Necrotizing Enterocolitis

you want to. I want to introduce Jose Prince, uh, who is the director of Pediatric Injury and Inflammation Center for Immunology and Inflammation, the Feinstein Institute for Medical Research, Director of minimally invasive Surgery, uh, uh, Steven and Alexandra Cohen. Um, what does that mean? The teacher has the student. Uh, he's at North Shore LIJ and he's going to be talking to us about necrotizing enterocolitis. Jose, thank you. Thank you very much for the invitation. It's my pleasure to be here and I I'm really grateful as the most uh junior presenter here to get the topic that has the least data and the most uh opinion, uh, in terms of what we're going to discuss today. Uh, to begin, I um, I want to start with just a straightforward case, uh, 25 week old, uh, premature child who's now 3 weeks old, so 28 weeks correct at gestational age, who the neonatologist consult you for, uh, abdominal distension, feeding intolerance, and, uh. And hematochezia. Uh, this child weighs 1100 g, and, um, I guess the first thing I'd ask our panel is, uh, and, and our, and our guests remotely, uh, can we predict which child will go on? Are there any predictive factors that we know of to tell us that this child will, will develop a severe surgical case of necrotizing enterocolitis? Um, I, I, I don't think that there's anything obvious here. I think the, the baby's a little distended. He's a little bit older, so, um, I don't think there's anything that can really tell you other than just frequent examinations and watching the baby. Yeah, I agree. It's kind of a black box, you have to kind of take each baby case by case and um yeah, just, just go on your key, key indicators to operate. Yes, and there's, um, as of now there's a pretty extensive amount of uh literature to to argue that we are unable to predict which child, and this is a summary question that that will be available to you in a little bit at the end for your maintenance of certification, there really is no clear predictive information that will help us to identify which patients will progress um uh forwards. So, um, straightforward case at this point, what's the optimal way to manage this case? Uh, antibiotics with the NICU care only? Uh, peroneal drainage, and exploratory laparotomy, uh, diagnostic laparoscopy. Is that open, that's open for polling, OK. So while, while that gets voted on, I don't think this will be too controversial, so, um, we'll just move the case along, uh, and now say, what if, what if it's a 600 g child? Does, does that in any way, uh, alter the calculation for, for, for us, um, and, and I guess maybe this is a good opportunity to ask, uh, is there anything that we could do or could have done is a better way to put it, to prevent this from happening? So do we have any preventative strategies that are available? Uh, again, this will be a maintenance of certification question for this this session. Is there anything that's being done at different hospitals either here around the world. Uh, what doesn't, uh, affect it that I always thought did was, um, rate of feeding. Um, I think there's pretty good evidence now to show the things that we thought, um, you had to be really slow with going up on the feeds that there's really no correlation with that and developing necrotizing enterocolitis. Um, as far as prevention. Uh, you know, I don't think that there's anything that, that I'm aware of. Um, I guess I'll wait to see what probiotics have been. I think that's probably has the most and it's, it's shown some pretty good evidence that may help. Yeah, so, so, uh, that's, that's the only one that I've been preparing for this and, and speaking to folks that has the most recent Cochrane database supports the use of probiotics, uh, and, and argues that, um, it does, uh, provide a benefit. Um, the other things that we were concerned about making things worse, such as the rate of feeding, the time of feeding, when relative to the onset of the, of the child, do not in fact bear an impact in terms of reducing, uh, the more antibiotic therapy or lack of antibiotic therapy, um, as well. So, um, I guess with that in mind, um. Many places, at least in the United States, I think, do not routinely use probiotics. And so I would be curious with our panel here and uh and maybe we can add this as a question if we want back home, um, on the computer, how many institutions are using Antibiotics are not given that there seems to be the that's the only data that we have. John's been here longer than me. I'm not aware of that we're doing here? Oh, you're out of here. OK. Uh, so, uh, you're not, are we using it? Yeah. What about Pete Chop are you using? Probiotics routinely it doesn't seem to be catching on just yet. Um, I think we're still waiting for, I mean, I'm not familiar with this Cochrane database, but I need to look into that and see. I mean, do they say specifically which ones, because that's the other thing about I think whenever anybody says probiotics, they often mean different things. I mean, I mean, obviously in a baby you're not talking about yogurt, but in adults or bigger kids, it seems like it ranges from yogurt to, you know, uh, something very expensive on the internet. Yeah, I know at my institution, while the neonatologists believe the data. They have not implemented it because they are not sure how to implement it, so that the debate about the different data from the different locations have used different, um, different cocktails and it's not clear that you can formulate a standardized formula and dose, and so they're, they're, they're still on the fence about the actual implementation even though they believe the concept to be sound. Cincinnati. Uh, are you, uh, have you switched to using probiotics? So again, I mean it's just not clear exactly how to do it. And so I don't know if around the world if other, other, um, questions out. So we'll we'll, I guess whenever those start to come back in, we'll uh we'll work on that. So, um, again, 600 grammar, uh, it's, uh, what's the best way to manage this, this, and this I guess gets to the question of size, which we'll try to develop a little bit as the as the cases continue, um, with the 600 grammar be treated any differently with um this early, uh, necrotizing enterocolitis? So what if we took the same child, um, but now, um, I asked the question of what would it take for any of us to go from medical therapy to surgical intervention. So you have a 28 week child who has abdominal distension. And would it take, would pneumatosis alone be sufficient to, uh, to perform whatever procedure you would perform? Uh, would it take pneumatosis with hemodynamic instability? Uh, would it take a fixed loop? Uh, would you only operate when there's free air? Is that the only indication that you would have to operate? Um, and, uh, or would you never offer an intervention because the child's 600 g and therefore it's no intervention is indicated. within our group here. I operate with all those um All those, uh, relative indications like pneumatosis, um, um, a fixed loop, any of those things, they all drive me, but they not as, as alone, uh, single entities. Usually I have to have a couple of things in indicating that something is going on. Uh, so if they have pneumo, for example, C would be an indication for me to operate because they have Pneumatosis, modemic and, and a fixed loop. I think that that usually pushes me over the edge. It's not, uh, a definitive answer, but all for every case, but that's my general rule. Tim, yeah, I would agree this is a moving target. So in a patient you've been watching for a while that has C, you'd probably operate on, you'd almost always operate on a year. The others are a little subjective to the, if the baby has pneumatosis and hemodynamic instability, it may be for respiratory issues. So those are things you'd kind of look at other things like platelet counts and. Um, overall exam. Uh, for me, I don't think there's any reason to, to change my approach because of size. I think that, uh, this, these are the kind of patients you have to see on a frequent basis, um, as a surgeon, you're the cleanup crew, so you're trying to figure out when they're perforated. You're trying to figure out when they have a, a, a section of dead bowel or they're just getting sicker from all the, the inflamed tissue, so. Um, I think it like, like Tim said, it's a moving target and it depends on where you're at in the course of it. Certainly B, I think is why we're operating that or free air in the 1st 48 hours for most of the babies, and then sometimes they develop a fixed loop. I'd also had worsening ventilatory status, so worsening of the blood gas, worsening acidosis, increasing ventilator pressures and difficult ventilation would be in the same category as hemodynamic instability. So a global worsening physiology overall. So, um, let's push this case along now. So now the child has a pneumoperitoneum, and I heard at least from a couple of people and, and is, has now been come in, has intubated, has pressors, is showing worsening physiology, um, and seems to have ticked off, I think, most of the group's sense of when they would be, uh, inclined to act. So now the same question from earlier, uh, and again this, this is an 1100 g child, uh, what's, what is the optimal way to, uh, treat the child? Would you, uh, continue with the antibiotics at this point? Um, again, arguing that the size child you won't, would not perform procedure in any case, uh, would peritoneal drainage be the appropriate maneuver, exploratory laparotomy, or diagnostic laparoscopy? Uh, I'm laparotomy, laparotomy if they're under a, if they're laparotomy over 1 kg, laparotomy. And you want to do something different. This is a 600 grammer, 1100 g, 1100 gramer. I would explore. All right, so we have uniform response here. I don't know if we have enough time for, uh, it looks like 68% ex lap, 33% per drainage, um. You know, the study, most of the studies that we work with, uh, the Doctor Moss's work from the New England Journal use, uh, 1500, uh, as their size. So, so certainly there, there's room for people to discuss the use of peritoneal drainage. I personally also use, um, a kilogram or, or over in terms of when I would operate as opposed to use, uh, placing a peritoneal drain, um. Do we have some of the other? Should we pause for a second to catch up on some of the other surveys that we've been sending out from them. Which ones do you want? We can go back. So, um, is there a particular one you want to see because Jonah can pull it up for you. Um, well, uh, I guess it was for case number 2 for this question. for that one, sorry, I should have just told you for that one, almost everyone said C, um, pneumatosis, and uh yeah, there it is 43% said C. That's the majority, but a quarter of the folks said they would only operate for pneumoperitoneum in that in that scenario. I think that's uh. That's interesting that that's the threshold at some places. So even with the conversation we had about physiologic parameters that wouldn't move some individuals. That was before we talked about the, uh, this was pre-discussion, so maybe these results would change. I think part of it is that the whole concept of a fixed loop, I think, is a little fuzzy. I don't know. I mean, that's sort of the board's answer. I think if they present it that way, in other words, implying that there's a dead loop, of dead loop of bowel, then, then I think most of us would say that's an indication for exploration and a kid who's hemodynamically unstable and doing unwell. But um, I don't know. I found in clinical practice it just seems really hard. I mean, does that mean a physical palpable loop, or does it mean an X-ray? Uh, so I think, I think it's just one more bit of information in it and otherwise what is often a jigsaw puzzle of a of a diagnosis. So for me I've a dilemma. I've used just X-ray. If it looks exactly. the same for several days. It's usually pretty indicative that it's when you go in, it's a dead loop of bowel, um, but it doesn't mean, even though, so I might see a fixed loop and say, I'm almost certainly going to be operating on this kid, but it doesn't mean I'm operating on the kid now because I want it to be more clear what I'm resecting. So, uh, it's more of the timing thing, not the decision to operate, it's when to operate. Yeah. You know, Todd, uh, uh, focal abdominal wall erythema is one of the most sensitive indicators for underlying dead bowel. Uh, and so a lot of people would, Might use that as a, as a single, so do you use that alone or do you need other, no, you need other things. But it sways you. But it makes you, I, I think it makes you feel much more comfortable suggesting intervention if you have a focal area of, um, abdominal wall erythema. So let's, let me ask this question because we all agree that you need multiple things except for free air, but I want to ask if there's anyone here. That would operate on necrotizing enterocolitis for one single factor, um, other than for air, but by itself. In other words, what about, um, portal venous portal venous gas? Is there anything that someone would operate alone other than just for your, or do you need a constellation of several different things? It looks like here just for the virtual audience, um, everyone here in the studio says that the only single factor that would take them to the operating room is free air, otherwise they need two or three different things on top of each other that say this patient needs an operation. John, you're gonna say I would agree completely with Witt. I think that uh. Uh, you see that much more commonly than you ever see a fixed loop, and I've yet to operate on somebody who had a red abdomen who didn't have a piece of dead bowel underneath it. So. Yeah. I think that's probably would be a, a close second. Yeah. How about greenish abdominal wall discoloration in the very small green. So you're, you're worried that there's free air? Is that what you mean? Well, suck suck in the abdomen. Yeah. Cause, you can transilluminate the 5 mg baby's abdomen. I think that's a maybe a different entity, maybe the isolated perforation rather than yeah, then we're getting into if the baby looks good and they have evidence of perforation, that might be a patient that would get a drain in a certain situation, but we could talk about that. Alright, let's. Well, we're certainly gonna hit that now, the same scenario, but uh now the child's 600 g, so has free air, pneumoperitoneum, but is now different from the last case, uh, now weighs 600 g. And so I put the question out again, would, uh, Would you just continue antibiotics and make you care for the 600 grammar? Is the kid sick? The, the kid is sick. So if the kid is sick while while the pole is going, I would still do a laparotomy even in a 600 grammar. So the kid is sick, antibiotics, perineal drain. Uh, perineal drain with a salvage laparotomy in 48 hours if their condition doesn't improve, uh, an exploratory laparotomy out front as you just said you would do, and diagnostic laparoscopy. And if the kid was too sick to travel, then I would consider doing a laparotomy at the bedside. I used to put a drain in these kids, um, but I've shifted, um, to, to doing more aggressive laparotomy, um. I put drains only in kids that I think have an isolated intestinal perforation. Um, so I don't know what I'd say if, if a, if a kid is 600 g and take them to the OR, you're going to increase their risk of demise, um, just with the travel and the ventilatory parameters and getting out of the NICU and coming back and the volume of fluids they get typically is unmeasured. They get a lot of fluids, um, the PDA is open. So, I think, you know, peritoneal drainage to the bedside or lap at the bedside would be appropriate, but you could. You know, put a drain in, see if you get return, and then, you know, monitor it in terms of whether you have to re-operate in a couple of days or, um, you know, just do a formal laparotomy. I don't think you lose anything by popping a drain. I don't. So this is the, um, setting that Doctor, um, uh, conceptualized the use of drains. It was a temporary maneuver, uh, to stabilize the baby and then take the baby to the operating room. Now, over the last 25 or 30 years, uh, that temporizing, uh, maneuver has transitioned to a definitive therapy, and that's why there are various trials that have been done. But anyway, I think that, um, drainage would be good, stabilize the baby, but I, but then plan on operating the baby once stabilized in 1824 hours, something like that. But 30% of those babies never need an operation. Yeah, but I'm not sure that's, that's in the 600 g, Baby, um you mean with, with, with NEC, like pneumatosis and dead bowel? Cause that's, I've been hesitant to drain anybody who has pneumatosis where they have inflamed bowel compared to what Doctor Sold mentioned, someone who's probably perforated, who's a little micropreemie. So Dan, based on what you said, does that mean you drain them, the 600 g participating in a trial. I would pull the randomization card and see what they get. And if you weren't participating in the trial, I would be tempted to drain this. Uh-huh. Does that have a laparotomy to follow within 24, 48 hours? So, so I certainly going back to what Tim said, I think if it was between going to the OR. Or not, it would be a drain. But I think that at least in our, uh, well, actually I haven't, I think so here, at least where I came from, we would do this at the bedside, a laparotomy. So I think it's between, I think we all agree not to transport this kid. It's between drain at the bedside or laparotomy at the bedside. And I don't quite understand the Don't, I'm not quite sure I'm convinced even though I've go back and forth every few years. I'm not quite convinced that a drain is any, uh, safer than a laparotomy if you're staying at the bedside. So, it's not any worse, right? That's what the data would suggest from Doctor Moss and others, right? But I, I guess, um. There's a reasonable chance that I'll be going back in that baby's belly anyways, and you're saying it's 30% or is that what you're saying? That, that, wait, what percent? 30% of the time you do or don't have to go in the belly? You do not have to operate. In this sick kind of baby, I know we're not talking about it's a, you know, it's a study, so it's a heterogeneous, so it's, you can't apply that percentage to this one patient because it's a study that's got to have somewhat, that's one of the criticisms of the study is that it's a heterogeneous population. So I don't know the answer to that, but there is probably some percentage of patients, remarkably enough, who you put a drain in and they get better and you pull the drain out and they never need an operation. Again, not to be, but I've had a lot of successes with the kids that are doing well, but I haven't had, I've anecdotally, which means nothing compared to a study, but I have not had the same success with a sick baby as I had with a well baby, um, for our poll showed that we were about evenly divided, but I think it was 40%. Uh, responded perineal drainage with a salvage laparotomy in 48 hours, 40% laparotomy, um, right off the bat, and, and 20% rounded out with a peritoneal drainage down the road. I'm sorry, Dan, what, what size would you not being unsteady, would you not, would you stop draining? I think I, I personally, I use about 1 kg. So if they're 1000 g, then I, as we did with the previous patient here, I personally would take them to the operator. I mean, personally, I, I think if you can operate on them, you make them better faster and they get better faster, but in the spirit of trying to figure out what the right answer is, I think we're obliged to study it and find out what the, whether it's drain or or laparotomy. So now just to push the ethical boundary a little bit, same exact patient, 600 grammar with free air, who's sick, who has a bilateral grade 4 intraventricular hemorrhages on ultrasound. And the question is raised, what's the optimum way to manage this case? Antibiotics and NICU care only, peroneal drainage, drainage with laparotomy in 48 hours, a laparotomy right away, uh, diagnostic laparoscopy or comfort measures only given the severity of the interventricular hemorrhages and the, uh, propensity for, uh, uh, long-term neurologic sequelae. Um, I've not made that call based on anything but the family's wishes. If the, if this has been a long course and that's where the family's at, I think I would certainly support comfort measures. Otherwise, I treat them the same. I do the same thing. It's hard for us to make a judgment at that time to say I'm not going to do an operation because your child has this brain, uh, lesions or status, and I don't think we can predict it. So we, I treat them the same way. Anyone one way or another? All right, let's keep going. Is there a 60% peroneal drain and salvage laparotomy. Which is funny because nobody would do a laparotomy. So, so we washed out all the, it was divided before, but now everyone's doing 40, yeah, so it did influence, uh, at least many of us in terms of our conversations or our thoughts. So let's say now it's a 1.6 kg child and you find, uh, necrosis of the terminalum. This is an example of your specimen. What's the best way to manage this patient? Do you, uh, Uh, fashion an endileostomy with a mucous fistula. Do you, uh, uh, perform primary anastomosis? The bowel otherwise looks, uh, viable, uh, at this point. And the, um, or do you make an endileostomy with a Hartman's, uh, pouch, uh, or create the anastomosis, but then divert approximately to this. Um, I do a 1600, so this is a 1.6 kg, a bigger, bigger kit. Just to take the weight out of the equation, you do A or C. I don't know if there's a lot of benefit in making a mucous fistula. It just depends. You think about your next operation, you know, where it's going to be. You would not do a primary anastomosis, probably not. OK. I've not done a primarystomosis. Would anyone do a primary anastomosis? Yeah, so Miguel Gilfan presented his, uh, experience doing primary anastomosis at our necrotizing entercolitis conference. Had and it was pretty impressive his results. My concern with that is they're still sick when you're not operating and how do you know if you're leaking? How do you know? You just can't evaluate the kid's belly after doing a very scary tenuous anastomosis. But I will tell you that what we've got in the poll results from that symposium that a lot of people were trending towards primary anastomosis. Only 10% is it here? A different audience. So now it's 10%, yeah. With um the other half pretty much equally divided between an endostomy with a mucous fistula, I think 10% is pretty high, um, 1 out of 10 that would do that. I mean, I, we're down to 8%. OK, fine. This Alright, what if, what if on exploration it looked like this? What if on exploration it was a sequence of skipped uh areas of necrosis with uh with viable bowel and intermixed. Uh, what's the optimum way? Do you do a complete endorectomy. That's the only way to take care of all of this bowel. Uh, no resection. Uh, close the abdomen. This is not survivable. Uh, resect all the necrotic areas and open multiple stomas. Place a silo, uh, and see how things look in two days. Uh, take out the necrotic segments now to see if you help the child's physiology, and then, then put the silo and wait for 48 hours before you make stomas or anastomosis. Well, the, uh, Pittsburgh paper, the Shishka baby where they where they put, uh, a tube through and you just throw a couple of stitches in all those little segments, doesn't take very long and bring this end stomas out. I've tried that a few times. It works quite well. I think that's a still a pretty fast operation and then divert them proximately one proximal. Uh, stoma and mucus fistula and through the mucous fistula you put a tube through the rest. You take all those little sections and you put a tube through them and you just, you don't do a formal anastomosis. You just put a few stitches to hold them together and you bring both ends out, both ends meaning both ends of the, of the little pieces. Of the ska baby and then you divert most proximal. So I've tried that, uh well, for an atrisia. I haven't tried it for necktizing I mean if, if you got more than about 34 centimeters, then you can put them back together and really and help the patient at least that's so you have 3 stomas so you have 3 stones, yeah, at least ended approximate oh Stefan, can we stop? Yeah, so it's the proximal, the proximal stoma. The, the proximal stoma and then at least 2 more and then the two from either end of the loop. So I do the, I'll do a clip and drop and then come back. So I guess that's the and then at that point I would do a click and drop. I've tried to, yeah, OK, or some variations. Tim, what do you do? Yeah, I guess it varies. I, I think depending on the age of the kid and older kids, you can sometimes not do anything, come back and some of that bowel will look better the next time you come back and explore it so you can not resect so much. But if you, the kid's really sick, then I'd probably, you know, do a proximal diversion, um, and I have done the, the Shishka baby as well. Um, so it depends. Looks like 50% to E, 35% D, 14% C. Um, So let's say that you, you, um, made, um, uh, stomas and the, um, Uh, baby, um. Um, is kind of floundering along in the NICU, um, on TPN, uh, at the beginning, but survives the, um, the initial insult, um. What um Any kind of work preoperative workup you would want before you would go back to um To take down these stoma? And, and what time frame would you think about and that that kind of brings us to the contrast to the next question. So I think everyone would get a distal contrast enema just for the purpose of having the conversation, um, so when, when would be the time to, um, if the child can't reach full enteral feeds. So if the kid gets dental feeds, you send the kid home maybe even and have him come back in 3 months and you get a study and, and then you put them back together. But this kid can't. This kid's on TPN. The bilirubin is going up a little bit, and uh how long, what would be the earliest you would go back, uh, given the concerns for colonic strictures and other stricturing processes that are still taking place potentially. Prior to the Washington DC, um, uh, I would have waited. 8 weeks, uh, minimum, and 2 kg 2 kg, 8 weeks. Um, but the data that Andrew Badillo, I think was the one who presented it. Showed that you can do early, uh, anastomosis much earlier than I had always done. So, yeah, 4 weeks would be the soonest I'd do it. That's good. If that's what's holding the baby up and, or they're having some complication from the, you know, the not being on full feeds, then 4 weeks, 6 weeks, 2 kg, those would be the criteria I would use. That's fine. Yeah. And I must tell you in, in that slide, I would not bring the stomas out at the each end of the transverse incision. Because you're going to have to open up the entire incision to get the two ends, uh, which then means disturbing the bowel and all of that in the abdominal cavity. So I think there's a lot of advantage to bringing the stomas out side by side, and even, even a 1600 g baby, 1800 g baby, if you had to go back in, at least you're just disturbing right around where the stomas are and you leave the rest of the bowel intact. Do you bring it out in your incision? Yes. I do the same. But I would not, I would, I would not separate them like that. Because this isn't a, I mean, this isn't a, uh, the only reason to separate stomas, at least in my opinion, is with an anorectal atresia, uh, and you don't want overflow of the proximal, uh, bowel contents into, into the distal bowel contents. Otherwise, I think bringing it that side by side makes a lot of sense. OK. Any other comments? OK, I, I'm a big fan of smaller incisions. I don't make that big transverse incision. In fact, I try not to cross the midline. I just think cosmetically it's, uh, it's better, and it's just I've never found it necessary. I can usually explore the other side of the abdomen even through a small right lower quadrant incision. I was gonna ask you, just bring up a Hartman's below. I leave a Hartman's go below the um the um I go below the, below the umbilicus. I just go right. Above or below above above above or below. Oh, I start at the umbilicus. I don't make it all the way across and then I kind of hockey stick it down a little bit to stay away from the liver because I've seen, especially in the under 1000 grammars, the liver bleed to the point of, of, uh, quadrant. I didn't realize kind of a similar type incision, and I bring the in the little babies, I bring it right through the wound. OK. All right. Next. So the uh the answer to the poll at the time was the poll? Oh, it was mostly 6 weeks, 60%, 6 weeks. And again, a lot of that's because you wait for the inflammatory response to subside and adhesions to become, you know, more flimsy, so to speak. But if you have to go back earlier, if you have the stoma side by side, you don't have to worry too much about the adhesions and the rest of, of, of the abdominal cavity. Has anyone tried a stapled anastomosis in a small baby like this? No. I, I have, if the limb of the, the distal bowel, which is usually the colon, if it can slide over the endo GIA stapler, I have done that and it's worked out well. Yeah. Yeah, I've done it in babies, but not in a. Not. Depending on how old this baby is 160. Not in a 1600, yeah. But it works quite well in neonates who are, you know, 4 or 5 kg. OK. Next. OK, so now this is what you find. And this is when uh oh this is in the still a 28 weeker who's um uh let's say in that 1100 g category and, uh, when you explore you see this, there's nothing. Nothing viable. Nothing. Well, um, what, what's the op? You're not hiding something underneath there, a little, uh, 15 centimeters of good num that's hidden by the, yeah, let's say that there's, uh, let's say that there's, there's, um, that's everything seems to be involved by this process, the whole, the whole small bowel and the colon. Everything seems to be involved. So your choice at this point with it looking like that. As opposed to like this is to perform a complete enterectomy now. Uh, no resection. Close the abdomen and, um, call it, call it because that's it. This is going to go on to neck to talus, um, and is not salvageable. Silo with expiration in 48 hours or decompress the bowel and irrigate and then silo it for 48 hours. Can we see the photo again? So I would silo this baby and, and close the other one. That's what I would do. I would come back in two days and look. I think I spent so many, so much time in Pittsburgh, I would silo this also. That's a whole another discussion. But the second one, I would, I probably, well, I'm not sure the first one isn't just going to the second one. That's the only thing I think. What's the difference? I think to me that's bland necrosis rather than, uh, you know, frank necrosis the same, I think. If it is necrosis, I mean if it's extensive pneumatosis, can you sometimes be confused? I don't know if it matters. It's a good question. That's what I was wondering at that. That looks pretty dead to me even though it's white. I, I, you know, if I thought it was all dead, I would just, uh, close. I don't know. I'm learning from you guys. It's one of the toughest things you have to face. It is. I think I'd come back in 48 hours. I'd offer them that 48 hour second look, not in that second case, but in this case, I've moved on to this question so that we can get a poll response as well. I think the one thing about the case, if you're going to silo it, I, I would probably try to decompress the bowel because I think the distention sometimes causes more ischemia. You might salvage a few pieces. I've tried that if you're not going to take it out. So we have pretty good variability in the responses, as you guys can see, 40% would just close. About 30 of each C and D would put a silo or decompress. And then this is the last case. And case 9, I think, did we, yeah, case 9 was the was the same thing I was, yeah, so then we, we covered these summary questions earlier in terms of which factors are, are able to be predictive of disease progression that would require and really none of them have, um, have of these have been proven to, uh, to help us and of all the different therapies that have been tried, whether it's antibiotics or immunoglobulin or lactoferon probiotics seem to be the, uh, and the timing of feedings. So, uh, seems to be the only one that. May be preventative and, and yet we are not applying it, uh, universally. And, uh, and then the articles are here that all of these questions are are referenced and based on. Well, that was actually you, I think you did hit most of the major points that we do address in necrotizing your colitis in a very short period of time. So that was very nicely done. Thank you. I don't know if there's anyone who has any quick points they want to make about neck that we didn't address. Before we move on to the last topic, I think the only question is, we do see it in full terms and then what if you get a, either a mid-gut volvulus with total, uh, small bowel necrosis or, uh, an NEC with total intestinal necrosis, but the baby's 3 kg. What what's everybody doing with that? I mean, it's 1200 g. I think it's a little easier than I'm curious what Tim's answer to that is because I think that those patients may have a better chance of making it to small transplant. The ones, uh, the malrotation complete volulus or the neck is a fewer, uh, a fewer component of the ones that get transplanted because they don't, they, they have intestinal failure prior to the, to the time they're big enough to get a transplant. But, uh, you know, those, those are the kids that they kind of look over your shoulder and say, hey, why, why don't you. Give it a shot. Why don't you give it a shot? Sure, I think, I think, um, but as of, as of maybe a year ago, I think the last time I had a conversation with a number of folks who are, I don't think there's actually a child with the neck totalis we've just depicted that has actually successfully survived the transplant. All the, the, when we look at the data for transplant and bowel failure for necrotizing enterocolitis, it's not the neck totalis kids, it's, it tends to be more shortcut, shortcut kids who then, Nathan Navotny says, what's the lower threshold of length of bowel to, to not just close? So we say totalis. So, so I think that that number has, has, you know, the shortcut literature has shown us has, has really dropped, and that's one of the arguments that the trend. So I think that um many people would use 20 centimeters potentially now and and some would even use less. I don't know if the other um members of the panel would have different institutional numbers that they would use and then again others would argue if you have 20, right, if you have 20 cents of small bowel but you have the whole colon, then that's obviously more favorable if it's an 800 grammar, they still have a lot of growth and the growth rate that would, that's a good point. Tough, tough, tough questions and not answering today, but I think we got good uh good summaries. Jose, thank you. Thank you. All right, rounding this out here now, closing up the uh