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Slightly um and a bit different from the program. So we're going to, it's a, it's a real pleasure um to introduce Miss who's come, kindly come up from Cambridge to come and talk to us today. She's um a transplant multivessel consultant in an Adam Brooks and the first female transplant consultant in Adam Brooks and is going to talk to us today about multi visible transplant for colorectal surgeons. And it's a really great talk. II hope you really, really enjoy it. Well. Well, thank you very much for having me at your Dukes Club weekend. So something very different from the talk you've just had. Um And this is a bit about intestinal transplant. Um and how we operate on people from those who've had abdominal abdominal uh problems. Um You might get uh ischemic bowel to people who've had IBD to people who had, who've had cancers. Um And some of these patients you may have come across. Um So a bit about intestinal transplant. How common is it? Um So there are, so there's quite a lot of kidney and liver transplants each year. Um but not that many intestinal transplants and overall worldwide. There's there's been just over 4000 intestinal transplants. Um And roughly each year worldwide, there's about 100 or so. Um And there's four main types of intestinal transplants. So I'm going to talk a little bit about what we do in Cambridge. Um in terms of the intestinal transplants, when we talk about a small bowel alone in Cambridge, we include the pancreaticoduodenal complex. So this allows stabilization of the sma in the celiac and allows us to preserve the middle colic artery. Um and hence include colon um in the transplant. Um You then have a modified multivisceral which is essentially a stomach um with the small bowel and colon as well as the pancreas. And then you've got our two liver containing grafts. So the first one is a liver, small bowel where it's the liver with the pancreas, small bowel and colon. And then the full multivisceral is essentially everything from the esophagus to the colon. Um which is probably the most um most, I suppose I don't know what the correct word is, not necessarily traumatic but one of the most difficult transplants you could potentially do. So why do people need an intestinal transplant? The main indication tends to be irreversible intestinal failures, those patients who are on PN for whatever reason. So it could be short bowel, it could be a congenital disease and then that leads them to life threatening complications. So, whether that be intestinal failure associated liver disease, which is I found or loss of central venous access veins above the diaphragm veins below the diaphragm or life threatening infections. But also those people, for example, who technically can't have a liver transplant alone due to port a mesenteric vein, thrombosis may end up needing a liver and a bowel transplant. Those patients who have fap hemo tumors where you have extensive growth in the mesentary causing frist disease or encasement of blood vessels. You also have patients who need it for the quality of life, but also who have got widespread mesenteric ischemia. And these are just some of the causes of those patients who present with short bowel. As you can see, the majority are ischemia and Crohn's with smaller patients needing them for trauma or for volvulus. So if we look at our unit in Cambridge, we're the largest center in Europe. And on average, we're doing anything between 12 to 14 transplants a year. So the majority of transplants we do are the liver containing grafts which you can see is MVT and the liver small bowels approximately half or so. So what happens when somebody is referred to us? So we have, we have referral letter. Our main referral centers tend to be the large intestinal failure centers. Some of them, you may have worked at ST Mark's Salford increasingly, Newcastle Southampton. Quite a lot of um our referrals come from Scotland, particularly Glasgow. Um And so we have the letters, we look at them at our local MDT. And then we, then we make a plan as to whether or not we need to invite them for an assessment. So our assessment over a number of years, we've taken it down from maybe sort of a 2 to 3 week inpatient assessment, one week outpatient assessment where they see a number of specialities. And then once the assessment is done, there is a further local MDT meeting and then if they need a liver containing graft or if they need a kidney transplant as well, then they are assessed at the local MDT there. And then they are presented at NAS which is a National Adult Small Intestinal Transplant Forum. And this whole process can take up to two months, sometimes a bit longer. Once they're presented at NAS, um we await the outcome which is usually yes, proceed to transplantation or have some more investigations done or not suitable for transplant. So those people who are suitable for transplant are then um go through a pathway of of having uh vaccinations, potentially a few further investigations. And then they're activated on the waiting list. And that can take anywhere between maybe days to weeks to months depending on how acutely unwell the patient is. And then once a patient is active on the waiting list, you wait for a suitable owner to become available. And when that happens, the patient is called in for transplant. So in terms of our team, we go out and do the retrievals ourselves rather than using the National Organ Retrieval Service. Because it's a highly specialized service and, and to the retrieval, there's usually always a consultant, a retrieval fellow, a registrar scrub nurse and, and a and somebody who does the perfusion fluid um and usually the donor and the recipient operations are happening simultaneously. So it needs to be quite a lot of careful coordination between the abdominal and the and the cardio thoracic teams. So once we get to the donor hospital, we have a look initially at the organs and assess them to make sure that they are. Ok. And if they are appropriate, then we call Adam Brooks and say fine, you can start the recipient operation, which will include quite an extensive explant and getting the abdomen ready for when we take the organs as part of the retrieval team. So the actual donor operation requires quite extensive surgery. It's mobilization of all the organs, um isolation of the celiac and the sma coming off the aorta isolation of um if it's a non liver containing graft, then it's the portal vein. If it's a liver containing graft, it's the IVC. There's quite a lot of communication between us and Adam Brookes as to when we are ready to what we call to actually do the aortic cannulation and the perfusion of the cold fluid. And then the abdominal organs are retrieved on block on an aortic patch with the celiac in the sma. And if it's a liver containing graft, as I said, the cava or the portal vein, so we tend to go all over the country. These are just some of the places that I've personally been for these donor operations. The Red Star there is Cambridge go to. As you can see, we go quite far and wide. Normally, if it's quite a long journey, then we tend to go in a plane. And that's purely because we need to keep the cold ischemic time down to six hours, very similar to a hard for a lung. And that's just us unloading and loading the organs. So in terms of the recipient operation, it's usually a multi consultant operation. Um you, we tend to use uh intraoperative hemofiltration, um intraoperative, look at the, look at the teg um we have a machine in theater and it can be, and it can go from quite being a reasonably calm situation as lots of people to potentially quite significant hemorrhage and various complications. As you can imagine that the abdomen of these patients can be quite hostile. They've had. For example, if they've had really bad Crohn's, they'll have had multiple operations. If they've got portomesenteric vein, thrombosis, they'll have significant varices and portal hypertension or if they've got a very large desmoid tumor, they can be quite stuck. And so they can be quite, um that can be quite tricky as you can imagine. You can also imagine that we've got a very large block of organs that has been on ice for anywhere between 1 to 5 hours. And then you reperfuse that. You can imagine all the potassium and the lactic acid and everything that that is there at reperfusion, the cardiac instability that can happen. Um And also you can have, you can imagine that we're putting in potentially more than we actually removing. So if you've had short bowel and you've only got 10 centimeters of judging or something, you're putting in a whole, you know, meter, meter, small bowel and colon. So how do you close the abdomen afterwards? As I've said, there can be significant loss of blood and also these operations are actually quite long. So how do we adapt to these challenges? So the pre emptive filtration is actually very useful to help with the potassium and the lactate. If it's going to be quite an extensive surgery where we're literally eviscerating the abdomen, then preoperative embolization of the celiac and sma in the recipient can help significantly with blood loss. And also we're using much newer techniques for abdominal closure, which I will show you. So the preoperative embolization um so is where we embolize um the recipient sma and celiac. So, so the blue arrows there show the show the plugs in the common hepatic, the splenic and the sma. And, and the red arrow shows that we've preserved the left gastric because actually we, we will in this patient, we would have wanted to do a gastrogastric anastomosis. Um Now, people who have lost their vascular access and they've lost all access above the diaphragm. How does the blood then get back to the heart? So, um this was somebody who had quite bad Crohn's um and had been on PN for a long period of time. So these were his, these were the blood vessels that were returning all the blood back to the heart from the legs and from the rest of the body. So, preoperative mapping of these abdominal collaterals to know where exactly you're going to make your incision and then where the stone was going to come out. So you can see a pre op and a POSTOP um picture there. So once you so say if you're doing a full multivisceral transplant um where you've eviscerated the abdomen. This is roughly what it looks like. Um I don't think we've got a pointer. So you can see um that you can see the stapled off esophagus. You can see a clamp on the hepatic veins. Um And you've got this arterial arterial conduit here, which is um which is from the donor onto the recipient aorta. So that's what the eviscerated abdomen looks like. And then these are the, these are the organs for transplantation. So I know they look a funny color, but that's actually quite good. So that's what your organs would look like if they were perfused with, if they had the blood drained and they were perfused with a cold, cold fluid. So this is actually very good, healthy looking stomach, small bowel and the liver. And then once they get, um, once they get transplanted, this is what they look like. Now, I'm not quite sure if this will work. So, let's see. So, so this is literally within minutes of reperfusion. As you can see, the bowel is pink, it's healthy and it's peristal. And then in this picture, you can see the um the donor thoracic aorta which has been sutured onto the recipient aorta, um just post reperfusion. So we get sent a number of abdominal disasters and um problems. So, um I'm going to show you one case that was referred to us last year and this is the type of phone calls that we tend to get. So we have a 35 year old gentleman in Scotland reasonably fit and healthy, goes to see his GP with some flank pain, um and is being investigated for renal stones and goes to have a CT Kub and the CT K UB picks up something funny looking in the pancreas and he gets diagnosed with a neuroendocrine tumor. So he has, so then this triggers a cascade of events where he has CT S MRI S pet scans, oate scans and he's graded um as a uh as a sort of mild to moderate um neo endocrine tumor of the pancreas it's fairly extensive. Um, and it's surrounding um the vascular structures. And so, so this is the elective operation. He has, he has a subtotal gastrectomy, a splenectomy, part of his left adrenal gland, taken out, obviously, his pancreas removed his duodenum and the distal bile duct. So that on day not the surgery goes reasonably well. Um, day one, however, he becomes acutely unwell and he has quite extensive um, ischemia of his, of his ilium and his, and the colon, they go back in his sma looks fine. His SMV looks fine. They're not quite sure whether there was some sort of effect of compression or twisting. But for, for whatever reason, he has quite an extensive small bowel and colon resection. Um, he then goes back to ICU, he becomes acutely unwell overnight. Again, they do a further CT scan and they find that he's actually got acute thrombus in his portal vein. He's got further small bowel ischemia and further ischemia of his colon. And so they take him back to theater, they remove everything else that that is ischemic and they do a Porto renal shunt. So he is then in hospital for a number of weeks, um, quite unwell and then when we have a phone call, um, th this is what we're told. So he's got literally a small pouch of stomach that is stapled off. It's got a foley catheter in it with a balloon blown up 20 mils capacity. And that is leaking. He's got a tube in his bile duct. He's got a rectal stump and he's essentially got six strains in his abdomen, which is growing a number of different organisms. Can you please see him and sort him out? Um, so he gets sent down to us and, um, I'm just gonna show you what his CT scan looked like. Um, uh, when we did the scan at Adams. Oh, it stopped. It's about to be ok. Do you want to use that? Right? Could you forward the slide on? Oh, ok. All right. So let me just go back. So, ok. So this is just going down from the liver down to the, down to the feet. So, so this is showing the leak from this 20 mil pouch of stomach. You can see the contrast coming out. You can now see you can see a kidney, you can see these drains, but actually what's missing, it's the bowel. So that's essentially all there was in him. So he had these drains and everything. So we worked him up and put him on, on the waiting list and he essentially had a liver, small bowel now because he had, um, just a small pouch of stomach. He essentially needed an esophagus anastomosis. Um, and we weren't quite sure whether the esophagogastric anastomosis would have a high, high rate of, um, uh leaking. So he actually had live a small bowel and there was a loop of J put up to his esophagus. Um So he didn't have a stomach. Um and he had quite a, um he had quite a ropey um post operative course and he had a number of complications. Um, he ended up on ECMO and was in our local cardiothoracic unit um for a number of weeks. Um, he then got better from that. He then had a leak at his esophagogastric anastomosis, which we treated conservatively. Um He had recurrent chest infections, we then managed to give him COVID. Um He had quite a high stoma output for a long period of time. He had quite significant renal impairment and also his abdominal wall sort of didn't do particularly well initially, but we managed to get there. So he spent um almost six months with us. Um but he's actually doing quite well now. So that's him with his family. And um he's quite happy, he's eating and drinking and trying to get back to a normal life. Now, this is another patient. This is another patient. This patient would have been in their twenties. So they would have. So I think they had a nissen fund application as a child and they had some sort of very mild learning difficulties and and, and nothing major apart from that in their past medical history, they presented their local hospital in small bowel obstruction, um and initially were treated conservatively and then had a laparotomy and vision of adhesions. They then um after a few days became unwell, went back to theater and I think they ended up having a AAA short segment of small bowel being taken out. Um And then after that, they didn't really settle, they had quite a extended abdomen were not feeling particularly well, but it was initially all put down to an ileus POSTOP until acutely one night, they presented with bilateral ischemia of their legs and quite unwell and when a CT was done, um this is essentially what it showed. Um So it's not quite right now before I tell you what the abnormality is. Would anybody like to tell me what they can't see in the CT scans that you should be able to see anybody? No, anybody want to ha ha ha hazard a guess who said somebody was saying something? Yeah. So yes, you can't see the AORTA or the IVC. They had really severe abdominal compartment syndrome that got missed to the fact that they had completely compressed their aorta and CAVA and they had ischemic legs and ischemic bowel. So they got sent to us with in not a very great state. So this, so this gentleman is now 10 years post transplant and he had a modified multi viscal. So we managed to save his liver, but he had a stomach, a small bowel and a codon. So you can get so if you are in a local DDG H and you have an abdominal catastrophe, you have ischemic bowel. Many years ago, people used to be open, they saw dead bowel, they used to close and they used to palliate them. Please don't do that. Definitely give us a call. We may be able to help those patients. Um, so the tumors, so the tumors that we are coming across increasingly are the fap desmoid tumors. Now, I'm sure if you guys have worked in these specialist units, you may have come across them. So to date, we have operated on 19 patients with the desmoid with an age range of 20 to 50. Um almost half of them or just over half of them were on PN because they have this fistulated disease, chronic sepsis and can't be fed enterally. They have multiple enterocutaneous fistulae. Now, the way the desmoid grow, particularly in the retroperitoneum, you can have quite significant ureteric involvement, you can have extraabdominal tumors and also some of these um patients also have colon cancers previously um that have been resected. Um And we've had one patient who's died of a gastric cancer that was in a pouch of residual stomach. Um And we've had a bit of a change in practice since then and we're doing much more modified multivisceral than small bowel alone for these tumors. Um So I'm gonna present to a lady who was a 32 a 34 year old lady who essentially was um referred to us from another unit who had an F AP uh smo tumor, which had essentially been mushrooming out of her abdomen. She'd had a number of different types of chemotherapy that hadn't worked. And so we got her in this stage. She was only like 45 or 46 kg. But the tumor that, that we, that was initially removed from her was a 6.7 kg tu tumor. But then this had then grown again and I'll show you further pictures of it and she ended up having um a small bowel transplant um where we again took a loop of jun up to the esophagus. Um And she also had a renal autotransplant because she had quite extensive in involvement in her pelvis. Um And so we auto transplanted her kidney cos we had to resect part of the ureter from the normal position to her um iliac um to the iliac region. So she had quite a few challenges POSTOP. Um She had a bile leak, we had to reconstruct her abdominal walls. Um She's had extra abdominal desmoid removed, which I'll show you pictures off. And then Justin Davis, who I think will be doing a talk later on actually did the completion proctectomy on her. So the issues we have with these patients in general is closing the abdomen where actually we are putting in more than we're taking out. So with her, this takes a bit of time to load up just because so many photos. So this is what her abdomen looked like. So she had this massive tumor mushrooming out of her belly and taking out most of her and taking up most of her abdomen. And then you can see these bumps further up. They were various desmoid tumors. So the way that we reconstruct these abdominal walls is by taking donor rectus fascia. So from the donor, we take out the rectus abdominis muscle and then we essentially um take out the muscle from, from the fascia. So you have the, you have the anterior sheath, you have the posterior sheath and you have the peritoneum and this is non er it doesn't have any blood vessels and this was the um defect that we were left with in the abdomen. And as you can see, it's been closed with the fascia. Um you may not be able to see it at the back but people at the front may be able to see some, some blood vessels that are starting to develop in the fascia and it becomes ascaris from day sort of 5 to 7 onwards. That um we left for a few weeks and then we put a back dressing over it and then maybe after, I don't know, maybe 4 to 6, maybe eight weeks later, this had what is, this is what the abdomen had come down to with the fascia. Um patient then had a split skin graft and then this is what her abdomen now looks like. And again, she's sort of coming up to at least maybe something eight or nine years, post transplant. So there are, there are other ways that we can close the abdomen as well with the fascia. So as you can see here, so the fascia is very, it's very versatile and actually, you can actually stretch it. So when you're given this, you're given this small bit of fascia and then you have this massive defect and you think that's never going to close it. But because it's human tissue, it, it can actually expand and you can actually feel quite large defects. This is just showing how you close the fascia, use a bit of, you just use a bit of proline and you suture it around. And then when you want to bring out a stoma um in, in the further picture, you can see we, we bring the stoma out from a junction between the fascia and the person's own abdominal wall and then you can bring the stone out through the skin and then that's how the skin closes at the end. And that's, and, and that's an end, an end colostomy there. Um So this is a picture of an autotransplant. So this is how um you take out the kidney, you remove the part of the ureter um that is involved with the desmoid tumor and then it's placed in the right iliac fossa, how you would do a normal kidney transplant. And this is the same patient. She then essentially developed a really large desmoid tumor of her, of her, of her back. And this was taken out by one of our, one of our er surgeons at Papworth, which is our cardiothoracic um uh um hospital. Um she's now got further, further tumors growing. And we've been asked whether she can use one of these new checkpoint inhibitor inhibitors for desmoid tumors. But we're not, we're not really keen on that because we don't know what sort of effect that will have um in in a post transplant patient with the immunosuppression. And so for the FAP and the desmoid tumors, I think from our point of view, we think early referrals for surgical planning is important. And now we're increasingly getting young patients who are being referred in their twenties in their early thirties who have actually quite bad fistulated ESMO disease. They can have issues with vascular access and liver dysfunction. And it's whether or not you need to put in a stomach. So we look at, we look at the Spigelman score, how extensive the FAP tumors are in the duodenum in the stomach and then tend to take them out and whether we do sequential or simultaneous. So if you look at the worldwide data, there's quite a lot of sequential transplants happening in the fap desmoid population. But we're increasingly trying to do the simultaneous um transplants where it stops the patients being on PN for a long period of time reduces the liver dysfunction. It allows us to do non liver containing grafts which have a better overall survival. And now if we have a look at IBD, just wanted to highlight early versus late referrals. So we're now, I'm sure in the next few years is going to become an increasing indication, its failure of medical treatment. So these patients who have quite severe IBD have been through a number of biologics and actually, they've got recurrent sepsis and fistulated disease. If you put them on the biologic, they get recurrent sepsis. If you take them off, it, it's very difficult to treat. They're being put on PN and um it's essentially failure of medical treatment. Um Now I know that new biologics are coming out and that may change. But certainly at the moment, there's an increasing cohort of patients that we're being referred from all over the country. So this highlights what happens if you refer somebody slightly earlier than if you refer somebody slightly later. So two patients with Crohn's a young patient who was 33 diagnosed just before they became a teenager, had been through steroids, azaTHIOprine, all the mabs had had previous hearts and a subtotal colectomy, but essentially just had problems with really severe fistulated disease and infections and had been on PN um for, for a couple of years, but unfortunately, had fallen into the category where they had got recurrent infections and loss of vascular access. So they had lost all their right sided central vein. They ended up having a small bowel transplant and stayed in just over a month and is actually doing really well compared to somebody who was actually referred to us quite late. A 61 year old lady who'd been diagnosed just almost 40 years ago and had 40 years of problems with Crohn's multiple small bowel resections had been through all the immunosuppression therapy and be, had been on PN for quite a few years and ended up having further further fistulas and had been on PN for quite a long time and and um had noticed that the liver function had been deteriorating. But by the time she was referred to us, she actually had established cirrhosis as a result of being on the PN and also intestinal failure. So, um again, a slightly late referral needed a liver, small bowel and actually was in hospital for quite a long time. Um And so, uh a bit about the difference in terms of when the patients are referred. So if you have a look at the, if you have a look at the survival, certainly for our bowel alone, the one year survival is about 85 to 90 per cent, roughly, and the five year survival is about 80 per cent, which is sort of comparable to other organ groups and certainly better than heart and lung transplants and particularly the liver containing grafts. We are slightly, well, the results are getting better. But overall, we're trying to avoid giving patients a liver and a bow because we know they don't do as well. And an early referral is much better if you look at some of the SN data where they look at what, what sort of five year survival is um for, for PN. Actually, it's getting to the point where it will be comparable. So a bit like a kidney patients with renal failure where being on dialysis, potentially not seen as good as a transplant is a better option. I think that's where we're going with potentially bowel transplants as well. And I'm just going to finish off by showing a video of one of our patients. Um And I think you'll find that quite helpful. Now, can you, can somebody play that? Oh, ok. Hello. My name is GERD Shergill. I'm 57 and I've had a multivisceral transplant. My journey started about 18 years ago when I was diagnosed with autoimmune hepatitis. I was put on low dose steroids and lived a normal life up until about three years ago. It was then noticed that my condition was deteriorating. My local hospital then got in touch with the transplant team at Adam Brooks and they felt I was a candidate for a liver transplant. However, following further investigations, they also found that I had pancreatic cysts and I have mesenteric thromboses which are blood clots in the vessels that supply the small and large bowel. It was then decided that a liver transplant wouldn't be the correct option that I would be a candidate for a multivisceral transplant. They then put me on the waiting list for that to happen. Unfortunately, in December 2021 I developed COVID and my condition rapidly deteriorated. In February of 2022 I was admitted to Southampton General Hospital where I remained until my transplant, my condition continued to deteriorate. But fortunately in April of 2022 I was transferred to Edin Brook's Hospital where a donor had been found. On the 25th of April, I had my multivisceral transplant. This transplant included having my liver transplanted my pancreas part of my stomach, my small bowel and my large bowel and it left me with a colostomy. My postoperative period of recovery was fairly turbulent and it was felt that this was because I was so ill prior to my operation, I was in itu for several weeks and in high dependency unit uh for about two months before I was transferred to the transplant ward, my weight had dropped down to about 55 kg and my mental state had taken a real battering. However, over the next few months, I continued to recover and I finally got home in September 2022. Even at home, my recovery continued and I got stronger and stronger, but still, I found that there were a lot of things I couldn't do because I still had a colostomy. And so in May 2023 I had a reversal of my colostomy done at Ain Brook's Hospital. Following this, I went on to make a very good recovery. And eventually in October 2023 I returned back to work as a consultant, orthopedic surgeon and I continued to work doing my clinics and operating. This has been a long journey, not only for me but also for my family and especially my wife and my two daughters. They suffered as much as I did, but would they help and support? I am where I am now. There are many people without whom I wouldn't be here today. Fly, the organ donor and the organ donor's family who selflessly donated their loved ones organs at a time, which must have been devastating for them. It has certainly changed my opinion and my family's opinion on organ donation and we continue to spread the word of the benefits of being an organ donor. Also, I'd like to thank the transplant team, not only the surgeons, Mr Butler, Miss Armin and Mr Russell, but also the gastroenterologists who looked after me after the operation and continued to look after me and also the transplant nurses. It'll continue to monitor my progress. Also the ward staff, not just the nurses and the health care assistants, but also the physios and the dieticians and even the people who bring you your food and bring you your tea and make sure that you eat and drink, even when you don't feel like it, it has been a long journey, but a worthwhile one and me and my family will be eternally grateful. Thank you. And as as was in the video, this is a massive team effort. Um It's not just one person or a few individuals. It's, it's lots and lots of people from all around the hospital who are very helpful and give up so much of their time to look after our patients. So, thank you very much. Thank you very much, Miss Smon. It's really quite extraordinary to see the work you're doing. So, thank you. Um, we've got time for just a couple of questions before we go for our coffee break. Um, has anybody got something that they, they'd like to ask? Mm. So thank you. Uh, do you always bring them for the reversal in Adam books? And is there a reason for, for that? Um, so not everybody can have a reversal of the surgery. So it depends exactly what bowel they had to start off with. If they've just got a bit of a rectum or something, then no, if they've got a reasonable amount of sigmoid colon, then yes. And they all come back to Adam Brooks for their reversal surgery. They're immunosuppressed patients and leakage rates can be potentially high. We may have to alter the immunosuppression during the course of surgery. So we tend to do most of the operations at Adam Brooks and I've just got this one question. Um, you were showing the survival rates and showed that for small bowel, it's, it's good and for liver it's good. But when you put them together, it's really significantly lower. Do you have any thoughts as to why that is? So, in terms of our um survival, so in terms of the liver containing grafts, the, the, the group that have the least good survival are the four multivisceral. So you can imagine that that's actually a massive operation to have your spleen, your pancreas, your liver and all your colon and your stomach taken out. So there can be quite significant loss of blood, a very long operative time. And then essentially you're having all your organs put in with potentially high risk anastomosis. So the esophagogastric anastomosis tends to be quite high, not having a spleen puts you at even further risk of infections. Um And so it's just the magnitude of what the patients have to go through and how sick they have to be um to potentially need a full multivisceral. So, hence, we like to if we can preserve the upper block of organs, so preserve the spleen, the pancreas, um the duodenum in the stomach and then transplant the liver and small bowel. Um And that tends to give you a much better survival. Hello, I've got a question over here. Hi. Um Thank you for your talk. Um That's quite mind blowing. Um So what I wanted to ask was we often will see patients um with intestinal failure that are on TPN. Um I've got one that I can think of that just sat on our ward for months and months and months. Um which patients are we because there must be lots of patients around the country with intestinal failure. And so it's just wondering which patients you'd be interested in seeing? Should we be referring all of these or how would you like to? So, so, so essentially you, you have a number of patients with intestinal failure on PM that may be on surgical wards or on if f wards. Um So first of all, it is, is there any continuity surgery that can be done for them to come off the PN? Like? Could it be surgery plus one of the GLP drugs that are coming through? So these are obviously used mainly at the intestinal failure centers. But if you have somebody who is, who's got intestinal failure on PN, have they, are they getting recurrent infections from different organisms or fungi? Are they, are they losing their access above the diaphragm? Have they, have they already lost one point of access? How many points of access have they got? Have they got a derangement in their liver function? But particularly the people who have intestinal failure and short bowel. So those who are may only have 10 to 15 to 20 centimeters of Judum to a stoma and they're on PN their rate of progression of liver disease is quite significant. So, we've had patients we've been caught out with who have lost their bowel have maybe got 20 centimeters of judging them. And we've listed them for a small bowel transplant. And we've done a baseline biopsy which shows minimal liver disease. However, by the time we get to transplanting them, it might be a year or two years down the line. And then when we do a biopsy of the liver, at the time of transplant, they've shown severe fibrosis or almost coming up to incipient of cirrhosis. So people who have short bowel who are on PN you have some indication of de arrangement in their liver function are at much higher risk of if if is not that well. Well, increasingly it is but isn't as well understood as the other liver diseases. So, I mean, so certainly if patients fall into this category, then, you know, so, so they are potential people that we can look at and when I was thinking of was somebody that we did reverse and then their bowel just didn't absorb and just wasn't functioning. And so they stayed with us for like months and months and months and mainly they were in because we just had to give them loads and loads of fluids and everything. They ate just kind of shot straight through and then they ended up with lots of other complications, ended up having to have like a fasciotomy of their leg. And so I was just thinking about which point in time we should be even sending them to you because the intestine intestinal failure team see them once in a while. It's quite hard to get them to routinely see the patient. And obviously they had some medication and um at what time point we should be sending them to you because they then ended up in a much worse position from having their multiple infections. And I was just kind of thinking back to at what point we shouldn't. So, so, so I suppose if you had reversed them and they're still not coming off the PN and you're not quite sure where to go. You know, we're happy to have a chat on the phone. We're happy to be emailed anyway, you know, and if there's, um, and sometimes we do get patients like this and actually what we tend to do sometimes is to take them to the National Adult Intestinal Forum. And actually you have a lot of, if centers you have, you have a lot of other centers, so you can have a national discussion about these patients. And if appropriate, we can see them for an assessment, even if it is to say, actually, we think there are non transplant options possible. We, we would advise you go down this route. Yeah, so we're always happy to take a phone call. An email or a letter. That's not a problem. Thank you. Ok, thank you very much. I'm afraid just to keep the time, we, we'll end the questions there. Um It's been a great session just to say, thank you very much to prof Brown for coming to talk. Um We give a big clap.