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Okay, thank you. Yeah, hello, good evening everyone. And thank you for joining our whipping are tonight presented by the Dukes Club. Uh webinar. Today is about the fundamentals of inflammatory bowel disease surgery, which is a challenge faced by any corrector surgeon or any surgeon interested in. Correct all practice. Uh As we all know, there is a lot of decision making involved and a lot of decisions to be made regarding uh surgical intervention, the timing of surgery, the type of surgery optimizing patient's before and after and uh managing inflammatory bowel disease patient's usually involves a big team uh from surgeons to gastroenterologist, dieticians, psychologists, which can be quite challenging. And uh to address this today, we are excited to have to quite esteemed speakers and both have vast experience in practicing inflammatory bowel disease surgery. In one of London's biggest teaching hospital. We're very grateful for them for agreeing to share their wisdom with us tonight. Uh I'll start by doing some housekeeping. So, uh we'll have both talks done back to back and then we'll be answering the questions at the end. Uh, the attendees, if you please put your questions as we go in the chat section. And at the end, uh we will uh answer as much questions as we can. The questions which will not be answered during the webinar can be answered by the speakers through the chat after the webinar is finished. Uh So thanks again, everyone. And uh I will pass you now to uh my friend Osman Choudhry, the next Club Inflammatory Bowel Disease representative to introduce our first speaker. Thank you as my uh yeah, thank you side. Thank you everybody for helping to organize this. Um My name is Osman December 4. I'm an S T seven east of England. Um, current do club IBD representative. And I'm very happy and pleased to present our first speaker, Miss Katie Adams. Um He was the previous presidente of Dukes Club in 2016 and 17 and chair of the early years consultant network in 2021 22 its current member of the A C P G B I IBD subcommittee and clinical lead for GI surgery at Guy's and ST Thomas's Hospital um where she practiced robotic IBD surgery. And I'm very happy and pleased that she's here with us tonight tonight to discuss the surgical management of ulcerative colitis. So thank you, Katie. Thanks Osman. Thank you for the invite from the Dukes Club. And tonight, I'm going to talk through a common scenario for colorectal trainees, general surgical trainees, which is going to be about the management of acute um severe ulcerative colitis. Um So federalism in already that I'm a kind of rectal surgeon based in London. Um, and unfortunate work in a unit where there are three specific IBD surgeons, but we have a big sort of general surgery cohort. Um, and we have an even bigger gastroenterology department where there's a lot of patient's with ulcerative colitis. So we have quite a lot of patient's coming in. So seeing a patient with acute severe Aasif colitis is a really common scenario and it's certainly something that comes up in exams. Um So thinking about ulcerative colitis, so about 15 to 25% of patient's will present who have ulcerative colitis will require hospital admission at some point. And the classification for that is we can have patient's with mild, moderate or severe. It's usually only the patient's with mod severe who get admitted. And that's because they need systemic therapy such as intravenous um still, which will come onto when we're looking, looking at the severity. Um the most commonly used is the true score, um which will often be asked to calculate and you might even have that companies and questions which I did. Um and rather than ESR which was one of the original parameters used, it's now CRP. So we're looking at about part of it is clinical price based on the patient, partly it's biochemical and partly it's physiological. So we've got bowel movements of at least six or more. Um plus every 24 hours with visible blood in the stools, often pyrexia. Well, a pulse rate greater the 90 anemic with a CRP above 30 and CRP itself is also an independent predictor of severity. So of about 100% 100 patient's who will send with at least one episode of acute severe ulcerative colitis. 40% are going to end up needing a colectomy. Now, actually, 25% that colectomy is going to be on their first admission to hospital. So off patient's who get admitted a quarter are going to need an operation before they go home. A much larger proportion are going to need an operation within the next year. And of the 40% who have an eventual colectomy only 12 will need it within three years. So admission to hospital itself is a predictor of needing a colectomy. So we really need to take these patient's seriously. We need to know how to assess them, how to counsel them and what both the medical treatment is where the boundary between surgical and medical treatment lies and how to guide our patient's through those decisions. The main guidance document that we have in the UK is the British Society of Gastroenterology consensus guidelines. So this is the document which will take us through for both adult and pediatric patient's. And there's a separate pathway for pediatrics and most of us will be dealing with patient's who are over 16 who are kept present in the acute setting and are admitted usually through A and E or it might also be through gastroenterology clinic with acute severe or city of colitis. And there's a rough time frame which is going to take us 10 days through to potentially up to two weeks. Hopefully not. Um But it's important that we go through this in a step wise fashion so that we know when we see patient's how far down this timeline they are and what the extra days in hospital or days without surgery might mean for their risk. So initially on day one, if patient's come in, and initially, they're going to have stool cultures, we need to exclude that they've got c difficile. Um We need to baseline investigations including my chemistry for blood count and blood cultures if they're federal. And as soon as possible, these patient's need to be started on intravenous steroids. The most typical will be hydrocortisone given 100 mg six hourly. And in addition, with an inflammatory abdominal condition, these patient's are going to really be hypercoagulable. So these patient's also need to be given concurrent low molecular weight heparin prophylaxis. We need to stage these patient's with a flexible sigmoidoscopy and often more octopus, colonoscopy versus flexible sigmoidoscopy. Actually, it doesn't matter. And we'll come onto accordance of flexible oscopy staging um versus colonoscopies aging. And again, we're going for these same parameters that we saw before, which is bloody stools and then temperature, heart rate hemoglobin and a CRP during that 1st 24 hours and daily from then on, the patient should have a see a gastroenterology review. And if the patient starts to show deteriorating function's really early surgical review is required, especially if they're becoming systemically toxic, showing severe abdominal pain or any suspicion of toxic megacolon or perforation, we will often still see serial abdominal x rays. But actually, those patient's who you suspect they might have a perforation or a sudden deterioration. A CT is preferable. So of those patient's who aren't getting better and remember only 60% will get better. The remaining, they're going to need an operation within that at me. So day three, if they've still got really frequent bowel movements or they're only soda little bit, but they're CRP is still above 45. At that point, surgeons should be called. So that's really early on. These parents will still be on IV steroids, but at that point, they should commence second line therapy. So the day in which patient's re reach their first dose of second line therapy, which nationally is I sort of IV Infliximab. Um and other units may still use IV cyclosporin. You should also have a surgical review if patient's have got worse before that there shouldn't be a dilated theater. So those signs will be toxic, megacolon perforation, hemorrhage or another acute deterioration. So, paper becoming more septic or tachycardic um or a lowering BP, you may find that those patient's already improved by that point. In which case, if they bowel motions less than four per day for two days and no rectal bleeding, they could start a step down therapy. And generally the step down therapy is switching to all prednisoLONE daily. Um, restarting there a S A considering a thigh appearing, um, and discharging, but only if they've had 24 hours on all therapy. If they've already started on Infliximab, if they've reached this improvements later down the line, um then those patient should complete their loading either time they go home. So these patient's, if we imagine our patient now hasn't got better as the surgeons, we've seen them, we've started to review this patient, we've canceled them, we've examined them and then the days are continuing. Patient's may still improve at this point. And if they haven't here rated, but really just not doing better. So they still got our motions above a today, they've still got a high are CCRP, they might still be Tacky Kardec. And if the albumin is falling, their hemoglobin is falling at that point, we really need to start considering a colectomy. So at this point, the patient's will be four or five days post their initial loading dose of Infliximab. If they haven't got better at that point, then only in specialist units will they consider a third line treatment such as two opposite? And then, but for most patient's at that point, were considering doing a colectomy. Patient's may have already received their second dose of infliximab by that point, if they've been grumbling along, but for the most of them, and it is about 80% if they've had one dose of infliximab and they're not improving. Then at that point, this patient needs to be considered for a colectomy at any point along this timeline. Before considering collecting me, they may have a sudden improvement. Often just seeing the surgeons alone is enough to mable motion, stop. The patient's still need to go down that same pathway. So they still need to have all prednisoLONE. They still need to have had an improvement with 24 hours. And one of I think quite a vicious cycle as a patient steps down to oral starts doing worse again, they start back on steroids again. Um And they go a bit around that loop for a while. And in the past, it used to be that we didn't see these patient's until 10, 12, 14 days after they've been in by that point, their nutrition is terrible there, fluids all over the place there, electrolytes are harder control and really they're in a bad way and they're really going to end up with an emergency colectomy um usually open which we're trying to avoid. So endoscopic assessment. So these are the sort of images that you'll see of the left colon. Um And with these patient's, yes, you may get to the extent of disease. You may not, this may be a pan colitis by this point, but we're going to assess this on the U C I S scoring system. So this is going to look at three different factors within the clonic lumen. So, vascular pattern, bleeding erosions and ulcers and these are going to go together to a score and that's gonna add up to say how severe it is. So for most of these patient's, by the time they're assessed, they've got a completely obliterated vascular pattern. You may find front blood within the lumen of the colon and you may have deep ulcers with either slightly raised edge or excavated defects. And those again are really poor prognostic signs that this patient is not going to improve without surgical intervention. So once we're seeing the patient, remember that for a lot of patient's 25% a quarter of a patient, a quarter of the patient's, this will be the first time they've been told they've got ulcerative colitis, they've come into hospital, they've been on steroids for a few days. So their mind is buzzing with all of that extra sort of steroids, steroid, driven cognitive thought. Then we're going to tell them we're going to do a life altering operation to remove all of their large bowel and they're going to have a stone that's a huge amount of information to take in in one go. So seeing patient's is really key, seeing them more than once seeing them with your gastroenterology colleagues is excellent. So that you have that one message that medicine may not be enough. If it isn't, that we all agree that surgery will be the next step. Always assess your patient's nutritional status. And then you've got to start balancing up the risks of operating versus waiting. And this is where it's difficult, especially for the patient's whose bowels open, say five times a day, maybe they're not federal, maybe they're CRPS only 50. And it hasn't changed very much. Actually, this is the cohort of patients who actually do worse because if they're the ones who wait till a week, 10 days, 11 days, the mortality risk of having an operation goes up every day and it actually doubles from day 32 day six and almost triples by day 11. These patient's are often young, working, considering family planning. So discussion's of fertility for Cundy for quantity and sexual function's really important. And this is again, one of the reasons why we do the subtotal colectomy rather than a full colectomy. Um, as opposed to, you know, doing a pan procto. In addition, these patient's are too sick in order to have that you want to do the least invasive operation possible. Um, and these patient's have got a lot of information that they've got to absorb and it's often too much to take in in one go. Having some sort of information to give the patient is really useful. Something that's really balanced. You know, I think it's really hard to find something that's not too pro surgery or two anti surgery. The Crohn's and Colitis website is really good for this. Um, there's a whole section of surgery for ulcerative colitis. It may be the first time the patient's thought about the digestive system and how it works. So, having something they can read when you go away and then returning again is a really useful way to advocate for our patient's. All patient's are worried about the stoma. If they're not worried about the stoma, they're not telling you the truth and it can be really scary. They may either know somebody has had a stoma that may be more anxiety provoking or they may not know somewhere the stoma and it feels completely alien. This is where your stoma team are so vital. They will have counseled patient's about stoners all the time. They can even give patient's devices to try out and stoma bags to put in their abdominal wall to see what it would be like. If the patient's going for theater, having a well placed stoma is really important so that each patient can have the stoma in the best possible thing. It's possible position even in an emergency. It's not possible say if the collectively suddenly you've just got to make a decision and go that night. Um But even if your patient's awake, you know, your consultant surgeon will often be able to mark them awake, leaning them forward, seeing where their trousers hit, seeing if they have a crease in their abdomen. You want to avoid those areas, you want to imagine a bag on their skin, you know, where is that going to be best placed for them? So as soon as you mentioned, so HMAS, all sorts of questions are going to come up. I often mention it towards the end of the consultation because you often don't get much further than that because the questions that are going to come up is I'm gonna just smell all the time. I'm not gonna be able to work. I'm not gonna be able to fly, you know, will I be attractive to my partner? Can I eat? Can I swim? What would I do if the bag fell off? You know, it's such an alien concept for somebody unlike us. You know, we think about bowels all the time. Um This is something that's going to be really outside their comfort zone. So patient's need time, they need time with you. They're, they need time without you. They're having a patient advocate, their friend, their relatives, their partner is really useful, being able to show them pictures, being able to draw them a diagram so that it doesn't feel as bad and also being positive. You know, patient's will say often are stone is the worst thing that could happen. Actually, quality of life wise and particularly patient's who are diagnosed before they came in. Having a stoma is lifesaving, you know, particularly patient's going towards megacolon, you know, having a perforated colon versus having an end ileostomy. The quality is a lot of life is a lot better if you have an end ileostomy. So you've decided the patient needs theater. So next is who's going to do it? How are you going to do it? And when are you going to do it? So the majority of these operations will be performed by general surgeons if you have colorectal surgeons in your unit, and if you have on top of that, even IBD specialist surgeons in your unit, patient's will do sequentially better. So patient's will have a better outcome in terms of post operative complications, recovery and even quality of life. If done by a colorectal surgeon versus a general surgeon, patient's will also have a sequential improvement. Um Looking at recent kind of patient outcomes following emergency reception of a retrospective cohort study, which was done in 2021 if done by an IBD specialist surgeon. Certainly in our unit where I work with a mere direction, we try and have most of these colectomies done by one of the IBD surgeons because we know our patient's will do better and it's not just operative technique, it's operative decision making, which will come onto as well. Next, you've got to decide how are you going to do this operation? Are you going to do a minimally invasive approach? Are you going to do an open laparotomy that's going to be guided by? How sick is the patient? How quick does the operation need to be? What's the time of day? What's your access? Um And what's your skill set patient's do? Well, if they haven't got a toxic megacolon inside them, getting it out safely without perforation in a way that gives you good visualization, good homeostasis and good wound protection is going to give the patient the best chance if you can do minimally invasive surgery, that patient is much more likely to go on to have a further minimally invasive surgery down the line. Whether they choose protect proctectomy or restorative option, but it's not the deal on it. And all the initial patient safety is paramount when you do the surgery again, is up for debate. If patient's are grumbling along, putting them on your next elective list can be very appealing, particularly if that means that will facilitate having a minimally invasive approach. But again, if they're sick, a laparotomy on the acute surgical list, and if the general surgeons doing it, that patient will still have a better outcome than waiting and perforating. So, doing a sub total colectomy, you're going to take out all of the colon from the sequel pole down to the rectosigmoid sort of just above the pel pelvic prominence. So now you've got to think about you've got a rectal stump. What are you going to do with that. You've got four main options. One is you could do a formal mucous fistula. You could do a subcutaneous mu mucus fistula. You could have the stump drop back inside and put a rectal tube in or you could leave the stump inside and just do a proctoscope if needed. And all of this is in a view to trying to avoid a stump blow, blow out where paradoxically as we know and trying to explain it to the patient's that I'm going to take all of your colon out, but roughly, I'm going to take out the better bits and I'm going to leave the worst part in seems so counterintuitive. So we've got to find a way to try and avoid stump, blow out. Now, I'm just going up for everyone so you can put your choices down. Um Have a think about what you would do. What have you seen a unit and what do you think the benefits are? And then we can come on. Oh, I would do. So, everyone who's answered so far by far, the commonest outcome at 38% is a subcutaneous mucous fistula, far, roughly even split by rectal stump original. Um but rectal tube and then practice scoping if needed and only about 1/5 would do a formal Nikos fistula. So let's look at what the evidence shows for that. So these are the two main operative strategies that we're going to talk to where this one is a subcutaneous one just through the sheath. And then we got a patient with an intraperitoneal rectals and a rectal tube. So if you were to do a subcutaneous mucus Fischler, those patient's will have a lower level of pelvic sepsis. It does blow out, it's going to form a, collect the skin which then will spontaneously open or can be opened up inside or even in the G P practice or in the emergency setting versus intraperitoneal where you are going to have a wound rates, you haven't got bowels sitting directly underneath the skin, however, your mortality is going to be high. So actually, you get safer outcomes by doing a subcutaneous mucous fistula. And interestingly end most of the audience selected rectal stump intra paired to the erectile tube. So which is fine in terms of the initial recovery and infections in the wound. But actually looking at the system matching out three years ago, what you're going to find is that during and after emergency colectomy for you us, you see you're going to have a higher mortality rate and that's because of the uncontrolled pelvic cept that can happen and it isn't men more than women longer and tighter angles, it'll sink where you're going to have a build up of much more likely to get a rectal stump blowout and those patients are much more likely to get in depth cysts post operatively. It's really multidisciplinary. The same as reactively where we've seen the patient's with the stoma team, with the gastroenterologists POSTOP is no different. So, things to consider. Do you want to start wheeling down those systemic steroids as patient's aren't gonna need them extended vte prophylaxis. These patient's are going to remain hypercoagulable for at least three weeks and the standard nationally is to give four weeks of extended vte prophylaxis stoma education. I think, you know, most of us who do the surgery all the time. I've had patient's, you can't look at the stoma for the first few days. So psychological support is also key together with the stoma, key stoma team physiotherapy. These patient's have often been in hospital for a few days. Um Well, steroids, they've been maybe in bed more than they would have been before, you know, so they're going to need to get back up on their feet and enhance recovery, enhance recovery is something that will help patients' get back to a normal diet faster, more mobility faster. And actually, they're going to do better the same as enhance recovery for other colorectal receptions. Some units will give routine MS Alazine or steroid enemas. Um that's common in different areas of the world. So it's less common in the UK, it's more common in Scandinavian countries where they've got a much higher rate of colorectal anastomosis. Once the patient's recovered, we've got to think about what now, what do we do next? So we've got to think about further surgery and these patient's may not be ready for surgery for a while. Others can't wait to have a completion, protecting a pouch so they can get back to what they feel is their best quality of life. So the options of what to do next is a patient may not wish to have any further surgery. In which case, they would need to go undergo routine stump surveillance. They're likely to have a degree initially of also colitis and eventually diversion colitis. So they will have an overall aggregated, increased risk of erectile cancer. So they need to have intermittent stump, oscopy, early erectile anastomosis have already said that's commoner in different areas of the world. And that's because patient's will need to have a fairly vigilant approach to miss Alazine or steroid enemas both acutely prior to an anastomosis and intermittently long term. And some places like Sweden will do it, you know, for life, patient's who've got to have intermittent mesalamine enemas, compete completion, proctectomy and keep their ileostomy. This is actually the group which is increasing fastest in this country. I think that's as sort of stoma stigma decreases. Patient's are no longer seeing, you know, my ultimate goal, a good quality of life is getting rid of my stoma. Actually, a lot of patient's will come to clinic and say I've got the best quality of life I've had for a long time. I don't always have to know where the nearest toilet is and carry some in constance pads or a change of underwear in my in my bag, completion, proctectomy, and restorative ileoanal pouch is still a really good option, particularly for patient's who wish to restore continents, who've got good anal sphincters and are prepared to undergo. You start the surgery for a completion proctectomy. They will need a covering ileostomy and most units and of the patient's who have a pouch. A significant proportion are still going to have to do adaptive techniques and adaptive medications to maintain a good quality of life. One of the groups that we do need to think about carefully for acute severe als to colitis is those with PSC. They're going to have a much higher rates of ending up with an acute severe episode. So if the 70% of patient's with PSC, they've got underlying inflammatory bowel disease as opposed to only 5% of patient's with ulcerative colitis will develop PSC. Again, we need to think about fertility. A lot of men will proceed with an ileoanal pouch if that's what they decide or a proctectomy at an earlier stage. A lot of women having discussed the relative drop in for Cundiff tea. So the ability to become and remain pregnant to a live delivery, their fertility and for quantities going to drop by about 30%. So having those conversations really important both upfront, but once they've recovered, so they can consider their options moving forward. So overall, we need to assess these patient's carefully. We need to counsel them early. We need our allied health professionals, particularly our stoma nurses and our gastroenterologist to all be there together to guide patient's through what can otherwise be a condition with a really high mortality. Thank you. Thank you, MS Adams for this very interesting talk and uh it's very helpful that you shared with us in a few minutes. Uh All aspects of managing a patient with uh as of colitis flare from managing them uh as an inpatient to addressing their expectations to managing them even after the long run afterwards. And uh it's very clear that that timely uh fashion that you shared with us would be quite helpful to any surgeon who is managing a patient with uh colitis flare up. So this was very, was very helpful of you. And uh also to me, to me personally, it's like it's quite helpful that you uh discussed some of the very debatable uh points in managing patient with uh class flare uh like the pool you uh chair, we can see that even the uh all the audience, they, no, they won't all agree oral option. So I think it was very happy that you showed what you will do with evidence. So uh I think this will help us all make better decisions when we are managing patient with us. A class flare up. Thanks MS Adams. Very nice talk. Thank you. Next, we'll move to our next speaker, Mr Amir Traction, uh Mr direction, uh quite experienced uh inflammatory bowel disease surgeon, uh the the lead of inflammatory bowel disease surgical service in guys and ST Thomas Hospital. Uh and he will talk to us today about uh managing uh very operatively patient with Chron's disease. Thank you, Mr Action. Thank you. So, uh you hear me okay now. Yes. Can you very well? And in terms of the talk is the, is the, you see my talk at the moment? Is it? I've got a split screen. Is it up on the screen now? No, not yet. Okay. So what do I do? It was working earlier, wasn't it? I haven't done anything else but how do I share it? I think it might be that I booted you off when I share. So you might need to share again from the medal screen. From which one? Sorry, the medal, the one on your web browser. Okay. The middle thing here. OK. Bring it to share your screen and we said um entire screening. We, yeah, I've got two. There we go. Is that working now? Yes, we can see it now. Perfect. All right. Thank you. Uh Moving forward on yours as well. Brilliant. So just a little bit about Crohn's disease, I think uh in terms of what would be ideal for you to know um uh they'll be talking about preoperative optimization as you can see here. Really idea is that this is quite the most important part in terms of managing patient with Crohn's disease. The surgery itself, we want to in a minute but really important part of managing patients' with uh Crohn's disease much as in. Um, could this be here as much as we have in patient's with? Also colitis is making sure that we're optimizing them before they have surgery because it reduces their risk of complications and mortality crozes as you, I'm sure you will know is a, is a chronic trans mural inflammatory disease and involves any part of the gi tract from the mouth to the anus. The inflammatory process appears to start at the mesenteric borders. That is a mucosal disease which starts with the mesenteric edge of the bowel lumen and it becomes progressively small, severe and with due to the ongoing and repetitive cycle, if you imagine what's going on, you've got disease which is persistently inflamed. Your body's trying to repair at the same time and you end up with areas of fibrosis and stenosis and then the bowel upstream from that becomes dilated. You get pre started meditation and this can happen in segments and that's a characteristic feature of Crohn disease. And often you'll see this the sort of um stage stages of disease along the bowel itself, complete obstruction of the bowel is actually quite rare. Usually as before that happens, some other sort of catastrophe or complication arises. Then due to this sort of chronic subacute uh process, often patient's will end up having a localized perforation. And if you imagine, as the disease become progresses, it tends to burrow through the bowel wall and just before it perforates. So, unlike something like a peptic ulcer or, or divertic disease is not an acute event, sudden event, that surface of the bowel becomes very inflamed and sticky and before it perfect other organs can stick onto it. So if it hasn't had a chance to make it a little bit of seepage of bowel content with a small abscess forming adjacent to the disease segment. And if it has had a chance to adhere to another organ, then went often, there will be an internal fish that either into an adjacent loop of bowel or into bladder, into the ovaries or into the flow country, etcetera. So anything that sits adjacent to it sometimes, uh we do see patient still who would have a perforation of posterior perforation. If you think about where the disease often occurs, it's terminal ideal in particular. And it's not uncommon for patients to have an idea. So it's abscess and you know, much like in the old textbooks, you'll see patient's having an abscess pointing into the groin because that's where the abscess drains too and you can get ideas. So, securitate ation, you know, pain or walking, uh inability, fully extend hip, etcetera. So all the cardinal signs of. So it's irritation. So that's the sort of natural progression. The other thing then to remember, there's, that surgery is not, is not curative. In fact, Crohn's is not a disease that can be cured in surgery. Whenever you operate, there's always a chance of recurrence and we call it recrudescence. It's not the disease that hasn't gone away and come back. It's just in the background and, and really patient needs to understand that regardless of whether having surgery or medical treatment to a large extent, recurrence or recrudescence is almost inevitable. In fact, about all, about half of patient's uh with current disease will go on to have at least one operation during their lifetime. So, what is it about Crows that makes it's a high risk or risky surgery? What, what actually do we mean by high risk? I mean, is there something anything we can do to reduce that? Well, by risk of, we've said already, most patients will have surgery actually up to 70 or so, we'll have one or more operations during the lifetime. Uh In recent years, there's I'm sure you all know there's been a huge wave of new biologic treatments that have come on board. And MS Adams already has mentioned some and a lot of those have been used in Crohn's treatment for a number of years. So the the anti tnfs and Flicks, um OB has lymphoma been the Jak inhibitors more recently, but these, these are all re aimed at reducing the inflammatory process despite that though, although there appears to be a reduced risk of surgery in the 1st 255 to 10 years, that lifetime risk of having surgery appears to be unchanged. Um The post operative complications from for patient's with uh credit is particularly more uh emergence type of surgery. So if you do uh an elective versus an uh an emergency surgery, post operative complications are significantly higher and will come into why that is. But also mortality, 30 day mortality in this current this day and age are still up to over 5% mortality. Overall mortality in patients with Crohn's disease. Obviously, that's higher an emergency compared to the 1% in elective. And if you look at the subgroup, the risk of dying 30 day mortality is much higher in patients with Crohn's than you see. So 8% mortality for an emergency operation is pretty high if you consider uh what's going on. So what are the risk factors? And why are these patient's doing so poorly? Well, often the chronic illness. So there will be an underlying poor nutritional status that may be due to short bell, but often the actual inflammatory process itself. The gut is disease, it doesn't work properly. Often the patient has anemia and anemia, we know has a significant impact, not only on post operative recovery, healing but that every complication you can imagine. So, higher risk of wound complications, high risk of intraabdominal collections. All these are all related to anemic state, often patient's will have other comorbidities. So we talked about Crohn's being disease from uh affecting the gi track from the mouth to the aims. But often they will have extra intestinal manifestations. But also the their disease of the other medication can cause other comorbidities. If they've been on steroids for a long period of time, chronic steroid use, as you well know, can cause other features. They can get adrenal suppression, diabetes, osteoporosis. And the all these will obviously have an impact on their general well being. Um we know patients, we have a problem, many diseases. Well, often they will do poorly, uh maybe touch on that lecture on. Um and if they've got a an acute complication, so we talked about that they can get penetrating disease and abscesses if there is an underlying app to sort of intraabdominal collection, uh this excel eggs also is a higher risk factor. There will be on immunosuppressants, steroids. If there are a smoker, we no smoking in Crohn's disease is associated with at least twice the chance of recurrent disease. So it's really quite important for patients to stop smoking and and an ex smoker has an equivalent chance of recurrent disease as a patient to is as non smoker patient. So it's important if they are smoking, it's not all doom and gloom, it's important that they are encouraged to stop before surgery because we know if you have an operation, smoking results in a high chance of early recurrence. So stopping is, is quite important and then the surgery itself can be challenging. Um, we know that the complicated disease you can see on that picture there that say, you know, kind of advanced Crohn's thickened, dilated bowel with fat wrapping. Uh, those are all sort of uh typical features for Crohn disease. And that's a patient who had been on IV nutrition uh for six weeks. So, due to the complicated uh nature zoo, the operative time is often quite prolonged. Uh if there has been a complication from the disease that maybe generalized peritonitis, maybe localized abscess patient may have obstructive features. Um They may have had previous surgery already said a lot of patients will have had multiple operations already. They'll be extensive adhesions. They may have had significant reception of the bowel. So you've got to be quite careful about respecting further about uh unless you render themselves with short bowel. And if they've got Penetrating official ating disease, there may be other organs that have been involved. So all those things really add up to a higher sort of complication. And if the risk of surgery itself postop particularly, there's a higher chance of anastomotic leaks, surgical site infections, prolonged hospital stay, thromboembolic disease as well. Okay. So these are all all add up and you can imagine why these patient's have high postoperative morbidity and mortality. So, in emergency surgery, you got a patient who needs an urgent operation or emergency operation for, for example, a perforation or a segment of bel that's ischemic. Well, really don't need to get on and have surgery. There's no, you can't uh significantly achieve further preoperative optimization outside of what you would normally do with someone who has peritonitis. So if there's clear size of perforation and ischemia, there's no point really messing about taking the theater. If they've got small bowel obstruction, as we said all around this earlier on, it's quite unusual for patients to have complete obstruction, there will be significant, significant narrowing, but often there's a way through and this is something that's progressively occur. And if you looked at that picture earlier on, you can see that is about that has been chronically obstructed. And so it becomes thickened and dilated. And so you're not dealing with a small bowel that has become acutely obstructed. So, perforation is much less likely. So in these patient's, if there is a significant inflammatory component to the stricture or the stenosis, to know segment, it is worth considering some form of medical treatment, steroid treatment. A short sharp bursts, a high dose steroids or even biologics may reduce some of the inflammatory component. And really what you're aiming to do is to try to reduce that pre stenotic load, reduce the pressure and convert what, what convert, what would be an emergency operation to something that's semi elective or electively. And we've talked already about the reasons for that because overall mortality rate is over 5% in an emergency as opposed to an elective situation. And if you operating someone in an emergency setting, the chances of needing a resection with a stoma is significantly higher. And I remember having a stoma is not without its complications itself. Other things you can do is if they've got a stricture is trying to dilate that. And there is, that is an option where and sometimes we do do that particularly in the upper gi strictures. Because the magnitude of surgeries, someone's gotta Tutino stricture or proximal digital stricture. The consequences can be quite high. If you have a high general stoma, high output from that stoma patients actually has short gut and they will be in hospital for a significant period of time. So we try to dilate if possible in that situation and success, it is successful. So over almost 90% of patient's after diet, Asian will be symptom free as you can see. And even at that uh subsequent follow up, that maintains itself, there is a risk of complications. But the overall complication with bleeding and or perforation is just under 3% as you can see. And uh almost three quarters of patient's at two years will need to go on to have further dilatation on that stricture, but almost half will ultimately need surgery. So really, it is another technique which we can use to either repeatedly dilate to achieve symptomatic control or temporize their disease to get them to an elective situation. As you said, you're going to be, the stone is all great. You can get the patient out of trouble with the stoma, but it is that they do come with their own host of problems. And, you know, when we all consent, patient's for surgery, uh, the stoma is almost afterthoughts, but, you know, we don't really spend that much time talking about the stoma itself or the complications. And you will see all of those, you'll get a stoma, that's ischemic. You can, you'll see patient's with a, a retracted story, particularly emergency setting with the stones really thick and injury rated, they can retract, uh sorry, they can prolapse. They may be a parasternal hernia. The age is made to come detached and often as as MS Adams. So patient often dislike that and there would be a significant psychological impact to that as well. And ultimately, at some stage, you'll need another operation to close it. So as we said, what we're trying to do here is convert the urgent or emergent situation to elective. There is a good evidence that if surgery is carried out by IBD specialists in specialist, I really centers. The outcome is certainly better. A lot of that as MS Adams have already touched on is the MDT approach and you know, the strength of any specialist unit is just that is that it's not just the individuals carrying out the surgery, it's all that goes in beforehand. And after uh the patient has had surgery, you can see the list of that which I won't read to you. So, what is, can we do with preoperative optimization? We talked already a little bit about the dilatations of stretchers, etcetera. But where we have patients with, with sepsis, if you've got uh abdominal collection or an abscess, we can try to drain that. Um And so that can be done percutaneously. Think that was my slides of become gobbled. Um Yes, I think it's there we go. We can drain that percutaneously. And suddenly with, with large abscess is that there's a small abscess and again, there's no fixed limit. But if you got a 23 centimeter abscess, which is not easily accessible, it may be worth trying to treat that with antibiotics. But it's one of those things you manage, expecting that you monitor the patient very closely and if they're not responding certainly one, well, then think about draining that percutaneously. Uh the, the complications. Um Sorry, beg your pardon. If you can successfully drain the abscess in patient's who've got a localized perforation. Sometimes you can get away without surgery, they may respond to that, especially if they've got a segment of disease. And then if you couple that up with medical treatment, uh sometimes that does allow you to get them out of trouble, but more importantly, allows you to get them ready for surgery. And we know that if you operate on someone who's got a large abscess in the abdominal cavity, the chances of carrying out in a primary anastomosis are significantly lower. So, patient having surgery with the collection is more likely to have an abscess. So we have a stoma. Um this is a picture or a scan really quick scan to show you. Uh this is a patient who had a collection drained, percutaneously doesn't really project. It was meant to be running and it shows your percutaneous uh drain. It was put into an idea. So it's collection from a recurrent crows with collection next to the, you know why it's not running. Apologies next to the anastomosis, which was drained pre operatively and then allowed us to resect and actually carry out the primary anastomosis. Nutrition is another really important factor to try to optimize preoperatively. Uh mentioned already that often patient's have had previous surgery, previous bowel resection, bowel that's in flames doesn't really work. They may have fish related disease that may be an internal for bypass bowels, strictured. Uh And often the patient's either restricting their diet because of the pain associated with that. All the appetite's for anyway. And they may have profuse diarrhea with its own inherent uh electrolyte imbalance that occurs and often they are on other uh medication which may have an impact as well. Again, if we look at that preoperative optimization involves either having an exclusive enteral nutrition's uh V E N or intravenous nutrition, TPN or a combination of the two. If you're going to do that, you need to carry on for at least six weeks, preoperatively to have desired effect. If you look at that, uh this meta analysis that looked at over 1000 patient should be no, that the overall uh complications post operatively was significantly reduced from over 60% to 20%. If you sort of look at the subgroup, exclusive enteral nutrition appears to be a slightly better than intravenous nutrition. So the patient can tolerate E N uh for up to six weeks, preemptively, not only does it reduce complications, it produces a general inflammatory load which is reflected and reduced CRPS surgery is often easier produced operative time for your complications and reduce the need for uh stoma steroids. Often you'll come across a situation where a patient is already on stem and what steroids rather what you, what you do. Um And that's a, is a sort of contentious point. The, the the dose of the steroid uh doesn't in itself, you've got a high dose steroid steroid dose, it doesn't seem to matter. So, anything over in sort of 15 mg of prednisoLONE, uh it's basically considered as a high dose of steroid um whether use prednisoLONE as opposed to budesonide. Again, various papers will suggest one maybe slightly better. But, but really, uh overall that appears to be little difference whether you use Budesonide as you know, budesonide has little systemic effect, primarily affects the ballot alone. So a little difference between prednisoLONE that will be destiny and have equal efficacy. Um And in long term, so as if someone's been on that, a fairly high dose steroids, 15 mg for a long period period or high dose just before surgery doesn't really seem to matter. They have a higher risk of complications and really for these patient's anastomosis, um leaking is, is up with a 50%. So you got to be very cautious about carrying out an anastomosis and someone who's on steroids. So it's important to try to wean that dose down as much as possible. Uh, and ideally stop the steroids. But if you can get them down to 5 10 mg, then you've got a higher chance of an estimate, particularly if you've addressed all the other components. We've talked about sepsis and nutrition, the need for a stress dose of steroids, preoperative week. And that's been uh sort of promoted that doesn't appear to be of any value, to be honest with you or about biologics. Again, a lot of work and talk about whether to use biologics preoperatively by large, most people, uh sort of stop biologics for about two weeks before surgery. But there's little evidence for that. Uh, it's really based on a couple of incidents where patient's had and I think the young patient's who had overwhelmed except this, but there's probably other factors involved and that hasn't been borne out in uh larger studies. And again, the type of biologic that you use, it doesn't appear to make a difference either. There was initially some talk about Red Lizama with higher wound related complications. But again, subsequently, it doesn't appear to be any problem. So if you needed to operate and the patient hasn't stopped, biologic doesn't really matter. Um If you have the choice, what we tend to do is is try to time it such other patient's dose, uh The last dose is at least a couple weeks before their operation. And then as soon as we can afterwards get them back onto it, that's sort of our data. But I want to go into that. So really, so to summarize that, really soaking at the what we would do, they were looking at patient's with uh preoperative optimization. We're looking at that uh sequence their sepsis treating where we can add antibiotics, draining the abscess. Uh interventional radiology obviously is crucial in that and then where you can stop in suppression nutritional support. And really ideally imaging is really quite important because you want to try to map out and, and demonstrate the anatomy and pathology beforehand. Often because of where the disease is terminal area, there may be a urine terek involvements of getting those. You're otis stented also would be uh necessary before surgery. Um So if it's not possible to minimize the risk factors are practice journals to try to avoid the anastomosis. Given in that situation, there is a uh about a 50% chance of leaking. You want to avoid that and therefore, will tend to give a stoma. And the preferred type of stoma we tend to use will be in a double barreled stoma. So if you've got a highly secret resection, both these small and large bowel will be brought up. So like a split Islay ostomy and if it's just had a small bowel resection, you have the double barrel, a small bowel uh ileostomy there, which is closed later. Okay. So that's what we're going to talk about depending on time, etcetera. I've sort of got some additional slides which we're sort of looking out um different sort of an estimate Strictureplasty, but I'm mindful of the time. So I'll put them on a separate talk which I'm happy to share with you outside of this. Thank you very much, Mr Direction. It's a wonderful talk presentation in surgical management of Crohn's disease. Actually, I was very surprised at the 8% figure you gave mortality for emergency patient's, I didn't realize it was that high. Um I guess there's a lot of work in the peri operative preoperative. Um So management of these patient's perfectly as we sometimes see them on the wards for multiple days or weeks going through M D T and so and so forth before they get some form of um surgical intervention. Um I had a quick question on sort of thoughts on M D T based because uh so sometimes when we see this patient have localized MBTs, I know there's a, a view of getting uh some of these IBD patient's particular pouches and also clients into centralized units. And is there thought of having more of these mbts in a centralized manner rather than the local M D T s? And would that help in terms of management? Not only for the elective cases, but sometimes for the emergency ones as well? Um Can you hear me? So, so I think M D T is so vital to what makes the difference to general surgery care and really specialized inflammatory bowel disease care. And they're obviously is a big spectrum in between. There will be a lot of units with colorectal surgeons and general surgeons with a really wealth of experience either linearly or due to just personal sort of caseload of these patient's. However, I think that is becoming less and less common, more and more we are seeing these patient's centralized both in the elective setting and you're right, the A C P G B I s in the process of Pouch Unit accreditation, which came out a few months ago. Um looking to centralize and what we know is that 80% of trust in the UK and Ireland do fewer than three pouches a year. Um You know, so, and if you're having something that's so important to be done well. First time you would want to be somewhere where they do a high volume of that. I think in emergency care is probably of similar benefit to go into higher volume units. So I know where Mr Derek chart and I work that we have a big M D T, we get through a lot of patient's. We have a lot of other centers dialling in and that's both for acute care. That's what planned care. So you heard a mere talk about that six weeks leading uh ventral nutrition or parental and then bridging to elemental, if possible, that gives time for patient's who are at a local unit and haven't fall into that scheme. Your orders sort of widespread perforation to reach the point of relative stability. That's not to say they're better, but they could be on a pure liquid diet, antibiotics. They've had a drain for a contained preparation that patient can then have essentially preoctive optimization, pre habilitating. But for IBD for six weeks, they can get to a high volume elective center, they can have their more likely then to have a safer surgery. If they've had a limited diet, they're more likely to have an anastomosis. They're less likely to have had a larger incision. They may even be able to have a minimally invasive surgery, even more complex disease. So, because we know that we try and avoid operating other than if they've got a scheme year or widespread perforation that really lends itself to centralized special is um that's good both with the initial initial operation, that's good for future decision making because patient's with an IBD surgeon are more likely to have bowel preservation. They're more like to have Strictureplasty over a section and they're more likely to have a safe outcome. So, whilst I'm not saying that, you know, every patient needs to go to a specialist unit. Certainly for patient's with multi visceral disease, fistulation, relative obstruction, the need for preoperative optimization. Yes, a lot of them will benefit from being in a specialist unit, limited, stricturing terminal a little disease. I think you could make an argument for being in a less specialized center. But even then I would say that we usually do Akono S anastomosis for these patient's because we believe it reduces or we think it will reduce recurrence. We're currently doing the Mayor cat trial um to look at that specifically, you know. So I think all of our patient's benefit from coming to a specialist unit, but also other patient's will benefit. You know, patient's coming to our unit will be in the meerkat trial and other similar high volume centers doing it as well, which means future benefit, patient's will benefit because we'll know what works better. You know, just I mean, I totally agree with that. I mean, I think, I think it is a center that's high volume, essentially specializes. IBT it's interesting. It's not, it's not necessarily that the other centers, other hospitals can't manage them. As Kate has said, it's more, if you think about it, that's, that's our entire firms then voted to that. So we don't look after patient's with cancers, et cetera and those pressures are different. So before I stopped doing cancer surgery, we would have patient's are being optimized for IBD and then there'll be somebody needed cancer operation who Trump's the patient. And therefore, the IBD patient needs to be pushed back in that type of situation. It means that their treatment is already less than optimal. So, you know, that, that just needs to take priority. So the, the whole team is geared towards that. So if you the it's a process of the, the there isn't a delay, for example, patient comes in or shouldn't be uh delay when patient comes in with IBD for, gets admitted on the gastroenterology team. As you know, we do joint IBD ward rounds uh with nutrition team specialist, uh gastroenterologist and the sort of they're all together. And so we see patient's, the idea is that decisions are made on the spot uh rather than waiting days between one specialty to to another. Uh the radiologists are on board, we can get, you know, uh MRI scans, interventional drainage, etcetera within often within the space of a day. So all these are based on the fact that the team's working together. So because of the pressures that perhaps are other centers will be under. Uh which luckily, we, we can sort of almost certain meant to a degree. It means that those patients get a more bespoke treatment. And I think there is uh has to be a recognition of that because ultimately, if that translate into better outcome, one has to say, well, if you were in that position, where, where would you want to have your operation? Okay. Thank you, Mr Adams and structure. That was really a very comprehensive answer to your question. I think a lot of our colleagues will ask especially if they are not close to a specialist center uh with, with an his accessibility to specialized IBD service. So next, well, start taking questions from the audience. Uh So the first question about ulcer colitis is from Michael Baghdadi. He's asking as a surgeon if you review a patient in in the clinic and uh it happens occasionally that the patient's coming with like some pr bleeding or minimal symptoms. And his uh investigation showed that he has like mild to moderate ulcercolitis. Will you start medically treating this patient? Uh or will you refer him straight away to custom Trelegy? No cake for Katie or? Um yes, I think that's an unusual scenario. Most patient's are diagnosed at flexible sigmoidoscopy or colonoscopy. Um So I guess the scenario could be that you see a patient who is referred for possible hemorrhoids, you do a proctoscopy or rigid sigmoidoscopy and you see sort of proctitis. Um So in those patient's getting a diagnosis is really important that patient needs an urgent flexible sigmoidoscopy. They need stool cultures. Um and they need sort of baseline biochemical and hematological markers. I would probably unless they were acutely unwell, send the for a flexible sigmoidoscopy so that they haven't started say on steroid foam enemas before you get biopsies. Um So that you've got a definitive diagnosis, usually the patient then starts treatment and endoscopy. Um and they'll be whisked away. You might get them for a follow up six months later and say, oh, my hemorrhoids have got better, but my rasta colitis is terrible. Um You know, but it's, it would be unusual that you're diagnosing them in um the actual colorectal clinic or general surgical clinic. But if you see someone with proctitis still, still sample, do a fecal calprotectin, do baseline hematological markers, including if you do suits real proctitis, do iron levels hematinic and get them for an urgent flexible sigmoidoscopy or preferably an eye leo colonoscopy. Um And you know, if you're right, usually I've seen this patient has got florid proctitis, they'll be put on an IBD list or at least a gastroenterology list. So they can do serial biopsies. I mean, it's similar to that. I mean, I think if you, if you see outside the NHS, we do sort of see this situation. So if you see a patient who has coming right to leading you scope them and they've got florid uh inflammation there. Um, in the ideal world. If you wanted to ideal Management, you see them, you've got a diagnosis, you've taken biopsies, it looks like you see, it smells like you see, it tastes like it. You're just going to go and treat it like you see. So while you're pending the biopsies, you can start them on like a zoom call the high dose is uh 4.8 g a day and you start that for 14 days. So you get them on that treatment. And then if you, if you had the opportunity when they're seen by gastroenterologist within that 14 day period, then that's the ideal management. So that's ideal. And then there's a reality where on the NHS, if you did that, the patient will disappear and then they'll come back with renal or liver failure. So you got to make sure that, that if you're going to do that, that, that follow up has been arranged. So individually speaking to gastroenterology, making sure that they're seen as a priority in clinic. So if you, if you're fairly sure it is, you see, and the patient's symptomatic, this sort of moderate to severe symptoms, then you can start them on something like a physical uh at that dose. Thanks a further question from George Rashid uh has mentioned is a uh rectal anastomosis of valid option for selective patient's with Crohn's Disease after Colectomy or only for host of colitis uh add onto that was sometimes I've seen histology come back as indeterminate colitis. Not necessarily sure which one or the other is then advice for those who have done a subtotal colectomy for. And so come back in the middle. So essentially with Crohn's disease, you, you do, you know you take out the disease, that's the, that's the underlying thing. So with also client is, once you've taken a code on the rectum act, it is truly all supplies the patient's cured. Uh with Crone's disease, you're not going to achieve cure. You remember? So if there's relative sparing of the rectum, then yes, you can leave the rectum behind and so you can do an iron erectile anastomosis. But then you've got to be sure that the rectum is healthy. You need to make sure that their anus is healthy. And patient's with Crohn's often will have Perianal Crohn's disease as well. So if you've got Perianal Crohn's and they've had multiple operations, their sphincter may or may not be functioning perfectly. And on that point, if you, if they've had Perianal Crohn's disease, officiating Crone's disease, rarely in itself or cause incontinence. Ok, become incontinent because of surgical intervention. Okay. So once you start flame, the patient's anus open with all the sepsis. Not surprisingly, they become incontinent. So if they've got a healthy anus, they've got a healthy rectum with suitable length and the rest of the bowel appears healthy, non erect, an osmosis is not a bad idea, but the function may not orange. Okay. Good. I don't think we have any more. A big one in determined. So you said I forgot about that. Indeterminate is the difficult because it's, it's, it's indeterminant. So what you do would you treat them as you see your right? So the, the, the you will tend to almost treat them as a crime station really depends on what the symptoms are like. So if they've got indeterminant, it is usually the other way around that is assumed to be, you see, for a number of years and then generally over time, they start to exhibit Chrome's type features. And so it's more indeterminate and that's probably more relevant if you're been thinking about what, you know, if they're going to have restorative proctectomy and if they've got indeterminate colitis, then you're going to be a little bit more cautious about giving an idea angle pouch. Yeah, I think the numbers that we quote is a 50% failure if you have a pouch and it's chrome's, um, you know, you're looking at 15% if it's ulcerative colitis, probably somewhere in between if it's indeterminant. But as the mayor says, they'll often start off, you know, that they've got ulcerative colitis and then suddenly they get a period or fistula or peri pouch, fistula and then a bit more inflammation and then you end up reclassify them when they go on a biological treadmill decide if they have a recoverable disease. Um But it is tricky. I think you want to be, you do want to be really fairly sure that either patient absolutely wants a pouch with an indeterminate, but even then with caution or that they've got ulcerative colitis. Yeah, great. Thank you. Uh Do you have time for one last question? Uh Just yeah, just a question about your thoughts about continents, ileostomy. Um So there's different types of continent Ileostomies. They have different predominance depending where you live in, in the world. Certain areas again, kind of um very northern Europe have a higher um incidence of either A B C I R or a Kock pouch. Um And that is where essentially you've got a reservoir in the abdominal cavity with a slender port that's going to the skin. So essentially, it's almost like an ace. You've got an access channel from the skin which at rest without intubation is continent. That patient may wear just a pad over that area. Um The challenges are similar to those patients'. You have um an ace, you can get a lot of stenosis. You have to be prepared to revise the area. Patient's can get still sort of um inflammation within either the cock pouch or BCI are um it is challenging surgery. Most will need revisions and most will need more than one revision. So, quality of life data is difficult. It's one of those sort of love it or hate it in the UK. It's not really taken, offering much. There are a few centers doing Kock pouch is um and a lot of those are doing them as a post operative care rather than putting new ones in. I think also a stigma of having stoners go down and patient's more embrace it as you know, another normal facet of life. Um Overall, globally, those numbers have gone down and they haven't really seen a massive uptake because I think it was a route to avoid the shame of having a visible stoma. Um And in addition, quality of life of, of not having a pouch that fills up over time. But for me personally, the need for re operation, the potential complications for these patient's. Um, for me, I find that too high. Um I don't think there's a massive call for it. I don't think there's a huge call for it from patient's. Um And, you know, if patient's do want to consider that they need to go to an area where it's done regularly and it's done well, but patient's then have to be prepared. They've got to be really invested in, you know, pouch intubation, the need for, you know, either laxatives, you know, long term, you know, possibly to keep the effluent thin enough or an altered diet thin enough or that they're going to have to have multiple revisions which most will looking at data previously. Um Most will have at least three revisions of their access channel um following formation and there's a high failure and excision rate and one of the real challenges and this is the same to have patient's having pouches, excised. Patient's often think I'll have a pouch and then I'll go back to a stoma. Your function and quality of life is never quite as good as when you first had the ileostomy. So going to an ileostomy approach pouch pouch, excision or post Kock pouch or BCI are excision is never quite as good. You've lost a bit more bowel, you've got more scarring, you've had more surgery. So it's one of those things that you would need to. Absolutely, counselor, patient about multiple times, speak to patient's, you've got them find a center that's not only going to do the surgery that support you afterwards. Um, and at the moment, I would still find it really niche. It's a great question. You can tell we thought about it and there anything you would. Uh, I mean, I think, I agree. I'm not, I've not been sold on continence pattern. I think it's not sure it offers anything over and above. And, and it's much like in the ideal pouch, it's, you've got to be the main reason. And the only reason for a pouch is the patient doesn't want an idea, ostomy. That's the thing to bear in mind. There's absolutely no medical reason for it and, and part of the benefits of ulcer colitis where the patient has a sub total and they have an IV ostomy. These are often patient's who came the numbers that are entirely well and end up having a colectomy are quite few. So they will have some preceding illness. And what generally happens is they have this general slide over a matter of years where they become more and more sick and they almost forget what it's like to be healthy. So once they've had a colectomy and they've got an IV ostomy, initial attitude is like I can't possibly have an, and they asked me once they've got that, I've had so many patients where they've been sick throughout their teens into the late teens or early twenties. Once they've got a stoma, they're starting at a new lease of life, they finish their studies, they get their job, they get promotions to get, you know, go into relationships, etcetera. And then the prospect of going through potentially numerous operations because you mentioned you're gonna have a restorative procedure, whether it's a pouch or continent stoma. And then you're faced with the prospect of having more surgery, they often go running out of the room because it's, it's just, they just don't want to be sick anymore. Um And so the patient who really can't live with a stoma, then there's a very select few in which case. Yes, you can think about it. Remember that's not something you would do with Crohn Disease. Uh It's something you would only be using with patient's with Ulster Times. Yeah, great. I don't think we have any more questions. And uh then I would really like to thank Mr Mean direction and Miss Katie Adam for these wonderful talks. Uh I'm sure all the audience will find them very useful and we'll enjoy them as much as we did. Uh I'd like also to thank my colleague was Man Choudhry for his great effort in helping organize this. And I'll thank uh Dukes Club Presidente Mohammed Robbia and special thanks. Of course to Lillian who will provide all the needed technical support because middle is quite new to all of us. So she made a great effort to make this not happen. So thank God for all of you and I hope you enjoy the rest of the evening. And I'll pass you now too to Libya and the Vicepresidente of Chips Club. Thank you Lydia. Thank you side. Thank you to all of you for spending so much time with us. Uh First of all, I just wanted to say thank you to Mr direction and MS Adams for giving up your evening. Um Those talks were insightful, brilliant, and incredibly important. We still have almost 45 people on the on the counter and 70 registration. So you can see how um important uh this topic is to trainees. Um Thank you, Jasmine inside for organizing this for us. Um Just some quick announcements to our members um about A C P G B I next month, Duke's, we'll have sessions every day of the week at A C P and we will also have a fellowship village running on Tuesday afternoon. If you're a senior training, looking into fellowships, this is an incredible opportunity. So I would say sign up to the A C P conference if you haven't done so, and come to those sessions, we'll also have socials on Monday and evening. So with that, I'd just like to say thank you once again to everyone. Have a great evening. Thank you. Thank you. Yeah.