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Uh Knox. Can you see my first light? Yes, I can. Ok. Um Greetings from East London in South Africa. Good afternoon. Good evening. Good morning. Wherever you are joining from. I know we have few attendees right now, but I'm sure people will join as the meeting progresses. And I am really very pleased, actually honored to welcome my dear friend, Doctor Aja. I call him Raju Saudi who is a pediatric surgeon in the central Indian city of Nagpur, who has kindly uh agreed to share his knowledge and expertise and this really special area where he has developed special interest in pediatric surgery. Uh Do Saudi did his general surgery training in Nagpur and pediatric surgery from the northwestern city of Chandigarh and this institute especially is very well known for high-quality training. He has also been a fellow of minimal access surgeon society of India and something very close to my heart. Like what we have established a not for profit organization here in East London. The one for the Children Trust. Doctor Saudi has been a director of Friends of Children Foundation, which is an NGO for kids with surgical problems. And in the past 22 years. He and his colleagues have performed more than 2000 surgeries free of charge for Children, not only from India, but also from other countries. Um Doctor Saudi has a big really see which one can be proud of, but just a few points to highlight that. He has been an invited guest speaker at International Congresses on esophagus all over the world. He has conducted live operative demonstrations and has been the lead faculty for esophageal replacement in Asia including India and Middle East. He is now in the process of developing the department of pediatric surgery and the training program in nur he has 18 published papers and three art chapters in the books and this case, Sogana gold medal is really a prestigious gold medal of the Indian Association of Pediatric Surgeons. And he was awarded that in 2018 for his excellence in esophageal surgery. He's a regular faculty at the endoscopic Congresses and workshops and uh that uh he also is a faculty on the bronchoscopy and thoracoscopic training at the Institute of minimal access Surgery training in Mumbai. And we are aware of this institute because doctor Siksha has given a couple of lectures. Uh and he uh the director of this institute, he doctor s finds time from his busy schedule. Um and he loves cricket like any Indian does, but also football, gardening and reading. So Raju welcome. We I'll stop sharing and we will listen to your talk that um thank you, Doctor me for that very kind uh interaction and your generosity. Uh I am also at the same time extremely privileged to speak in front of uh the or in your academic departmental academic meeting, uh which uh the recordings of which uh I have been quite regularly following listening and learning from it. So initially, in fact, uh I am in a state of bit of uh rapid uh if I can live up to the reputation of past speakers and the way it is conducted, uh Nevertheless, I'll try my level best in the next few minutes. Uh If I can begin with the the title of my Heart, uh it's a novel enhanced recovery of the surgery protocol of esophageal replacement in Children. Now, um uh I am sitting here from uh uh central India City called nur which is exactly a zero milestone area of geographical area of India. So also the city is known for its very unique flavored uh oranges also named as Orange City of India. And we are surrounded by uh tigers, unlike lions that people have there. So it is also referred as uh tiger capital of India uh and showing these slides because uh ii work in this hospital, but this is very important uh milestone uh I in our uh uh development of this uh he center esophagus and airway treatment center where this five years old uh boy for the first time on his birthday could eat his birthday cake. And uh it really uh sort of given us the impetus to start the center. Uh And this is uh these are our uh various team members which are involved and they keep on helping me um incessantly and whatever I like to develop uh uh about the center. So with this background of my city, I come to, there are really not very relevant disclosure, but uh this manuscript on this topic has been in the process of uh peer review for the publication. And I presented already based on the progress in the month of October uh uh at Cincinnati Children's Hospital and in our National Labor uh uh of Indian Association of pediatric Surgeons, uh whenever we think of esophageal replacement, it it's a very, very major undertaking in Children and to be also even in adults. But the difference is in adults, you got several protocols, several meta analysis, systemic uh systematic reviews and various uh uh guidelines because she volume of carcinoma and esophagus for which it is done. It is very high. However, in Children, there is an unmet uh sort of a need to have really very focused and goal directed protocol to minimize uh or to mitigate all these uh complications which are there. And with this, I thought if I and make a template to reduce surgical morbidity, uh a and create some uh uh friendly protocol which is resource conscious everywhere. Um to handle multiple problems by multiprofessional and multi disciplinary team. Um These, these lines are very a I said uh uh to a topic uh of replacement, we are the students of problems and they cross across the borders. Uh and, and the matter of discipline. So we need to have a, a very collaborative type of approach uh to things. So what we are talking about, uh what is it about the era concept? Basically uh is a multimodal and multiprofessional uh approach to uh improve surgical outcomes uh in a surgical care in the postoperative period. It is based on very scientific evidence based guidelines and also medical techniques. It is very well structured and has strong implementation strategies and it takes feedback, audit and feedback so that it keeps on evolving and keeps on helping and keeps on improving uh uh the condition of patient. It basically focuses on nutrition, immobilization, limiting the opioid analgesics. And more than that uh holistic inclusion of patient, it is an adolescent or caregiver in the health care and also health care team members. And they look so look into the satisfaction of these members. But uh origins of us have their, they are rooted actually in the concern that patient outcomes can be improved through the modulation of physiologic response to the space. And this is what uh exactly I have tried to uh sort of inculcate in the protocol which uh I have designed, which I'm going to share with you uh uh in next few minutes. Uh Let me take you to the mm uh history how uh the pioneering people uh contributed to this era. Uh The first name comes uh from which everybody takes inspiration and the uh groundbreaking work uh The gentleman has done, he's hen K uh a Danish surgeon uh in 19 nineties, they uh he reported colorectal surgery and his discharge day was second or third which no could believe. And they thought probably it's a Danish way of getting it. Nobody uh thought of game. It's a, it's a, it's a esoteric type of concept. But he focused uh that time uh on a fast track. Uh and his background was of uh pain and epidural anesthesia and the real uh contribution, a landmark contribution given by his uh multimodal approach to recovery. Um taking this further, these two gentlemen, uh a linguist uh from Stockholm Sweden, um and uh Fon uh from Edinburgh in 2001 again for colorectal surgery, they showed how this has really changed after taking inspiration from the gentleman. So instead of giving uh important only to time, like they say, let's have a recovery in a very holistic uh uh uh fashion and therefore enhanced recovery after surgery concept has really got uh the birth and subsequently, it has really spread like a wildfire and many specialities uh have taken it out uh e except pediatric surgery, which I'll come to it later. Uh This approach, basically inculcate several pathways. Uh And these are 21 pathways uh which are, in fact, I have taken this figure from the book which was published in a book in 2015. Uh many of such are applicable to our patients, Children. Uh Many are not applicable uh which I uh highlight subsequently, then it involves all the processes, preoperative, intraoperative and postoperative along the entire journey of surgical care. And this is how uh it is followed surgeon and nursing and everyone other uh specialty people are also uh involved into it, no doubt. Uh uh This has led to the formation of uh adult era society in 2010 with a very noble concept of improving perioperative care worldwide on a pro bono basis. But if you look at here, the pediatric concept, we have not yet uh sort of embraced uh a and it took 2018 to have this first world on pediatric society uh in uh uh on 30th in Virginia. And from here, they discussed several issues. What are the challenges of your pediatric uh patients? Uh And uh which I would like to share with you and the first and the foremost is change of culture of our practice. We are taught traditionally to do surgeon will be managing a surgical case. So we have to basically we are in our traditional silos and we have to change it uh to a collaborative care and they are several reasons uh why our resistant hinges um o on several things, uh why we are reluctant to accept this collaborative care. But it's slowly opening up again. Our age group is from neonates to adolescent. We entire state of infrastructure training, nothing stuff equipment, which will change from here to adolescent. Also, we are we are very much aware of unique physiology of a newborn uh and its surgical uh requirements and its postoperative care. And when they evolve into a older child or adolescent, what is required more is very nuanced communication and deci decision making and involving them also along with the parent in the decision making. So therefore, there is increased responsibility of parents or caregiver uh outside the care um uh of the hospital premises. And also there is a lot of variability uh among the various anomalies. So these are various challenges with this background of basic uh errors. Uh II will begin with my uh talk or e as far as esophageal replacement is concerned. Um We do generally uh esophageal uh replacement for benign condition, esophageal atresia and corrosive injury. So therefore, being benign, they have got several decades of life ahead. And therefore, naturally, parents have got high expectations from surgeon and the team uh if we minimize uh say complications and recover them smoothly, it will pay away for a very wellbeing of a child in the future. So what is the big difference we do regularly, various other big surgeries like liver resection, reconstructive surgeries, maybe. But what is so different about esophagus, esophagus. It's got a very unique anatomy. It runs from neck, uh uh chest uh and into abdomen and in close relations with very vital structures and also sharing embryological origin with the airwaves and many other uh situations. And it will i it involves extensive dissection in the abdominal cavity and thoracic uh cavity. What it results into setting it uh of a very uh severe systemic inflammatory response. And many times it gets de dysregulated and results for hyperinflation and resulting into uh complications. Therefore, it requires a very distinct and demanding care. And uh when we think of as a, we try to sort of uh refine ourselves uh to prevent all complications early recovering. But what has been realized in the recent past is that these two individuals or their teams and their contributions during surgery and the postoperative period have a tremendous impact. In fact, much more than the surgical impact uh in the postoperative recovery. Therefore, uh this is extremely important with this knowledge available because there are no pediatric sick protocols. Most of them are dependent on the personal preferences, how people are trained, what are the uh uh sources available with you and which part of the geography you are working in? So there is no such protocol and therefore, I thought to uh uh sort of uh uh test the hypothesis which I thought of uh uh uh preparing about the goal directed uh resource conscious protocol uh which is a sort of uh recovery uh type or like uh and propose that it's better because it reduces the length of the stay in the hospital by mitigating challenging issues associated with esophageal replacement in the early postoperative period. So what these challenges we have got positive fluid balance. It is amazing how much blood body fluids are shifted from one compartment to the other and how it leads to several problems. Then we have a cardiac and pleuropulmonary complications like hypertension, arrhythmias, pleural collections, s like picture, et cetera. Then we have another major issue of depending upon the type of procedure you are doing. Infection is another major pillar in major part of the world. Of course, with all these complications in hand, mortality is not very far away. Uh Then another question is uh when we can start child feeding early uh uh for early as well as uh through the stoma, if it is there and logistically, if you consider all these state, the cost of care which is extremely important, particularly in a resource uh uh conditions if you have to deliver this care, uh it is extremely important. So these are very challenging issues. So to work on these challenging issues, what uh uh type of uh study we are set, uh I'll just go through it. Um uh It is a retrospective case study comparing two protocols. If you see on the level of evidence, probably it will be somewhere between two and three or at the most three. Uh But the impact practically it has given uh is uh or what has been mentioned according to the lab. Uh it is a single surgeon who has operated at multiple surgical care facility. More than over two decades. It in involved neonatal group, admittedly, neonates are very large in number because of the selection criteria. ARCA have done only six in that total number of cases are 100 and 16 out of 126 you saw Major Resia 95 and corrosive in 221. Um This is uh the inclusion criteria just to maintain homogeneity uh and having uh uh sort of a, a similar type of candu uh uh and the passage et cetera stomach has a candu as a uh gastric uh pull up or any tubs, uh posterior media, the primary cervical anastomosis of Eric and, and therefore, uh these uh situations are, are taken out. So only 10 patients are excluded. There have used a couple of colons, then the root is different. The conditions are rare. Now, uh gastric pull up are 100 and three and reverse gastric tube I used to do in the earlier part, uh uh 30. Uh I use both open and minimal access surgery, minimal access surgery started in the last 67 years. I've done uh 14 cases again. Uh uh I have a very selective criteria for that. And uh there are two groups uh in which I have compared them uh a conventional or traditional protocol, which is usually a broad based, as I told, it's a personal uh based personal preferences, however, person where he trained uh and uh resources available in the area where you're working and so on. Whereas in us or early uh or announce recovery after the surgery, I have about 62 cases. So, you know, 100 and 16 cases where this is a goal directed, very focused protocol and it is extremely resource conscious as you will see, uh a as it come uh uh across. So now, uh I come to the protocol proper, uh it is divided into three phases and as there are multiple challenges, the approach is also multimodal. Uh and it involves several specialties, several people and several team members, they all have to be on the same page and understand about it. So therefore, a lot of educational and nursing activity keeps on going as far as these things are concerned. Now, in the preoperative phase in the preparation, um uh we have given up uh traditional fasting beyond midnight, the clear are given 1 to 2 hours prior to the uh surgery, either to the stoma or wherever, you know, it's uh strictures. Uh It is available uh for orally no in bowel preparation. Uh uh like uh any more um major uh bowel wash or preparation or even stomach preparation, only laxative and the next day morning supposed that sufficient enough investigation. Apart from routine contrast, enhanced ct, particularly auto pulmonary um, vessels, the most common associated anomaly, which I have seen is right, uh, aberrant, right sub artery, which will exactly come in our way of, uh, posted dissection. And there are many other situations as a result of previous surgery, uh, related issues which we can discuss in the discussion. Another, not a very old concern. Um Not again, uh a very uh uh uh earnestly followed uh in our uh earlier part of the study, uh what we call it as a a prehabilitation which involves focuses on nutrition. Uh uh Here, the nutrition specialist is involved in taking the care and he very nice line which I like think globally and act locally. So the the concept of nutrition taken all over the world from all over the world. But what is suitable, what is locally grown, whatever cheaper? What about our digestive system tolerate uh if provided to these Children? Uh and the special and nutritional uh person is uh involved into this. Again, physical optimization of such patients, many of them would not be uh in a good uh um condition of development. So uh uh Optim them uh in a a proper way with a good albumin level and protein level before surgery, education is a very, very important part. So for example, she feeding uh uh if it is not given they develop aversion in the POSTOP period and then various other methods of taking care in the postoperative position, timing, how they should change their lifestyle, at least for a few years. Uh to tackle this all. Go into education of a child or education of the parents. And it's a demanding psychological support you will never realize unless you go into the depth of inquiring. Uh not, not by a casual thing because we, I don't have time. Therefore, a psychologist is also very important and constant support. Uh These families, they require more than a child. Uh the parents they require particularly in the area. Then the premedication uh since I use broncho uh uh as a sort of a part of protocol to have a nice dry airway uh and avoid stimulation. Uh use that now coming to the intraoperative uh uh phase of the protocol, uh it will be shared by anesthetic and surgeons alike, but anesthetic also plays a very, very important role, very major monitoring and blood gasses. Uh central venous and arterial lines are established contrary to the standard er protocol where most of the time, I think it has been ad advocated for open surgeries. They, they suggest about regional block and uh no epidural somehow. II personally did not find uh much ril which we again can be discussed uh in the discussion part. So we, we don't uh uh we have given up, in fact, after initial uh implementation. Now IV fluids is a very, very important and the most crucial part uh uh of this uh improper failure on the part of anesthesiologist, there is no allowance given for the fasting period. What is important is a very restricted type of rate that is 23 MS per kg per hour. And the expected urine output is 0.5 to one per kg per hour. Then if there is hypertension and if there is no volume loss, there is no need for any bolus which is usually a major reaction on the part of the leg just to rush in the fluid. Whenever they notice hypertension, hypertension could be because of simple mechanical presence of your finger or hand media and you take a everything returns to normal. But if hypertension passes and there is still no major loss while you lost. Um uh I know probes and vasopressors are uh integrated uh uh into the uh care making rather than uh giving the fluid poly. Uh we tried to extubate patient or table as far as possible. And more than 40% of our patients, we did not require any ventilator care. Uh because uh very uh strict adherence to this uh uh protocol uh investigation in the form of blood gasses, ate electrolytes, uh uh at the beginning of surgery, middle of the surgery and the end of surgery. So we have noted there is practically no change with the restricted fluid regimen for you. Uh And before shifting to PICU, we take xrays uh in the back you sometimes accidental opening uh of the pleura or uh noting of a proper placement of the central line tubes, et cetera and checked in this. And then the patient is the P you now intraop surgeon. Well, uh here, we would like to uh have a little more uh as because we are always similar to all our defines. So, bronchoscopy is a part and partial of my uh procedure here. Uh I personally myself do both depending upon the need, uh flexible as well as bronchoscopy, but depending upon the system people. Uh Well, there are uh I heard there are triple scopy which are done by pulmonologist, ent surgeon and a pediatric surgeon. Uh So it depends upon uh it, it gives you really, really very good important information. Um double fistula associated laryngo clip, hypoblastic cartilages, vial bone or diverticula and many more uh things. Uh you, you get uh we, I have two videos and photographs. Again, time, we can go ahead and, and that the dese sequence which I said uh neck dissection is very important because recurrent laryngeal nerve with that brace, thoracic duct. There also is that brace uh that it requires daily uh dissection and it matters uh if the patient has been operated for the go somewhere else. Uh Many people do it on the right side. Some people do uh a lateral, somebody do an cat, all are not things somebody would do on the later wall and all these complications can really uh reserve into major situations. Therefore, dissection sequence which I prefer uh is cervical of media uh followed by abdominal uh and then followed by uh lower posterium. They fly remaining uh on the anterior surface uh of the vertebral body without much deviation. So how much is the space we call it? Uh the particularly at esophageal and at the um thoracic in leg, uh there should not be any compression, there should not be development of any edema. And when you pass A can, it should really glide nicely without several attempts. So it should go uh uh uh a very uh nice way. So in a yeah, in, in a case of gastric pull up, uh uh after everything uh done on the abdominal side, that is gastrostomy is with the um uh GP or P, then you come to the front surface, stretch it and then measure the weight of the stomach by the suggest finger. And accordingly you make uh the tunnel that will be the weight, the osmosis should be very meticulous, it should be planned that way and it should be executed in the same way. It will be two layer, uh it will be primary, it is end to end. It's a fundic type of uh anastomosis uh in the uh neck region and I create a nipple valve, this nipple valve, uh uh is of uh two importance. One, it will prevent barret's uh because it acts as a valve there. And another important thing is that aspiration results are practically gone uh after creating this valve. So this is a very bold statement I'm making. Uh we can discuss uh uh this uh issue. I have demonstrated it by um uh G man of uh uh gastroscope. Uh how the valve remains there and how it is helpful. Uh We use uh 40 migraine uh or poly a suture, pyloroplasty pylos, a simple safety valve. It has to be there. And stomach anchoring I feel is another very important area where you can evas media and this can be prevented. So any big occur. So, posterior stomach wall is fixed with the prevertebral facia in the neck just below uh the anastomosis, uh 23 centimeters below uh usually three stitches are required and the stomach sits there and doesn't drag on the anastomosis. So, probably anastomosis related complications are also minimized and the severe complication is also minimal. Therefore, I have highlighted it here. Uh very minimal usage your brain or if they are placed like there is no radiation, brain cervical, very, very sparingly depending upon how bad is the dissection and depending upon the previous omy intercostal drainage tube only. So as if there is any pneumothorax, which really worries us if it is a small one, it usually settles down. Uh So very minimal usage of drains and tubes. Now in the postoperative period, uh a very goal uh directed and a focus uh management. The importance of uh diuretic, the loop diuretic uh a low dose given on a continuous basis for 48 hours. It is amazing to see how body compartment we shift from one place to another. And it is urine output, which is there despite all restrictions intraoperatively and the postoperative period. So, diuretic takes care of that. Um steroid has got uh uh uh many people say controversial role. Uh but what is important that beyond doubt that it is no good blood systemic inflammatory response. But in particular, this situation where uh going to talk about is stabilization of glycocalix which is present on the endothelial wall. So the capillary leak is prevented, therefore, interstitial edema in the various organs, vital organs uh which are um sort of uh vulnerable to inflammatory response when the dissection in the mediastinum, particularly heart and lungs and airways. Uh So addition of steroid to that hydrocortisone uh uh helps uh but I must admit that uh whether only steroid are sweet or when you can, can uh connect multiple dots. Uh of uh what I'm talking about steroid, which helps uh at least uh remain to be seen antilog because bronchia is very common as you dissect behind the wall uh and handle that a uh to uh to reduce uh those secretions and minimal uh uh sec uh secretion aspiration in the POSTOP period and the walls are used when to get care if needed. Usually, we are requiring less than 24 hours. With this strategy, IV fluids again, very restricted 50 to 60% of the maintenance fluid. Mind you, it gives unbelievable amount of urine output with this uh strategy uh being used there. Um analgesia and sedation again, they will be painfree uh situation by analgesic by using simple paracetamol or diclofenac suppositories, uh depending upon age and weight of the child and keeping them just sedated by using very, very lowest dose of fentaNYL and midazolam combination are only alone. So that is arousable but not very deeply sedated. So this is how our target is and accordingly, we, we I described it in great details, even dosages also um that we can see later internal feeding. We starts uh on the third postoperative day. The investigations we do uh are blood gasses, lactate is electrolyte uh once after 8 to 16 hours. If everything is OK, these investigations are not repeated subsequently. The contrast. So is uh uh done somewhere between 8 to 11, postoperative day to see the test. Uh the integrity of anastomosis, any diabetic line or any containing uh uh position of the stomach. Is there any twist there? And so many other things uh and baseline antibiotics, ampicilina me for seven days there, uh duration and stepping off of antibiotic depends upon subsequently, the complications they are arising or not. So with this, um yeah, I would come to our, this would like to share our outcomes uh length of the stay in the hospital, which is one of the important part of the er uh uh protocols. Uh If you see number of ventilator days in ICU ICU stay without ventilator, uh then uh I got uh uh uh uh uh board room or floor, whatever you want to call uh uh there in the hospital and total length of stay in the hospital. This significant difference according to P values uh and this has dramatically come down from 23 days, uh 21 days to 13 or 11 days. Nowadays, I'm sending you on eighth or nine a day. Also now coming to the cardiopulmonary complication, if you see there is drastic fall in the cardiac complication with a significant P uh P value. Uh Same about pulmonary complications which are very important uh morbid situation which created postoperative period. Then if you see anastomotic leak has dramatically gone along with the anastomotic technique. And uh of course, fluid strategies also. And uh postoperative early feeding days, which has come down from 56 a day to uh third day and overall complication, infection rate has also dramatically gone down and the mortality probably there is no significance here because number of patients are not very much to compare them. Uh So pr may not be or statical s statistical significance may not be showing there but there is definitely lower trend. Uh You can see uh for 9.3% to 1.8%. So with this, I come to the conclusion of my talk uh and would like to uh emphasize that the protocol I like novel protocol which we have made has got a transformative potential. Uh It has been practiced at several centers in India and they are positively giving me feedbacks uh about uh how their practice has changed. Uh And how uh useful they are finding about it. Uh It is extremely useful because it has reduced the total length of uh state, the hospital which is a, a very important principle, reduced early complications because of uh those strategies. And logically, it will reduce the cost of care and more important. It is very resource conscious and it is possible uh uh to uh adapt or integrate uh into one system. Uh This slide has got a meaning uh which I would like to show you before I say you. Thank you. Uh You can see turbulence over here. This turbulence can come from multiple, several complications. Are there? Therefore, this multinodal uh model multiprofessional uh approach which is required, we have got several ways of helping you out to see this uh rainbow effect of what you are doing. Uh And this cal effect in the postoperative period. Otherwise, surveillance can really put you into difficulty with this. I rest my case. Uh Thank you. Very much for your patience, listening, uh and all questions and discussions are very much welcome. Thank you very much. Uh Raju. Thank you really, very much for an excellent talk and, and uh this is uh a difficult surgery, complicated surgery and, and results are not really great everywhere. And um uh what uh uh as I said to you when I looked at your presentation, I learned a lot today. I've got uh to understand your philosophy much better and really kudos to you and your team for a fantastic achievement. And thank you for the nice presentation. There are a couple of uh comments uh mainly from professor uh Chaudhury who is a senior pediatric surgeon in, in Pakistan. And I think he, he has applauded your presentation, but he also has, I think a couple of uh comments. Uh His first question was, how long do you keep the child nil by mouth? Can you answer that question? II, uh There are two situations here when we talk about this, like, uh usually these Children will have gastrostomy or feeling gastrostomy or omy. So I give almost up to one hour before uh, clear fees. Clear. Feels by that. I mean, uh, uh uh a little on the hypo smaller type of uh feeds. Uh, if you use a rate as a concept which has been dropped off in the um, uh, juices without color or older Children. If they want tea or coffee, that is without milk and of course water. So 1 to 2 hours, most of the time we give up to one hour. So therefore very uh minimal premate uh or sedation, which are required to keep child quiet, particularly those we are doing around one year of each. Ok. Raju, thank you. Um I saw Doctor Derek Harrison had joined, but I don't think he is in the meeting, Derek, are you around or not around? I don't think he's in the meeting. I also saw Doctor Selo Maa, one of our consultants he was in but uh maybe problem of internet. So I only see Doctor Nkole Masha who is our youngest consultant. She has trained at Baragwanath Hospital in Johannesburg. So, Knox any, any comments, any questions to Doctor Saudi? Thank you for the wonderful presentation. Um It was very enlightening. Um Doctor S um Thank you for pointing out the, the very important um integral involvement of the anesthetic team. Um preoperatively, I just wanted to ask um because this kid uh most of the time they are used to coming to theater so frequently they have anxiety um especially since they come in for esophageal dilatation, et cetera. Um Do, do you see a role of um the anesthetic team giving preoperative um analgesia or Anzio Anxiolytics? Firstly, and then the second question that I also had was um for, for patients that maybe you initially approached um thoracoscopically or laparoscopically and had to convert to open um, do, do the guidelines change? Um, for instance, maybe the number of days of antibiotics that you give, um, or the number of days that you keep them. NP, et cetera. Thank you, um, for that, uh, uh, difficulty in listening here. But if I can get up the question you asked regarding, uh, how to settle anxious child, uh, am I right? Yes. Yes. Yes. Uh, when you give, uh, uh, uh, feeds either already or through gastrostomy, most of these babies or, or toddlers, uh, they remain quiet. They are with their family in the preoperative zone, uh, until they are taken with the per line and the anesthesiologist shift them to operation room. Uh, he would be giving them, uh, their usual admin and uh olam, uh, and they put to sleep and then they are shifted, uh, majority of the time we sort of, uh, take like this. But having said that every time it will not be the same group, um, Children up to 10 kg of weight, try to fast ploy works wonderful. Uh, if it is given 45 minutes to one hour before, uh, and older Children generally, uh, uh, the IV line, which is there, they are within the date of preoperative zone. Um, uh, uh intravenous, um, pine or, uh Midazolam is given to them. Uh, a, a are you happy with them or you have some, you need some more clarification. No, I'm happy doctor S Yeah. Secondly, I think you have asked about minimal access surgery, uh, uh, in esophageal replacement. MRI. Yes. And then, uh, do the results change if you have to convert from minimal access to open, uh, surgery? Ok. Uh, minimal access surgery. Mm. Uh, as, uh, uh, traditionally thought, uh, to be, uh, yes, excess is minimum but the invasion is almost similar like what you do by your open surgery. Uh, that is number one. Number two, it is extremely useful in a uh corrosive strictures or very badly damaged esophagus due to multiple dilatation, anastomatic leak, et cetera for type C type of uh uh uh esophageal resia. There I use uh to start with uh after initial cervical um mobilization uh that also helps in coming into the thoracic inlet, the area which is really very critical even in the uh thos scopic magnification magnification, you, you are a bit in a um sort of uh worry if you are going to damage any structure. So while doing cervical dese, I already entered into the posterior mediastinum and then turning patient uh in the modified uh bone position and then beautifully you dissect entire esopha under vision, whatever you go from uh you go to the normal side first, uh take it on a umbilical tape or any other thing and keep on dissecting close to the wall of the esophagus. This way you will not in, in your trachea or any important nerve or thoracica. So the difficulty most oftenly experienced is uh in the region of say T two or T three to T five level where by the patient of TUS and, and the area is very critical in, in that zone. Suppose after uh good patients, if it is not possible to separate uh is a fal wall that scarred wall from the wall. Uh I just open it up. Uh They all uh mucosa, burn it there, whatever mucosal is uh and keep that whatever bits of uh tissue of uh scar tissue of the esophagus on the wall of the esophagus rather than hero trying to take and then repair the pain. So that is one, then you uh make child in the supine position and then do uh like uh any other thing. So this works very well. Uh For, as I told, Thoracoscopic approach along with the laparoscopy or thoracoscopy with open sort of a hybrid approach um uh in a esophageal like crazy long gap. But if you are doing for a long gap, esophageal like crazy without fistula, uh you can very easily enter entirely by laparoscopy without doing uh thoracoscopic A. So you can enter that. But what I find not really very useful in uh isolated esophageal aia uh uh is that uh your tactile uh feel uh of, of that track uh which is gone um with the poor heptic uh perception or the feedback of endoscopic instruments. Uh It takes quite a bit of time to go into very diligently, uh decide. Thirdly the uh the exact assessment uh into the mediastinum. All these things are depending upon experience. Also, you can uh try but it doesn't add much to the uh pain in a situation because you will require P four to introduce your uh stapler. Uh You will require gastroenteral uh junction when the lower end ST to close, either you give a small incision and take it out and close. If you are doing pyy pyloroplasty x-ray pads, closure on gastrostomy. If you do it entirely by minimal access surgery by and while it will take much more time as compared to um the uh open quick uh uh approach. And of course, at the end, you have to uh have a safety net in the form of um uh omy. So all these four procedures, they themselves are uh quite a major. Each one has got potential to keep your patient. It develops complications. So I use it very sparingly whenever needed. Another third situation where there is corrosive injury where there is not much of ear fibrosis entirely. Again, transvaal laparoscopic approach can be used. Uh uh and I use that uh that works well. Uh definitely uh the stress response, uh there is a difference but again, it depends upon case to case, not all cases will have that uh difference anyhow, the entire media is dissected. So it is not at all minimally in that way. Uh So these are my views uh as far as minimal access surgery is concerned. Now, your question is that when you require to change over to uh from uh minimal access to open, does it have more complications? Uh It depends upon how you look at it and how you do it? And what is that your, for your experience and how your team uh deals with it, particularly in a specialized at that particular moment. Otherwise, I have not found out, I have done, I have gone through all these difficulties, uh not found out so very selected situation, I select them for a minimal approach or hybrid approach. Uh Something like that. Uh That is how I would like to answer your question. Thank you. Um And, and Knox, I think this is so very important, honest, practical advice that don't car get carried away with uh the overzealous use of minimal access. What do Saudi has clearly indicated that the excess may be minimal with the stress may be maximal because you are spending hours together trying to mobilize the stomach and do thoracoscopic dissection. So I think Raju that is very, very important practical advice to use uh those minimal access uh techniques and facilities in selected cases when you really have the required skills. And uh are you also one thing I wanted to highlight is uh how you ha or, or, or sort of conquer how you highlighted the important role of uh anesthetist which Knox mentioned, but also of the intensivist. And I distinctly remember many years ago, um, it was probably around 2010, 2011. We had done an esophageal replacement for a child with uh esophageal atresia, esophageal fistula, multiple anastomotic breakdowns. And un unfortunately, we had to give up her esophagus. We did a fantastic operation but we did not have uh a separate dedicated uh intensivist in the pediatric ICU. And our doctors were not able to sit by the side of the patient for the 1st 48 to 72 hours because our on call doctor was running around, running around in the hospital. Look uh going to the emergency unit, going to the theater, going to the ward, doing appendicectomy. And that's, that's not uh appropriate. If you do a surgery like esophageal replacement, there has to be a doctor who is probably like within meters uh who is responsible for the postoperative care. And um what I decided that uh unless we have the entire system, which is capable of handling such complicated cases, we really should not be doing these operations. I have full faith in the surgical abilities of my junior colleagues. They are skilled surgeons, they can do these operations nicely skillfully. But if there is nobody who is able to look after this child, this child in the POSTOP period, then I don't think we have a right to do these operations. So thank you for that. I think there is, there is uh there are two different questions. One is from doctor uh I Arua, I'm sure. I think he's from Nigeria and he's asking, do you do feeding jejunostomy as a routine or? And what do you think about transotic tube feeding POSTOP? Uh It's a very nice question. I do it as a routine because uh again, um what probably you highlighted about uh doctor, uh the issues, somewhat similar issues uh are also faced by us here. So what I feel having digenos is a very, very important safety val. Yeah. Uh you have got several resource related issues. Even if TPN is available, there are several issues associated with it. It's complications associated with it. Stomach tube uh is possible. Uh We can start and give it suppose that tube comes out accidentally or uh if the stomach gets distended and results into compression over the airway, then you have to withhold it, then you, if there is no, I mean, you don't have anything in your hand but to rely on uh low calorie IV fluids. Um if program is uh not really very well geared up with it, uh Having said that these systems are well developed in one system uh in one's uh area of uh practice, uh I think one can get away with it, you know. So, but still, uh even if I were given that opportunity, I'm quite convinced that there is need for uh this type of uh um some safety one because you will discharge patients. Say after two weeks home, you may have given PP you may have given everything. But what about at home? Supposed child developed abortion? Now what to do the child require again, readmission. These readmissions can be reduced by using the geno study. But a caveat here is not free of complications time. You can feel a patient also, you will have to re explore patient also. So if you do it properly, teach parents properly how to take care of it, I feel it's it's extremely important. I think very well. Said Raju, I will fully support your view that the safety valve of agnosy cannot be overemphasized. And I see our registrars are here. Some would be registered the, the one registrars are also here. So I think and the young uh consultant surgeons were here, you will never fail with a ginos toomy. If you don't have a ginos toomy. And as doctor Raju said, patient develops complications, you may be in trouble. Uh Raju, there is a nice question from Doctor Mansoor NASA. Uh He says it's an amazing talk. What is the selection criteria for minimal invasive versus open procedure? Do you have any specific selection criteria? Yeah, I in my situation in my setting, as I told you, uh if it's a corrosive injury, I utilize generally hybrid approach. Uh after cervical decision, do thcy mobilize esophagus then flip the patient again in the SUPP position and then do uh a sort of open approach which I finish very, very short time uh after doing almost 100 and 31 cases over now. So, um that way I save a lot of time with a lot of um uh sort of uh uh reassurance to myself that what I'm doing uh is well within time, well within the accepted uh factors which uh the care which is available on me. So that is one area. So you can call it as a hybrid type of thoracoscopy like this, then uh thoracoscopy as well as uh um uh uh laparoscopy. Uh a very limited situation time particularly I do, I don't take out the entire esophagus, particularly uh pan esophageal stenosis or lower one third of the where the anastomosis comes into the media stum there. I do uh thoracoscopy, laparoscopy, uh first laparoscopy then come to thoracoscopy and do uh anastomosis there. But that is not the point of talk today. Then another situation is uh uh uh corrosive injury uh which is not really very badly uh fibrosing around which you judge on uh CT scan and overall course of the patient and assessment on endoscopy and who had undergone several uh um dilatation program in that situation, entirely transhiatal because this patient do not have gastrostomy or esophagostomy in the first place. So they just came because there are several types of dilation done and still they are not doing Well, so these are the situations uh where you can go trans highly with the laparoscope and do a wonderful job. Uh This, I took a cue from my own experience because I never required to do open thorax whenever I used to do open with the uh um corrosive injury. Whereas if you see a very great and very important series from grade or state of 192 cases, 47% of the cases for which they have done thy to mobilize the esophagus. That was quite contrary to my experience. Uh So that gave me a good uh sort of a platform going for uh laparoscopic transit type of work in that situation. Ve ve very nice Raju. There is a which I would like to dug in since you about minimal surgery. Uh where I use again, uh a sort of hybrid approach is that if someone has already done, uh it's a major replacement, I have got almost 12 or 13 in such cases where it has failed for some or other reason, either recurrent f or loss of graft or uh substernal thing is not working where I go to my position for substernal fail, either tube or gastric, pull up, immobilize them uh from uh with the thoracoscopy that gives beautiful picture under nice uh vision magnification. You preserve all vascularity, you deliver that tube or stomach again into the abdomen and reroute it through the posterior radiation. So you don't really disturb that tube, a person who has done a good job, but for some reason, it has not attracted and what it done. So that is another area where I use uh type of approach uh mobilization of substernal candy. I think Rager, you also uh highlighted uh the lack of, of uh feel during uh uh a laparoscopic or thoracoscopy surgery. And uh uh and and in older days when these minimal invasive techniques were not available, the surgeons basically did the dissection with fingers and it was a advantageous in Children because they were, they were small in structure and surgeons who especially had long fingers could meet the fingers from top and the bottom. There's one more uh question from doctor I Arua is uh in a patient with cervical esophagostomy. Do you always resect the distal esophagus during gastric pull up? Can you answer that for you? Uh So uh uh it means there is negative eos which is hard due to some reason which is there in the post. Uh You're asking about that. II think so, I think he's asking probably not of the caustic injury but uh but in the patient, uh I don't know, maybe failed anastomosis, there is some remnant of the esophagus and the child has an esophagostomy. Will you go and make attempt to remove that remnant of the esophagus in the chest? No, I uh that is very clear whether it is corrosive injury or any other abundant I always resect it out. I don't leave it behind. The reason they, these patients, they come, people have left it behind and I have taken it out. Uh There is dramatic improvement in the retrosternal pain. Uh uh iron deficiency anemia. Some of them came with uh uh low grade fever with a mass in the chest as a result of mucocele which is getting infected there. Um This side, some of a large one which has resulted into a duplication is sort of a formation and compression over the. So such type of uh sort of variations you see with the remnant is a bigger one. Of course. Uh people talk of malignancy though it is very, very uh low on the card, but you can't rule out uh if the child has to live for say 6070 years with a scar is inside and recurrently visiting a hospital for pain. Uh hypo uh microcytic anemia. Um This um uh abscesses uh formation of um esophageal cyst, et cetera. Uh I it is really very, very troublesome. Uh Thank you, Raj. I think that answers that question. I'll just take a couple of comments if, if uh these people want to comment, I see Doctor Nilesh to who is a pediatric surgeon, I think he's in AAD Gujarat Nilesh. Any comments, any questions for Doctor Saudi? No sir. I think all the, I mean general questions uh uh questions which uh uh and under uh postgraduate or a trainee would ask, uh, I think all questions have been covered and very well answered by the, uh, the s sir. So, uh, uh there's no any uh further question from my side. It was a very well presentation, uh, called Almost Everything. Uh, each and every aspect of the topic. And, uh, I hope, uh, there won't be any question after uh, uh having this presentation. Thank you, sir. Thank you so much for this lovely presentation. Uh I fully agree with you. I think uh uh tho those surgeons who have assisted uh or or been involved in in esophageal replacement surgery, there are lots of uh you know, the key technical points which uh Doctor Saudi has indicated. So somebody like Knox doctor who was a young consultant, I think it will be worth uh viewing this presentation uh especially if we are planning to do an esophageal replacement surgery in our unit. I think I just ask, we have two of our registers here, Doctor Ne Neha and Doctor HGA. Any one of you wants to ask any question uh to Doctor Saudi Neha, you can go first. I have no questions, but it was quite enlightening to actually see those revised protocols because I think we did have recently a talk about it. So it's quite nice to see that we should try even not just on just what he was speaking about his o replacement, but also in most of our patients. Yeah. You. You're right now. Yeah, I think we should call. It's nice to see. Yeah. Yeah, I agree. Um, we need to consider Ira's principles in each and every operation we do in our department. Yeah, I fully agree with you. Now, uh, HLGA, any questions for doctor S, um, it was a very good talk. Thank you very much. I learned a lot. Um, I have no questions. Thanks prov, I think Raju please give your take home message. I think it was wonderful talk. Uh excellent discussion. Very good questions. So we will close with your closing remarks, your take home message. Well, um it, it, it's definitely a, a very major undertaking and you have to be prepared uh for this surgery. Uh Do your homework. Well, uh prepare your patient. Well, um, you have your plan A plan B, let's have discussion a day before. Uh If you're not very familiar with the anesthesiologist or intensivist wherever you go, uh, they all should be on the same page, nursing staff, uh resident doctors, patients, family, very, very important part because there are lots of uncertainties which will keep on occuring whatever way you approach. So they are also gonna be included and told about educated about uh all these plans. Um Secondly, you have to be uh uh uh while taking such type of uh in the, um if you have someone uh who has got experience around with you, it's better to take uh him or her with you uh to start with or at least to have some to supervise you. Uh I think because at any potential time, II tell you in abdomen, uh there are four or five procedures right from opening the abdomen or regions inside, which can result into a major blood loss and other things, sometimes if it is you are unaware of this uh jejunostomy which can create have uh pyloroplasty, pyloromyotomy can create the mi mucosal opening are inadequately done. Um Is a ARIC junction, similar situation can occur. If you do a bulky thing, it will come in your way at the fundus. Um gastrostomy, I have seen a child dying as a result of gastrostomy, stoma not closed properly and leaking from there. Me and so these are each and every area can really, really result into very hard complications. So you have to be very meticulous. You have to plan it properly and go third important area within the mediastinum. Uh Even if you want to learn this from your senior, don't diver too much because prolongation or the type of dissection you do in the mediastinum duration of the exam is an independent risk factor for all complications. Because this response uh to this uh will be different if you multiple people keep on putting hand to the mediastinum in order to learn. So you have to be very quick uh and uh very efficient and very sort of pragmatic uh as far as learning is concerned uh in this situation, another important area if you are planning eom beat on the left side, II don't know most of the time I see it on the right side. Um, left side is a natural line of the esophagus in the neck. It will remain in a straight line when you do uh esopha fundic or whichever um do anastomosis. If any dilatation is required, it will be uh uh relatively easy. Um Secondly, thoracic duct injury talked about, but I haven't seen it at all really in all these years during our uh so many cases. Uh So I think that is again a type of a thing. If you take uh proper care, don't crate lateral to the mm uh stoma or anterior to the um uh carotid sheath. Another important thing if there is difficulty in dissection of upper pouch, don't sit it on the lateral wall because the distal whatever 12 centimeter will keep on growing and that itself will form a diverticulum. And once you an up to the lateral type of a thing, I have at least five or six such cases where I have to do review in the neck for that. Mm. Bronchoscopy is another very important aspect which perhaps is not highlighted as much because uh I have noticed my first uh this up about fistula um when I burn my fingers, my child was not improving. Mm So that is the situation a little cleft. We say they are rare, they are not at all rare, I would say. Mm. So these are the areas we really need to assess our say um stump which also grows with the child. When we do type C repair, sometimes that pouch is so large and it collects, it has a tendency to have pulling of secret there and can result into a problem. So these are various issues which I thought uh one should take uh take compensate uh in, in each area it is there. You have to really plan it well, uh and realize it well, uh thank, thank you Raju. I think uh the complications, what you have, all you have mentioned, we have encountered all those complications and uh we also uh do uh end esophagostomy on the left side. So I think uh NEA HGA, it's a very nice tutorial for you about esophageal replacement in general. And uh many of these things will be asked in the exam because they are important. I see. N has raised his hand Nilesh a quick comment question. Uh Just a small question recently. Uh we had a patient uh type a Atresia uh which is a pure Atresia who has undergone uh esophagostomy and uh uh gastrostomy uh during the new one period, but he uh has a tof or fail. So, and he, he had two or three. So he has undergone open cardiac surgery for uh the TF repair. The cardiac anomaly. So how, what should be the best approach in such patients who has undergone the open cardiac surgery like Thoraco uh uh uh the median ster. So what's the best approach uh to treat such patients for replacement? That is my question. OK. Very nice question. I have that question. Yeah. Uh for such cases of pathology of fellow who had gone for um oxy or um blade shunt initially. And then what for the definite, uh very important thing when you do esophageal replacement as a uh procedure subsequently, after they repair, uh you better to have cardiac anesthesiologist, cardiac surgery. Anesthesiologist, definitely they score over our routine anesthesiologist because of the hand of that problem. Ok. Otherwise they have got tendency to go into a mental complex, uh a and the postoperative issues. Second important thing whenever uh definitive surgery and the shunt is carried out, there is a tendency of development of collaterals. Uh They come in your post meal way. Um This aortopulmonary, um contrast enhance CT scan is extremely important, which will give you idea the size of the collateral. They present their number and their exact location if they are coming in your way or not. Uh That is otherwise I tell you if their procedure, two procedures have gone smoothly, your procedure also goes very smoothly. There is nothing to worry about and you go through the posterior mediastinum. Uh and uh do the job. Uh Thank you, Raj. Um uh uh I think you also highlighted the importance of, of planning meetings. So meetings between pediatric surgeon, anesthetist, intensivist family altogether. And that applies not only to his official replacement, but actually to any other surgery. And I'm sure you uh might also be conducting some mock operations because now uh experts are advising that um what uh what uh surgeons do for separation of uh conjoined twins, I think for ma major surgeries, it is better to have mock operation. Uh Just make sure that everything is properly set up. Um uh Whatever is deficient is addressed before you actually start operating on the patient. Because uh uh as as it has been said, the the prime responsibility of keeping that patient alive during and after the operation actually lies in the hands of the surgeon. So the surgeon needs to really work as, as a leader of the team, captain of the team, but get each and every member involved in the planning of the operation, then the execution will go smooth and then the postoperative care will also be better. Obviously, there will be uh an um the the problems which may not have been thought about, but there will be solutions which were thought and they can be implemented. I think we should conclude the talk. Raju. Thank you very much. Again, it was an excellent talk, excellent discussion. I learned a lot myself and uh we hope to see you in person soon, maybe in South Africa, uh, as I said to you about 2025 we will probably see you here. And, uh and next month it is going to be a double F about presentations on the second Tuesday of uh April, there will be a talk by Doctor Hans Raj, man who is a senior pediatric surgeon in Peter Barb in the province of South Africa. He has set up a new um, a novel laparoscopic uh minimally invasive suturing course. And he's going to talk about their experience of setting up the course in resource constrained enrollment. And the following week, there is going to be a talk by Doctor Warwick Tegu who is a pediatric surgeon and in charge of the trauma unit. I think he's at Melbourne Children's Hospital. Uh But that talk will be at eight o'clock, 8 to 9 central African time to suit his Australian clock. So we will see you in a month's time. Uh Thank you, Raju. Thank you everybody for participating and uh I wish you a a good day further. Bye now. Thank you very much. Bye bye.