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Ok. Mm. Yeah. So hi guys, welcome to our second session for surgical emergency series. So today we'll be learning about acute calculus cholecystitis and its uncommon complication of gallstones, which is meria syndrome and gallstone is, it will be taught by Mr Panel who is a senior clinical fellow in general surgery in London. If you guys have any questions, you can put it in the chat box during the session or after the session. And if he's asking any questions in between, you can pop the answers in if you know. Ok, and over to you, Mister P. Thank you. Uh sorry, I just wanted to know everyone is here. Uh We have 18 online now. Ok. Fine. Thank you. Ok, let's start. So gallstone disease is something which is known as symptomatic gallstones. Ok. If asymptomatic gallstone, it is not cold as gallstone disease. Number one, 40% of people in UK according to and you will get the references, of course, would be not having any problems in gallstones. So, thank you. But uh the last time I was commented, I am slow but I'm slow. Yes, I am slow. But please, this is the underlying there is a complications of any gallstones and common are acute cholecystitis, including xanthogranulomatous cholecystitis. And my question to you all guys is, what is Gho gho means a fat and granulomatous means creating a granuloma means body response. Ok. So I'm making it simple to answer cholecystitis and Hyers five means when do we say hyma and, and, and Hyatti means with an n cholecystitis? And I'm making it simple and I will be fast because I was commented I should be fast but think that, ok, uncomplicated except 571. Why? Because when something creating air, that means it is not right. Yeah, we have seen gangrene, we have seen all other things. Whatever creates are is not right. Complicated gallbladder, cholecystitis with perforation or pericholecystic abscesses means already perforated and creating an abscess means collection around the gallbladder. Yeah, or a stone has gone to CBD which is called choledocholithiasis gall stone pancreatitis. If it reaches the um sphincter porcelain gallbladder, I would like to ask whoever is attending what is porcelain gallbladder. And I will answer that me syndrome, we will go around cholecystoenteric fistula will go around. Ok. So this is the scenarios, cholestasis blockage to flow to while we have an answer for post gallbladder by abbreviation calcification of the gallbladder wall, correct? But when does this calcification happen? It must be chronic? Anything which is chronic will have calcification. So I would like more questions, more questions because last time I was asked. OK, you are asking questions but I'm not answering. So I want more questions. OK. Calcification. That means chronic. Chronic means what? So please answer it and we, we, we can talk OK. Cholelithiasis as you can read choledocholithiasis means se stone simply biliary colic means without inflammation. A stone in the gallbladder, cholecystitis, inflammation of the gallbladder, cholangitis means inflammation of the full CBD. And uh I'm sorry, I'm just thinking but end of whole biliary system because see uh biliary system is literally no bacteria. Yeah, are not inflamed whenever a bacteria comes into the play that is called cholangitis. Yeah, same way. Pima pima means what pus again, infection cholecystectomy means what removal of the gallbladder, you all know very well cholecystostomy means what putting a tube in the gallbladder, you all know. Yeah. So we have asked for chronic inflammation of gallbladder as untreated episodes of cholecystitis in the Yeah, it can be chronic, it can be acute. But in the sense like for example, per a gall uh perforated gallbladder, we put a tube in for the first instance. OK. So um mm the aim is to control the infection, control the inflammation and then we can do the next step. So final verdict, treat first, control the situation first and then go ahead. Is that OK? So I'm going like types of now, I'm going to my presentation and calculus cholecystitis types of gallstones. Now, the question and I have already written that 80% of that is cholesterol stones and 20% of that is big man stones. So my question to hear is what are the pigment stones I already written here that please. Is there any answers? Ok, then I'll go ahead. So, uh it is called five F fat fertile f female. In her forties, controversies, there are four apps take out fertile and there are six FS E flatulence. Ok. So in the sense, young female comes with right upper quadrant pain, think about gallstones. First of all, number one. Ok. And uh cholecystitis, of course, when someone comes with right upper chondron pain and uh it it can be anything to be honest, but when someone comes with right upper quadrant pain step one call me standard nice guidelines. Pan allergic type plus or minus amikacin. Yeah, but it depends on trust to trust. Of course, metroNIDAZOLE needed in the sense of newer guidelines. No, depending on the situation currently. Ok. Currently means when you assess the patient is patient looking septic, if yes, you need to escalate and uh what we call venular radiologist. Sorry, I just wrote Ir but interventional radiology to drain the gallbladder or heart gallbladder surgery within 72 hours. That is national guidelines. Ok. And otherwise if patient is stable enough, so plan for interval cholecystectomy. Ok. Now we are coming to something called laboratory values associated with whatever. But the thing is what I'm trying to sow here is what is bili. Yeah. Well, no blood results are altered, cedo means alp and bilirubin should be altered. Pancreatic means coming with acute pancreatitis secondary to gallstones, elevated amylase. We don't do a lipase very routinely. But liver functions would be altered. Cholecystitis. White cells would be up mild elevation of bilirubin and it is very, very important to understand the borderlines of these um taste. In fact. Ok. So chronic cholecystitis means if someone had a bilirubin of 29 and it is still 29 it is normal for that person. So, do not panic. Now, let's go to investigations. Like if someone comes with right upper quadrant pain and you are told it is acute cholecystitis. Yeah. So ultrasound is the best, uh, in the sense and I will say why? Because it is not invasive, easily, acceptable, easily done within a day. Ok. And 98% is the sensitivity 87 to 98. But yeah, it is very sensitive for gallstones. Whereas computer announce as in, we call CT scan, 78%. Bye. Remember that 80% of the gallstones are from cholesterol and about 40% only are. Ok. Ok. So you need to keep in this mind like CT scan is not the best way to go around the gallstones. Either you do MRI as you can see on the screen or first thing, noninvasive, easily access ultrasound. Ok. So, ok, someone is diagnosed with now we are going to step another choledocholithiasis. OK. What is the treatment? If someone is saying or even in ultrasound that is a stone in. What do you do? MRI? I would say no because it is already seen in ultrasound. That means it is prominent straight. E RCP. OK. Now, if you do MRE RCP, uh I mean that is another choice and that's why I said M M RCP. If there is a confusion. Bye. If it is straight. Two years, simple, straight and I'm sure that wherever you are working, it won't be refused. Anyway, common complications of ercp, pancreatitis. Yes. How would you diagnose any answers? I'm waiting. Hello. Nothing yet. Ok. So pancreatitis is a clinical diagnosis after we have an answer change in amylase levels, elevations in CRP another answer. Am I list three times above normal limit? Good. The third one is the best. Yes, that is the true answer. Clinical. First of all that you examine the patient if there is epigastric tenderness and you like o on a clinical grounds, I'm saying that if you think this patient can have pancreatitis in the sense like severe epigastric pain, um nausea, vomiting and so on. Ok. So that is when you should be worried. Ok, because personally I do not do amylase on the second day of E RCP because it will be elevated because most of the AP they do sphincterotomy means sphincter of ODI they cut it and yeah, if I say on a single like sentence, there was a sterile system and there was Unsterile system. Yeah, and gate is opened so it can be even cholangitis. It can be pancreatitis. Yes, I agree. But if the and amylo amylase is not the marker, clinical grounds are the markers. So it's up to you how you think. But on my clinical grounds, I would say check it clinically, patient is fine. No other symptoms. I'm ok to discharge the patient with safety guarding. So that is one thing. So I know everyone here would be thinking, no, no, it can have pancreatitis. It can have cholangitis. Yes, it can. It can. I'm not saying no, but it can. Ok. Second is bleeding, bleeding, uh very rare complication, cholangitis. I already told about you and perforation when they do sphincterectomy usually most severe. But if it is perforation, it is perforation, bowels. I mean a duodenum is perforated and it is dangerous. So of course, that is the worst scenario. But the diagnosis clue is whenever the perforation do the CT scan and it will tell you. Ok. For example. Now this is the next question to my listeners. If there is a color called lithiasis or lithiasis, sorry, my wordings. But if es is not possible, I've already written the answer. But uh if someone can comment, why PDC? Is there any answer? No? Ok. Main aim of pig disease to achieve drainage first. Correct. Yes. No, that is absolutely correct and call a cystostomy to relieve blockage. Answer. See when a stone is ending CBD. Where is the blockage? Yes, it is. Right in the sense that yes, we can do. Mm I mean, all the sisters told me we can do PTC. But why PTC? Then the sensor drain first, reduce inflammation and secretions and then we can look at other options. Correct. And whenever we do PTC, by the way, if I tell you the further uh reason is whenever we do PTC, we can do further what we call Antegrade stenting. OK. So that stent can go from the PTC line too. Whereas if we do cholecystostomy, yes, it is. It is good enough for controlling the situation, but it cannot do that. We have a similar answer. PTC is a two way street. We achieve drainage and can also be used as a stent. Correct. Yes. Yes. Very correct. Yes. OK. And commonest causes of pancreatitis before alcohol. I mean, of course, alcoholic pancreatitis is very common in this country, but more common is gallstone pancreatitis. So, no, II had a lot of things to say here. But if a stone is stuck to ample of, for example, OK. Now ofter, I'm sure everyone knows and if stone is stuck where the of water is and stands up as gallstone pancreatitis, so the next step is I want to know anyone. No, no. Yeah. Next step is the ASAP my friend. We need to take out that stone out. That's it. Anyway, let's go ahead. Intraoperative facts. OK. So, interoperative, basically, it is all about understanding the anatomy. Ok. Whatever is here. I have taken it from whatsoever slides which was made by me. But the SNC is you need to understand the anatomy. The same way I was saying and hump the same way I was saying. Cal triangle the same. I it is the same. It is all about like keep your eyes open. OK? And do your best. Yeah, because uncontrolled arterial bleeding during laparoscopic cholesterol is serious problem and then blah, blah, blah, blah or whatever, but I'm not that person. I look into the anatomy. I look into the things and I'm sure you guys would be understanding what I'm trying to say. So your safety. So basically what you need to know criteria of cvs. OK. What is C vs fat fibrous tissue cleared out fine. You can pull them down whatsoever. And only two strips, two structures need to go into the gallbladder. Simple as that. And lower cystic plate should be clear, you know why? Because I already told you Hans hump hump should not be there. There should be only two structures which is entering gallbladder and you lift it up and that's it. That is the safest part and no one can challenge you. Ok? Backup measures. If you cannot achieve this, it can happen. It's like fibrotic gallbladder or whatsoever. Yeah, with the tube and wasn't open, you have an option of sort to operate. But if you get this view, you're fine. What is bariatric surgery? And when is this done? And in fact, why I have put it here is whenever they do bariatric surgery. Ok. Mainly mainly triple bypass. No, I'm sorry. But I'm not going to go into the details of triple bypass, but whenever they do triple bypass, ok. Or even bypass, they remove the gallbladder. The reason behind is cholecystokinin. Now, uh I'm leaving it to you all guys to think what is called a cytokinin. But postcholecystectomy syndrome, which is something like, you know, when you don't have gallbladders and uh people or patients would ask you that. OK, what is the side effects? So these are the side effects, diarrhea, indigestion but usually body takes over and everything goes normal. Now, we are coming to me disease syndrome. Now see uh this me syndrome uh II, I'm going to be very much detailed and I'm very much interested about it but uh known as Extrinsic Bile Complexion syndrome, lots of um what we call the and the logics are there but simple as that, which I'm going to go in the next slide. Yeah, Pablo Luis Miri defined this syndrome and he did the specification of what is Miri Syndrome. OK, which is like classified mean two types based on the findings like one is external of succin and one is inflammation and fistula. I would put it as simple as that. Ok. Later in 89 send this Me syndrome in four types. Characterize fistulas. Yeah. But I'll make it simple to understand. And this is Me Syndrome. Yeah. Whoever is listening. Type one, I'm just reading that, but I can explain you that external compression of the bile duct by a stone infected in the in means stone is there but it is just compressing. Yeah. Type two fistula, fistula. What means? What already opened the wall and going somewhere else? Yeah, it can be cholecystocholedochal cholecystohepatic, correct? And fistula which is more severe. Two thirds of these circumferences of the duct means it can go anywhere. Typ cholecyst biliary fistula and it is blocking the bile tag. So if you see from top to below, only type one is without fistula, whereas type 234 and everything else is with fistula, small big even cholecystocolic fistula gallstone ileus. Yeah, or complicated cholester. So it is, it is simple to understand in, in my sense that type one, if you are giving the exams, type one. No, fistula, type two small fistula, type three, two thirds of the fistula. Yeah. And usually it is between the uh, biliary system. Cholecyst fistula with complete dru uh obstruction of the bile duct type 45 f along the interim as in bowel. Yeah. Five A without gold Ilias, five B, gold I and I will repeat this slide for at least three times because this is very, very important to understand what is Mirizzi syndrome and what is gallstone areas? Ok. You can read it. It will be available but think about it and make it simple to understand what is Mai syndrome type one? No fistula, type two fistula stones. Ok. I'm sorry. Prevalence. So prevalence of miz fact, 0.05 to 4%. Most of them are woman hypothesis, recurrent inflammation and biliary stais. That is the problem. And remember one thing in me, gallbladder cancer whenever you see me always and always check for gallbladder cancer. Ok. It ranges from 5 to 28 percent. It is good enough. Now, let's, so let's go to Goldstone complications. Of course, mechanical into uh intestinal obstruction due to a gallstone which has going to the bowels from the gallbladder. Simple as that. Yeah, most frequent type of fistula is gallbladder to duodenum. And we'll go now into the next slides. But, oh, most common complete MS cholecystocholedochal fistula, second cholecystoduodenal fistula and third cholecystic cholic fistula. So let's go again. Uh, the Goldstone uh, mortality ranges. Uh These are the true figures. Anyway, you have all these on your plate, but GS incident for only 4% under 65 but as it is rising, it goes up to 25%. And the reason behind that is gallstone was ignored and it gets bigger and bigger. More prevalent in women, female male ratio 3.6 to 1. Uh, everything is on your plate path pathophysiology. That is important are cause fistula, of course, recurrent episodes. Well, now this is your uh what we call exam questions and please get it through that while trans reported an infected stone in close contact with inflamed mucosa first developed ischemia. So in uh gallbladder, yeah, infected stone because it is infected and because of the repeated contractions of the gallbladder. Yeah, it develops ischemia of the wall and then necrosis and then because of the inflammation and necrosis, it creates basically proper inflammation, maybe perforation or even surrounding adhesions. Yeah. But infect the stone can get through them. And of course, forms of fistula. When does it happen? Stone size is significant for the more than two centimeter in the sense? Ok. And all the references are here again, I'm putting it here because I want to see all of you. They think one, no perforation. After two, everything is perforated. Depends on where does it perforate. Ok. So most frequent fistula between the gallbladder and duodenum. Fair enough, isn't it? Representing over 85% choledochoduodenal cholecystogastric cholecyst vaginal ileal very uncommon cholecystocolonic. Mm Reasonable. Yeah. And hepato your needle, other mechanic. Uh mechanisms of obstructions are passage of small stones that migrate through of water, which happens, which happens means uh we have got a lot of patients like it was a small stone. It has passed with the abnormal LFT S. But yeah, patient is fine now. Oh, got it even during the cholecystectomy when we handle the gallbladder. Stone can migrate. Ok. So remember these things, but clinical presentations and let's go to the details. I'm sorry, I'm a little bit slow here, but I think I will be a bit slow and be quick as well. But not syndrome is the stone whenever uh, it is uh gastro, oh, sorry, cholecyst uh duodenal obstruction. Ok. It can be, but not, or it can be covered. Bernard is when stone gets stuck with the elus wall over, it is when it gets stuck with the, uh, itself. Ok. Any questions by now? Ok. If not fewer than 4.8% present, 4.8% only present with colonic obstruction, obstruction means only 4.8% would have cholecystocolic fistula because remember small bowel is smaller than large bowel. Of course, I'm not making a joke. But if something can pass through small bowel, it can surely pass through the large bowel. That means if someone is coming with colonic obstruction with a gallstone, it is obviously cholecystocolic fistula onset, acute subacute chronic. Ok. So, basically small bowel obstruction or large b obstruction. There is something called Karski syndrome as well. Whereas, uh, basically what happens is stone passes through bowels and lots of time when it goes to an obstruction, it's like ball wall mechanism, but it is not ball wall mechanism. I'm sorry. Uh, it basically makes its way and there can be multiple fistulas in the abdomen to be honest, it can be from, for example, it can be from the gallbladder to duodenum and then to the lead B and then comes down I it is possible and it is called Carves syndrome. OK. It is very, very, very, very uncommon, but I've given the references here and uh you can find it out, ok. But physical examination, laboratory reports, basically, uh it is like how you diagnose. Ok. So M types history of gallstones, signs of acute cholecystitis and a bowel obstruction. Simple as that. So Barre syndrome, if you remember previous slide, it is a stone in the duodenum. Ok. So stone in the duodenum means one gastric outlet obstruction. Ok. So gallbladder gallstone. Now, if I can say about gallstones, most of them, there are, most of them are radiolucent, not radio, um, margin can be radio but not the there is something called me sign. So can I ask please if somebody is interested to answer? What is me sign? Hi. If anyone knows the answer, you are free to put it in the chat box. No. Yeah. Yeah. Any other answers? Ok. Hi. Hello. We have an answer. So, yeah, nitrogen gas within the stone, it looks like a star shaped pattern of nitrogen gas inside the stone. And how does that happen? Anyone? Let's give you a few seconds. No, that's fine. I II will give you the answer. Basically. What happens is whenever the stone is found and if it is like, for example, bacteria is there OK? And they create bacteria breeds to be honest and that's, that's how I take it. But because of their metabolism, the stone's bre center becomes a triangle. That means bacteria. Was there any ns we have bacterial growths within the stones? Nitrogen gasses? Yes. Yeah. Yeah. Yeah, I agree. I agree. Completely agree. Ok. Good. Let's go on. So diagnostic approach. Yeah, of course. We check white cell count, cholecystitis, abnormal liver function test. And so and so and so on. Ok. When do we do supine, erect, supine and erect abdominal X ray? Any answers? II, I'm here and uh anyone can read that. So answer is there in front of you. But when do you do that in a clinical scenario? Um Like all cases, it is to separate the gas and the fluid. Yeah, fair enough. Ok. Now my answer is whenever someone has a history of gallstone and comes with bowel obstruction, two criteria, history of gallstones. Longstanding, don't small one and history of like current presentation of bowel obstruction. Ok. Then, and then only this is justified. Otherwise there is no point of doing this kind of x-ray. But anyway, we are talking about gallstone A. So, uh those are the two criterias where we need to be curious to know that according to my presentation. Regular Stride. Yeah. Where is Radio Stone? Which cannot be there because gallstones are not radio, as I already told you, Pneumobilia Yes, that is called coal menser sign and obstruction. Ok. So I'll go through that and uh, Rigler is also there. So let's go next. This is the one. Ok. So F one RR and Tetra pneumobilia. Can you see Pneumobilia, I'm sure you can because I can point it out. This is the stomach. Yeah. And this is Pneumobilia white arrow, of course. Yeah. Dilated loops, of course. And stone, now stone can be radiolucent as I told you. Yeah, because cholesterol stones are not radio loose uh radio pack. OK. Let's go to the next. Uh This is all ancient workup to be honest, but M RCP is the best. But then we need to know this and FT sign. Yeah, which is called snakehead with a clear hallow made up of radiolucent calculi not radio remember and parenzyme material through the biliary tract means gone up means say sphincter of ODI is very functionate whenever sphincter of is disturbed. Either E SCP sphincterotomy with sphincterotomy or a stone in the sphincter of ODI, they behave like sphincter has to open and it is a sterile atmosphere outside. They go inside means bacteria or even a die and they create uh havoc. So it is now not used anymore, but it is good to know that sign and ran sign if in case you come across. OK. And that's why I have written like uh baby administration is contraindicated whenever the section is indicated, but it can create a havoc. So let's go back to be sign, which is a duodenal obstruction due to a gallstone with a fistula. So this is what it looks like. Ok. Stomach full, gastric outlet, obstruction. In simple sense, the stomach is full. Nothing is going anywhere. Gallstone is there in the duodenum. Yeah. And with pneumobilia and one and because it is most common, that's why I'm giving all these slides to you guys see that stone, OK? Only the ring can be seen in the CT scan. Ultrasound can detect more, but it is an obstruction and this is the endoscopic view. So let's go to the investigations. Now, any bili liver pathology ultrasound is the best, as we already said. OK. Bowels, yes, density scan is the best. So this is uh a well known study where it says CT scan is the base for bowel obstruction, pneumobilia and stoning G A tract. OK. Now, the treatment, yes, we try to re like take out the stone by endoscopy and no red means I must say that if it is in the duodenum, OK? Or colonoscopy, colonoscopy four. I'm sorry, I'm going to ask a question because rate is due needle stone. So colonoscopy for, what is that? The answer? Not yet large bowel obstruction, correct. Yes, laurate duodenum, Bernard Ileocecal valve. And that's why I went back. OK. So I want you guys to understand Barnard and Barre. OK. One is stop, one is down. OK. Let's continue diabetic procedures can be done by endoscopy. OK. And these are the facts. Jelinski colonic gallstones. Even he tried electrohydraulic lithotripsy. What does that mean is like renal stones? They, they try to break the stone and then it comes out. Ok. In the same way, lower colonoscopic removal of infected gallstone in colon. Yeah, there is also papers that are extracorporal shock wave lithotripsy, what we call es WL which is used for renal stones. Yeah, or intracorp, lithotripsy or endoscopic mechanical lithotripsy for fragmentation. Everything was right. Yeah. But usually they end up with a surgical treatment, gallstone i surgical treatment we try endoscopically. I've already told you. Yeah, surgical treatment of Goldstone ileus is performed. You can read that. So I don't want to read that, but there are surgical options and I'm going to that enterolithotomy means removing the stone wherever it is. OK. Enterotomy, gastrotomy and so on. Technique of choice till the date. OK. Well-known recurrence rate of gallstone ileus 5%. But surgical intervention depends. OK. And recurrence is 10% about. So one stage, one state means what you just do involves particularly cholecystectomy, cholecystostomy fistula, what other fistula like cholecystoduodenal fistula, cholecystocolic fistula, everything is done in one stage. OK. And uh I put that uh report as well like ridge San Juan. And we compare the result of enterolithotomy alone versus one step. Surgery means removing the stone wherever it is and tapering the fistula, the groups were similar. They concluded and I would underline that concluded that even though they do not support one stage surgery, it could be an acceptable procedure in low risk patients. Low risk mean, what if an 85 year old or 76 year old? Yeah, with a lot of comorbidities? If someone comes with that, what would you do? I'll answer that in our presentation. And there is something called two stage surgery. It means you do the initial a removal of the stone and then a repair of the fistula slide is in front of you and ranges from four weeks to six months. But it has got a lot of things to be considered. Some articles report that spontaneous expulsion. But then it depends on the size of the stone. Latest laparoscopic approach. OK, which has got a lot of uh claims like faster recovery time, less morbidity mortality. However, this procedure requires, of course, it does. And moreover in emergency, it depends. Basically we need to choose as a doctor. When do we use? What? Simple as that? Now, I have managed an example case. Ok. Wheelchair bound. 75 comes with this. Ok. 70 millimeters by 48 millimeter stone in descending colon. And it was cholecystocolic fistula, of course, because that cannot go with UC wall. Yeah, 68 millimeter. Here, this is the endoscopic view. We try to pull it out through endoscopy. No success. We ended up doing the mini laparotomy and removed it by enterotomy, which is the first choice as mentioned earlier. And this is the stone, you can see the size and this is the uh last biggest, which is two millimeter less than what I got it out. B it is important and it is published of course and you can see that it was quite big. So going back to my essence of this lecture is what is Marie syndrome? This is all part of Mirizzi Syndrome, even Goldstone areas and everything else. Yeah. You know the cholecystitis, you know everything else, but you need to know what is Me syndrome and please take this picture and C and C it every day so that you do not forget I do it every day and these are the references. Yeah. Uh We have a question which is asked quite a few minutes before as to burnard syndrome is the retrieval via colonoscopy. I'm sorry again for Bernard syndrome is the retrieval of the stone via colonoscopy. No, it can be, it can be. But this time, I mean if I'm saying example case no, but yes, it can be, it can be. And that's why I'm coming to that uh slide where it says ileocecal valve. Yes, it can be. But depends on the size and depends on the fistula because most of the large stones, if they create fistula, they are more than two centimeters. And and I am not talking in the air, but you can search it but if it is more than two centimeters, then it will struggle to go through IUC wall. So it can be colonoscopy, can remove it depending on the size. Any other question. Nothing yet. I think you can continue. No, I'm literally done because last time I was uh like told that I should be fast. So I have been fast. OK. OK. So got got hi. And if anyone has any questions you can ask them now, no uh discuss it. See this is a friendly platform and uh whoever is listening to me, please ask questions so that I can answer. Ok. Mm I don't think there are any questions we can give you a few minutes just to see if anyone has any consistency. Yeah. Yeah. Yeah. Um Yeah, no questions but thank you for the presentation. Ok. Are are you going to send this presentation to all? Yeah, I can upload the video. Yeah, please do so. Oh, someone has a question. He's just typing. Yeah. Yeah. Yeah. In patients with Barre syndrome due place an NG preoperatively. Yes, of course. And I would ask like, OK as a clinician if I'm saying yes, put a nn G tube Y and the answer is treat it as gastric outlet, obstruction means if gastric outlet obstruction is there, that means there are, there is high chances of aspiration as well. So empty the stomach as a clinician. So yes, please put an NG large ball empty the stomach so that you can save someone from being aspirated. Mm Any any other questions? OK. I don't think they have any more questions. Ok. Yeah, nobody has replied yet. Shall we wait for a few minutes or? Yeah, we can. But I must say, OK. Uh there's a question, what are the long term POSTOP care management guidelines for these patients? Uh For which patient you see? G gi Yeah. So I have said one stop, two stop endoscopic like one stage. Yeah, just we remove the stone and we leave the other things for the Yeah, the same way. That way, I mean, repair it whatever the fistula is two stage re repair the uh stone, I mean take out the stone and then we remove the fistula later on the stage. But enter lithotomy is just the removing of the stone and most of the people do well with that. But then if someone is young, for example, then we do this 11 stage surgery. And I already uh said that like one statements, remove the fistula, remove the stone and that's it. But it it depends on the situation to be honest because if it is for example, cholecystoduodenal fistula, then we end up doing, for example, even sometimes uh Whipples, Whipples is not like Whipples, Whipples, but removing the part and doing the divers. So it is a big decision to be honest. And depending on the health of the patient health of um being or going through the surgery. If that answers your question, that the best thing and equally good is just remove the stone wherever it is and then deal with the uh fistula later on, which is called two stage if patient is young, otherwise, uh as I have said, 75 year old female, and we have removed the stone, not possible by endoscopy and she still lives with the fistula but without the stone. So it is all like empathetic and sympathetic approach, what we do for a patient, but it should be acceptable by a patient as well, to be honest, so that I hope I'm answering your question well enough. Yeah, the answer was fine. No further questions. If anyone else has any questions. Yeah. Thank you. Mhm II. Don't think anyone else has any questions. Think. Yeah. Yeah. OK. Maybe we can. Now uh I would say uh please pass on this presentation to uh whoever is interested, please contact a link and uh thank you very much for listening to me and hope you all best. Yeah. Thank you all for attending the class and thank you Mister Panchen. Uh If you could fill the feedback form and take a minute and then you will get the certificate as well. See all inci. So yeah, thank you. Thank you. Yeah.