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Hello, everybody. Um My name's Osmond Chowdry. Um I'm one of the ST sevens and the Duke's Club Intestinal failure rep and I'm absolutely pleased and honored to be able to present um the AC P GB I subcommittee um by Car Bay to give us a talk on how to prevent an abdominal catastrophe. Um We've also got Lilian Hare, Lian Reza, who's the Duke's Club vice president, um who's helped to coordinate and to er get this on the platform. And without any further ad you, I'd like to introduce Caroline Bay to you all who's consultant at Saint Mark's Hospital and the current chair of the if subcommittee to start the webinar. Thank you. Thank you very much. And I'd like to point out how much work Osmond's put into this because he's put it all together. He's chased us for some slides, but other than that, it's all his hard work. So, thank you Osmin. Um I'm going to introduce the rest of the panel um in alphabetical order in case anybody starts getting upset about who goes first and who doesn't. So we'll start with Dermott. Dermott is associate professor in Leeds. Um And er, we very much enjoyed your talk at AC P GB. I, um, a lot of good feedback on that Dermott. Um, and then we've got Gordon uh from Manchester Salford Royal. Um, and uh, and Andy King, he's from Southampton. Um, had great fun when you came to Saint Mark's for a year. Andy. Um, and, er, I have a specific, er, mention for my very lovely colleague, Akash, particularly as it is four in the morning in Sydney where he's joining us from. Uh and last, but not least uh Nina, who's from Newcastle. Can we go? And that's it. So, Gordon, I, I think it falls to you really um my co-chair to introduce this leaflet that we did in um 2010 a very long time ago. Yeah. Well, Carin, it was actually published in 2010, but you will remember it took about 18 months of putting together. Um And I think for those of you who are interested in what we're talking about today, um I think this, this leaflet um which is actually quite a bit bigger than it looks, it probably runs to about 25 pages um very carefully edited by this committee who are at the time, probably regarded as the people involved in this field. Some of them have retired. In fact, in fact, three of them have retired from clinical practice since then, leaving Only Caroline and I involved in it. But I think this this leaflet which you are able to scan and download, which is really great because it's not easy to come by on the internet. Pretty much summarizes the key, take home messages today. Um So you don't need to worry about writing anything down. It's all in there. But what you're going to hear, I think from um all of us is how to work through some of these cases and apply the messages to patients um under, under your care in the future. Um So by all means, download it and have a look at it. Um Caroline, do you want to lead on and, and start the discussions? Yeah, thanks Gordon. Um I think the most important thing is to prevent interstim failure. Um You know, it's a devastating condition and we just don't want to be seeing it if it's at all avoidable. Um Does local and regional management of interstim failure was referring to the tertiary center for ongoing management. We're gonna cover strategies of ongoing management in a tertiary center. Um And then something on the controversies and novel therapies in the management of internal failure. So I'm gonna hand over to for the first case. Uh 68 year old male with abdominal pain. Thanks Carolyn. So I'm just gonna briefly talk you through this case, which was seen at a local district general and then was eventually referred to intestinal failure team at Newcastle. Quite common scenario. We'll see a, a generic general. Surgical take 68 year old man. Previously, just a history of hypertension came in with one week history of abdominal pain, generally unwell by the time he actually presented to it and he was cold clammy and basically just shut down and they were actually struggling to resuscitate him in recess. So he was resuscitated and went for a CT scan. Next slide, please. So the CT scan which just shows uh looked like um possibly perforated appendix with a quite abnormal looking ascending colon. So he was taken to theater and had a actually what turned out with the appendix looked normal. It was actually cecal perforation, but they didn't think it was looked like cancer at all. But they did a right hemi stapled of the transverse colon and hepatic flexure and brought out terminal ilium as end IOST toy. By the time they finished, he was on maximum dose of noradrenaline, wasn't really passing any urine and was needing quite a lot of vaso pressure. So he ended up going to it POSTOP day two. He was still quite sick but his uh no ad and vasopressor requirements are going up. His inflammatory markers are going up and his stoma just looked quite dusky and ischemic. He was seen by the surgical consultant decided it's probably too early for the CT. Just give him some time and observe day three again, same picture rising lactate inflammatory markers getting worse. Finally had the CT which what you would expect at day three POSTOP in a sick patient. It just shows bit of free fluid, bit of free air. And actually the trans colon looks ok. The only thing they did was they started him on TPN. Now the Stoma remained quite dusky. So I think at this stage, what would you do next if you were the on call consultant? So, just wanted to know on the messages and there's some poll questions that are available. So, um if you go on to the messages and polls, there's a question for you to answer and then we'll carry on once a few people have responded at the moment. That's 13. Just wait out a few more seconds and see what everyone's voting for at the moment. It's quite a lot of split. 38% midline laparotomy, 37% long course of antibiotics. There's a split between laparotomy drain and antibiotics. Things seems like an even spread across three options at the moment. Well, next slide, please. So we actually did the third option. He, well, the local team did. He just continued to have long course of antibiotics and just observe. But unfortunately, he just continued to get more and more unwell day eight. Had another CT which looked like that. Actually, the transverse colon staple line has given away. What would you do? Now? That's interesting for Leno. So 84% would do midline laparotomy. How's my next slide, please? Well, unfortunately, this patient didn't. So he had, uh, it was seen by the surgical team and actually his white cell come down from 26 to 21 and CRP is hovering around 300. So we can carry on with antibiotics. His chest was getting worse. He had grown some bugs in there. So it must be the chest that's driving all this. So, carry on further with antibiotics. Same thing again for another few days. There's never been a significant improvement. So now we are at day 22 and he has another CT oh, I thought I had to put that really so sorry, mind if you go back to the other one. So you can see this was his staple line and now his entire right abdominal wall is starting to fill up with horrible mucky stuff. He's sitting on the ward with TPN and AD GH with raise worsening inflammatory markers, but actually clinically. Ok. Next one, please. Anyway. So that was day 22. And now we are day 50 or day 49 when he actually got referred to intestinal radio team because having, despite being on TP and he has lost weight, they were actually basically just struggling to discharge him and they didn't really know what to do with him. And this abscess, they didn't really know, despite having two radiological drains, they couldn't figure out why it was still draining 200 mils puss and brown stuff on a daily basis. And as you can see this was tracked, tracking all the way down under his intercostals and down to his scrotum next year. So he came to us and, but on his initial assessment, he's lost over a stone in weight. He's been on every single antibiotic you could possibly think of. He came in with two wire drains in and on the clinical exam, it looks like there is an underlying fistula, which if you go speak to your friendly radiologist, he confirms, what would you do? Now? We are at day 50. Ok. Uh So 50% said radiological drain, he's already got two radiological drains in his CRP has never come down below 300 and he's always had a temperature of 37 5. So actually what we did next slide, please, we actually took him to theater because he was in such a negative balance from a cata bolic sepsis driven that he even though he was on TP. And he was actually getting no nutritional value from it. And what we found was the transverse colon hepatic fracture as well as three loops, loops of small bowel were fistula into this. And you could actually separate every single abdominal wall muscle layer with pus cavities between them all the way down to his scrotum. Actually, some, somebody in the last hospital had to organize an ultrasound testicle to rule out a testicular cancer for him. So we took all the disease bit away brought out mucus fistula as well as a new ileostomy. Put lots of drains in and continue with antibiotics and he's actually thriving quite well. At the moment, Nina, can I, can I make one or two points here, which I think are important, additional learning points. I think, I think the first thing just, just to say to our younger colleagues is if you think you're going to be able to get adequate source control, when there's a big hole in a piece of bowel by getting a radiologist to stick in a percutaneous drain. You're probably mistaken occasionally, what you'll be able to do is convert an abscess cavity into a fistula and things will settle down. But quite often what you get in this scenario without de functioning of some sort or exteriorizing is exactly this chronic ongoing infection, inadequately drained. The radiologist can do the best, but it's not going to control the source of infection adequately. And this is what you get. And actually I would say the most important take home message for me in a case like this. And I don't know what your experience of it is as colleagues. I'm talking about my consultant colleagues, but also my, my my junior colleagues is that would you have done an anastomosis under those circumstances? I guess the answer is probably no or I would hope it would be no because the guy was knackered and clapped out and really ill when he came in, why wouldn't you do it well, because you think it's not going to heal. So why would you leave a suture line or a staple line in a piece of barrel inside the abdomen at that operation? Why was that going to be any, any more likely to heal? So, if this guy had had a right hemicolectomy and both ends out at the same time, this would have been avoided entirely. And I think that's, that's one of the lessons we've learned over the years. And you've heard from Caroline, that prevention is better than cure. So this could have been prevented just by getting both ends out at the same time, you know, couldn't it? This is what I said to my registrar who was operating with me. I was like, the drains are good but they're false reassurance. And if, by day 20 day 30 you're still getting 300 mils of pus. You need to think what's driving it, why is he not getting better? And, and when I took her through the CT scan, it was, oh, yeah. Actually, I was like, you have to know this, that in a sick patient, the surgeon who actually referred, the patient said when they did do the surgery, his registrar at the time said, oh, no, no, that's an old fashioned thing that you brought that bring out a mucus fistula. Like by who standard can I just say to all the, um, the, the one of you who are early in your training, you will see cases like this and you will work with surgeons who get away with an anastomosis from time to time and they will congratulate themselves and they will tell you that it's the right thing to do, but there may only be a 30% success rate in that situation and you may be submitting the other 70% to misery. And so don't always believe the triumphant trainer is what I was saying. And I think I would say that as, as a registrar, don't be afraid to ask for a uh second opinion or et cetera that if you think that because in this case, this poor patient has just sat there for 49 days before someone actually decided, maybe we should ask someone else. Could I also make a point? Sorry, Nina. Um One of the things that you mentioned in which is a very impressive and excellent presentation is the fact that the patients failed to thrive. So to say, you know, one of the reasons for you to take a theater, you know, for everything to kind of get kick started is the fact that he was on BN, but actually wasn't making the progress you'd expect from somebody on adequate BN. And I think that's really important because I think there's a risk that patients get started on BN. And then that's kind of that, that's it, right. Patient, obviously, patients on BN and that's the best treatment for them. So that's it. And I think having that critical view to see, well, actually we're giving adequate and it's not working and critically assessing whatever treatment modality you started, whether it's antibiotics, BM drains, whatever is really important in these situations because it is so easy to not recognize a patient actually slipping away under your fingers. I totally agree. So there, there's a question from Liam about whether or not it would have been acceptable at the index operation to leave both ends stapled in the abdomen closed and then do a planned re-look. And I think there's definitely a responsible body of opinion that would support in a very sick, very unstable patient doing that. I think if the patient's reasonably stable, it's perfectly acceptable just to get the ends out, wash out the abdomen, put some big drains in and close and there's probably probably nothing to be gained from leaving the abdomen open in that scenario. That's what I would think. I'm not sure what my colleagues think. I think what I've found is that non colorectal specialties, they are more comfortable stapling and leaving to end in. But then what we find is that we pick up a higher rate of open abdomens after. So it's, it's a fine line between what you define as a damage control and what actually is because yes, he was sick, but you're just doing a limited right? Hemi. So if you can do that. And as you said, bring out two ends and close the abdomen. That's a much better outcome for him than just having another re by the time he would be quite edematous, you can't close the abdomen and then it just becomes an ongoing saga. Could I also just say that there's actually some evidence, it's not, it's not, you know, extensive, but there is evidence, there's the Dutch relap trial which looks specifically at patients with intraabdominal sepsis, purulent or fecal peritonitis. Um and randomized between a re look on demand versus a planned Rook. And that's basically what Liam was talking about is a planned re look like you're, you're condemning the patient to needing to go back in a few days later. And actually, there was more mortality, significantly more mortality in the planned re look rather than the reup on the man population. I think the other thing I to point out is damage control laparotomy is a concept, a valid concept in the setting of trauma and ischemia. Um It is probably not except in very extreme circumstances, a valid concept in the setting of abdominal sepsis where it is about source control rather than damage control. And I don't see and I completely agree with Gordon and Nina, there's very little to be gained in this patient from leaving the staple ends inside rather than just exteriorizing them. So a cash, the other thing is that we probably won't mention this again. Um, because there isn't a case on this, but I've just had a lady transferred to me who they've left 22 bits about with both ends stapled off long term. So she's got 30 centimeters, then she's got a 50 centimeter bit of bowel. Then she's got another, which has staple both ends and she's got another 30 staple both ends and then she's got terminal ileum to colon and I, I have no idea what state this bowel is going to be in by the time I get in there. Um, it's difficult to know when to go in. We, we had not long ago, someone who actually perforated a staple off bit of bowel. Um, you can go in, it can be shriveled up, you can go in, it can be dilated with mucus. It's very difficult to tell her what her long term outcome is gonna be. So I would just at this point put a plea in, don't leave staple end, both ends, stapled off on bits of bow. Um, in the long term, can I make a suggestion? We need to move on? It was such a good case. So I think what's coming over as a message is that surgeons often cause fistula and they can do that by reoperated too early by operating on the unprepared patient. Clearly in the emergency, you don't have a choice, but in the elective setting, you do have a choice and pre habilitation is becoming ever more popular. Um, and er, we, we have a great pre hab unit now in our hospital next slide um by not closing the abdominal wall, it used to be, you, you leave the abdominal wall open to let those evil vapors out. Um, and you know, yes, you can put some plastic over it, of whatever description. But actually what happens is that you get a retraction of the abdominal wall muscles, you're leaving exposed bowel, which is more likely to fistula and you're gonna have a heck of a problem closing that abdominal wall in the long run by not getting your anatomy right. This patient had the, um DJ Fletcher, uh anastomosed onto the, um, descending colon when it should have been onto the term ilium and they just left the term ilium stapled off inside the abdomen. Um, so no favors for this poor patient who actually could have done extremely well. Um And, and never got to an if unit, if only they'd got their anatomy, right? Um And by using non-absorbable or crosslinked biological mesh next to FRB or bowel, I don't know if you want to chip in about Perco Gordon as you've written the most wonderful papers on it. Well, no, just, just that, that, um, there's ample evidence to suggest that if you leave, particularly if there's a staple line or a suture line. Um, if you leave crosslinked biological mesh, which really just behaves like leather. Um Although the manufacturers will tell you it's safe to leave in the peritoneal cavity. There's any number of publications, including some of our showing. It's very far from that and it sticks like concrete to the bowel. And actually when you go back in the plane of dissection is within the wall of the bowel, so, so don't leave non-absorbable and in particular, crosslinked biological mes like Perco inside patients abdomens next slide. Um by using suction directly next to friable bowel, next slide. Um And I think above all, by re operating madly, I think this woman had had about 12 laparotomies in a row and they didn't get anywhere and even when she had an abdominal cavity left, they were still trying to re operate on her. So moving on to the next case. Yeah. Thanks Carolyn. It's Emma be from Leeds speaking. Hello, everybody. Thanks very much for joining us. Hopefully, I won't take up too much of your time with this case, who is a young fellow who is working as a teacher, keen teacher, very tall, very keen on lots of things, but very keen on the attention of doctors, nurses and healthcare in general. But he had quite nasty Crohn's disease. So he ended up having the right hemicolectomy, as you can see in July 2014. And unfortunately, that was complicated by a leak. So he went and had a good operation for that complication, which was an ends stone. And as we've heard about they brought out the distal end. So that was good in the local hospital. Um And then a few years later, he eventually persuaded himself to go back into the hospital. Wasn't keen to have a laparotomy and had his G I continuity restored. And then a year after that had a mesh repair of a right ale hernia, whether that was related or not, it's difficult to know, but that's how it was. So, next slide, please. Osman, thank you. So, um, fast forward a couple of years, he went on a holiday to Egypt, Egypt. And um, whilst he was there, unfortunately presented to the hospital in Egypt with abdominal pain and turned out he had an Ileos psoas abscess on a CT scan. So he had that drained percutaneously, as I said, wasn't very keen on being in hospital. So hopped on a plane and came back home to the UK, but wasn't well when he got back. So he was admitted again to the same local hospital where he had his original surgery. Ok. Thanks salesman. And that's your CT scan. And um, what that shows really is that he's got some fluid top left. As you look at it, the deep blue is fluid in his um, in a bag on sa anti abdominal wall, which is probably the drain bag. And then er, also a big Ileo Po collection, which is the different shade of blue bottom left as you look at it. The irregular shaded blue. And then the rectangle is over a bit of distal dilated ileum, which would be close to his previous ileocolic anastomosis. And the point of showing you that of course, is that it's dilated and it looks a bit chronically dilated and it's probable that the collection in the alley psoas area is causing obstruction and thereby leading to continuity of the fistula and the blue stuff that you see outside the skin in the drainage bag. So that's what his scan showed. So there you go nicely summarized. What are you gonna do? Now? He's just pitched up from a plane from Turkey feeling a bit miserable. Still got his shorts on bucket and spade close to hand. He doesn't like the look of you because he doesn't like hospitals. Ok? I think we got the answer there. So, um, pretty much split mainly slightly in favor of a radiological drain. Ok. That's what your oral laparotomy. Ok. Um Anything else you're going to do? Just go back one sli Osman, any suggestions in the chat, you can think about whether you're going to do any further tests, um, or think about anything else, ask advice from anybody that kind of thing. Let me know in the chat and we can answer those questions or comment on your suggestions. Ok, thanks Osmin. Um So, um he was in hospital for a short while he was starting on T PM because he got a fistula. So what else are you going to do? TPN? Fistula, fistula TPN? That's what we do. We've already heard that antibiotics have a role of some description. We're not quite, not sure what it is but off he went home because he wasn't staying around. He wasn't keen, but unfortunately when he was reviewed in clinic, he just wasn't progressing. He realized he wasn't progressing, he couldn't get on with enjoying what he wanted to do, which was watch cricket wasn't getting anything from that losing weight. We've heard about that not thriving stuff coming on from his wound. We've heard about that already. So they brought him back into hospital. Ok, Yasmin. Um this is the sort of er picture that was seen in hospital. Uh You're probably not familiar with the system that they use, but the green chart, the green line is his temperature, the yellow line you can ignore for. Now, that's not very relevant. The red line is his pulse rate and BP at the back at the bottom in black. So he's got a bit of a swinging temperature. He's a bit tachycardic. Um, yeah, next one please. Osmin. Uh there's his blood results, he just read it out. Really? He's slightly anemic, his white cells are raised, his platelets are raised and you could take these blood results any day of the week. That'd be very, very similar. His U and es are great. Um, maybe that's because he's on TPN and his albumin is a bit on the low side, on his LFTs, his FS are slightly slightly off maybe, but that'll be down to the TPN. Won't? It always is. That's what I'm told. It's always the TPN making his LFs go off slightly. So, if you could just tell me, please what you're most concerned about on all of those. Uh huh. Good. Ok. Great. And I think it'd be fair to say that the 80 odd percent of the people who, oh, there we go. Some more people put in some responses, it stays the same. Great. So, sepsis is pretty much responsible, I would say for the anemia for the bio chemical abnormalities and for his psychological state. Good. So, sepsis is underlying everything, isn't it? Ok. Next one, please. So we were taught some years ago now, uh 1997 by a man called Nigel Scott and uh his senior colleague, Professor, Sir Miles Irving, how to manage fistulas. And the message really hasn't changed. It's a four letter word starting with S and ending with nap snap. And of the most important letters in that is really snap whenever I'm talking about it, which I often do. I spell it with about 10 Ss and then nap snap because everyone forgets the sepsis. Ok. Next time please. Yasmin S is for sepsis. N is nutrition, a anatomy P plan procedure at your stage. You need to know that if you don't need that. If you don't know that. Then I hope you'll do some reading about it. Once we finished tonight we'll relisten to this, um, web education session. Um, I think we're probably running a wee bit short of time. So we'll move on from that snap, read about it. Sepsis, nutrition, anatomy and then procedure or plan. So, here's someone who came to our hospital recently. They've been in their local hospital having had emergency surgery, which was for ischemic bowel, ischemic small bowel as it turned out. And, um, they had a very short, um, judging as a Jujuy. Um, sorry, I beg your pardon. They've done the ischemic bowel operation, took, taken out most of his small bowel and then done an anastos between 30 centimeters of ju and, and 30 centimeters of terminal ileum and postoperatively, he developed a fistula. And the picture on the left hand side is his wound when he arrived with us. And the picture a day later is his wound once we'd opened it out because underlying that cavity, you where the fistula is underlying, that is a load of small bowel contents associated with sepsis. And despite the fact that stuff coming out of the fistula, despite the fact, you've got a drain in a radio logically insert to drain in another patient, you're just not draining the sepsis effectively. So for us, that was easy to do, we just opened the skin. Ok. Uh Next slide then and then we into this problem of skin care. A very quick snapshot of the ingredients you need for the recipe of skin care. Those are what we use where I work in leeds. But others are, I'm sure available because before you know it, when you get small bowel contents onto the skin, it takes four hours, six hours for the skin to turn wild, takes another week, then for it to repair. And this is what you need and you need dedicated input from your colorectal specialists. If you're fortunate enough to have them, there you go. Next slide, please. Osmin. Um The other thing, of course, you can use, er, er, this, the whole purpose of this slide really is just to show you the thing on the left hand picture in the person's hand, that's a gloved hand using suction, all beds, all hospital beds have suction. I don't know if you knew that whether you realize that it's meant to be used, er, mainly for si emergency situations to suck out the trachea. If someone's collapsed and they need CPR something like that, you can use it, you can use it to suck stuff from the fistula. When you change uh fistula bags, you can get the patient to use it, keep stuff away from the skin. And if you do that a week later with special specialized skin care, you'll go from left hand, horrible looking situation to a slightly better, not perfect situation on the right hand side. So I'd encourage you to use that, er, be mindful that you clean it or change it before you use it for the airway mind. That's important. Um, so here you go. Here's somebody slightly different patient but very similar situation. If you can see the arrows, they show a big fluid containing something or other, you might call it a collection right next to a staple line. Um, so what you gonna do with that? I would like to know, just give you a few more seconds because I haven't got many responses again. For either drain, radiology, radiologically or midline laparotomy. And some people would favor a local surgical procedure. Um, local circumstances will dictate exactly what you do because there's no exact right answer to that. But the, er, answer I would want you to choose and you've probably all chosen. It really is drain the pus if there's pus about, get it out and if a local procedure will do it, then do a local procedure. If a local procedure won't do it, do a laparotomy, do a local procedure under general anesthetic. Do it on the ward. Radiological drain. Gordon Carson's, uh, very sensibly suggested that that often won't work. Sometimes it will. But he's right, more often it'll turn a tricky problem into a slightly less tricky problem and give you a bit of time because the drains are just tiny, aren't they? Ok. So drain the pus pus about, get it out. Ok. Thanks Osmin. So, here's our fellow back to our 28 year old teacher who hates hospitals. And, er, he had that big collection that, uh, I showed you that was draining some of it was draining through, out, into the fistula bag on the outside. And he also had a couple of other exit points. I'll call them for the fistula and of course, in the local hospital he's told, he's told he's got two or three fistulas. He hasn't got two or three fistulas. He's got one fistula, one connection to the bowel, but multiple exits because the pus is trying to get out. Nature is telling you what you need to do. You need to drain the pus. So to drain it all out would have meant a huge incision in the skin going down to his right groin. Um So what this shows you is just what we did a local surgical procedure under anesthetic mind to give as good drainage. And then the purpose of those plastic drains there is really a bit like a fistula and ao same idea to prevent it closing off at the exit. So the pus will continue to have a way out until the wound starts to heal up and close down. And the drains will prevent the closure of the skin, the closure of collection of infection underneath the skin that I've chosen to leave. It's not a definitive procedure, but it does drain pus. Ok. Thanks husband so frequently. When people get, come across from other hospitals, um, they come along with what I call the NT thing. The knot, um, process, I guess they're on nail by mouth. They're on octreotide T DS and they're on TPN and the beam that way, not know by mouth octreotide and TPN for at least two weeks. Usually six weeks before someone gives me a ring. I would encourage you not to do that. I'd encourage you if you're thinking of doing that or if you come across a patient who's on that regime. No, by mouth TP N octreotide, just give someone a call. It doesn't have to be me. I'm happy for it to be me. It could be anyone on the committee. I'm sure it could be your dietician who's seen it all before, who's concerned, but too afraid to speak could be the physio who can't get your patient out of bed. It could be the nursing staff on the ward who just wish they could tell you when they remembered it from 10 years ago when it happened and ended up having the pus drained out, just give someone a call. And I think, is that where I'm up to Osman? Yeah, thank you. So, have we got any questions in the, in the chart? Is it, is it worth pointing out Dermott that there's no evidence to suggest that octreotide does anything at all? Yeah, we had a slide on that before and we removed it. So, you're quite right. Yeah, it makes the drug company a lot of money. Yeah. Um, and if you're thinking of using octreotide, your patient's not on it. And you've got the fistula or a high output stone. And you think? Oh, I know. I'll start octreotide. Don't just pick up the phone because it tells me you've run out of options and it's your last throw of the dice and it's very unlikely to achieve anything useful whatsoever. Maybe once a year prescribe it, uh it can give you jaundice and it can make you feel very sick. Yeah, that those are not generally considered positive developments in intestinal failure care. So, yeah, I think you're absolutely right, Caroline, there's, there's no evidence based on randomized controlled trials that it was anything at all. So please don't use it. Ok. I think this is your case, Caroline. It is. I was just wondering if there were any questions for, for Dermott, there was one in relation to the last case, um which said if this was your, your patient. Um And he was with you in the first week POSTOP. When would you have gone back in? I don't know if we can remember the last case, but I think because I think as Gordon and I discussed that we knew that this was being driven by lack of source control. So yes, we don't want to do laparotomies beyond day 10. But at the same time leaving this guy as you can tell he never really got better. So, if this was within the first week and I could see the Staple Line has fallen apart which the CT did show, then I would have gone back in. Yeah. Absolutely. No other questions on the chart for now. So we'll plow on with this one. This was a 74 year old homeless man. Um, and we got a phone call from HD in another hospital. And interestingly, it wasn't the surgeons. It wasn't the junior. It wasn't anybody except the anesthetist who really could not bear the surgeon going back in and back in and back in. So he pleaded with us to take the case. Next, next slide, please. Osmond. So this was the patient's history. Hartman's for diverticular disease reversal of Hartman's an ileostomy back in, back in, back in, back in, back in next slide. And on arrival at Saint Mark's, um he was quite a substantial patient, big abdominal wall defect. There are little bits of mesh sticking through next slide. O uh he was septic jaundice, naf severe back pain. Um He had right Iliac fossa collection which had previously been drained but not adequately. So there was an element of alcoholic cirrhosis. He was in mild chronic renal failure, he was very depressed. Um And radiological mapping had already been done and he did have an ongoing um leak and stenosis at the old rectal anastomosis. I don't know if we've got a pole for this, have we? Yeah. What is the priority with this man? Yeah, it's great drain the sepsis is and, and get control of that sepsis and all the rest of it will just fall into place after that as it in fact did. Um, and once we had drained the sepsis, then yeah, we established nutrition. There's not much point in getting on nutrition until the sepsis is, is controlled funnily enough. The one thing that was good was his skin to start with. Um And no, we didn't put him nil by mouth. He had this fistula established for a while and there is no reason for this man to be not by mouth. He's just gonna get more depressed and there's no fistula that was big enough for us to establish um distal feeding. Next slide, please. Osmond. So, resuscitation, antibiotics. Um look for pools of sepsis in the abdomen. Remember he had back pain, we MRI his back very early on because we do see cases of disc itis in these patients. And unfortunately, he didn't have that. We drain the collection, we stop the octreo time, reduce the lipids. Um And those two things together with sorting out the sepsis of what will bring your um your jaundice under control. We removed the little visible bits of proline mesh. Um As much as we could, we did it in theater under local. Um because we always like to have a bit of diathermy if we're going to start doing mesh removals unless the mesh falls out from a heap of sepsis. Um, he, he did actually have dis itis this guy and he didn't respond to the first set of antibiotics. Um, and we ended up actually doing a disc biop biopsy and culture to get on the right antibiotics. And we've referred him to psychiatry to a dentist because he had awful dentition. And the last thing you want, um, in an anastomosed, um, bowel, um, slightly friable bowel, er, is for patients not to be able to chew their food and of course he's homeless. So he goes along to the social worker as well. He's going to be a very complex discharge next slide, please. So he gets discharged home to temporary accommodation on home, parenteral nutrition, minimal lipids in the parenteral nutrition. As he's got ongoing abnormalities of his illes, he's never going to learn how to put it up his own, um, parenteral nutrition. So he gets home nursing, he's got his dentures. Um, it's slightly difficult because his partner's alcoholic and she's very antisocial. Um, and the HPN nurses are not having a good time of it. Um, and, um, he gets bolus feeding just prior to, um, prior to putting them back together. But you'll see in another slide that actually that wasn't for another 18 months. So we've got another pole up at the moment. So the majority of people don't use distal feeding. So I think one of the take home messages from today is, um, that it is very useful in a lot of cases. And that actually, um, bring up those distal ends and if you can and we'll come back to this in another talk, bring them up next to the proximal end. So this chap, after 18 months, we deemed he was fit for a further major surgery. He had Botox into his abdominal wall. Um We kept the surgery simple. We didn't try to um take away his end colostomy. We were actually able to get a primary closure to the abdominal wall after the Botox, he self discharged at day 22 and he was able to come off PM one month later. So are there any questions on him? Was there another pole? Nothing on the chat at the moment? Ok. Let's just wait for this pull. Thanks, Carolyn. Is it worth just reemphasizing the fact that sepsis is frequently related to the abdominal wall and the fistulas and then into the abdominal cavity. But also can occur in almost anywhere such as disc itis uh uh in the eyes, re all those places need to be considered. Yeah, which is what you did, teeth dentition and most commonly, of course, the central lines that are placed at um by the the referring units. Yeah, and often not single lumen that are dedicated to parenteral nutrition. You know, there's there's nurses going on putting antibiotics and all sorts down the line. Uh, and, uh, they're just contaminating the line every time they touch it. I, I just wonder Karen whether it's worth, um, just discussing for the benefit of our junior colleagues. Um, what we think as a group is an acceptable rate of infection in central venous lines being used for TPN. What rate of infection is acceptable? Do we think at home or in hospital, in hospital? any comments from my colleagues or do you want me to tell you what? I think? I think I know your answer. Goon I know your answer as well. It's zero. Yeah, which should never occur because it's completely preventable with adequate aseptic technique. The um SPN and um bay pen have established a standard of one per 1000 patient days of treatment. Um and anything above that should cause concern. And the reason I emphasize that is because I know we have patients who come in from hospitals where 10% of their lines are infected within five days of insertion. And it's actually pretty unusual for a line not to be infected within 28 days of insertion. And I think that that's just poor nursing care. And actually the main culprit is the doctors because the doctors are allowed to handle the lines, take blood from them drugs through the lines. Um The dedicated intestinal failure units that Caroline was referring to in, in the, in her introduction are all united by the fact that they all have really low rates of Lyme infection so they can provide safe parenteral nutrition for these patients for months on end in hospital without having to worry about Lyme infection. That's really important. Good and agree entirely. Of course, I would, uh, at the same time, the sad thing is that many of these patients didn't need TPN at all anyway, if they'd just been allowed to eat. Ok. I think we're, we're moving on to the last case if we have time and we have Akash who's joining us from down under. Yeah, thanks. Thanks Gordon. Um I'm a mata, I'm one of marks colorectal and if consultants I'm currently logging in from Sydney. Um and I want to take you through the story of Mr A who's 46 a bit of an unfortunate history. He had a blunt abdominal trauma and needed a splenectomy as a child in 2000, sustained a gunshot wound to the abdomen um causing the usual runs of multiple laparotomies. He was out of continuity for a bit and back in continuity and he, he had a large assist hernia, which he was actually managing very well. Fast forward two decades and on Valentine's Day 2021 make of that, but you will, he was stabbed with a pet knife in his incisional hernia, um which he thought was kind of nothing. He had a little skin opening, he didn't think much of it, but about two months later, he did go to his local a and because he actually had a bowel loop now prolapsing out of what was initially that really small hole. So, um with the bowel content coming out of it, so he had an enter contagious fistula, he was a smoker as well. Um, his current situation at the time that we first meet him is that all his enteric output is coming from his fistula. He has been established on parental nutrition and of course kept not completely no by mouth, but, but you know, very limited by mouth in his local hospital. And importantly, he is thirsty, very thirsty. So I believe we have a pull now about how uh what the important next step is. So we'll give you a few minutes or a few seconds, right? Oh, yeah. Ok. So we, we only have six responses so far. Well, it's kind of even between, oh, there we go. OK. So isotonic electrolyte solution or continue feeding and see what happens seem to be uh the main options chosen with fluid restriction and loperamide coming in um as well. And there's 3% who are saying the patient should be kept no by mouth. All right. Next slide Osmond, please. So, um this patient basically has a high fistula and what are the treatment modalities? Now, there's, there's various components to this. It is about um drinking the right stuff in the right amounts hypotonic fluids, which is basically everything, everything, water based um is a hypotonic fluid. Unfortunately, that also includes the water which you take your medication with for that also includes things like 40 sips and ensures and everything like that. Um And it's about they're allowed to drink it just limit it to about a liter for 24 hours. As long as importantly, they're also drinking the right stuff in the right volume, which is a glucose saline uh solution also about a liter a day. And then on top of that, of course, there is uh what, what we now call the usual concoction medication but basically is antimotility and antisecretory agents. Um Intestinal trophic is the the the new kids on the block. Uh The intestinal growth factors, it's they probably do not have a role in the acute um management of an a fistula, but more in short bowel. Uh But there, of course you get on the block in terms of medication in intestinal failure. Next slide, please. Osman. So, uh coming back to this again, Dermott has very eloquently um pointed out to us um that keeping a patient nose by mouth more often than not is unjustified and uh uncomfortable and plain wrong. Um It's about again eating and eating the right stuff. Um And we normally would suggest encouraging patients to have solids which are low in fiber and relatively high in salt. Like I said, it's about allowing the correct fluids in the correct volume so hypotonic fluids, which again is virtually everything uh up to a liter a day and then a glucoside solution uh also about a liter a day and then antimotility agent such as high dose loperamide and codeine, not loperamide or codeine. Mind you unless there are contraindications that, that they work synergistically and they, they, they, they uh augment each other in relative high doses. Uh monitor QT intervals and do ecg at relatively high loperamide dosages, specifically antisecretory agents. Proton pump inhibitors uh are the most commonly used. Although you could also use H two antagonists, especially if you are struggling with hypermagnesemia. Uh I've already spoken about and I I also personally do not think really has a role in these, these patients but are not helpful and we do still quite regularly. See patients on them are um pancreatic supplements unless there's, there's proven pancreatic insufficiency and things like cholestyramine and chola and everything because there's no point in giving them because the majority of these patients with the high input small bowel fistula don't have their colon in circuits anymore. So there's very little point in giving those agents. Next slide please. Osman. So, coming back to electrolyte solutions, what do we have on the market and what is is reasonable to use? Um So there's the wo mix which is relatively high in potassium. This is a marked electrolyte mix also known as a Mark solution. Ey, um which is um isotonic and does not have any added potassium in it. If that, I I know that in the country, there have uh there have been problems in the availability of various components of some electrolyte mix. So there's an alternative that diur like the problem is if you read the manufacturer's instructions for diur, like they suggest um one sachet in 200 mL. So that's five sachets in a liter, which is not enough and that does not, that is still hypotonic. So we would recommend double strength or so that's 10 sachets in the liter, which gives you a good volume. This which makes it isotonic, even hypertonic but also packs a whopping amount of potassium. So these do need to be checked on a regular basis. Um Just to dispel some myths. Unfortunately, the sports drinks Cuza Powerade and everything are not, are not meant to be used as a replacement of electrolyte mix or double strength a light. They are hypotonic solutions. Even if you add a teaspoon of salt to them, they're still hypotonic next slide, please. Um Can I, can I just stop you a second before we, we move on to feeding and and off fluid therapy and electrolytes. Um because this seems probably the best time to do it. Um Do you, do you have any thoughts and can we discuss for our colleagues, how should we be monitoring these patients in terms of fluid and electrolyte replacement? What, what routine things? Um Do we think are worthwhile asking people, including our nursing colleagues and our laboratory colleagues to measure, to make sure we've got it right. Really, really good question, Gordon. So, of course, first of all, if we're talking about asking, ask the patient whether they're thirsty, uh I, I routinely when I, especially if I meet patients in clinic or see them for the first time on the ward, I ask them, show me your tongue. Um I, I ask them, you know, how, how often do you go to the loo to pass urine? And is it very concentrated? You know, those are the kind of things importantly, do you have cramps in your legs on a regular basis, which could, you know, indicate hypomagnesemia? Um Of course, there's, there's quite easy physical examination signs to look out for from a biochem point of view. A lab point of view. Of course, there's the usual genies and everything, the random urine sodium I feel has become my best friend in these things. Um I'm, I'm not as a surgeon. I'm not clever enough to really understand why w what, what exactly does, but there's a cut, there's a cut off of 20 isn't it? So I've learned a random immune sodium under 20 means that the patient more likely not, is in a dehydrated state and therefore whatever measures are in place are not sufficient in hydrating that patient. I think that's a really, really good point. A ash and, and the take home message I would suggest is worth thinking about is if the patient's urinary sodium is below 20 they are hyponatremic because they often are hyponatremic, particularly when we start giving them intravenous fluids. Then what that tells you is the patient is probably still sodium depleted and therefore, you've got to give them more salt. If they are hyponatremic and they have a, a urinary sodium greater than 20 then you're probably giving them too much non sodium containing fluid. The other point I would make is, and I'm not sure whether my colleagues do this, but you, you talked about giving proton pump inhibitors for these patients. But I'm not sure how many of us actually measure or ask our labs or our nurses to measure the ph of the fistula output. And it's important to recognize that the reason that a lot of these patients have a high output is because they have gastric hypersecretion because they lose the negative feedback loop by not having enteric content in the distal isle in the so called ile or break. And therefore, their stomach produces more acid. So we should be aiming to get the ph of their small bowel content of to seven or above. And that means you've got to be able to measure it and therefore titrate the dose of a proton pump inhibitor to establish that it's not just bunging them on, you know, a bit of lansoprazole and assuming its job done, they may need a much higher dose to get control of that gastric hypersecretion. I don't know what my other colleagues think, but we found that really helpful to get some of the fistula outputs down. Yeah, I totally agree. And I think also it's really good for the, the skin is, is, is really upset by acid and I think it's, it's really crucial to do that in, in, in patients who are really struggling with the skin. Yeah. No, no, that, that's great Gordon. Thank you. Um So could we move on to the next slide? So a few slides of distal limb feeding already been mentioned in the other case. And in this patient as well, it's about infusion of feed into a distal limb of an a fistula or a loop or double barreled stoma. Uh It does a few things. It promotes interstim adaptation before reconstructive surgery. It can replace IV nutrition in very selected patients or at least reduce the need for reduced their parenteral requirements. And it may by reactivating some of the breaks which Gordon also just now mentioned, reduce, actually reduce the output coming out of the fistula or the stoma. Um Next slide please. Osman the there are the distal feeding is not one thing, there are many variables um where you infuse into, into mucus fistula into the fistula loop stoma. What is the goal? I I personally think that in the majority of patients, it is uh mucosal adaptation. Although you could potentially meet nutritional requirements in, in a selected group of patients. What type of feed do do we use? Is it entering nutrition? Vital. 1.5 being probably the most commonly used one or do you want to reinfuse the, the fistular stoma outputs back in? How do you do that? Is that a continuous feed? Which is possible, but it is quite labor intensive, especially you want to send the patient home on it. Um Or is it bolus feeding which patients could potentially do themselves? Um And what tube do you use? There? There are a variety of tube, balloon, gastrostomy G tubes, gastrojejunostomy. There is one of the the newer kids on the block is a pump called the insides pump, which is uh very useful in terms of uh chime re infusion in relatively decent volumes as well. So it's not bolus feeding, but it does reinstill high volumes of the chime. Um The issue with that is coming back to a common carin made as well. That that only works if both the ends. So the ati and the N end are in the same bag. So it isn't just about exteriorizing everything but if possible, exteriorizing proximal and distal next to each other in a loop in a loop or double barrel type configuration, stoma rather than one, only one side and one on the other side of the abdomen. Next slide, please. Osman. Um a very busy slide about the dietary management. But again, I think we can all agree, these patients should not be kept no by mouth. But it is of course about choosing what the correct input is. Now, this could be enteral feed. This could be actual food, but it's about relatively high caloric food, high protein content, um low fiber uh uh input checking micronutrients on a very regular basis um with relatively high salt. And on top of that, of course, a fluid restriction with some form of oral rehydration solution, be that sar electrolyte mix or double strength dili next line. Um So a all when should we actually operate this patient or these types of patients? Give you a few minutes? Ok. So uh we have a few patients, uh a few, a few uh responses going for a relatively early intervention. So between week two and week six, the majority going for a relatively late one. So beyond week 26 a few of them in the uh in between the two and and a few going even further. So beyond the year. All right, let's move on osmin. So again, there is some data to suggest that the longer we wait, uh the better it is for the patients um in terms of lower fistula recurrence rates with a longer interval to time. But this particular study could not really uh specify what the timeframe would, would be. Uh next slide Osman, this is a pooling together of um outcomes in terms of mortality and fis recurrence rates uh from a wide variety of, of papers and uh distinguishing those rates in a very early intervention. So, you know, within two or three weeks, um 3 to 12 weeks, 6 to 12 months and beyond 12 months. And I think it's abundantly clear from this, that there's a definite trend towards lower mortality rates and lower fis recurrence rates, the longer one waits. And I think most of the people on the panel would agree that that, that ideal cut off is a minimum of six months but equally and Carly show this very well. In her case, quite often for a variety of reasons, we end up waiting longer and that is only of benefit to these patients as well. We look at the rates beyond 12 months. Uh Next slide, please. Osmond. Now, anatomy. Um That's again, you know, the a uh of the of the snap. Uh What is the most important modality of mapping the bowel prior to repair? And how do we image the bowel? OK. It'll give you a little bit of time to answer that. OK. So that's interesting. So the majority says fistulogram, um OK, we're changing a little bit. So still the majority says a fistulogram with various O g or even the colonoscopy and the CT coming in close. Second. Now everybody does this differently, right? So I'm not going to sit here and say, well, this is how you should do it, but this is how we kind of do it. We normally start with a barn door CT scan of the abdomen and pelvis with intravenous and positive oral contrast. So that's Gastrografin or water soluble whatever oral water soluble contrast in selected patients, uh patients with Crohn's for instance, where you're also interested in looking for disease activity, probably something like a CT enterography which is basically a CT with negative oral contrast or an MRI toy might be slightly more useful if there's a clear vascular insults underlying all of this. So mesenteric ischemia, then probably imaging the mesenteric vasculature with the mesenteric uh angio phase CT would be useful as well. Then you augment all of that by uh basically getting contrast enhanced imaging of all the other bits of the digestive tract which have not been opacified with contrast with this CT scan. So that's O g, distal two fistulae, um water. So contrast enemas to, to ensure the patency and integrity of the colon, uh you can use colonoscopies, especially if you're concerned about disease activity in the colon or alternatives. And I think also very important is thinking ahead if you have a patient, especially female patient, uh who may already have had some issues with a bit of continence prior to all of this. And you know, you're going to be anastomosing relatively short segment of small bowel to maybe an incomplete colon. Potentially, you could actually be uh making things worse for that patient in terms of uncontrollable diarrhea incontinence. Um So, assessing uh the pelvic floor function with anal electro physiology and an endo an ultrasound might help in the decision making and the consent process with that patient next night, be Osman. Um So in this patient coming back to Mr A who's been literally shot and stabbed in his life, um we started with that barn do CT with intravenous and positive contrast. We did a fistulogram down the distal limb of his kind of prolapsing loop fistula. So to say we requested the contrast enema which the patient declined because he doesn't feel comfortable with that concept. Next slide, please. Osman, I will show you the CT scan. This is a a snapshot again. Remember a fist gram is not a snapshot study. It is a dynamic study uh which needs to be interpreted in real time by the radiologist. But this is a, a nice picture showing nice opacification of a decent length of small bowel uh distal to the fistula. In this patient, you can also see in the left upper quadrant, a lot of the the the gunshot pellets from his initial gunshot injury from all those years ago. Next slide, please. Now there are various ways of doing this. Uh You can just uh rely on the the the radiological reports, you can make your own kind of little report and put it all together and keep it somewhere in the system or dictate it in a letter. Uh We have uh developed a mapping template uh for which, which we can use to make a patient's map. Uh And which we've decided to, we've chosen to upload to the PAC system so that it always follows this patient around as part of their imaging and everybody can access it. And for this patient, you can see that there is a decent uh segment of small bowel outer circuit distal to the fistula. The colon is completely intact and patent. Um They've also got AAA midline defect of approximately uh 13.5 centimeters. And the other crucial thing which I've not mentioned so far, which we should really use imaging for explicitly is what is the safest part of the abdomen to enter when you when we are doing our operation. Um And that most often I think is Subxiphoid sometimes is low down and if all else fails, it will be around the fistula uh to go in. But that's key and we, we document that in our map as well. Next slide, please. Osmar. Um Again, coming back to the feeding on the left, you see a evolving fistula. It has not happened yet, but there is a collection which probably will break through the skin at some point and become a fistula. But as long as that's not the case, as long as you still have a collection, this cavity which just fills up, probably de sensible not to establish start enteral feeding at that point in time, once it is broken through and you have an established fistula, it is absolutely fine. Just like Derma said to feed the patient enter and potentially add in a form of distal feeding fistular crisis, enterolysis if you have an established fistula, but there's still this cavity and not everything is draining properly. It is reasonable to continue PN but the moment you don't have that anymore to start entering nutrition. Now, it may well be that you still need to give PN on top of the enter feeds if you're still feeding into a relatively short segment of bowel of about a meter or so. Next slide Osman. So in this chap, we ultimately um established him on a low fiber diet and distal feeding. And what we did with him is he could not tolerate diur light. He just, he just couldn't, he didn't like it, it just did not. And we decided to help him reinfuse the diur light into that segment of small bowel, which is actually longer than the segment he was going to drink it into. And we used that inside pump in him and he did that really nicely. Unfortunately, ultimately, there were some issues with compliance, but also um crucially some issues with local access to dialys and definitely also to some mark electrolyte mix. And there were multiple readmissions to the local hospital and in the course of those admissions that he, his renal function was deteriorating. He was dehydrated. He kept on being topped up with IV fluids and electrolytes. But ultimately, he was losing weight and his renal function just went downwards and he was kind of heading towards the CKD uh type population. Now, we've had a poll in the meantime, looking at the most important considerations prior to fistula repair. Um, and the majority feel that that's uh delineation to G I anatomy followed by fitness for surgery and, and weight gain right next slide, please. Osman. So we decided ultimately because we did not feel he was really coping that well to, to admit him. Uh One of the things we just set up as a surgical nutrition unit at Saint Mark's and we got him in for preoperative optimization to kind of kick start the rehabilitation program as an inpatient. And we ultimately got his weight to steadily increase and also stabilize his renal function. And ultimately, we decided that he was not going to get much better and he was as good as he's going to get for his definitive operative management. Uh Four weeks prior to that, we injected Botox into his lateral strap, musculature of his abdominal wall. And ultimately, in September 2022 we performed a single stage in fis repair and abdominal wall repair rather than reconstruction where, where the Botox worked so well that we were able to just actually get the, the the, the midline closed, primarily that is not in any way, shape or form a formal decent uh or durable abdominal wall reconstruction. And he and I know that he will probably possibly develop a hernia in his future if that's not causing him any trouble and he avoids getting stabbed into it, that's probably fine and we can leave that alone. Um And if it causes him trouble, then he has a non contaminated abdominal wall reconstruction, which, which we can do with him. And depending on your unit that could even be done minimally invasively. Uh Next slide, please. And this is him. So the left photo is him um on the table just before we start. So what's what's not clear is that he's got quite a wide bore abdominal wall defect in the midst of this prolapsing. Um loop fistula, I call it and this is him uh on the day of discharge just before packing his bags and going home. But you can see, you know, he's got a midline scar. Um he's got a little bit of superficial dehiscence. Er But overall he's done, he's done really well after that. Uh next time, please, Osman. So what's important when we get these patients from other hospitals? Again? Number one, not just drain any sepsis actively and aggressively. I would say look for sepsis. Don't just assume that the patient will, will make it apparent if they're septic, but look for it and exclude it stoma and wound care is so important also in, in, in just making sure that each patient go home, giving them a sense of autonomy and independence. And all of this, I think as surgeon, I find it very easy to kind of say get the medical bits sorted. So you know, Crohn's optimization diabetic control, all all all that stuff is important like Dermo has said, let them eat and get them out of bed, psychological support as needed. And I would probably pose that it is always needed. II I think virtually all these patients have a degree of PTSD. Um having been in the hospital for many months and seeing bowel content coming out of the midline wound um is quite traumatic and crucially, it is important for the patients to also realize that we will hardly ever offer them their ma definitive reconstruction in that index admission. And the plan is not to offer them surgery. The plan is to get them home safely, uh establish them whatever nutritional support package they need with a plan for surgery in the future when the time is right next. Uh Slightly Osman and I'd like to give the final word. I think this is the final slide of take home messages to my colleague, Dermot Burke again. Thank thanks, Akash. I was fascinated. I'm so busy being fascinated, didn't know what was coming up, but there we go. Great. Thank you very much. Um Someone's asked a question about Crohn's disease in the chat, whether they should have a capsule endoscopy or not. And I think most of us would think you've got to be very cautious with capsule endoscopies in people with Crohn's, as you point out in case they've got a stricture and it will get stuck. But I thought there were dissolvable capsules that you could test that with if you're really keen for them to have a capsule endoscopy. I think in general, if you've got multiple Crohn's strictures, don't go for a capsule. Yeah. Get friendly with your radiologists. Get very friendly. Well, not overly friendly. Actually, there's a story about that won't go there but get friendly with them. Know your radiologist, know what skills they have, appreciate their skills and get them on your side. Um, so Napoleon wasn't a radiologist. He was a bit of a crazy dude, I guess. And he's much, er, detested in England and the United Kingdom, but in France he's nowadays revered wasn't always, thus, he was a bit of a bad lad in that. He tried to become, take over Europe and that's really what got him into trouble at the end of the day. Just wouldn't stop doing that. He did a lot of good things though. Um, but he ended up isolated in a place called Saint Helena, which if you look on a map is in absolutely the middle of the Atlantic Ocean, uh, difficult to get anywhere from there. And he was surrounded by guards and that's where he died. Having once been Emperor of Europe, he was finally, had his last days in this lonely place. So he knew a thing or two about being in battle, being close to death and he knew a thing or two about, um, living a lonely life. And, um, so this is one of his quotes, I'll read it to you. It was, it's one of the few things I'll read off a slide. Er, death is nothing but to live. Defeated and glorious. Not many of us have a chance to find out what it's like to live. Glorious, I guess, but defeated and ing glorious is to die daily. And the patients I see when I get a phone call who've been in hospital for 4 to 6 weeks with their fistulas. Oh, definitely living a defeated and inglorious life on a daily basis. Inner side room slightly jaundiced. Oh, it's the PTPN not having eaten for weeks. And the most they get from the medics, uh, from my own personal experience is a knock on the side room door at eight o'clock in the morning to ask them if everything's ok. And yeah, we'll see him again later and that's how it is. And that's not good enough because death is better. According to Napoleon, a man who should have known than to live a life like that. Defeated. Anding glorious in a side room. Septic and jaundice waiting near by mouth for something to crop up. That's better. The best you can do is pick up the phone. That's a great final message, Dermott just to pick up a couple of questions right at the end, um Liam asked about um the use of Botox and abdominal wall reconstruction at the time of fistula closure and actually suggest in fact that the question, what's the most important consideration prior to fistula repair? Um is, is possibly not a brilliant question because I noticed almost nobody said a planning abdominal wall reconstruction. And what I would say as a take home message is that if you're ever going to do an operation for a patient, particularly who's had an open abdomen and an entero atmospheric fistula, you have to plan the abdominal wall reconstruction when you're planning the operative strategy. Because if you don't, what you find is that you've spent maybe six or eight hours taking everything apart and then putting it all back together again. And by then you're knackered and then you suddenly find you've got a huge hole in the abdomen that you can't close. So you have to plan your strategy for reconstruction of the abdomen, even if the plan is that the most we're gonna do is put a piece of, you know, vil mesh into the defect and then get out because that's all the patient's going to be well enough for. But you still have to have that plan before you start and most importantly, explain it and discuss it with your patient and also your colleagues. But increasingly, I think if you do that and you've got patients who are fit enough, like the patient at Cash has described and you know that you're gonna be able to get an extra bit of traction on the abdominal wall by putting Botox in and close the abdomen, maybe with an implant. Um then it's reasonable to do that. Our personal strategy in Salford has always been to do that kind of an abdominal wall reconstruction. But as a basic principle, anything that's complex involved in abdominal wall reconstruction like flaps over, we never leave an un um unprotected anastomosis behind it. So if you have to bring a flap over the abdominal wall, um you bring the ends out and leave the patient with a double barrel stoma. If there are anastomoses distal to that they're protected by it because the last thing you want is an anastomotic leak behind a complex abdominal wall reconstruction, you usually only get really one good bite at the cherry in that. So that, that's that message. Um Yeah. So just about the question about the strategy, uh the consideration strategy of all the wall reconstruction. I think the thing is you cannot have one strategy. A it is not a one size fits all approach. I think those who say we will always do a single stage. ECF repa not the wall reconstruction equally those who say we will never do a single stage, probably are both could, could be that those are strategies which could be improved upon. Um I I it is very much a a product of the, of the expected and then experience complexity of the interstim bit of the operation and then the the expected complexity of the abdominal wall extraction. Now, I think in the majority of cases but not all that product is still, it is safe and probably the best thing to just go ahead and do, do the abdominal wall at the same time as well, but that's not always the case. And I think the other thing is the strategy is good, but you also need to be open minded enough at the time of surgery during the surgery to change your mind uh based on the intraoperative developments as well. So I have had patients, you need to be able to bail. I've had patients where I felt quite often going in while we just do everything in one go. And interop consideration may be, you know, not, not bill but, but bridge with the inter do enough. And then you have to get out. We do know that patients do better with a shorter time on the table, don't we? Absolutely, we, we got a couple of questions. I mean, we do sometimes take a chance and put an anastomosis behind her. Um uh an abdominal wall reconstruction. A uh you know, a big, even a big flap but we do it with our hearts and our mouths a bit and there's usually a good reason for it. Um, we've only really, well, we haven't even got a minute left but if, for those who do stay on, um, there's a couple of questions somebody's asked, um, akash about experience with the inside system. But you're actually leading the trial Dermott. Er, yeah, happy for, er, a to answer that. Of course. Um, but we have, er, patients in the trial and patients out of the trial and I think it's great. I was asked to review the paper in the bjs before it was published and, er, did it on a Sunday and by Sunday evening I was in contact with the team in New Zealand. Bit jealous actually that I haven't thought of it myself. But, uh, it works, it's very, very useful and it's easy. Can, can I add a note of caution then and, and perhaps present the opposite spin. We've done it in about 30 people now. So we've got quite a lot of experience with it. Um, and when it works it's ok but it's not for everybody. It's not for people with very high output fistulas. Um, it's not for people who are not prepared to substantially modify the way they eat. They've got to eat a lot, they've got to eat a low residue diet. Otherwise the whole thing, gums up and blocks and you've got to have a patient who's prepared to use it regularly and committed to use it. So, I think for a selected group of patients, it's pretty good. But actually whether it's any better than distal enteral tube feeding with a bit of osmo light, er, and bearing in mind it costs about 50 times as much remains to be seen. And actually that trial is not being done and it probably should be And I suspect nice will want it to be done before they're prepared to fully endorse it. Shall we just end with the last ques a question from Omar Ally? Is there a place for enteral nutrition in a high output fistula over 500 but no undrained sepsis or collection. Um, and yes, I, for me there absolutely is we let all our patients eat after an a fistula is established. Um, it's, it's not the food, it's the, the liquid that puts the outputs up more. I agree. Carolyn, I think it's important to recognize though that if you've got a patient with a high output fistula, they are probably not going to be kept in energy balance simply by the provision of enteral nutrition. It's important to let them eat and drink and it's good for morale. Um, but you're probably going to need to feed those patients parentally as well or provide some distal feeding or possibly both, but it is cruel to keep them. No, by mouth. Yeah. Agreed. Completely. Yeah. Are you gonna wrap this up, Gordon? I will wrap you up. So, you've seen the advert for the RSM, um, Study Day on doing no further harm. I would very warmly recommend you to have a look at it and sign up for it if you can go. There's some excellent speakers there, some of whom you've heard today. Um, I think the most important take home message here is that the vast majority or at least a very substantial proportion. We don't actually have any epidemiology to tell us what proportion but certainly a considerable proportion of abdominal catastrophes can be prevented. The most important surgical strategy is actually to do no further harm. It is not a success to have done a 15 operations on a patient and leave them with 10 centimeters of small intestine because 14 of those operations were done in a hostile abdomen and resulted in further bowel injury much better, particularly outside a specialist center to sit on your hands, control infection and then refer to a specialized center who can then put the patient back together using the principles that you've heard. Um And if in doubt, ask for guidance, there's loads of support around. I think that's all I have to say, Caroline, anything I've missed. No, I don't think so. And then I want to thank everybody actually who's joined us and for their really helpful questions which I think show us that you have taken it on board and are interested in what we've had to say. And they've been very insightful and stimulating. I hope you found the presentations very useful. I want to thank all of my colleagues and in particular Osmin and Lillian for actually setting this up. I know it's been a huge piece of work. Um And I think I can speak for all of us in saying that if you want to do something similar again or explore a specific area that we've discussed in more detail in future, then I think this subcommittee of AC P will be very happy to help. Ok. Can I just add on to that? A huge thanks from Dukes Club um for all of your time, especially Mr Meta being in Australia. I think it's four in the morning and spend that commitment is shining through with the presentations and the discussion and we are very thankful for it, not only the Dukes Club, but all the members who have listened today and um I just give one final time to Lilian to absolutely thank you so much. Thank you Osmin for organizing this. Thank you to the AC P um subcommittee. This was a fantastic webinar. We, we're already getting so much great feedback from the audience members, we hopefully will have you soon if possible er for further discussions on these hugely complex cases, we love hearing from you and your experience. Um So with that, I'll just leave the audience members with a little reminder of the Duces Club weekend, which is coming up between the 15th and 17th of September. Please save the date. Ask for annual leave or study leave and come join us. It's completely free if you're a Dukes Club member via AC P. So thanks again everyone. Um Have a great evening night. Good night. Thank you too. Bye bye.