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Hi. Hi HGA. Can I just try and share my screen and see if it works? Please do, please do. I've allowed you to do that. Thanks. Looks like Eskom is be, be being kind to us. Yeah, my load shedding here was not load shedding related. It's a different issue. Ok, that's fine. I can uh ok. Profer is also joining. Ok, I wanna see. There we go. Hello, Martin. Hello, Martin. He's still connecting. He's still connecting. Yes. Hello Martin. Sorry, Martin. You need to unmute yourself. Try again. Yes. Yes. Yeah. Ok. That, that's perfect. That's perfect. Um Hi, greetings Martin from East London. No, thank you very much. Uh Thank you for the opportunity opportunity to join you guys. No, no, I will. We'll just wait for a few minutes. People are just joining and then, then I'll introduce you formally, but uh Colin sends his greetings and apologies. He can't be with us today. Um Yeah. Yeah, I know you must change my, my regards as well. I will do that. I will do that actually, he's closer to you than to us now. He's in Kalak. Oh, wow, that's good. Yeah, that's great. Is he still, is he still operating or not? Really? No. No, he's still working hard. Hard. Ok. Yeah, that's good news. Yes. Wonderful. Yes. He still, he is, uh, no longer doing sessions for our department but, uh, he's still, is running, um, full time private practice and he's done doing, um, uh, university work as well. He is associate dean for the Faculty of Health Sciences of our water. So, university in East London. Really? Yeah. Yes, that's wonderful. Yes. And his health is still, his health is still good and so on. He doesn't have health problems. Martin. He's, uh, 4 to 5 times stronger than me. Oh, yeah. No, he still cycles. No. Yeah. No, no, he's, he's good. He's good. Yeah. And how's his, how's the weather with you guys? Um, spring has arrived nicely, which we are grateful. But, uh, the, we still waiting for rain. Uh, ok. The, the same with us. It's, it's quite warm these days of, uh, the spring is here but we're still waiting for, for, for, for showers rain. Oh, ok. Ok. Yeah. II see, uh, Doctor Murray Kirsten is also joining, uh, I'm, I'm very happy. Oh, ok. Great. Yes. Yeah. Uh, hello. Good afternoon, Mary. Good afternoon. I just have to unmute myself to greet. Yes. No. Wonderful. Wonderful, nice to have you. Thank you very much. Yeah, Martin is your niece still in East London? Yeah, she's still there. Uh, working in casualties. Oh, she's working in casualty. Yeah, my son, uh, he did his, uh, Zuma here with three military hospital. Uh, yeah, now he decided to join the army there. So, which is nice because, you know, they have lots of off time and things like that. He's doing a lot of sport, uh, these days. Ok. So they, yeah, they sent him with, uh, down there to East London. He was there last week in East London. Really? And this week the, in, in, uh, oh, yes. Yes. Is he, is he also a medical doctor? Yeah. Ok. I think he's going to Queenstown at some stage. No. Yeah. No, we knew that there was an SN DF team which came and they were spending one week, uh, I think in, in East London and Port Elizabeth. Yeah. Yeah. I don't know. It's just maybe to, to show that the, the defense force is also doing something, you know. So, I just, I don't think there's much work for them to, to be done. No, no, no, he's a little bit so he's a little bit frustrated but maybe it's, it's a good thing for him to see that the army isn't. Maybe the answer, you know, and, and what level is he Martin? Is he doing internship or community service? What is he doing? Now? He did his community service last year? Oh, ok. And he, he stayed on at three, the internal medicine department. Ok. And, uh, he wants to do the, the diploma early next year. So he also wants to sort of, uh, do internal medicine at some stage. Ok. Ok. Ok. Ok. He saw how his dad worked and everything. So I think he decided surgery is not for him. You know, he's, he's absolutely not interested in any surgical things. So, no, but I ei even took him to a I PG meeting in London two years ago and even that didn't, uh, you know, impress him much. So. Yeah. So that's the story. No, but, but that's good. Actually there will be a different perspective, uh, in medicine, in your family there. Yeah. Yeah, I know. Definitely. You know. So I think it's a good thing, you know. Absolutely. No, I didn't know, I didn't know he was here otherwise I would have made a point to say hello to him at least. Yeah, the thing is, you know, they, so they go with the bus in and there even, they, they stayed at the hotel, which is nice but they have to sit in menus and, you know, they have to go as a group and, and, you know, and go for supper or everything. So he's quite restricted. No. No, I think, yeah, I think they were almost like moving as a group if I'm correct. Yeah. That's right. Yeah. He's not allowed to do his own thing. Yes. And, uh, yeah, he's doing a lot of running and so on. But he said he's too dangerous in those areas. Yes. Yes. Yes. Yes. He's just going to the gym and so on. The. Yes. Yes. Um, Martin, I think, uh, most of the people are here. So, so I'll just introduce you formally. Uh, and then we will start the talk in a minute. Um, good afternoon everybody. It's really, uh, my, my great pleasure and privilege, uh, to welcome you all, but especially to welcome Professor Martin Ficker who is a professor of pediatric surgery at University of Pretoria. And um he um mainly works at uh if I'm correct, Martin can correct me at Kloof Medi Clinic in Pretoria. And I know him for very long time, almost uh 20 plus years. And uh he is one of the most experienced laparoscopic and uh thoracoscopic pediatric surgeon in the country and he may tell us the exact numbers, but I'm sure he has done or over 1000 laparoscopic knees and fundoplication. And um and it is absolute pleasure that with this uh pandemic, with the Zoom platform, we are able to get uh his uh his advice, his opinion and he will share his, his um uh his ideas about uh this common problem we face with. And I also welcome uh Doctor Mary Kirsten. I also know Doctor Kirsten for a very long time and she has been a permanent member of the Department of pediatric Surgery at Steve Beer Hospital. And uh and welcome Doctor Kirsten uh today uh our registrar Doctor HG House is going to present about gastroesophageal reflux disease. She has been mentored by our consultant, Doctor Selo Mataya who is um, a consultant uh with us, one of our four full time consultants with uh he has special interest in uh gi surgery and hepatobiliary surgery. So, without further introduction, um I'll invite doctor in the house uh to, to start her talk ga please go ahead. Good evening everyone. Yeah. My topic today is gastroesophageal reflux disease in Children. Um And due to time constraints, uh we'll fly over some topics or some aspects of it a bit faster and we'll go into more detail on some other aspects. Um First, a few definitions just so that we are all on the same page. Um Gastroesophageal reflux is considered the passage of gastric content into the esophagus, gastroesophageal reflux disease. The part we are talking about is reflux that has pathological consequences like esophagitis or nutritional compromise where the child has failure to thrive or respiratory complications where they aspirate feeds um or have recurrent low respiratory tract infections. Then regurgitation is an effortless reflux up into the oropharynx or above. Um considered also obvious gastroesophageal reflux or some people call it spitting up and then vomiting is a forceful expulsion, engaging abdominal and respiratory muscles of refluxate out of the mouth. Um often the two regurgitation and vomiting are distinguished whether if the regurgitate is coming up and just running out the mouth or whether it's going forceful against the wall opposite the child. Just to keep in mind these different things, when we see these Children and try and figure out what is going on, coming to some mechanisms that prevent reflux. These are important to know when we investigate these Children and especially when we start offering surgical management for them. Um One of the important factors is the esophagus and esophageal clearance. How fast can it move reflux ate? That's gone up back into the stomach. One very important component is the lower esophageal sphincter. It's um to, is very important, especially in there are small Children. They have a decreased tone of the lower esophageal sphincter, which is why they often um have reflex. Also, the position of it is very important. If the lower esophageal sphincter is below the diaphragm, it prevents reflux much better, which comes to the next point length of intraabdominal esophagus is important in adults. It's considered 3 to 4 centimeters is adequate and Children, I couldn't find any specific numbers. And one that we are very concerned about in our surgery is the angle of his. We want an acute angle of his so that it can as the fundus fills up close, the esophagus where it inserts into the um stomach and then the crura of the diaphragm are also important as they help the um esophagus close and prevent reflux. We'll come back to these when we come back to the surgery. Now for investigations for the majority of Children is often not needed. Usually history and exa and clinical examinations are the only two that are needed. And for the majority of patients, that's all we need to make a diagnosis and to start management, whether it's to reassure patients, um, start medical management or surgical management. The only patients that really do need diagnostic evaluations are those that, um, have complex disease or we don't know exactly what's going on might be something else that's wrong or we're trying to rule out other problems that can be causing something that looks similar to reflux. The current gold standard is the multichannel intraluminal impedance study which through multiple channels measures a difference in charge or resistance. Um and can therefore measure anything that goes, whether it's gas liquids or solids goes up or down and how far it goes and where it goes and this gets traced over 24 hours. The precursor to this had been just a esophageal ph study which only measures acid reflux and doesn't seem to be that appropriate in Children as they seem to have more alkaline reflux. However, the best is to combine these two in a single device and measure over 24 hours. How much reflux do they have? What is the duration of um refluxate in the esophagus? How long does it take to clear? It can also distinguish between swallowing and reflux and like I said, between gas liquids and solids. However, we don't have this available at our institution coming to the next one, which we do have available is what we can um call a contrast swallow. Um can also be a swallow and follow through. It does not accurately reflect the frequency or the or diagnose gastroesophageal reflux disease. If we don't see it on these studies, doesn't mean that there is no reflex as it gives only one point in time where we can see what's going on. But it is quite important to rule out any other problems, whether there's malrotation, whether there's an web annular pancreas, um achalasia or even strictures and sometimes it can even show us a hiatus, hernia for that. It's quite useful in the neurologically impaired Children. We also use it to assess the ability for them to swallow because they don't just require um a fund application for the reflux, but they often require gastrostomies as well. But in, yeah, like I said, it's not the most accurate study to be done. And the current recommendation is actually that it doesn't really make much of a difference in the majority of patients unless we expect another problem in a study done in 2010, it showed that only 4.2% of patients doing a contrast swallow made any difference to their operative management. However, when they did a survey in 2011 80% of pediatric surgeons said that they require pre-op um contrast swallow to see what's going on. So it might not be the most accurate, but it's definitely the most commonly done endoscopic studies are also very important because we can check for the consequences of pathological reflux or esophagitis. We can see strictures and we can take biopsies and possibly distinguish between reflux esophagitis or esophagitis secondary to other issues. Um Yeah, and we can also see anatomical problems like hiatus hernia just to mention. So, because we had spoken about it previously, uh xenophile esophagitis is a chronic immune mediated disorder, um which is different to um reflux. It can look similarly on endoscopy, but it does not show the same on biopsy and it gets treated differently. It's therefore important to distinguish um that from reflux esophagitis. Um Again, we don't do the study very often. But the North American Society of Pediatric Gastroenterology Hepatology and nutrition reco um consider endoscopy the most sensitive study to evaluate gastroesophageal reflux disease. And their current recommendations and indications are to do endoscopic studies when we fail medical management. If there's weight loss in the child fecal cold blood, um recurrent pneumonias or hematemesis, we only do it on selected patients. Um and not that commonly. Then the milk scan, which was described in Red Cross, we can't do it, but we still need to know about it. However, it's not done much internationally anymore. It's a study where we mix technetium 99 with milk and let the child drink that and to see what happens. Where is the swallow, uh, where is it going? Um, it's the most accurate study to see whether there's any aspiration as you can see on the picture. However, it's not done very commonly at all, then medical management. Well, uh, the first step of it is actually more lifestyle changes like in adults as well. Um, first to avoid tobacco smoke exposure, which has shown to lower the esophageal sphincter pressure and improves um those Children with symptomatic esophageal reflux disease quite significantly if the parents avoid smoking in their presence or stop smoking altogether. The next one is to avoid overfeeding. So rather smaller and more frequent feeds, keep the Children upright after feeds. Um, for about 30 to 35 minutes, semisupine or in a propped up position can make it worse because it um can raise interabdominal pressure which makes the reflexing worse. So these Children should rather be kept upright, hold upright by the mom than be propped up in a um, baby carrier. They still recommend that the Children should sleep supine because um sudden infant deaths, some drug. Um yeah, syndrome should um, is considered to be more common in a prime position. Another recommendation is to thicken feets. There's um some debate how effective that is, but it seems to work at least for some patients and it's worth trying and then avoidance of cow milk and soy protein. If all of the above doesn't work before we start off going on to other avenues because about 40% of patients with suspected gastroesophageal reflux disease actually have intolerance to cow milk and soy protein and need to get very hydrolyzed milk products. Or if they are breastfed mom must try and avoid all of these products and that significantly improved their symptoms coming to pharmacotherapy. Um, it's for a majority of Children not indicated, especially in infants as it's uncomplicated reflux and usually improves um with just um lifestyle changes and if they do become irritable, some studies have shown that it doesn't improve their irritability of the child. However, if it gastroesophageal reflux disease is symptomatic. We usually give PPI S to try and improve their symptoms. It doesn't improve the refluxing, but it improves some of the symptoms as less gastric acid is secreted and refluxed. Um The indications currently are if with mild esophagitis on endoscopy, we give her a two-week trial of PPI S and see what happens after that. Um or when lifestyle changes have failed or if they have moderate to severe esophagitis, they then should get PPI S for 3 to 6 months. PPI S are currently the recommended drug as hh two or histamine two blockers are not as good in Children. Um They develop tolerance and might need to increase the doses and only has a short term effect and, and pro kinetics are not at all indicated in Children, problems with PPS that we just need to keep in mind if we put Children on long term PPIs for various reasons is that it can present with increased risk of diarrhea pneumonia because it eliminates the acid in the stomach, which is one of our barriers to infection can cause vitamin b12 deficiency, iron deficiency and possibly, which is still in debated a higher risk for allergies coming to surgical management, which is where it gets interesting for us. Um the indications for surgical management of few and only very few of the many patients that have reflux will ever end up with surgical management. However, the ones who failed medical management will need surgical management. Also, the ones who have failure to thrive are neurologically impaired Children, especially those who need gastrostomies. Um You often also have reflux and will come back to neurologically impair Children in a bit. Um, Children with reflux and respiratory complications in Children who have witnessed a um adverse life-threatening events. Um spells like near death from aspirating refluxed food or severe pneumonia. Children with Barrett's esophagus Children who develops esophageal stricture secondary to reflux disease and symptomatic gastroesophageal reflux secondary to a hiatal hernia. All these all usually end up needing uh surgical management. The most commonly done operation for these Children is laparoscopic fundoplication. Its advantage is that it has small incisions with less pain, POSTOP and less need for opioid analgesia and usually faster recovery. And it's even though laparoscopic surgery needs more skill from the operating surgeon, it's often easier to see what we are doing and to get into far up under the diaphragm to see where the esophagus and the stomach and the diaphragm when all these things come together for our experience has been the same, the disadvantages. Um, in a 2016 study has shown that it has higher failure rate which might be secondary to previous um more dissection around the esophagus and the diaphragm, which is currently um not advised anymore. So, the aim of a laparoscopic ness and fundoplication is to get a floppy tensionfree wrap of the fundus around the distal esophagus. Um to do the operation, we place, place our patients supine often with the legs hanging off the table or in a frog leg position or in the older child in the lithotomy position. Um This position has to be sometimes changed for the neurologically impaired Children as they often have contractures, scoliosis already. Then the camera port is placed at the umbilicus with two working ports and one port for attracting the liver. First. The gastrohepatic ligament is taken down. Then the posterior window is dissected carefully between the esophagus and the crua. Um staying closer to the curve as the vagal nerve runs along the posterior part of the esophagus. And at that point, you can see if there's a decent length of esopha intraabdominal esophagus. Sometimes we need to take down the short gastric to give the stomach better mobility and to a access the posterior part of the esophagus easier. Um It's generally recommended because it um gives a better floppy wrap. Um Once that is done, we need to check how big the Hiatal opening is between the cru and whether those need to be closed, they're usually closed with nonabsorbable sutures and then a pull stomach has pulled posterior to the esophagus through the window that was created earlier. Um We check for adequate, adequate space with a shoeshine maneuver and like I said, in the beginning, this must be tension free um floppy rep. And once that is achieved, the um wrap is secured um with usually two or three stitches. One of these at least need to go through the esophagus to prevent migration of the wrap, um which is one of the complications seen. The other two don't usually have to be secured and then we can proceed with a gastrostomy depending on whether the child needs it or not. There are some alternatives to this operation. One is obviously our openness and fundation which we sometimes do for our small Children who already have aspiration pneumonia you won't tolerate um A pneumoperitoneum. Um Alternative wraps are the Toupe which is here. Number B, there's also a poster wrap but only 270 degree wrap, not a full 360 degree as the Nissan over here. Then the door wrap is a anterior 180 degree wrap. Um And then the to and application is a anterior wrap of 270 degrees, sorry. Um Sometimes our reps fail and we have to do redo fund applications. However, they become more difficult as there are already more adhesions and then esophageal gastric associations just to show what this is all about. It's uh um technique described by very few surgeons in the world has been done only a very few times but is a rescue procedure if the other ones don't work. Um and is often done or is more commonly done in micro uh stomachs and in neurologically impaired Children, what it all involves is the stomach. It's um disconnected from the esophagus. Uh uh pil plasty is done and then um distal Jegen as, as a wire procedure pulled up to the esophagus with this one connected further down. Again. Surprisingly, these Children do very well with very little reflux um and tend to do much better nutritionally after the operation is done. But again, it's done in very few patients in very few centers in the world. One was described in Cape Town for a micro stomach which is where this picture is coming from. Then the neurologically impaired Children are our most common patients that we do. Um N and fund applications for. Thank you generally have more problems with gastroesophageal reflux disease because they already have problems with initiating swallowing. They have motility disorders of their gut, which includes the esophagus with the hyper um increased time and decreased time. They often have very poor positioning. They often have recurrent seizures which increases the risk or the times of um refluxing and aspiration. They already have uh even further decreased, lower esophageal sphincter tone, which makes them even more prone for reflux. And because of motility disorders have delayed gastric emptying. The the dilemma with these Children is that they are largest group that need fund applications, but they also are highest risk for complications. So we really need to look after these Children. Well, before, before op in op and POSTOP. So pre op, we always need to do a chest X ray and chest physio as far as possible to check for aspiration, sort out any uh pneumonia, get physio to clear them, their secretions in our center. Recent for the last few months, we've had them admitted for 23 weeks pre-op which gives us time for physio to teach mom to teach positioning to clear secretions. Um It also gives us time to nutritionally rehab them as they often come with feeding problems can't swallow properly. So they're very nutritionally behind and we often place tubes for them first to feed them up better and then they tolerate the operation much better. Very important. We should get seizures controlled as good as possible. Sometimes not as uh completely eliminated. The reason this needs to be done properly is these Children um have increased risk procedures POSTOP and we've had a few who ended up in status epilepticus where we couldn't abort them at all and eventually demised. Uh And as I said earlier, if the uh consider a fund application at the time of the child is referred for a gastrostomy because they're not eating properly, then intra op we, other than the usual things we do for all our patients, for the neurologically impaired one, we have to look after their positioning and pressure points much more carefully than the normal Children as the they often have contractures already and scoliosis that need added padding or different positioning and POSTOP. They are much higher risk for pneumonia. They can develop uncontrolled seizures, as I mentioned earlier. Um A lot of ours have done very well POSTOP if we looked after them very well, pre-op and got them better before we took them to theater complications. For these procedures. Not necessarily just for the neurologically impaired, but for all Children intraop obviously, hemorrhage, bowel perforation is um colon and is very close up there. Pneumothorax as we are working up by the diaphragm and injury to the vagus nerve surgical site. Infection is one of those that we can see POSTOP empyema again because we work up by the diaphragm esophageal strictures. What it looks like, esophageal strictures if the wrap is too tight and then pneumonia, longer term complications are hiatal hernias if the wrap moves back up, breakdown of the wrap, um slipped wrap Gla Gas Bloat syndrome, which is described more in adults, but they struggle to belch with the phone application, which might mean it's a bit too tight. Um, they have an inability to vomit because we don't want any reflux that to come up. They might develop a slow eating habit as it takes time for food to pass through the lower esophageal sphincter where the wrap was done and some have described dumping syndrome. Um, risk factors to develop these complications were studied also by the Cape Town Red Cross team. Surprisingly, to me, they found that neurological impairment itself was not a risk factor for complications. However, these ones listed here is what they found um, cardiac problems. The younger the patients were Children under three, had a higher risk of complications in Children who were older than 37 months, Children with esophageal atresia, esophageal strictures and Children who need gastrostomies, which often does include their neurologically impaired Children. These Children also need to be followed up carefully to see, to look for complications and to see whether our operation has worked well for them or um initially, parents and then later on, Children need to be educated on what was done and what can be expected um that they need to have soft diet for the first two weeks and can feel very bloated. But these symptoms often improve after two weeks, they can start solid feeds, um which is not that much of a problem for a neurologically impaired Children and then on repeat visits, we want to take good history on whether they have developed any dysphagia or bloating or whether there's recurrent symptoms of gastroesophageal reflux disease. If there's any concerns, we need to investigate them for complications with um contrast studies and endoscopy before starting any further medical treatment or suggest any further surgical treatment. And once we know what's wrong, we sort them out from there. So, in conclusion, reflux is a very common problem, especially in infants. They usually outgrow their problem. Though the majority of them don't need any investigations and not much more treatment other than lifestyle management. And it's important to know who are the ones that do need surgical intervention and to work them up well and look after them well, so that they can do well because those are the ones to complicate the easiest. Thank you very much, Helga. That, that was, that was a very good presentation. Uh, Professor, er, will comment but it is a big vast topic and, um, we asked you to compress it in 25 to 30 minutes and you have finished exactly. I in 30 minutes. So, so that is very good. Um, I think at this stage I will invite Professor Ficker to, uh, to give his opinion, advice, starting from advice about presentation but then, uh, opinion and, and advice in general about reflux fundation. Uh, so Martin, please. Yeah, thank you very much. Thank you. It was a very nice presentation. Can I ask the presenter if you uh do a, an, a lap medicine in a child? And you use a very needle for access and the patient's BP dro drop. What can be the causes when you, when you start the procedure? Do you know all the very good? Yeah. OK. Go ahead, Elga. Ok. Um But uh the increased pressure from the pneumoperitoneum can mean decreased um venous return, therefore, decreased cardiac output, which can be the reason for the um lower BP as you expand the intraabdominal cavity, you also um decrease the or cause pressure onto the pericardia or yeah, pericardium, which can um irritate the heart and cause hypotension or you have injured something that you shouldn't have and your child is bleeding, I guess, but the blood big blood vessels are rather posterior and you shouldn't go that far deep. The thing is if you, if you do the access procedure with a various needle, there's always the possibility to, to injure the big uh blood vessels, the or, or the IIAC vessels. So uh when you look at the scope, OK, you, you place your port, you look at the scope and you don't see any blood. What next? You don't see any blood in the abdomen. I'll tell you what I just, there's a lot of maybe there are a lot of other questions, but the thing is uh a auto injury or one of those injuries or a retroperitoneal injury. So you won't, sometimes you won't see blood in the abdomen. It will be retroperitoneal in that area. So if you just look with the problem, the other thing, that's the, these days, very much on the cards are uh co2 embolization. When you use a various needle, Steve Rosenberg uh described 10 or 15 cases where uh after placement of the, of the, the V needle and C two in infusion, then the BP dropped uh and so on. And that is because of CO2 uh embolization. And obviously, if you, if you start the thing, if you start with your C two, you know, first empty your, your uh the pipes and everything of normal air because air is a much more dangerous thing. You, you need much less uh air to cause that problem. And uh can I just ask you the last question at the end of the procedure? If your BP drop, drop and the and your saturation drop, what is the, what can be the problem that you've caused a pneumothorax? Yeah, that's right. So not, not even if you, if you have enter the, the peri uh pleural cavity, sometimes the CO2 just seeps through. And the other thing is there are uh congenital pleuroperitoneal canals or openings that can also uh cause this problem. So it can happen in any laparoscopic uh operation that C two goes to there. And cause a capax. Thank you very much. Uh I just wanna say about the esophagogastric dissociation. Uh I saw on that picture there was a poroplastic but because that uh then you later said there was a micro stomach because normally you don't do a poroplastic. And the other thing is most people, I think there's no place to do it as a primary procedure. Uh Most people will do it after three or so failed uh in this medication uh especially in neurologically impaired Children. Uh Then you can maybe do that. Uh other, other option is then maybe a feeding u nosy. And what also sometimes help is to if you do a gastrostomy is to put a gastrostomy on, on the laser curvature of the stomach that helps a lot to prevent a reflux if reflux is your problem. Yeah. Um I'm just going to mention two things and then maybe somebody can, can ask questions. The one is if you have a baby with, if you have a baby with reflux, uh then uh the problem in more than 90% of cases is not a problem with the valve. It's a neurologically dis dis motility problem or uh pharynx esophagus motility problem that causes the problem. So it's almost never necessary to, to give uh to give a PPI in small babies. So, uh what we do in those Children, we uh you can do a contrast study just to exclude other reasons for uh other reasons for reflux. And then we scope most of these babies, uh, in previous years, we didn't do much, uh, gastroscopy. But these days, for me, that's one of the most important, uh, special investigations to do gastroscopy, to look out, to look for, uh, ahi esophagitis to exclude other pathology. There are many other things that can, can also, uh, influence the esophagus. And then what, what also is important. If you look in the textbook, you will see that there are about 20 K things that can influence your stomach as well. Well, so you can have uh autoimmune problems and all those things affecting the stomach. So if you, if you do biopsies, you must do biopsies of the esophagus, at least distal esophagus, middle and proximal esophagus. One or two biopsies and biopsies of the stomach and duodenal biopsies. So that child, uh, that we're talking about, we will, we'll, we will do a gastroscopy on that child. And then we will uh, uh look for, uh, you know, allergies. So we might give the, the patient, uh protein protein or uh uh so uh uh feeds otherwise protein feeds and things like that to exclude, exclude uh allergies, milk allergy. But for the rest, uh yeah, we put in a nasogastric tube and then see if we can feed the child. Uh, in most of the cases, the problem is in the stomach and you can feed the child for a, with a nasogastric tube. Uh that problem, uh motility problem usually goes away by four or five months. So you can give the child a, a place, a nasogastric tube, you can change the feet, you know, make smaller feet or even continuous feet. And the child can even go home with a nasogastric tube in, in smaller babies, less than 33 kg. It's tell them that the tube falls out, but for the rest, uh sometimes the parents are willing to place it. Otherwise they must just come back for us to place the nasogastric tube. And some people, some doctors even give Erythromycin because it's a alternative problem and they will uh or sometimes even give Botox to see if that doesn't improve the problem and still not give PPS. Uh if, if the gastrostomy tube, uh nasogastric tube doesn't help. You can give her, you can place a, a nasoduodenal tube. Uh But that sort of tube, you can't send the patient um because they can't replace it. It's difficult to replace that tube. So you can keep the, the patient in hospital for a, for extended period of time. But uh if, if it does not improve uh with a a nasoduodenal tube, uh the patient can't go home with that tube. So maybe that, that patient eventually might need a this infant application. Um Yeah, what I want to say about the PPI S uh in Children. It's, it's a, it's a, a problem with the infections you can get pneumonia, you can get clostridium, you can get me, uh, because of PPIs. So it's not a thing that you want to give it if it's not necessary. Uh, then if we can talk about the, the operation, um, I think, you know, previous previously before the whole thing wasn't worked out 100% there was an increased incidence of recurrence. But uh these days, if you look at the, uh, the large series of Steven Rothenberg and all those people, then there is no increase of, uh, of complications or recurrence of reflux if you do the laparoscopic procedure. So I think that, that, uh, laparoscopic method is, is the gold standard these days. So you have to, uh, offer that to the patient. It's the same as a gallbladder. There's actually no place these days for open cholecystectomy. So you must give the patient the option of, if you can't do, uh, uh, laparoscopic surgery, you must give him the option of laparoscopic surgery. And then there, there are quite a few tricks with the, with the, uh, I just wanna mention a few things that, that maybe will help. Uh, the one is minimal dissection. So we don't, uh, you know, we go around the esophagus, we immobilize it a little bit, but we don't go between the ray, uh, and we don't damage the front esophageal ligament. And then not everybody agree. But I think most agree that the, we, you must take the Vasa Brea because then you can make a better Nissan. You can also better uh you know, identify the left cruise if you take the Vasa Brea. And uh yeah, the other thing is that uh some people uh you can make the, the Nissan, the, the, the RP too low. You must make it on top of the left gastric artery. But sometimes even if you do it there, the gap is, is too low. So your proximal stitch, the upper stitch, we do uh put it to the stomach. We catch the uh esophagus and we uh catch the, the right cruiser eye up and then we, we catch the the other side of the stomach to fixate that uh rat eye up. So it's not too low. And uh then there's also that you mustn't pull in too much. Uh You must, mustn't pull uh too much fundus under the esophagus. And if you do the wrap, you mustn't, you must take the, on the right side. The area that you use for the wrap is the area where you take, you've taken the vasa brea and on the other side, you just take the edge there. You don't take too much uh stomach to have a lot of uh stomach anti and it's only two centimeter wrap. Usually it's two or three stitches. Um Yeah, that's, that's basically the story. So, uh and then I also want to say in adults, we don't uh if you see a adult, an older adult patient, a patient that's 10 years old with reflux, then the first thing you do is to, to put him on a PPI for four weeks. If he impro improves after four weeks, you can put him on eight weeks and after three months, you can stop it. And if he continues to have problem, then you can do some investigations. But that's also like adults, adults, we don't go and scope directly or do special investigations. You try and see what they do on, on p um So anybody that wants to ask a question is welcome. Yes, Martin. Thank you very much. I think those are, are uh you have emphasized uh what is given in the books, most of the books, but you have also uh given uh the practical um uh hints and advice. Um I have a, a few questions and I will start with my questions and then we will go one after the other consultants. Uh So, uh I just have, have, uh uh have a few comments uh for HGA, um uh HLGA and others. We can do milk scan in East London. It can be done in the nuclear medicine department. Uh I in the East Coast radiology. But for the reasons which you said uh to us, we don't do it often. And uh secondly, uh we haven't done a gastroesophageal disconnection since you arrived here. We had done a couple, uh a while ago and uh Professor Lazarus in his private practice because he does so many fundal applications in general and majority of them are neurologically impaired Children as exactly as Professor Van Niekerk said after two or at the most three, failed attempts. I mean, you do it recurs it causes problems, you do again, it causes problems again. Then I know for sure in the last two or three years he has done at least three or even more gastroesophageal disconnections. So that just some information for you, Martin. Um, uh, one more, um, just a comment. Um, those patients said infants, uh, you are able to send home with nasogastric tube. Are they majority of, most of them, are they your private patients coming from, uh, good socioeconomic background because we, we never send, uh, or dare to send our patients home with nasogastric tube. Yeah. Yeah, all of them are private patients. Oh, yeah. So I think, yeah, that makes sense. Um, and then I must say in 1st, 1st, world countries, that's, that's the norm to send the patient home with a naso gastric tube actually. Yes. So they have good transport but usually the, the parents doesn't have a problem to, to place it. Can I just comment, can I just comment on the M SC? I do. Don't do milk scans at all. Yes. If you, if you go to the American or European Society of Gastroenterologists, both of them say it's a useless investigation. There's no standardization. Uh The, the, what you see on the M scan doesn't correlate with the uh with your impedance study, you know, that sort of thing. So we have it but II never do it. Uh because it, it uh I don't believe in it. And then I just wanna say about the esopha GST disci for the right patient. It is a good operation. I just wanna say the uh immediate uh complications uh is 17% and one of the complications is leakage of that anastomosis between and that's a serious problem. So patients can die from that and the long term complications are also 70% 17%. So you have a 35% chance to have some sort of uh problem after that operation, but I don't want to, to shoot it down that uh uh you know that it doesn't, it's not necessary in some patients. It is necessary, but now it, it's got serious, can have serious complications. No, no. Thank you, Martin. Thank you for clarifying about both things. The M scan and the gastroesophageal disconnection. Um If I may ask you, uh, what investigations do you currently do? I will give you two different scenario. One is, uh, let's say, um, a, a six month old baby or a nine month old infant with uh gastroesophageal reflux which is not improving with medical uh supervised medical management. Uh So w would you do any investigation and what would it be? Yeah. What I will do a contrast study, right. Uh, it doesn't help me that much but because there's only a 4% gain with as, as, as you said on the presentation. Hm. And, uh, uh, the problem is if you, uh, if you, when you place a patient like this for long term on pp, then the gastroscopy is, isn't that accurate because you've treated already the yes, esophagitis with, with me medication. So uh I'm I'm still doing in that patient. I will still go and do a gastroscopy. Yes. And do a good gastroscopy and also take everywhere biopsies. And uh if I want to, if I want to operate the patient, yes, then uh then uh I will definitely do impedance study or a PH study. Yes. Uh just to have something on paper because what do you have history of the parents? The, the child can't give any history. Maybe you've kept the patient in the hospital and see the vomiting situation. But I want something on paper because for medical legal reasons. So all my patients, I do impedance study, ph impedance study just to have something on paper. Um II know these days there is a sort of uh turn away from, from PH studies and impedance studies. Most people don't think it's that important, uh you know, in their decision making. But uh for me, it's still ii used to, I have the facility. So II do everything, what I, which I can before I operate a job. Uh, no, no, thank you for clarifying that. Also, I fully agree with you that it is better to have, um, uh, a, a proof for, of some sort. Uh, because, uh, for, for later use and again, just information to Helga, Helga, we do not have access you correctly said. But 24 ph study can be done in private hospital and unfort, I mean, we can get, uh, a, a authorization and can get it done. So that's, that's, that's that, um, Martin, the next question will be, do you ever do open fundal application now? And if yes, when, uh, are you? Yeah, the only, the only thing I can think, look, I also want to say one of the important things is, uh, for the laparoscopic thing is to accept the pain and everything. The pain is the big factor. The other thing is this child can eat immediately. He doesn't have a nasogastric tube and have s for five days lying there in the hospital the next day he is up and about, he's eating, you know, that sort of thing. So there's a vast difference. If you compare the two patients the next day, you could immediately see which one had an open operation and which one, not. Mm. And uh, the other thing is maybe after I've, uh, or, uh, if somebody else has done two or three or it was very difficult, the laparoscopic one the previous time. So sometimes if it's a redo, I will do it openly, especially if I want to lengthen the esophagus. If it was a tough repair. And I think that's the problem, the child, the thing reoccurs, then I will do the open operation. But that's, that's almost, uh, the only situation if the medical aids don't want to pay for the nurse and I refuse to do it. Like if they don't want to pay for the laparoscopic, I will never do it as a primary procedure. Thank you. And I remember a couple of years ago uh uh you, you flew down here and it was one of Doctor Lazarus's patient. Uh an obese adolescent boy who already I think had two sort of failed uh fund applications. And between the two of you, both of you did your best but because of lack of access, you had to convert to open operation. I remember that. Um Yeah, the thing is that is an ideal one that actually before the time, it also depends the previous time. If, if it was already difficult. Correct. Yes, you would have expected. There is a problem. But sometimes if you immediately go in with a, with a scope, you place the, the, the, the scope port and you see it's one mass of, you can't see where the intestines are. You know, it's just one mass of adhesions, then maybe it's better not to, to operate uh uh to go on laparoscopy because you can give it a try. But you will quickly see what the situation is if you can continue or not. Yes. I think you did the same in that patient. I remember in about 15 minutes. Both of you decided. No, it's futile. And uh then, then you opened the procedure. Uh My last question I got, I can remember the open one was also difficult when they called you for help. Yes. Yes. No, no, I was there and I was, I was the retractor. So II distinctly remember that. No, no. Thank you. My last but one question to you is do you always do a this in front of application? If you are asked to do a feeding gastrostomy in a neurologically impaired child? That's a very good question. And firstly, if it's a neurologically impaired child, II do a few investigations, I do. Uh, that's one of the, if I don't know if there's a reflux or not, the child needs probably needs a gastrostomy, but we're not sure about the, then I will make sure I try to make sure with a special investigations if there is a reflux or not. So in them, I do gastroscopy, I do impedance study the whole thing to see if this child has reflux. Um because it can sometimes if, if you do unnecessary medicine, that child can have more problems, post surgery, uh, you know, if he, if he doesn't need because you have a tight wrap there and the child now struggled more with, with saliva and things like that. So I think most people these days agree, don't do it if it's not necessary. And what I also want to say in that patient, I also do a contrast study to see if there's aspiration from the pharynx uh area into the lungs and how the swallowing is just to give us an indication what is going on there. Um Yeah, so that's, that's the story. And if I only do a gastrostomy, I do it on the greater curvature quite low down so that it doesn't interfere with uh with the uh a in the future. I have such a patient that I'm going to do on Monday with the gastrostomy tube was very high placed. So, yeah, it's impossible. So I have to take down that gastrostomy. Now, the whole thing, yeah, which is not nice and then, you know, a place, a new, a new GG tube as well. Yes. Yeah. And the other thing that they say say is that uh uh I don't know how it works, but they say you can use blended food through the gastrostomy tube after the age of one year. So that uh apparently also help uh with reflux that it's not a problem in the future. It helps a little bit with that. And, and also with the ring, apparently that might help. Uh, yeah, the, the, the contrast study is also to look at the emptying of the stomach and, and things like that. So, I do all the investigations. The other thing that, that is sometimes difficult is if you have neurologically impaired Children, small ones and you have to do, uh, you can't, you know, they probably have reflux but you can't prove it, but they definitely need a gastrostomy tube. So if you have a three or 4 kg child already with gastro 72 uh, like, listen, Martin, sorry, there, there is some problem with your phone. Hello, Martin. Ok. Hello Martin. Uh, and will, but so I, I make sure if at that stage. Yeah, so much. Mhm. Mm. What? Yeah. Three. Mhm. And no. Ok. So. Oh, ok. I ot uh, and the, I guess, um, esophagitis and cheat on those lists and it's, um, some centers recommend the PPIs because as you're saying of that improved esophagitis because of the PP. So some people recommend you stop it for a short period of time, do your scope and reassess and see from there. Um, I think what's also important as well. Um, why I think prof, um, chits who, um, decided to ask you every single question, which I was going to ask, um, what's important is to, um, see, especially the operative, operative side because what happens is that we have situations where it's a four or five month old with failure to thrive with recurrent um, chest infections who um at that point in time has a gap where we can actually try to do an uh any form of r but we find that um from the anesthetic point of view, it might not be safe. Um, because they also worried that the increased pneumoperitoneum might cause splinting might affect um, respiration intra op or ventilation intra op. So, um to try and actually eliminate that factor, we have a tendency of kind of being uh coerced if that's a nice word of saying it into doing more open uh fundation. But this is more limited in the very, the in, in the infantile um group, not the more big guy kids. Um with my very limited experience, um particularly with um esopha GST Association. Um because I've had the pleasure of actually assisting uh prophylax in private in some of these cases. Um find that with the kids that um we've done the outcome has been surprisingly good because um the, the whole notion of you connecting the esophagus straight into the. So there's rapid, clear and so there's no halt, there's no risk per se of, of aspiration there. But obviously, we have to do with other factors such as dumping, which can be a problem. Um So I II like the, the procedure um definitely it can be used but with a very, very select um patient neurologically impaired with um failed sence, I think those um are the ideal ones. Um The only question uh pro that, that I can maybe address to you is when we, when you have a child post uh esophageal atresia um that you repaired and um has uh strictures which we dilate. Um what's the next step? Are we worried that the stricture is purely from the anastomosis that we did or the element of reflux, which we kind of expect post um repair. And so which one would you think just dilate and treat it as a, as an uh anastomotic stricture or would we consider that it's a reflux stricture that we will dilate initially, then do a rep. Um Basically, how soon do you think we, it's ideal to do the rep? And should we try to do it via the abdominal route or thoracoscopically if feasible? Yeah, the thing is uh 50 50% of uh esophagus atresia patients have um pathological reflux. But uh most of them from my side, you can treat medically and, and they improve. Uh if sometimes you have a patient with a di difficult anastomosis with you within the first month or so, you see that there's a problem and he needs a few dilatations. I won't be uh that worried. But if it doesn't improve or a late presentation presentation of a stricture, then I will with the dilatation, II will do a, a biopsy. We do the scope and do a biopsy. I sometimes do a contrast study to see what the situation is and I can, we can sometimes do impedance studies. So II investigate the child uh for those that doesn't, doesn't improve or, or if it's a sort of uh stricture that I thought is not going to happen with that child and we struggle with the stricture. Ok. Um Thank, thanks for that. Yeah. Um Since yes, please, doctor question and I make a comment. Uh First one is about the contrast study in all our neurologically impaired patients at CP hospital. We would do a very by the speech therapist who's present there and recorded properly and not just only in the radiology department and ordinary swallow and, and see how the stomach empties. We do a, a proper video swallow and you've got that on record and that also sometimes will tell us if there's reflux or not. But I mean, that's not the most important reason. The reason is that we can then the speech therapist can clearly evaluate exactly the swallowing process and we've got it on video so you can look at it afterwards. So I think that that works well for us and then just to touch on what you've just said. Now, when you started your discussion is I think if it's clearly a surgical patient, then we can do all these discussions that we're doing now. But the, the the issue is, as you've said, what about this, between three and six months old child that referred to you by a, um, yeah, it seems that this, she's often that, you know how to evaluate this regurgitation. Is this reflux or is it reflux disease? Um, because you're gonna see some of those patients in the pediatric surgery department, they don't come saying this is a clear cut one for, for you just to evaluate when to do the surgery. I think that's quite important. Yeah, I can also say that, uh, I want to come back to that contrast study. Uh I use it a contrast study also in neurologically impaired Children. If they uh you know, as a previous uh gastrostomy and we're not sure about the, the reflux. Then I put a lot of contrast like uh uh milk feet through the gastrostomy tube and, and look for reflux. Uh that for me is an important uh test. And also if I do re redo surgery, I want to see exactly some of them as translocation of transmigration of the stomach. I want exactly to see how much stomach there is in the chest. What exactly is going on there? I want to look at the emptying of the stomach and uh we all have seen patients that had a MRI and end up with a infant implication. So I do all those tests because of medical legal things as well, which is right at this, at this moment. All right. Thanks Bob. Um, maybe you can give the other consultants opportunity to speak um, your shoulder. Give you five cents to add. Ok. Uh, hi, everyone here. Um, thanks. Hello and thanks doctor for joining us. Um, I just wanted to ask about, I more specifically to how her, if she came across the transient, lower, lower esophageal sphincter relaxations. Hello. Have you already asked her about that? II actually did and II, II got out. Yeah. So I didn't, oh, no, I didn't ask her about that. Now, I don't wanna make, give her unnecessary headache. Um, but maybe she can kind of, uh, tell us what she thinks about it. It, it clarifies why the child gets reflux and why the, the infants get reflux. So maybe she can just comment on it quickly. The only part I've come across is that the infants have a lower tone of the lower esophageal sphincter. So it relaxes more frequently and for longer than it does in older Children and adults and therefore they are high risk for frequently. Yeah, it's actually that they have longer periods of that relaxation. Um, but the tone is actually normal. So it's still under investigation, but it's good to know why they're having the reflux. And what's the, what's the mechanism behind? Can I comment on that? Um Yeah, I think, you know, normally if you swallow within two seconds, you have relaxation of that lowest sphincter. So, uh, if there's in coordination of that or if there are more of these relaxations without swallowing, not associated with swallowing, uh, uh, if that is increased then, uh, well, it's an important factor. That's why they use also this van as a treatment because that has an effect on, on those, uh, uh, you know, uh, relaxations. And also it was showed that if the child lies on his right side, you get more of those relaxation periods. That's why some of the conservative management people say you must lift the head up and the child must lie on his left side. That also helps. Yeah. Ok. Yeah. Ok. Yeah. Should I go ahead? Um More questions for me? Yeah. Yeah. And then I didn't get uh very clearly the indications for surgery. I think that needs to be cleared up. Well, because the, the one that I was listening for, but I didn't hear was the acute life threatening episodes and the apneas in the infant because that for me would be one of the emergency indications if you think it's reflux that's causing it. I did mention not the apnea one, but I did mention the acute lifethreatening events. Ok. Sorry, I'm trying to get there again. No, that that's fine. Um II maybe I missed it. But yeah, that's one of the, the, the uh you know, hard indications and then the complications obviously of reflux. So the recurrent esophagitis barrett's and um strictures. Yes, we have a patient recently who has stricture that we will do it for. So I just didn't hear that. Exactly. But, uh, that's fine. I know. Um, it's probably just an omission. Uh, can I ask you something? Yeah. Can I ask you first? II think apnea and, uh, apparent life threatening events, there might be association but it's not proven if you look at all these things, if you are asking if you ask the pediatric gastroenterologist, they will say it's not the case. I, I've operated one or two with the para life threating events for me. II don't even, I don't see that patients. Uh I don't see that many of those patients. And I'm not, maybe there is an association but it's not a very strong one and it's not the, it's not worked out. I think it's probably more our neurologically impaired neonates and infants that we get that, but we do do them for that and it does, I think it does help in those cases. Can I, can I, can I, uh, ask, tell the registrars there's a textbook esophageal and gastric disorders in infancy and childhood from August? So that's an excellent textbook you can read about apnea. You can read uh uh uh about life threating events, the whole thing. There's a chapter on every, every one of those aspects. OK. Yeah. Uh Then can I ask you about technical stuff about the operation? Just because I'm still starting out? So I'm still refining my technique. So I just wanted to ask, how do you retract the liver? Do you use a Hanson retractor. No, I II said uh I use a snake retractor. It's one that you, that you can bend. There are two sizes. So I put, I place a port on the lateral side of the abdomen and then put the, the retractor under the left lobe of the liver. Some, some people only use a, a grasper and just grab the diaphragm under the liver. And uh there's also a, a thing that uh if you do single incision there fund applications. We've, we've done a few, then the liver is a problem and they use glue to stick the left lobe of the liver to the anterior abdominal wall. And then they, they work like that. So glue was used in those people that just the idea to use glue, glue received a very, a big price for that order, you know, so that the other thing, yeah. The other thing I want to tell you, I haven't seen a thing. But uh if you have a small baby, some people, I also don't actually see why it's necessary to close the in a small baby. It's normal academy. You haven't worked there. Why bother there and put in a few stitches. So I, I've done it, I've done it a few times and I was actually stupid not to, to publish it, but there's now a paper out about that. And I also firmly believe in that it's not necessary every time to work there. Stay out of the, but especially in small babies, I think it, I think it's not necessary. Mm. Mm. Yeah. So, II normally don't, but when there's obviously AAA hiatus hernia, which I had recently, then I had to close it. But normally I wouldn't, I do a minimal dissection and I would, um, that area, uh, the other thing was so the snake retractor, we'll, we'll have a, uh, we'll try to look for that. It's, it's often the rate limiting factor in my operation is getting the liver out of the way. But we are working on getting a Nathanson retractor. I uh what I did is I, I've used one na na uh Retractor. I've showed it to somebody and they made me a dozen of them in different sizes. So II have a dozen of those, but I actually don't use them. I II prefer the snake retractor. So you can actually make your own ones. No, if, if I can just uh uh Colin got uh a set of uh we call it Amada Retractor because Amada is the suburb where our hospital is uh located. And uh he has donated one set to us and um uh we uh our planning to procure the frame uh so that we can attach those uh retractors. But I think it will be a good idea to get details of the snake retractor from prof Martin. And uh we can always look at that. We don't have to go with the Amada Retractor. So that's, that's a nice option we can look at. OK, go ahead. Any other questions for me, for that? And then the other 11 quick ques one last question, quick question is if you always take down the short gastric vessels. Um Yeah, II do that. Uh But I don't have a problem with the people that don't do it. Uh As I said, I think I can do a, a more floppy medicine. I can uh do a better medicine without uh rotation, abnormal rotation uh of the of the, of the stomach. And I see the left cruise much better if I clear it and, and has taken the, you know, Vasa brea away. Ok. Ok. Thank you very much. The other thing is I also still use dilators Boies to do my, except for the small ones, the small babies. I sometimes I don't do it and for the neurologically impaired Children, I also don't use it because if they can't swallow, I actually want a more tight uh and with more stitches. Yeah, I don't want about uh uh a floppiness and I actually don't want a floppiness. Yeah. Yeah. And do you do? Sorry one last question. Do you always do a listen, you don't do any of the other apps? No. So either floppy or a tightness and Yeah. OK. OK. No, th thank you. So, thank you very much. Thank you. Um uh I would like uh uh uh sorry, I got interrupted in between my internet just deep down, but I'm glad Doctor Macha took over. Uh So Martin, we have heard from Doctor Mataya, uh doctor who is the other consultant and I would like to then invite uh Doctor MAOA who is our third consultant. And all three of them are quite skilled in doing laparoscopic fundal blockage. So Doctor Moola, please make your comments as questions. Uh Sorry. OK, go ahead. Uh Can you hear me now? Yes. Yes. Yeah. OK. Now I was just saying um good evening everyone. Thanks Paul for the um the input and also sharing your knowledge. I don't have any questions or comments cause uh I think everyone else has covered most of the things that I had wanted to ask off. Thank you. OK. Thank you. Thank you. Uh Just 11 comment to Doctor Murray Kirsten's uh information. Uh Yes, Marie, we also uh involve a speech therapist. So, in fact, when uh a fund of uh uh when uh uh swallow contrast swallow is being done in the radiology department, one of our doctors and a speech therapist, we both accompany the patient there. Unfortunately, uh my knowledge we don't have a video facility, but so maybe I need to ask the radiology department. And um so we, we also do the same understand the swallowing mechanism of these Children, especially ones with um with uh neurological impairment. Uh Martin, I've got one more question for you. Um Do you see more complications in neurologically impaired Children? Um Yeah, the only complication I see is that uh the, I think there is a higher than uh incidence of recurrence. Yes, that's all for the rest. There is not a problem. Not at all. Um Can I also say the uh the sealing devices that we use? Uh we started off with ligasure. I still like the ligasure. If it's a small baby, we can use the stores. Abe it's a uh that's a possibility that you can use. And then these days of the just right sealer uh is also available. It's quite expensive but it's a, a wonderful instrument for the dissection for, for working in the, in the uh for doing and such. But I think that's a very, very nice thing. It's a three millimeter sealer from just right. Um And uh it works wonderful. Uh Sorry, Martin, I didn't catch exactly what is the stars instrument? You said it's a, it's a articulating uh the sector bipolar that you get from stores. It's not that nice because you can only work on the tip, but uh the just right instrument is fantastic. So, is it just expensive? Is it the name of the company? Yeah, it's that company of Steven Rothenberg. But they in, in the country now, if you want information I can send you, we've, we've tried out, they also have a five millimeter stapler, but quite expensive. 24,000 rand for, for that stapler. Oh, ok. But I sometimes I sometimes use it for the imperforated anus patients to, to, you know, just the, the fistula through. Very nice. Yes. Yes. You know what I'm going to do. If, if anybody wants to go and see a nice, a nice listen, just go on the internet, uh, uh, type there. Steven Rosenberg. Just the right Nissen. He's got a, he's got a few other operations that's on the internet. But if you want to see a nice ni on a small baby, have a look there. Wonderful. Thank you, Martin. You know what I'm going to do, Martin, I'm going to uh share your contact details with doctor Manic and she will contact you about uh all these uh instruments and things which I'm hearing for the first time and you can advise her and then we can, we can uh get their quotations and all those things and um one more question sort of comment uh isn't higher failure rate inversely proportional to the experience of the surgeon. So as, as you go, um as you do more and more of them, um uh don't, doesn't your uh uh feel your rate go down? Hello? Hello? Yeah, there's definitely a factor but anybody can do a N so, but I think you need uh at least 15 previously, they said 30 s but I think these days they talk about 1515 lessons. Yes, but not on your own with somebody that knows how to do the operation. Yes. Yes. No, that's so, it's not that difficult. Yes. Yes. No, thank you, Martin. Uh HGA. You did the presentation? So do you have 111 comment, please, please, please go ahead. If you, if you do the, if you do the dissection of the esophagus, never go on the outside of the right cruise, especially in the superior part. I've, I've once injured one of those hepatic veins there and that's not a nice, uh, complication to have. So stay away on the cruise. Yes. And that's a story. Especially superior. You won't believe how close those things are to the, to the esophagus. Yes. I think the smaller the baby, the closer these things are to the esophagus and to the crura. Now, Martin, uh, if I can just summarize, I think you have highlighted adequate investigations and proper documentation of investigations and everything before, uh, making a decision, uh, to do a fundoplication because if, uh, I'm correct to say the word, it's an unphysiological operation and especially in neurologically impaired Children. And, uh, you have time and again, emphasized the, the minimal dissection. So don't overdo it. Do what is absolutely minimum. Um, and, and I think you can, you can summarize, you can say, uh, say the last word. Hello. Hello. Yeah, you're off, but I can't hear you again. Sorry. Sorry. Now I think you uh you summarize, you emphasized it very well adequate investigations and documentations before doing an in in front of medication, especially neurologically impaired Children and at the time of operation, minimal dissection. So, so uh anything else you want to to add on? Um I think then we can end the meeting. Yeah. No, I'm happy with everything. Thank you. Thank you very much. I maybe I must just caution everybody that uh for medical reasons, medical legal reasons, make sure that you have the right indication for the operation because it's sort of a, a child that's not uh sick that you, it's just got reflux, you know. So if you have a major complication or a death is totally unacceptable and the first thing they investigate is why did you do the operation? Mm Really? That's important. Yeah, I'm now busy with the court case. It's the same situation. Yeah. Yeah. Yeah. I think most of us uh would have heard and read about this tragic case. Uh So I think that's really the final, final uh uh very, very practical and useful advice. So I think if there are no more questions, uh I would really uh profusely thank professor for again, uh Doctor Mary Kin, all our consultants, Doctor Macha man, um Majola and uh especially Doctor Nahas for uh doing a nice presentation and inviting uh such a nice discussion and teaching and comments. So, thank you everyone, Martin. All the best hope to see you. Thank you for inviting me. I, I've enjoyed it a lot and, uh, in the future, if you need me for something, I'm more than willing to, to, to join you. No, we will call you. Uh, we will call you for anything and everything. Laparoscopic. Yeah, exactly. Ok. Thank you, everyone. Me have a nice evening. Thank you. Bye bye bye. Bye bye. Nice meeting you. Listen to you. Bye-bye. Bye. All right. Thank you. Bye-bye.