Latest / Behind The Knife: The Surgery Podcast / Bad Day on Call: Live Case Discussion from ASGBI Conference
Transcript
- cases podcast === Speaker: [00:00:00] Hi, everyone, and welcome back to Behind the Knife. We're back with another installment of our BTK ASGBI collaborative series from our friends across the pond. My name is Agnes Premkumar. I'm one of the Behind the Knife education fellows. I'm a general surgery resident that's gonna be representing the US side, along with our UK-based co-hosts. I'll let them introduce themselves. Speaker 2: Hi, everyone. I'm Geeta Lingam. I'm a surgical trainee in the UK, and also the current president of the Moynihan Academy. Speaker 3: Hi, I'm Elizabeth. I'm also a surgical trainee in the UK, and I am the current vice president of the Moynihan Academy. Speaker: All right, so this episode is unique since we're going to be doing things a little differently. We're going to tune into a session from the recent ASGBI conference that was held in the UK just a few weeks ago. We wanna use some cases to highlight the differences and similarities in patient management between the two countries. Speaker 2: That's right, Agnes. So each year we have our annual conference, and the highlight this year was the Bad Day on Call session, where various providers discussed hard cases and their strategies and thought processes for the [00:01:00] management. Speaker 3: During the session this year, we had the privilege of having three countries represented. We had the UK, the US, and Canada. We had a large panel with multiple providers from the STAGE committee, along with acute care trauma surgeons from Canada and acute care trauma surgeons and general surgeons from the UK. Speaker 2: The panelists that you'll be hearing from are Dr. Rob Lim, Dr. Courtney Collins, Dr. Michael Cripps, Dr. Caroline Reinke, Dr. Krish Schlachter, Mr. Christian Mikucevicius, Mr. Adam Peckham-Cooper, Ms. Kate Hankorn, and Mr. Demetrios Damascus, as well as, of course, our Moynihan Academy past president, Jared Vogel. Speaker: That was quite a mouthful, Geeta. I'm glad it was you reading the names. And lastly, we three will also jump in intermittently to explain a few UK-specific lingo that might come up by the panelists. So without further ado, let's get started. Speaker 4: Last but not least, everyone, the infamous and famous Bad Day on Call. We have a [00:02:00] stellar lineup of panelists that you can see. I'm gonna hand over to Jared, who will start. Speaker 5: Uh, thank you. So Bad Day on Call. This is case number one. So here's a patient comes in, we'll say 40-year-old male, recently diagnosed type 2 diabetes, had a stoma from previous diverticular stricture, which was, uh, a Hartmann's procedure in 2015, and had a peristomal and incisional hernia, but was told upon discharge from that, you know, "Hopefully you don't need any surgery 'cause it's a really difficult procedure, so we're not gonna organize anything electively for you." Also has hypertension. Uh, on several medications, metformin, indapamide, amlodipine, atenolol, candesartan. He has a BMI of forty. Is independent normally, is a carer for his wife. He's a car mechanic three times-- three days per week, so he's kind of semi-retired, does it for the fun. Has no walking aids, is a non-smoker, and doesn't take any alcohol. This is a video. It's a cross-sectional CT scan. There's a stoma in the left iliac [00:03:00] fossa, and there's a large hernia in the lower abdominal wall within the abdominal pannus as well. And within the hernia, there's free air, there's evidence of inflammation and a small bowel obstruction, and the CT is reported as such, with a small bowel obstruction with perforation within the hernia sac. This is showing a perforated hernia. The overlying skin and soft tissue is also extremely thin at that point. So question to the panel. What would you do at this point? How would you approach this situation? Speaker 8: Okay, in the UK system, we're a little bit more holistic. First thing I would do is have a good chat with him and find out what he wants. Make sure that we're treating any sepsis and, or like all good FRCS candidates, make sure that the ABCDEs are sorted. Speaker 3: The [00:04:00] FRCS is the Fellowship of the Royal Colleges of Surgeons, and it's a qualification that allows accredited professionals to practice as a senior surgeon in the UK and Ireland. Speaker 8: So we've got all of that. The first thing that comes to mind is we've got a candidate that would be high risk of necrotizing fasciitis of the remnant pannus, and so my immediate thoughts were we need to get him out of trouble. We haven't been given any blood tests, but I imagine his lactate will be through the roof. He won't be in a great state or shape, and so we need to think about treating the problem, not the cause of the problem. So we need to get him out of trouble. As our wonderful Courtney Collins says, "Leave the hernia for later." I'm gonna pass over to Mike Cripps because he's gonna get VATS or robot or something out. Speaker 6: Thanks. Yeah, you can get target fixation on the wrong thing here easily. So the problem is here we have perforation, we have something that's dead inside there, and that's what's gotta come out. So IV fluids, resuscitation, IV [00:05:00] antibiotics, get ready for the OR. Have that discussion with the patient. Tell them that they're gonna wake up, and the hernia is not gonna be gone, but we're gonna do what we can to save their life. Speaker 5: Okay, so moving on. As you rightly anticipated, the patient is septic. NEWS of eight, which in the UK system is a composite score of heart rate, blood pressure, respiratory rate, sats. Speaker 2: NEWS is the National Early Warning Score, which is a system used in the UK to determine the illness of a patient and suggesting the need for critical care intervention. A NEWS of anything above zero indicates that the patient is somehow unwell, and so a NEWS of eight is very much not a good sign. Speaker 5: Essentially, they're not very well, and a lactate of seven point four. So they take him to theater. Patient was unstable and needed stress steroids as well, so they took a damage control surgery approach. They found peritonitis with enteric content in the lower abdomen and within the sac as well, as seen on CT. A small bowel [00:06:00] resection was performed with thirty centimeters of terminal ileum with only five centimeters stump of TI, and they left an open abdomen with the AbThera system. So was there anything else you would have done in this first operation? Are you happy with what they've done? Speaker 8: I'd be worried that his abdominal muscles may retract, so I'd wanna set us up for mesh-mediated fascial traction with just some Vicryl. Um, we've got nothing, nothing to lose from that. If this is gonna be a protracted closure, at least that allows us to keep the muscles. Speaker 3: Mesh-mediated fascial traction is a technique where the mesh is divided in half and sutured to the fascial edges with sutures. The two halves of the mesh are pulled towards the midline under tension, and a negative pressure wound therapy is placed superficial to the mesh to protect the viscera. The mesh is then tightened, and the excess material is trimmed every forty-eight, seventy-two hours. The traction sequentially strengthens the abdominal wall so that once the [00:07:00] fascial edges are close enough for primary closure, the mesh can be removed, and the abdomen is then closed. Speaker 6: One of the things I'll check for, and, and it was brought up earlier that there's a possibility you can get, like, this internal necrotizing infection going on there. So, uh, after we take care of the source of contamination spillage, I'll also take a good look around at the rest of the fascia, the skin, the subcutaneous fat, and if there's anything that's grossly dead, that's gonna come out at that operation also. Speaker 5: Okay. And so they did that. You are now looking at the patient forty-eight hours down the line, still on midoradrenaline and high oxygen requirement, still on stress steroids. ICU thinks that waiting any longer before addressing this situation is gonna make things bad. You're strong-armed into doing another operation. No, you want to do another operation, and you take them back at this time. On re-look, you see fibrin over the bowel. There's no enteric contamination nor abscess. Uh, adherence is starting to develop. You've got a [00:08:00] proximal end of the abdominal wall that can reach, but not the distal end. There's a significant loss of domain. So what do you do now? You're looking at a big hole that you can't get closed. Speaker 7: I have no personal qualms about a five centimeters of internal ileum, leaving it there connected to the colon. That's totally fine. There's a lot of interesting questions that we didn't get to, of course, because the patient's so critically ill. It was supposed to be designed that way. But, you know, I think one of the questions, if not on such severe support in this case that we often will debate is whether or not you're gonna do an anastomosis in the divert proximal ileum versus just doing your end ileostomy. Interesting. And I think that's one of the things that I like about having an EGS team is that, you know, we are the people who will then take down most of what we do. And so thinking about like six months from now, you might make different decisions in the OR than you otherwise would. Again, in this case, because they're on a lot of support and a lot of steroids, would [00:09:00] probably not be one that I would consider. When you talk about five centimeters of internal ileum, like ten is usually my more happy place. But actually, a rule of thumb that I follow from one of the colorectal surgeons training me is that if the veil of Treves is still there and complete, then you probably actually add the plus five. So less, it's about the actual numbers and more actually about that piece of fat for some reason which seems to be meaningful. Speaker 9: Well, this is my case actually. So kind of question we had at that point is we had a loss of domain. Mm-hmm. And whether the question was how much more we were going to do as the patient was not improving at the rate that we hoped they would be improving at. And so the two questions I had during this case was, first was the... Well, save life first, save gut second, save abdominal wall last. [00:10:00] So the life in a way is saved in the sense that the patient is under the ICU support and, you know, they're doing whatever needs to be done from their end. Save gut there is no more bowel to be removed, and I've noticed that the abdomen's already starting to become frozen, so I'm very skeptical about mesh-mediated fascial traction at the point because I'm starting to think that every time I come back here, it's gonna be even more awful And again, I wasn't that worried about the stump, but I do mention it because in the UK setting we quite like loop ileostomies if we can get both the distal out. But it wouldn't reach because of the patient's BMI and the fact that the stump was very short. So I don't know. I can- well, I will tell you and you will see what I've done. But so is the answer still remains mesh-mediated fascial traction? I mean, that's the question I have. Speaker 10: Can I just speak? It depends how sick they are, but [00:11:00] is there an option to mobilize right colon and bring out a double-barreled ileocolostomy? If the patient's dying or close to death and all you can do is save their life, so be it. But if you're in that intermediate They're a young fella. They've already got an end colostomy. Giving them an end ileostomy and leaving bowel stapled off, the-- that- that's a lot. If they were well enough, I would think about mobilizing enough right colon to bring out a double-barreled ileal colostomy to one-day reverse. As I said, the abdomen was already Speaker 9: starting to become frozen, so I didn't consider that. But even let's say we did that, what do we do with the abdominal closure? Speaker 11: I don't think it's unreasonable to do a trial of mesh-mediated fascial traction. You can take him back to theater within twenty-four, forty-eight hours again. If you've-- if it is fixed and you haven't got any movement at all, then you can abandon. And if we've used a Vicryl mesh, which Christian has, I, I don't normally use a Vicryl mesh. Um, but if we've used a [00:12:00] Vicryl, then you can just close that mesh and accept your ventral hernia. So if we've used a, a Vicryl mesh for our mesh-mediated fascial traction, we haven't lost anything. Speaker 6: Sometimes I'll just close the skin over it. Speaker 9: Yay. Speaker 11: Yeah. Speaker 6: That's it. Yeah. That's, Speaker 12: that's totally Speaker 6: fine, you Speaker 12: know. Speaker 6: Well, I'll pull the skin over it, stitch it up. It's gonna dehisc. Speaker 8: Yeah. Speaker 6: And it's gonna be a big wound, but you can handle that. Speaker 9: Did you preserve the sac? We did not preserve the sac because it was heavily contaminated. Uh-huh. This is a very valid point because you could close the abdomen stitching sac to sac. Yeah. Cutting the sac in the middle when you do your laparotomy, preserving it, and then closing sac to sac, yes. But not in this case because there was fecal matter within the sac. Fair enough. So it had to be debrided alongside a lot of skin and subcutaneous tissues. Speaker 12: Yeah, no, I, I mean, you do whatever you have time for with the-- I think the patient's, you know, uh, stability. I think that closing skin over it is fine. Making sure it's skin that's gonna live, though. I think that's what people forget about. Like, that if it's really that thin, you're gonna have to excise some, otherwise that- Excuse me ...is gonna die, you know? Um, and we're, we're not [00:13:00] very good at skin in general surgery. We need to think about that. If you have time to put a Vicryl mesh in, I think that's great. If you have time to throw a few figure of eights, that's great. But if not, like, that's-- just, just get out. Like, we'll, we'll figure it out later. Speaker 13: Sorry, I didn't quite catch whether still the two ends are inside stapled. Are- Yes, they are still stapled ...so one of the problems is that you have to start feeding entirely the chap as quickly as possible. So you need to have some of the intestine out. You need to have an ileostomy. Now you have a fat guy who with edema of the wall and they have a fat mesentery. To get an end ileostomy is very, very difficult. But it is the priority number one to get it out to start the NG feeding. Otherwise, you're going to go from bad to worse. You can wait for another forty-eight hours to start bringing the fascia together. That's not a priority. The priority is to get the ileostomy out and forget all the rest. It may have two stomas.[00:14:00] Who cares? But the priority is to get him moving, and to get him moving is to get the NG feeding. Otherwise, you lose. Speaker 9: Yeah. I think for the interest of time because we have more cases, I'll tell you what I did. So I took a BioA mesh out of the shelf and I stitched it against as an kind of an open I-POM or an open inlay, say it whatever, however you like it. So stitched, I couldn't get the fascia closed to the- Speaker 8: So you bridged? Speaker 9: Yes. So a bridging closure, not because of the contamination, but because the sac had been resected. So there's already loss of domain, inherent loss of domain. This wasn't a case of risk of intra-abdominal hypertension. This is I had no abdominal wall to play with, and I thought if I used mesh-mediated fascial traction, no matter how much I would do it for, I [00:15:00] would never be able to get midline closure because of the loss of the abdominal wall. And then I sh- stitched the skin back together, as you said. It was, a lot of it had been debrided, so and it didn't look right. But my hope was that if we gave it enough time, the skin would become a little ischemic, but at least would have a week or eight days that his abdomen would freeze completely and the mesh would hold things together, so even if the skin gave way, he would not eviscerate Does that sound reasonable? Sure. Did he Speaker 8: survive? Speaker 9: Well, let's see what's happened. So this is a few days after this, uh, second procedure. The skin has already become ischemic, and the lower part of the wound has opened up, and the mesh is exposed, and it's a BioA mesh. And we took the patient back. [00:16:00] As you can see in the central part of this picture, the-- you can see a whitish area. This is the BioA, which is stitched as an inlay. And all the subsequent re-looks that we did on this patient were all essentially skin debridement. We didn't do anything else to the abdomen as such. So that had in itself more of a limited impact on the patient's physiology. And you will see that the patient, three weeks in after that index operation, we started closing the skin from its direction, and you can see the imprint of the negative pressure dressing, to be more precise, on the subcutaneous tissues. And then week five, where it has completely granulated. And following that, the patient went on to plastic surgery. They put a nice thin skin graft on top, and the patient was discharged. That's nice. So that's [00:17:00] case number one. Any comments? Speaker 14: I don't have any experience with BioA mesh, so I would have been a Vicryl mesh person in these cases. How difficult was it for you to get the plastic surgeons to come in and put the skin graft on? No, because it's a relevant question 'cause I've had unfortunately more than one case similar to this, and if the delay in putting skin over that mesh is too long, you're gonna end up with an intracutaneous fistula almost certainly. And I'm just curious what your relationship is with your plastic surgeons, and do they understand the urgency of putting skin? Speaker 9: They are very accommodating, and the only thing they want is two negative- wound cultures Yes Otherwise, you know, they won't put a graft unless we have at least two consecutive wound cultures which are 48 hours apart that are negative. And then in my unit, they are not in-house, but they will just, we'll book an operating room for them and they just come in, they put the skin graft. The patient stayed under my care, [00:18:00] and they just came every few days and checked the graft sites. Speaker 6: Is there any particular reason you don't do your own skin grafts? Speaker 9: Yes, there is. I'm not trained to do Speaker 6: them. It's, you take a dermatome and you go neeee. And then you mesh it- He won't have a dermatome ... and then you put it on there. Speaker 8: He won't have a dermatome. Speaker 6: Or you take the knife and then you go neeee. You pull that up and you mesh it and just put it on there. It's, I mean, split-thickness skin grafts fall directly in the purview of trauma and acute care surgery. It's really not that difficult to do. You take the skin donor, you mesh it, you can pie crust it if you don't have the mesh machine, and you can put it on their self. So and the reason I bring it up, beside just controversy because I like it, is you can end up in these sort of delays. And so as we're talking about- Yeah if you end up having to wait and wait for a, a subspecialist to come in and do something that you already know needs to be done, then you can end up in some really, really bad scenarios. And if this person gets an aeroatmospheric fistula, that can be a lethal event. And so [00:19:00] being able to do this sort of stuff on our own, to be able to get that skin graft on there and get it covered up as soon as possible will significantly improve their outcomes. That Speaker 8: was beautiful. I'm gonna just ask a medical legal question about that. So I agree with Mike, and certainly we did our own skin grafts in South Africa. What are the medical legal implications if we do our own skin grafts and it breaks down? Speaker 11: So we do our own skin grafts because I agree that the delays in care are what we're trying to avoid. So we do liaise with the plastic surgeons, but it's not something that is hard to do and- Okay ... it's part of our routine practice. So I think we've probably got the governance there to demonstrate that, you know, we're performing it within the appropriate service. All patients are consented. We would involve plastic surgeons if required. Direct medical legal, we haven't been challenged on it, so I can't honestly say what the position would be. I don't know if in the States you've got any- Speaker 6: They'll be [00:20:00] fine. No. I had a certificate on my wall says I'm clear to do this, so. Speaker 4: Thank you. I'm going to wrap that case up if it's okay, and then we'll go to the next case. Yeah. Speaker 9: The only thing I will say because this is recorded, like they do in the BBC, I'd like to say that other commercially available meshes apart from Bioia are available. Speaker 5: Very good. Speaker 9: Okay. All Speaker: right, so the next case, your second-year resident calls you about a 90-year-old man, uh, with a large medical history. He has Parkinson's disease. He has hypertension. He has AFib. He's on apixaban. He has chronic kidney disease. He has hypothyroidism. He has sick sinus syndrome, and he received a pacemaker four years ago, who's presenting with one-day history of severe abdominal pain and no nausea or vomiting. Any initial thoughts? Speaker 15: So the first thing would be what's his frailty, if you have a formal scale, and then talk about what is his life wishes, his goals of care and whatnot. It's never too early to bring that up. Now, [00:21:00] that wouldn't be the first question I ask him when I go visit him at the bedside, but that would be in the back of my head as we're making out a plan. Yeah. While we're waiting for the CT scan, I should say. This would definitely be my plan. Speaker: So he is very independent. He lives at home. He cooks his own meals. He follows with a kidney institute for his CKD, but he's never required dialysis thus far. He can't remember the last time he got an echo, but he is full code and wants to be full code. His only pertinent surgical history is that he's had an open left inguinal hernia. You get some labs back, which are that he's leukopenic. His white blood cell count is two point two. His hemoglobin is fourteen. His creatinine is one point eight six, which is close to his baseline, and his lactic acid is six point one. Speaker 4: Any thoughts from the panel? He's dead. He's, he's- Yeah. We-we've got he's dead at this- He's dead ... on this end of the table. Speaker 15: So the leukopenia is certainly worrisome, and the under-resuscitation is concerning. Most of our anesthesiologists won't put someone to sleep [00:22:00] with a sodium of one twenty-eight, so that would have to be cr-corrected. And then, of course, the lactate is concerning also. So, um, maybe some of that is from hypovolemia, but something seems to be dying or very concerning. But most-- and probably the most telling would be that white count. Speaker: So we have the CT scan. You see some flux of air in the upper abdomen around the liver, around the stomach. There's no irregularities in the stomach wall. However, there is some pneumatosis of your small bowel, which we'll get to in just a bit. So knowing his age, his medical comorbidities, what would you like to counsel him or offer him? Speaker 15: Well, so the frailty that was described, he seems to be functionally independent which is a plus in his side. I think you said he-- you don't know when his last echo was, but- Yeah ... was fine. So, uh, and no evidence of COPD. So the major ones, I think, that affect immediate post-op seem to be [00:23:00] okay. However, you're talking about needing extensive bowel resection here. Certainly, the discussion about how far he wants to go with this, I think is appropriate. But I do think if he's a full go with all this, then surgery would be the next step, assuming there's some-- been resuscitation of the sodium. Speaker 4: Would anyone on the panel, would everyone on the panel, just a show of hands, or maybe not a show of hands, but would everyone offer this man surgery? Speaker 6: No. Speaker 8: Not yet. Speaker 6: Not yet. Speaker 4: Caroline, that was a yes? Yeah. I would do it. So that's what? One, two, so four, five. Mike, no? Speaker 6: Oh, I-- Not at this exact-- Not based on just the CT and history just yet. It doesn't mean he doesn't-- that he doesn't have a surgical problem. It just doesn't mean that he might not necessarily get better from this. So we have to have a talk first. Speaker 4: Christian? Speaker 8: Currently, on the information I've got, I-I'm not currently gonna book him for an OR, but I wanna have a, a look at the arteries in the sagittal view. Yeah. I want to know what's the probable cause of the ischemia, the extent of the [00:24:00] ischemia and if he's got any portal venous gas, I can then go back to him and say, "Most people with portal venous gas won't survive." And then we have the whole discussion about what's the best way to die, with your family around you or in ICU tube. So I, I need a bit more information. Speaker 4: No, no, fair enough. Uh, it was a, it was... Joey, go. Speaker 14: Just a question about the portal venous gas, because when I was a trainee, before you were born, um portal venous gas on a plain film was, you know, one hundred percent mortality. Mortality, yeah. But I see a lot of portal venous gas on CT scans now, and those patients walk out of hospital, so I, I'm- Speaker 8: Ninety-year-olds? Speaker 14: Well, I'm-- You're ageist now I mean, it all contributes to the discussion. Yes. But my experience is that there very few people say, "Just let me die." I mean, we have the goals of therapy discussion for sure. Yeah. But if he's a well-functioning ninety-year-old, I think the most important thing is to discuss how no matter what you [00:25:00] do, they're unlikely gonna go back to the lifestyle that they had before this event occurs, and that often changes the discussion. Yes. Speaker: The part about the vascular study, so we did look at his SMA and his celiac, and everything was open. It didn't look like anything was thrombosed. We had a frank discussion with the patient and the patient's family, who was very involved, that if it was mesenteric ischemia, there is a chance that all of his bowel is compromised and that he would not make it out, and they understood the risk and wanted to move forward with at least a look to see how much of the bowel was compromised and if something could be salvaged. Okay. Moving on Speaker 6: Did y'all s- uh, discuss doing a laparoscopy? Speaker 4: Yeah, so I Speaker 6: was about to- A laparoscopy to stick a scope in and move things around a little bit? Speaker 4: Lose by sticking a scope in. I don't think you lose anything, do you? Is- One time. Who would stick a scope in, and who would go straight to a laparotomy? Speaker 6: I'd stick a scope in. Scope. I'll scope. Speaker 4: Scope. Scope. So wh- how many... Hands up for scope. Speaker 6: Scope? Yes. Speaker 4: So for the purposes of the listeners, that's, that's- Yeah. All of us ... four or five. Five out of six of, opt for a scope. Speaker: Yeah. [00:26:00] Uh, we ended up doing a laparotomy, um, and contrary to the popular opinion- It's, Speaker 4: it's all about the training numbers though, isn't it? That's what matters. Speaker: Yeah, exactly. Needed the numbers. Speaker 16: Interestingly, it was not mesenteric ischemia like we assumed it was. There was no dead bowel. There was no discoloration of the small bowel. Speaker: So we see multiple small bowel diverticula throughout the jejunum and the ileum, and we see that one of the diverticula had a perforation, but it was less than a centimeter tear. And the question at this point was, what do we do now? So there's one perforation. Do we address all the diverticula? Do we leave it alone? He also has this broad-based diverticulum that kind of looks like a Meckel's, but it's full of diverticulosis. Would it be healthy enough to put together? Speaker 4: Caroline, looks like you're about to- Yeah give us your wisdom. I've Speaker 7: got a long piece[00:27:00] Like this seems a little bit crazy Yeah, it's diverticulitis of... Probably different than diverticulitis of the colon, right? That you, you manage the one that's causing the problem, and you leave the rest of the colon up, and it's not much Speaker 4: else you can do. On, on that subject, it-- and I'm going to be deliberately controversial. Is there an argument to treat small bowel diverticulitis or perforated diverticulitis conservatively like we might colon or never? Speaker 7: We- I don't think in this one. Not, not, Speaker 4: not this one, but- Speaker 7: In this one particular patient, um, because he-- we've taken the patient to the OR and not been able to find which one was perfed, there were so many. We closed him up. He had time. So now when he comes back with a perf, if he's not... Like, if it's just free air, he's otherwise fine. Hmm. Sometimes we leave him, so. Speaker 4: I know, I know there's a controversy around a small bowel diverticulum and [00:28:00] perforated. So this guy, one diverticulum getting fixed. Is that, is that the general consensus? As in we're doing a resection of this- Yep. -diverticulum. Yep. Joining them up? Speaker: Yeah. So we just resected that portion of the diverticulum. I think we took a little bit extra just to make sure that we had relatively healthy bowel to put together, and he did well postoperatively. He was transferred to the ICU. He did develop an ileus, so we started him on some TPN. But he was discharged less than two weeks after this operation, and he actually went home, and I think part of that was that he had a strong family support who helped him walk and ambulate while he was in the hospital. Speaker 4: Excellent. Joined or with a stoma? Speaker: Joined. Stapled anastomosis. Speaker 4: Any comments from the audience? Speaker 9: Maybe just to highlight, obviously, we have a national database on emergency laparotomy, and it's great outcome the patient went home. But we do know from our national emergency laparotomy database that over ninety years old patients that have an emergency laparotomy, most of them are not [00:29:00] alive in twelve months after this procedure. Speaker 6: M- a lot of ninety-year-olds without any disease processes are not alive in twelve months, so the mortality rate for taking a nap when you're ninety is not zero, so keep that in mind. But, and, and this is a great outcome, and it's also probably if it could have been done laparoscopically, could have even potentially been a shorter hospital stay, less rate of ileus, less need for TPN. And so that, that is just something to, to keep in mind as you're progressing and as you're trying to improve your minimally invasive emergency general surgery skill sets, that there is distal reasons for doing that, not just the incision. Yeah. Speaker 4: How many units from the panel w- have the support of geriatricians for patients like this, out of interest? Is that universal? Not quite universal. Three and a half, I think, is kind of that Speaker 7: Friday from eight to Speaker 4: five. Okay. So four, four [00:30:00] and three quarters maybe. Well done. Brilliant. Excellent. Yeah. I think it's been a really fascinating conversation. I'm sure we could all sit here for hours listening to the, some expert, some kind of banterous conversation, shall we say. Thank you to the SAGES panel. Thank you to Christian, thank you to Kate for their expertise. Thank you for bringing your cases. Speaker 16: And thank you to all of our listeners for listening. We hope you enjoyed this episode and you learned about some of the nuances in clinical expertise across these three countries. We would love to hear from you if you would've managed these patients differently in the cases that were described. Thank you as always for listening and as always- Speaker 8: Dominate the day