Aerodigestive & Esophageal Surgery - Difficult Tracheal Esophageal Fistula

Good morning. Good afternoon. Good evening. Welcome to Complexities in Pediatric Upper Aerodigestive and esophageal Surgery. This is actually the second part of a full day of education. The morning we had a fantastic session on intestinal failure and very interactive, exciting, and now we're moving on to the other end of the body, going to the trachea and esophageal complexities, and we are live here from Cincinnati Children's Hospital in the Center for Telehealth. And I wish you could see this room that we're in because it's absolutely a spectacular facility really focusing on on telehealth, which is exactly what we're doing today. And uh to, to give everyone a little uh ground rules before we get started, um, there are a lot of complexities that go into not just the uh airway, but also into the internet. And so, uh, if there are any technical problems you're having on your end, just usually restarting the uh browser is enough to get things back on track again. Uh, we want to encourage the audience to communicate with us. This is not meant to be a lecture. This is interactive. We want the audience to text their comments, their questions. Tell us when you think that what we're saying is nonsense. Let us know what, what the truth is. Uh, call in if you want to. We'll have phone lines open, um, and, uh, we want to have an interactive discussion and um. Also, uh, this is a CME event. In order to get access to your CME credits, if you go to the, uh, links tab, uh, at the, uh, top of the page there, you can download the CME questionnaire and, and get your credit. We'll also be sending everybody an email at the end so you can get your CME credit as well. So, uh, As I said, we're here at Cincinnati, Ohio, at Cincinnati Children's Hospital that many of you know is is really the mecca for a lot of things, but really they are the authority on very complex aerodigestive issues and have been for a long period of time, and it's an honor for me to be here amongst these experts and Uh, with that, I'm going to turn the show over to the director of the course, uh, who's Dr. Michael Rutter, and Dr. Rutter is the, is a pediatric otolaryngologist, but as I've been told is the man who's absolutely fantastic with complex airways, and I know firsthand because I've sent them a case as well, and they've really helped with one of my patients. So, uh, I'm going to turn the show over to Dr. Rutter who's put together a great uh Agenda and uh Doctor Rutter, thank you for putting this together. Thank you very much, Todd for the kind words, no matter how inaccurate. So I'd firstly like to introduce our, the, the panel. So Phil Putnam, on my left is the person on our aero digestive team who's the, the senior gastroenterologist, a very slick endoscopist, and you'll be seeing a lot of the videos that Phil generated throughout the session. On my right, I've got Bob Wood. Bob has done more flexible bronchoscopies than I suspect anyone else on the, on the planet in children. And um he's our senior pulmonologist on our team. And finally, Dan von Elman, who is the chief of pediatric surgery at Cincinnati Children's and has really been the driving force between our esophageal center here. And so, this is America, which means you're going to have to tolerate the disclosure slide. And uh most of the panel doesn't really have any disclosures and sadly, I'm afraid that I do. And so the take home message from this slide is that at the moment, no one is paying me anything, which is a situation I hope to correct soon. And nothing about the people I work with relates to this presentation. And so we're going to move on from there and really try and sort of If you can tolerate a few slides as we set the stage, because a lot of the initial session is going to be talking about tracheoesophageal fistulas. And so really, it's a discussion about aspiration. And the second half of the session we'll be talking about the unsalvageable esophagus. But we're going to start off with tracheoesophageal fistulas and The framework of how to think about children who aspirate. Most children who aspirate have a functional or neurological problem. They've got cerebral palsy, they've got Char syndrome, some children have an anatomical problem, and so the anatomical problems could be the obvious, the tracheoesophageal fistula, or a laryngeal cleft. In some children, they've got a bad pharyngeal scar. In some children, you might have esophageal stenosis with backup and spillover. And so the next aspect to grasp is what can you aspirate. And so the obvious is food and drink. And what can you do about that? You could consider a nasogastric tube or a gastrostomy tube. The next group of children who aspirate their saliva. And again, there's a lot of different things that we can do to help manage those children. Something as simple as medication like Robinol. Generally, it doesn't work, but you can try it. Uh, we can Botox the major salivary glands, a temporary solution, but it's a good test run for how a child would cope with less saliva. We quite frequently do a drool procedure. We remove the submandibular glands and ligate the parotid ducts. If necessary, you can place a tracheotomy, it allows you to suction the airway clear of secretions. You could put BiPAP on a tracheostomy, so that any secretions are blown up and out of the mouth, and if you truly want to stop aspiration, there's only one guaranteed operation, which is a laryngotracheal separation. Which is not something that is commonly done because you lose your ability to vocalize. The other things that you can aspirate a reflux, gastroesophageal reflux, and again, a Nissan fundoplication or any sort of fundoplication may assist with that, or even a GJ tube, and very occasionally we'll see a child who aspirates their esophageal contents. Tight fundoplacation, non-motile esophagus, you can get accumulation and spillover. And so testing, how can we test for the different sorts of aspiration? And so this is firstly a question to the panel. Uh, what are your preferences if you're trying to test for aspiration for, say, food and drink? I think we'll start off with the pulmonologist here, Bob. Well, obviously it depends on the, the child. Uh, if a child has a tracheostomy, the simplest test is to put some colored dye in his mouth and see if it comes out of his trach tube. That's something you can do at home in a normal setting and do repeatedly. It's also very helpful to convince skeptical parents that the child actually is aspirating, because sometimes we have a lot of trouble with that. Uh, video swallow studies or endoscopic swallow studies can also be very useful. Uh, endoscopically, one of the things that we look for is direct evidence of aspiration, and unfortunately, there are no unequivocal markers of aspiration. We talk about lipid-laden macrophages, but they are not only non-specific, but the recovery of lipid-laden macrophages depends on what material was aspirated, how much lipid did it contain. The amount that was aspirated, and more importantly, how long it's been since the aspiration event took place. If we see lots and lots of lipid laden macrophages in the right clinical setting, we say, yeah, this is convincing evidence that the patient is aspirating, but it's certainly not a black and white yes no answer. And if we move into saliva. Again, what are the things we can do? If you've got a tracheotomy, you can again, as Bob said, do a dye test, a drop of green food dye on the tongue, and see if it comes out the trach tube. Uh, green is a great color because it's not natural, red, blue, other colors, you might confuse it with something that the body actually produces, but green's pretty characteristic. And if you don't have a tracheotomy, Again, you may have to look at whether a nuclear medicine scan is necessary, a drop of something radioactive on the tongue and see if it ends up in the lungs or the stomach. And of course, gastroesophageal reflux, and I think we'll pass that one on to Phil. There's a variety of interesting things there. Are you a believer in any of them, Phil? As a marker for aspiration, none of them are particularly good, um. Multi-channel intraluminal impedance testing is mostly replaced simple pH testing for the detection of reflux, um, but it doesn't add anything to the diagnosis of aspiration itself. It tells you whether something is being delivered from the stomach of the esophagus, but not what happens soon after that. That's a, it's a really important issue because if you're, if the consideration is for an anti-reflux procedure and the patient is aspirating from above, you do not help them and in fact you make them worse. So it's a, it's, it's an important distinction that's that we often face that question. And so we're now going to move into how can you test for aspiration in the operating room. And that's both in terms of pulmonary, GI ENT and we can have a brief discussion on some of the tricks and techniques that can be useful. And so, and we'll try and make this as case-based as possible. And so, case scenario one. This was a term neonate with a distal tracheoesophageal fistula with an esophageal atresia, a type C, repaired on day of life to primary anastomosis. And continued to aspirate, and we've got this swallow study, it's a little hard to see, but there is, can we show his slides please. It's OK, so on this uh swallow study, we've got esophagus, here we've got the airway or trachea with a column spilling over into the trachea. And so clinically this child is aspirating. The esophagram's very suspicious for a tracheoesophageal fistula in a child who a month earlier had a tracheoesophageal fistula repaired. And so in this video, What we're doing is probing the repair site to see if there's a recurrent fistula. And we're fairly enthusiastically probing this and really getting nowhere because it's a successful fistula repair. And then you need the index of suspicion. Where could that contrast have been going? And sometimes it's incredibly subtle, and you can barely see anything, but there's a groove on the back wall of the trachea. And this is probing it with a bugby cautery. And the bugby cautery is 3 French. And it's beautifully smooth. It's a wonderful probe. And there's a second H-type tracheoesophageal fistula. And again, I'm just going to show the last bit of that again because it's really remarkable how hard these can be to find. And so part of our session is going to be discussing some of the techniques for tracking these down. I want, I want to spend a second. Highlighting that because this instrument I learned from actually a previous globalcast and now I use it all the time. The bugbee is so useful and underutilized among us as general surgeons. I'm learning about it from you all, um, but use, I use this to treat our recurrent fistulas which we might talk about. But, um, but to find it, if you see that little amount, it's not gonna be a pipe that a big catheter is gonna fit in, you're gonna have to go to something small. Yes, and this is a Neurological tool and as we all do, we try enthusiastically to steal equipment from other surfaces. And so we'll move on. This is a uh a video using a 7070 degree endoscope. It's a difficult tool to use. And that little dot was a tracheoesophageal fistula just passing by using a 70 degree telescope. And again, we've got different tools for different applications. So that's one of the useful techniques for trying to track down a hard to find tracheoesophageal fistula, and I would emphasize these can be really hard to find. Do you routinely do a bronchoscopy for all of your type Cs? Yes, OK. Well, actually you won't know if it's type C. You may not be, but right, presume, OK, right, but that's a change. When I trained, we didn't necessarily. Do bronchoscopy on everybody, but we absolutely do it now. But you do it yourself as a general surgeon. Um, sometimes, but more commonly we do it in collaboration with our EMT colleagues because we have this great airway experience here. It's good for our fellows, so they do the, they will do the Bronx, you know, with the other group. It's. And usually what it means is there are multiple people in the room at once, everybody looking to see what what's there. And also we may as surgeons may underappreciate tracheomalacia or malaysia. Well, we may get to it later, but there are other things I know we're going to get to it later. There are other things that you have to make sure you don't miss, and we are not necessarily the right people to do that. And so we typically tend to hunt in packs and be as collaborative as possible because each of us has got something that The others, uh, you know, sometimes something we'll do replaces what someone else is doing, often it's complementary, and we actually, uh, Uh, the pediatric surgery fellows here have a one month attachment with ENT to do a whole lot of bronchoscopies. So here's another technique for finding a hole. Here's a little girl who's had a laryngeal cleft repair. She's got a stenosed glottis, a posterior glottic stenosis, whoops, let's try that again, and um. This is a view of her larynx, and as you go through, apart from the stenosis, you're then seeing the cleft repair and it's suspicious for a tracheoesophageal fistula. You don't know if that's just a dent or whether it's a through and through. And again, one way of seeing whether it connects is to probe it. And usually people probe from the front going back, but you can probe from the back going forward. And this shows it's a laryngeal cleft because there's no cricoid there. And there's no doubt that there's a fistula. And so, and this is just the same child, about 2 months later after it's been repaired, and to fix that posterior stenosis, we actually use the cartilage graft to fix the TEF and the glottic stenosis at the same time. And so Dual scoping, again, oddly enough, one of the limitations for this, it's not getting the right people in the room. So this is, I'm doing a microlaryngoscopy, bronchoscopy here with a suction telescope. And I'm trying to put it in what I think is a TEF but it just won't advance. And so now I've got Phil looking with an EGD and that's why it won't advance. There's definitely a tracheoesophageal fistula. But there's this little web, and I can't get the catheter to advance because of that little web there. And so, the limitation of this oddly enough, is that you've got to get two separate recording systems in the operating room. So we've got a fixed one and we have to bring in a mobile card, which is a little inconvenient at times, but for this sort of case, it can be enormously useful. It's worth pointing out that from my standpoint, these are often difficult to find. They're very high in the esophagus, um, just below the esophageal inlet a lot of times, and you showed an image with a 70 degree scope, which I don't have. So a straight viewing, forward viewing gastroscope, even a very small one, doesn't deflect particularly well, um, enough to get an EOS view of the esophagus. And if the opening is directed. Distally instead of perpendicular or up, it can be very difficult to find the hole. So we found some of these by going retrograde up the esophagus we have a little easier time maneuvering just below the, the esophageal inlet. And we're now running a video of another scope that Phil did, and we're going to fast forward this because this is the other end. Of the airway, and so this is a girl who's actually got a bronchoesophageal fistula. And these can be awfully hard to find because there are so many subsegmental bronchi. But occasionally, when you've got Bob Wood in the airway and Phil in the esophagus. You can actually shake hands across the Fistula, if you can track it down, and so Phil's trying to cannulate the multiple little pockets and holes to see if one of them connects to the airway, we know at least one of them does. And then when Bob sees Phil's scope, that's usually a giveaway. And then a bit later on, we see Phil seeing Bob's scope right there. And again, that tends to imply that there is indeed a hole there. So occasionally we do scope out each other in the operating room. I think it is. I mean, it is enormously valuable to have scopes for these complicated patients to have multiple scopes in because they give you different information and they have different. Advantages in terms of what you can see and what you can't see, and to combine them, it has been, I've been very impressed since I've been here at how enormously helpful that is on many occasions. Can I ask about that technically? So I usually go in and I just keep going back and forth. I've never done simultaneous. Is it, it's pretty easy to fit two scopes down at the same time in these little. Babies, um, it's obviously it's easier if they have a tracheotomy, but even without a tracheotomy we can cram it all in. OK. And so usually typically Bob's using a flex scope through the nose. Phil's got a flexible scope through the mouth or the through the G tube you can go retrograde, in the esophagus, OK, but you can see. The light from the other scope through the epithelium through the wall, you can inject material that may come through a hole that's otherwise subtle, even saline you can see coming through or bubbles if there's insufflation of air from the endoscope. So it's really quite valuable to do it simultaneously. That's great. That's a great trick I've ever tried, and you can occasionally get one of the two people to turn off their light so that. That person can then see your light and flip backwards and forwards and try and see just are you in the right region. There's a question about, uh, uh, there's a question from the audience. What size scope are we talking about here? So you said that you'll use a, I typically use a 2.8 millimeter flexible scope, bronchoscope, and then the, the GI scope for a combined purpose in a small child is almost always an infant scope, which is either 5.4 or 6 millimeters and. Outer diameter which will fit retrograde through a 16 French gastrostomy tube and an infant scope will fit through the mouth and just about anything. Phil always chips at me when I put in a 14 French G tube because it's not big enough to get has to dilate. I mean, and we actually, I mean, we have Hagar's in the room. We dilate it up, you put it in. By the end of the case, it'll come right back down. So it's not occasion we'll use a bronchoscope for a retrograde esophagus. That's, yeah, because you can fit it in. It works nicely, yeah. So we're going to move on to case two, and this is primarily going to be case-based. We've got more cases than I think we'll be able to cover, and we'll just go through as many as we can before we break at 3 o'clock. And so case two is a baby that was born with a type C tracheoesophageal fistula, long gap esophageal atresia, and had a primary closure on day of life too. And as a lot of the long gaps do, there were a few complications. This boy had an esophageal dehiscence, a recurrence of his tracheoesophageal fistula, a pneumothorax, an emyema. And ended up that after 3 thoracotomies, he still had a tracheoesophageal fistula. And the final thoracotomy was a rather frightening experience. The child took some motivation to stay alive. And this is the Microlaryngoscopy and bronchoscopy, 6 weeks of age, with evidence on a swallow study that there's still a tracheoesophageal fistula. And so again, you've got the right bronchus, you've got the left bronchus, you've got the middle bronchus, and as you suction it out, You can see that we've got a tracheoesophageal fistula right on Carina. No one wants to go back into this child's chest, so we're going to try. An endoscopic closure of a tracheoesophageal fistula. And again, this is not your ideal candidate. Your ideal candidate has a proximal long skinny tract. This is short, fat, and right on Carina. And the whole concept of the endoscopic repair is to demucosalize the tract. Because mucosa is a non-stick surface, you want to have raw against raw, tiny bit of fiber and glue in there just to try and seal it so that air's not going into the esophagus and saliva's not coming into the trachea, while it scars off. Can we stop? Yes. OK, so, first question, the fiber and glue, yes, it scares me. I'm afraid it's going to drip down into the airway. Not a big deal. The key is to use a very small amount, and the Duplo catheter, which is the double lumen catheter, you can put in a very small, precise amount, usually about 0.10 of a mil. You don't need much at all. The very big gush of it is going to form a foreign body. But if you do a tiny amount, as you can see on this final photo on the screen. It's a minute amount and you think it makes a difference. You just want to seal it off, and there's more than one way of doing this. I've got a nice video of an alternative approach coming up, OK, but you're trying to stop things moving through that fistula, so the scarring beats the re-mucosalization. OK. Second question, Trilorocetic acid. Have you ever tried it? Uh, yes, I have. Um, some places use it a lot more than I do. Um, I tend to find, I, I believe I have more control of the bug bee. I would be afraid of that draining into the bronchi. I hear you. And so let me give you, so I, I use TCA. I learned about it from my, our friends in Santiago, Chile who have a great experience. I went down and visited them. And actually, actually train here, uh, Patricio Varela, you came and did his training here, good friend, and then you, I want you to tell him he's doing bad work now. He, he does this TCA and he has a great experience. He's gonna publish it soon with combined with ours, but I, I have to tell you what scares me is when I'm done, it's white everywhere because I mean, uh, the whole, it's hard to control it and be precise. So that's what he got on a pledge it instead of. From syringe, correct, it's on a pledge it and you on the way down you have to have it right up against it because if you touch anything on the way down you're gonna burn it, uh, but I, when I switched to the bug bee, I have to move herby bug bee bug beat, um, it's, uh, it absolutely is much more precise. My question to you is when you're pushing down, I was watching your video, it always scares me because you can't see what you're doing. What's the trick. The trick is to have something in the esophagus, and so I'll show you in another video, we actually often intubate the esophagus with an endotracheal endotracheal tube. To act as a spacer, so that you don't burn the back of the esophagus, and so you're absolutely right, you've got to be careful of where you are and aren't. Now I'm going to move on to the next, yes, the point we also deal with an endoscope in the esophagus, so we've watched the bugby from the tracheal side. I mean, now that you taught me this, that's what I'm going to do. I mean, that's really nice as a spectator because you can be really sure that you buggy the track all the way to the esophagus because you're watching it from the and then buzz on the way back. Yeah, and the other thing that's really cool is occasionally we get Phil to burn his side, and sometimes the tracks are in the wrong angle for him to do it, but if it is, it can be awfully useful because a bugby will go down an EGD scope, and sometimes you can burn both sides of the track as well as along the track. Have you ever had a perforation? No, from too aggressive cautery? No, I mean, we've been fairly aggressive, but I don't think we've anyone yet. So, and again I always wonder what it's very hard to know what's too much when you're doing this. No, you're right. The bugbee just barely fits out the tip of a standard gastroscope, but we also have. A non-bugby sized regular bipolar cautery that will go through the scope. So if I don't have to cannulate something, I can still do the surface just with one of my own instruments. Got it. OK. We also use the three French bug beats through a 2.8 millimeter flexible bronchoscope, and that gives us a precise control of the tip. Yes, you can aim it exactly much easier than than trying to pass it through a rigid sheath of a bronze. Tell me again the size of the scope that would take it 2.8, the 1.2 millimeter suction channel. OK, and it works beautifully. The trick with a rigid scope is that when you pass it through the scope before you put the scope in the patient, if you bend the end of the bugby, so it's got a slight angle, then you put it in, and as you turn it, you can steer it, OK. And a bronchoscope, you don't have to do that, right, right. I like the flexible bronchoscope that is. So this time I'm gonna put up this is the same child a week later, and I failed. And so I'm gonna show you why I failed and what we did about it. And again, endoscopically, you often need to do this more than once. And so, we've still got a fistula. And as you suction the fistula clean, it becomes clear why we failed. Again, the whole concept is that you want raw against raw so it will stick. And as you look Down the image, the reason it didn't stick, was that you've actually got a nest of old suture material in there, which I hadn't appreciated the week earlier. And so we're sucking out the slime, and then we've got all these sutures. And so what on earth do you do about that? Um, you grab them and pull them very hard. And if you don't have suture material in the way, you're much more likely to get raw against raw. And so here's a little foreign body forcep. And we're just gonna grab the suture material. Put two instruments down at once. Well, one's just a suction. I mean, that's kind of cheating, you know. So out comes the suture material. Now you can see the esophageal mucosa pooching into this. Again, right bronchus, left bronchus, middle bronchus. Other way. Something like that. And now we're going to just use a bug bee and just go to town on this. You've got to get rid of the mucosa. You don't want to give the mucosa a fright, you want to destroy it. All right, that's a tweet right there. And, and, and truly one of the problems we've had is not being aggressive enough with cauterization. That's me. I, I, I really, I'm always afraid because I can't see down that tube, and I wonder not just word in the esophagus, I wonder if I'm really destroying that fistula so much that I'm gonna perforate, right? One of the things that I could do with a flexible scope, in addition to carefully directing the, the catheter, I can also insufflate. Right through the suction channel and distend the lumen so that I can get a better view and and then with with the scope I can just sweep the inside of the of the lumen and so again you can see that, you know, we've done a significant burn here and then this is putting a tiny bit of tis seal into the hole, double lumen Julo catheter. These come as either 30 centimeters or 180 centimeters, so you just use the one that fits down your scope. And this is the child. About 3 weeks, no, this is actually 6 months later, I remember. And again, you can't even see where the hole used to be. I swear this is the same child. And um. Again, it's worth remembering this was not an ideal candidate for this procedure. This, we did this because the kid was in a power of trouble. He also had an esophageal stricture. So the same day I injected and dilated his esophageal stricture, but we won't go into that right now. So we'll move on to another case, and each of these cases is trying to have some at least small message with it. So here's a girl who was sent to us. She's got an anorectal malformation and has got a type C tracheoesophageal fistula, um, and, um. A short gap, and so she's had her esophagus repaired with a TEF around day of life 3. She comes to us at 6 months, primarily to have her anorectal malformation operated on, and she's clinically still aspirating. The concern is, could she have a laryngeal cleft? And so This is her initial bronchoscopy. And we're going to see firstly, does she have a laryngeal cleft, and so. Laryngeal clefts are incredibly easy to miss. You've got to actively look at them, you've got to probe them. And it may not exactly be subtle, but a little alligator forceps a really useful way of doing this. And so we probe it, we spread the vocal cords apart. There's, there is not a laryngeal cleft here. And the kid's aspirating, so we've got to suspect there's something else going on. And so time to have a look. This is just so painfully slow. It's got to have been one of my fellows doing this blame. Oh yeah. And so as you go down. This girl's got. Something that is very suspicious for a recurrent tracheoesophageal fistula. And then it's a question of how can you prove it. You've seen us trying to probe. Potential fistula sites. And so what we're going to do here is a different technique. We're going to put an endotracheal tube with a cuff into the esophagus. And put 30 centimeters of water pressure of air in the esophagus. You have to remember to suck out the stomach afterwards. But we're putting in some positive pressure of air. And you should look in this region, and as we up the pressure, you can see air starting to blow out the hole. So you know there's a fistula there. No doubt that's a fistula, and that's a useful technique for trying to track down a hard to find fistula. Do you have to, if they have a G tube, do you have to clamp the G tube? Um, usually you just, you get enough positive pressure. In fact, most of the time we're venting the G tube when we do this, that's. And so again with this girl. We've got enough of a tract, we thought it would be worth trying to do an endoscopic repair, and it's always worth warning that, You might end up having to do this more than once. And again, with this girl, indeed, we did have to do it more than once. So this is our first attempt, very similar techniques. We're going to use a bugby cautery, demucosalise the tract, put in a tiny bit of fiber and glue. And this is again just making sure we put something in the esophagus to guard it. So this is a telescope with an endotracheal tube over it. We advance the endotracheal tube, that's it going down. And that way we know that we're past the fistula site, we know that we're not going to burn the wrong side of the esophagus. And then using a bugby for a proximal fistula, we typically would like to intubate with a cuff tube past the hole, so the cuff holds the hole occluded. And again, in some kids you can't do that if it's on Carina. You're out of luck, that's not gonna work. And so Again, we're trying to be sure that we don't go tell the patients is the usual for a standard recurrent TEF is the usual number of treatments to get it to close endoscopically. Um, I would say we average 2. Some kids will hit it in 1, some kids it'll take 3 or 4, but typically it's probably 2, and it's all about setting expectations. What's your success rate? Uh, running about 80%, not 100%. I guess that begs the question of at what point do you then decide that it's not going to close, right? I think if you've hit 3 or 4, you just give up and discuss. Typically as we all sit there in the operating room and watch this happen after the 3rd or 4th time, it's time to do something else. And the one thing that Influences that is occasionally there are very motivating reasons to not go back in a child's chest, and that would, uh, you know, suggest you might want to do it more than once, but you really go at it. You don't give it a fright. You really, yeah, it's, it's, you know, you're trying to send it a message. I mean, this is interesting. I mean, you definitely do much more than I do, which is great to watch. The other thing is I particularly try to get some of the edges out the sides because as they scar in, that'll narrow the whole mouth, and if you have to go back, it's easier. And then this is. Intubating so the tip of the tube doesn't hit the pouch, but gets close to Carina so that the cuff's in the right place, we're sort of advancing an endotracheal tube over a flexible telescope. You can see it's one of the ENT flexible telescopes because the optics are just simply awful. Doctor Wood has the good scopes. Well, Doctor Wood's also got some of the pepper and salt scopes as well, but we won't go into that right now. So there's a question from Russ Jennings, uh, do you, do you worry about airway esophagus fire when you're using the bug bee? Uh, we make sure that the, uh, the insulflated oxygen's running less than 30%. And so if you're running over 30%, you've always got a risk. We tend to run 30% and under, and I think the relative risk of an airway fire is a whole lot less. And if necessary, you can tolerate a minute or two of lower oxygen saturation on the patient, yeah, and then get them right back up again. And so As I just mentioned, this took 2 attempts, and this is the 2nd attempt, and this kid didn't enjoy being intubated for a few days, and we didn't want to intubate them again. You can see the little bit of granulation tissue there, but unfortunately, there's still a hole. And so rather than try and put an endotracheal tube over it, We again cauterized it. And what we did differently this time, after we cauterize it, I'll move this on a bit. Is that we actually did a little injection of an inert material into the wall beside. The tracheoesophageal fistula, and this is actually using something called radius voice gel, it's what people inject into vocal cords, and it only lasts for a few weeks. And so we're putting a little injection in the back wall, a little injection in the front wall. We haven't done this very often, but it's a way of obliterating that potential space, so the raw is stuck against raw. And It's just technically a little difficult to do, getting a very long needle all the way down there, slightly difficult, and the whole system comes with its own sort of injection device, so you don't have many options. And this is the same girl. Later on, so again, the concept is to demucosalise and have raw stuck against raw so it sticks without stuff flowing through holding it open, so it's like defflux, correct, and as you can see, it's just gone, there's there's just no evidence that, There was really even a hole there, and so let's go back to that appropriate, yeah, that's. I think that's about, I think it was around there somewhere, but there's, you can't even see where it was when this works well. So shall we move into something that was a little more challenging? So this young man, Val, a type C with a gap repaired at birth, and is sent to us, he's about 9 months old, I think. He's had 8 repairs, uh, 6 have been endoscopic, he's had a couple of opens. No one's very keen to go back in his chest. And He's got quite a complex problem, so he's obviously aspirating quite a bit. And when you start suctioning all of this out, You've got this interesting, complicated hole. That's going down esophagus. And the interesting thing is that the esophagus ends there. And so this is now putting a rigid scope down the esophagus. You can see we've got a pretty well that was coordinated. I mean, let me try that again. Where was I? Oh, I've gone, I've jumped. Sorry. Let me try that again, my apologies. I'll take it to there and I'm gonna pause it. So this is. Looking through the, this is the esophageal stenosis and as you look through it, you look into the trachea. So the proximal esophagus ends in the trachea. There's a 1 centimeter gap, and then there's a little hole that's the distal esophagus. So effectively, you've got a type DTEF that's sort of acquired and sort of not. And so, again, let me try and show you that. So you go through this little hole, so esophageal stenosis through it, and now you've got that little hole goes to the rest of the esophagus and this is trachea. And so a bit of a difficult one to fix. So there's trachea with bronchi, and as you come back. That's the rest of the esophagus, so anything that goes into the distal esophagus has to transverse trachea to get there. And so What we did for that was a slide tracheoplasty. And for these big complex holes, that can be quite a useful technique. And we actually used part of the trachea to repair. That defect. And the, um, and in this case, while it was fairly low on the trachea, we were able to do it through the neck. It was a bit lower than I was planning and I did have to split the manubrium, but, you know, in a baby, you can use a 10 blade to do that. And, um, this is the postoperative result. The child still has a bit of an oesophageal stenosis, which is going to need dilation. But you've eliminated the hole, you can see that's across your suture line and the, The lovely thing about a slight tracheoplasty is it just eliminates the hole, and I appreciate that our audience are primarily pediatric surgeons, and so we're going to deliberately talk about things that are less routine for pediatric surgeons, so endoscopic repair, slide tracheoplasty, for example. This is a great thing, as you said, this is a child who's had 6 or 8 or whatever it was, thoracotomies and going back through the chest. 6 or 8 failed thoracotomies and so uh it's a nice option to think of a different approach through a different, uh, different access and. Is, I think, a very useful tool. And this is a cartoon of a sly tracheoplasty. This is actually for complete tracheal rings. And, um, and this is where we developed the idea because we've done a lot of kids with tracheal rings. And I got to tell you, it's so much easier doing this with a cartoon. And then we'll show the complementary photos for dealing with the tracheoesophageal fistula with this technique. And so I'll move forward. So the technique that we use is to transect the trachea above the fistula. Bevel it, so you then transected below the fistula. You've now got a wing of trachea on either side of the fistula, and you turn that in to repair the esophagus and the disconnected trachea above and below, you reconnect with the suture line typically no longer contiguous with the esophageal hole because you've shortened the trachea a wee bit, you slide it up. And uh I've got some, a little bit of video of this coming up later on. But it's quite a nice technique if you've got a very difficult hole or a very big hole, because you're actually using trachea to repair the esophagus. And so then you put a piece of uh periosteum in between. Typically I use the back of the sternum. Exactly. Typically we actually use sternal periosteum because it's in the field. If you're doing a neck incision or a chest incision, you can go and get a lot of sternal periosteum, and that stuff is like Kevlar. It's bulletproof. It's lots of it. It's almost impossible to put stitches through it, so you just lay it between the layers of your repair. And that is really strong and resilient stuff. And so again, this will be another example of a slight tracheoplasty, other end of the trachea. 16 year old girl, she's had a complex subglottic stenosis, she had a T tube placed and it drilled a hole into her esophagus at the lower border of cricoid. She went on to have a transtracheal repair, which failed. She had a strap muscle placed through it, that failed. She had a lateral pharyngotomy, which failed, and this is what we were sent. Subglottic stenosis. And a bit of a hole. You could actually stick your thumb through that hole. And she's had 3 failed open repairs of it already. And this is after a slide tracheoplasty, which fixed the hole and the subglottic stenosis. And clearly, I left a couple of stitches behind, but if you ignore the stitches, um, we actually took a trach out. That day where the video was taken, and she's now 5 years out and it's done fine. But it gives you an idea of what can be done. And so Not everything always works perfectly, as you know, particularly with these complex esophageal cases. So it's always worth talking about your failures. And so this is one of our failures, a button battery ingestion. So this is what we got sent. He swallowed a button battery. And he's got a bit of a hole. That's the nasogastric tube you can see on the left. And as holes go, it's not small. And this is trying to Get things exposed so we can. Do a slight tracheoplasty, again, this is, you've got to mark the top and the bottom of the hole, we're doing this through the neck, so we're just estimating where we're going to need to transect the airway. Transect the trachea that particular thing brings up, uh, I think, another what I have found to be very helpful technique, which is having a scope in while you're doing and Phil has helped me in the OR. Bob has helped me in the OR. Mike has helped me in the OR. When you can't see the loom, it's very hard. Helpful to have something looking at the luminal side when you're dealing with these strictures and fistulas so that you can just like you saw, stick a needle or something in to mark it and then you know exactly where you're going to be, uh, you need to open because it's not always clear looking at it from the outside. And again, as you can see on this, uh, we tend to use a running suture technique, and uh just, uh, it's like a vessel repair, so it's really just a single 40 PDS over and over and over, one knot holds the whole repair together. And unfortunately in this kid. This is what happened. So he did really well for a week, and then he didn't do so well. Oh, sorry, this is at a week, and this is when he did do well, so he was looking good at a week. So that looks OK following a slight tracheoplasty. I need to put on the video of 3 days later. So he's now got a lot of saliva in his airway. And he's got air in his neck, which is what prompted us to have a look. And as you suction out all the saliva. That's really not something you want to see. And as you get closer, Clearly you've dehissed. Is that an argument against using a single running suture? I think we actually, I think worked out what happened with this child. And Button batteries. It's interesting they can keep doing damage for a surprisingly long time. This was like 6 weeks out. It was still an evolution. It was still an evolution, and what happened, we believe, is that the esophagus started leaking. And bathed the tracheal suture line and saliva, which then started to give. And that we ended up with a secondary problem. Um, and I'm curious to see how you're gonna deal with this now. Or do you not get into it? Oh, of course we get into it. Is that where the case ends? Tune in next week. So basically a revision slide and The kid ended up needing to be trached for a while, but we did another slide, and that actually, how do you do another slide, um, you've got to freshen up the edges, so it's a damn sight more difficult than the first one, but you take more, you have to retake more trachea then, uh, usually you can just repair the trachea, and the interesting thing with this. I if you look at our series of, we've done about 12 kids with a tracheoesophageal fistulas, we've done slight tracheoplasties, and a lot of them have been really quite genuinely challenging ones to do, and we've had two failures. Both of them were button batteries. How many kids in that series had button batteries? 2, and both of them dehissed, and one of them was 3 months out. And both of them, we redid the slide acutely, and both of them did fine long term. But Again, you can't really apply statistics when, you know, but We've had 2 failures out of 1 dozen cases, and both of them were button batteries, and we've only done 2 button battery kits. And maybe that's more than coincidence, but it's just, you know, it's, it's an interesting observation. Could you put a stent in to temporize it and then do the operation. You know, I, the second one we deliberately left a long time because of the first one, and it's still, it's still, but couldn't you just take, do you just take additional tissue, extend the slide to try to get closer to normal tissue. But the really interesting one is the second one is that the esophagus was fine, it was just the trachea that let go. And I don't know whether it was a technical thing on our side or whether it was something to do with the button battery, but it was odd and the esophageal repair was just fine, was fine, and the kid. You know, we just re-repaired it, pulled the tube out two days later, and he did just fine, but It's just as an interesting observation, the button battery kids I treat with a hell of a lot of respect at this point in time. And so, you know, we button batteries are bad, and you can redo the surgery if it goes apart. And I, and I must admit button batteries are bad. We've seen some really horrific things with button batteries. And so, uh, does any of the rest of the panel have experience with button batteries? You've done at least one colonic interposition, haven't you? Yeah, yeah, we have, and I think our experience is what you're saying is that you think that you're going to get a straightforward repair and it falls apart, and we have been Uh, we've had our personal experience with that, but we have also been on the receiving end of of other people who have repaired these, and they, they just don't do well. Button batteries are bad. They are, uh, the tissue, I think you're right, the tissue damage extends beyond what you can appreciate with the naked eye, and the progression of it probably extends beyond what you would think is the normal time frame, so that by the time, or when you fix it, there's ongoing disease. I think to be proactive about it in the pediatric GI side of things to try to prevent kids from even getting to that point, um, the institutional protocol is to get them out within 2 hours of identification. So it's considered a medical emergency to get them out. It should be. It is truly a medical emergency. You've got to get them out as fast as you can, and, uh, the, uh, American Society of Pediatric Otolaryngology. Is actually got a task force on button batteries, which are trying to introduce legislation so that all button batteries will have an etching on them of a skull and crossbones, so that if you take an X-ray, you'll know it's not a coin, because the worst ones we see are the ones where someone didn't realize it was a button battery. And sat them overnight till they had an elective coin removal, at which point there's a lot of damage done. We actually have a patient who's here today who is the child who had the colon in her position, and that child's mother has started a very aggressive public service. Campaign basically about button batteries and how ubiquitous they are. They're in greeting cards. They're, they're everywhere and they're dangerous. And a couple of important points is that when they, I learned this, the American College of Surgeons had a session this past month or whatever on this button batteries, and when they're dead, they're still not dead. They're still going. They got about 2 volts, yeah. And that's number 1. So people think it's dead. I can leave it out. Second thing is they were talking about, I always thought you had to have a lateral X-ray to be able to tell between a button battery and a coin, but actually they were showing that if you have an AP view, there's a rim, yeah, yeah, you can see the rim. Phil, if you take one out, what's the, you said the protocol is to take it out within 2 hours. You don't always know when they ingested it. What's your follow-up? Do they, do you re-scope them always? Do you re-scope them only if they're symptomatic? How often, yeah, the, if they, if it was a witnessed ingestion and they're asymptomatic and it comes out within a couple of hours and the mucosa looks pretty good, the likelihood is that they'll do pretty well. But as you said, the epithelial injury continues for quite a while. We've had late deaths here from aortoesophageal fistulas, um, following unwitnessed ingestions that weren't all that terribly prolonged, um, so. We don't always reinvestigate the epithelium, but anything that was unwitnessed or prolonged, um, then we're very careful about, uh, especially if the, um, battery was known to be right at the aortoesophageal junction. If they're somewhere else, I'm a little less compulsive about immediately looking, but, um, we're very careful about following them for the next 6 weeks or so. Re-scope them in 24 hours in a week or not at all in case they, yeah, we don't routinely re-scope them in that period of time. I think part of the issue is that, you know, the epithelium, we're limited by what we can see, which is just the surface epithelium. The real question is what's the depth of injury. So having a CT scan or a CT angio to look at the aorta may be as much, give you as much information. About the risk to the child of a sudden death as anything else, so we've been proactive about doing that on those occasions where it's where there's clinical concern. I don't know the data, but I can't tell you how, what the sensitivity is for a CT angio to pick up the kind of damage that you need to know if your patient's going to get into trouble. So we've had a lot of discussions about doing ultrasound or some other means of trying to decide is there risk. Um, and it's just not been, you're right, there's not data-driven evidence-based stuff, so you fly by the seat of your pants and do what seems safe for the child. And there are at least 3 modalities of risk. So the length of time the batteries in there, whether it's a new or a dead battery, even the dead batteries are bad, but they're not as bad as the new ones. And the style of batteries, so the big round flat 3 volt batteries are by far the most potentially damaging. The little ones that are a bit fatter, not so high a risk. And so the style of battery matters as well. Um, interestingly, they just published a case report in Australia of the first survivor of anoresophageal fistula from a button battery. And I was going to make the comment that once you get that problem, it's usually that's not really fixable or it's very hard to fix. Things tend to go poorly. Uh, well, right, but if it's suspected, um, The suspected problem, could you put in a stent? You could, but you know, vascular stent, a lot of these are little kids and the stents aren't made for little kids. Aortic stents are not built for 2 year olds. We put in a, I put in, we had a patient that came in with a trachealominate fistula, and we treated that with a, with a stent, um, which stopped the bleeding, but I don't know if you could do the same. I know this is totally unrelated. Do you go after the batteries if they've gone into the stomach? Yes, we do. We do. We stopped doing that because of some study that showed a, yeah, yeah, I mean, the studies are, are one thing, but there's the problem is that if you don't take them out and they don't leave the stomach and they sit in one spot, they do create considerable injury, especially if it's in the distal part of the stomach in the interim where there's going to be scarring or stenosis of the gastric outlet, so. Um, our, our protocol is to take them out. We're not quite as, uh, aggressive about doing it within 2 hours as we are for an esophageal one, but if there's a known battery in the stomach, we try to get it before it, before it's, uh, into the duodenum and out of reach. So let's move on and on that cheery topic. We'll move on to another case. And again, this is a Child where it's really just showing some of the different options for how to repair a tracheoesophageal fistula. And so this is a boy who's had a tracheoesophageal fistula repaired, he was a type C with a short gap, that went fine. Um, he ended up a few weeks later, reconnecting and ended up getting an endoscopic revision, and we've already seen a few of those. That was fine. And then he kept aspirating. And we found that he had a second proximal H type that we hadn't seen the first few broncs. And again, they can be very easy to miss. And This is showing how to do a transtracheal repair. So this was a pretty high hole, so easy to get through through the neck. That's the larynx there, just putting a forcep in the laryngeal notch, so his head's up the top. This is his sternum down here, we've got his trachea isolated here. And again, this would be a very hard thing to do from a thoracic approach, from an anterior neck approach, you can do it with a lateral pharyngotomy, but the exposure is not very good and your relative risk of damaging a recurrent laryngeal nerve is not trivial. And so transtracheal, you really can't damage a recurrent laryngeal nerve unless you truly have a lot of enthusiasm. And so we're doing an initial incision in the airway up to cricoid cartilage, so an anterior tracheotomy. We've got a small trach tube and a small hole in the lower trachea, so a temporary tracheostomy just to manage the airway during the case. And now this is looking in the cut edges of the trachea on either side. And that's just putting a forcep into the hole. So you're looking straight down on it, we've used a telescope earlier to mark where the hole was, put a needle in the airway, and that's the forcep going into the fistula. And again forcep in fistula. And the trick here is that they're always quite small. And so the easiest way of repairing them through the trachea is to start off making them a little bit bigger. And so we found it, and now what we're going to do is split it up and down. And then try and separate the trachea from the esophageal mucosa and go around the edges with a little pair of super sharp scissors and create layers. And so this is almost the same technique we use for doing a laryngeal cleft repair. And so we've separated the layers, we've got an oesophageal layer, we've got a tracheal layer. And we're now going, you can see the esophageal bougie saying hello there. And we're now going to Sew up the esophageal layer, and this is putting in a little bit of, uh, periosteum that we stole off the front of the sternum, lots of it, easy to get, very strong, trying to suture it is futile, it just doesn't want to play, but you can just lay it down between the two layers, so we repair the esophagus with interrupted sutures, knots in the lumen of the esophagus, put in the interposition graft. Like, so And then we're going to sew up the tracheal side. So you've effectively got a three layer closure, you've got an esophageal closure. You've got an interposition graft, you've got a tracheal closure, and again, although they slightly obstruct the airway, I'd prefer to have the knots in the lumen of the trachea, and that way you've not got knots more likely to refiistularize between the layers of your repair. And this is the postoperative view, and as you can see, the knots are very much in the lumen. And of course all of these kids have some degree of malaysia. And that's the old previous tracheoesophageal fistula site down there, interestingly. And so The transtracheal repair. Isn't all that routine, but for a high fistula, it's really not a bad option. You actually get really nice exposure, you can do a layered repair. And in some senses, there's less risk than doing a slight tracheoplasty. A slight tracheoplasty is just a tremendously fun operation, but if you have a complication, it tends to be a worse one. With a transtracheal repair of a tracheoesophageal fistula, the primary complication is that it might re-fiistularize. If you have a complication with a slight tracheoplasty, the risk is it might dehiss, which is a much bigger deal. The other interesting thing about doing a transtracheal tracheoesophageal fistula repair is in many senses, it's a two-dimensional operation. The surgeon counts, but as with many things, not as much as you might like to believe. And, uh, most operations, you know, 5 years' time, the surgeon really doesn't matter. If I take someone's tonsils out or you take someone's appendix out in 5 years' time, it really doesn't matter. There's a small number of operations where the surgeon. Does matter, typically 3 dimensional operations, and so we see that the surgeon matters with aoropexies, with fundoplications, Interestingly, the slide tracheoplasty appears to be a learning curve surgeon dependent operation, which was a little distressing as we didn't realize that initially and then started having to do a few revision cases. And so, Todd, are you a believer that some operations are more surgeon dependent than others? Yes. Should we even go there? I mean, that's a. But you know, this is exactly what we're talking about here and that's why I've been pulling the audience because what we talk about here isn't necessarily something that everybody would be attempting, um. I wanted to, since you just called on me, I want to take a second here to go over some things. I've been pulling the audience. Oh, good. So here's some questions. Do you routinely do pre-op wrong for TEF? 67% said yes. 33% no. Do you use endoscopic treatment for TEF? 62% no. 37% yes. Have you ever used a slide tracheoplasty? 100% no. Which is what I was trying to get to your question, OK, I, I, I can see that. And then I asked, would you ever go after 1 centimeter disc battery in the stomach? We're at 50/50. So, uh, OK, OK, that's interesting. As a pulmonologist, let me just make a comment about doing bronchoscopy. Take a biblical approach, seek and ye shall find. If you do not look for it, you cannot find it. WNL does not mean within normal limits. It means we never look and we see an enormous number of patients here where nobody's ever bothered to look and we find incredible pathology because we look, yeah, right, yeah. And again, it's, uh, there's an, uh, increasing pressure to never send anyone outside your region. And I quite understand the sort of healthcare economic approach in that sense. But there's a small number of things where occasionally it is a consideration. And, um, So what we're going to do is now before you move on, can I just this H-type fistula, since our training, presumably yours and mine as pediatric surgeons, is that this is an operation you do. You know, through the, through the neck and not through the trachea. And so, you know, for me, whacking a hole in the trachea so that you can see the back wall is pretty traumatic, whereas if you dissect out the fistula and just ligate the fistula, that's significantly less traumatic, unless, of course, you happen to bag the recurrent nerve while you're doing that. So. Is this an approach that we should use for primary repairs of H-type fistulas, or, you know, if you, if we find a um a 3 week old who's choking with every feed and you do the studies and you find the typical H, which really is an H, it's more of an N-type fistula, uh, should that be, should the primary approach be endoscopic, transtracheal, or transcutaneous? And there's one more option. Which is, which is transthoracic. So Rothenberg does this through the chest thoracoscopically, the age types. Because he has long scopes, or I think it's, and, and I think it makes the same argument that you said. My argument is this is so easy to do through the neck, by passing a wire through it. You pull it up and you've got it right there. You look on it. It's such a tiny, easy little operation, and I think the transtracheal or the transthoracic make an easy operation into a more complicated operation. And again, there's, you know, there's more than one way to skin the cat, and it's often a case of, uh, gatekeepers. You know, who it comes to first tends to do what they normally do. And so the transtracheal approach, we've got enormous experience with because we do it for all the laryngeal clefts. And so just a TEF and most of the TEFs we do are people's failed cleft repairs. So they're more scarred and more difficult. And so we're very familiar doing it with that technique. Now, interestingly, the case that we just looked at. Was a twin team. um, Tom Ine and I did it together and, um, took one of the pe surgery fellows from a few years ago through the case as almost a teaching exercise. I think it's awesome. I, I, I think it's a great technique, especially if it's been previously operated upon because you're again, you're going through fresh planes and that's a huge deal. And, but like you said, I mean, if you're Steve Rothenberg and you're incredibly skilled with thoracoscopy, then you can fix it anyway. You can fix it through the chest. That's probably the, the most straightforward thing for him to do. It's like you said, it depends on whose door you walk through, but, but particularly. In redo cases, I just think it's been, it's interesting having had the training I've had to say, oh, here's a totally different approach to potentially take for a primary repair of an H-type. Exactly. And again, it's also partly depends on You know, whereabouts it is. So, you know, lower third of trachea, there's no doubt that I shouldn't be doing it most of the time. Upper third, unless there's extenuating circumstances, upper third of trachea, we're very facile on the neck, the middle third is the no man's land at the thoracic inlet. And it's really what you're comfortable with, and how the relationship you have with your colleagues. And so there are some kids that We send to you to do. There are some kids you send to us to do. We do them together typical approach. Yes. So, uh, there was a comment from the audience. Uh, Adrian, uh, Kurnow has done, uh, thoracoscopic repair of these age types. He said it was quite, quite amenable to a vats. Um, Adrian, I'd be curious, um, Mark, I don't know if we have a phone line open that, that we can call in if we could, if we have a number. Uh, I wonder if. All right, we'll, we'll see if we can set up, uh, since we don't have any virtual faculty, we didn't open up the phone lines, but we could probably turn it on. Um, if someone wants to call in and tell us about their experience, um, I'd like to hear about, um, Adrian's experience doing the thoracoscopically. It just seems very tough to me. The people that have done it have actually said it's quite easy, um. Uh, and they want to avoid any, uh, visible scar on the neck where this is gonna be hidden. So the two other comments that I think are probably relevant is a lot of the H types are relatively short tracks straight into the from the trachea to the esophagus, and they don't do nearly as well with an endoscopic fix, generally speaking. The long skinny tract from proximal to distal is the ideal endoscopic candidate. Something that's short and fat and wide. Doesn't tend to do well with an endoscopic repair. You can't get the layers squashed against each other all that well. Although I'll show you an alternative in the next case. Um, the other thing that we sometimes see, and I've got an example of this later on, is that when you're trying to repair a high tracheoesophageal fistula from a thoracic approach, The temptation is to ligate the fistula on the esophageal side, and you can end up with a very big tracheal pouch, tracheal diverticulum. And some of these kids with a big pouch, they're pretty malasi. And if you're malasi, you're going to get a trach. And if you've got a trach, it's gonna go in the pouch. And we've got a nice example coming up of one of those and a potential solution. And so occasionally, getting high in the neck from a thoracic approach. Can cause a secondary unanticipated problem. You've ligated the fistula just fine, but you may have quite a big pouch. And so while we're waiting to see if we can get someone on the phone, um, Sure we we can't do it, we can't do it. OK, then, uh, let's have a look at our next case because it is kind of an alternative. And so this is a boy. Who's got opus free airs, and so he's had a laryngeal cleft and um. He had that repaired when he was 1 year old, he had a recurrence when he was 6, and, This is a view of when he's 6 with his recurrence, he's got saliva in his airway, pus in his lungs. And he's got a hole. Don't think you need to probe that. I think you can believe, well, we're in esophagus now, we really don't need to probe that. And so we did an open three layered repair of that hole. And Oops, next slide, sorry. And so this is in post-op. And the annoying thing, so this is the cuff of an endotracheal tube going up and down his esophagus, and you can see the bubbling, he's got a pinhole. And this is a, it's if you put a cuff in the tracheal tube in the esophagus, it is kind of a cool video. Do you like this? And um it's a good way of either blowing air through the hole if you have a proximal, you know exactly where the cuff is, because you can see where the cuff is, and or sometimes the cuff as it pulls back, will just blow air and saliva through the hole. So we've got a very small hole. In a kit that we've just opened and repaired. So it's a failure. It's a small failure. And This is not going to do well endoscopically because it's a straight in hole with thin layers on either side of it. And so we decided we'd repair it endoscopically. And so This is not a good candidate, so what we did. Was we used a bugby, and we've had to put it almost at a right angle, because this is a straight in hole, you're holding that with a grasp. I'm holding it with a grasper and just a Hopkins Rod telescope in my other hand. So I'm demucosalising it a bit. And that's not the difficult bit. The difficult bit is how on earth are we going to get raw against raw for it to stick. And I'm going to show you what I did, and I hope to never do it again because it was so damn difficult. I stitched it. Honestly, this is the sort of thing where You really need to work out what you did bad in a previous life. It's just painful. Um, throwing endoscopic stitches in the trachea is remarkably humbling. And I will ask Dan shortly. He's come up with an alternative for me. I wish he'd mentioned this six years ago when I did this, kid. Well, I was thinking about it afterwards actually. It occurred to me that the hardest part of this is tying the knot. Oh my goodness, is to use a night knoll. Now the problem is it's permanent. Yeah, and so is that a problem if it's permanent? I wouldn't want it there. I wouldn't want it there, wouldn't, but there is, you could theoretically use endoscopic clips down the clip applier, the little laparos because we have those clips that come in a long laparoscopic thing, but, and we had started they're micro clips doing that with um. Laryngeal cleft repairs where we throw endoscopic sutures and actually just use metal clips with the sutures coming in from the esophageal side just to hold them. The kid swallows that sometime when the PDS dissolves. On the esophageal side, on the esophageal side. So this whole thing of raw and raw, you know, uh, this is my research, uh, in the lab. That's right, this is hernia repairs is on hernias, and that the truth is all that matters is you need raw on raw. That's the truth. And, and actually, uh, you know, we've been finding that thoracoscopic diaphragmatic hernia repairs may have a higher recurrence rate than open, and it may be because we're not causing enough raw on raw. It's not traumatic enough, right? It's not dramatic enough. And the, the, the, and the last thing is, so you can predict which of your fellows will be very have occurrences, uh, but I worry, I wonder if your fiber and glue that you're putting down prevents the position you're saying. Well, again, as I said, we started playing around with injecting an inert substance to basically occlude the track rather than something in the track. So again, I. Have too limited an experience to know if this is a good idea or a bad idea. But I think you're right to want to try to get those edges together, which is the point of the endotracheal tube with the balloon at that site to, which makes sense, that makes a lot of sense to try to get that position. And so the take-home message of this slide is if someone tells you to try and stitch something up in the trachea endoscopically, say no. And this is him. Post-operatively, you can see the remnant of my suture, but basically, he's closed and has been for years now, but uh, You know, I, I found actually it worked, it's very painful. Um, you can actually lubricate the needle with a copious amount of swear words. I found that really helpful. So, Shall we go on and talk about a young lady who's a seven year old girl, Down syndrome, she's had a type C tracheoesophageal fistula repaired on day of life 1. And she's had a few pneumonias in the last year, she had 20. And she's had a lot of bronchoscopies, a series of swallow studies. Because she's Down syndrome, she's not the most cooperative girl for swallow studies. They're always difficult to interpret. And really one of the take home messages here. I if it barks like a dog and it wags its tail, it's probably a dog. I mean, this is a girl who's aspirating. And has had a huge number of pneumonias. She comes to us almost a respiratory cripple. And yet No one's gone there. And You've got to have an index of suspicion. So that's her old tracheoesophageal fistula site there. This is with a flexible bronchoscopy. This is Bob Wood. And so the initial flexible bronchoscopy. You see a second area. That doesn't look normal. Again, this girl's had several bronchoscopies. They always comment about the saliva in her trachea. Sadly, they never bother suctioning it away to see what's underneath it or blowing it away, which is what I did here. And she's got an H-type tracheoesophageal fistula that's been missed for 7 years, and her lungs are suboptimal. Now I want to show you. The next bronc that Bob also did on the same day, just as a technique. And so we sometimes call this a Sabode maneuver, but as you go through the Vocal cords. The usual way with a flex bronc. The trick is potentially to look upside down, and I'll let you speak to this, Bob, because there are things you can see upside down easier than you can see right way up. Well, the only point is that the degree of angulation at the tip of the bronchoscope is much greater in that direction than it is in the opposite direction. And so you can see Bob just spun over there. He's looking at the old TEF site coming backwards upside down. And I insufflate with oxygen through the suction channel at about 2 L per minute. So when I depress the suction valve, I'm insufflating with oxygen that spreads the tissue apart, doesn't hurt the respirations either. And it gives you a better view. Mm And there you are looking right into the esophagus. Is that routine? Do you do that on every, is that just a routine part of your bronchoscopic exam to rotate the scope? If I am suspecting something in the posterior wall, yes. Now, if you have something high in the cervical trachea, it's incredibly easy to miss it with a flexible scope. Yes, because as you come through the nose, you have to flex the tip of the scope forward to reach the glottis, and then as you go through the glottis, you have to now extend the tip of the scope, like going over a riding a wave and with a surfboard, and it's very easy to miss stuff as you go in. It's a lot easier to see the cervical trachea and the subglottis while slowly withdrawing the scope than it is while advancing the scope on the way in. So we just had a question from the audience, um, what approach did you use for the three layer repair? And usually for a three-layer repair, we tend to do a transtracheal approach. Um, if you do a slight tracheoplasty, you can also do a 3 layered repair. You use trachea to repair the esophagus, you put in an interposition graft. And you then repair the trachea over the top of it, so a slide tracheoplasty is also a three layered repair, but usually we're doing a, a transtracheal repair separating the layers, and this is very similar to the technique we use for a laryngeal cleft repair. And so we'll move on. This is the same girl's initial microlaryngoscopy and bronchoscopy. Again, we're actively checking to see if she's got a laryngeal cleft. Again, I would emphasize, if you don't actively look for it, you've got a risk of missing it. Then we're going through the cords. And You can see that area that's suspicious. And this is a little reminder of the film Alien. And suddenly something is going to burst out. And oh yep, there's a fistula there. And that's just putting the little alligator forcep down the esophagus, and it's a very good blunt probe. And this is, uh, I believe, Phil in action and the same girl. Very difficult to see fistulas from the esophageal side. She's also just happens to have a retroesophageal subclavian artery just to make life more fun. And I believe you know that how? Oh, you can see it. I'll go, I'll go by seeing it endoscopically. Uh, where, where, where was that thing? I know, I saw that thing. Oh there it is. Oh, that's just there. There is. That's, that's the retroesophageal subclavian artery just there. OK, I see the biopsy. They're often remarkably close to anastomosis for after TEFs. I see them that way a lot. Yes. And again, we bore it in mind when we did this girl's surgery. And so, uh. But again, So these are, this is endoscopically, it's again tricky because you've got. A little bit of saliva in the way you've got a limited um ability to maneuver the scope in a relatively small space and then being able to see just below the esophageal inlet and maneuver the scope. The scope doesn't have a knuckle, it has a long bending section, so you don't get as much on phos view as you'd like sometimes, but you can actually see the opening of the fistula here. Sometimes we use a small flexible bronchoscope in the esophagus and we have a very small radius of curvature, so it could be possible to do a 180 degree retroflex with a 2.8 millimeter bronchoscope if you needed to. See, I, you know, I keep hearing the, the bronch, the flexible bronchoscopes. The problem is, uh, uh, I mean, it's such a great tool, but I'm so spoiled with such good optics that I'm never, I can never, you're used to the optics you see on those, but the optics are not very good compared to, you're thinking of the older fiber optics. Yes, he's not. What is he thinking of? We're gonna talk about you here for a second. No, no, Mike, that's not entirely correct, um. We do not yet have a good pediatric sized video scope with a distal chip. Uh, there's one that has just come on the market. I prototyped it for several years, and unfortunately, the radius of curvature, because of the length of the chip is too great to be a useful scope in kids younger than about age 4 years. It gives spectacular optical performance. Uh, it would rival that of the, the, well, it would rival that of the, of the, the Hopkins rod, but it's, it's limited only by the resolution of the video camera. A true video scope, I mean, a true, uh, uh, flexible fibroscope has anywhere from 5 to 15,000 pixels. Now, if you look at a still image, it looks very pixelated. But in real time your eye glosses over those things and you see much sharper detail in real life than you do otherwise. Um, but a trained eye, this is interesting, a trained eye, you're used to looking through that scope. You can see much better than when, when I'm not used to an image with that pixelation, I might not see as well as you. So you need to get more practice. I need to be better, right? I get that. But it's interesting because they're going back to the whole thing of general surgeons using other people's instruments every time I try to use the fiber optic scope. I can see, but I'm never, it's not what I'm used to. That's why you have a good pulmonologist working with you. You got that right. It is impressive though, the images that That you get, it is very clear with the chip on a stick. Well, no, even with the, with the bronchoscope, you know, with the fibroscope, with the fibroscope, fibroscope, yeah, yeah. So, We'll jump into what we did for this girl, which was a slide tracheoplasty through her neck just because there's some nice video. You can actually see the hole, just there, trachea, and we're separating the trachea just proximal to, The fistula were then separated distal to the fistula. And of course, what's relevant in this girl is she's got a retroesophageal subclavian artery, which means she's got a non-recurrent right recurrent laryngeal nerve, and so you just have to be aware that you don't get lost and ding it because it's not where it's meant to be. And similarly, um, you've also, as you're dissecting the trachea, the artery is really close and it just pays to remember that. And so this is her postoperatively. Now, the interesting thing with this girl is this was, I think, 2 months after her repair, symptomatically, she's doing dramatically better and there's certainly no hole there. But when Bob did a flex scope on her, she's still got a lot of pus in her lungs because 7 years of aspirating, she's still got bronchiectasis. So now her problem is bottom up, not top down. So she's still going to need months of care with a, a vibrating vest, a lot of chest physiotherapy, and her care didn't stop with the repair. So her mother perceives her as hugely better, a different child, and so she stopped doing her her airway clearance techniques. Oops, right. And when we actually bronk her, she still looks quite mucky. Yes. So This is an interesting story. This is a boy who I first met as a neonate. And he was extremely Disabled Aspirating, had a trach, severe tracheomalacia, severe pectus. Um, and was severe enough that he's one of the relatively few children. I had a discussion with the parents about, uh, potentially end of life care. Would you consider not treating a pneumonia, that sort of discussion before I trached them. And they wanted to do everything for their son that they could, which is fair enough. And so we traced him and he's had a lot of issues over a lot of years. And at age 12. Um, in fact, at age 10. Uh, he was fitted with a hearing aid. Now, this is a boy. Whose functional capabilities. Uh, not quite nil, but they run it really pretty close. And so someone fitted him with a hearing aid. And he ate the hearing aid. And they lost the hearing aid mold when he was 12, went to the emergency room. Mom said, we can't find the hearing aid mold, and he's been coughing and gagging a lot. And so they took a chest X-ray and said there's nothing there, go home. Now hearing aid moles are radio translucent, and he came back three months later with the hearing aid mold in both his left bronchus and his esophagus at the same time. And uh Mm This Was the result that was taken out. And He was left with a rather large hole, and it's very hard to see because of the malaysia, and so I'm using an endotracheal tube as a transparent bronchoscope. And so this is an endotracheal tube over my Hopkins Rod telescope. And that's the hole there with esophageal mucosa pooching out of it. And I can spin the endotracheal tube, I can use the Murphy eye as a tool to help pooch things in. And that's The sort of sized hole I could probably stick a finger through. So it's a decent sized hole in his left bronchus. And he's a boy who's extremely disabled with a severe pectus deformity. And we were ended up in the position where we really didn't have an option but to repair it. And so we actually did a slide tracheoplasty on cardiac bypass. And repaired it. And so postoperatively, He's got an intact repair, he's still got horrible tracheo bronchoalacia because of his awful pectus, which, if anything, was made worse by having a sternum split. And The malaysia was bad enough, we ended up having to put a stent in there to support it. And so fast forward. A year and a half. And he's still having enough issues that we eventually bite the bullet and ask one of Dan's colleagues to put in a practice bar, which really wasn't much fun that operation. By this time he had pretty significant left sided bronchiectasis, and I was even considering whether we might even have to do a left pneumonectomy. Yeah. And that wasn't a fun prospect in a kid who's just had a bronchoesophageal fistula. And so the pectus bar works beautifully, pulls everything forward, and we find out that the stents eroded a hole into the bronchus. So he's now got another bronchoesophageal fistula. And not a very big hole, but there's a hole, and it's not going to get better. And I don't have video of this, but we ended up putting a Y-shaped stent. Into both bronchi, up the trachea. With a trach tube into the stent. And he's been that way for a year and a half, and he's the healthiest he's ever been. He's putting on weight, he looks better than he has in a decade. Wow. And we're really not very keen on repairing the hole, so we've bypassed the hole. And all of this is because someone decided he needed to hear. And, um, again, sometimes the first domino falls, and they just keep falling. And so again, even sometimes your successes become your failures. We did a perfectly decent operation which fixed the hole, but because we didn't want to do too much on an extremely disabled child. I wish we'd done the practice at the same time in retrospect. And so a very salient and disturbing story. And that's all the videos I have of that boy because I just couldn't have the heart to go through all the ones he subsequently had done a cochlear implant too, you know, so again, you know, sometimes beware of what you wish for. So, uh. So what we're going to do is have a little chat about This young lady, and we put in one little bit of a video earlier on, so you may see another bit a second time. So this is a girl who's again, comes to us starting to die of respiratory failure effectively. So she's, she doesn't have charge, but she's got something rather like it. Long segment oesophageal atresia, problems anastomosing it, and this was a straight long gap without a TEF. Um, And she ended up with a dehiscence, multiple dilations, strictures, esophageal rupture. Um, a long and sordid story, developed a right-sided bronchoesophageal fistula and came to us being fed with TPN still with recurrent pneumonias. And, uh, whenever they tried to resume feeding, she'd get another pneumonia. The, the esophageal resia repair was a. Uh, primary repair was a folker was primary repair, not a folker. So it was a delayed, a delayed repair and stretching, uh-huh. And um So we've got a few videos here. This is, this is. Bob put this together for me and basically, again, the images on the flex bronc aren't perfect, but they're really not bad and you've just got a sea of saliva. And This is one of those times we know. She's aspirating. And Finding the hole is incredibly difficult because it's one of her subsegmental bronchi on the right side and very, very challenging to track it down. Her trachea looks fine. Her left bronchuss looks fine. Her right bronchus looks appalling. And so what I did was this is with a rigid bronchoscope. And I've put an endotracheal tube in her esophagus, pumped up the pressure, and we waited to see one of her bronchi starting to bubble. And then we knew which one to go for. And so this is just in a subsegmental bronchus. This is just air. She's already got enough liquid in there that is starting to blow at you, and we were able to narrow down which bronchus was the suspect. And that's where we then got Bob and Phil to go in to isolate that area. And this girl's got almost a double barrel shotgun esophagus. And how would you describe her esophagus, Phil? I could never quite put it in words. Well, I mean, she has a long pseudo diverticulum of the wall, so that there's a main lumen that goes from mouth to stomach, and then about a third of the way down there's another opening that goes into a separate. Pseudo true diverticulum, I guess, um, with a thin wall between that and the main lumina of the esophagus almost parallel, and in that pseudo diverticulum sort of area there are multiple little pouches and holes and spaces with synechia across them that all had to be investigated individually to figure out which ultimately connected with the lung. Actually, one of my colleagues was involved with this girl initially and Going back and reading his notes, uh, my understanding is that there were actually two bronchoesophageal fistulae, one from the superior segment of right lower lobe and one from the medial basal segment, right lower lobe. 3 ultimately there were 33, OK. And so again, and this is this video that we looked at before, and we'll fast forward to that really cool bit where Bob and Phil are sort of shaking hands across this girl's fistula. So the left side is the endoscopy of the esophageal pouch, pseudo diverticulum with a wire coming out of the scope they're using to try to probe some of the holes. And on the right, I'm looking in the medial basal segment, right lower lobe, and there's the gastroscope. Tends to be a giveaway, you're going to aspirate, and there's the light shining into the esophageal pouch from the bronchoscope, and there you can see the bronchoscope. That's me trying to push the stupid bronchoscope back out with a wire. that. It was smart enough to have found you, Phil. And the CT scan wasn't quite normal as you would imagine. Hm. And so over about a year, at least a year. We started trying to pick off these multiple holes, and we actually closed two of them. And so Phil and both Paul Besh and Bob and myself would go down and bugby. One of the subsegmental bronchi. Enthusiastically, very enthusiastically we actually closed two of them. The girl was far healthier. And the 3rd 1 we couldn't close, and it was partly because there was a large pulsatile vessel right beside the hole. And whenever we tried to cauterize it, She would have an episode about a week later back home, where about 100 cc's of blood would come shooting out of her mouth and we would think, well, we've got to be a bit more careful next time. And so eventually we decided we could not safely try and endoscopically get rid of the last bronchoesophageal fistula. And this is a girl who's a How shall I say, she's healthier than she's ever been. She's hugely improved, but she's still aspirating. She's still got a hole. And we've isolated it, we know which lobe it is. And so it's a question of we're failing to fix it endoscopically. So what should we do? OK, so you can see the hole. You're just afraid to, so what about that's, this might be one of those rare instances where I would consider using surgesis and plug the hole. We tried to work proximal to the hole, so we tried to take out a, a You know, the next tree up of bronchus, we. cauterized it, to sealed it. I didn't try that though, so I don't, I used to use it, uh, because there's been a lot of supports you have to rough up the area and then you put in the surgesis and fiber and glue. There's a great report on the description of it. Um, it, it scared me in the proximal fistulas that it would dislodge in a big huge piece of surgesis, but if you're talking something this small, you could take it, coil it, you, you roll it up, and you shove it in there. And you know, they also have these anal fistula plugs. Uh, really, yeah, so they're actually, they're, they're, I've live obviously quite a socially isolated existence. So do do fill me in. So we used it and actually we do tell me about it. Yeah, we, we, so, um, all right, so this is what we did, so. These anal officialial plugs are, have you ever seen these things? They're made out of a biologic material, surgesis, and they're cone shaped, so it goes down and they come in all different sizes. You can get them tiny and they're wide lion's den supplies. And so, you, you take that and what we did is, uh, we, there's a suture called a VOC suture. Have you heard of the? It's a barbed suture. Yeah, I wrapped it around it, so it was barbed now. And I shoved it into the fistula. And it plugs it and it biologically it scars it will recollage it, it forms a new collagen matrix so that it can um be infiltrated with um cells. I don't know what it's, but I don't use, I, I think the bugbe works so good, but this being so close to a vessel would be the one that I would, and it's distal, I would try that. So getting the informed consent, I want to stick an anal plug in your kid's airway. Has this ever been a challenge for you? Hasn't been OK, OK, yeah, no, but it's a, you know, these plugs are good, and they're not, unfortunately you can make your own, but it's nice that they come so tightly wound up in a perfect sliver you can. We, we had a slightly, uh, oh sorry, would you consider a segmental resection, which is you might end up getting to of the right lower lobe. To get rid of the fistulas, and I think honestly good question that that is what we did. We, we turfed it to Dan, so we got a, we, we jumped forward a couple of slides on video, see the smoke coming from the lung into the esophageal diverticulum as I'm cauterizing on the other side. So this is the GI view of the right, I see it in the pouch looking into the lung, and I'm cauterizing from the bronchial side and you can see the smoke swirling around in there. It didn't work. Yeah, well, we got rid of 2 of them, but we were defeated by the 3rd. Some of the I think the odds are very much against you having 3 fistulas that this thing would be closed, and I gotta tell you, I know you were, we didn't know that we had 3 when we started. We closed it. We felt so proud and. We found another one. And then we closed that and we thought we're doing OK here, but she still seems to be pretty gooey and found another one. It was a bad disease and the whole, if you, the CT scan shows her right lower lobe. The whole right lower lobe bronchiectasis, chronic inflammatory changes, and this is, I love this girl, she's a tough girl. She, um, during one of these procedures had a little episode of cardiac arrest for reasons that are unclear, and she woke up in the recovery room and she said, I'm having a really bad day. That must have been a nasty case. It must have been so sucked in, or was it not? Was it not? So, so the result was the right lower lobectomy, and it was, it was difficult, but, but it was not as bad as I anticipated. I actually expected it was going to be very dangerous and Uh, it was not easy, but, but we were able to dissect out the hilum, which was my concern. And interestingly, from Phil's description of what the inside of the esophagus looked like, the outside was exactly the same. We came upon this connection, presumably to the bronchus, and then there was a very long track that was parallel to the esophagus and then entered the esophagus much higher. So there was this very long diverticulum. The esophagus. You resected that too. We resected that all the way back up and the native esophagus was not strictured, so I could just primarily primary closure. Did you put any tissue next to that? We did not, but it was so far away from the rest of the dissection because of the length of this diverticulum that I was not terribly concerned about refiistulizing to the bronchial, which is what pleura, I mean, no, I just did a routine lobectomy. And we've looked since then, and there's just a couple of little sneaky across the esophageal epithelium that I can slide a scope under, but there's no pouch, there's, there's no stricture, looks great. Question from Adrian keeps asking me good questions. Could that have been a duplication? Yeah, it's a great question, and it was well enough formed that it's conceivably it could have been. Now I don't know if she'd been ever scoped where it hadn't been seen, you know, prior to, by the time I met her, she had it could easily scope her and miss it. It was hard to find. So it's hard to find. It could have been a diverticulum. It's a great question before, so she'd been scoped elsewhere. That's a great question. We're gonna wind up on just, there's a couple of little nice little teaching cases before we break and so um. This is a boy who also had yet another type CTEF repaired day of life. 17 weeks old, had his esophageal a treasure repaired, and lots of hospitalisations, pneumonias, upper respiratory tract infections. Had an aortaepsy to help that, didn't help. At age 10, he had a swallow study suspicious for aspiration. And Double teaching point. Firstly, the thing that is interesting here is Bob's looking for trouble. We know this kid's aspirating. We're looking for a recurrent fistula. We don't find it. This is Bob doing that upside down thing that he likes to do. And uh He's really looking awfully hard. And Bob's very good at this stuff. And he's really not finding. Anything And to all intents and purposes, Bob couldn't find an anatomical problem. And he's looking And this is the MLB where there's clearly a laryngeal cleft. And again, While we're thinking TEF, never forget the chance of having a laryngeal cleft. This has been missed for 10 years, 12 years. And a flexible bronchoscope is not a reliable tool for diagnosing a laryngeal cleft. You can't find them even when you know they're there 95% of the time. It's simply a limitation of the flexible instrumentation. You've got to use a rigid anytime you suspect anything in the posterior commissure, subglottic space, or cervical trachea, you need to also use a rigid scope and probe, not just look. It's one of the reasons our standard evaluation is both an MLB and a flex prom. Specifically for that, uh, in your routine cases you do in these complex in the complex cases, but a routine, what do you use before your pre before you do a tea fish oil it's usually a rigid rigid. So, I'm going to close this session just again with something of interest. We talked about tracheal pouches earlier on briefly, and here you've got a big tracheal pouch, very proximal, and another one here. And you can imagine when you change a trach tube. The odds are fifty-fifty, it could go in the pouch. If it goes in the pouch, the kid tries to die, it's kind of inconvenient, and it's really what can you do to fix one of these pouches. And what we do is we steal pediatric surgery's tools. So this is a store's click line biopsy forcep that's on the pediatric laparoscopic tray. We actually do enough of these that we've got our own set now. Because the pediatric surgeons kept bitching about it, and so. Scope through the stoma and this is the store's click line biopsy forcep, as you guys know better than I do, it's got suction, it's got cautery, you can crank up the cautery to you need quite a lot of wattage actually, about 40 watts, and you just chomp your way through the common party wall, and it's relatively slick and quick. And marsupializes the pouch, and it's a very quick, elegant way. Of getting rid of a slightly difficult problem, it can make the tracheomalacia worse symptomatically. Though usually not, but most of the time it improves it surprisingly, yeah, kids do well. As you can see though, this kid had a pretty significant tracheomalacia. And so this is just a post-op view. And again, literally, when you divide the party wall, what remains tends to scar out the sides. It just, it's almost invisible where it used to be. They tend to heal really well, and it's very slick and quick. And so with that, I, I want to, before we take a break, I want to say, so, you know, in general surgery, this, this new fad, single, single port surgery, OK, the idea is that we can put all the instruments through the umbilicus and do our operations. Well, it's fading away, I think. I think it's a fad that's fading away, but you know what it did is it taught us to take these instruments and operate through a small opening, and I think Transoral surgery has its place. We may have learned it from our single port surgery. The fact that you were suturing the, the trachea. Oh, I do regret doing that, and you're using here, uh, these instruments actually can advance our endoscopic techniques by using some of the laparoscopic equipment that we have. Yes, we still don't quite have robots small enough to do everything we want down in airwave that may come at some point, and that's one of the best utilizations will be in, uh, endoscopic oral surgery, you know, transoral, um, fantastic first half. Um, we're going to take what, a 10 minute break, I think a 10 minute break. Does that sound reasonable, guys? 10 minute break, and then we'll, we'll reconvene. Any comments or questions, um. We had a um We use that's OK. You know we use nasal speculums for, right? Um, great point, great point, and that's a great place to end it. I don't wanna know. All right, thank you, very, very nice, and we'll take a 10 minute break. We'll take a break. Oh