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He's starting. So for the third time I would introduce God. So um thank you very much. Hi for being with us today. I know that you had issues with the connection at the hospital and thank you for offering to offer, you know, to come back on now and present to talk about the uh about cancer. So we're not going to take more time. We're just going to get you to start and go on. Okay. So thank you for asking me to talk about bowel cancer in the colorectal clinic. Um It's, it's going to be slightly hopefully bit more straightforward than the five abscesses that you've done with Abby and, and the subtotal colectomy you did with Katie before that. Um Before, before you go into the clinic, I think it's worth understand, knowing potentially path that the patient can come to see you in the clinic. First one I want to talk about is the bowel cancer screening program and this is something that you need to be aware of. All 60 to 74 year old registered with the G P in the UK will be offered a stool test every two years. Uh And since April 2021 there's a gradual expansion to include a younger cohort of patient's between 50 to 59 year olds and that's face across according to different parts of the UK over a certain time, if a patient is tested positive and fit, they are then invited to have a colonoscopy. When you define a positive a cancer, for example, then they will be referred to see you in the clinic. But the vast majority of the workload in the clinic comes from the two week referral pathway. And this is a performer driven exercise that the GP get and it's very cancer specific. So for example, in ovarian cancer, it has a different performer compact to a colorectal cancer because the symptoms are different. And if they, if they are some specific symptoms that match the what we have agreed on as a rate flex symptoms, then they can referred to um the hospital uh within the two week period. We will need to see the patient. A diagnosis has to be made within the 31 days. And the patient must have received their first treatment within 62 days from the time of referral. But there's something more uh even even better. Now, the government has introduced something called a faster diagnosis and they've dropped the timeline to 28 days, meaning that all patient's with or without cancer need to have a diagnosis uh within 28 days and no longer 31. So the three days will make a difference. Great. Uh The other option, which is less likely, but you're still possible is getting a routine referral from GP. Uh So the patient's with, with rectal bleeding, for example, but no other reflex symptoms, there is a very small proportion, there may actually have cancer and you can pick it up through that route. So let's go to the clinic. Now. Uh We've just seen a 67 year old lady who has been referred by the two week way pathway with a three week history of intermittent fresh rectal bleeding. Um She has associated urgency, fecal, urgency and uh frequency. So as as if urgency and frequency generally fit and healthy. Apart from control hypertension, when you examine her, there's nothing much to find on the abdomen, but on digital examination, there is tender, left lateral ulcer in, in a rectal junction. So what do you do? The first thing you'll go through your head? Is this a cancer? Um There are lots of other things that it could be. And in the previous talk ever, you mentioned a series of that. But since this is a bowel cancer clinic, the first thing we're thinking is this a cancer. And if it, if you're highly suspicious, then when you see the patient, we should be talking about the probability of it being cancer. But more importantly, getting diagnostic tests and staging tests as well. So a ct thorax, abdomen Pelvis is one of the standard ones that we, we request and purpose of that is to detect for distant metastasis. MRI Pelvis is to look for local regional patasse's particularly lymph nodes and this is something we use for suspecting anal cancer or rectal cancer. We don't tend to get MRI Pelvis for colonic tumor's. The colonoscopy is to confirm the diagnosis and allow us to take biopsies for histological confirmation. Now, further down 45 and six, they are not necessarily the standard test that we do for across colorectal cancer. So they only used for certain ones to give an example is CT PETA. Uh This is something that we tend to use for routinely if we're suspecting anal cancer. And it's many uses because we want to work out whether there are any inguinal notes affected. And the reason for that is because a lot of these hot notes will at what these notes will end up avid or hot on the scan. Uh And you, one thing I've put here is you do need to remember the lymphatic drainage of anal cancer, which is different from rectal cancer because it goes down into the I'll ex junk short on, on the groin. And why it's important is because the oncologist can then at the groin as part of the radiation field as part of the treatment. And that's why City pat is a routine test we use for a suspecting anal cancer. And the problem issues with um suspecting anal cancer is that it is very low light and vast majority of the time it's below the dentate line. And even the yes, they have a colonoscopy. But one of the challenges, the ability to take biopsies quite low down without actually hurting the patient. Um So in many cases, uh tend to end up organizing an additional examination as part of the diagnostic tests and that's to get confirmed diagnosis, but also help us in assessing how mobile it is and whether it's invaded into the sphincters, which will allow us to corroborate with the MRI findings. And a rectal ultrasound tend to only be used uh for early rectal cancer. And rather than anal cancers have put in Estrich Day something to be aware of, but it's not something that we would routinely use when we suspect an anal cancer, then they go off. Once you've got all the tests, the patient's case gets to the M D T. And if you've been to the MDT before, it's great that some of you who haven't, um it's worth knowing who attends the MDT and what their rules are in the meeting. So you have 126 there. Um And I'll go through with you what their rules are really. So the first is histology. So the pathologists will talk about the biopsy results particularly and they will give us a confirmation of the cancer cell type. So in anal cancer, we'll be looking at whether there's confirmation of squamous cell carcinoma in rectal and, and colorectal tend to be adenocarcinoma. Sometimes the biopsies can be so superficial. They will say it's not diagnostic, but we are suspicious of malignancy and pragmatic terms. That's as good as a cancer. But they do more than that. They also do molecular testing and the ones that we tend to do as a routine now is the mismatch repair K ras and be rough mutation. And it's worth knowing what Caro's do uh knowing what Mmr proteins are. So they're basically proteins that are responsible in repairing DNA sequences. The short DNA sequences called microsatellite and they can get there at risk of errors are during replication. And if you have a mismatch repair protein available, it can mop up and repair these sequences or getting destroyed. If you have a deficient in Mmr, then these sequences were allowed to do uh to be replicated in errors and that can lead to a colorectal carcinogen icis. Uh Why it's important I mentioned here is because patient's with Lynch Syndrome, generally half they have a deficient Mmr but sometimes we do see deficient. Mmr proteins are in sporadic colorectal cancer. So having a deficient Mmr does not mean necessary that the patient has Lynch Syndrome. Then what the radiologist do. Well, they will, we will go through the results of scans that we have requested and they need to give us a predicted TMM TMM staging. Tell us whether there is risk of a metastatic disease on the scan and also from the surgeons point of view, in particular, in the rectal cancer, whether there is evidence of threaten circumvention, resection margin, the role of the surgeon and the C N S is, as you can imagine, we generally are the first person or the only person being in contact with the patient that we have an idea about the patient's performance status, uh their frailty. And if some consultation have taken place, we have some indication about what, what the patient choice is. If the diagnosis of cancer has been made, the discussion between oncologist and Sergent uses discussed about whether the patient should have a curative or palliative treatment. And that depends mainly on what radiology shows us. Uh and also whether surgery or chemoradiotherapy should be the first line treatment for these cancers. Finally, but not the least that MBT coordinator records all the things that we've discussed, what the summary of it in the Sunset Cancer registry and the hospital records of the treatment plan outcome and GPU should have access to that. So this is just a very short brief talk about what and who is in the M D T and the rules are and what they do. Um Once normally we have an outcome, you will end up seeing the patient again in the clinic. Um And this is to go through the results of of what we have discussed So, in my practice, I think these are, this is the bit that, that really I feel needs to be done well because it has a big impact on the patient's psychology particularly. So I've listed here 10 tips are on breaking bad news. Um, in the clinic don't do it alone. First thing is always do it with a C N s and they help in a lot of ways. What I found is that sometimes we have a little bit of chat even before seeing the patient. Um, they tend to do are CNS tend to do a lot of writing during the discussion into a booklet which will then give to the patient to take home because most of the time they'll just be focusing on the discussion and they make miss some of the information you have disseminated to them a good idea to turn off your, your mobile or put on silent or just turn your bleep off. You don't really want to be disturbed during the crucial stage of, of, of the discussion. Always check what the, the, the MG T says and not come up with, with a treatment plan that is completely different. Um And when you bring them in, uh I tend to ask what they know already and you will find that most them will have some idea that it is cancer or highly suspicious cancer. The reason for that is by the time they see you that most of them would have had a colonoscopy and we are always as endoscopy is, will, will be asked to tell the patient about what we think it is. Uh So they have some idea. Um I'll keep it simple. Um I don't tend to use, I don't know, carcinoma or sec or suspicious of cancer. I might tell them the biopsy is not diagnostic, but I will tell them what I think when in my practice, sometimes when it all the time when they come up with suspicious of cancer, it means cancer, I used to work cancer so that there is no um, ambiguity about the diagnosis and patient will understand 100% what cancer is, cancer is cancer. Uh The next bit is the key stage. Um The reason why they're there, the first thing is they want to know whether there is a spread or not because it makes a huge difference. This is a bit that is, they're really, really anxious about and I tell them, you know what the CT scan shows that it's spread all. No. And this is the point. I tend to pause for a bit and you, you can look at their facial expression, they will go black up blank for a minute. Either if there's no evidence of spread, it will be a joyous blank and anything that you say immediately after that will still be a blank to them, there's no point saying it or unfortunately, if, if there are metastases that this is at this point, it probably won't be able to take much straight away. So I'll give them time to pause and, and let the information thinking. Now, assuming that that's passed. Now, then um if it is a curative potential curative cancer, I always use drawings and adjunct. See if you have a model of the colon to help explain the surgery. I like to keep a very close eye contact with them and not just with the patient but also with a relative who they bring in with. So that you get an idea whether they understand uh they're following you in your explanation. Allow plenty of time for patient's. I give 30 to 40 minutes out for these um for these patient's because it takes time to have questions and often the CNS will follow them up after the consultation just to consolidate the things that you have said, you can't expect them to remember every single thing. So these are things that I would recommend when you attend a breaking back news, face to face clinic with them. There are some general rules about treatment for cancer, but there are some exceptions. Uh So you probably have gathered reception. All surgery is the first line option for localized means. Other words, operable, colorectal cancer, except for lymphoma, of course, when it's meant to be chemotherapy. And then second chemo radiotherapy is generally the first line option for squamous cell cancer of the anus anal cancer and they have a much excellent complete response er uh with chemo radiotherapy unless they require a defunction colostomy first. And these are usually reserved for cancers that are quite aggressive and invaded interdistrict is and patient have severe urgency frequency or even incontinence again. Chemotherapy, chemo radiotherapy is the first line option for advanced rectal cancer with threatened circumferential resection margin again, except if they require the function colostomy first for the same reason as the advanced anal cancer where it has invaded into the sphincter's chemotherapy is the first line option for metastatic colorectal cancer, except in obstructed cases. In which case, we tend to provide surgery first, I'm not going to go into the role of, of stenting today because it's just a bit too much, but generally, um it will be something that we have to do to relieve the obstruction before chemotherapy. Um finish off what we discussed in M D T. It's worth just knowing so that you can follow. As I've included the current oncology concepts. Uh flora flora pyramid in is the mainstay of chemotherapy agent for colorectal cancer. Uh Not anything else is five F U and that's the IV version and keep sight. The bean is the oral version. Uh If you've come across a new a juvenile, which I said chemo and radiotherapy. And that's because when you add in 5 €30 or any fluid perimeter in based chemotherapy, it's meant to sensitize the cells to radiotherapy. So it has a combined and enhancing effect. When we say new a juvenile, we mean it's given before surgery. And that can be two types long cost, radiotherapy or short course, long course. As the name suggests, it's longer and it gives the period is also longer and also the fraction is higher, which you can see on the slides here. And the difference between a short course and long course as well is you don't take the patient theater. Uh, so the surgery straightaway, they tend to be a delay for at least eight weeks. Sometimes in some places we're extending up to 12 weeks because we've seen some improvement. Uh The, the effect of the long course chemoradiotherapy continues short course is only 25 grade driven over five days. And this is usually followed by straight to surgery. And these long cause radio chemo radiotherapy tend to be treatment for rectal cancer. Okay. Um Indication for Ajman chemotherapy. That's usually when, uh, in the post surgery histology, there is evidence of lymph node positivity. There are one reception or if there is metastatic disease. Uh And finally, I think it's worth knowing some of the newer, um oncology concepts. We'll call the new kids on the block. They're not routinely being practiced yet, but it's showing some promise and it's worth knowing. So there's something called a new adjuvant chemotherapy for locally advanced colon cancer, which has been shown in a Foxtrot trial. Uh, things published already or about to be published. Um And they have shown that it has um it offers more down staging. Um So preop versus POSTOP staging, there's a higher rate of are not resection and it has a lower recurrent and residual disease at two years. It is given up front for colon cancer. The potentially it's, it's it is good, but they tend to be reserved for advanced colon cancer. There is also something called total new adjuvant chemotherapy and this is the addition of chemotherapy as a consolidation to a long course chemo radiotherapy already in locally advanced rectal cancer. And in a couple of trials called the repeat oh and prodigy 23 adding chemotherapy to the long course chemo radiotherapy has resulted in a higher pathological complete response in the Specimen and a better three year disease free survival and control. And I think one more most recently that have really caught the eyes of a lot of oncologist is immunotherapy. There is a drug called diastolic map. And in, in a study, very small, I have to say in only 12 locally advanced rectal cancer found to have mmr deficient has led to a complete clinical response at six months. So don't get your hopes too high up for this. It is very early because of only a follow up period six months and it's only 12 cancer and bearing in mind, a lot of rectal cancers tend to be mmr proficient rather deficiency. It's only for a very small subset group of cancers and the full up is very, very short. So these are some of the things that it's worth knowing um for the time being. But the obviously the standard oncology concept is what you should all be aware of. And that's it short and sweet. I hope. Thank you very much. Thank you, Kai. We got there in the end the time. Lucky. Um uh So in the interest of time, we're going to move on to our next speaker, if anyone's got any questions sent through on the chat and hopefully we can answer those for you. Thank you. Thank you guys. So, our next speaker is uh Shaaban who would be talking to us today about the preoperative uh operative care. Now we're doing our ward rounds and uh I'm sure we would all enjoy the talk by father. Thank thanks father for joining us today. Thank you for inflation. Can I check? You can hear me and see my slides. Uh I'm probably one of the corrector surgeons in Edinburgh. Uh two disclaimers. One, I'm not an expert in area here uh to, I've borrowed a lot of the slide from, from our expert who's Angie, the virus nurse. So, and, and again, 20 minutes is too short to run through everything, but I'll just run through the things that you will come across on, on our ground as an S T three leading the world run or correct word. So well done a clinical case, you've got a 57 year old male is normally fit and well, he presents with pr bleeding and change in bowel habit. He gets sent a cuf it which most places are doing now and that's over 400. So he gets 300 to colonoscopy direct to test. So he goes from G P to test and actually the lesion at 14 centimeters. So upper rectum Brecht, a sigmoid um and the biopsies of that come back confirming an adenocarcinoma. So he then goes to staging CT scan MRI and go to the M D T discussion. And the plan from the M D T is for for a laproscopic anterior resection plus or minus Lupoli ostomate. So this is our patient, we're now gonna meet him in clinic. So first thing to say is, is it's a big team and you've heard a lot of talks from several members of the team today. Essentially, if they go direct to test the first patient, the first person they meet is the endoscopist that can be gastroenterologist, a nurse, endoscopist there, a colorectal surgeon, the information they get very slightly but, but they're essentially told that there is suspicious, there told it's suspicious. So they don't get surprised. They usually then once the diagnosis is made, meet a colorectal surgeon in clinic, usually with the CNS and, and Chi is kindly touched on that. It's imperative that the CNS is there in clinic for that consultation. If the decision is for surgery, they go on to meet the pre assessment team, which can be a telephone consultation with an aesthetic nurses or the actual anesthetist, especially if it's a high risk. And we have a specialist high risk clinic. If they, if we are considering a stoma, whether it's a permanent stoma or a potentially temporary one will meet the stoma team pre operatively. And again, they'll be talks about that and they'll meet our era's nurse specialist. So, Angie or earache nurse will meet them in the pre assessment clinic as well as on the world on, on the first day post surgery. If they need to, they'll meet our dietician or are pops team which are, are care of the uh the relation team for elderly patient having surgery. So enhanced recovery after surgery. My main, my main issue, my main takeaway message is the words after. So I think a lot of places have now started calling it enhanced recovery program because there is a program, it starts from moment of diagnosis till moment of discharge and beyond. So it's not, it's not truly for only after surgery and, and eras and what involved has evolved since, since 97. And the pillars have stayed the same. But essentially there are more and more things that are involved in grass and you can't quite see what that on the side that will go through through the main, main, main ones. And again, the latest paper in 2020 is also divided into, into separate, separate um areas as you can see to do with the physiology to do with pre operative, post operative. But also focusing on things like the psychology and, and, and the learning and, and informed consent that has to come with these, with these cases and these patient's. So the fundamentals of of eras or E R P and the things will, will be looking at through the stock is is the preoperative preparation and optimization that includes the consent and the information giving, attempting to attenuate the stress response and reduce that. And that's a multi multifocal way to do that. Multimodal analgesia, ideally opioid sparing. So if we can minimize the amount of opioid use and we'll talk about that minimally invasive surgery, I'll touch up on that very briefly. But we've heard lots of talk about the benefits of that early return to gut function and the nutrition involved pre and POSTOP and early mobilization. We've touched upon the fact that it is a multidisciplinary team working lots of cogs and you know, lots of cogs in the wheel and wheels to, to get this going. Uh Most of it is evidence based practice, although some of it is not. And the attempt, the idea is to reduce clinical variation and get the patient as the center of this process and program. And the key is to audit the outcomes and the compliance with the enhanced recovery program and, and research associated with that. So again, the pre operative clinic, it's the first time we usually meet the patient's, the first time you confirm the diagnosis to them with the pathology. And ideally already have the staging scans to deliver that. The delivery of the information is key. The CNS in that clinic is key and like I I have a discussion with the CNS before the patient comes in because they may have had a chat on the phone. And I always start with asking the patient what they know already and, and most of them know something. Uh And, and so we all start from, from the same again. I tell them about the sands first of all because that's the thing they're waiting for and you need to keep attention to the next of kin because because they'll be taking this differently to the patient themselves. I tend to use diagrams, especially when, when I'm reinforcing operations, what it involves. And from experience, the patient's prefer that because it just means they can associate things better when you draw it and show them bits that need to be removed and what you can do with both ends. We then follow that up with the written information. They all get a copy of the clinic letter which include what we discussed, what operation involved and the risks involved and that legally speaking, but also clinically speaking is more important than the actual consent form signed on the day. And they usually all get called the next day or two days later from the CNS that was in clinic to, to catch up on questions that they haven't thought about in clinic. So this is the first step of the program is manage their expectations in clinic. Tell them what to expect, tell them that they're coming in on day of surgery, whether they involve ball prep or not, what the recovery is expected where they go lines capital. So for the more information they have beforehand, the easier, easier it is for them to manage the recovery afterwards. So education is important. So we have six different booklets on the top left of that screen. And essentially it's from the pre op from diagnosis point to to to follow up 60.0.5 years, follow up and for different stages and they get the first four during the pre assessment clinic. So they have them and the other two on admission, there's lots of information both online in paper form, in application form, websites informed consent, lots of, lots of information relevant to the to your own trusts or, or or nationally, there's even a lego movie video about eras for the whole song gonna sing along. I highly recommend you Google that it's the first hit you get. So the benefits of pre operative education. So it definitely reduces anxiety, the more the patient knows before surgery, the more they expect what is about to happen, the easier it is for them to manage it. They tend to have less in if they're aware of what the procedure is. And, and, and the, and the realistic aims of a minimally invasive operation versus an open operation. Most patient have improved satisfaction if they have good preoperative education. And, and certainly some studies have shown even improved outcomes, the more the patient knows. So it's important to spend time, as I suspect in most places, we have doubled the time allocated in clinic for an M D T cancer patient than we do our urgent and routine patient's. So the pre operative assessment is the next step. So we offer them once we book them for surgery, they refer to the pre assessment clinic and like I said, that's a combination of telephone and face to face and the key is to try and find the modifiable risk factors. There are things that are fixed that we can't change. You're not going to change the patient age, gender or genetics. But there are things that are you can eat change more easily like alcohol, smoking, diet activity and some risks that you can improve or or modify like ischemic heart disease, COPD, a FN anemia. Certainly we have a good service of getting IV iron infusions if they need it or pre operative transfusions if they need it. But the key is to, is to work with the team to find which of these we can modify. And like I said, we've got good access to a pre and pre assessment, high risk and aesthetic clinic, as well as the care of the elderly support clinic to try and essentially improve their pre operative function before surgery could. Surgery is a big insult and the better position you get them in before the better tear it is. And that leads us to the concept of pre habilitating in. So, although it's not a new concept, it's certainly gaining more momentum recently and it's defined differently in different papers. But the idea is that rehabilitation is essentially training for surgery, but like training for a marathon, it's a big insult to have surgery. The more you train, the better you'll do with cancer surgery timings of an essence and they tend to have the surgery quicker than benign disease. But even pre pre habilitating for two or three weeks in that process has been shown to help. And that includes things like medical optimization. Can you improve the heart health can improve their lung health? But also things like physical training. I tell my patient's to increase their physical exercise if they can, even if that's a 15 minute walk, three times a week, if that whole it can manage. That makes a difference. Same with nutrition, dietician involvement if needed and again, trying to cancel them and help them. If, if, if an understanding they will have some anxiety issues, um lifestyle modification as we mentioned, but also it's important to focus on the caregiver and educate both the patient and the next of kin and, and provide them with the support. And the idea with that is if you look at the red line that people without the pre habilitating in, that's the insult of surgery to kind of a third down the line and, and it does take a big hit on them and they put up recovery to their functional recovery is on, on the red line. Compared to the blue line. If you pre habilitating them, they end up the recovery gradient is the same, but they'll end up in a better functional status after surgery if you have done the full pre debilitation program. So the attenuation of stress response and again, in 20 minutes, we're not going to go to the pathophysiology of this. But, but essentially the things that we need to look out for are things like the anesthetic agents of what we use, the analgesia and the medication that we use again, try to, to avoid opioids as much as we can regional anesthesia. But also the surgical techniques, minimally invasive surgery has has a lower stress response. There's some evidence that giving steroids help with the stress response. And certainly nowadays we give them to shocked and septic patient's on I T U N H T U and served two nutrition, both pre and post of and fluid management. All of those things are essentially pillars of the enhanced recovery program and the all health to attenuate the stress response. That's a big response from surgery and trying and, and improve the recovery from that multimodal. And as analgesia is the buzzword. And the key is if you use more than one analgesic, the likelihood is that they work better than things like simple energies like paracetamol Ansaids that there's evidence, uh kind of some people do not give them an estimate of evidence is not very strong. Uh Same with local, regional and local anesthesia, spinal epidural rector, shift, tap blocks, lidocaine infusions is a controversial topic at the moment, but certainly studies to show that it is some benefit. Um and same with gabapentin roids and things like cloNIDine and ketamine. Again, most, most big hospitals will have a specialist pain team and certainly in our hospital, the pain team will come around on the patient the next day and help us with those decisions, minimally invasive surgery we've touched upon in several talks. It's a lower insult, it's a quicker recovery, it's a lower, shorter length of stay. Um So if, if the expertise is available and there's certainly evidence that minimally invasive surgery improves outcomes and enhanced recovery and that, you know that, you know, open procedures on the top left all the way down to robotic procedure on the bottom, right. That's the key provided the skills are available. So nutrition is a big topic. And again, that's like I said, pre and post operative. So that the four main things we look at is carbohydrate loading, fasting, presurgery, early resumption of diet and early resolution of or, or, or uh retaining of gut function. So carbohydrate loading. So unfortunately, that's not a big, nice Italian pasta dish, but they both, they get to pre op nutrition. Drinks are quite, quite heavy loaded with calories and, and these are the instructions, they get their very clear instructions of the operations in the morning versus afternoon as to when to drink those carbohydrate drinks. And what time to be nil by math. Certainly there's some evidence that that reduces your length of stay and improve your outcomes. But again, controversial evidence about whether it actually affects outcomes like SSI in instamatic leaks. But, but certainly it does no harm fasting. So again, different instruction, different places, the rules of two inch six. So for pragmatic reasons, we tend to tell patient's and the war staff if they're on the ward nearby. Math from midnight, on the assumption that the operation be at eight or nine o'clock in the morning. And most people don't wake up for a snack at three o'clock in the morning. However, the key is the 66 hours without solid foods and that the idea that it reduces aspiration risk and two hours without clear fluids. So now all of our pre admission wards and our processing clinics have these symptoms, send um posters where patient's can continue to sit on small amounts of water until they're sent foreign later. And that improves patient satisfaction. Certainly in the not the hot Scottish summer months and the anaesthetic team play, play a big part in that and again, both in the pre assessment clinic but also on the day of surgery. If if there is the the change in order, for example, then aesthetic team are quite good at lazing would be with dosa for, for things like fasting. But also the post operative resumption of oral intake is key and patient should be encouraged to drink when ready provided. There's no indications and an elective setting, we mostly say they can eat and drink as soon as they tolerate that. And and and for some patients that are having operations in the morning, that can be the say the evening or it can be the next day. Why is it important to resume diet early? Well, it certainly decreases postoperative infectious morbidities that in this is uh the hospital say but, but it definitely increases patient satisfaction. There are some, there are some uh fears and some contraindications to. There is the historical fear than the anastomosis will do worse if you feed it too soon and certainly elective setting, that's not been shown the case. We ideas might get worse if we feed them too early and same with nausea and vomiting. But again, they all get pre emptive anti emetics by the any set is add induction and they all have them written up as part of the post operative bonded so that it's given before they get to the stage where they're two nauseas to eat. But the main thing is, is patient experience is better in order to say is that documentation is key. So we've recently done an audit. There are 15 colorectal surgeon in Edinburgh and what we documented the notes after an elective orations. About 30 ways of different things. We document arranging from eras. That's all we right or eat and drink as tolerated or little and often or soup and jelly or so, we just need kind of consensus so that the nursing staff and the patient's know exactly what's expected and what they can cannot eat. So the earlier early resumption of gut function um is a big topic. And again, it's a multimodal thing. So things like early earlier diet, early oral hydration, early mobilization uh certainly make a difference, minimally invasive surgeries make a difference. Pre operative carbohydrate loading has been shown to make a difference. Some, some poor evidence that chewing gum might make a difference. But again, all those things do no harm. So, so again, if patient's aren't really feeling operating, I say you can have some chewing gum if you see see how that does some evidence that early laxative use can help with enhanced recovery and bowel function. Most of us I suspect are quite a bit reluctant to stop that and certainly in a high risk or a low, low, low anastomosis, but certainly on day three and four, if, if, if they're behaving well but not opening the valve, we may, we may start the gentle laxative to get to get their gut going. Yeah, fluid management is key. So, so again, as in everywhere else, we have, we have foundation doctors rotating every four months and it takes a bit of time to get used to surgical patient's versus medical patient's and the accused versus the elective. Just a cautionary note that a bag of saline has the equivalent of 28 packs of salty water, stressed salt. So it's not great patient's get edema, edema around and ask gemesis is not a good thing. So it's a key to keep an eye on and and our sinuses are quite good at managing that in preoperatively, it's the post operative period that can be a problem. And certainly with patient's, for example, that have an epidural and have a slightly lower BP, which is, which should be accepted is usually knee jerk reaction is to keep giving them bonuses of fluid until until the balance tips the other way and under overloaded. So the next killer of the enhanced recovery program is early mobilization. And again, the key is to start this information and education as soon as possible. So I again, tell the patient's in clinic at the point of diagnosis and the point of planning surgery is that you go to h to you for one night and on the next morning, the nurses will already encourage you to get out of bed, sit in the chair, even go for a walk if you can. And it, you know, it's been shown both an elective and emergency setting to reduce certainly pulmonary complications, whether it's infection or V T E, it reduces the complications of prolonged bed rest. But also it has been shown if you mobilize in between these one and three postop, it increases the chance of a full successful virus package or pathway. Um and the failure to mobilize or deviate from the pathway does increase the length of stay. So there is little benefit that the post of mobility but the higher level of impacts of immobility. So that's the key is is to reduce the immobility post post up. And we certainly have lots of posters that, you know, with the N P J paralysis around the world to try and get those patient's going as soon as possible. Um So the the trying to facilitate that, like I said, I warned them early in clinic as much as you can reduce the pain, transverse incision, smaller incisions, multimodal analgesia, avoid sedation if we can by avoiding opiates, avoid the fluid overloaded. So all those things help with, with, with different things but certainly avoid the tubes if you can drains capitals, uh IV fluids. But if you can take them out as soon as you can and maintain your nutrition so they can maintain their muscle mass and get their mobility going. So I'll touch on a few other topics and there, there are part of the Iris program or, or part of the preoperative recovery, but quite the Iris program. So bad preparation is, has been again controversial topic when I started training every, you know, we see about preparations bad for patients' dehydrating. We should stop doing it. And now it seems that we've gone full circle and we're going back to giving patient's bowel preparation beforehand. I certainly give all my left sided resections, bowel preparation. We're not quite up and ready with the antibiotics associated with that. And there's been a very good review by Sarah Da Fatal in, in corrected Disease in 2020 about the advantages and disadvantages of mechanical bowel prep with or without oral antibiotics. And then, and there is a cock ring review this year about that. And essentially the conclusion is that with mechanical bowel prep and oral antibiotics have been shown to reduce complications, mainly s s eyes and anastomotic leaks. There's not enough evidence whether it's the ball prep alone or the antibiotics alone and more studies are needed. But, but certainly the majority places now have gone back to giving well prep with or without antibiotics for left sided resections. So these are questions you may be asked on a ward round on a pre assessment clinic to come and sign ball prep. If in doubt, ask again, as coagulation preop will be something you'll be asked or POSTOP will be something you'll, you'll, you'll be asked upon on a war grand. And again, I've put these tables, don't expect you to read them, but just I, I got these of our internet website. So essentially most doctors have very clear guidance, complicated guidance, sometimes about when and how to stop anti coagulation and what to do with high risk versus low risk patient. In terms of bridging the key message from this screen is the three telephone. So if in doubt phone, so you can phone the hematologist, you can phone the pharmacist, you can find the pre assessment clinic. Most doctors will have very clear protocols about what what to do in these scenarios. And it will differ from patient to patient, both pre and POSTOP. And certainly nowadays, there's a lot more than Warfarin that the patient's are on instead of the Xanax and, and other anticoagulants and anti platelets, extended vte prophylaxis is another controversial issue. So again, uh the nice guidance and suggest that people with abdominal surgeries have a minimum of seven days of et pharma pharmacological vte prophylaxis. And it says consider extending that for a period of 28 days postoperatively if they've had major cancers surgery. So it's a bit big in terms of what classifies in that and it varies from unit to unit and consultant, consultant. Again, the evidence is not, is not great one way or the other. And most of us will give vte prophylaxis pharmacologically in hospital. But certainly for the macroscopic straightforward, right, I'm collecting that goes home on day three, most of us won't give it up for extended period. However, we would for an extended pelvic exenterated, for example, with reduced mobility, very quick mention of tranexamic acid and colorectal surgery. So again, that's an emerging topic recently, it's certainly been shown to help with bleeding and lots of other situations like trauma and by hemorrhage in the elective colorectal setting. Again, the the evidence is varied, there is some evidence that it does reduce inter operative bleeding with minimal complication. Again, I don't think it's become the norm everywhere. Certainly in our unit, we use it selectively for the bigger more complicated cases that we expect more bleeding but not the straightforward laparoscopic resection. So in summary eras, inaction should look like a dream. Patient should be drinking, eating and mobilizing as soon as they can after surgery. It's about the dynamical ization criteria. Let discharge effective follow ups or Iris nurse Angie shown in those pictures, calls them the next day and the three and five on the PA protocol or or or varies depending on what they find. They also get access to our patient advice line so they can phone our nurse practitioners during daylight hours. It has, it does reduce length of stay, it reduces complications and more and most importantly, it's a better patient experience. Thank you. Thank you, uh Fat Low for that fantastic overview. Obviously, it's a a really important area for, for trainees who are looking after these patient's pre and post operatively. So, uh we'll see if there's any talks that come in on the chat function would be great if you could stay behind for a few minutes to answer any of those. And then we will go on to our next speaker. Thanks for uh I would like to introduce our next speaker. Uh It's Mr Sadak. Um and um he's a consultant, collective surgeon uh in market and uh he will be talking to us today. So there's a slight change in the schedule. So we will have to talk about the power storm, uh sorry about the storm of complication and the storm management. Uh Thank you uh for joining us today. We can uh thank you momma than Nicola been inviting me. Uh Can you hear me and see uh flights? Yeah. So we're in the, in the ward, right? Aren't we? So I'll be talking a lot about the acute problems in the, in the wards. Uh But let me just go through a quick few slides, giving you a brief um history and uh and the definition stoma is basically an opening your mouth and Greek. And as you all know, they're surgically created to pass feces and urine. Uh There can be temporary or they can be permanent uh known for the last 300 to 400 years. They were first formed in 17 hundreds but not very successfully. Uh The stoma is in the form we know now are being started in the late 19th century and again, performed the first loop closed me using a glass floor which we now use uh plastic bridge instead. Uh Ernest miles to the AP are giving a permanent sturmer. And Hartmann's, which is so common procedure. Now, I was first described in 23 and the spouted I lost me uh was first described in 1952 right? So types of stemmers, it could be end sturmer, it could be loops, termite could be split when I mean split. There can be two different openings uh for the stoma to find is when you don't do a laparotomy, just make uh you know, small incision in the abdomen to remove uh bring out a loop, a bowel to do a sturmer. Uh And in the form, we know more commonly colostomy. Slyly, ostomies. Urostomy is jejunostomy is uh mucus was July is a nonfunctioning storm which is a blind loop end or it could be uh formed because you have to bring out the end of a rectum or something like that after protect me and stuff like that. So, uh stoma care, it's very important quite often we uh deal with patient's in acute situations, we speak to them uh talking about more important operations, but we don't give enough importance to the stoma and, and main concerns the patient's. If you actually ask the concerns, they have plenty of questions to ask. And it's important that you give adequate time to these patient's discussing. If it's elective. I think they should, we fully discussed about the political problems. Uh And I'll suggest that uh you should go and sit down with one of the storm anizers when they actually uh uh when they went actually cancel the patient's for a stoma because the concerns could be how it's going to look where it's going to be cited, how it's uh you know, what are the appliance? So they're going to use, I'm able to change it comfortably and how it's going to impact their lifestyle, their body image. There also concerns with the multicultural society that we have in terms of religion and cultural problems, right? Um I would like to a lot of things. He has a busy slide but fight things which I need you to to keep in mind. Good citing, which is pre marking of the stoma, good vascularity of the, of the bowel. Uh At the end, the third thing is uh adequate length so that you mobilize it well, uh and then the defect in the fascia has to be adequate and make sure that when you put the stitches they're quite good. So attention to detail to take either full thickness or as sub mucosal stitches uh to the skin so that you make sure it well, quite often I see this uh and then keep correcting, you know, uh the mucosa is quite often at the matters at the edge. And you find that you think that you've taken a stitch to the full thickness, which you're only taking the mucosa and, and these, these are the main problems which can, which can lead to problems. Um Close to me in general is flushed through the skin produces soft feces and, and usually empty once or twice a day. I lost me. You need to create a nice about at least 2.5 centimeters. Uh It produces usually loose to semi solid stools and it takes about 4 to 6 times empty. Same thing where you asked me only difference. It process continues a urine. So when you go on a pool state ward round, uh you got to examine the patient and did examine and do everything what Chadwick said, you know, enhance recovery and so forth. But also when you examine the patient, make sure that the plans that is put on the stoma has got a transparent uh front end so that you can actually see the stoma itself uh and make sure but some storm uh some storm or bags will have uh an opaque. But if you uh and with, with a clear, transparent lining underneath, so they are fine as well. So they can actually inspect the point. Here is inspecting the stoma. If you can't inspect it through the storm or bag, take the storm bag out. It's very important in the first few days. Post tropically, you inspect, uh you lost me, uh lost me is pretty much functioned straightaway. The colostomy sometimes take longer, sometimes days. Uh initial might be just, he must have fluid and inflators and, and, and, and physical fluid, you know, he must have fluid. Sometimes the it's reported that storm is already working. But no, you have to convince yourself that is thesis before you say that it's actually functioning, inspect the color of the stoma, make sure there is no retraction, make sure that it's not dusky. Um look at the significant knees junction that, you know, it's not given where the stitches are not falling apart. Uh It's also useful to sit down when they do the storm. A training with the storm illness. Um uh General risk factors is sort of the stoma complications. Patient factors. I'm not going to go through this, but the risk of stoma complications is higher with emergency surgery for cancer. And also those patients who are on immunosuppressive agents. And more of what if the patient is not marked pre preoperatively, it also gets to put it outcomes. Um A lot of complications we don't see. Well, the one we see more often is uh communication or, or high output stoma Zor, we've seen the clinic, Palestina hernias later. Uh very rarely, we do come across uh normal prolapses and uh stomach stenosis. But actually, the more common complications are retraction and the mucocutaneous separations. Uh These are picked up by the nurses in the, in the community and they're quite often managed conservatively and quite well managed conservatively. But some of them actually can cause serious troubles if they happen early. Uh And uh and you will have to deal with them. So, so mitigating is separation is basically, can you can you see the curse that I don't, I'm not sure you can see the cursor. Uh This is a picture of uh you cook it in a separation. It can happen because of poor technique. Uh I mean to say if you don't take good stitches through the edge of the storm, a wall to the skin and if you just take stitches to them because it can, it can fall apart. Sometimes it can be due to excessive traction or tension on the storm itself which can make them to fall apart or uh ski mia especially on the edges uh and causing the closest and can happen. Um These patient's on your ward rounds if you see that this has happened. But then within the 1st 42 72 hours, if there's nothing like this, then the occasions do form between the stoma and the uh and the subcutaneous tissue and you may get away. But if you can uh inspect it on a regular basis to make sure that the patient is not deteriorating in some ways. Is there any cellulitis? Because if there is a leakage from the side, it can seep under the secretary station causing cellulitis and sepsis. And very rarely, this can actually seep into the inter particular cavity from the side of the stoma and cause peritonitis as well. These patient's will certainly require return to theater. But in most cases, as I said, they're usually minor separation that Asians was already formed and the heels with the nice graham vision tissue, the second in tension and these are quite well managed by the stoma nurses in the community with packing and filling paste. But as I said, if you have to, then you have to take them back to theater sepsis is the most uh important risk here, which you have to manage if it happens early dusky uh stoma, right? This really stops in the in the theater. Um And as I said, you need to make sure that you have adequate length, make sure that you have a lot of uh you know, make sure that the vascularity is good. Uh But it could be high risk even high be of my patient's even if you managed to do a good mobilization. Uh and, and make sure that the blood supply is good and when you actually brought and bring it out to the surface. You find that the, the end looks a bit dusky, don't compromise. You may have to make the defect in the fashion bigger to make sure that it comes out without tension and without compromising the blood supply. And then you actually close the abdomen and then you open the stem align, you take those stitches out or the staple line out to mature the stoma if you see that uh because I is ischemic, I think there's a concern that you need to raise with your swing is with the court with a consultant. Also, when you're opening at ABC, don't see any bleeding edges. Now, that's the concern as well. It might be challenging in very good these patient's and you might have to compromise an occasion because you've done everything inside even then it looks a bit dusky. If it looks mildly dusky and part of it looks pink, maybe you can get away. But if it is still very dusty, not bleeding, you may have to go back into theater. You know, I mean, go back into the abdomen after having close to do more mobilization because if we can climate lee avoid the problem with the stone, but especially with the scheme. Yeah, if you leave it, it can lead to necrosis and, and that's why it's important that you are pedantic about achieving that good blood supply uh in theater before the patient lives. But if you have compromise for whatever reason you need to have serial examinations, make sure that it's improving, make sure the blood's of BP in theater and uh, and the recovery is good. Go and check the stoma yourselves and the next morning, you know, make sure that you check it again and it looks similar, maybe it might be okay. But if it looks more dustier, you may have to check with the transformation test. The thing that goes off first is the mucosa. So the mind, the mucosa might be looking dusky. But if it's translating and nicely shining through the light, you might be okay. But if it's not, it will establish itself into completely crosses within 24 to 48 hours, it will go black if it's black, it's bad news, you have to take them back to theater. And quite often if you know that you have done a good mobilization, you might be able to locally mobilize the storm and pull it out if you can. But you can't, then you have to go back in and uh do a full naproxen me, do a full mobilization, which you potentially could have done at the first instance. And this is what is important. Some of them have uh you know, are quite challenging. I have, you know, with my experience in the past, you know, highly of my patient's are the ones which are really, really difficult. And in those patients', I tend to make bigger defects in the, in the fascia as a technical tip because you can deal with the Palestinian a hernia in future. But to deal with a, a dead stoma is much more daunting how consumers are also not uncommon and they're quite common with ileostomies, especially those that had uh extensive receptions of the small bowel in the past like IBD, uh Crone's disease, for example, by definition, hired consumers are, uh, more than 1500 mils a day. I think you can accept from Ileostomies about a liter a day as normal under the liter days is acceptable, to be honest. Uh and and uh when these patient's in the post of day 12, when they start functioning, they do over function. So don't take it the 1st 23 days or 1000 meals as higher past Irma's, they usually settle 2 to 400 to 800 mils per day. But by the time we have discharged in 567 days, they're still high output. Don't ignore it because this is the time when they start going to have a K I S and stuff like that and start getting uh electrolyte imbalances. Uh some patient's once you're discharged, they bounce back a couple of weeks later with dehydration and kid kidney injury. Obviously, these will require flu Theresa station. Uh huh. Obviously we'll need to have a strict in productive chart, correct, electronic imbalances, uh treated usually with fluid restriction with oral hypotonic solutions like ST Mark's solutions, you can also use antimotility medications, loperamide, codeine, uh sometimes uh PPI S and doctor type do help but they're not use routinely uh escalating. Those of loperamide are quite useful. Uh And there's a very good guidelines from ST Mark's which you can use uh in extreme cases, especially if it's a loop ileostomy and you're not able to manage them. You may have to consider early reversal. So you can do uh check the Testim Asus that you've done for a lap. And here, for example, and if it's all intact, uh then you can probably do an early reversal of uh ileostomies. Uh if it's a permanent diagnostic or, or, or a stoma that is over functioning and there's not enough length about, then you probably have to think about uh parental nutrition. You, you may have to refer them to uh understand failure unit if you have to stabilize them prior to the referee stoma trick retraction is also not that uncommon or that we don't see them in the acute phase. But this is more common in high B M. My patient's uh and again, as a result of inter accurate mobilization or tension on the, on the, on the, on the store might sell uh occasionally it can be secondary ischemia. Uh and then it kind of starts to track down once uh there's a separation quite often they present with skin complications due to contact with affluent as you can see there's a dip uh where there's a retraction. Uh And if it happens more acutely, this patient might have um you know, between the separation uh and may need to take them back to theaters an emergency. Uh because the stock market completely drop down into the political capital in these situations. Uh again, to prevent them, same princess apply adequate mobilization, make sure good vascularity and also make sure you did good stitches as well. Uh Management is mostly conservative, it's not really uh dig down too much uh especially in high risk patients'. Uh But they might require re fashioning in future if they have completely matured in a few months down the line. There's another buried complication, early bowel obstruction. You've done an operation, you've given a stoma and you're hoping it will work and then you're gonna send them home soon. You put them enhanced recovery but doesn't work. Uh You might, you might think that this is a lius, but sometimes you have to ensure that there is no mechanical obstruction and the mechanical obstruction can happen due to technical reasons. Uh like when the storm is twisted on its access, when you're creating the sturmer, if you're bringing a loop storm, it can be completely opposite uh from inside. You might even find that uh your storm has been perfect. Your operation has been good, but unfortunately, there have been acute intraabdominal mutations which does happen. Uh Or sometimes there can be a loop of bowel that have got down to the pelvis and got obstructed there. But this is not true stoma complications. It's truth from the complications of the mechanical things that happened because of the still myself. But you have to investigate them. Uh, imagine is so important with oral contrast. Ct with oral contrast, you have to treat them the drip and sock. And if you know that there is a knuckle bow, say stuck in the pelvis or in the uh port site or something that you have to or even an acute paris, normal hernia, you may have to take them back to theater. But in high risk patients', if you don't find a true cause you might sit tight, give them uh trip and suck and see, you know, they settle. If you don't, then you might actually come back to theater. By the way, prolonged diet is definitely uh known entity and some patient's do uh progress quite slowly, especially that infirm have got multiple commodities. You might want to put them on TPN. Once we excluded mechanical problems, uh you might even try, promoted two drugs in these patient's. Uh you can include things like uh metoclopramide or Erythromycin. Uh skin complications are also common, especially with ileostomies. But this can happen with any stumbles, to be honest, uh more proximal, more problematic because athletic is uh recline and you can digest with enzymes as well. More common with high output Stover's like I ileostomies, especially watery output, uh poor citing uh especially emergency. You might find that the storm is properly placed on the crease and uh nothing fits the storm storm bag is not fitting well. Uh sometimes poor spouting. I used me or too small or it had retracted. All these problems can cause uh skin problems. There's something else apart from the, the a friend itself, it could be a reaction, allergic reaction to the stoma bag case itself. So this patient usually present with mild dermatitis, too severe ulceration, itching and exploitation, uh usually managed with uh barrier creams uh and to prevent them, make sure that you have a tight fitting uh stoma bag, make sure the skin is dry before you apply these appliances. You certainly will need a lot of help from Stir Minister because there's a lot of tricks up the sleeve. Uh sometimes simply by changing the applies to another manufacturer solves the problem. So these are things you need to keep in mind. Very, very rarely, you have to recite the store might, becomes uh quite aggressive. I'm not going to go too much in detail about Palestine a hernia because it's quite a bit topic itself. Uh by definition forming a SOMA will give you a risk of Pastor Mauretania. There instances quite high. Uh although not many patients will complain to you, uh it's an excess of 50%. It's more common with emergency surgery. Uh, higher risk is with smoking. COPD, high B M I, elderly patient's immunosuppressed. Uh It's very evident. Um, clinical examination. The patient does tell you that they have a spelling around the stoma. Sometimes it becomes quite ghastly big. Uh and they might be associated with the incision hernias from the, the problem is as well. Uh How do you prevent them? They're quite difficult to manage. There's been lots of studies, there's been a record seven trial recently was published. I think a couple of years ago using a prophylactic mesh. I really don't know which works. Uh making a tight uh rent in the, in the fascia. You're compromising the blood supply. It's a balance and quite often you manage these patient's, uh but uh conservative measures, small asymptomatic hernias, you can leave them. Uh You can ask them to use an abdominal course. It's, you can ask them, uh you can, you can get the storminess is to give them some uh abdominal binder, incorporating the stoma bags there, quite a few gadgets around. Uh But if you have to uh offer them surgery, it's usually a mesh repair, uh which seem to have some advantage. I think, uh those patients who have large hernias or symptomatic hernias and have opponent uh and stone muscle, they probably deserve to have a repair of these past with her news. Um In general, the, the sugar Baker technique seems to be quite, quite good results to have quite good. That's what I prefer modifieds, a good baker. But in high risk patients', it's quite difficult to do a mesh repair. You might just do a suitor repair, which, which can give short term benefits but probably not very successful. Uh Most patients who have complex of dominant that probably will end up having uh to recite the hernia. Sorry, least I disturber again, these patient's again, have risk of getting another further past um of hernias. So it's not an easy thing to deal with uh normal prolapse. Again, not very common, but actually, these are quite common with transfers. Look colostomies. Uh uh As you can see in the picture, it's, it's, it's quite easily treatable. But in, in patients who have uh high risk, I think uh you tend to manage them conservatively, you push back and maybe having a title, try feeding appliance with the cost is on top. Uh But to prevent it, especially when you're doing the chances you crossed me, uh make sure that you, you don't live in a redundant proximal uh colon, which means that you mobilize the uh the chances call on uh and place the storm as close to the hepatic flexure as possible. Uh Even then these two uh recur uh you can resect them. You don't need to do a laparotomy. You can do a simpler reflection of the stoma excise the uh redundant uh loop and then uh refresh in the whole thing uh This can happen with and I lost, um, says, well, it's not very common that, uh, signaled colostomies. Uh, it's all probably related to the degree of pace dialysis steno stenosis. I couldn't find a good picture but I've dealt with a few of them. Uh, usually happens, uh, duty ischemia or the stoma or attraction and you would only notice them many months down the line and these, uh, stenosis progress and become smaller, smaller, smaller I've seen, uh, devices as small as a pinhole. I don't know how they were managing it. Uh But usually about a centimeter by the time we actually present with obstruction, uh Most of these patients are managing the community. Uh and they use self administrative store, more dilators which are provided by the stoma nurses. They can be refashioned. Uh Again, a local division is quite uh useful, making a pace normal uh incision and then try to mobilize it as, as much as you can and then try to remove the very end and then social it back, it works quite well. Uh Occasionally the president's emergency. In which case, you probably have to do a laparotomy to mobilize the whole colon of him to say the respect to call on and then give them a proper stoma uh can't impress how much it's important to understand the problems these patient's face. They don't tell you even when you see them in the, in the clinic post topically or for surveillance, they actually don't tell you about the anxiety. They have all, sometimes some patients' to end up with the depression, they accept the fact that they have a stoma which is probably permanent in their case. Uh but really has a lot of implication on their personal life. And I think looking beyond a patient into a person is very important when you see them for the, for the follow ups or, or servants and, and have a chat with them and see if we can help them in any way, sending them off to uh you know, uh psychiatry or, or some help for mental health and stuff like that. So as I said, find things a good technique in terms of make sure that the citing is preoperatively place and it's a good place. Make sure there's a good vascularity to the loop that you're bringing out, make sure that you have done adequate mobilization so that there's no tension, adequate defect in the, in the fascia. And also uh make sure that you put good stitches. I think if you follow them uh to prevent any sort of problems, but prawns will still happen, at least you've done your best. So that's from me now. Thank you. Thank you very much, doctor. Thank you. And uh it's, as you said, it's, if you avoid them, it's much easier than managing them because, you know, these patient's usually have had a big operation and to take them back and try and sort it it's usually difficult. We've had a question which Nicola has answered but you can have a look as well and, uh, at anymore it's about earlier reversal of Ileostomies. And, uh, again.