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Many thanks for that very informative, excellent presentation. Um Just before you move on, I just want to introduce the rest of the panels. We'll be um involving them in the discussions upcoming. So very lucky to have Professor Dermott Burke who's joined us from leeds, teaching hospitals, consultant, colorectal and inal failure surgeon. Um He's also on the ACP if subcommittee and sorry. And we have Miss Lisa Massey who's joined us from Nottingham co colorectal consultant. Um I have um abdominal wall and IBD surgeon and also is the lead for the ACP guidelines Committee. So many thanks to you all for joining us today. Um So next, we are just going to run through a couple of cases quite quickly. But the idea is just to get you to think about the decisions that have been made in the process and how the patients have progressed and whether you'll be doing the same thing. Um So the first one, I don't know if we can get this. Can we get the slides up, John? Um the Yeah, the case one please, if not, I can talk through it. Um If that's ok. No, no, no, it's the it's the, it's just the two cases. Not a problem. I can just talk through them if need be rest. This, put weeks of work into that presentation, we'll start. If it appears that would be great. Yeah. Or we could, we could move it around. It. Would it be all right if we do, um, Miss Massey's presentation next and then we'll just do the cases at the end of discussion with that as well. Yeah, if that's ok with you. Yeah, perfect. Thank you. Yeah, tell him how much weight you put in to get arrested. Hi, everyone. And thanks for the invitation. Really delighted to be here. I really enjoyed attending the Dukes Club as a trainee a few years ago. So looking forward to being back. So I'm a co direct surgeon with interest in IBI F and abdominal wall working in Nottingham Hospital. And I'm just gonna spend a few minutes just talking about how I, how I came to be um an if F surgeon. So um I'll talk about these things in my talk. So I moved around a little bit in my training. So I started in the east of England. So I started in London actually medical school and then went to the east of England. Then went down to the South West for my registrar training and did most of my follow up years in training in exeter. So I sort of got to the final year or two of my training, which I'd really enjoyed. I knew I definitely had an interest in inflammatory bowel disease and was developing an interest in abdominal wall surgery. And I'd sort of, I think probably in, we had relatively little experience of intestinal failure surgery. During my training, I'd worked for maybe a few people who had an interest in it but only perhaps seen maybe two or three operations at the most related to it. But it was definitely something that sort of piqued my interest and I thought I wanted to find out a bit more about. So that led to me looking for opportunities for fellowships and where there's actually very few fellowships that are specifically in intestinal failure, surgeons. But one of the places that does do a fellowship is ST Mark's Hospital. So that's, that's where I went and I was actually ST Mark's first specific if fellow in 2021. Um So this was sort of just after the very peak of COVID and I worked for two consultants who worked for Akash Me and Karen and Bay. And this was sort of for nine months. So I had my experience was sort of 23 theater lists a week which was sort of mixes of intestinal failure, but also their, their other interests including IBD, pelvic floor and abdominal wall. I usually had roughly two clinics a week of which one was mainly the clinic and that ran simultaneously with the gastroenterologist's if clinic So we would sometimes do shared consultations, which was particularly interesting. We had a weekly if MDT where we went through all the inpatients and we also discuss sort of some new referrals as well. And one of the benefits about ST Mark's is there's always lots of other interesting things that are going on in the department. So I was able to in any spare time, sort of pick and choose what else I looked into. In terms of my operative log book, I think I had 169 cases in ta 18 sort of major if cases, 11 abdominal wall reconstructions for GST insertions that I'd been involved in. And in terms of what I found particularly useful. So there was of course the in patient care of complex intestinal failure patients, which would include Azak Ash lead to some people who we would be transferred in more in their acute phase. They generally would go to the dedicated if ward and were looked after mainly by the nutrition team. But we would often start to have some input of early in. So I'd come to know those patients quite early on. I was involved in seeing and sometimes triaging some of the tertiary referrals. I compared to a sleeping which basically trying to find out what on earth has happened previously in this patient, what surgery they've had, what other treatment they've had and what their anatomy is and then starting to plan their pre operative work up. There's often a lot of coordinating with other specialties, partly in this phase of trying to work out what's happened in the past. But also in planning surgery, we said that if they may have anatomy, that means that they'd be at risk of iatrogenic damage to things like ureters during the operation. Then we may plan in advance to involve the urologist to stent or put a catheter or guide wire in the ureter. If we think it surgery is going to involve possibly a resection of other organs, then they may need to be involved in patients, for example, who may have had a thrombotic etiology for their intestinal failure, that may involve speaking to vascular surgeons and hematologists as well. In terms of technical skills that I learned, I think probably the most important one was safely entering and operating in a hostile abdomen. And that's something that I thought in advance I would find useful. Even if I didn't go on to become a dedicated intestinal failure surgeon, I still think that's the case. So that's really useful skill for, for all of us to learn. And I definitely did pick that up. The nature of this surgery is that you're always operating in reoperated abdomens, um meticulous identification, avoidance, and identification of iatrogenic injuries. Um And as we've already mentioned, always measuring the bowel length at every operation. Partly because then um that that can be useful to the gastroenterologist to know also whether it's how much Judum and dili are remaining rather than just the total. So that can be relevant to their nutrition. Um, but also in, in sort of speaking to the patient after whether or whether it's likely to be feasible for them to come on for parenteral support or what parenteral support they may need afterwards. So I came to the end of my fellowship and I think fairly early on, I sort of thought that this was something I was going to find quite difficult if I had to give it up and not continue in it in my consultant practice. So that I started to think about where I could work where I would be able to continue with this. And intestinal failure is short stories. It's nationally commissioned. So there are certain regional centers that are funded to do this work. And I hadn't actually worked in any of the places other than ST Mark's being one of the national reference centers. I hadn't worked anywhere else in these regional centers. So I started reaching out to people who may need someone to do this work and where I currently work is Nottingham. So they are one of the regional intestinal failure centers. We're a very busy tertiary hospital. We're a level one trauma center and I had visited them and had several conversations for quite a long time, probably around 12 to 18 months before it came to the job coming out me interviewing for it and it's so we're spread across two sites. The Queens Medical Center is sort of the bigger site and is the trauma center and the city hospital has some of the specialties and is coming probably over time to becoming more of an elective site. But that's where we currently do all of our elective operating. So we've got four surgeons who do intestinal failure called colorectal surgeons. We have atic nutrition units including an in patient ward, which is one of the requirements of being a regional center. We have a weekly MDT and a monthly discussion of all the type two intestinal failure and outpatients as well to track their progress towards their planning for surgery and making sure they all have a plan. One of the things that I have negotiated to my job plan is having a monthly clinic where I see most of these patients rather than my other work and they're all dedicated 40 minute slots where I really have the time that I need to speak to these patients. And we also have a monthly abdominal wall MDT and access to Botox which slightly expands our repertoire of adominal wall surgery in terms of research. So showed you earlier a video of the insides pump which is sort of the automated distal eluent feeding pump. So I think there'd been relatively little distal feeding done in Nottingham before, before this. And so we've been passed a trial which is randomizing patients to either receiving the pump and using it for several weeks before surgery versus having their standard care. This people who are on parenteral nutrition and actually my first intestinal failure patient was recruited to this study by me and was randomized to the pump and he was able to come off parenteral nutrition and just need IV support before surgery. I'm also the local pi for the ocean study, which isn't if specific, it's for pre operative in Crohn's disease, but it has a nutrition sort of slant to it, which is why I'm involved in that. Um So my 1st 12 months I sort of went encountered and sort of on my, I guess under my care, I've got 15, what we called true type two intestinal failure patients that I'm sort of working up for surgery. At some point when you have a practice intestinal failure, you then tend to get refers what we refer to as I patients who don't meet the true definition for but who, for example, have laparostomy, big abdominal wall defects, maybe are requiring some nutritional support but not meeting the definition for intestinal failure or need restoration of continuity. Um These patients take a very long time to work up. I did my first um sort of intracutaneous fistula repair for an intestinal failure patient that was under my care just over 12 months since I'd started. Um And so there, there were sort of a lot of people that I was looking after before II came to do my first operation for, for a patient under my care. Um So I've now done three of those. I've done a few restoration of continuity for, for, if that didn't sort of involve a big laparotomy 16 hours lysis, which again, it was sort of someone who was chronically obstructed but not in intestinal failure, but that, that sort of work tends to come to you. Um And I also have done sort of my, my other interests, IBD um and some cancer resections as well. So, reflections, I guess on my first year and a bit. So what I really enjoy about intestinal failure is that this is completely transformational for patients. Patients. Been through such a difficult time, they've often had a surgical complication. They naturally are very scared of having further surgery, very worried that they will have another complication similar to what they had before and they need a lot of support through that. Um But their quality of life can be improved dramatically by this. I enjoy that we work as part of a team, including gastroenterologists, stay nurses, maybe tissue viability, nurses, dietitians, and pharmacists in the team. And I've really valued my supportive colleagues and mentors. This is definitely the sort of work you do need people that you can find when you're in a difficult situation. When you need some support. I think it particularly uses my skill set and strengths I think I do actually have the patience for a six hour t your license procedure. And I do really enjoy planning and this does involve a lot of planning. Some, some maybe of the challenges finding the time that these patients need, which is in clinic, but also sort of seeing them as an inpatient. Um trying to sort of organize how we do things like joint operating in particular for people who need sort of a big if operation and then an abdominal wall reconstruction. At the end, these can end up being very long operations. Um And it's useful to be able to do them with a colleague if possible. And also working out logistics, things like joint clinics with the gastroenterologist and the logistical difficulties of just never quite having a complete picture of what's happened in the patient's past. Um and working with some unknowns and also trying to get all these investigations done, trying to get the patient optimized at the right time when you are able to operate on them. So things in the future just locally, things about service improvement, maybe just things to continue to get more joined up care for patients in particularly at both sites at the moment are for operating on a separate site to our nutrition unit. And that has its challenges. I wonder about whether we're going to build on being part of the inside studies to use maybe more distal feeding sooner in patients organizing joint clinics. We would really like, I think in the future to have an intestinal failure and or abdominal wall fellow that we train in our unit, perhaps looking at regional MDT S and then building on research that we already do and perhaps involving one of my other interests, which is guidelines. Thank you very much. Yeah. Um We're just thinking if there's anyone that's got any burning questions from either of the talks, we can deal with them now or if you'd like to send them through a medal, we have access to them as well and we'll just deal with everything at the end. It probably going to be work better if we get through the cases and then that might actually stimulate some more um conversation anyway. But thank you so much that wonderful run through your path, really helpful for those of us. Um Thinking about an if career in the future and what to expect from the early years. That's been brilliant. Thank you.