Focusing on the surgical aspect, uh, of the renal transplantation. Maria, thank you very much. Um, the general surgical, uh, needs for these babies can change a little bit with time. We often get, get called within the first few days of life on, on these babies, um, to consider placing a gastrostomy tube and a peritoneal dialysis catheter, um. As Jens has been saying all along, babies that make urine, uh, are not likely to need to be on peritoneal dialysis for a little while, but you know that they're likely to need it in the future. We'll oftentimes do both at once. Um, we'll do a gastrostomy tube and a peritoneal dialysis catheter, uh, at the same anesthetic. Um, if that's the case, we like for the, for the peritoneal dialysis catheter to be, uh, left alone for a couple of weeks if that's all, at all possible. Um. Because these kids will sometimes need bladder reconstruction down the road, uh, we try to focus our, um, gastrostomy tube placement to be mostly along the lesser curvature or close to lesser curvature if we can, so we don't destroy, uh, Doctor Reddy's pote potential to use the stomach for bladder augmentation. So we do the gastrostomy tube, uh, basically laparoscopic assisted. Um, so that we can see exactly where we are on the stomach and then we just turn the, the, uh, camera down into the pelvis and make sure we have our PD catheter positioned well. Um, and then hopefully the babies won't need to be dialyzed for the 1st 2 weeks of life. Um, if we take that approach, uh, on occasion we get called a couple of months into this saying, oh, you know, we really haven't needed the PD catheter and the baby's otherwise ready to go home. Can we take it out? Um, and we on occasion have taken them out and been asked to put them back in, but by and large, um, I think the nephrology team is pretty good at predicting who's gonna need the PD catheter. The hemodialysis catheter, uh, is something that we get, uh, don't get asked to put in on the early side very frequently, um, but I did, you know, mention a little bit, they can be difficult to maintain. Um, they need to be a fairly large caliber, and we stay as much as possible to the right internal jugular, uh, site because that's a straight shot into the atrium. A little later down the road, uh, if these kids have made it, you know, without a, a G tube and without us being involved, um, we can ask, get asked to put the PD catheter in for the first time, but probably more often than not, we're asked to either remove or revise an existing PD catheter because it's not working or because they haven't been able to clear an infection. And that's the scenario where we have to come up with um a tunneled hemodialysis catheter so that they can be dialyzed uh until the peritoneum has a chance to heal. Um, the other potential involvement for us early on would be with, uh, inguinal and or umbilical hernias that can develop when the babies are on peritoneal dialysis, and our approach has has generally been if they're not affecting the mechanics of the dialysis, they're not particularly symptomatic. We tend to leave them alone, um, but on occasion we've had peritoneal dialysis catheter tip that wants to sit in the hernia, and, uh, dialysis is not very functional at that stage, so we have to revise and remove them. So once we uh get the, the babies plugged in with their gastrostomy tube and, and their PD plus or minus PD, uh, then we sit back and relax for a while until they grow. Um, on occasion, uh, the, you know, the growth, um, can be a little bit slow, and, uh, sometimes we get the, um, You know, the phone call that we've got the baby up to almost 10 kg and we see them in clinic and they're 10 kg but they're around, uh, and they really haven't grown much in length, uh, and that's not gonna be terribly helpful. So the ideal weight for us would be around 10 kg if they're not on PD, uh, and if they're on PD they generally have a more accommodating abdominal cavity and a little laxity in the abdominal wall so we can, uh. Pretty safely do kids closer to 8 kg. We've gotten smaller in certain situations, um, but all of our pediatric, all of our infant recipients have been transplanted with adult, uh, donors, so, uh, getting that space is, is important to us. Uh, over the past several years we've stuck directly with an extraperitoneal approach, so it's a bit of an extension on the upper edge of the incision up close to the costal margin. Um, and if the babies, um, for whatever reason have a normal bladder, then we do our own reimplant, and if the babies, uh, have a bad bladder or Doctor Reddy and his team have been involved with these kids, then they will generally do the reimplant during the transplant. Probably the biggest complication we've had from a general surgical perspective, um, surprisingly are wound complications as opposed to vascular complications. Um, we've had a couple of kids that we've only been able to close skin in this scenario and have developed either leaks, um, or dehiscence of part of the incision so that we've had to go back and, and use a, uh, an in position of in the fashion and generally we use something biologic like derma matrix, uh, and to get them closed. Um, but for the most part we've been able to close at least the external muscle layers and we've had good results with, uh, with this approach for the smaller kids. And this is one of our recent Patients that I had in the operating room for removal of the PD catheter at this stage, uh, in this picture he's about 11 kg and you can kind of see where we have things set up, um, you know, this was a G tube that was placed, um, early on in life, um, when he was in the, in the nursery, um, the PD catheter incision is on, on the right hand. Uh, just to the right of the, uh, umbilicus, and then we tunnel the PD catheter over the top to the left and just to try and, and keep the, uh, the PD catheter away from any potential transplant incision, and, um, this is our most recent transplant incision which is about 2 months, it's about 2 months post-op in this picture, um, when we finally got him in to remove his PD catheter and his, uh, stent. Um, so you can see he's got a little bit of asymmetry in that right flank, but not much, uh, and as he gets bigger, it becomes even less, less, uh, obvious. That's sort of my general information I wanted to pass on about the general surgery role. Any question for Doctor Alonso regarding renal transplantation? I do. Go ahead. Hello. So, um, I want, can we go back to that picture of the baby with the G tube? Tell me when it's up, if we can get that back again. So if you notice that G tube, I heard you said it was put in early in life and it's up on the costal margin now, um, we looked at a 13-year follow-up of G tubes in babies and they all go up onto the chest. So, I go really low if I think it's gonna be a baby that's gonna need it. So I, I wonder maybe in these kids where you're putting them in up front, if we could put, you know, put them in almost closer to the umbilicus, what do you, is it, does it interfere with the PD catheter if you put it that low? It, it, it does, uh, from an infection standpoint early on, um, because the, there's not enough, uh, space between the G tube site and the PD catheter site, and sometimes the. You know, the drainage gets underneath the dressing of the PD catheter, um, but, and, and we're not married to having to have the catheter exit on the left side. That just usually where I start, um, so if you put your catheter in, uh, the exit side of the PD catheter in a different position in the upper abdomen on the right, or some people even go all the way up to the chest wall, um, with the PD catheters, then, um, you can put that, that G tube a little lower, uh, I mean, I, I think. In general, we, we try to shoot for 2 finger breadths below the costal margin for the insertion site and uh and that's where this one was. So that's where I, because I do 22 finger breads too, unless it's a small baby, I go like almost 3 or 4 because I know it's going to rise up. I have another question. Yes, so, um, for the patients specifically with the posturethral valve, so as Dr. Alonzo alluded to in her presentation that they actually put the location of the G2be very specifically. Uh, high up on the stomach towards a lesser curvature because they want to allow us the ability to use a gastric segment if we're going to do an gastric gastric augmentation later in life. So if you put it too low, wondering what, OK, that's one problem. The second problem is that some of these babies will need urinary diversion with a vesicostomy. So we'll be getting, you know, we'll be having a vasicostomy about 1 finger breadth or 2 finger breadths below the umbilicus. So you want to mitigate the infection risks by moving things away from a future potential vasicostomies. It's really incredible to me how much thoughtful planning has to go in these babies and as far as geography with their abdominal wall, um. I have a challenging, I have a question though. I know we keep getting asked at, at, at the different institutions I've been at, um, DC Rainbow, and now Akron, where they say put in the upfront G tube. And I've always. Question that. And uh number one, do you get leaking from the, the dialysis out of the fresh G tube site? I haven't had a problem, but I wonder if you have or infection. Why not just wait? Why not do a PEG? I do I love lap G tubes, but why not do a PEG other than you won't be able to see exactly where to put it in the stomach. That's one disadvantage, but you can be pretty close. Peg wise and then you could put it in when you need it. We've, we've done them both ways and I think from the perspective of my other pediatric transplant colleagues we actually prefer to do the G tube later, um, and I think the sort of the, um. The tenor of our our nursery has been more pro-G tubes and getting them in and getting the kids up on them and the family um up to speed on taking care of them, um, but if there's a baby that doesn't make urine that needs a PD catheter for dialysis early on, that G tube is way on the back burner. I mean that that happens when. You know, when the kid's bigger and they can tolerate being off PD for a little bit or they can tolerate, tolerate being placed on hemodialysis for a couple of days. Do you, and I'm sorry, I know that I'm spending probably too much time on this, but I think that for, for general pediatric surgeons as well, this is such a common problem. But when you put in your PD catheter, do you put it in in such a way, um, where you tunnel it so that you can use it immediately? Or do you say, no, you have to wait 3 to 7 days before using it? Um I personally put it in a way that it can be used immediately but with lower volumes, so I, I'm not, not to go straight to full volumes, um, but when we're doing, when we're putting the laparoscope in and, and looking, I mean it's just an extra hole and if they could leave things be for a while to, to heal, that's better, but low volumes I'm OK with. And uh one last point related to that is, um, anecdotally, a lot of these babies and Doctor uh Johnson, Doctor Ryan, and, um, Doctor Jaco and Doctor Posing can comment on is a lot of these babies had pretty small stomach. Um, Again, anecdotally, but um, Perhaps related to minimum amount of uh amniotic fluid during the development, uh, for a period of time, uh, but we certainly had encountered some uh babies with bladder outlet that the stomach is quite small and it's hard for us to pull it down, you know, below the, the planned site of uh gastrostomy. I would just say that's another reason why I like to do the amnio infusions uh when the patient presents for the first imaging in order to look at the baby's capacity to swallow, see if the stomach fills. I have to say I've never thought of it in terms of decisions for 567 months later, but it would be an interesting study to uh take on that. I think we could standardize some of the Measurements that we take of the abdominal contents, both, we always measure the bladder and the bladder wall thickness and the isthmus and those things, but to look at the stomach, uh, would be a very interesting. Prospective analysis. Now you have the challenge. Now you have So, um, yeah, go ahead. I'm not aware of this, Mark. I'm not aware, you know, that that you've noticed the small stomachs, but you almost kind of wonder when you have these early onset humongous blatters that go all the way up and push the diaphragm up and push the stomach, you know, back, and I wonder if that has something to do anatomically long term, that the longer that. Distortion occurs and maybe the stomachs end up a little higher. That would be an interesting thing to study. Yeah. Thank you, Mark.
