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OK, good afternoon, everybody. Um I'm sorry, there is a bit of a technical problem. So our registrar is uh not able to present um uh due to some technical unavoidable reasons. But uh I am delighted, I'm very happy to have uh Doctor Patel as our invited guest and he is kindly agreed to give his talk uh without even our register, giving his talk. And um and and II know I knew Doctor Patel for about six years or so. And in fact, I probably was one of uh his examiners when he uh did his oral exams for his fellowship. And um I'm so proud uh to, to say what Doctor Patel has achieved so far is absolutely remarkable. And uh we just need to remember that we have such young surgeons in our country who are uh are doing very well. And um I just had to project this uh this image of his beautifully made business card which is so attractive that I thought I should project it here. And um Doctor Patel is uh currently a consult pediatric surgeon at Chris Bars Hospital in Johannesburg. Affiliated to Wits in your city. He I believe also has some private practice. Um But in his state practice and everywhere he is quite keen about surgical education. Um and his fears of interest in addition to general pediatric surgery are hepatobiliary pancreatic surgery and minimally invasive surgery. Um And nav as, as a person uh has lots of dimensions. Um I don't know whether you people notice that he also has not only bachelor but master's in arts before he decided to medicine. And that really gives a very different perspective uh to any doctor who have done master's in arts. So N is one of those rare breed of doctors. And uh I was so happy and proud to know that after his community service, N has offered his services uh to MSF in Somaliland. And he's also one of the directors of Surgeons for Little Lives, which is a not for profit organization, something very similar to our Yabu for the Children's Trust which we have formulated in East London. And this is um this is in in and in greater Johannesburg area. He obviously is a proud wits throughout from undergraduate still fellowship and consultant position and also proudly South African, he loves to travel. Um and he's a perfect family man. And this, I'm sure many of you will recognize this beautiful photo of Tiger Monastery in Nepal where Nera just already visited. So he makes me actually jealous of him. We are very, very happy to have you and please you, I will stop sharing my screen and you can share your screen and you can, you can share your thoughts and we have plenty of time. So please do not cut short any part of your presentation. Uh Thanks very much pro um you guys all able to see my screen. Yes. OK. Ok. So, um yeah, I didn't manage to get a um a look at Doctor Juli's presentation before he presented. But uh today I'll be presenting on pancreatic tumors and phi or persistent hyperinsulinemic hypoglycemia of infancy or congenital hyper insulin. Uh uh Thank you very much for that. Very nice and kind introduction and congratulations to your team and yourself in East London for hosting these. Uh he uh pretty high quality and consistent uh uh seminars for us to all learn from. Um So again, today's topic is divided into two parts, pancreatic tumors and PHH I, they're quite diverse, but uh there are some similarities in terms of um the surgical management of the, of the conditions and the implications of such um management for, for the patients. And I'll try and uh draw some commonalities there. So, uh beginning with pancreatic tumors, um they're exceedingly rare, I mean, exceedingly rare um in the United States, the malignant tumors of the pancreas have an incidence of about 0.46 per 1 million population. So, just to put that into perspective, um what that number actually means is that in a country of 350 million individuals in a 50 year, uh cohort between 1976 and 2004, 1974 and 2004. There were only 100 and 20 cases of pancreatic malignancy. We don't have any national South African data that I am aware of, but that Barra Doctor Harrison and Doctor MS uh, did a, um, a review of all, uh pediatric oncological cases between 4007 and 2016. And what they found was that we, we treated 330 solid organ tumors of interest that were malignant and 57 that were benign. So we had one pancreatic tumor in the malignant group and one pancreatic tumor in the benign group. The pancreatic tumor in the malignant group was located in the head of the pancreas and uh the patient underwent uh uh uh whipple's pancreaticoduodenectomy. The, the mass that was found in the benign group actually turned out to be hemangioendothelioma and the patient was treated medically. So, basically, pancreatic tumors can be classified as either endocrine or exocrine with exocrine being further sub classified as epithelial or non epithelial. The main risk factors for pancreatic tumors or malignant pancreatic tumors in Children are female gender and age. So your age greater than 10 and female gender. Um And this is uh a table from a, from another large case series. You see that the numbers in uh patients over the age of 10 are much higher and um the ratio of males to females is nearly 2 to 1 or females to males is nearly 2 to 1. There are certain types of pancreatic tumors that are associated with congenital abnormalities such as Bew Wierman syndrome and multiple endocrine neoplasia, namely uh pancreaticoblastoma and insulinoma. But by and large are the main risk factors are gender and age amongst Children. There is a clear bimodal distribution. You would say that that's the correct terminology. Um Children under the age of 10 generally suffer from pancreaticoblastoma and gen Children under the age over the age of 10, generally suffer from solid pseudo neoplasms and endocrine tumors, most particularly insulinomas. So, pancreatic tumors are actually a heterogeneous group of tumors. Um um there's a very wide range of diagnoses uh that the tumor may be and they may be in very different locations within the pancreas. But overwhelmingly the majority of tumors are pseudopapillary and solid pseudopapillary neoplasms. So this is a table that came out of a systematic review of all the literature, all English literature on pediatric pancreatic tumors between 1976 and 2018. And in that review, they were able to document 489 different cases of pancreatic tumors in Children. And uh uh a a full 300 or 60% of them were solid pseudopupil tumors. With the remainder being split up between pancreaticoblastoma um and neuroendocrine tumors in the main, just to demonstrate the heterogeneity of the types of tumors that you can get. We know that the majority of the tumors are solid pseudo purpura neoplasms. This is another table from uh uh papers published in the United States demonstrating the different types of malignancies they found in the head of the pancreas. And I mean, it's, it's a very, very wide range of different malignancies. Children with pancreatic tumors don't present in the same way that adults would, Children generally present with abdominal pain and a mass. They may also present with loss of weight and then symptoms of compression, early satiety or constipation, tumors that are secretory uh will obviously present slightly differently. And the majority of those would be insulinomas, Children would present with symptoms of hyperinsulism. This is important because Children don't present like adults. So they won't necessarily be present with painless obstructive jaundice or anything like that. So, it's important to keep in mind that abdominal pain can be uh nothing and can be something that's extremely serious in Children and not to, to always maintain a very high level of suspicion. The workup for these types of tumors is basically dependent upon imaging. And in some cases, tumor markers do play a role that relevant tumor markers are alpha fetal protein ca 19 9 and ca 125. But essentially the workup of these patients for isolated or non uh non metastatic lesions involves uh your preoperative imaging. Most centers advocate for starting with the abdominal ultrasound and then moving on to either a high resolution contrasted CT scan or an MRI. The choice between the two really depends on the institution. The benefit of the MRI is that uh it does decrease the child's radiation exposure. Um There may be a role for endoscopic ultrasound. This is particularly uh for patients that don't have um paop neon features on either um high resolution contrasted CT scan or an MRI for the type of tumor that you're dealing with. So, endoscopic ultrasound is useful if it's available at your institution for performing uh a biopsy. And sometimes we're also localizing uh localizing a tumor. Uh A dual modality is always preferable to a single modality. But the dual modality really implies using an ultrasound and either a CT scan or an MRI, not a CT scan and an MRI together surgical resection is the mainstay of therapy. And this is so because of the increased survival and decreased recurrence associated with surgical therapy, the goals of surgical treatment are essentially complete surgical resection with a minimization of complications. Biopsy may be necessary particularly when imaging characteristics are not back on pneumonic for a particular the particular malignancy. So if there, if there's any suspicion that it's not a solid pseudopupil neoplasm, it may be necessary to perform a biopsy in order to decide whether the patient should receive neoadjuvant adjuvant chemotherapy, it's also useful in patients whose tumors are deemed irresectable to decide whether the patient would benefit from neoadjuvant chemotherapy. And what is the appropriate therapy to do? The biopsy can be performed open percutaneously or endoscopically. Um uh endoscopically being the least invasive but requiring specialized equipment and a specialized set of skills. So, once you've gotten over the uh the need for performing a biopsy and neoadjuvant therapy. When you approach pancreatic tumors, there's a few questions that need to be answered. Is it appropriate to a approach the tumor open or laparoscopically? Where is the tumor located? So, is it in the head or the neck? The tail or the body for tumors that are located in the tail is spleens pre. Uh the tail of the body is spleen, preserving surgery safe. And for tumors that are located in the head and the neck, is there a need for uh vascular reconstruction? And this refers particularly to the portal vein and then to the si mesenteric artery, the celiac axis and the hepatic artery. If you try and answer those few questions, then it would give you a good approach to uh how to approach these tumors. This is again from uh that same um uh systematic review that I mentioned by Milan. And it just uh uh illustrates that uh about half of all pancreatic tumors are found in the head and the neck, uh about one third are found in the tail and about uh 20% are found in the body So it's actually very difficult to precisely define the different parts of the pancreas. Um It's not well defined within surgical textbooks and it's not well defined within radiological textbooks, but just as a rule of thumb, you could think of everything to the left of the inferior mesenteric artery as the tail, anything between the superior, inferior mesenteric vein. My apologies, anything between the superior mesenteric vein and inferior mesenteric vein as the, as the body and anything to the right of the superior mesenteric vein, as the head and the neck. So the type of surgical resection that you perform really depends on the location of the tumor. And there are a few different options that can be considered. The first one is a whipple's pancreaticoduodenectomy for masses that are in the head and the neck of the pancreas. The second one is a distal pancreatectomy or a spleen sparing distal pancreatectomy for masses that are in the body of the tail. And then there is the possibility of a central pancreatectomy or enucleation and I'll discuss each one of them. So, within the literature, there are a few case series of relatively small number of patients spanning multiple decades of Whipples, pancreatic pancreatic or duodenectomy in in Children. Um The the the pathology necessitating uh whipple's procedure in these Children is actually quite heterogenous and I could find uh a report um of a child as young as four months old undergoing this procedure because there's um not um because there's a lot of trainees and maybe not everyone has spent a lot of time in general surgery. I think it's important to just illustrate what the Whipples actually is. So, essentially, it's a resection of the and the Pylori and the duodenum and a reconstruction via pancreatic origins toomy, a Gastrojejunostomy and Hepatic Vst toy. I think that's quite important to, to know because we often say Whipples, but we don't necessarily know what it means. So this is an image of uh actually one of the Children at uh um who underwent uh pancreatic Orey for a head of pancreas mass. And uh you can see the mass here in the coronal view and in the Sagittal, you can see quite nicely how big the mass is and how it displayed the, the the celiac axis in the superior mesenteric artery. So essentially, you get two types of uh whipple's procedures. You get a pylori preserving and a standard procedure in Children. The pylori preserving procedure is um reported to be associated with higher rates of complication, these complications being delayed gastric emptying and and tumor recurrence. I was unable to find um any, any description of a laparoscopic pancreatic adenectomy in, in, in any of the pediatric patients who underwent uh this procedure for a head of pancreas mass. It's also important to note that there's two ways in which to do the pancreatic or jejunostomy. And this really depends on the size of the duct that you're trying to anasthe to. So if the duct is very dilated, you can do a duct to mucosa anastomosis. But uh in very young Children, this may not be possible and you may need to do the anastomosis to the capsule of the pancreas. The complication rates for whipple's procedure in Children are reported to be quite low and this is probably a function of the fact that Children have um predominantly pseudo papillary, uh solid pseudo papillary neoplasms which are of very low malignant potential. And because they have uh good planes, uh the most common complications that are described are uh pancreatic fistulae of the pancreatic fistula, delayed gastric emptying, tumor recurrence and pancreatic exocrine and endocrine insufficiency. In some case series, I found uh reports of up to 60% of Children uh suffering from exocrine and endocrine insufficiency after undergoing pancreatic OD adenectomy, the younger you are when the procedure is performed and the more mass of the pancreas that is removed, the more likely it is that you will develop e endocrine insufficiency as you grow, recurrence rates were reported to be up to 40% with a mortality of up to 50% for pancreatic go adenectomy in Children. But really, this is actually just the function of the of the of the tumor histology. So your your recurrence rates and your prognosis is worse with non uh solid pseudopapillary neoplasms and where there's vascular involvement. But overall uh from my reading. My understanding is that this is a well tolerated procedure in young Children. OK. Yeah. So turning to distal uh distal pancreatectomy, like I, like I mentioned, there are two different types. There's a spleen, preserving and a non spleen preserving distal pancreatectomy from my reading and understanding. The laparoscopic approach is the gold standard and where possible histology permitting clinic preservation is the way to go. It has a relatively low complication rate this particular procedure and it's very rare for patients to develop exocrine or endocrine insufficiency from the reading that I did. I was not able to find any report of a of a of a laparoscopic spleen sparing, distal pancreatectomy with *** vein reconstruction was required. But this is something that uh should be considered. Prof did ask me for uh videos of uh pancreatectomy whatever form uh uh we, we had available to us, but unfortunately, we don't have a very big case series and we don't often um uh take videos of our operations. I have provided a link for a nice video that I found on youtube for a laparoscopic spleen preserving in distal pancreatectomy that uh people can look at when they have some time. The enation and central pancreatectomy are very well described in the literature. My understanding is that they should be only applied to very well localized tumors of low or no malignant potential intraoperatively. It would be useful to perform an ultrasound to check for ductal involvement. This is particularly important in order to prevent a pancreatic fistula. I think in Lation in the head of the pancreas, although it is described is potentially a very tricky procedure because it's probably very difficult to obtain a negative margin in head of pancreas masses. Due to the proximity to major ductal structures, the pancreatic and uh common bile ducts and major vascular structures. The advantage of enucleation in central pancreatectomy is simply that the pancreas preserving and you don't run into the problems of exocrine and endocrine insufficiency that you may with uh with, with other forms of pancreatectomy. But that comes at the expense of possible tumor recurrence and developing a pancreatic fistula. So again, this table comes from the, the systematic review that I told you about and you can see of all of the 489 cases. Uh Only about 10% were done. Uh uh Only about 10% underwent central pancreatectomy and only about 9% underwent tumor enucleation. Chemotherapy and radiation do have a role to play both as neo adjuvant and as adjuvant therapy in the management of pancreatic tumors. But they're not common in the management of the most common pancreatic tumor, which is a solid pseudopupil neoplasm for all other endocrine epithelial and non epithelial exocrine tumors. They are routine. So this is uh a table depicting our experience at um at Chris he and in private. Um since 2011, um we had five cases of pancreatic tumors. Four of them were in girls. All of them were in the head of the pancreas. We had three solid pseudopapillary neoplasms, one hemangioendothelioma and one pancreaticoblastoma. Four patients underwent the pancreat, pancreaticoduodenectomy with two requiring a portal vein reconstruction that didn't require a graft. Um to my knowledge, all patients were alive and well at last follow up with two requiring revisions of the hepatic orost. The one patient uh was managed uh by interventional radiology. The other patient required a surgical revision of the hepatic origins toomy. So even in our center, I mean, it's a very limited experience uh over quite a quite a long period of time. So in summary, I would say that pancreatic tumors are extremely, extremely rare. Um imaging is fundamental to the planning of the management of these patients. Surgery, surgery is a fundamental or is probably component of management and the procedure that you perform is really determined by the tumor location and the likely histology pancreatectomy in whatever form is safe in Children, adjuvant and new adjuvant therapy may be necessary in the management of these patients depending on the histology in our series at Baraga Hospital. And in private, all of these tumors have been managed by pediatric surgeons. Um uh whether the pediatric surgeon should be performing these cases, given their rarity and our relatively relative inexperience with this type of anatomy. And this type of procedure is a matter of debate. I think it would really depend on um the, the particular skills that you have available at your institution, given that these tumors are so rare. I would like to hear what people think about uh the need to centralize care for these tumors within particular centers uh um In our country. Uh I'd be quite interested to hear what people think about that. So, uh I anticipated that uh I'd follow Doctor Julie, so, uh I didn't really want to talk too much about Ph I, so I'll just keep it quite brief. Also being mindful that I don't want to run over my time. Um Phh I for me is a heterogeneous disease. So genetically it's a heterogenous disease and histologically, it's a heterogenous disease. Although all of the patients will present in essentially the same way, these patients will usually present as neonates with symptoms of hypoglycemia. And the goal of the biochemical workup is essentially to show that they have an abnormal level of insulin relative to their blood glucose level. This is different from insulinomas where patients would have an absolutely high level of insulin. The backbone of therapy of PP PHH I is to treat patients with medical therapy and this is in the form of uh continuous feeds or a dextrose infusion and various different drugs including diazoxide, a somatostatin analog Glucagon and climus. I think about five or six years ago, a sirolimus was touted as the new wonder drug in the management of um congenital hyperinsulinism. And this was because it was shown to have worked in patients with insulinemia. And the thinking is that it decreases eyelid cell production of insulin and increases peripheral resistance to insulin. It was started as a drug that could be used to avoid surgery in Children with diffuse ph I. But since then, there have been multiple studies that demonstrate that the effect of croim is actually variable and it has a very high, very wide side effect profile with some of the side effects. In fact, being quite serious. Unfortunately, it's not the wonder drug that we initially thought it would be. So given that um there are different forms of Phh I genetically. Uh and that because of this, some patients respond better to medical therapy than other patients. Um It may be necessary for some patients to undergo surgery. And essentially the purpose of the surgical workup is to differentiate between focal and diffuse disease because it will be this differentiation that determines the type of surgical resection that is required for the patients. Um Previously pancreatic venous sampling was the gold standard in determining the differentia and trying to differentiate between focal and diffuse disease. I think this has changed quite substantially with the advent of this uh 18 flu fl dopa pet CT scan, which is now the gold standard for determining the different uh for for differentiating between focal and diffuse disease, the management of patients that are not responsive to medical therapy. So patients that are not responsive to diazoxide is always pancreatectomy in whatever form. If it's for focal disease, then it's a focal resection. If it's for diffuse disease, then it's neo total or subtotal to neo total pancreatectomy. There's no major reconstruction involved and it's very important to consider your preoperative imaging and potentially make use of intraoperative ultrasound, frozen sections, loop magnification and palpation of the pancreas to help you to decide whether you have achieved this uh uh um uh acceptable resection or not laparoscopy. Laparoscopy is very well described and this is particularly for well localized focal lesions. So just to end on phh, I um for those patients that respond to medical therapy, surgery is not indicated for patients that do require surgery. The important things to do are to differentiate between focal and diffuse disease in patients that have diffuse disease and undergo subtotal or near total pancreatectomy. Pancreatic insufficiency is extremely common affecting up to 60% of patients. This is both with respect to its exocrine and endocrine function. I think that this is a very difficult condition to manage in spite of having a multidisciplinary team approach. And I would and I would like to uh put it to everyone in a patient who has diffuse disease. Is it preferable to try and manage the patient's hypoglycemia medically with the risk of recurrent hypoglycemic events? Or is it better to take a more aggressive approach, perform surgery earlier and then potentially leave the patient at risk of hypoglycemia. E either in the immediate postoperative period or later as they grow. I'm not sure what the answer is, but I think that it's an important discussion to have with the parents of these patients. So in Joburg, um uh I did some, some digging and found uh uh about 11 patients. Uh two of them were missing data. Three had a glutamate dehydrogenase uh abnormalities. So they responded to medical therapy and six underwent surgery of the six that underwent surgery. Uh three initially underwent a uh a 95% pancreatectomy and three under uh a 90% pancreatectomy. The three that underwent a 95% pancreatectomy required further resection. All three of them of the six patients that underwent some form of pancreatectomy. Three or half are now currently insulin dependent and all have pancreatic exocrine insufficiency. I had a, a chat with the pediatric endocrinologist at, at Bara and uh they actually had no cases at Bara uh that they could recall and in the textbook uh the the the prevalence of or incidence of um phh I is reported to be one in every 50,000 live births. So uh I would like to ask um all of you from all of your different institutions if you have any experience with these patients in the public sector and if you don't, then where are they? So I'd like to thank uh Doctor Grieve Pro Loveland. Doctor Connor and Doctor Boshoff for helping me collect the data and providing some images and uh for any of the trainees, I have a little quiz and uh when I see you, I'll give you a, a surgeons for little live Tshirts for anyone that can answer. Answer the question. If anyone can tell me what is the origin of the name Rapamycin? Not for the consultants, just for the trainees, you know, thank you very much. That was uh really an excellent uh si relatively simplified and very practical talk on on pancreatic tumors, which is quite a rare but an important topic. And uh PPH I, which I think is also quite a difficult topic and uh which we do not see. So I will certainly invite comments from our colleagues who are attending, but just a very co couple of very brief comments is I think, you know, we are missing all those patients in the public sector. They are just getting hypoglycemic, some of them getting neurologically impaired and they are just not getting diagnosed uh enough workup uh for us to find either an inulin or PPH. That's number one. And um uh secondly, I think uh you asked about uh whether we should centralize uh the management of pancreatic tumors in Children. I would certainly support that concept. I don't know what my colleagues in center is bigger than East London would think. But I think uh it is time that we start centralizing um care of such extremely rare conditions. But that's I think something for us to discuss as uh South African Association of Pediatric Surgeons to take it uh forward. So Nero thank you for your talk. Uh Yeah, I would like to invite doctor Derek Harrison who is also one of the consultant pediatric surgeons at Paraguana and also uh partly in private practice if I'm correct and has keen interest in uh pediatric surgical oncology. So Derek, please give your uh comments, your advice, you need to unmute yourself. Um uh Hi Melin, thanks. Um So yeah, just going to your persistent hyperglycemias. We have seen them in the public sector but not at bar. They've been the times I did my rotations at Charlotte. Uh we had a couple there. Um So we have done a couple there but yeah, ii for some unknown reason, I don't know why there haven't been any at bar. Um And then yeah, your pancreatic tumors. Yes, they certainly are rare. Um They also you, you know, some of the generals, well, the, the H PB units are doing kids above 10 at Barona. So they have, in fact, they did two were done just recently by the, by the adult H PB guys. Um and they both were solid pseudo papillary tumors. In fact, one was a massive one and at a quite an unfortunate outcome at the end, but the other one which I was involved in had quite a good outcome. So that was good. But of course they should be centralized. I mean, it's just, they're just so rare and not everyone knows how to do the surgery. And then of course, if you're not familiar with it, then you should, you know, work together as a team, um, with, with the adult guys. Um, but yeah, it's, it's, it's, it's, it's actually was a nice presentation by ne. So that's well done. It was very good. Thanks. Uh Yeah, thank you, Derek. I fully agree with you. I mean, if you have to do any pancreatic surgery in a child, you rather do it with. If you have uh uh experienced hepatobiliary surgeon or general surgeon, you take one of those colleagues with you because with pediatric surgeons, we really do not do much pancreatic uh surgery. So, thank you, Derek. Um I saw Doctor Charles Scina was here but I think he has exited the meeting. I'll now invite uh Professor Headley to give his comments a proof. Uh Hi. Hi. No, thank you very much doctor. Thank you very much. Indeed. It was a lovely uh presentation. The, the questions you've right. Yes. Pancreatic tumors are rare. I mean, in, in 30 years at King Edward, I saw one which we resected in the company of the adult hepatobilliary guys. Um And uh you're quite right for each individual surgeon. Personal experience is, is very low in, in terms of centralization that I if we were a much smaller country, yes, that, that, that would be a good plan. I mean, the centralization works very well in places like the Netherlands. But um you know, the, the the disruption to the family of sending people from Durban to Cape Town or to Johannesburg for, for liver transplantation has shown us that the the ease of centralization is, is not as easy in, in, in this country as it would be in a smaller or European or elsewhere country. So I it may be idealistic to centralize, but in, in practical terms, I think it's a lot more difficult than we think in terms of um, uh hypoglycemia. Uh you can deal with the complications of surgery, the um, um, the, the need for insulin replacement, but you can't deal with an adult, a, an adult brain once the brain has gone. Um, then the, you, there's nothing you can do about it. So particularly perhaps in the public sector where monitoring might not be quite as complete and sophisticated as it would be in the private sector. We've always been very aggressive in terms of uh, um, prescribing surgery for these patients. And I think really in our circumstances, early surgery is uh what we should all be aiming for, but I thought there was a fabulous er, presentation. Thank you very much indeed. Uh Th thank, thank, thanks for that. Um uh, yeah, so, II actually agree with you. I think it's very easy to say things like centralize and all of these things. But I mean, ultimately, we're dealing with the patient and the patient comes with the family because we are pediatric surgeons. And it's very important to very important to think about the impact of your management on the patients rather than just technically being able to do a good job. Uh So I II do agree with you in that regard properly and also with respect to the Phh, I question, I actually agree with you as well. II think it's easier to manage a patient's hypoglycemia than to be left with a patient that is hypoglycemic and now has to live as an adult with the effects of um of repeated episodes of hypoglycemia on their brain. Um Yeah, thank you. Thank you, Nera for, for uh stressing and emphasizing that I think just on uh I see there's one pediatric pediatrician colleague from Queenstown of s who is attending, which I'm very glad about and uh probably a message for her, but also mainly for our junior uh team members. Uh that hypoglycemia is deadly, especially in newborns and infants. It's really very serious. If it doesn't kill you, it, it kills the quality of your life because uh you can become neurologically so severely damaged that you may not be able to function. So, as uh Neo has said, as uh Doctor Harrison has said, and as I said that it is probably relatively easier to treat, uh, to, to treat hyperglycemia by adjusting the insulin dosages rather than managing the serious bad effects of uh, attacks of hypoglycemia in a newborn because a patient would just not offered surgical treatment, um, and was continued conservative management. But nea thank you for showing those different types and which ones can actually be managed completely medically and which ones need surgery and also clarify which ones need localized surgery, which ones need generalized like uh near total or total subtotal pancreatectomy, et cetera. So all all very useful information. So I think, you know, we are coming to the end of the meeting. So I'll just ask you to give us a take home message um from, from this today's meeting. Uh OK, so I think the for me, for reading about this, the, the, the main, the, the the mainstay of therapy for both of these conditions is, is ultimately surgery um uh in, in pancreatic tumors, probably that surgery should be done uh with the general surgeons, especially in s where, where you don't necessarily have an individual pediatric surgeon with uh familiarity with that, with that area and the ability to perform potentially complex vascular reconstructions. OK. Nira. Uh thank you very much. And uh with your permission, I will uh share the recording of our meeting uh with our colleagues uh uh in, in the rest of the country and also on the PSA whatsapp group. So, you know, thank you again. Um I see there was one hand raised. Uh um yeah, it, it was me. It's just, I'm just, like I say, it's so unusual for a speaker to agree with me on two consecutive points. I, I'm actually going to seek AAA copy of this recording en normal. Just try to also to, but as much as I could, you know, he, he, he, he is a very, very sincere and, and humble young pediatric surgeon. So that's probably the reason why he has agreed with you on two points in one lecture. Oh, yeah. Now you've deflated my balloon. But uh thank you. Thank you, provide Derek and, and all the uh attendees and I'm sorry that um there was a problem and our register couldn't or didn't present. But uh but uh Patel had such an excellent top quality practical presentation that we really didn't miss the presentation from our junior. So next week, uh there will be a talk by Doctor Neha Gautam, our medical officer about transitional care in pediatric surgery. And uh I'm almost certain that Professor Sherif Emil from Montreal Canada will be our invited guest for that talk. So uh we will see most of you and many more. Uh sorry la uh um my apologies. I need to ask doctor Ya man for her comments. II saw her but Yashoda, my apologies. Please give your comments, any comments, any questions? Oh, thanks prof but uh it's ok. My, my comments would be redundant because I think everyone has covered what I would have said, uh, especially what you said about the hypoglycemia in the newborn being uh an emergency because of the long term neurological damage. And I have to agree with pro on both those points too and that has nothing to do with the fact that he trained. So, thank you, Nira. It was a great presentation. Ok. Ok. Sure do. Thank you all. Uh, and have a good evening and we'll see you next week, Tuesday at the same time. Bye-bye now.