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Dr. Steve Rothenberg

Pediatric Surgery · View profile →

Should We Resect Asymptomatic CPAM Flake vs Langer

Video Published 2019-05-14 Updated 2024-02-10

Timestops (4)

Limitations of surveillance for CPAM

Discussion of the inability to effectively follow pulmonary lesions due to lack of good surveillance methods, CT scan ra…

Risks of operative intervention

Debate on the mortality and morbidity of thoracoscopic lobectomy, with acknowledgment of documented deaths in thoracosco…

Natural history and infection risk

Contested estimates of lifetime infection risk (20-30% cited by one center based on 10% at 4-year follow-up, versus a sm…

Shared decision-making and outcomes data

Advocacy for balanced counseling allowing families to decide, acknowledgment that 23-25% of polled clinicians do not adv…

Topic Overview

A panel discussion on the management of asymptomatic congenital pulmonary airway malformations (CPAM/CCAM), focusing on whether routine resection is indicated. The core clinical debate centers on balancing the risks of observation—including infection (estimated at 20-30% lifetime risk by one center's data, though this figure is contested), malignancy (pleuropulmonary blastoma, PPB, though acknowledged to be extremely rare), and the limitations of surveillance imaging—against the risks of thoracoscopic lobectomy, including rare but documented mortality. Speakers disagree on the interpretation of natural history data, the adequacy of follow-up studies, and whether a selective versus routine operative approach is appropriate. One center reports seeing approximately 25 new prenatal diagnoses annually but only one de novo PPB case every 3-4 years, while another cites a small prospective study showing 18 of 21 asymptomatic patients developing symptoms over follow-up.

Key Takeaways

PPB is radiologically indistinguishable from CCAM but remains extremely rare (1 case per 3-4 years vs 20-25 CCAM/year at high-volume centers). (3:42)
One center's data estimated 20-30% lifetime infection risk for CCAM, but this extrapolation from 10% at 4-year follow-up is contested. (4:50)
Thoracoscopic lobectomy mortality, though rare, is documented; massive bleeding is harder to salvage thoracoscopically than when open. (1:25)
Asymptomatic CCAMs are nonexistent in autopsy series, unlike extra-lobar sequestrations, suggesting natural history may favor symptom development. (9:30)
Experienced centers report 2-day hospital stays and minimal complications (2 transfusions, 2 air leaks in 100 thoracoscopic lobectomies). (13:37)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1 — guest
Speaker 2 — guest
Speaker 3 — host
Jack — guest
Steve — guest
Jean Martin — guest

Chapters

0:00Limitations of surveillance for CPAM — Discussion of the inability to effectively follow pulmonary lesions due to lack of good surveillance methods, CT scan radiation risks, and inability to differentiate CCAM from PPB radiologically until advanced stages.
1:06Risks of operative intervention — Debate on the mortality and morbidity of thoracoscopic lobectomy, with acknowledgment of documented deaths in thoracoscopic cases, disagreement over whether experienced hands should have zero mortality, and discussion of the extremely low incidence of PPB versus the frequency of CPAM.
4:50Natural history and infection risk — Contested estimates of lifetime infection risk (20-30% cited by one center based on 10% at 4-year follow-up, versus a small prospective study showing 18 of 21 asymptomatic patients developing symptoms). Discussion of the lack of CPAM findings in autopsy series versus known extra-lobar sequestration findings, and the frequency of infected cases in the pre-prenatal diagnosis era.
10:06Shared decision-making and outcomes data — Advocacy for balanced counseling allowing families to decide, acknowledgment that 23-25% of polled clinicians do not advocate routine resection, discussion of the need for unbiased registry data (NSQIP), and report of one surgeon's series of 100 thoracoscopic lobectomies with only 2 transfusions and 2 prolonged air leaks as complications.

Key claims

0:12CT scan is the best method to follow pulmonary lesions but induces a certain incidence of malignancy — Speaker 1
0:22CCAM cannot be differentiated from PPB radiologically until stage 2 or 3 occurrence — Speaker 1
1:25There are children who die from pulmonary lobectomy, particularly done thoracoscopically — Jack
1:45Two cases of mortality from thoracoscopic lobectomy were reviewed by the speaker (not at their institution) — Jack
2:03In experienced hands, thoracoscopic lobectomy should have no more morbidity than open and mortality should be zero — Steve
3:04Massive bleeding during thoracoscopic lobectomy is harder to salvage than when already open — Jack
3:42PPB can be indistinguishable radiologically from CCAM — Jack
3:42The incidence of CPAM/CCAM is markedly different from (higher than) the incidence of PPB; PPBs remain extremely rare — Jack
4:23One high-volume center sees PPB de novo extremely rarely, approximately once every 3 or 4 years — Jack
4:35The same center sees probably 20 or 25 new cases of CCAM every year — Jack
4:39The incidence of cancer in CPAM remains extremely low — Jack
4:50One center's published data estimated a 20-30% lifelong risk of infection for CCAM, based on 10% infection rate with mean 4-year follow-up, tripled for lifetime estimate — Jack
5:25A prospective study followed 21 asymptomatic patients (8 prenatally diagnosed, rest serendipitously found) and 18 of 21 developed infections or symptoms requiring resection over an average of 2 years up to 13 years — Speaker 1
6:36In the pre-prenatal diagnosis era, it was not common for patients to present in teenage years or adult thoracic surgery units with symptomatic infected CCAMs, though it happened from time to time — Jack
7:20Infected CCAM surgery was not a rare event in San Francisco in the speaker's early career — Speaker 1
9:30Small asymptomatic extra-lobar sequestration is a relatively known finding at autopsy — Jean Martin
9:47Asymptomatic CCAMs on autopsy series are nonexistent — Jean Martin
10:21One center follows all prenatally diagnosed lesions with postnatal CT, and those not operated on are followed with chest X-ray and repeat CT — Jack
10:42The speaker mentions the word cancer to every family during counseling for CCAM — Jack
11:07Many families choose operative management once they hear the word cancer or infection despite being offered observation — Jack
11:53A poll showed 23-25% of respondents do not advocate routine resection of asymptomatic CPAM — Jack
12:20There is hidden mortality in pediatric surgery because people do not report bad results, only known through lawsuits — Speaker 2
12:33The American College of Surgeons Pediatric NSQIP will provide unbiased large-scale data on thoracoscopic and open surgery complications and mortality in approximately 10 years — Speaker 2
13:37Infants undergoing thoracoscopic lobectomy for CCAM are generally in the hospital for 2 days — Speaker 1
13:44A review of 100 thoracoscopic lobectomies (not sequestrations) by one surgeon showed only 2 transfusions and 2 prolonged air leaks as complications — Speaker 1

Points of disagreement

1:25Mortality risk of thoracoscopic lobectomy
- Jack: Children do die from thoracoscopic lobectomy; the speaker has reviewed two such cases and believes significant complications can occur with any operation done in sufficient volume
- Steve: In experienced hands with advanced thoracic and minimally invasive skills, thoracoscopic lobectomy should have no more morbidity than open and mortality should be zero
4:50Lifetime infection risk for asymptomatic CCAM
- Jack: Estimates 20-30% lifetime infection risk based on 10% infection at 4-year mean follow-up, tripled for lifetime estimate
- Speaker 1: Questions the 30% figure as speculative extrapolation; cites a prospective study showing 18 of 21 asymptomatic patients developed symptoms, suggesting the risk may be higher
6:36Natural history evidence from pre-prenatal diagnosis era
- Jack: Infected CCAMs presenting in teenage/adult years were not common enough to match the frequency of prenatal diagnoses, suggesting many remain asymptomatic
- Speaker 1: Infected CCAM was not a rare event in early career; questions the validity of the inference and requests data
10:36Management approach for asymptomatic CCAM
- Jack: Advocates balanced counseling allowing families to decide; does not believe every single lesion needs operation, though does perform many lobectomies when families choose surgery
- Speaker 1: Implies a more routine operative approach is appropriate given the risks of observation and the low morbidity/mortality at high-volume centers

Open questions

What is the true lifetime infection risk for asymptomatic CPAM, given the limitations of existing follow-up studies?
What is the actual mortality rate for thoracoscopic lobectomy in experienced versus less experienced hands, given underreporting of complications?
How should the extremely low incidence of PPB be weighed against the inability to radiologically distinguish it from CCAM when counseling families?
What is the optimal surveillance protocol (if any) for families who choose observation, balancing cancer detection against radiation exposure from CT scans?
Why are asymptomatic CCAMs essentially absent from autopsy series if a significant proportion remain asymptomatic lifelong?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Routine Resection vs Selective Observation for Asymptomatic CPAM

The points where the speakers disagreed, with each position presented side by side. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Points of disagreement · AI-written, human-reviewed

The Question

Should every prenatally diagnosed, asymptomatic congenital pulmonary airway malformation be resected in infancy, or should families be offered observation with the understanding that many lesions will eventually require surgery?

The Case for Selective Observation

One discussant argues that operative risk, though low, cannot be dismissed when deciding whether to resect asymptomatic lesions 1:25. Children do die from pulmonary lobectomy, particularly when performed thoracoscopically, and the speaker has reviewed two such fatal cases from other institutions 1:45. The argument is not that thoracoscopic lobectomy is inherently dangerous, but that any operation done in sufficient volume will produce significant complications 2:03. When massive bleeding occurs during thoracoscopic resection, salvage may be more difficult than in an already-open case 3:04.

Against this operative risk must be weighed the actual frequency of adverse outcomes from observation. While pleuropulmonary blastoma can be radiologically indistinguishable from CPAM 3:42, the incidence of the two lesions differs markedly 3:42. One high-volume center sees de novo PPB approximately once every three or four years 4:23, compared with 20 to 25 new CPAM cases annually 4:35. The incidence of cancer in CPAM remains extremely low 4:39.

The infection risk, while real, may not justify universal resection. One center's published data estimated a 20–30% lifetime infection risk, derived by tripling the 10% infection rate observed at a mean four-year follow-up 4:50. The question posed is whether every patient should undergo lobectomy to avoid this risk, particularly when most infections can be treated and lobectomy performed afterward if needed 4:50.

The natural history argument draws on the pre-prenatal diagnosis era: if asymptomatic CCAMs were as common then as prenatal imaging now reveals them to be, one would expect to have seen more infected lesions presenting in teenage or adult years, but this was not common 6:36. The position is not that no CPAM should be resected, but that families should receive balanced counseling and be allowed to decide 10:42 11:07. Many families do choose surgery once they hear the words "cancer" or "infection," and the discussant performs many thoracoscopic lobectomies as a result 11:07.

The Case for Routine Resection

The counterargument challenges both the infection risk estimate and the natural history inference. The 20–30% lifetime infection figure is questioned as speculative extrapolation 5:25. A prospective study that followed 21 asymptomatic patients—eight prenatally diagnosed, the rest found incidentally—showed that 18 of 21 developed infections or symptoms requiring resection over follow-up ranging from two to 13 years 5:25. This suggests the true risk may be substantially higher than 30%.

The claim that infected CCAMs were uncommon before prenatal diagnosis is disputed on experiential grounds: infected CPAM surgery was not a rare event in one discussant's early career 7:20. The inference that many lesions remain asymptomatic lifelong is questioned, and supporting data requested 7:20.

Autopsy series provide another line of evidence. Small asymptomatic extralobar sequestrations are a relatively known autopsy finding, but asymptomatic CCAMs on autopsy series are nonexistent 9:30 9:47. This suggests that CCAMs, unlike sequestrations, are not benign variants that remain silent—they present with infection or other symptoms 9:47.

Observation also presents practical problems. CT scanning is the best method to follow pulmonary lesions, but it induces a certain incidence of malignancy itself 0:12. CPAM cannot be differentiated from PPB radiologically until stage 2 or 3 disease occurs 0:22. The ability to follow these lesions in any reasonable manner that would prevent malignancy or allow earlier detection is limited 0:12 0:22.

At high-volume centers with routine experience, the operative risk is extremely low. Infants undergoing thoracoscopic lobectomy for CPAM are generally hospitalized for two days 13:37. One surgeon's review of 100 thoracoscopic lobectomies showed only two transfusions and two prolonged air leaks as complications 13:44. In experienced hands with advanced thoracic and minimally invasive skills, thoracoscopic lobectomy should have no more morbidity than open, and mortality should be zero 2:03.

Where They Agree

Both positions acknowledge that operative risk exists and that infection risk is real. Both agree that PPB can be radiologically indistinguishable from CPAM 0:22 3:42, though they disagree on how heavily this should weigh in decision-making given the rarity of PPB 3:42 4:23. Both agree that families must be counseled about risks, including the word "cancer" 10:42. Both acknowledge that many families, once fully informed, choose surgery 11:07. Neither advocates a rigid protocol that ignores individual circumstances.

What Would Resolve It

One discussant notes that the American College of Surgeons Pediatric NSQIP will provide unbiased large-scale data on thoracoscopic and open surgery complications and mortality in approximately 10 years 12:33. Until then, the data to make truly informed consent are incomplete 12:33. The hidden mortality in pediatric surgery—known only through lawsuits because bad results go unreported—means current complication estimates may be unreliable 12:20. A poll during this discussion showed that 23–25% of respondents do not advocate routine resection of asymptomatic CPAM 11:53, suggesting the field remains genuinely divided.

Takeaways from this story

18 of 21 asymptomatic CCAMs developed symptoms requiring resection over 2-13 years follow-up, challenging lower infection risk estimates
High-volume centers report 2-day hospital stays and low complication rates for thoracoscopic CPAM lobectomy
Asymptomatic CCAMs are nonexistent in autopsy series, unlike extralobar sequestrations, suggesting they eventually become symptomatic
CT surveillance induces malignancy risk and cannot differentiate CPAM from PPB until stage 2-3 disease
23-25% of surgeons do not advocate routine resection, and NSQIP data in 10 years may resolve the debate

Keywords

CPAM CCAM congenital pulmonary airway malformation pleuropulmonary blastoma PPB extra-lobar sequestration infection malignancy cancer thoracoscopic lobectomy pulmonary lobectomy open lobectomy resection CT scan chest X-ray

Hashtags

#PulmonaryHealth #PediatricSurgery #Lobectomy #ThoracoscopicSurgery #MalignancyRisk #InfectionRisk #PrenatalDiagnosis #SurgicalComplications #PatientCounseling #CysticLesions #PPB #CCA #CPAM #SurgicalOutcomes #ThoracicSurgery #Morbidity #AsymptomaticConditions #HistologicalEvaluation #NaturalHistory #AdvancedSurgicalSkills #SurgicalDebate

Transcript

Observed right. The other thing that you mentioned was, uh, you know, with the, with the PPB issue and malignancy issue is, uh, you know, if you choose to follow them, then counsel the parents accordingly. The trouble is there's no good way to follow them, as you know, and the best method is CT scan, and that induces a certain incidence of malignancy in and of itself. And so you really have limited ability to follow pulmonary lesions, and because you can't differentiate a CCan from a PPB, it doesn't really matter whether you follow them or not. You're not going to be able to differentiate any clearer until you have a stage 2 or 3 occurrence. So. It's, it's an area I don't think you can follow them in any kind of a reasonable manner that's going to prevent the incidence of malignancy or allow you to catch it even earlier than you would otherwise. I don't think you can counsel a family and say the word cancer and have them watch. I mean, that's just almost universal. That has not been a frequent request, Jack. You don't have any thoughts on this, right? We're waiting. Go ahead. So I think, uh. When we talk about making a decision to operate on something or not, we have to always weigh the risks of not doing the operation versus the risks of doing the operation, and there's been very little discussion about the risks of doing the operation during this panel so far. The risks are low, especially in experienced hands, but there are still children who die from pulmonary lobectomy, particularly done thoracoscopically, and we can't ignore that before Jack, where you've just made a comment that I think you need to. I would, where's the data for that? Well, I know, I know of two cases, um, that I have been asked to review, uh, not in our institution, thankfully, but, uh, there are two that I know of that um. That I was asked to review and I'm sure that there have been others as well that people don't report. I just think first of all, you shouldn't be doing a lobectomy thoracoscopically unless you're experienced, and I think in experienced hands, uh, thoracoscopic lobectomy should have no more morbidity than open. So I just, I worry about, I hear that comment all the time, and that bothers me. Um, you should not be doing this operation unless you have advanced thoracic and minimally invasive skills, and if you do, there should be, there should be. The mortality should be 0. Well, that's a, that's a bold statement, Steve, and, uh, I'm glad that, uh, your mortality is zero so far as is mine, but, um, I think we have to admit that you do enough of any kind of operation, you're gonna have significant complications, and that can be open orthochoscopic. So I can be open orthoroscopic. I, I'm, I'm talking at this point about operating versus not operating, and, um, I think, uh, maybe, maybe you took exception to my saying, particularly using the thoracoscopic approach, but I think. You know, Alan described a situation where he had massive bleeding. I think if you have that kind of massive bleeding when you are already open, your chance of salvaging the situation is probably better than if you have that kind of bleeding in a thoracoscopic case. I can't back that up with data because fortunately there aren't enough cases, but I think that most of us would agree with that. Anyway, what I want, the point I'm trying to make is that that there are complications and potential complications that can be serious to doing a lobectomy. And when we're talking about the benefits, we have to really look at what are the frequency of the bad outcomes from watching. And I think we, we all agree that that PPB can be indistinguishable radiologically from a CCA, but when you look at the incidence of CCA or CPAM and the incidence of PPB. It really is, is quite markedly different. Their PPBs remain extremely rare. The paper that Peter Kim, um, published in our institution that Jean Martin mentioned, uh, was histological evaluation of, of these lesions in the using the new Stalker classification in which one of those classifications has been termed PPB, but we don't really know what the natural history of that histological finding is. What we do know is in a center like ours, which is a pretty high volume center, we see PTB coming de novo extremely rarely, like once every 3 or 4 years. So, and we see probably 20 or 25 new cases of CCA every year. So I think the incidence of cancer remains extremely low and has to be balanced against the risk of the operation. The risk of infection, we have published on that, and the estimate that we came up with based on our data was somewhere around 20 or 30% lifelong risk of infection, which is not insignificant. But the question is, should you put every patient through a lobectomy to avoid the risk of a 30% risk of infection, where most of those infections can be treated and the lobectomy can be done afterwards. I think, I think that's a questionable figure, Jack. What the 30%. Well, that's the only, nobody really knows that number. The only prospective study that followed patients for a long period of time, it was a small study, uh, showed 18 of 21 asymptomatic patients developed symptomatology. During that interval of anywhere from, I think the average was 2 years up to 13 years after their entry into the prospective observation study. So that number is questionable. I don't know what it is. I'm not claiming to know what it is, but I don't think you can state that you can absolutely say that a lifetime risk of infection with a seca is 30%. I believe it to be higher than our data was 10% with a mean follow up of 4 years, so we tripled that, right? Yeah, but we tripled that and we tripled it just. Come on, I don't know that there's any evidence that why didn't, if it was only 4 years follow up, you know, and you live 70 years, maybe you should have, uh, multiplied by 35 or no, sorry, 15, maybe, OK, maybe I, I, it remains, which would have given you an over 100% instance of. You know, the thing is that, uh, we, we now know how common these lesions are because we see them so frequently prenatally, and in the days before prenatal diagnosis, it was not that common for people to come in during their teenage years or even in the adult thoracic surgery units to come in with symptomatic infected uh secams. It happened from time to time, and the adult thoracic surgeons knew it existed, but we weren't seeing. The kind of frequency that we would expect if every one of those C cams that was asymptomatic and had not been picked up prenatally had, had just been followed. So we can argue you're not older than I am, right? So you're saying, OK, we've both, uh, grown up in the prenatal diagnostic era, and even early in my career, I remember doing sea cams that were infected, um. Several occasions in my first few years in San Francisco, it wasn't a rare event to see a sea cam that was infected. I'd like to see some data on what you just stated. Well, let's, OK, I mean, you know, what was the frequency of infected se cam surgery back before prenatal diagnosis? I've never seen anything that would give me a number for that. Well, would you accept that if, if we see, let's say for the sake of argument, we see 25 new prenatally diagnosed asymptomatic cases a year in the Toronto area, that you would expect if, if none of those were operated on. And, and let's make the assumption that all of those patients stayed in the Toronto area. We should be seeing 25 infected cases. We should, all of those should come back if it's 100%, should be coming back infected. So shouldn't we be seeing 25 cases a year? Of infected depends on the time. We don't see that depends on the time course and the frequency, right? So suppose it's only 50% within the 1st 10 years of life. All right, you're gonna see a low number on a yearly basis. Jean Martin, you had a comment. Yeah, I was going to say to Jack they'd probably go to Hamilton to get operated. Exactly. Well, the other thing is I think as it turned out you're really reaching here with speculation, Jack. No, but my point also, it's true that we don't have a long term cohort of patients to know the exact incident. The only thing that's out there in the literature that people keep quoting is actually a letter to the editor saying, oh, we're following 100 patients and only a couple have got into trouble, but there's no data, there's no, you know, there's there's a pretty good paper. It's a small number of patients. It's by Wong. It was published in Pediatric Surgery International a few years ago that followed 21 patients that were 8 of them were prenatally diagnosed. The rest were picked up serendipitously and were asymptomatic. And of those 21 patients, 18 of them developed. Infections or other symptoms requiring resection. But the counterpoint, Jack, to the fact that you don't, you don't know how many get infected early, there's several old autopsy series of Cases and we know for example that a small asymptomatic extra lobar sequestration is a relatively known finding at autopsy. It's something you can see just like in situ papillary carcinoma of the thyroid, but a CAM on autopsy series, asymptomatic C cams, it's just nonexistent, so they present. Later on with infections with different things, but I think the majority do become symptomatic. It's just not a normal variant. Of your 25 new, what you call CCAs per year prenatally diagnosed, are they really all cystic lung lesions confirmed by CT postnatally, or are they some, you know, echogenic lesions that then disappear and there's nothing left? No, we follow them all. We, we CT them all, and, uh, and the ones that uh we don't operate on, we, uh, we follow with chest X-ray and then with another CT, and that is, as Alan suggested, uh, is also problematic, the, the follow-up of these patients. I, I also want to make it clear that we are not advocating non-operative management of all CCAs. Um, I mean, I, I'm often put into the position of, of taking that side in this argument, but When I talk to these families, I am very clear about what the risks are, and I mention the word cancer every time, and many of them, as you've said, as soon as they hear the word cancer or even as soon as they hear, um, the, the word infection, um, they say, you know what, I don't want to live with that risk. I'd rather have the, the very low risk of the lobectomy, and, uh, and so I actually do quite a few thoracoscopic lobectomies for these lesions. All I'm advocating is That we give a balanced approach to the families and allow them to decide and not, I don't believe that we should be taking an approach where every single one needs to have an operation. OK. Um, and just to, to accentuate that point, you know, there's a comment from Ramesh who is unable to call in but that they, they selectively decide who to operate on based on resources, based on the family, the patient, and they don't have a, uh, an, uh, a dogmatic approach of, of operating on everyone, and I think that's an interesting point that it depends on, uh, also the, the patients, the families and the resources and the location. I was actually very interested to see the little poll that you put up there a few minutes ago that 25% of people do not advocate routine reception. I was surprised by that. Here, um, let me pull that poll up. We still have it live. Um, it seemed like it was about, was it 30% that did not, uh, Jack, I'm gonna pull it back. It looked like around 25% the last time I looked at it. He's see, it was 76 to 23%. Um, well, I think this brings up the point that, that, uh, Doctor Langer mentioned about the fact that there are, there is a hidden mortality with a lot of what we do because people don't report bad results. The only way you know about them is through lawsuits and the like, and I guess the 10 years from now if we all participate in the American College Pediatric NQWIP. Where it is unbiased, there'll be large amounts of data. We'll have some idea about thoroscopic surgery and open surgery and how often the complications and the death really occur. So I think a lot of this is we don't have the data to really make an informed consent. So we have to give the families the whole, the whole picture and let them decide, which is a tough thing for them to do. Yeah, and I, it obviously depends on your perspective and the volume of these lesions that you see and your comfort with, uh, treating them. I. You know, doing thoracoscopic lobectomy shouldn't be taken lightly. It's, it's, it is a, you know, a major investment in time and learning to become proficient at it, but I do think centers that do these procedures routinely and see a volume of CCAs can treat them with an extremely, extremely low morbidity and no mortality. There's always a potential mortality out there somewhere, but You know, it's amazing how well infants do. They're generally in the hospital for 2 days and they go home, and I've had, we just reviewed the last 100 thoracoscopic lobectomies that I've done, lobectomies, not sequestrations or otherwise, and, uh, there were 2 transfusions and 2 latent pneumothorases, and that was the only, those were the only complications. So,

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