Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

And no bribery, please. No, bribery. Okay. So I'm, I'm Joe Curry. I'm joined by Elizabeth Conner. Uh And this is a general session. Um So we'll uh if all present ear's could keep their time as before. Um And uh just a comment from the last session, if you could just make sure your mobiles are on quiet mode, please. For the present for the presenters. Okay. So, um we've got Kareem Omran who's going to present determinants of growth failure in neon eights with enterostomy. Good morning, everyone. Thank you for the opportunity to present. So, a little bit of background about our project. So neonatal antrostomy is a known risk factor for growth failure, but there's limited research on the reasons for this and the long term consequences on brain development is largely unknown. We hypothesized that episodes of acute phase response such as in neonatal sepsis may be correlated with catabolism and ultimately faltering growth. So we retrospectively analyzed all patient's was necrotizing enteric colitis from 2012 to 2021 who had a stoma form that laparotomy. We collected body weight at stoma formation enclosure and calculated weight for age Z scores. And we also collected cereal crp urea and creatinine. It, we then calculated the area under the curve for those three biomarkers to get an estimate of their total burden. We also performed trend analysis, plotting the cereal crp urea and creatinine measurements to see how they, how peaks and those three biomarkers associated with a change in med school. So 79 near Neitz met our inclusion criteria and I just like to draw your attention to the fact that at stoma formation, 91% of neonate had a weight that was below the average and 22% were underweight as defined by the who as being two standard deviations below the mean and 8% were severely underweight. And on top of all that, almost 80% of infants experienced a further decline in their bed school while they had a stoma was 20% experiencing severe faltering of their growth. We then look to see which variables were most associated with a change in that school. So we first performed a uni variable analysis and we took the significant predictors to a multi variable model. And these were days with stoma, the area under the curve for CRP and the area under the curve for urea. Although CRP was not statistically significant, it was associated with a decline in the school. And the only statistically significant biomarker was the area under the curve for UREA. Ultimately, this showed us that the burden of Urea was the main predictor for a change in dead score out of fast three biomarkers. We then looked to see if there was any trends in our data and we found that peaks and CRP were correlated with peaks in your area and that the number of peaks was associated with faltering growth. However, when CRP and urea peaks coincided, there was much more severe growth failure. In conclusion, we found that inflammatory burden was linked to a cata bolic state. And that serum biochemistry disturbances predict growth failure. We therefore recommend aggressive sepsis management and specialized nutritional support for neonatal with antrostomies. And special consideration should be given to the nutrition of neon aids when they have suspected sepsis to limit the hindrance of their growth. Thank you. Okay. This paper is open for any questions as we've got a question from Clary's. Did you wait for patient's to reach a specific weight before planning to close the stoma? And do you think this might have affected your results if you did? Thank you very much for the question. So, as far as I'm aware, our institute, the stones are usually closed around 6 to 8 weeks and I'm not too sure if there's a specific weight at which clinicians wait to close the stoma question from the floor team. We test, you know, the sodium uh at all in his patient's and use sodium supplementation as often that really does help with their weight improvement. Um I guess that is also take into account the stoma output and uh length of bowel above the stoma. Thank you very much for the question. So that is something that we were looking to collect in the future for the rest of the cohort. So currently we did not collect urea sodium for any of these neon eights, but we look to do so in the future. Another question from Steve Donald. Do you have any data on the head circumference for the babies? Um As far as I'm aware, no, we did not collect any data on head circumference. Okay. In which case, I think we'll move on to our next presenter. Thank very much. Thank you. So our next presentation is regarding does chewing gum lead to earlier post operative gastrointestinal recovery in Children a systematic review and meta analysis? Mm It's, it's very exciting subject clearly uh please when you're ready. Okay. Uh Good morning and thank you for the opportunity to present our findings and I'm Adrian from Hong Kong. It's not uh presentation moving you get it quicker, officer. Yeah. Okay. Okay. So uh with the success of enhanced recovery after surgery protocol in adults with aimed to provide holistic surgical care, it has been transferred to the practice of pediatric population as well. And two recent scoping review published by our center, uh which focused on gastrointestinal surgery as well as pediatric urology. Uh It was found to the protocol has planned to improve pre operative outcome in terms of shorter hospitals, day, as well as early recovery of gastrointestinal function. And among all these uh items in the end Iraq's protocol. And one of the component is the use of uh chewing gum selectively for older Children. And uh for the aim of stimulation of gut motility and the use of chewing gum has been uh uh employed in adult with an aim to decrease the risk of post operative Eilis. And it has been uh concrete evidence on the concrete review in 2015 that it could result in quickly recovery in the gi function after surgery in an adult. However, there is guess evidence concerning this and and the use of Children, whether or not it is useful in in Children and whether or not it could enhance post operative gi function recovery, it remains unknown and we, our study aims to address this research gap. We perform a systematic review and meta analysis according to the Prisma guidelines and we also registered on the Prospero Registry. Uh we performed uh searched on the pop met MEDLINE and based and concrete trialed dated on the first of January 22,005 to July 2021 and all together, over 3000 records has been screened and after removal of the duplicated record as well as uh populations uh result in six studies included in the review. As for the six study included in the review. It, they are all a randomized control trial. It comprises patient's uh 357. And from the treatment group, they either received bubblegum flavor or struggle list chewing gum. And for the control group, they do not have any gum given and they do also do not have a place even given as well as for the surgical procedure include gastrointestinal surgery, economic and small bowel resection and appendectomy, as well as a spinal fusion. All of these are known to have an increased risk of post operative ideas as for the result in terms of a gi function and uh time to pass. First latest was found to be two hours earlier in the treatment group. And the time to first about movement was found to be six hours earlier in the treatment group as well. However, both of these do not result in a statistical significance and furthermore, the time to tolerate or intake as well as the length of post operative hospital stay has been revealed. And both of these actually are quite similar in in the treatment group as well as a control group and they do not result in a significant differences. And we also look into whether or not the use of chewing gum can improve in a pain control. And as for the opioid consumption, uh pain score as well as the National school. After the operation. They are all quite similar between the chewing gum group as well as the control groups which result in uh no significant significant differences. So in uh to conclude our study, do not find any concrete evidence for the use of uh chewing gum on the post of gi function Children. Not that I'm saying that it's not useful, but uh wants to know is that much majority of these studies are actually quite uh with a very small sample size and therefore, it could uh make it under power to delineate the true effects of the chewing gum in Children. So, future adequately powered trial as needed. While we're surgeon, we're focusing on operating on our patient's. We also to put more effort in improving the quality of care as well as the patient satisfaction throughout the preoperative journey. And thank you. Thank you. Any questions from the floor Lucas? Hi. Thank you very much. Very interesting presentation. I meant I saw that three of the papers that you included, where about posterior uh spinal fusion? Did you take them away and analyze it again to see what the results would be? Actually, I I do because actually I after I try to remove them and just focusing on gastrointestinal surgery at in fact, the result is still quite similar, they do not have any effect. On the other hand, if I remove those gastrointestinal surgery papers, it's actually result in a significant results. So it is quite useful and patient's receiving us spinal surgery. Okay. Thank you. Um I think we'll move on to the next paper. Thank you very much. Uh So the next paper is investigating the children's surgery outcome reporting program treatment, success school in an existing cohort of 1383 infants with surgical conditions. And Benjamin Allen is going to present that. Thanks, good morning. So, on behalf of the children's surgery outcome reporting program, I'd like to present our work investigating the seesaw treatment, success score in an existing cohort of Children surgical conditions. The sea salt treatment success score uses an algorithm developed from the results of a discrete choice experiment that was conducted with 1100 participants to combine the number and type of operations. The child has undergone, the number of times have been treated in hospital for an infection related to their underlying surgical condition. The quality of life and duration of survival into a single numeric value that summarizes how successfully the child has been treated. The best possible score is one, a score of zero is equivalent to palliation and scores less than zero. Describe outcomes are considered worse than palliation. The aim of this study was to investigate whether the seesaw treatment success score varies appropriately according to infant characteristics that are known to affect prognosis. In order to achieve the same, we combined six UK wide prospective cohort studies known as the bats cast studies into a single database that contained 1383 infants with Hirschprung's gas risk ISIS CDH any CPUV and esophageal atresia. We had demographic data 28 day and one year outcomes data for all infants and long term quality of life. Data for Children with Hirschprung's disease and gas risk isis were calculated seesaw treatment, success scores at one year of age for all infants using derived quality of life data for those who didn't have it. We then describe how these characteristics vary according to see how these scores vary according to key characteristics that are known to impact prognosis within the cohort. Roughly 18% had any, see, 15% had CDH, 26% gastric isis 11% esophageal atresia, 9% puv and 22% had Hirschprung's disease. The cohort was approximately 50% male and predominantly of white ethnicity. Roughly a quarter had one or more additional structural chromosomal anomaly. When we look at the distribution of sea salt treatment, success scores across conditions, we see that it varies appropriately with scores mean scores lower in infants with any C and CDH at 9.53 and 9.59 than in Children with Hirshman sees and gastro spices which are up, that means scores of 9.73 and 9.75. Similarly scores for infants with additional anomalies were lower at 9.64 than those without at 9.6. 7. Appropriate variation is also seen according to the gestational age at birth of infants in their ethnicity. Infants born at less than 28 weeks had a mean score of 9.48. Whilst the mean score for those born at greater than or equal to 37 weeks was 9.7. 1. We see a lower mean score in black infants of 9.5 than in white infants of 9.68. In summary, the sea salt treatment success court combines four characteristics that are known to define how successfully a child has been treated into a single numeric value that this study has shown varies appropriately according to characteristics that are known to impact prognosis. We therefore believe that the sea salt treatment success score is an appropriate measure to use to describe how successfully a child with the surgical condition has been treated. Thank you very much from the check um question from the floor Bruce. I'm a bit stupid but your error bars were one standard deviation, right? And all your numbers were within one standard deviation. So your score didn't vary at all. They're all the same so that there is no correct. There's no statistically significant difference is not statistically significant difference or the same. We wouldn't, wouldn't want to see that the size of cohort though. You wouldn't expect to see that you can't come and see the various the same. There is, there is a significant trend in those schools. What statistical tests are you using to discern a statistical trend and it's all within one standard deep mission. We haven't applied, assist with test because it wouldn't be appropriate. So there's no statistical difference is there, there, there is an appropriate, there is an appropriate variation in those schools according to the characteristics, they are lower in the infants that you would expect them to be lower in. They're all within one standard deviation of the same. Okay. We'll carry out conversation on afterwards. Sean. Uh Yeah. Winston Churchill defines success is moving from failure to failure with undiminished enthusiasm. Um Where's the option for failure in modern surgery? Um Because if you're defining success or partial success, um when we're not allowed to fail and therefore, we're not going to learn. So how is the score actually going to help surgeons to learn? So the way that we are proposing to use the score is you can use it to both describe the observed outcomes. We can also predict what we'd expect a child score to be based upon their underlying characteristics of things like gestational age of birth, birth weight as an ethnicity and condition specific. So that that's just a risk categorization. So it allows us to identify whether Children look like they have been more or less successfully treated. The new expect. You can then combine that with additional deeper information about the child reviews into what is going on in terms of practice, to try and understand where things are working, where things aren't, it is not a measure to give a yes, know this works. This doesn't, it's, it's a tool to highlight where. So, but there are lots of conditions already have reasonably well validated um, risk categorization schools. Why do we need this? So we believe that we need something that is useful in a range of different conditions. So the rationale behind the seesaw program is to investigate whether we can set up a system which will allow us to detect where there is sort of unwarranted variation in management. In order to do that, we need to be able to combine outcomes from a range of different conditions. We therefore need a measure which is as applicable to Children with Hirschprung's as it is to those with a soft palate trees here or to to posterior you throw valves, we therefore set out to develop something which is relatively general and defining a measure of success, which we believe is as applicable across all of those different conditions. And we think that this allows us to, to do that. Thank you. Ok. Thank you. We'll stop it at that point. It's clearly a long conversation to be had. Ben. Thank you very much. So, our next presentation is regarding pediatric thyroid surgery, clinical outcomes and patient perspectives. Good morning. Thank you for the opportunity to present. My name is Amy. I'm presenting our work on thyroid surgery and thank you to my colleagues who also help with the project. Um Oh, sorry. So a bit of background thyroid surgery and Children is, is really uncommon. So in the UK, they're about 6000 thyroid operations a year. But in Children are under 21 is about 140. Um the gift, an adult under crime surgery recommended a minimum workload over over 20 adult cases per year. In 2021 most underground surgeons recorded fewer than one pediatric case peer. So we established a formal joint pediatric under crown surgical service. So this is a bit about our service. So, patient's were reviewed in a joint clinic by a pediatric and an endocrine surgeon. Both surgeons were always present interactively, pre and post operative care was delivered on pediatric surgery wards. A pediatric endocrinologist determined which Children were going to be discharged on calcium and we had a joint follow up. Um So it was started in 2011 and stopped in well, it's ongoing, but we got data till 2022 and 98 Children had an operation in that time and there's a graph of an annual workload. Um So our aims in this study, we aim to assess the clinical outcomes of thyroid surgery along with patient's and parents perception of morbidity in a continuous cohort from a combined service. It was a retrospective cohort study and all patient's under 18, between 2015 and 2020 were surveyed and we chose not to interrogate um any of the patient's before that because the um the surveys quite, we're quite detailed and we felt that asking very detailed questions from very historical events would be quite a Hroniss. We reviewed all the operative notes, the blood tests and the histopathology and we invited all of the patient's to complete a questionnaire that and they were all standardized. So one about voice changes, one about swallowing and what about the appearance of their scar? So a bit about our results. So we also had a look at the results between the responders and the non responders. Our patient's were generally female. Generally about 14 or 15, most had a total thyroidectomy and most of the time it was for graves' disease, for benign disease. Um So a bit more about our results, calcium requirement, postop about 50% of patient's did not require calcium, postop. We had only 3% of patient's that required permanent calcium and that's kind of in line with the literature. So, in this Swedish paper, you can see that 7% had permanent hypoparathyroidism, voice results. So sorry, most of our patient's didn't really have any voice impairment postop. You can see that a score of not to 30 in this scale was very mild voice impairment and then swallowing schools. Um this swallowing school starts at 10. Um So again, you can see that most of our patient's didn't have any problems swallowing post up and then scar results. We use the Manchester scar scale to have a look at the scar results. Postop um the scar scales were actually comparable with other papers. So other papers that had to use this particular scale had similar results to us, but we had six patient's that were referred for scar revision. And that is actually more than has been seen in the literature before. So our conclusions, we established an effective collaborative pediatric endo coin surgery service results are favorable with regards to nerve injury and hypercalcemia and patient reported outcomes. Here provide the first evidence of patient's and parents perception of thyroid surgery. Thank you. Are there any questions? Um Could I just start with the first question? Which is it, this is one of the procedures where clearly adult surgeons have high volume. Um And is this an operation that should be done by adults surgeons or should it be done by adults surgeons in children's hospitals or should it be done by Children surgeons in children's hospitals? What where does your data suggest? Um I think our data suggest that this particular situation works very well because you have a surgeon who's got really high volume. Um but actually has very little experience operating in Children, working in collaboration with children's surgeon. And that also means politically, you have access to all of the pediatric services that way as well, which I think undoubtedly Children are better served by being in a children's hospital. So it allows both to happen. You've got the volume and you've got all the children's services. So essentially by an adult surgeon, the children's environment. Yeah, collaboration between the two of you, Sean Marvin Sheffield. So the adult surgeon is going to do the one year old prophylactic thyroidectomy. So they will do it together, a pediatric surgeon and an adult surgeon who's leading in North America. There's good data about pediatric surgeons leading on thyroid surgery up to this age, a range that you've described and and older the NHS long term plan refers to a 0 to 25 seamless pathway as a aspiration of the future um for Children and young persons. So this is an opportunity for pediatric surgeons used to do these in the past. I don't see that they need massive volume where we're just as careful as an adult surgeon. Um So this is an opportunity and the politics is that maybe we don't want to do it. Uh But maybe we could and maybe we should in fewer high volume centers in a few pairs of hands. But I would agree and I agree that I think the technical aspect is in many ways the least important and it's about all the peripheral services that well, equally, maybe as important. Yeah. But the endocrinologist who should be a pediatric endocrinologist, if you're treating all of that, I get all of that. But thing about the surgeon, otherwise we'll just turn the clock back and we'll hand everything back to the adult surgeons and we'll do everything under, sorry, we'll just, we'll just move on on from his conversation and we'll go to Paul, we'll just, we'll just want to clarify that point. Obviously, it's a big discussion, a big debate. I mean, we are doing some prophylactic small Children, three year old, not one year old, but certainly three, uh, in the men group. Um, and I think the partnership works really, really well but, but there's no doubt about it that in the current culture in the adult world, which you are going to be the litigation side of it, they have that the, the nerve is very, very much something that they will based on minimum numbers. And they, there's, I think working together works really well. We do, we actually have it in our hospital in our theatres with us controlling that. But we also have the protection of um in this example, the presidente of the, of the current endocrine British endocrine society actually operating with us. So I think we've got to be careful with this one. I totally agree with, want to reverse it and lose the Children. But this is the best model I think for these Children. It's certainly what I want for my own child. Um You know, you don't have to have one. You're currently on Juul injury and without, without doing at least 20 a year and you're in trouble, there's no doubt about it be indefensible. Thank you. That will make you. So the next presentation is optimizing outcomes for laproscopic balloon, gastrostomy, Vyse any Acerra? Okay. So, hello everyone. My name is Doctor Zegna Sarah. I'll be presenting on a project I completed whilst I was a medical student at the Royal Manchester Children's Hospital. Uh We looked at optimizing outcomes for laproscopic balloon gastrostomy. He's so I'm sure as many of you are aware. Laproscopic gastrostomy, knees are gastrostomy in general are a mainstay of long term entropy feeding in Children with an estimated 2700 gastrostomy is being performed in the pediatric population annually. Um in the UK. Yet, despite this frequency, there remains an 11 to 26% of complications. Um these complications range from gastrostomy site leakage, two tube displacement as we've previously demonstrated in our publications. Um Laproscopic approaches significantly reduce this rate of complications. We're continuously striving to improve our outcomes with gastrostomy insertions. And to this end in 2019, the Department of Manchester switched to a Seldinger technique when inserting these and this study aims to assess and evaluate the outcomes from this. So, the technique involves placing 2 to 3 sutures between the abdominal wall and the stomach and using the underclothes device to bury the knots underneath the skin. This previously before the Seldinger technique, we use laproscopic scissors to create the gastrostomy. But now we use an NG tube to inflate the stomach and then a guidewire is introduced through the needle and then the tractor serially dilated over the wire and the gastrostomy is inserted over this and then the stay sutures are tied. So our study design involved doing a retrospective cohort study which looked at all. Laproscopic gastrostomy is inserted between 2016 and 2022 by our three upper gi specialist surgeons. And the exclusion criteria are as noted on the diagram. So we had 331 gastrostomy insertions and of these 236 used a Seldinger approach and 77 used a non Seldinger approach. Outcome measures included major post operative complications such as laparotomy. Um a time to first contrast time to a any re attendance and rate of a an eerie attendance operative times. And uh yes. So the results are as follows. None of the patient's required a laparotomy which further supports the fact that uh laproscopic approach is safe. Um 10% of the non Seldinger patient's required a contrast within the 1st 48 hours of insertion um due to developing a pyrexia, none of these patient's developed a leak and all of them resolved with conservative measures. This is in contrast to the patient's and selling a group whereby only 4% of patient's needed a contrast uh time to a any re attendance was longer in the Seldinger group at 19 days versus 15 days in the non Seldinger group. And the rate of re operations was higher in the non Seldinger group at 5% versus 0% in the Seldinger group all of these were statistically significant. So in conclusion, deciding a reproach in laproscopic billion gastrostomy insertions improves outcomes through the reduction of the need for early contrast studies. Uh reduction in the rate of re attendance in A and E and in the 28 day postoperative period and in the reduction of the rate of re operations. Thank you. Does anyone have any questions? So, we've got a question on the chat. Have you compared your complications against lap assisted pegs? No, we've only focused solely on laproscopic uh gastrostomy in sessions, not lap assisted. Hi, thanks for a good presentation. Um Claire from Bristol, I was just saying that you had a re operation rate in the non cell digna technique group and I was wondering when those re operations happened because you've switched practice from one to the other. So presumably you've got a much longer length of follow up in your non seldinger ones. So the re operations, that's true. They did take place over a period of time. I don't think we limited it um in, in the same way that we had limited, for example, 28 days just for the A and the re attendance. So that's, that's a fair critique. Another question. Um What was the indication for the contrast that is in both of your groups? And did you have any positive results? I was in? So, as I've said earlier, it was, if they developed a fever, they were then sent for a contrast study. Um and none of them had a leak. So it was useful in determining that. Okay. Thank you. Yeah, thank you very much. Thank you. So, the next paper is the benefit of a double stitch in laproscopic inguinal hernia repair. Thank you very much for the opportunity to present. Are we presenting our work on the benefit of a double stitch in laproscopic inguinal hernia repair? So, the aim of our study is to review our experience of laproscopic inguinal hernia repair in a single center to review the complications and assess the practice of closing the a symptomatic contralateral processes, vaginal. This uh we uh did a retrospective review of a prospective, we held database over 12 years and documented data on hernia characteristics which includes the presence of a symptomatic contralateral PPV. AKON committed undescended testes in any other pathology. We looked at our operative outcomes specifically, the rate of recurrence, the incidence of iatrogenic cryptorchidism and any wound complications. All procedures were performed under general anesthetic with both consultant and trainee operators. We use a three access technique with a super umbilical open Hassan port insertion and to feather stab incisions for the instruments. In three millimeter instruments were used in the majority of cases. Um The closure was either a single person in the future or a double stitch and the double stitch was dependent on the operator. It would either be a double pestering or a single purse string with an overlying Zed stitch. Looking at results, we had 1195 patient's of which the majority were male. The median gestational age operation was 55 weeks and the median weight was 5.5 kg. The right sided uh symptomatic hernia was more prevalent. Looking at our outcomes. We had 20 recurrences which equated to 1.7% of which 40% were treated with re laparoscopy. There were two port site hernias early in the experience and 10 patient's developed iatrogenic cryptorchidism which equated to 1% of our cohort. We had 31 high scrotal or undescended testes at initial herniotomy, of which one did spontaneously descend. Looking more specifically at factors influencing recurrence on Univ ari it analysis, we found that recurrence per open ring was significantly reduced with the use of a second stitch. This was also confirmed as on binary logistic regression with a positive influence of a second stitch in the prevention of recurrence. Looking at analyzing all other factors such as patient age weight, use of the suture material and consultant and training operating. There was no difference in recurrence rate. Looking at all those other variables. Looking at the practice of closing the asymptomatic PPV, we closed 1855 brings 75 5% of those were symptomatic and out of the uh asymptomatic PPV. S for that actually equated to 40% of patient's and asymptomatic PPV. Was more common on the left than the right. Although that difference was not statistically significant, the only factor that did influence the rate of contralateral PPV closure um was preterm gestation. Um And further analysis on preterm versus term, we did not find any other differences in complications, recurrence or iatrogenic cryptorchidism. So our take home messages are that laproscopic inguinal hernia repair is safe and the recurrence risk is reduced to for second stitches used. And a contralateral PPV is observed in 40% of our cohort and the closure of this was not associated with any additional complications. Thank you for your time and I'm happy to take any questions. A question from the floor. Hi, this is Patrick from Hong Kong. I'm doing the same technique as yours. I mean the purse strings. So just two questions. So what kind of structures do you use? And the other concern is after you apply the first purse strings, the ring, the anatomy was this, this will be distorted. So there's any concern that you, when you apply the second stage, you're a hit on the vast difference of the testicular wrestles. Okay. Thank you for your question. So, um the mature either a three or four of praline and that is dependent on consultant preference. Uh with regards to your point about accidentally catching the vassal vessels in a boy doing a second stitch. That is a consideration. I think that is one of the reasons why a lot of surgeons prefer the Zed stitch because it's easier to miss those structures because you go either side and go very wide. Thank you. Uh Good Robin. Thank you very much presentation Robin got Cox Bristol. Um with regards to the contralateral, uh PPP, you've closing 40% when we know that only probably 7 to 8% show you up with, um attack MS hernia means you're operating on a lot more with a 1 1.5%. I think it was loss of testes on that side. Does that concern you? So, actually, the closure of a contralateral PPV did not result in any complications. So there was no I tra genic cryptorchidism or any complications associated with closure on the A symptomatic side. Does that answer your question? I've got a question just about that contralateral side. Do you use a second stitch for the contralateral people? Know most surgeons do just do a single stitch on the contralateral, a symptomatic side. Thank you, Stokley London. Thanks Eddie. Did you look at emergency surgery? And can you tell us about that and what the difference is? Well, yes. So we did do a, you know, very analysis on recurrence. An emergency surgery did not affect the rate of recurrence. Another question from the chat. Have you tried re creating an open operation by dividing the sac which has been shown to have low recurrence rates compared with a stitch alone. Uh So because there is a large variety of different methods of doing England or hernia repair, which actually is reflected in our center. There are some surgeons in our center that do cut the inguinal canal disrupt the sac in some way before closing the stitch. But we didn't analyze for that. Okay, to find a question from the floor. My question is about the same technique in open surgery. We divide the PP we and like it, why are we not replicating that in laproscopic surgery? There is no good evidence that if you do a circumferential incision of the deep ring, you can easily separate the Watson vessels and you'll find that you don't need a level stitch for that. Um Yeah, I mean that is a good point. And once again, there are surgeons in the center that this state comes from that do perform kind of like a herniorrhaphy type procedure. Um But once again, did not analyze for that specific um uh procedure. Okay. Thank very much. So, our final presentation for this session is on the use of botulinum toxin type A, an abdominal defects in Children K series experience from a tertiary pediatric surgical center in the UK. Thank you. Thank you very much, apologies about my voice and do my best. Um So abdominal world closure can be challenging in the pediatric population in a variety of different pathologies. Uh such as for example, large congenital abdominal world effect or when there is traumatic loss of domain or following prolonged laparoscopy. Me. The use of between toxin hey has been demonstrated and effective a junk in adults in the management of complex large incisional and ventral hernias. On the other hand, in Children in the literature, the only case reports available we do know is that Botox is safe and licensed in the pediatric use and is currently included in nice guidelines for other um pediatric pathologies. We present our experience in the use of preoperative or intraoperative injection of botulinum over a four year period of time data were collected retrospectively from clinical and pharmacy records. 14 patient's were included in this study. Six were neonate with a medium weight of 3.2 kg and it does use range between 1 5200 and 50 units. Uh eight in the eight older Children cohort. As you can see, the weight is obviously um the weight range is obviously larger but that those used was consistently 500 units. Clinical indications varied in the neonatal period. The majority where congenital abdominal wall defects but botulinum was also used in cases such as for example, extensive NAC um even with regards after laparoscopy me values where the conditions included, uh such as for example, following trauma, complicated liver transplant or in a case of open abdomen, uh following a complicated perforated appendicitis as expected due to the complexity of pathologies. In eight patient's, we had a primary facial closure while six patient still required a patulin mesh preoperative injections were all performed ultrasound scan guidance. Uh But when they were performing to operatively, they were done on the direct visions, there were no recorded uh botulinum related complications or abdominal compartment syndrome. This is an example of one of our patient's that that was referred to our center with an exam follows major. This patient had at each stage of preoperative injection of botulinum. This is the appearance after the first stage, they were then went on, on wearing a course it in the post operative time and this is the final result. This is another patient. Uh again, a quite large examples, major. This is after the first stage and this patient is currently waiting for the last stage of his procedure. So in conclusion, we can confirm that bottle in um is actually safe in our cohort of patient's can be considered an adjunct in patient's requiring complex abdominal wall closure. We hypothesized that it does have different effects based on when the injections are used. Our protocol currently recommend uh used of those between 255 100 units. Ideally 3 to 4 weeks prior to the operation. Uh We do monitor abdominal pressures in the first possibility period. Finally, we do recognize that this is a retrospective review of a single institution data. Um So our next steps are really to collectively prospect prospectively collect data, apologies and then um do uh this in a multi centric way. Thank you very much for your attention. Be happy to take any question. Run, Shaun run, run, Run Sean Marvin Sheffield. Uh Yeah, thanks for sharing that information with us. Um Yeah, in Sheffield, we've taken a different approach. We've been using the component separation technique and therefore we haven't had to use any prosthetic material. Um The cases that you used prosthetic material, were they in the giant um fellow seals? They were mixed. But yes. So, so you, but you might have achieved fascial closure if you'd considered component separation or some of the other techniques of fascial release. I think that's an excellent point in our data. We were are not able to statistically make an analysis regarding the different techniques. But that's also part of why I think we will proceed with prospective data, analyzing and taking into account different techniques. Absolutely. But in my opinion, it's better to avoid the prosthesis, get fascial closure. So it is possible. Absolutely. Thank you know, Bruce, again, I don't understand this. You're suggesting that you're avoiding a compartment syndrome by paralyzing the patient's muscles. If that was the case, if I got a tight abdomen surely should take them back to theater and give them muscle paralysis. You don't get a compartment syndrome because the patient's contracting their muscles, you get a compartment syndrome because that space isn't tighten of paralyzing their muscles won't make any difference to that. Absolutely. I do apologize if that was the message that came across. We're not suggesting that botulinum does prevent compartment syndrome. What we are suggesting is that possibly it does have a role as an adjunct in this complex patient's. Thank you, I'm one of the authors. So just to respond to Sean a component, uh separation is a major procedure and does carry long term complications. That's why we tend not to do it, but it's, it's an option in the, in the long run. Uh Bruce, uh The reason why you inject Botox is to help partial gradual long term reduction. So because it expands the to me easily over the following six months, so it's not to award compartment syndrome is to make the tissues go down, organs go and gradually and then they come to the next stage and then you can close it. Thank you. Thank you. Thank you. If the presenters could just check the chat, there may be other questions inquiries that have been asked. So please feel free to respond to those. I think.