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Good afternoon everybody. Um uh today, uh Doctor Neha Gautam is going to speak about esophageal replacement and we are glad that Professor Sad, she is uh available with us as an invited guest to give his comments. Uh pro Professor Sheikh uh is uh is the current president of the College of pediatric Surgeons of South Africa. He is a senior practicing pediatric surgeon in Durban. And he in addition to being a general surgeon and a pediatric surgeon, he's a qualified vascular surgeon as well and he has significant experience in um uh surgery for esophageal replacement and he does uh those surgeries uh in infancy at, at young age and I'm sure he will have lots of uh advice uh for, for us all. So um Neha, you can start your talk. Thank you. So good afternoon or good evening everybody. My talk uh will be about a severe replacement just so o replacement surgery in Children has major surgical challenges. It also is known to produce significant morbidity and mortality with complications in the postoperative period that are challenging for the pediatric surgeon. This type of surgery requires a multidisciplinary team that manages the child from the initial consultation till discharge. Therefore, expertise is essential. The child's figures is still the best surgical conduit to meet the nutritional needs of the child. However, if this is not possible replacement becomes the better option to meet those nutritional needs and improve quality of life. What are the ideal uh characteristics of an osteal substitute? The operative technique should be technically straightforward, reproducible and adaptable to small Children. The substitute must function as an efficient conduit from the hypopharynx to the stomach to satisfy the nutritional needs of the child causing no compression to the vital organs internally or externally, gastric acid reflux into the conduit must be minimal. And if reflux does occur, the substitute should be resistant to gastric acid and most importantly, the substitute must grow with the child and continue to function well into adult life and the indications of replacement. So, the first indications are usually due to long gap servi atresia or pure osteovit atresia. This is defined in a neonate which the proximal and distal pouches of the esophagus cannot be primarily anastomosed. If all these efforts are futile to perform a definitive surgical technique in a very small neonate, the procedure must be abandoned and then one must commit to a replacement surgery. The other causes are strictures. Caustic strictures usually result in full thickness, burns, they can be long, they can be torturous refractory and eventually intractable. Despite being on a dilatation program for about 6 to 12 months there may still be a requirement for replacement surgery and then the other causes are infective strictures in the developing world is often the result of HIV associated disease. Any osteovis candidiasis, viral esophagitis due to CMV virus, idiopathic osg ulcers are all important causes of strictures in HIV infected Children. An audit was performed in K ZN that looked at 39 Children presenting with strictures, which of almost 20% of them were HIV infected and had complications related to their disease which were strictures. There are four common methods employed for replacement surgery. These are colonic interposition, reverse gastric tube, digital interposition and gastric transposition. As illustrated on this diagram. Each procedure has its own comparable complications and outcomes and the choice is usually dependable either on the institution's experience or the surgeon's. So the next few slides, we'll be looking at the different types of replacement and what are the characteristics as well as the advantages and disadvantages. So, with colonic interposition, it involves the use of transverse colon or left colon. The left colonic artery is its blood supply. The right colon may be used and based on the middle colic artery, the mobilized segment of colon is placed into the chest and anastomosis is done isoperistaltic to the esophagus and the stomach. The advantages of this type of surgery is that it's a technically straightforward surgery. We have a large body of published data on colonic interposition in Children and which has shown good outcomes. The blood supply of the colon is dual, meaning that the graft is supplied by either the left colonic artery as well as the marginal arteries and it has good considerable length to adjust. However, there are disadvantages. This type of surgery requires three different anastomosis, strictures and reflux have been reported. And over time, the graft becomes redundant and leads to stasis of food. In gastric transposition. This entails that we mobilize the entire stomach, keeping the right gastroepiploic artery and right gastric artery intact and carefully dividing the short gastric arteries. The left gastric vessels are ligated. The duodenum is mobilized and a pyloroplasty is performed a tunnel is then fashioned in the posterior mediastinum strictly in the midline for the stomach graft to be placed by blood dissection. Finally, as you see in this picture, the position seen is that the stomach is in the posterior metastin a single or for gastric anastomosis is in the lower neck and a pyloroplasty is performed. A feeding ginos tube is placed and a nasogastric tree. Nasogastric tube is placed on free drainage to prevent gastric dilatation. The advantages of this is that also it's a technically straightforward surgery. One anastomosis is required, the stomach is an organ that has excellent blood supply and therefore graft failure and redundancy is minimal. However, the problem with the stomach is it is a bulky organ and it compromises a lot of the space around the area where it sits, therefore causing severe cardiorespiratory failure. The stomach also lacks peristaltic active activity and hence any food bolus passage is mostly dependable on gravity, strictures, leaks and even reflux have been reported in the literature. In reverse gastric tube. A tube is created by the greater curvature of the stomach. With its blood supply being the left gastroepiploic artery, the right gastroepiploic artery is divided and the arcade is carefully preserved. Step by step. Division of the stomach takes place by means of a gi stapler. A cervical esophageal anastomosis and pyloroplasty is done to prevent delayed gastric opening. The advantages of this, it has the to bridge long gaps. The graft also being a stomach has good blood supply is less redundant and less prone to gastric acid injury. The disadvantages are, it may be quite a challenging procedure for the institution. But if the institution has a gi stapler, this can become an easier procedure. There is a long suture line. Therefore, the graft is prone to leak and the stomach capacity is reduced. Mortality is usually related to the respiratory issues or respiratory complications. And then the last one is small bowel with the use of small bowel. A segment of gin about 3 to 5 centimeters will be used for the interposition. This is mobilized on a vascular pedicle and brought into the chest where an anastomosis is performed at the oops and stomach or the proximal small bowel. One needs to be very careful not to twist. This graft on its vascular stalk. An opening is now made in the mesentery of the transverse colon somewhat on the left side to pass the digital graft through in a comfortable way. And then finally, the anastomosis is performed a trans a an anastomotic tube is passed a chest drain and gastrostomy are also inserted. Advantages of this is that the damage of the bowel is similar to the esophagus. It's also not bulky. So therefore, respiratory complications seem. Hello, ne we have lost your sound. Oh, dear, looks like nea has a bit of problem with the internet connection. I'm sure she will join again. Now you can share again. Yeah, I'm sorry about that. I think my internet uh connection is unstable. Therefore, I was disconnected. So I'll start again. So we were talking about small bowel with the use of small bowel. A segment of jenin about 3 to 5 centimeters will be used for the interposition. This is mobilized on a vascular pedicle and then brought into the chest where an anastomosis is performed at the osophy and stomach or proximal small bowel. One needs to be very careful not to twist this on its vascular stalk. An opening is now made in the mesentery of the transverse colon somewhat on the left side to pass the digital graft with its pedicle through a comfortable way. Finally, an anastomosis is performed and a chest strain and gastrostomy are both inserted. The advantages of this type of replacement is the diameter of the bowel is similar to the esophagus. It's also not bulky. Therefore, respiratory complications may be avoided and also retains its peristaltic activity. The disadvantage of this type of replacement is that the literature, literature reports on a very few studies that are prospective in nature that actually report good outcomes in the short and long term, the blood supply with the use of small bowel is also questionable. Therefore, there's a high chance of graft failure. It's prone to acid injury and is not resistant to damage, leaks and strictures have been reported and also the graft becomes redundant. There are three different routes used in replacement where the graft may lie. The most common u common used route is the po posterior metastin due to it being a direct route that the stomach is contained in that space where little compression of the lungs should happen. Also, this allows the surgeon to avoid a thoracotomy. There are three different routes you there are sorry, excuse me. When it comes to the age, there are more centers that prefer replacement to be done in the sitting up, thriving infant. And this allows that gravity to pass any food passage easily. And then on the other, on on the other side of the spectrum with neonatal populations, replacement surgery has been performed and outcomes of surgery have been published in the literature as seen on this study, Gupta and his colleagues from Ames New Delhi. Had reported a, a series of 27 units who had undergone gastric transposition. His team reports favorable outcomes and then a study done in the last 10 years was Tauri and his team before they did the study in 2011. And they made a comparison of 100 and 29 Children who presented with osteophagia, atresia requiring replacement surgery. The comparison, the comparison of the main complications and mortality rates in walking Children was performed surgery in the first months of life showed that the incidence of cervical anastomotic leaks and graft graft failure was similar in the two groups. But unfortunately, the mortality rate in the first months of life was greater than the infant group. So the recommendation made in the study was that surgery or any form of replacement surgery is best performed when they start walking, that will result in good outcomes in the short and long term. Also in the literature, colonic interposition and gastric transposition have been compared and its outcomes have been studied. There are two big centers that have done. So this being Oxford and Red Cross Children's Hospital. What was noted when these two graphs were compared that they both had similar complications in the long and short term. They noted that sepsis was a significant complication and more anastomotic leaks were seen with colon. Respiratory issues are a major concern in gastric transposition. And during the study, the institution required to change their surgical methods they therefore adapted the reverse gastric tube as a means of replacement. And this reduced the bulky nature of the stomach and therefore reduced their complications. Significantly mortality rate is about 6% in both grafts. And then to conclude in the study, what they did conclude is that both methods of replacement are both safe and efficient to be used in the children's population. And another systematic review performed by Liu and his colleagues reviewed over 593 studies of which the patients had undergone replacement due to long gap esophageal atresia. Most of these studies were were res retrospective in nature. Colon and gastric transposition had good and comparable outcomes. There is limited data to report outcomes on small bowel and currently, any research that has been done on replacement still lacks good prospective trials. Also the follow up of these patients in the short and long term seems to be poorly done. So in East London, we have adapted the use of gastric transposition since 2012 and there are few reasons why we believe the operation is technically straightforward. It requires one anastomosis and the complications are within the limits of our junior team members to manage in the postoperative period. We have noted that even the long term follow up of these patients have produced good outcomes and then there are complications also in these type of replacement surgery, they can be early or they can be very late. So some of the complications I have listed here are complications listed about gastric transposition surgery. Earlier in the surgery, they are usually the cardio respiratory complications that are the issues and then anastomotic leaks can present early and towards the late period. Um, issues with nutrition, swallowing and appetite and then eventually one either become dislodged or blocked. And reflux dumping syndrome and strictures have been reported in the literature. And uh, to conclude about the stroke replacement surgery has significant morbidity and mortality in the short and the long term. However, mortality is low. There are various sub various substitutions used to the OSHA colon and stomach have the most published data on them with very good outcomes. But one can conclude that no graft is superior to one another. The healthy sitting infant is the best age for replacement surgery. The choice of the substitution depends on the characteristics, the experience, the patient profile, the resources available and the ability for the team to manage the complications follow up of these patients is very necessary even and beyond adulthood. Thank you. Thank you, Neha. Um It was a very good presentation. Um If I can just request you to go back to your slide about uh different routes because I think I'm technically our experience on the next few slides. No, no, no. Can I go ahead? No, no, that uh the different routes, I think because of your technical problem, you just mentioned about posterior mediastinum. But uh there are two other routes. Um I think you can just mention about that. So that roots of uh of taking the conduit to the neck, um I'll go through that pro with you. So the other two roots that are described is um retrosternal and transpleural that have been described. Yes. Yeah, if you just want to just highlight few important advantages and disadvantages. OK. So, um with retrosternal, um um the procedure is um easy. Uh The routes, if any other routes are unavailable, this can be used. This disadvantage of the retrosternal method is that it's a very long route. There may be issues with angulation of the grafts and there may be problems if the patient has prior cardiac surgery with transpleural. Um It is generally an easy procedure, however, it can displace the lung and it unfortunately requires a thoracotomy with posterior mediastinum. This is one of the common routes we use. The advantage of this is that it's the most direct route. Um The organ is contained within its, the space where the replacement will be done. There is little compromise on the lung and the heart and not always do you require to do a thoracotomy in this type of um route. Um However, the mediastinum space may be small. It may even compromise other surrounding organs and it can become unavailable if previous surgery has happened. And if there's fibrosis or inflammation makes this route very difficult to use. Yes. Uh Thank you there. Huh? I specifically asked you to mention that because later in the discussion, I just uh uh uh discuss about it. OK. But that was a very good presentation. Yeah. And uh finished within time. So, uh I'll invite now, uh Professor Sad to, to give his opinion advice. Um And I'd just like to say now, a couple of times you say that these are straightforward operations, but I think all of our surgeons will, will say and, and emphasize that even even though it's what anastomosis, none of these operations is straightforward. It's quite a major surgery, major undertaking for the child, for the team. So uh none of these operations are straightforward. But uh ii get your point that gastric transposition, there is one single anastomosis versus three anastomosis in colonic transposition. So, thank you, uh Malin. Uh thank you, Neha. That was a, a good overview of the topic. And I'd just like to emphasize what uh Proft has just said. This is this may be a straightforward operation, but it's an operation that gives many surgeons a lots of sleepless nights until the child is uh finally discharged. There are a variety of things that can go wrong. Uh a variety of problems that may or may not be related to your surgical technique for which we have some responsibility that can contribute to complications in the POSTOP period. But this is certainly an operation that uh is one that certainly in, in my experience and talking to colleagues who do these kind of operations really is one of those that makes one lose hair or develop lots and lots of gray hair. Uh I think from my side, um me, unfortunately, I'm sorry, but we have had to restart work here and I'm trying to catch up with lots of work. So that's why I'm still in the and I'm and a mobile connection. So I can't show you the, the clips that I was hoping to, to show. But overall uh my experience or my contribution towards this discussion, II think I'll limit to my small experience with neonatal uh gastric replacement. And uh doctor Gotam very early on when she defined what the ideal replacement uh for an esophagus is makes it very easy to see why the stomach would be the one organ that would fit into that category very easily in terms of the number of um uh properties that she described such as acid resistance, mobility, good vascular supply. Uh And all of those advantages are really fairly easy to, to accept. And the area that uh in terms of esophageal replacement in older Children, these are fairly well covered. There are huge numbers of discussions about them and each center develops its own particular technique and experience for me. I prefer using the reverse gastric tube, but I see Prof Hadley is online and he's the one who's introduced me to that. And, and taught me quite a bit about that particular procedure. So he will chat. Uh he'll probably have a comment about that. I'd just like to share a little bit of information on neonatal gastric pullthrough for esophageal replacement. So I have a small experience with this, a couple of cases, about eight patients. And uh these are the patients who had psophia atresia and it's developed over a long period of time as to what the ideal conduit would be in these patients, both in terms of improving their ability to recover functionality, minimize the number of times they go to the theater later on in life when uh a as they develop. And in terms of what would give me the best sort of uh result that I would that be seeking, I must say over the past 18 months to two years, I've seen very few Children with esophageal atresia, the numbers really seem to have diminished dramatically or um there, there may be going to alternative practitioners but overall, the numbers certainly decreased. So the oldest child I have in whom I've done a neonatal transposition is about eight years old now, actually about nine years old. And um the reason that I had to perform it in that particular child was I had tried a, a er maneuver and unfortunately, we had some overaggressive uh nursing staff who yanked quite firmly on the um suture that was attached to both the proximal and distal uh bits of esophagus. And uh a quite a large piece of the esophagus was damaged both proximately and distally, it happened to be an, a niece to this child. And the options were as we would normally have, leave them with a gastrostomy and do the, uh, and a cervical esophagostomy and do a procedure uh, much later on when they were toddlers. But after discussion, I offered them the option of a gastric pullthrough and we went ahead and did that. Fortunately, it was successful in that particular patient and we then did it in a couple of other patients, the differences or what has happened over a period of time. Just to add to the surgical description that uh Doctor Gautam has presented is what I've done over the past last few cases have been that the entire gastric mobilization is done laparoscopically uh with time and with the experience, this becomes fairly uh a a dissection which takes time and it is tedious but can be done can be learned fairly quickly. The second part that is done a little bit differently is that the dissection in the posterior mediastinum is done under vision with the uh laparoscope. II, either used the curved uh laparoscope or I use a flexible scope to get into the mediastinum. But if anybody has done this particular procedure, they know that the most harrowing part of uh gastric replacement in any child is the blind digital dissection in that posterior mediastinum in that space which is so close to the esophageal adventitia. So using a a laparoscope to pass through that poster me under visualization and dissecting both by blunt and sharp dissection that space that you are making to pass the stomach through really helps in a great uh great deal. And then the neck anastomosis remains the same. It's fair. It's fairly standard, it's an open neck dissection and um it's an area that we, we all know about. It's fairly standard procedure. For me, the important, the biggest advantage has been with the stomach in the neonate is that this is an atrophic stomach. It's a small stomach. It hasn't had any fluid. The child hasn't been able to swallow any uh amniotic fluid and fill up that stomach. So the stomach in the neonate with an esophageal atresia is effectively a small gastric tube. And from a space point of view, the fear that we had initially that it would cause a, a problem in terms of occupying a large volume of space and, and giving us respiratory related issues was not as big an issue as I, we thought it would be. We've had a couple of patients where we've had to go and do Opex on. We've had a couple of patients who required prolonged ventilation and there are certainly a group of Children who have long term respiratory issues, all which which are manageable, requiring uh inhalers and uh those forms of uh interventions. But certainly the stomach in a child who is in a neonate with an esophageal atresia is a lot smaller than uh one expects and fits into that space fairly easily. Now, this is obviously different in the child with an caustic stricture who is four years old and requires uh an esophageal replacement. In which case, the reverse gastric tube may be a much better option. So the Balkis has not really been too much of a problem. Uh The second, the other point that I just wanted to briefly make was that uh doctor also suggested that the stomach may not have peristalsis. I'm not sure II have read about this but I am not too sure about this particular issue because if anybody has seen a child with pyloric stenosis, one notices the peristalsis very clearly. And if the stomach is if the actual mobilization is done, oh, sorry, if the gastric replacement is a total gastric replacement rather than uh than a reverse gastric tube. And if laparoscope is used, trying in some ways to maintain some neural stimulation of the stomach, then I think peristalsis may not be such a lot. Uh such a huge issue and contrast. Uh swallows done on these patients will show active uh pro peristaltic movements. But uh it it has been mentioned as an issue. One of the factors that they are directly related to this is what is how we address the pylori. I always perform uh pyloromyotomy in these patients and during the mobilization of the stomach and popularization of the duodenum, try and get the pylori to be as close as possible to the esophageal hiatus as I can because this will also uh be amenable then to a dilatation if required. But I now routinely do uh is a myotomy. I'm not sure how long that actually lasts. But uh the p myotomy is routine in order to manage the one other problem that we sometimes have with this procedure is, and that is of reflux in the neck and the cervical anastomosis. Once the stomach is attached to that cervical esophagus, there is the likelihood of reflux in that area and that's the only area that the reflux can cause significant uh issues in terms of anastomotic strictures, um problems in terms of uh discomfort, regurgitation. So, what we, what you can sometimes do and what is often possible is that if the stomach is immobilized adequately, it is fairly straightforward to perform a limited fundoplication using a flap of stomach around the esophagus. The majority of the times that I've done that I've managed to get a sort of 100 and 80 degree fundoplication around the esophageal anastomosis. And that appears to help with the reflux uh into the neck, be in the older Children. Although I must uh I agree that the uh reverse gastric tube is the preferred option. If you are using stomach, there are a number of advantages still to the whole stomach being used. And uh the idea that the stomach may be contributing to the respiratory problems in these Children does not always ring true because a number of these Children who have an esophageal stricture have had recurrent aspiration pneumonia. They've had uh reflux of saliva down into the bronchi. And these Children already have evidence of chronic lung disease and letting the stomach. I mean, bringing the stomach up in there may cause some space occupying lesions which may give rise to urgent uh problems. But these tend to resolve over a period of time. Whereas the chronic lung related issues such as the need for inhalers and bronchodilators tends to continue. So that may actually be related to lung injury during the period uh uh prior to the actual um esophageal replacement surgery. So overall from, from a gastric replacement side, uh these are just some of the comments that are from the neonatal uh replacement. I think the majority of the rest has been fairly well discussed and has been overall, uh each person has to develop the skill that they require for the particular operation that they wish to do. And you'd rather do one operation really well and do many operations in a mediocre fashion. Uh Just a brief comment about small bowel uh replacements that you have very limited experience. There's just two patients in which we've used it. You get very select patients who require this and uh they are fairly good for mids strictures because I mean, many of you will know when you try to use more for other, for other procedures like I contu or using them to place in a stricture and things like that. Uh small bowel can be immobilized quite a bit if you choose a good segment and good vessels. Uh once again, one of them, uh I have done with the open and the second one, they used a laparoscopy and a thoracoscopy form. So that certainly helps uh laparoscopy and thoracoscopy helps in terms of visualization and uh making surgery a li a slightly uh uh easier in terms of defining the tissues. Um I think that covers most of my comment, colon rarely in my experience is very limited. It's usually been a salvage procedure when I moved back to Stellenbosch. Uh most of the patients that we started performing gastric replacements on or using the stomach to as a conduit was to manage esophageal uh manage complications related to uh colonic conduits. And um that was where most of my experience with uh colonic conduits came from uh very little experience except in the few patients with uh who complicated uh related to other issues. So I'll limit my comments on the colonic replacement. Mm I think overall that should cover most of the comments I have uh me and I'm happy to answer any questions on, on something that I may have left out uh related to that. Uh uh Thank you so much. I'm just uh a bit uh keen to know a little more about uh the use of uh curved laparoscope because I fully agree and all the surgeons will agree that the dreaded part of uh any knee replacement, especially the gastric replacement is the blind dissection in the mediastinum. So, what do you use? Uh is it the normal laparoscope or um can one use it even if we do um uh open mobilization of the stomach? Yes. Well, I started off using the normal laparoscope. And the, what you would have to do with the normal laparoscope though is you would uh and even when I did the open procedures, I would use it because it's, it's excellent for visualization. So even during an open procedure, you can use the laparoscope into that esophageal bed and you can even use uh the laparoscopic instruments because it has fairly good length, gives you good uh sort of mobility and movement and reach. So what I would do in when I was using the normal laparoscope is that I would uh go as far as possible from the uh abdomen and you'd be limited obviously by the uh curvature of the scope. So this was a straight scope as soon as you started uh reaching a sort of 45 degree angle. So it would become difficult to, to maneuver. And then in those patients, what I did was actually use the laparoscope through the neck and uh through the cervical incision, mobilize from that area inferiorly and meet the bottom and under vision. What I then did was that there is a hysteroscope, uh 3.5 millimeter hysteroscope which is curved. I found that in the Gyne cupboard one day and it is uh hysteroscope that has a very gentle curve. It's fairly long, it's about uh 30 centimeters, but it has a nice, gentle curve And because it has a nice gentle curve, you can actually use that and the curve itself helps guide you across into the posterior media. The spinum uh a couple of times, I have used a flexible um ureteroscope and a flexible ureteroscope also gives you really nice pictures because what we've got to remember is that all I'm using this way is visualization and the dissection is being done outside of a sort of working channel uh with those scopes. And then most recently, uh I've been using the Fosco, we have a number of fos Copes. The Fos Copes have are curved in different uh with different curvatures uh specifically for fetal interventions. But that has worked very nicely in uh the small uh babies. So the initial if you only have a standard laparoscope and you're doing the procedures openly, it's a very useful instrument to use with a 30 degree lens. I think that's very important, a 30 degree lens. So you can move that around and have good visualization and you can use that both through the esophageal iis and then on, uh from the cervical side as well. Uh If you have a flexible ureteroscope, that's a fairly nice diameter, even the bronchoscope would work a flexible bronchoscope. Those are fairly nice diameters to use and give you a fair, quite good visualization. Uh If you really want to use a curve scope, you have to rate the um gynecologist uh cupboards and you'll find uh your uh hysteroscopes and they probably don't even know they still have those hysteroscopes lying around. So you can use that. The fetus Cope is obviously a specialized instrument. If you uh do get your hands on that, then the optics and the visualization are exceptional on that. OK. No, thank you so much. I think. Um just uh for, for Doctor Moni and, and Doctor Moola, I think we just need to keep this in mind when we plan the next uh gastric replacement. Um uh I'll now invite uh Professor Hadley uh to give uh his, his ideas and uh just tell us about his experience. Uh Yeah, pro thanks Melin and thanks so much and um yeah, uh thanks to Doctor Gautham for her presentation. Um There are very many advantages to being old, but one of them is that I've, I've seen most of what uh we we've been talking about today. And the first issue I raised with Doctor Gautham is that the esophagus is not necessarily the best conduit, a healthy esophagus is the best conduit, but these Children don't have a healthy esophagus. And I think we do tend to keep going too long trying to salvage um, an esophagus that is never gonna work properly. And we, uh, we've been breeding esophageal cripples. Uh, for many years, these patients would very often have been best served by having an earlier uh replacement. And we, we're, we're discussing here two different animals. We're discussing the patient with esophageal Atresia who's got a virgin Mediastinum and uh uh maybe a, a neonatal or maybe an older child, but she's got a, a virgin Mediastinum. And then we're talking about oesophageal replacement in the caustic injury with um with peri uh inflammation and uh very often fibrosis. And they are two completely different beasts. Um When it comes to the conduit, I've uh we tried doing the whole stomach and we real sick of seeing Children with what I called a superior mediastinal compartment syndrome. It wasn't just the fact that their bronchi were uh being compressed, but their entire venous drainage from their head and neck was being compressed as well. And they looked uh um in severe distress and we had to take their conduits out. And once you've done that, once or twice, then you start thinking that maybe there must be a better option. And we went back and we looked at the work of uh Gabri Liu, the Romanian gentleman who first started the reverse gastric tube story. Um, we did this operation on innumerable dogs and then followed it up by doing it on innumerable adults and then on a few Children. Um, but the reverse gastric tube, um, to me is, is as good as we can get in terms of a compromise, uh, between all these various options and, um, with the stapler, it's a much easier operation. I'm afraid I've been around long enough to still over. So my staple lines which makes the operation last uh 15 minutes longer than it. Uh It would otherwise do. Um It, the anastomosis is easy. You've got plenty of length. You can in fact, amputate the distal end of your uh reverse tube to fit the length required. Um Sure, it's cervical anastomotic leakage. Well, it's, it's so common as to barely warrant men. Um But it's easily managed. Um I admire uh Mr Shank's confidence in doing a pylor pyloromyotomy on a normal pylori. I find it very difficult to see and to control my enthusiasm for dividing muscle, uh which is already very, very thin indeed. And uh uh sometimes despite my best intentions, ap apa P plasty becomes uh performed. So. 01 other thing I wanted to say is that there was AAA while ago in um a hospital um not far from the waterfront in the city down in the, in the south west of the country um where they used to do reverse and you do colon interposition in a retrosternal fashion in Children with esophageal caustic injury and leave the native esophagus intact. You can't do that that unfortunately, um, is, uh, well recognized now that, uh, esophageal cancer will occur in the caustic remnant. And so you have to remove the, the burned native esophagus very often. That's impossible using a blind dissection technique. And, uh, we end up doing a thoracotomy to get the esophagus out. Um, so that apart, um, it's all, uh, it's all clear when, when they, of course, I don't do any anymore. Um, but if, if, if a patient has come to me requiring esophageal replacement, uh, and it wasn't a neonate because I take what Mr Shaikh says about the size of the stomach and a neonate. Um, it, it's quite correct if you've ever tried to do gastrostomies on these Children. Uh, it's impossible for almost to s to see where to put your gastrostomy to. Um, so that they're, they're a separate beast. But, uh, for any other Children, I think I would head for a reversed gastric tube, uh, eso Plasty and we didn't do a detailed long term follow up of our patients either. And I know that we only remember the ones that kept coming to see us, but the ones that kept coming to see us were growing and developing reasonably well. Um, I, you know, I think our, our results certainly weren't disastrous, um, or, or, or, or sufficiently bad to make a strange old technique. Thank you. So, thank you prof um, just for, for Neha and the other juniors in the current issue of uh, general of pric surgery. There is uh, an article about quality of life and uh it is from one of the Scandinavian countries and uh because they have such excellent record keeping system, they have done like 3040 years follow up of these patients and they have concluded that both gastric replacement and colonic replacement have a reasonable quality of life um in the long term um uh uh of of these patients. And um I see Prof Lazarus is here. I know that he could only join late uh halfway through prof she's uh comments, but uh he has really vast experience of colonic replacement of esophagus in adults. And uh initially with him, we used to do colonic replacement of esophagus in Children as well. And subsequently, I know he has also shifted to gastric replacement of esophagus. And I also know that he also does it quite early about three months of age. So I would just invite him uh to just summarize his experience and give his comments. Please call in. Hi, thank you for the invitation. But I really, I've turned up to this meeting too late. Heard Larry's excellent thing. Sorry, I missed a lot of what someone had to say, Linda. I don't feel I it's appropriate for me to come in now. Thank you for the invitation and I'm sorry, I had to be late this evening. Ok, no problem, no problem. Um I'll invite now, Doctor Manic. Um uh because we have done a few together and we have struggled through these operations and especially stormy postoperative period. So she can just uh give uh her opinion comments. Yes. Sure. Hi. Yes. Uh Thank you and thanks for the presentation. Uh, well done. Um And thank you to prop Sheikh and prof had for sharing their extensive experience. Um It was good to hear what prof sheikh does as well. I've had the good fortune of seeing the reverse gastric tube and the colo uh the colonic Conduit in Durban um in my training and then to do the gastric pullups now and II would like to share the slide of our experience if that's ok. No, that's perfect. I think we have enough time. Uh So, so uh she can share those slides and then we can ask Doctor Moola to come in. Yeah. So we've been doing the gastric pull up and like you say, it's, it's not easy. Um And often, I mean, every time actually, we do it as a team. So uh four consultants would be in theater doing this operation. And uh we've had a lot of acute complications but a lot of long term complications to a long term. I mean, you know, a year or two. But what I find is that the problem with the stomach, is that the, the, the food collects or the fluid collects in the body of the stomach. And even though we do a full pyloroplasty, it still causes us problems later on. And I was wondering if any of our props had any, um, advice on that because we've, we've had to go back once, at least to try to correct that. Um, you showed it if, if, if I may interject, I think, um I think, I think sad, um, pointed to the way forward here when you're doing the operation, put your pylori as close as you can to the esophageal hiatus and then you can uh endoscopically dilate it if you're getting uh gastric retention. And that would certainly be worth trying in the first instance before you have to go and do anything more major. Yes. II OK. I think that's, that's a good suggestion since um, yeah, we've had to kind of change the uh the way we had, uh we had to actually tack it down in a different position so that it would drain easier. And I think also what she was saying about the nerve um supply of the stomach. I think we may, we may be damaging that further and they're not, they don't have the peristalsis that he was talking about. Um It doesn't seem like that with our patients. So that's something we need to learn how to overcome and the other complication that we've had which um, maya didn't have in our, in, in, in her, her list was a recurrent laryngeal nerve injury in uh the cervical dissection. So we do have the neck, the cervical complications as well. So it is very difficult operation. It has a lot of complications. It requires meticulous surgery. Um, and I guess we're still learning, uh, you know how to, um, prevent those complications and that's why is doing an audit of our patients, uh, to see what we can, we can learn. I am keen to try the reverse gastric tube. If we can get our hands on a stapler, I think, uh, it will for, for the problems that we're having it. Uh, it seems like a, uh, like a good, um, option to try. Uh, can you show that? Can I, can, I just chip in here again? Um, on your diagrams, it always looks a long way from the, er, esophageal, um, hiatus to the neck. It isn't a long way. It's in the, the reverse gastric tube doesn't have to be a, uh, a long uh tube. Um, and, and I've done a number simply hand sewing the, uh, the repairing the stomach and carrying on the suture line up onto the reverse tube. Um, remembering to stop your continuous suture line about uh two centimeters before you get to the end so that if you do need to trim it, you can do without disrupting the whole suture line. Um, but it's, I mean, it's entirely possible to do it with, um, with a piece of bicral and, um, uh, a needle holder. Um, staplers are nice. Takes a, a good 30 45 minutes off the operating time. Um, but as I say, I still over, say the staple line anyway, because I'm an old fogey. Um, it, it's, it's often struck me as, as odd that we, we endlessly go on about the tension within our suture lines that we use to a fixed height of staple no matter what the thickness of the tissue we're using it on. Um So, yeah, I II overate the staple line and, you know, the amount of time it adds. Um, it's not very much and it's, it's stress free just sewing a stitch line. Sure. Ok. Thank you. And, uh, this, these are our complications from the 10 patients that we did, but this includes, um, prophylaxis patients as well. So, um, yeah, we were very concerned about our outcomes. Um, uh, and they, they still seem malnourished and, uh, you know, at this stage, uh, granted it's still early. But, um, yeah, uh it was just concerning to us. Can I ask what your, what your indications for surgery were? Were they esophageal atresia or, um, uh, caustic strictures? Yeah, mostly esophageal atresia. There was one, who was an HIV related stricture. Um It, yeah. Uh Sorry. Um Yeah, we, I don't think n has the slide for the indications for the esophageal replacement. But I think uh what pro le is, is telling us is that these are different groups of patients, pure esophageal atresia, vagal atresia trachys, fistula, and obviously caustic or HIV related strictures. But um uh what you have said and we have emphasized that these operations need uh technical skills and uh uh uh we all must work together uh in, in the department and, and uh help you each other because these are not easy operations. But I agree with you. I think uh we, we should consider uh a reverse gastric tube if we have a particular patient. Now, do you have a second slide of this? Is there a second slide or this is the only slide about you? Our experience. The next slide is sort of a conclusion slide to our experience. Do you want? Yeah. Are you a few minutes and then I'll ask doctor to come in, you can go to that slide. So, from our conclusion of our lessons we've learned in this audit is we believe that respiratory difficulties are very early in the, in the postoperative period and they go through a very stormy period in the first, at least three days to even two months. Um It's actually difficult to interpret if it's related to the surgery itself or the um the disease process itself or reflux related. All these patients need intense IC support at least for the two first two weeks. They all require ventilation on clinical demand. And we also can conclude that early chest physio immobilization is essential in these patients. And what we did find out that despite our high morbidity in the ear, early postoperative period, we have comparable outcomes to the developed world that our mortality rate is very low in our series of patients. Um The small numbers that we have uh concluded may mask our results, but we believe this is important that we perform this audit. We ensure that our practices are safe and infect um effective as you show has said. And then later on, we developed some form of standardization of our techniques, our pro our protocol to actually improve our outcomes. Uh We also noted that these are challenging operations that require considerable technical skills from the surgeon and the team that manages these patients. And therefore it takes time to develop these skills. And it's important that we actually record these complications on a database and most importantly share our experiences with other centers in Africa and South Africa. As not, not much is published within the sub Saharan uh continent about replacement and experiences of single centers. And lastly that nutrition is so important and it will improve a better outcome. We had large amount of patients who had chylothorax sleeps uh may be related to the surgical technique, what we did we were thinking about and then therefore, early use of M CT feeds are actually um quite important to introduce earlier in the um postoperative period to prevent further disasters with their nutrition and their further complications. And then once again, follow up is essential in these patients as they have issues with weight gain, they are small and they have recurring problems into adulthood and that's all what we are blunt. Thanks. Yes, thanks ne Yeah. Um and I just, uh I wanted to say that if there are other centers who are listening in and uh participating, it would be great to hear of their experience, even if it's anecdotal. Um it would be very valuable and thank you to pro and pro ali for this. OK. Uh uh Doctor Majola. Um uh I know you have assisted Pro Lazarus also for a few cases in addition to the cases we did together uh any comments from you? Hi. Um No, no comment from my side. I just wanna thank our guests for their uh advice and uh knowledge that they've shared with us and also just going forth that we might um change a few things just to try and get our um outcomes a bit better. OK. OK. Thank you. Thank you. Um So as, as Doctor Marican has uh said, uh I know there are colleagues from Zimbabwe, colleagues from uh Nigeria. Uh So if anybody wants to make a comment, uh you have some experience, you have encountered difficulties, uh please uh raise your hand or just unmute yourself and give your comments. Mhm. All right. Anything you want to say? Uh yes, prof uh thank you very much for the uh presentations. Um I'm still very young in the department, less than 10 years. And uh I would want to say it's not a very common operation here in Harare. Perhaps, maybe if uh bo was part of the attendees, maybe you would have uh better information about uh the procedure. But thank you very much for all the insight. OK, thank you. Um I see there is there are a couple of colleagues from Johannesburg. So uh if there's anything different, you people do, do you want to just make a comment? I see. Doctor CIA Y is here. See anything pro om does different than what we have discussed. I don't think she is uh able to hear me uh any more comments, questions to Doctor Gautham or to the professors. OK. If no more comments, uh we are finishing exactly in one hour, which is always great. So I thank you. Thank you uh Neha for a nice presentation. And uh uh thank you to Prof Prof Hadley and to Doctor Man and Doctor Majola and thank you for all the attendees next week. Uh It will be on small bowel Atresia and uh we are hoping to get uh Professor Sherif Emil from uh from Canada to be our invited guest uh next time. So once I just confirm it with him, I will send the invitations. So thank you very much. Uh, have a good evening and we'll see you next week, Tuesday evening. Thank you, bye-bye.