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Summary

This on-demand teaching session is relevant to medical professionals and will cover common upper GI surgery emergencies, such as Bulla Hives and Obstructed Hiatal Hernia. Led by clinical fellow Jack from SUD Royal Hospital, the session will draw on his specialist interest in Bariatric Surgery Pre and Post operative care. The session will discuss best practices when early diagnoses is critical for the prognosis of the patient, particularly with Bulla Hives in order to increase survival rates. Come to this on-demand teaching session and gain insight into an often forgotten surgery emergency and learn how to reduce mortality.
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Description

Dr. Jack Thomson is a prolific researcher and a fellow at tertiary UGI centre, Salford Royal Hospital. He has a special interest in prehabilitation, health inequality and bariatric pre- and post-operative care

Learning objectives

Learning Objectives 1. Discuss the etiology of esophageal perforation, specifically Bo Nile’s with its risk factors and typical presentation. 2. Learn the criteria for accurate diagnoses of Bo Nile’s, Mala triad, and Hammon Syndrome. 3. Identify the complications associated with bo hives. 4. Learn the prognosis for Bo Nile’s and correlation to the timely diagnosis. 5. Understand the immediate management for patients with Bo Nile’s and discussion of an actual case.
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Computer generated transcript

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

Hello, everybody. My name is Rebecca. I can see more people are joining. Good evening. Um I'll be moderating this session today. Jack. Have you gone live? Uh I, I can as I shared my screen. No, no, just like click go live. I think so. Ok, good then. Um So Jack is um a colleague and he's a clinical fellow in SUD Royal Hospital in the upper G I department. He's um got an interest in bariatric surgery, um both preoperative and postoperative management of patients. Um He's going to be taking us on the common um upper G I surgery emergencies that we usually see, you know, in the upper G I department in R hospital, which is actually the subspecialty, um which is the specialty of the specialty hospital, the tertiary hospital for upper G I um in upper G I surgery in the North West. Um I'm going to in a few minutes, give the floor to Jack to carry on with some of these emergencies and how they are managed. All right, Jack, thanks. Thanks for the instruction. So, so yeah, so I'm gonna go through um a couple of emergencies. It's quite difficult in a short space of time to deal with all of them. Um, and I think it's really important if I've got the opportunity to discuss, um, what for the majority of people they may see once or twice in their career, if not at all. But things that we see most commonly as em said in the tertiary center. Um, so I can, if I present now, does that share my screen? Let's have a look. Yep. Yeah, we can see the screen, excuse my chaos of my, uh, desktop. Right. So we're gonna go through depending on time. Um, two major upper G I emergencies that we see those being bo hives and obstructed hiatal hernia. If we do have time, we'll talk about, um, some bariatrics as well. Um, which I, because I have obviously have a specialist interest in. So I want to go in through this in too much detail. But I think it's important to think about how upper G surgery has developed in the most recent times. And actually, it's really been the last, even 30 40 years where there's been big changes. Um, the, the majority of the big changes have been the introduction of proton pump inhibitors. So, there was previously a lot of upper G I surgery was in regards to peptic ulcer disease, um, with vagotomy, um, things like that. Um, if you can see on the top right there, that's actually, um, an esophagectomy back in the 19 I think it was just the turn of the 19 hundreds, 1910 or something um where they used tubing, external tubing as a neo esophagus. They called it for these patients. In fact, it's, it's, it's quite interesting, this patient actually lived 30 years after his esophagectomy, um which I think is quite impressive to live at that for 30 years. So the first emergency in the one that gives the majority of upper G I surgeons most fear and that's bull hooves. Um So Boho is a spontaneous perforation of the esophagus. It results from a massive increase of intraesophageal pressure with a negative intrathoracic pressure. As I've just said, you know, you may not ever see it. A lot of people may never ever see it in their career and it's about 3.1 per 1000 people per year. Um But again, that does change on regards to whether we're here talking about bull Harve compared to esophageal perforation, which I'll discuss in a little bit a little bit later. Um There's two peaks, 4th and 6th decades in the forties and sixties, males are more commonly affected than females. Um The majority of people who get true bull hives actually occurs in someone who's got a normal esophagus. Um But obviously, people who have got risk factors for bull hives includes people with underlying benign strictures from um reflux optic esophagitis, um Barrett's and also people with ulcers. Um It's obviously strongly associated with excessive alcohol and excessive um, er, binge eating sort of thing. So, it was actually first described um by an admiral in um, in Holland, I think it was who in the autopsy described smelling olive oil and duck fat from the chest and that's where it was first described. Um, it usually occurs at the weakest point of the esophagus, um which is at the distal left side, um about 2 to 3 centimeters from the go J or the gastric esophageal junction. The sudden rise in intramural pressure is it's thought to be caused by a in coordination between two reflex in your muscular and the Karyn ial muscles to relax. So it sort of traps itself in there. The theory is that when you're having someone who is vomiting. So on several occasions, because of the amount they're vomiting and the frequency they are trying to take a deep breath while also their body is thinking that it wants to vomit. And that's the theory behind it. Um As I said, it's usually the posterolateral aspect of the distal esophagus and a 2 to 3 centimeters from the GJ. It can also happen in the upper thorax. Um that's usually managed by ent um and that's usually managed very conservatively um with sometimes a cervical drain if anything. Um And normally in adults, it goes into the left, but interestingly in peds, it tends to go to the right, but obviously, it's very, very rarely ever seen in pediatrics. Um then there's no genetic risk factors. The prognosis for bull hives is actually really quite bad. Um The biggest and most important thing, football harvest is diagnosis early. So you've got a um prognosis of 75% survival if the diagnosis is made and treatment is underway in 24 hours. And then as you can see that it drops 50% and then 10% more than in 48 hours. Um The complications of um uh have, you know, includes things like the septicemia, pneum, mediastinum, mediastinitis, hydropneumothorax, empyema, and obviously subcutaneous emphysema. The thing about this is it's quite um it's profound if I talk about pneumomediastinum, for example, you can get type one and type two pneumomediastinum. So you can also get pneumomediastinum from Bulla called Hammon Syndrome, which is often something that gets referred to us for consideration of a um esophageal perforation. Now, the difference is is the pneumomediastinum with bo halves is quite significant. It's not just usually a couple of um air locus but quite, quite significant. Um If there is a pleural and an intrathoracic pleural breach, obviously, you can imagine the amount of air that has to go through the esophageal wall and then through the visceral um sorry, the parietal pleura as well to perforate through that. So the rest of it tracks obviously up the mediastinum between the esophagus and the parietal pleura, um subcutaneous emphysema can be seen with or hives. Definitely. And it's one of the critical symptoms that we'll talk about shortly. Um, with Hammon syndrome, you see really significant subcutaneous emphysema but not so significant. Um, pneum iun stum. So that's where they sort of opposite each other. Um, this one, I, I was, when I was making these slides, I was having a look at this. Um, and it was, um, quite hard hitting for me in that 63% of people with bore hives are incorrectly diagnosed on attendance to any emergency department. And actually on, on sort of reflection, I think that's what we see the most of um the um the majority of times the um respiratory physicians, for example, will call us um with a concern of a patient who's got a chest strain, who came in with the hydropneumothorax, A&E pays the chest strain and admitted to a respiratory ward and they're concerned that what they're seeing is tea and biscuits in the drain. And that's when people get sat on um, a medical ward somewhere for a prolonged period of time without treatment. Um And that's where we see the difficulties and the mortalities in these patients. So if we talk about the stereotypical history of patients with bo hives, um there is the Malas triad, which is vomiting, chest pain and subcutaneous emphysema that sort of pathetic of a concern over um, a esophageal blowout and, and a bo hives. Um usually happens in middleaged men. I think that's probably because they are more likely to be those who are drinking excessively and having excessive dietary intake. Um, hematemesis isn't usually seen um with bo hives which because it tends to collect in the chest cavity itself. Now, if you do have a patient with similar symptoms, chest pain, vomiting and hematemesis, you do need to think about a mall waste tear. Now, they can cause full thickness tears but they tend to be longitudinal quite long and going up the esophagus itself. Um They obviously can cause if they full thickness, they can cause pneumomediastinum, but they tend not to cause the significant um pleural effusion that we see with bore hives. Um And that's because it tends to be um quite linear instead of a massive explosion, you can think about with bore hives at the bottom of the esophagus. Sometimes you can see people getting a cough reflex, so they will drink something and then they'll start coughing. That can be quite difficult to differentiate between people who have got a potential tracheal esophageal fistula, which we do see in upper G I patients with cancer. So it um mostly squamous cell cancers. Um They often get cough reflex when they have fistulas. Um but it's more about a diaphragmatic um reflex compared to them actually being able to expectorate what they're drinking. Um And of course, shortness of breath is the thing of having a massive left sided hydropneumothorax, subcutaneous emphysema is seen in the majority of people and that's obviously within malas triad, um, patients who do come in with bore hives, proper bore hives as in vomiting against a closed glottis and esophageal blowout. They are sick. Um, so these patients often are hypotensive tachycardic, high temperatures, usually on 15 liters of oxygen and things like that. Um, the hamming crunch is nonspecific. It's quite difficult, I think to say. Um, the theory is that you can hear the, the pneumomediastinum on auscultation of the heart beating. I've never heard it, I've never heard it myself. Um but it's out there. Um Rarer things you can see on physical examination, tracheal and media spinal shift um from obviously a massive left hydrogen with thorax, which obviously in these cases, um you treat as your a three assessment and you go as you do as you go and you would treat with obviously an emergency chest rate at that point, hoarseness of the voice from a laryngeal current recurrent laryngeal injury. Um and you can sometimes see vein distension from such significant pneumomediastinum, which can cause cardiac compression and obviously things like that um proptosis. Um So this is just um just a brief case that I'd like to talk about. Really, um I have a lady 71 year old who presented into a local emergency department with abdominal pain, right, upper quadrant shortness of breath, she was really, really sick when she came in. As you can imagine if you can look at that CT scan on the right hand side there, she's got, she's got mediastinal shift. She's got a hygiene of thorax and a collapsed lung. She had a left hydro pneumothorax on a chest x-ray, she had um bilateral chest drains inserted by, I think it was the um uh A&E doctors um and then was sent up to critical care. Now, the drain was inserted and it drained obviously f pus. Um There was a concern that they were saying it, it was an empyema and all of these things and the culture they sent off at the time of insertion grew can. She was treated for three days on intensive care at a local hospital with intravenous fluid and intravenous antibiotics. And this lady was eating and drinking um with this without a ro ro out of an esophageal perforation. And this patient was quite lucky in the fact that there was a loco ICU consultant who was working on the day who said I work at Sulfur Royal. And this patient looks at me like they've got houses and that's where they got, we got the phone call. So the lady actually ended up doing quite well and was eventually discharged home, actually saw her last week in clinic and she was doing grand. So when people come in and I don't wanna prey to someone who is saying from the surgical side that your sea or ha all the time. But what I want to sort of try and put out there and reiterate the importance of is the simple measures like performing a chest x-ray for patients who come in with acute chest pain. So I'll give you an example of a patient who was treated for a as just recently who um actually had an esophageal perforation and he had such a massive hematoma at his dis esophagus because of the being treated with the clopidogrel and aspirin um that he was profoundly unwell with it. So patients with bull hives can get raised troponins and that can be from them having a type two mi but also having, you know, pork pie and chips in their mediastinal cavity, well, mostly air but, but it's still the same in the sense that it's irritant and it will and it can cause raised card enzymes. They can obviously also come in with profound um acute kidney injury from overwhelming sepsis, which can also contribute to raised troponin levels. I would advocate if patients, people are having a emergency chest drin insertion. Um even really with a history of trauma because you can have um esophageal perforation from blunt trauma. Although it's very, very rare is I would, I would emphasize the importance of doing simple tests like an amylase on these samples. It's really quick. It's easy. The ayla with it in a bore hus is extremely high. I I put more than 1000 there, but I'd say more than, you know, 4000, 500 is the highest I've seen. Um if it is very high and there is a concern, then you always, or a CT with oral contrast is always needs to be performed. And that scan um should be reviewed by a radiologist who is competent to um examine for an esophageal injury because it can be quite difficult to see. And if you are reviewing the scans, I would recommend when you are looking at the imaging is to um is to examine the actual density and the look of the pleural effusion itself. Um because you can't necessarily with a CT scan, see exactly where the esophageal perforation is. And that's because it's not a dynamic study. So you can obviously do fluoroscopic investigations which are oral contrast swallows where you can give them omnipaque and do several imaging and the x-rays at the same time to follow that contrast out. Now that you would be able to see exactly where the esophageal injury is, but it can be more difficult in the um to see that with the CT scan. So what you want to be really looking at to say is to look at the pleural effusion itself and say is that um you know, enhancing, can you potentially see contrast there? Now, if there is, you know, potentially a concern at these patients, should you know, to confirm diagnosis if you can't do a swallow, which you know, is a fluoroscopic study, it can be quite difficult and all hospitals have access to it is to do an endoscopy, um is to do an OGD and examine the esophagus under a direct vision. The reason why we do, we recommend doing CT S with oral contrast is not just to see the actual leak or the hole itself, but it also helps us to be able to plan the surgical operation plan if there is a perforation and we'll talk about that and the different ways that we can treat bull house shortly. But you have to think about what sort of thoracotomy or washout that you're going to have to do. And in order to assess that you need to see how bad the chest collection is and whether you need to do any kind of decoration and things like that on the chest wall. If we go back to this woman, she had really, really dense um pleural adhesions as you can imagine that she was left for three days. This was all scarred and she required about, we did about 22 hours of decortication on her to be able to expand her lung, um which is really important in the surgical treatment of bo hives um is to get that lung reopened because they have ongoing sepsis for a good week and more and they need that extra lung capacity to be able to meet their oxygen requirements from their sepsis. So, if we go to this lady that just that lady before, I've just this is a slightly different image um of the scan which she had. And I'd like to draw your attention here. So obviously, you've got bilateral um pleural effusions here that we can we can all see. Um this is after the chest drain was put in. So the pneumothorax has got better and this lung is a bit more expanded. Um What you can see here is this mediastinal gas. So you can see some air around the aorta here. You can see all this air here as well around the right main um sorry, the um the left main bronchus, but you can also just make out an esophageal injury here. Um It was a slightly unusual position to be honest with it. And that's because this lady actually um on several endoscopies, she had um pyloric stenosis that was thankfully benign. Um But that was probably one of the contributing factors to her bull hives and the fact that she was also an alcoholic. So she had peptic ulcer disease which led to um you know, poor gastric emptying and things like that and then chronic gastroparesis. Um but you can just see um there how that gas is going extra Luminal around the esophagus. So we talk about the management of bull hubs, I think um it's important just to talk about just some key points here that I think um really improve patient outcomes, obviously, of everyone who comes into the emergency departments and gets AAA 33 assessment. Um, these patients require like quite complex resuscitation, um, with, you know, lots of fluid IV, fluid oxygen. Sorry to cut you up, Jack. I don't know if it's me but I don't think I'm seeing the slight move. I think it's stuck on investigations. Sorry. Uh, let me try getting it out of it and I'll do reload it. Is it still stuck? Yes, it is. And, uh, uh, can you, what, what are you seeing now in MCA? Sorry, you still seeing? I don't know if it's from me, but I'm still seeing investigations is what I can see. Hm. Ok. Then I think it's from my end because the slides are moving, someone just chatted, put on the chat box, the slides are moving. Ok. Fine. I can't see the chat box if there's anything on there, please let me know. Yeah. So there's a question there but I'm waiting for you to finish the, um, management and then next. Ok, that's fine. Thanks. Yeah, I me ask you the question. Yes. Um, so, yeah, so they require quite significant resuscitation when they're in the emergency department. Um, early broad spectrum antibiotics, as you can imagine. The, it's interesting. So we always give patients antifungal therapy. Um, and it's, we consider that to be the gold standard. Now, I had actually had a very interesting conversation with the oncologist recently and he was suggesting that, um, there is lack of evidence for use of antifungals in bo hives. But then I went through it and I don't think there's been any decent randomized controlled trials because I think ethically you couldn't not give these people um fungal treatment when they are so unwell. So we do them and we give them antifungal therapy because the esophagus itself tends to colonize with, with can. Um And if you're blowing through that, then you haven't got the stomach to sort of kill that can. So I would advocate for the use of antifungals in this patient. Um If they've got significant mediastinitis and media sinal collections, they should get six weeks of antibiotics. And that's because of the, you know how deep seated it can be, it can be a bit. Um It depends on how good your claudication you think you've done in the operation and how much lavage you think. So, it's, it's quite a difficult decision about the length, of course, for antibiotics and it really depends on how the patient responds and does with the management that you give and all these patients as you can imagine require intravenous proton pump inhibitor, which is obviously omeprazole. I wouldn't recommend using the Hong Kong regimen, but just doing 40 mgs twice a day. Um PPI gastric drainage is really important. The majority of these patients and a lot of people who end up getting bore hives unfortunately have often have a history of reflux. They can be and tend to be can be obese. So, gastric drainage is really important in order to prevent, um, things especially bowel reflux, which obviously if you've got a hole in your esophagus, ain't going to help us with our healing. We've already talked about the investigations. Um, but we'll also talk here about making sure obviously the patient is nil by mouth and getting that patient early total on parenteral nutrition. So, if we're talking about from a dietician and a nutrition point of view, the overwhelming sepsis here with bore halves, um, it has a massive increase in their metabolic profile and these patients need like a lot and lot of calories and a lot of nutritional support. If they don't, they dramatically and very quickly lose significant amounts of weight and then you're in a losing battle with keeping them um systemically well enough to carry on in their recovery. There are several different operative options that we will be discussing and we'll go through some of them and this is all quite new and there's lots of different, there's been lots of changes in the last six years in regards to management of bo hives and any esophageal perforation. The, the simple principle that patients need to control their sepsis is a wash out of their chest. Um That is the, the intervention that is um life saving for these patients. So you can place wide bo chest strains and give them a good chest washout. Now, that washout can be achieved endoscopically and we'll talk about that in a little while or obviously by a um Vass or a Thoracotomy. The endoluminal vacuum therapy or EVAC is um EVT is a new technique that was introduced in 2013, 2014. Um Some people might not have heard of im vacuum therapy. There's only about two or three centers in the United Kingdom that are actually doing this. Um We do it at Salford and we've actually got some really good results from it. Um Otherwise you probably all heard about tea tubes, so you can use tea tubes with um um we have and we'll talk about how that's done shortly. Very rarely, people can have esophagectomy and esophagostomy. Um It's done very rarely because that's what an eight hour operation and the majority of times people aren't um well enough to be able to undergo that. And the anesthetist wouldn't be particularly happy if you turned around and said, oh, we're just going to do a quick esophagectomy and a colonic interposition for these patients. I think they would have a bit of a breakdown. Um But you can do um reconstruction later and just do an esophagostomy and then do a colic interposition later if needed. Um Sometimes you can do primary repair that often we can do that. We consider that in mostly younger people. And that's because they, they tend to do better um preoperatively and compensate better and do better on the vent ventilator when they are anesthetized. And there are different ways that we can do sort of patch repairs of the esophagus, but we sometimes do a collection of things. So we might do a pleural flap and a T tube. Um It depends on how big and how bad the um the perforation is. Um endoscopy, pre opening. That chest is really important to start thinking about planning. And that's why I was also talking about the importance of getting preoperative cross section imaging is to be able to see how big this contamination is in the chest. Maybe if we can see how big the defect is or have an inference about where the defect is. Um and things like that the other part of the operation and it's not to forget, you have to control the cyst, but you also have to make sure that you're giving the patient the best shot. So we often will do a venting gastrostomy and that is done because they, people can often go into IES um as well post um thoracotomy and laparotomy. So that's a way of being able to decompress them and we will usually insert a feeding jejunostomy, um which is a feeding tube into your Jejune with a whistle's tunnel. Um We do those instead of using a venting gastrostomy because we don't want to feed in their stomach in case they end up getting nausea from several, you know, reasons, medications, postoperatively anesthetic, all of this stuff and we don't want them to start vomiting, um, with, um, lots of feed in their tummy. Um, the, some centers do and I've heard of some centers do a venting gastrostomy with a Gegen extension, um, which is a two prong, um, peg tube, which has got a, um, venting part and also a feeding tube part. Um, I think as basic principles you just do as little as you need to and get out, um, making your life more complicated by risking having the part of the gastrostomy occluding because it's not big enough and all this sort of stuff. So we put a 12 French venting gastrostomy and we usually use a 12 French 30 catheter or a 12 French peg. Um There are others that we will talk about conservative management, stent glues end clips and we'll talk about indications for those. Um So this is a flowsheet that was used, um, quite, um, often and probably about six years ago and it hasn't really been updated yet. Um So this is done by came and it was quite a good thing. It was really helpful. It sort of looked at, you've got someone who's got perforation. How do you go about handling it? And it's, it's a, it's a direction for physicians and surgeons obviously to think about what sort of, um, how they should target this repair because it's, you've got a one chance saloon, so to speak. They come in. You've got a hole, you need to think about what you're going to do about it. So it sort of talks about how unwell the patient is and how stable they are. Um, and it also talks about whether there is potential malignancy stricture or whether there isn't. So that definitely does obviously change what your management plan would be. Now, this is very rare to say, I have to say, um, I've only seen, um, a perforation or a bore hives with a malignancy with esophageal cancer, which was an SCC. Unfortunately, that patient was, was very comorbid and wasn't fit for, for surgery or, or for any active management. But theoretically, if you had a patient who ended up getting a bore halves with a malignancy, you would just do, you could consider doing an emergent esophagectomy. Um The complexity of that is they have to be relatively well because the guidance is that you should not really be performing an esophagectomy without a upper G I anesthetist because it requires ventilation and one lung. You require specialist theater staff and obviously, um ICU support. So they are usually done in working hours the next day on the next, on the next, um, upper G I inpatient or outpatient list. Um, we don't tend to deal with, as I said, cervical perforations or talking about that because cervical perforations um, should be managed by the ear, nose and throat specialists. Um, we often do help them if we need to, we'll escape them, we'll get them hands and things like that. Um But we're talking here mostly about the thoracic and the abdominal. Um when we're, this is sort of become slightly outdated in the United Kingdom and that's in the centers that do it because of the use of endoscopic, more endoscopic treatment. And we'll talk about that now. Uh yeah, talk about that now. So first of all, as I said before, endoscopic treatment um is important even just for diagnosis at the before you um open their chest. So you definitely want to do an endoscopy. Um Everyone should have a chest drain before they even arrive onto the theater table. So they should get bilateral wide bore, you know, at least a 20 to a, no, I say bigger than a 20 you know, 26 French big surgical drain before they even get onto the anesthetic table to drain everything because otherwise their ventilation will just be near and possible. The other reason for the emergency chest drain in A&E is anesthetist will inevitably when they anesthetize, when they ventilate someone, they'll be pushing air down their esophagus, everyone knows that can happen. Um Now if there is a hole and it's leading to the pleura and they end up pumping gas and unfortunately going down their esophagus, they could, you could be dealing there with a tension scenario that could make a controlled environment suddenly very, very, not controlled in and an EMG created yourself an emergency situation. Um Endoscopic therapies include things like metal clips. So um Endoclips um or over the scope clips, they can be quite good from our experience at Salford. They have to be pretty small defects because they fall off. They cause strictures. Um and they don't really um have much use in proper hus, they have definitely have great use in endoscopic um perforations because those are inherently clean, you know, um the patient is starved for a prolonged period of time before they have their endoscopy and they are using well sterile, I um and they're using sterile water or sterile or insulation for air. Um And we're going to talk about the ezo sponge or the EVT in just a second. Another part of endo endoscopy, even for conservative management would be an NG and an NG tube. Um I wouldn't recommend patients who have bore hives in the emergency department having a benign ras tube inserted. Um because obviously you could just end up going through the perforation or making that perforation worse. Um The benefit of having J tube is obviously for feeding and the tube as drainage. Um This is another part of things that you have to kind of consider when you're thinking about hives is you treat it. But I'm talking, you know, six weeks down the line because that's how long these patients can be in hospital is to remember that if you're going to have such significant injury to your esophagus or from their pathology that may have led to their bore hives is that they will end up stricturing. And it's very, very common that people get post, um, bore Harve, stricturing and healing, um, sorry, stricturing, the scarring of their esophagus so they can get um benign strictures in the future. Um, so I think it's important to remember that because there will be investigations that people require as an outpatient, including dynamic oral contrast and also endoscopies in the future. And it's the fact that these patients don't get discharged and get no follow up in this part of our follow up protocol. So another thing here we talked about is stents. So I think if we talk about stents, um, we don't really use them in acute bore hives and I don't really see much of a role, although there might be some people who actually do use them online for stents in bore hus, they do have a role in, um, patients with malignant or benign strictures where they're perforated because they work very well. The problem with stents is they fall and they slip unless there is, um, pathology that's making something tight. So they have to have the good landing marks or landing points proximally and distally and in the middle, it has to be tight. Otherwise the thing will just fall straight through into the stomach and then cause a bowel obstruction. Um, it's also important to mention that use of stents in benign disease, they have to be stents that you have to think about removing because benign disease can improve. A malignant disease will be different. And you have to consider whether they're going for things like radiotherapy or chemotherapy in the sense that if you suspect there is a possibility that that occlusion or the actual pathology of the esophagus may improve, you need to make sure that you're keeping an eye on your stent. So it doesn't move out the wrong way because what's keeping it in place isn't the stent, it's that it's putting pressure against the pathology, there is up and coming. Um stent sponges. Um But we'll, and we'll talk about those in, in just a moment. So, um sponge. So I'm big on easy sponges. Em a cook can probably remember. We do lots of easy sponges at Sulfon and one with the biggest center that does that I think um apart from in Holland, but us in Holland in Europe. Um Now, so if we talk about the history of this, of, of endoscopic vacuum therapy, um you take it to, they used it, I think before in colorectal at times for anastomotic leaks in, in anterior low anterior resections. Um but it's kind of been slightly adapted and it's a longer tube for us in obviously, in our esophagus. So it's a new technique. Um So the data is up and coming and we've recently had um a big publication from what we've done at Salford. And our, in regards to use therapy, it's quite labor intensive because it, you have to go to theater every 3 to 5 days to change the sponge. Um And that's because of one of its things that it does is it promotes healing. So the sponge itself um goes into a cavity of the esophagus and it's placed on a vacuum at 100 and 25 mg, mercury um and it's on continuous suction therapy and it causes, and it promotes granular um tissue formation because it's drawing in um uh scarring and it's, and it's causing the body to have that reaction. It also obviously removes the sepsis by taking away the pus and the m and stuff from the hives and it takes it out of the body into the back. Um It can improve, obviously, the both the mediastinal collection and obviously the chest collection. Now, on that note, it's an important thing to say and that's if you are placing a sponge into someone for um who's got a heart who has, who has chest drains, the chest drains at some point will have to be removed earlier than what you would do if you had a T tube. And that's because if you are placing continuous suction on the sponge and you have a drain which is still in the pleural cavity, you'll end up sort of creating your own fistulous tract between the chest drain, lumen and the distal part of the sponge and then it just won't heal if we can consider a cavity at the floor of the cavity just here. So if you imagine you've got a chest drain that's inserted just on this patient here. And it say it's in the, it's a left basal chest drain. And the lumen is just here in the chest wall. The base of this cavity from this, what the sponge is creating this cavity here is, it will just create a fission and the floor of this will never heal. So as you can see, the sponge goes into the hole or the perforation or the ball half to it, and it creates this walled lining of this, of this to control everything. Now, each time we go in every 3 to 5 days, we remove it and that's because it will end up sticking to it. And then we don't want to pull out everything that we've done and heals. But every time we move it a bit further in and a bit further in and a bit further in until we're at a point where the sponge is intraluminal ie within the, within the neo esophagus, then this cavity ends up closing itself off. Um I suppose you can consider it minimally invasive because you don't necessarily need to do a vat or a thoracotomy. And that's because what you can do is you can just place when you do the endoscopy, you place the endoscopy and you go through the actual perforation and then you gave it a really, really good lavage with the chest drain in situ and then it all pours out of the chest drain. The anat tests can get a bit upset because, um, you want to put them in different positions and things to make sure you're getting rid of everything and we like to do it and we like to wash out until the chest dr runs clear because of the amount of times you have to go to theater. And the average sponge change that we do is 6 to 12. So you can talking up to eight weeks or six weeks of therapy, it's very labor intensive and it's very costly. Um, you know, you're talking about two hours in theater each day, consulting an assist intubation anesthetic, they have to be done under a general anesthetic because the size of the sponge when you're taking it out can risk them. Um, you can include someone's airway with it because it's quite large and it has to come out of the mouth. Um, so you shouldn't really be doing it under a local, um, under sedation or an endoscopy. Um, it's possible to potentially remove them if, then if they've been trimmed and they're not too big, but otherwise, um, it, it would be very dangerous to do it um, in, er, without being in theater because obviously it's a very new technique that means that it's quite specialist and it's not global. Um It's used in certain centers with very senior and experienced endoscopist. Um You, when you are doing each endoscopy, you need someone who does not use massive amounts of insulation and doesn't pump air because that will burst the hole. So you use low pressure, you have to um keep the sponge in the cavity whilst withdrawing the endoscopy as not to pull out the sponge at the same time. Um and just leave it in the wrong place. Um And you have to be able to um do a wash that is under both high pressure when you need it, but low pressure when you also need it. So it's obviously quite a specialist technique that um not many people will be able to be performed. Um So the, so this is obviously, I said this is the vacuum canister. Um This is on a continuous suction. Um in Holland, they do different pressure suction depending on whether it is in the actual abscess or cavity itself or whether it's intraluminal. We don't do that at Salford and we discussed it at a recent conference in, in Oxford about whether we should reduce the pressure. And I think the reason why they talked about it is because they leave the sponges in for longer than we do. So we like to take it out 3 to 5 days and we do it depending on what we feel. The endoscopy is how it's going to stick, we change and make it more is earlier, but they don't have the ability to have emergency theater or access to XY and Z theater when they do. So, they have it under lower pressure. That means that they do on average 10 to 18 sponges whereas we do 6 to 12. So it's a bit more intensive. Um And then we can talk about. So that's endoscopic management of um bull hives. And now let's go on to what everyone loves to hear about and that's the surgical option. So that's you got your knife in your hand, so to speak. Um When we're considering what approach or how we're going to approach a patient with bore hives, we have to think about a couple of things and I've already um sort of suggested one of them already and that be with the contamination in regards to the cross section imaging. Um But the site of where the perforation is, um if you're even going to be able to access it, if you want to do a primary closure, for example, um timeframe, a lot of people rarely present within 24 hours with bull hives. That's not necessarily just when they present to A&E but the point at which their diagnosis is made is very, very rarely, um less than 24 hours, you can tie your esophagus as much as you like or as well as you like more than 24 hours but it won't heal. Um, and it will just break down and then you'll be, find yourself in a worse, worse, more, um, difficult situation. Contamination of both the chest and the mediastinum, um, will make you, um, think about whether you need to do a decortication or whether a simple lavage or wash out from a vats will be satisfactory. Um, the health of the tissue and the physiological state of the patient. Um The, this is thought to do with, you know, the similar to an upper G I believe in regards to the er, er, the circle of, of whether they're too sick for theater or not sick enough for theater. Um And it's to say really that if they are profoundly unwell, you need to obviously make sure you're giving really good resuscitation. And there is an argument of delaying any sort of big operative management until you have people available who are senior in not just surgical technique. Obviously, an upper G I consultant needs to be there, but obviously your anesthetic staff, your scrub nurse, your ODP and all of these other factors that contribute to human factors within an operation. I mean, um we've gone into theater overnight and said we need an upper G I on the tract and then the scrub nurses that looked at us and said, what's an upper G I on the tract? Because she normally does neurosurgery. So it's simple things like that and it's surprising how much. Hi Doc. I think your microphone is off. Women. Can you hear me now? Yes, I can. Yes, I can. Yeah. Sorry, I don't know what happened there. Where was I, Mica? So, yeah, so sorry. So fundamental principles. Correct approach. Lavage, lavage lavage wash, wash, wash. Um That's meant to say repair to bride resect and what I talked about before being the importance of lung re expansion. So that's when we would talk about whether they need decoration and things like that. So if we talk about surgical approaches to hives, um different, it's difficult, I'd say different depending on the location of where the ball have, where the perforation is. If it's, if it's a proper ball Harve that it's left posterolateral, you do a left thoracotomy laparotomy or a vats. Um If it's more on the right side, then you might want to do a right approach and that's where the CT scan comes in. Helpful. Um You can do your um decontamination with lavage or, and large bo chest drains. In regards to repairing, you can do a primary repair or you can do reinforced repair, which is what I was talking about before in regards to the use of pleural flaps and pericardial flaps and all of these other things um or repair around the T tube. And we will talk about that in a second. You can obviously do if they are stable enough and they're young enough an or an esophagectomy. Now, primary reconstruction could be a clonic into position um or it could be a um conduit formation from the stomach. Now, if you're talking about someone with a significant esophageal perforation, you would want to go in and go out as quick as you can. And especially if you were doing an esophagectomy, you would probably want to do an esophagostomy and do a delayed reconstruction later with a chronic interposition. Um colic exposition, obviously, then you've got three anastomoses. You've got esophageal colonic, um colonic stomach and then colonic colonic anastomoses. So you want to make sure that your patient is not on significant amounts of vitro for sepsis when you're performing those three anastomosis cos otherwise they'll just leak from all three, which would not be very good for the poor patient. We've already talked about venting gastrostomy, feeding jejunostomy and not to forget the core surgical principle that nothing will heal or no perforation will heal if there is a distal stricture. So it's making sure that you have got an idea of your pathology about what you're dealing with. Are you dealing with someone who was on a binge, whether that's on a binge of alcohol or had? I don't know, um even an eating challenge or a food challenge, you've got to remember your history and your pathology about what's caused the perforation cos if you are missing a distal stricture from duodenal ulceration or things like that, they won't heal and you won't and everything you do will just not move. Um, so this is a tea tube. Um, I think probably people would have heard of tea tubes used a lot in other areas. Um, tea tubes can be used in the gallbladder. The small bowel, the stomach from a gastric perforation. That's not cancer. Um, as a principle, what the Q tube is trying to do is create a controlled fistula. It's divesting sepsis out of the chest. It's um controlling um the perforation around it and you'll have to have nearby chest drains here until that T tube is removed. So you place the tube within the neo esophagus, the actual, the, the t part of the tube, so to speak, um, it then comes out onto the chest wall. Now, this is made from a different type of material to a normal chest drain. So it's more like um material like silicone of a foley catheter. It's quite irritating, which is what you want it to be. So, because of the, the material is made from, is irritant. It creates this channel of fibrotic tissue around the edges and that takes 6 to 8 weeks. So this then creates a hole that you can control. So you could even call it an esopha cutaneous fistula along the P I mean, the base of the or wherever the G tube eventually ventures. Oh, and then it diverts everything along. Now you place the chest strain near the area because it will leak a little bit. And that's because when we were talking about, if you're doing this, why not do a primary repair? And that's because your repair here probably isn't very good. You're doing the best job that you can with the tissue that you're provided with. This repair doesn't hold particularly well. And that's why you have this tube in there. And it's to say, oh, no, don't, all this fluid. I don't want it to go through my, um, um, try and my, um, repair of my esophagus, but this, this channel is much nice and bigger. Please go this way. The tube itself needs to be relatively big. And that's because the esophagus is, is, uh, you know, quite, is actually a relatively big structure. Um, and, you know, there's a fair amount of things, even saliva that goes down there, unlike a T tube of your gallbladder, your gallbladder is a much smaller organ. Um, so it doesn't require as big of a, as a T tube. The time in which you remove the T tube is quite important. Um, you don't want to remove it too early because if you remove them too early, then you're not going to heal. So, what we like to do is a fluoroscopic or dynamic water soluble contrast study. And we do that and we want to see where the contrast is going. If it's leaking around the T tube, then you have to carry on and wait and you've got to be brave and say no, no by mouth. Continue with, um, jejunostomy feed, repeat the swallow study in two weeks time. And that's the process that you go through at the point where the esophagus is healed and it's no longer leaking around, um, your T tube. Then you can remove the T tube. You can just do it on the ward and pull it out and everyone gets a bit scared, but you just pull it out and it'll be fine. And then what you want to do is you then keep the chest drain. Keep on that chest drain and allow them to drink. Now, if they're, what we like to do is what we call a ribena test, which is just, you know, purple colored juice, get them to drink ribena. Now, if it comes out of the chest drain, it's not healed and you need to keep them no by mouth. But if it comes out of the fistula from the esopha cutaneous fistula, no problem. That's what we were expecting. This fistula will heal very quickly. Cos all fistula, a fistula will heal. As I said before. If there was no distal obstruction, the actual lower esophageal sphincter is a false sphincter. It's not like your ample varta or anything like that. It is pretty open. It, it's not particularly tight unless you've got a, um, unless you've got pathology there, whether that's a distal esophageal stricture or something like achalasia or something like that. That's when your low esophageal sphincter isn't working properly. Um And you would obviously run into lots of problems there. Um It's quite difficult to decide now because of the sponge to sponge or to teach you. And a lot of times that's a conversations that consultants have together and that's what the wider MDT MDT discussions involve. So Cameron's algorithm that we spoke about before can still support us in this decision. I mean, fundamentally T tube requires a thoracotomy. So the person has to be fit enough for a thoracotomy. But what ea sponges has introduced is patients who previously would be considered for a chest strain and potential conservative management. Now, uh we're bringing those kind of patients into the realm of operative treatment in regards to the use of E sponge. Now, the EA burge itself is, is really quick, you know, you compared to a thoracotomy, it's a much shorter operative time. So some people have suggested that an EO sponge is great. Say your patients really unwell. They're on 10 mils of Nora, they've got an esophageal perforation. You want to try and control the sepsis as best as you can do a quick sponge. Bit of a lavage and take him out of theater. You're done in an hour and a half, two hours. But the problem is a sponge does need a cavity, which is when we were looking at here, the sponge will be it will be very difficult for the sponge to have proper effect if you just had an open esophagus into the chest without a cavity. So if they scope and they see from the endoscopy through the hole in the, in the wall of the esophagus, if you see lung tissue, then really, you can't really be considering to do a um eso sponge. So this one, for example, if you look at this endoscopy here, so you've got your knee esophagus there, your limen here. You can see, obviously there's a large defect at seven o'clock. Now, what I can see on that, that endoscopy is you can see there is a cavity here. There's pus here. This is the body has started to encapsulate a cavity to try and heal itself and protect. So this will be perfect for a sponge. But if I saw lung, if I saw lung tissue there, and I could see even on inspiration, there was lung tissue, you can't really place a sponge because you're not gonna be able to get that cavity for it to hold. So if we go, oh, where was I? Sorry? Um Yeah. So I think it's, it's still um the jury's out. I think whether you um do a sponge, draw a T tube, I think if you've got someone who is fit for thoracotomy, you should proceed to a T tube. And that's because it also um is less intensive for the patient. Um They have to go under general anesthetic every three days, which is going to make them feel pretty groggy. Um, the T tube means once it's in, we stop and we, um, we see how we get the other thing as well is the size of the perforation. The, what they're doing in, in, um, Holland actually is doing, sometimes doing people with two sponges, so double sponge where they've got one sponge and one nostril, so to speak. I mean, the, the tube coming out of it and they've got another one on the other side for really big perforations. We wouldn't do that at Salford. Um If you have got a cavity that's that large or a perforation, that's that large, you need to be able to, um, er, you need to put in a tea tube and you need to suture around it. You need to make that cavity, you need to make that hole smaller. Um, so some take home messages for bull hives. I think, I think it's, it's um, I think the opportunity to talk about bull hus because I think it, it's a rare diagnosis that people often get missed. But I think if you're talking about the context of in a patient with an acute hydropneumothorax, I think you always need to consider esophageal perforation in differentials and that simply could be doing an amylase from the drain or if you wanted to, if you didn't have access to an amylase, you could get them to drink some ribena and then look at the chest drain and see what comes out. Um, if what is in that drain is enteric is when you need to take them. Obviously, again, think about HS. It could be quite difficult because when you're talking about an empyema, it can sometimes look a bit, you know, pus can look enteric. The PH would be less than 7.2 in someone with bull ha because it's, it's got um gastric juices. So it's going to be acidotic. So you could make a false diagnosis of an empyema because you know, the PH and all these other things, the lactate dehydrogenase would still be high. Um and all this other stuff. So I would recommend taking an amylase level. The early diagnosis and intervention is lifesaving. I mean, I made that clear um 48 72 48 hours mortality, survival rate of of 10% and mortality of 90%. Uh It's a, it's a no brainer really. Um these patients struggle. Um It's difficult. They are in hospital for a long, long time and they're no by mouth for a very long time as well. So it can be very mentally challenging for them. They, you could say they've got type four intestinal failure at this point. Um because of the time frame that we're talking about. So you can imagine how difficult it is to be it is for them. Um What the small things that we can do to try and support them is, you know, we give the nutrition via the jejunostomy. We give them um, regular staff and we give them emotional support with our, a advance with our nurse practitioners that we have. It's important that I don't stay all day in bed and just, uh, they do their physiotherapy and they get moving, they all get chest infections and they're already on bleach because they're on Zoc and fluconazole and all these other broad stretch antibiotics for the mediastinitis. Um So it can be very difficult. Um Some other things and observations that that many years of doing it is um antibiotics. Antibiotics are important. The microbiologists get a bit upset with us. Um because we like to say we like to stop them, but they say they've got mediastinitis, but we take inference on what we've done for the patient to drain a collection or something. The difference between a patient with an empyema who has had not had a vats or something like that is source control. So we like to think that when we're doing what we're doing, we're doing good source control whether that's with the naso sponge or a T tube and that's why we're doing it in the first place. So if we are getting that source control in, then the length of course of antibiotics um is inferred from that about whether we do it for six weeks or whether we try seeing how they go off antibiotics. The team that we have for our patients is really big. We've got specialist dieticians who also do a nutritionist. We've got really great intensivist and we've got really great ants. So we have got such a great team that all collectively deal with these patients because they are pretty much some of the most unwell patients in the hospital who have got a pulse. Um So it does really require an MDT approach to it. So, has anyone got any questions at the moment on, on what we've just discussed about Bo Hubs? Em, was there any questions? Yes. Yes. There, there are some questions that thank you very much Jack for that detailed um session regarding hives. I feel like it, it, it's, it's, it's very rare. It's usually a rare um diagnosis, but then it's very important not to miss it because any delay can lead to very fatal complications and morbidity that we do not want. I'll just go through the charts. There's somebody asking for how long can trans eso eso? Yeah, this is, this is really hard, isn't it? Because actually today what, um a, I've got a, um, a patient at the moment who we really want to do a tie four who has got hus um he's had about six line sepsis. He's had six positive blood cultures with all sorts of Peps, Staphylococcus XYZ and he still was spiking temperatures. So we want to do a tie on him, but the cardiologist is, are a bit concerned about it because he's had a, a normal TTE, I think if you're talking about when it's safe to do, um A if so say for example, an equivalent what we, so upper G I surgeons don't do tis, but what they do do is we do s so endoscopic ultrasound, which is basically the same thing. Um But at a different level, but what I would say is so we wouldn't really want to do a um A E US from six weeks from post discharge. Um because the pressure that you could do with stretching of the balloon when you're doing an E US potentially could lead to, you know, um breakdown of the healing tissue. I would say it would be different if you were treating a bore hives with someone with an eso sponge compared to someone with a T tube. And that's because we don't yet have much evidence about when the T tube and the er, the sponge people who have been sponged when, when the, when that um scarring in that tissue is really adequate for something like in the US. So what we tend to do with these patients when they go home is they get outpatient swallows to see how it's healing um and dynamic studies to see how the esophageal wall is healing before we allow them to have a proper diet of food. So, what I would say is really once the patient is at a point when they are eating a normal diet, then you could start talking about a toe because if we can do an E US at that point, then we could do a toe. Does that make sense? Does, does that answer your question? Uh Sorry, my microphone was, oh, it's OK. Didn't get that. Um So I can see that you can read the charts to the next one again from Doctor Mac Triad. Um I think the Macro Triad. So it's you, it's more, it was used more often than not previously when they didn't have access to such, you know, CT scans and things. And I think it was a, a basis that they used more often um when they didn't have access to CT scans, the, the usual presentation of Bo Hives is changing and it's changing because if we're talking about the difference between a bo hives and an esophageal perforation. Mhm Hives is an esophageal perforation. But the, the reasoning behind it is different. So people having more and more people now are having um SD so endoscopic therapies or um you know, endoscopic therapies for esophageal cancer and all this other stuff and we're getting better and better at doing that. So the, the the patients that we're getting is changing from the classic presentation to being more maybe the day of or the day after an endoscopy where they come in unwell or they are unwell after the endoscopy. So it's um I would say now we see less people with the macro triad of chest pain, surgical emphysema and vomiting. And we see more people with iatrogenic or those kind of perforations. But I would say as a key principle, I would say it's still a, it's still a valid triad um for people when they are presenting into the emergency department. Um So I, I would still say that actually, I would, I would say it would be more than 50% when you take all of the symptoms to together. Ok. Um I have a, I have just, um, one question that I have asked you before as well. Um The T tubes, I'm sorry, the endos sponge or the sge that we use, like how long I, I know that we try to use it for patients who don't have like very severe um, perforations and all that. But how long? And how many can we use before we decide that? Oh, this procedure is probably not going to solve the problem of this patient. And, and what is the next step? Yeah, this response doesn't work. You have to make that decision very early. Um So you have to either say you start doing a T tube or you do an eo sponge and very quickly change your mind. You, you, you can't say that you, we've done 10, 10 sponges. We now need to do a T tube it's not possible. It's not possible to now tie that tissue because it, because the T tube still requires healing, it still requires the body to heal this part of the esophagus. If you're leaving it that long, you would have to do an esophagectomy because that, that tissue will never heal. Ok. So what we have done in the past, if we've done a sponge, we've gone back the next day and done the tea tube, that's different. We can still do that because the time still works. But if you're talking about someone who's had five and easy sponges, you're committed at that point. And if you are gonna do and change your management plan, you're talking about an esophagostomy, a thoracotomy, an esophageal resection because you're at that point, you're dealing with, you know, fibrotic dead tissue that it won't heal. You know, you, you're downed at that point. It's very rare that you would get to that point down the line where there is failure of endoscopic treatment. And I think I would hope that it would be identified sooner by our surgeons when it's, um, being used. But it is definitely something that we need to consider, isn't it? Because it, it doesn't always work as, you know, it, it, um, it does and it can cause strictures. And then we, like, look at stents, I think if we're six or seven sponges in Emmi, we, we can use something called the, um, the, the vac stent, which um I haven't shown a picture of, let me just quickly show everyone if you can see my screen. Um So what a vax then is about, it's about five centimeters, it can't do with anything more than five centimeters. Um And if you can see my screen, um, here, this is on the outside, here is the same thing that's on an eso sponge where you've got this gray matter, which is placed on a vacuum. Now in the inside, in the lumen of this, it's actually open. And in Holland, they use these quite often for anastomotic leaks after esophagectomy because, you know, it's quite, you know, esophagectomy leaks, they not tend to be that big in size. They tend to be more circumferential than longitudinal. So they got circumferential use here with a VAC and they actually allow them to eat. Now, if you can imagine an Aist in Oxford on a couple of weeks ago, everyone was like, oh my God, you can let them eat so unbelievable, but we will or maybe not convinced. I mean, there is use for them in very specific scenarios when you're talking about, as I said, circum circumvention leaks from an esophagectomy. But I suppose if we're thinking here about patients who have got um say six or five or six sponges in, we could use this therapy to allow them to eat, to give us a point where we can reevaluate and maybe then do an elective esophagectomy or a, you know, count them for those things. Sometimes we can also do a, what we call a rendezvous procedure which I think you may have heard about from discussions before. Eic, if you do, you recall us using the word rendezvous procedure. Yes, I do remember. Yeah. So, a rendezvous procedure kind of means we are going back in, we are opening up the chest again and we're taking that fibrotic tissue away and decorticating, decorticating. So you get healthy tissue and then starting again. The problem with that is you don't know how much debridement you're gonna have to do and you might not be left with anything left. Ok. I don't think I've got time to do the um anything about bariatrics or um Hiatal hernias. Um But I think it was, it, I was really thankful to have this opportunity to, to really discuss about such an important um diagnosis in regards to upper G I emergencies. And that being Boho. Yes, I agree. Jack. Um It's thank you very much for um the, the really detailed um description and you know, teaching about this because it's something that can be easily missed. It's I, I've seen some patients that have come in and they were even quite like, well initially and it can like, and the problem with this is that you can easily go south in any time and it requires a very um good history taking and, you know, understanding that this can happen. So to, to get to that um in the few minutes that we have right before we um call this to a close. Is there like for a patient who uh sorry for a doctor who is planning to, you know, um specialize or in the future, become an upper G I specialist. What would be your advice for them in the earlier stage of their career to make sure that they have like a good chance of getting into upper G I too. Yeah. So I think if you talk about, you know, upper G I is, is fundamentally a subspecialty of general surgery, isn't it? So you can't be an upper G I surgeon if you are not gonna be a general surgeon first. Um, so you have to still have ability to do emergency laparotomy, all of these other things to be an upper G I surgeon. And you have to have the core principles that come with being a general surgeon, I would say. Um, you have to make, I think, I think it's important. I mean, as you know, em I wanted to be to do and become an Upper G I consultant and then I decided later that actually it's not what I wanted. I think you have to come up quite early with an understanding that sur surgical, sorry, um, surgical specialties like upper G are very, very high risk um, operations that you're doing, they carry mortality they carry significant morbidity. You'll see patients in hate, say in the majority, you'll see them in clinic. They look better than they, they look better in clinic. But before you do anything, then when you actually do something to them, then they look absolutely shocking. So I think you have to be able to deal with the fact that you are, you're playing the long game here and you're dealing with people in the majority with cancer and being a surgeon who operates with people with cancer is really, really hard. Um Because as I said, you often need them potentially in a worse state than when you first met them. I think when people are talking about getting into training, um you know, going to conferences, discussing with specialists, um opens up doors. It does. So if you think about me, Mica, for example, I'm starting a phd in January. Um And I, I mean, I was able to be able to be offered a phd because of the people that I know in the specialty. Um So being able to develop those relationships is important, going to conferences is important and getting to theater. But like me, for example, now I could probably give you a better idea of how to do an esophagectomy than doing a lap appendix. But you should be able to be able to get those principles and to walk with what you run. And that is to say to, to, to get general surgical experience first and foremost, and then see how you go and then see if you like a subspecialty because you always have to do, unfortunately, do several clinical um fellowships. In order to become an upper G I consultant. There isn't a root training program really for it. You know, you're talking ST six ST seven when you'll probably get experience in upper G I surgery before that you probably won't. Um, so I think it's to say the usual things that you would do for making sure that you've got uh, the points and everything for core surgical training. Um And then, and then residency after that, you know, with, with specialty training and getting a training number, but I would say it, it's really great to sort of get stuck in because all of these consultants absolutely love talking about their specialty. So, going to conferences and discussing with them about their specialty will be my biggest suggestion about getting, um, tips and life experience with them because they'll always offer you a fellowship if you start chatting to them and seeing enthusiastic about it. Definitely. Thank you Jack. And, um, what are the growing opportunities that you think uh in OG I, even if not, like for instance, you, you're pursuing a phd in, I think, um, preop, preop, sorry, prep prohibit. And that, that's, that's, that's, um, that's, you know, an area of interest that is really not explored as much. Are there other things that you feel like doctors can explore apart from the upper G I surgery as a specialty itself for. Yeah. I mean, pre hab is so, I think the reason why pre hab em is so, is so different in upper G I surgery compared to things like other cancer surgery. Like, um, like colorectal and things like that is our pathway. Yeah. So, the pathway is very different. So, like, you can get diagnosed with colorectal cancer and have a right hemi in two weeks. Um you can't with an esophagectomy. That's because we do things like um staging laparoscopy. We do, we have to do feeding tubes and that goes back to the fact that it's such high risk surgery that you have to have very good evidence that your resection is going to be an r naught resection. So that's where it's slightly different between colorectal and appetite. So we have to do a staging map. We have to look for metastases and we have to examine the stomach to see if we can form a conduit to bring, able to ize the duodenum and pull it all the way from the abdomen into the chest. So we have to examine whether that stomach is viable and we have to examine whether it's resectable disease that is being missed on a CT scan, like a mental metastases or peritoneal metastases. Um that don't often get seen on pet scans or CT S. So what that means is, there is a period of time where the patient is not having an operation and having chemotherapy and having a staging laparoscopy where there is time to intervene and try and improve your outcome from your, your surgery. So your surgical dissection is one thing. Your lymph node count is one thing. But in order to reduce your complications, the biggest factor is how the patient is in their fitness and in their comorbidities. So that's where pre hab comes into play. In regards to, I've got a patient who's 68 years old. Their CPET is obviously all right, because otherwise they wouldn't be having been referred for a stage of laparoscopy and they would be for palliative chemotherapy or something. So they, they're of the baseline fitness, which isn't bad, but isn't bad is something that you can improve, isn't it? So that's what pre comes into play. If you're doing someone and opening up their chest and opening up their abdomen and dissecting them and leaving them on one lung to ventilate, you're putting a massive workload on their cardiac function. And that's why I'm interested in pre hab and it's to basically improve things for those patients. So they get better outcomes, you know, and I think other ways of, of how, you know, if you talk about upper G I and bariatrics, it's a, compared to say, colorectal or, you know, um, urology or something like that. It's a relatively new surgical specialty. Yeah. It's, it's got lots going on. It's got lots of new techniques and we're having massive advances in other, if you talk about the NDT of oncological improvement. So in the UK, now you've got better outcomes from having chemotherapy if you've got squamous cell carcinoma compared to an esophagectomy. So the majority of eso esophagectomy, we do are for adenocarcinoma. We rarely do an esophagectomy for squamous cell carcinoma at this point because the chemotherapy has gotten really good. So we're seeing new developments in new chemotherapy agents. We're seeing improvements in pre habitation and um an assessment of those things. And in bariatrics, for example, we're seeing new and new techniques of endoscopic therapy of um medical weight management and all these other things. So it's a surgical specialty that's got lots of excitement. Um But not enough people doing the stuff to get it done to get the work done. Um So that's one I, I would, I would encourage everyone to be involved with it no matter you'd have to be a surgeon. Like, like, you know, as you know, I, I don't want to be a surgeon anymore, but I'm doing a phd and I work there and I work with the team. So there are lots of options even if people are really interested in gastroenterology or um oncology. It's one of the special is one, is one area for patients that has got really improvement. Thank you very much, Jack. It's important that people know that even though even though like um, upper G I surgery is a very high risk specialty and it is quite demanding, there are other things that people with, you know, non surgical interest can also do, can also find um interesting in upper G I surgery. It's also a very new and advancing um specialty that surgeons, upcoming surgeons can easily, you know, get into and find I could please give people my email address if they want to have a further chat or to think about. Yeah. So um can you just, is it possible to type that in the? Um it says I'm not verified. Ok, I'll just type it before I leave. Ok, I'm going to and thanks Adie for that link. Um So I know actually know of this paper that you're referring to. Um But yeah, um they, they've changed some good data but if you want to email me about, about the that um that paper in bit more detail, then I'll be happy to chat to you about it. But as I said, the um the VAC then it's very, I mean, five centimeters sounds a lot. But you've also got to remember dots radi that you have to have proximal and distal landing points above and below where the actual problem is. So you're actually talking about a very narrow window of a circumferential hole. So it, it, it there's more to come from VAC stents but at the moment. I don't think they're quite there yet. I think we've, um, we've, I'll leave you all now because it's Saturday night. All right. Good presentation. Thank you. Thank everyone for listening. Thank you for paying attention. We've come to the end of today's, um, it's so unfortunate that we couldn't, um, finish up all that we plan to do today, but I guess everyone has gone up with something, at least how to recognize bo hives and how to recognize esophageal tears and what to do when we find these, wherever we are, the hospital. Thank you very much, Jack. Thank you. Have a good day. All right. Bye everyone. Bye bye bye.