can't even do the cholangiogram. Then you're gonna, you're going to do the cassa at the same time. I don't always require a liver biopsy preoperatively. In cases where, you know, it's a little iffy or it's not quite that clear, um, sometimes I will ask for a liver biopsy. Yes, I think that, you know, and actually I encourage the audience again to not beat a dead horse, but I really, the key value of this session is to get other opinions. So right, if something is being said that you do something different in your hospital, that's what we want to. Everyone thinks that what they do at their hospital, especially that's what I always thought, what you do at your hospital must be what everyone does, and you'll be shocked to see that they do it totally different in different places. So please feel free to write, you know, I'm not sure we do that at our hospital. It would be interesting to discuss it. Sorry, Kat, keep going. No, thank you very much. Again, as Dr. Anne Selma was saying, it depends on the history and some of the test results that we've received that determines do we go for an IR biopsy or do we go straight for an open biopsy or do we even do a laparoscopic biopsy and attempt to. Do the cholangiogram laparoscopically. I've seen that and uh, there's flow into the small intestine, and we just close up the little lap incisions and try to figure and then send the baby back to GI for them to figure out what the cholestasis diagnosis is, if it's not VA. So moving on here is an example of an intraoperative cholangiogram. And if there's no flow into the small intestine, then we move on to the Kasai procedure. And again, this was developed by Dr. Kasai in Japan. And so it's a ruin why. Anastomosis into the portal plate once you've dissected out the old shoestring looking biliary remnant once you've determined that this is biliary atresia. And here at Children's we typically use a 42 centimeter lamp rou lamb, attach that up and continue on, send close up the baby and send them post-op to the floor. So here's some surgical uh photos. You can see the BA remnant. You can see the gallbladder fossa there and an area where the portal vein is. And you can see a roe limb here will be hooked up to the portal plate there and with a few sprinkles of holy water and a few Hail Marys and hopefully we get bile flowing. We do know that timing of the diagnosis and moving to the cassai is extremely important. Typically, the younger the baby, the sweet spot being 6 to 8 weeks of age. Again, I've seen. Babies getting to size at 3 to 4 weeks of age and move on to transplant before 1 year of age. So again, there's many factors that you have to look at, but key is getting these babies diagnosed early. In terms of outcomes, a lot of different countries have looked at survival with the native liver SNL. A French study showed that 23% of their Kasai patients had their native liver 20 years post Kasai. Uh, most of these are not what we would consider fantastic outcomes. This is still a very, uh, stressful disease for families, as I was saying earlier, there's a lot of factors affecting survival with their native liver, one of them being the age at Kasai. We also have to look at the type of BA. There's different classifications. Looking at the liver histology, if there's a lot of bridging fibrosis already, those tend not to do so well. And looking at the caseload, so that's the number of casa that are performed at a specific center. In England, they increased their success with CSI by consolidating to 3 centers performing their CSI. Here in the United States we do not do this sort of thing at this point in time. But that is one factor is looking at the number of CSI. I know surgeons that see maybe one in their 2-year fellowship. Here at Children's, we see 6 to 12 babies a year, and we're considered a high, high rate of CSI. What do other people see at their centers? That's a, that's a good question. And Kat, I'm gonna put you on the spot. I put you on the spot. Absolutely. What do you think? What are your thoughts, um, about a surgeon who does one every 2 years doing a Kasai? Do you think we're, you know, well trained enough that we should be able to do it, or probably should hand it off to someone who's done a lot of them? Well, my personal opinion, which may not be the opinion of the surgeon colleagues I work with, I would think that if you had someone who really, this was their passion. That they should be the ones doing it. We have had surgeon colleagues say, you can have all of my casa. I've heard them say that to other surgeon colleagues. I agree with you. I think, I think that these are cases that should go to people that have high volume of experience. And if a surgeon wants to do it, have him do it with someone who's done a lot of them, because this is one thing where you only get one shot, and it depends on technique. I, I would agree with that. And again, not being a surgeon, I can only speak from, from the, the audience, so to speak. So, but again, a lot of these studies out of England, Finland, uh, France have all shown a significant improvement in their, uh their rates of survival with the native liver, postponing transplant as long as possible. And we'll talk about transplant and those issues in just a little bit. Anybody else have any? I know a couple people have chimed in saying, you know, 2 to 3 cases of BA a year, 6 per year. Yeah, 6 is not, not very many in a year at all. But I have a question, Kat. Maybe you can answer it based on Doctor Wong's experience, or maybe, maybe someone else can answer. Is there ever a point at which you would not offer a Kasai, say you have a 3 month old, 3.5 month old, you clearly have a cirrhotic liver and a jaundiced baby. Is it even worth doing a casai in that? Case or should you just stop and, and list the kid for transplant? That's a very good point, Doctor Anselmo. And yes, uh, of these babies, if we have a liver biopsy available or do a frozen while we're doing the the intraocholangiogram, if we see cirrhosis. We, we close up and, and say let's go to transplant. And again, looking at the age. Yeah. We have done a few 3 1/2 month olds. We have done a couple of 4 month olds, and we've been able to get them to a year of age before they go to transplant. But again, they've also had complications. They've had ascending cholangitis. They've had frequent hospitalizations. And then we get the unfortunate babies who weren't even picked up that they have BA until they're 4 months of age, so they don't have a choice. Yeah, I mean, that's, that's my, my question is, are you, are you bridging these kids to transplant and getting a little bit of biliary drainage, or are you creating ascites or increasing the risk of cholangitis, um, because I have seen kids get pretty sick after a Kasai, and, and don't do well. Yes, what tends, what I've seen over the past several years is getting these babies to an older age for transplant. OK. And yes, they do have some complications, but it seems the bigger they are when they're transplanted, it's easier at transplant for them. So and then when you look at developmental issues, we do know that these kids have impairments and they have done outcome studies with transplanted patients and there are consequences with associated with transplant. So there's a lot of uh interconnected issues that. We do see So moving on from our, can I ask, can I ask a question real quick? Have you, have you done a, have you done a survival outcome of kids who have been bridged with the Kasai opposed as opposed to those who haven't been, the older ones? They are, are there survival outcomes because I, it's gotta take a long time to get a transplant from our experience out here in the Midwest. Um, it seems like you're at children. Here at Children's we have an a very large, if it's not the largest living donor liver transplant center in the country, so we do have our kids do not, they have another option besides waiting for cadaveric transplant, which yes, a lot of them get extremely sick and do they do die, but since we're able to offer living. Related transplant we have very good outcomes. OK, so again, if your facility or you're able to get the child to a center that does do living donor transplants, the baby does have a high, a high success rate, a high survival rate. Very good point. So in the postoperative management of these babies, there's no standardized protocols for this, but most people will put these babies on antibiotic prophylaxis postoperatively until they're eating. We do put them on intravenous antibiotics. It's pretty much site dependent surgeon dependent what they would like to be on. Post-op steroids unproven and we'll have a little discussion about that later. Obviously these babies will need analgesia. So once they're taking orals. Yes, you had a question. So yeah, cat, are all of your patients getting, um, Broviax? No, no, most of our patients, we put peripheral lines in. So, so you only treat them with post-op, just immediate post-op. You don't send them home on IV antibiotics. No, we do not. Uh, did you use the ones that do. I'm sorry, did you used to? There's a protocol from, I think, 2002. It's from them. Oh, is it from you? Oh, it is from you. OK. No, I'm asking you, I don't know. With the one that we used to use, it was we'd send them home on 10 or 12 weeks of IV antibiotics and It seems like everybody's sort of moving away from that. Yes, the reason Laurie's asking is that I was trained on oral to use oral antibiotics. We used Bactrim and then we, there was a published protocol which I can try to pull up while we're here that showed, and I don't remember what it was from, which showed a better outcome when using IV antibiotics, so. The protocol changed to using IV from oral, and I can look that up and see, but I don't think anyone really knows. I think the data is very scant on that. Yeah, children, they're only getting intravenous antibiotics until they're, um, taking orals, and then we switch them to Bactrim. Again, if you have a baby less than 6 weeks of age, you would most likely put them on amoxicillin and then switch them to Bactrim once they're 6 weeks of age or older. We use 4 to 5 mg per kg per day for the Bactrim. These babies, we also put them on ursodeoxycholic acid. Twice a day, a lot of these babies because of their, the malfunctioning liver are fat soluble vitamin deficient, especially vitamin D, E, and K. Those we typically supplement and we use the aqueous solution, so Aquadek or uh ADeck. It's these fat soluble vitamins in an aqueous form so that they're more easily absorbed. I've only seen one or two of these babies on, uh, put on, not even ref like Atarax or Benadryl for some itching. They also need their bilirubin and liver function tests monitored. Folks have looked at other therapies. They're all unproven like probiotics, uh, herbal remedies, omega-three. None of these have been proven. And we'll get into the steroids. I have a discussion slide at the end. So if you can hold off on your questions, I'll get to that. Somebody just posted, what is the BARC protocol? It's interesting that you should say that. Uh, Children's Hospital Los Angeles is part of BARC, which is the biliary atresia Research Consortium. In 2009 I believe Bark and Click combined into children, so there's about 15 sites across the country all participating in an NIH funded UO1 study and the BAC protocol they were put on, um. Um, Urso, Bactrim, and then those that were enrolled, we enrolled 140 babies into a randomized double-blind placebo-controlled study with steroids. So that's what the BRC protocol is. I saw a little thing on the chat room. And like I said, we'll cover steroids in a minute. I've got some uh bunch of different studies looking at that and we'll pull you to see who's doing that. Primary care management, again, we need to have a multidisciplinary team watching these families or these children. Vaccines need to be up to date. The flu shot, their anthropometrics need to be measured, uh, careful with over the counter remedies and unnecessary medications. Family needs to return or call when they have unexplained fever. Whenever a baby that's had a Kasai has an unexplained fever, we suspect ascending cholangitis, so an inflammation of the rue limb, so the liver can be very affected by that. The jaundice worsened, the swollen belly, so again, looking at ascites. If their stools return to the pale color. I'm going to skip over these slides because I've been given the 15 minute warning. So again, as a chronic disease, we all treat families with chronic diseases. This really impacts the entire family. There's a lot of fear of the unknown, the, you know, when will my baby need a liver transplant? Will it be in the first year of life? Will it be when they're 5? We don't have crystal balls, unfortunately, we can't give them solid answers. If the baby has an event such as ascending cholangitis. I call it the other shoe to drop disease because these families are extremely stressed. Does this mean that now my baby's going to have to go for a transplant? We do know that the more times a baby has an episode of ascending cholangitis, it does further damage the liver and may lead to an earlier need for transplant. I have seen families divorce with the Kasai baby because of the stress. There's a lot of, especially for moms, there's a lot of what did I do wrong. So I do a lot of psychosocial, uh, interventions with these families and frequently have to call the social worker because that's way past. Past my training. Chad, can I ask a quick question about that? With the multidisciplinary approach that you use with these complicated kids, is psychiatry or psychology brought in the picture very early to help through some of the stressors? We have not referred to psych, but we do have uh a social worker. We have one in the GI division and one in liver transplant, so we run, run these families through the social worker if, especially if I pick up things going wrong and we try to introduce them in their initial hospitalization so that a rapport has been developed. OK, great, thank you. You're welcome. So again, there's a lot of living with uncertainty and a lot of guilt. So looking at liver transplant, again, biliary atresia is the most common indication for pediatric liver transplant. There's a lot of implications for that with the immunosuppression, I have seen malignancies develop. We did have one child that did die of lymphoroliferative disease following the liver transplant. They can get drug toxicities, infections, those types of things. So again, minimizing the amount of immunosuppression. And the close monitoring we do find with the living donor if it's a very compatible family member, we have had a few children. Get off of their immunosuppression, but again, there's no. Set in stone, yes, this is what's going to happen. All right, so we've already answered, uh, and had a lot of discussion, but I'm gonna present a little case study. So this is Sandra, and she's a 21 day old female with persistent jaundice. OK. Should her primary care provider be concerned, and at what age should a care provider be concerned about jaundice in a newborn at one week of age? We're gonna put that pole up. Fantastic. All right, so hopefully, you're seeing the poll. When do you think a care provider should be concerned about jaundice in the newborn? Well, here in the US we have the American Academy of Pediatrics, and their policy statement says all jaundiced infants at 2 weeks of age should have a fractionated bilirubin done. OK, so again, depending on your lab, you're either gonna measure conjugated and unconjugated or direct and indirect. So again, very important, and we do a lot of education with primary care providers in the community trying to reinforce this, that all these babies need to be explored more thoroughly at 2 weeks of age. And does this mean a policy change because You know, usually we see the babies at 5 days of age for a weight check and then we don't see them again until 2 months of age for their 2 months, uh, vaccines and health check, excuse me, so again. Excuse me. There's a lot of folks looking at policies here in the United States. And how do you identify jaundice in an infant? Here's another poll question for you. Do you look at their skin color? Do you look at their sclera? And how hard is it to look at the sclera of a little 2 or 3 week old baby? Should we look at their oral mucosa or use a combination of all of these factors? Well, in England, they did a study, they looked back at their babies and they found that Caucasian babies, their average age of diagnosis with biliary atresia was at 47 days of age. Non-white babies was 52 days of age. And any baby that was diagnosed after 100 days of age was only a non, was non- Caucasian. We've seen babies referred to us 4 months of age, and their eyes were glowing pumpkins, and you think to yourself, how could someone miss this? Again, sometimes it's really hard to look in a baby's baby's eyes, but again, using a combination of their. Skin color. A lot of times the auntie or grandma will visit and go, that baby doesn't look, that's not the right color for a baby to be, and, you know, new moms, how do you know? You see your baby. It's not like you wake up one morning and the baby is the color of a pumpkin. It's so insidious. They, a lot of times don't recognize that. But again, that's very important, using a combination. And then my next question for you is, is Sandra's stool a colic? So, looking and Doctor Frank Sinatra, one of our pediatric gastroenterologists, sent me this slide, which I think is just the greatest. And again in England they did another study where they they pulled physicians and nurses. They had stool color cards and they had some suspect stools, and 37% of the population did not correctly identify a suspect's stool. So again, a lot of families, they have no idea what they could say, oh yes, it's yellow. Well, our most of our clinic rooms are very colorful, so I'll pick a color on the wall and say the, you know, the baby's poop look like this or that. So, in answer to your question, yes, this is a colic stool. In our studies we use this particular stool card. 12, and 3 are not normal, and 45, and 6 are normal color stool. So again, with all the wonderful technology we have, we do have parents who text us photos of Johnny's diaper and the poop. It's great because we can say, uh, that that does not look good anymore. Please bring the baby back. And we always warn the parents, you will never see so many people interested in Johnny's poo than surgeons and gastroenterologists. So I always warn all the families, and then they Kind of gives a little bit of comic relief in a very stressful situation. OK. My next, uh, polling question is, this is Sandra's HIDA scan. Does this show tracer excretion into the intestines? OK, so take a second to take a look at that and do your little poll there. And the answer is, there is no excretion. OK. And this is my final polling question, do you feel that steroids would be beneficial to Sandra and improve her outcome following her Kasai portoenterostomy? Yes, no, or you're not sure. OK, let's have a discussion about steroids now. I'm gonna put a slide up with some studies. As I mentioned, the BARC trial, which is now children, this was just presented at uh AASLD, the American Association for the Study of Liver Disease. The 140 babies that we randomized between steroids and um placebo did not show any benefit from steroid use. And again, it didn't improve their outcomes with their native liver. It did we did see a more rapid drop in their bilirubin level and a lot of these other studies that are posted here. They also found that there was an increased jaundice-free or increase in jaundice clearance, but no one has really found that. That these. Prevent or lengthen the time until a baby or child needs to go to transplant, OK? So What do you all think? Do you think or how do your centers, I know we have some of our surgeons here like to use steroids, some of them do not. Sometimes we've rescued babies a few weeks out from a kai. Anyone? I'll, I'll chime in. I, I believe the data. My last two Kasai, I did not use steroids, and one was actually in an older infant. I think she was beyond 8 weeks, and they both drained well. I had been taught to use steroids. I heard, you know, during my training, uh, steroids were good, uh, but now I generally would not use them, um, unless it would, uh, the child gets cholangitis or if you need to try to rescue the cassai. And again, some of the theories, if you think about it being an inflammatory process in the bark trial, we gave steroids for 14 weeks after the Kasai. Is that long enough? Do they need to be on steroids for extended periods of time, say, you know, like asthmatics that have, you know, moderate to severe asthmatics that use daily inhaled steroids? I don't know, it's. Something that people are considering, but again, looking at some of these studies. Uh It doesn't seem like. Steroids are a thing now because we've, the chi the bark trial showed that there was no benefit and it was a well designed study. Uh, so where do we go from here? Again, we need to continue our research to determine why does BA happen so we can look at uh new. treatment for this. Do we do newborn screening in Taiwan and other Asian countries? They send stool cards home with every discharged baby so the parents know what color of stool is normal and what is not. They've done some pilots with that in Canada. Thinking about it in the US, I mean, how many millions of babies, how much would that cost? But what kind of savings would you have if you prevent, you know, all these liver transplants from happening early on. What kind of newborn screening, other screenings? Are there blood or urine tests? Doctor Wong, whom I work closely with, his lab is looking at different uh tests that we could possibly do. What we're doing here, continued education, educating healthcare providers to recognize this early on. And then with the children, which was again was the combination of bark and click together, we're starting prom CHLA will be a site where we're using intravenous immunoglobulin following Kasai portoenterostomy, and they're. hoping that if there's immune-mediated injury to the bile ducts, that possibly the IVIG will, uh, inhibit that as it is uh has anti-inflammatory properties. Questions or comments? Let me, I'm uh Kat, I think that was really great and I'm just I'm trying to. Maybe in the next 30 seconds or 1 minute since we're running behind, what are the key, you know, I, it was something that Jenny said, uh, actually it was Donna, I think before, I can't remember which one of you guys said the comments about. Um, when we were talking about abdominal wall defects, really hitting on the points that are, are relevant in day to day care of the patients postoperatively. So we heard a lot about biliary atresia. But what are the, are the things that give anxiety to the advanced practice providers here? What are the things that, that are the key points that we want to sort of even touch on for two seconds? Is it, I mean, uh, do you get into really preoperative discussions with the, with the families when the surgeon leaves to the families corner you and say, what's my chance of survival? Is that something we should address? Is it? Uh, postoperative management. What, what are the key points before we leave the topic? Is there any burning questions out there that are things that we really should hit on before we end the topic? I'm not hearing anything really, so I don't know if you have a, I, I mean my question is what, one of the, I had asked what the postoperative care really is. What about for the places that don't do that many? Do they have some type of a post op comprehensive approach to the patient? Patient and who's the main person that follows it? Is it GI? Is it the surgeon? Is it the combination? So I mean in a place obviously that does more of them, I'm sure you have a multidisciplinary approach, but I'm wondering of the places that don't have, um, as many cases. Go ahead. Well, I know at Children's, uh, the surgeons like to see the babies at two, you know, at the post-op two week check to make sure the incision is healed, is healing properly, uh, without any infection. And then our GI department follows all of these babies. Our surgeons, they don't measure, uh, vitamin levels. I don't think they would, you know, so again, the GI docs, once the surgery is done and everything's healed, GI, at least here, GI really takes over. We do have, you know, some of our favorite patients follow up with the surgeon, you know, maybe once a year, that type of thing, just, you know, more high. Some of our surgeons like to. You know, keep involved, but the majority of the follow-up care occurs in GI. They're doing the height, the weight, the head circumference, uh, anthropometric measurements. They have nutritionists, those types of things, more of the interdisciplinary care than what our surgery clinic could provide. I, I think that was great and I think we got to move on and I'll leave it to turn over to, to, to Jenny and Donna, but the key points I heard here were that at 2 weeks, that's when you get worried, uh, that conjugated hyperbilirubinemia is the big scare because a lot of kids have unconjugated hyperbilirubinemia, so it's 2 weeks, it's unconjugated. Um, it's get the HIDA scan. Um, a lot of places like, like you do give, uh, phenobarb ahead of time to rev up the, the liver, so it takes up the bile and the indo acetic acid so you can get a good scan. Ultrasound's good. Um, and then the, the, the, to what to guide the parents, we tell them 30, 30, 30, 30%, Work great. 30% never worked. 30% may work temporarily and long enough maybe to get a transplant but may fail. Dean brought up a good point about whether or not you just decide at a certain point you don't do the operation because they're just past the point of no return. And then postoperatively we had some good discussions. Questions on antibiotics and steroids. It looks like I learned in this that we shouldn't be using steroids. I use them in all my patients and maybe I might change after this conversation today. Antibiotics, we still don't all agree. It looks like from the polls of oral and IV, and postoperative care should be multidisciplinary with pediatric GI and surgery. I think that's a, a pretty much a great summary that you gave. Um, the, the, the last question I'll have is, does everyone here get postoperative labs? Uh, is there a reason to check the bilirubin postoperatively or just wait a few weeks until they come back? We tend to get, uh, bilirubin levels in the hospital before the baby leaves. I don't know if it's too soon, but, you know, the surgeons want to see what's the trend. Is, is this working? Did all the Hail Marys and holy water really work in the OR? Yeah, I, I, you know, I, I don't really care what the bilirubin is immediately. Post-op, I want to see a diaper. I want to see what the poop looks like. Right. That's what I'm thinking. If the poop, you know, if the poop's brown or green, then we, we, yeah, yeah. Laurie's seen me get, uh, frustrated when they keep throwing away the diapers. So, so I have to go in the garbage and dig them out for him. Yeah, yeah. Laurie, can you get that for me? Yeah. That's OK. I know. That was great. Thank you.