Latest / Behind The Knife: The Surgery Podcast / Clinical Challenges in Colorectal Surgery: Management of Anastomotic Leaks
Transcript
- Episode 2 Clinical Challenge CCF CORS === [00:00:00] Hey everyone, and welcome to Behind the Knife. My name's Alyssa Degi. I'm a general surgery resident at the Cleveland Clinic. And I'm Jared Hendrick. I'm a general surgery resident at Cleveland Clinic as well. My name's Dave Rosen. I'm the section head of the division of colorectal surgery at Cleveland Clinic Fairview Hospital. I am asu, also known as AJ Khin. I'm one of the partners one of Dr. Rose's partners. And I'm Joseph Zo. Also one of the partners here at Cleveland Clinic. Fairview and associate program director for general surgery residency. All right, so today we're tackling one of the most challenging complications in colorectal surgery and TMO leaks. Our discussion will focus on how to manage them both in the OR and post-op, and some practical decision making tips that can help surgeons navigate these high stake situations. So let's start with the case. We have a 50-year-old man history of recurrent sigmoid diverticulitis. His last episode was six months ago and he's been symptom free since then. And he sees y'all for an [00:01:00] elective laparoscopic sigmoid colectomy. Intraop. There's no signs of acute inflammation, although the sigmoids a little thickened, and you ultimately perform a stapled end-to-end colorectal anastomosis without tension or difficulty. And your interop leak test was negative on postop day four. He's mildly tachycardic. 2 1 0 5. His blood pressure's stable, systolics 1 45, afebrile. He's passing flattish, having some liquid stool. He's tolerating his diet but having some mild lo left lower quadrant Abdominal pain, we get some labs. His wife counts 14, which is up from 10 and CRPS one 90. So what do y'all think of this presentation? Well, given the, the title of our talk here today, I would be worried about anastomotic leak here. I think, you know, that's kind of the, the thing that as colorectal surgeons we always worry the most about. You know, especially in this kind of range, there's early leaks and there's some later clinical leaks. And this seems to be on the earlier side, but with the tachycardia the [00:02:00] labs and some abdominal pain you know, some kind of intrabdominal processes is on my mind. Whether it's an anastomotic leak, could you have something like a internal hernia that got incarcerated? Or something other, some other kind of internal intrabdominal finding. And I think the way to elicit this workup is a, a, a CT scan of the abdomen pelvis with IV contrast. You know, if you're ever, if the patient were also, you know, hypoxic and you were worried about a PE on your differential, you could also add in A-C-T-P-E and kind of do one round of contrast and get a chest out and pelvis imaging. But my work would be a CT I pelvis with IV contrast. Personally I don't use rectal contrast in these patients. I, from a theoretical standpoint, I worry about inserting the contrast and if there is a small leak, making it worse. And usually you can see the inflammation around the, the rectum and any fluid collections with just the IV contrast. And it doesn't change my management, but I know there are many people who you do typically do, do rectal conscious in these, but I'm, I'm not one of them. [00:03:00] Yeah. In my residency we used virtual vector contrast a lot. In fellowship. We didn't, and now in practice I don't anymore. But I think it could be very helpful in situations where you're trying to decide if the patient, 'cause someone like this is pretty stable. I mean, all the signs are very, very subtle. Honestly, clinically, this patient I'm probably still watching, right? Mm-hmm. But if you're worried about a league, I think a, a ct, a contrast can be held in this case where. If you see a collection and you can't tell if he's actively leaking or, or not, and what do you want to, what do you wanna do with the situation? I think if you see contracts contrast extra, that could be very helpful to know that this is something that's just started, for example, and, you know, potentially can get worse. So I think it can add some help information and give you a little more of a dynamic information. Yeah, and I, I got, I'll concur with, with Dr. Shinro about it is kind of a subtle subtlety right now. I'm not sure I would. If I'm ready to do something diagnostic at this point, or if his exam really has significantly changed, I think if his exam has significantly changed from [00:04:00] what it was the day prior and he's all of a sudden more pain, having more tenderness in the setting of these other objective findings, the tachycardia and the leukocytosis, then I think it would probably push me more to getting some radiographic imaging about what may be happening at your abdominal. And as far as the contrast, I, I, I. I tend not to use rectal contrast for the same reasons Dr. Rosen described, and I think I, I'm able to generally gather the information we're looking for, whether it's a contained leak or a non-con contain leak. I think one of the issues you're gonna have here is there's probably gonna be some error intrabdominal extra that you're going to have to decide whether that's postoperative versus something that's actually clinically significant. I think they're gonna have a little bit of subtlety to deal with there. Mm-hmm. Yeah. And I not to advocate for rectal contrast 'cause again, I don't use it, but I think that's also where I find it helpful. Yeah. Because laparoscopic surgery there's gonna be post-op air and I think sometimes just seeing that contrast could be had you give you extra information that prompts you to do something about it depending on how the patient is [00:05:00] clinically. Right. Great point. So, so we get a CT with IV contrast, no rectal contrast, but it did show a 3.5 centimeter presacral fluid collection with a small PO si of gas. So given this radiographic poten presumed potential leak, especially since the patient is clinically stable, how would y'all approach managing this patient? Like what factors help you decide whether to operate or to continue non-op management? And when you're in the or how do you decide on the best strategy? So, I, I'll start with, you know, in a situation like this, I think, you know, the patient's clinical condition is really gonna impact. You know, your, your ability to do certain things. If the patient is showing signs of severe sepsis or you know, you know, or goes down the road of shock, then that's gonna be someone that's gonna push you to the operating room. But is he's presenting with this sort of scenario of, you know, some subtle signs of, of sirs [00:06:00] leukocytosis increasing abdominal pain and what looks like potentially a contained leak or, you know, contained per osmotic collection. I think you can attempt to try to drain it. Try to manage it non-operatively with potentially interventional radiology, draining that collection and seeing if you can control this situation without another VE procedure. I agree with Dr. Rezo and I think the other thing that also matters is the patient's overall health status comorbidities. Meaning that can, they tolerate non-operative management and, you know, with a drain and antibiotics. 'cause sometimes the sicker patients don't have much of a res reserve. That you actually want to be a little more aggressive about managing it so that you don't get into trouble. Yeah. Yeah, I agree. I think, you know, anastomotic leaks are one of the things in colorectal surgery that our management strategy is overwhelmingly dependent on the patient's clinical status. If a patient is clinically stable, not so showing signs [00:07:00] of severe sepsis, hypertension, peritonitis, then it is very reasonable to pursue. A more conservative, conservative or non-operative strategy. Because if you take this patient back to the operating room, you really are guaranteeing them an ostomy of some kind within the operating room. But that being said, you do have to find a way to control the infection. So for me, for this patient, I, I look at oftentimes these presacral. Collections are very difficult and challenging for our IR colleagues to drain in terms of having a, a suitable window without bowel being in the way. Sometimes there's some trans gluteal locations that they can get to but if you were to if they were unable to drain it, then I think starting with iiv antibiotics and watching very closely to see how the patient does is a reasonable first approach because, you know, this thing has. Sealed off as a contained collection because if it [00:08:00] was not the patient would be very sick and there'd be a stool leaking out. Yeah. And to answer your question about intraop decision making, someone like this, if I do end up taking to the operating room the first thing I'll put a camera in, in laparoscope and take a look around the belly, kind of see what this fluid is in the pelvis. Yeah. Is it abscess, is it stool? And then at the same time also get endoscope. So, so when you're taking someone like this back, you should put them in lithotomy. You have a flex a endoscopy ready to go, so you can inter interrogate the anastomosis and test it as well. Sometimes something like this is a very subtle, small finding in that you might, you might not see with a laparoscope, but by doing a leak test, you would see that there's there's a leak and you could repair it and something like this. I would personally divert. I would not be comfortable just repairing it and getting out of there. I don't think anybody would. But I think that would be an error technical error. If you took the patient back, you identified he had a contained leak, or even if it wasn't uncontained leak and primarily repaired that leak and didn't divert that. I mean, I think you're setting yourself up and, and really you're setting this [00:09:00] patient up for a failure because that will invariably fail because you haven't given any relief to the problem area. Joe, tell tell, I, I've heard you so many times teach the residents really well about your option. Of what to do intraoperatively. When you go back and there's a colorectal Anas leak, can you walk us through, say, you know, the patient was a little bit sicker and forced your hand to go to the operating room. You, you find a say a one centimeter anterior defect of the colorectal anastomosis. Intraoperatively. What are your walk us through because you, you teach it so well, walk us through what are your options and, and what would drive you personally to each of those options. So, you know, I think it's. It again, it comes back to what you mentioned earlier about the patient's clinical condition. If this, you're taking this patient back and they're in septic shock, this may not be the patient. You're gonna be able to salvage that anastomosis. And if the pa you're, if it's sort of a very damage controlled situation, you can take that anastomosis down and bring up an end colostomy to preserve the patient's, you know, you [00:10:00] know, life or live. If it, your, the patient is in a relatively controlled situation and you have what, what looks like a repairable anastomosis, you could. Over sow that anastomosis with proximal diversion with diverting ileostomy. And that would be your, your other alternative. The one time you might actually resect it and revise it. Mm-hmm. That's a very select few patients. And I don't, there's not a lot of good, I wouldn't feel comfortable with doing that in most situations. If I'm gonna take down that anastomosis, I'm probably not gonna reconstruct it at that time. And I'd be more apt to give him an end if I'm gonna take down the anastomosis. The one time, if we're not talking about an anastomotic leak in the post-op period, if we're in the interop phase and we got a positive leak test during the, during that first creation of the anastomosis, I might take it down, redo the anastomosis, and not defer it as if this is a brand new primary colorectal anastomosis. And it wasn't exactly related to some form of sepsis or infection. And [00:11:00] it's more of a technical problem and we were able to revise the whole anastomosis and redo it without approximately diverting. So those are kind of my, that would be my, probably my most common iterations. And you also want to remember, you probably want to, or you also would typically drain the pelvis. So if you haven't left a drain, and most of these elective sigmoids wouldn't have a drain, I wouldn't wanna leave a drain in case it does still break down. So that you have some form of control of that leak and maybe you have a controlled fistula, though you are diverted approximately, so you don't have ongoing fecal contamination to the pelvis. So that's probably, I guess the, the algorithm that I would describe to the residents. And I think it's, it really is you, options are more when you have a patient that's relatively stable and pre preserving an anastomosis is important. And I guess I can add one other thing, not to go off too far on a tangent. And the other thing that you would want to do that would also push me to try to preserve the anastomosis and repair it is also how low it is. Mm-hmm. If this is a low colorectal anastomosis, like for say, a [00:12:00] rectal cancer, you may not have much left to preserve that patient's GI continuity. So repairing the anastomosis really may be your, the patient's only option to preserve that, their ability to be able to have continuity and taking it down completely and giving up an end. It basically may burn that bridge forever happening again. If someone is getting a sigmoid and they have their entirety of the rectum still there, you still have the option of taking it down. Yeah, that's some really great insight. So, okay, let's say the same, you know, scenario, the same patient was already diverted at the index case. You diverted them intraop and the leak test was negative. But post update four, they present the same, like the same vague symptoms and you're concerned for a leak. What do you do in this scenario? The patient's clinically stable, but they're already diverted. So I think, you know, patients who are, I like the idea of this discussion of anto automatically with a diversion. Though I will say most patients that are diverted, very rarely would they present with like huge symptoms presuming they got, [00:13:00] you know, a pre-op bowel prep and there's not a lot of stool there. Yeah. But for the sake of discussion, there's a great scenario. So if you're, if you're diverted already, you're kind of in a great place to try to do something to fix this. Mm. And it's often best, I would say this is the right time to do something, not operatively, but either, but endoscopically is kind of where I would lean towards doing this. So say you get your workup, there's an your concern for anastomotic leak. You want to, and I'm, I'm stealing Dr. Rezos thumbs are here. 'cause he says this a lot. And I think this is a great point. You wanna get control of both sides of the anastomotic leak. So. If you diverted them, you left a drain in the pelvis. 'cause oftentimes if you're concerned of divert, maybe there was a reason you would've left a drain, then you're kind of controlled on the outside of the anastomosis, on the peritoneal side of the anastomosis. If you didn't then though, and you had some kind of fluid collection, then I would try to find a way to get some type of percutaneous drainage from the [00:14:00] outside. And then endoscopically. I think this would be, if it's a this would be a great time since you're already diverted, to try to take a look and see what the. Defect looks like if it's a small defect that can be closed with some type of endoscopic clip or one of those big bear claw clips are often very effective in the one. Those over the, over the scope large clips, those are oftentimes very can be effective to, to get this. But some of it depends on what the tissue quality is like too. If you're getting in there and you're looking endoscopically and it's like, what tissue paper, not much is gonna hold. With other, you know, there are patient factors that matter too. If the patient had received radiation, you're in a much tougher situation than if they did not. So, you know, there's patient factors that come into play such as comorbidities. There's things that they've gotten before, like radiation there's tissue quality and all those kind of come into play. But my, in this situation that you devised, I would try to be doing something endoscopically to close it up since I'm already done. Good point. [00:15:00] Yeah. So we, I guess, can I briefly touch on when you pursue percutaneous versus transrectal drainage like, and with that sacral collection, and I know you touched a little bit on the endoscopic management of these matic leaks, but are there any thoughts on endo vac suturing the closure success rates with those methods or. I, I will tell you, I'm, I'm not I have not had a lot of experience with the Endo Vac. I know it's being done, but those are, those are more commonly utilized in situations where we have a low rectal anastomosis you know, where you can kind of get to that. A high rectal assmosis is gonna be very hard to control with some kind of transanal rectal. Whether it's a vacuum or even transrectal drainage, we've done that too, where you've actually placed some type of mushroom or malico drain through a trans transanal approach into a presacral cavity. Like Dr. Rose said, sometimes it's difficult to get our radiology colleagues to get into that plate, [00:16:00] but we can sub, we can run a drainage there to collapse that cavity and control the sepsis. It's not the most pleasant experience for the patient by any means to have a drain trans anally. But that is a, a means to control your parent, your presacral collections when you have 'em in this position. Something intra predominantly. Usually you can get some kind of interventional radiology drain. Yeah, you can, you know, the, the endo vx you know, are something that we, we do use it not commercially available here, I think, yet still in Europe, but you can jerry rig one and do it. It requires, you know, at least two changes a week in the operating room. And we use 'em sometimes for these low very low leaks where you don't have other options. I'll say as a final option that is used very sparingly and we talk about here at Cleveland Clinic often is a Turnbull Qta. If you need, if you have someone with a very low leak, you can do a pull through with a delayed choal anastomosis a week later. The function, I will caution is not that great afterwards for these patients, but it is a way to try to gain some GI continuity for these patients with really difficult problems. Yes. [00:17:00] All right. Those are great insights. So lastly, kind of wrap this up, are there any concerns that you look out for down the road with these anastomotic leaks that you manage? Expectantly? Like what are, so, so what are some things you're worried about or looking for? And then thinking even more ahead, you know, when do you consider reversing patients that are diverted and, and you work up involved in that decision making? So in situations with the smaller leaks that you just ended up repairing and diverting, I think those are usually a little more straightforward. You know, just wait in about six to eight weeks and get a contrast enema test to see if there's any evidence of ongoing leak. I think it'll be appropriate before you reverse such a patient. I think the patient's also where you ended up taking down the anastomosis and giving them a colostomy are also easier to manage. I think the situations that can be very difficult to manage are the ones where they have chronic, ongoing leak and then develop or sinus and then they can. Take a very, very long time to heal. You end up, you know, taking them for exams or endoscopic evaluations where you, you know, try to debris the cavity waiting for it to seal. I think [00:18:00] sometimes those situations can be hard to salvage and even if you do salvage them, I do think they can end up with a lot of functional consequences in terms of their bowel habits and, you know, from that standpoint. So I think if there is a chronic sinus tract that doesn't heal, you have no choice but to eventually go back and do a redo like resection and redo anastomosis, potentially divert them at that time as well. So I think that's the way I would think about it. I think one of the other, anytime you have a compromised anastomosis, you have to be concerned about the potential restriction formation of that anastomotic site. Mm-hmm. So part of that gastro and enema or contrast enema that you're gonna be doing, you're gonna want to assess that anastos. It may demonstrate on that EDMA test, but you should probably endoscopically want to look at that anastomosis because invariably, when an anastomosis has been revised in some way related to a leak or a controlled leak or, or even a repaired leak they have a high incidence of stricture formation. Before you reverse that diver stone, you better, you have to be sure that you've assessed for that because that [00:19:00] operation may again, require you to revise or, and redo that anastomosis. Because even though you thought you salvaged it, it may not be a salvageable long-term solution for this patient. So, and you do not, obviously the worst situation you could be in is reversing the ileostomy and then not fully assess that anastomosis and find out it was stricture. And then you really have put this patient in a very difficult situation. Yeah. This has been a great discussion, guys. So let's, let's discuss another case. So we have a 48-year-old woman, stricturing Ileal Crohn's disease on Remicade. No prior abdominal surgeries. You see her in clinic. She's had several months of postprandial abdominal pain, early satiety, some intermittent episodes of nausea, vomiting, and inability to pass gas. Normal CRP imaging showed a short segment, terminal ileal stricture. There was no evidence of active inflammation, and you're concerned for a fibrotic stricture, let's say she undergoes a laparoscopic ileocolic resection, stapled endo side anastomosis. Initially her [00:20:00] post-op course was pretty unremarkable, but now it's post-op day four. She's febrile, tachycardic, increasing leukocytosis. You get a ct, it shows a five centimeter by four centimeter ated fluid and gas collection adjacent, adjacent to your anastomosis. And there's gas tracking along the staple line. Let's say there's more pneumoperitoneum than expected on post-op day four, and you're concerned for an uncontained leak, so you decide to take this patient to the, or. How would you guys approach this case and what are you thinking about when you're in the or? Yeah, I mean, as you already pointed out, this is someone that has an uncontrolled leak. They are septic from it. You really need to be in the operating room with this patient, so make sure they get some resuscitation, some antibiotics, and then intraoperatively. I'm opening in this case. You can consider putting a scope in just to take a look, but my suspicion is high, so I'm making an open incision. My approach to this is usually gonna be resect anastomosis and give them an end ileostomy. The other thing that's going through my mind is should I redo the anastomosis? But someone already leaked [00:21:00] and already sick has Crohn's disease. I would not re attempt that. I think they're better off getting an end and then I can reverse them in a few months. That's how I approach it. I don't tend to repair the IOC colic, resect anastomosis because I think a lot of times the, the leak is from the transfer staple line and you know. The tissue, I just don't think it's easily repairable and salvageable. And then how are you gonna test the anastomosis, even if you divert them like how are you gonna test it down the line before you reverse them from diversion? I think it'd be hard to interrogate that anastomosis. So from my end of things, I would resect it and give them an end of ostomy. Yeah, I, I would agree that would be my plan going into the operating would be resection with an end ileostomy, particularly because she has Crohn's. Disease is a big part of what that plays in my book. I really try for someone with Crohn's disease to not do a diverting loop ileostomy. Even on initial index resections, I'm either trying to do an anastomosis or a resection with an end ileostomy, and that would apply similarly in a, in a take back. The reason for that is to take, you know, [00:22:00] these patients oftentimes need further surgeries, can have further small bowel disease, and reversing an ileostomy. A lot. I don't love doing a side to side staple, revers, oscopy 'cause they start getting disease that's a lot more bowel. You have to resect for the next time they have problems. And I find that you know, there's data that shows that hand sew, taking down these debris with hand some, which some people do, but contend to have a higher rate of obstruction or stricture. And I always worry about that. So yes, I would be doing a resection within ileostomy ear. Okay. So now let's say the patient did not have a leak in the immediate postoperative period, but you're seeing this patient now in the ED two weeks later, worsening abdominal pain, fever, nausea, vomiting. You get a CT scan and imaging shows about a four centimeter by three centimeter abscess near your anastomosis. So what are you guys concerned about in this scenario and what's your management for this patient? Yeah, I think in that situation, this is most likely a contained leak. It's a per anastomotic [00:23:00] abscess or a contained leak. If the patient is, you know, you're able to resuscitate the patient and they're not in shock, I think you would try to percutaneously manage this with an IR drain. And with the idea that you, you may just find purulence or you may end up creating a controlled fistula to the, to the anastomosis. So I think you. You have to know that that's what may invariably happen, but you're trying to control the situation and whether you're just draining an abscess or creating a controlled fistula, this will get this patient out of a, an acute situation that may be, it will be managed again non-operatively. Sure. And so I know we talked about this a little bit with colorectal anem leak. But now we are talking about an ileocolic anesto leak. Would you be concerned about similar long-term complications for these patients managing these non-operatively? I think the, the risk of stricter formation is still gonna be there, and that's something you'll be able to assess endoscopically. You're not gonna do a very good job assessing it [00:24:00] radiographically with enema testing. But you, you can endoscopically assess this anastomosis down the line. And you, you know, so that, I think that that's probably your biggest barrier if you're able to get them through without a reve intervention. But you sometimes you would prefer them just sort of declaring themselves into a stricture versus just willy-nilly back in there and resecting them, giving you an end ileostomy. 'cause there's no, there is morbidity to giving him a stoma. And when you may be able to get them up through an op without another surgery and maybe dodge another step in the, in this patient's. Course with a stoma and then a re-operation, then down the line. Sure. Yeah. You brought up a good point too, Dr. Zo, about stomas. So say you did give an Ill do an ileostomy for this patient before considering reversal, how would you evaluate and optimize this patient and how would her Crohn's disease play into the situation? So it. The main thing before [00:25:00] reversal is, you know, make sure they're recovered. Someone like this, I would make sure I give them probably three months before I go back in there. And then from a Crohn's standpoint, I wanna make sure they have no evidence of active Crohn's disease in the proximal small bowel, and hopefully not in the colon either before I reverse 'em. So depending, hopefully they've already had a colonoscopy before. If they haven't, I might do a quick scope if I can to take a look at the colon. Okay. But otherwise that's kind of, the main thing that I would care about is making sure the Crohn's is controlled before I take them back to the, to full reversal. And I'll most likely try to do an end to side in the Crohn's patient. Yeah. Yeah. And I think, you know, when you have a patient with anastomotic leak, it's really important to be thinking about other ways you can optimize these patients. You know, traditional thinking, I think long ago, talked about, you know. Putting these patients on TPN and keeping NPO, but it's actually really important to provide enteral nutrition to these patients. Let people eat, get their strength up, you know, physical and occupational therapy rehab control all their comorbidities, [00:26:00] really optimize and set yourself up for success. Get them stronger prior to taking them back. You don't wanna take them back too soon. You wanna control all their comorbid conditions, including the Crohn's disease, as you mentioned. Okay. And then do you guys have any. Kind of closing remarks, really big takeaways for management of anastomotic leaks prior to finishing up. I, I think that whenever you have a compromised anastomosis you know, I think it's all, it's, it's your duty, whether you've had to divert them or how you manage that. You try to, before you restore their continuities, that you optimize them nutritionally and you've reassessed that anastomosis for its integrity before you reverse their stone or. You know, bring them back to the operating room. So these are, those are the two big things. And the patient that has IBDI think it's also important to acknowledge if they've had, they've been on steroids, if they, you know, if those things can be weaned off. Usually we, we don't really, we touch on it, but biologic therapy, more times than not, we try to keep them on their [00:27:00] biologic therapy. That there's some debate about some of that type of thing. And, you know, maybe that's not in the forum for this conversation, for this discussion, but. You know, sometimes patients getting a flare of their Crohn's will actually set them back and removing all of their immunotherapy or immunosuppressive therapy is probably not in their best interest, but steroids will be impactful for their osmosis reconstruction. I guess my comment is you know, leak can be a emotional complication for a surgeon. And my pd, my program director from Fellowship will say this in a more colorful way, but he usually says, don't mess up the. You know, mess up. And leak is not necessarily a mess up, it's just one of the complications that happened with the surgery. But my, that is all to say that when it happens, I think sometimes doing the right thing is going back to surgery and, you know, resecting and giving them a bag. And don't be afraid to do that because sometimes people try to manage it with drain antibiotics 'cause they don't wanna go back to surgery. And then you can kind of create a situation that festers and becomes chronic and then the patient's functional outcome is not as good. And it drags on for a long time when you could have just [00:28:00] come back, give them a bag and just wait a few months and then reverse them. So that is all to say in situations where that is appropriate. As tough as that, it is, I think, you know, just doing that might be the right move and sometimes just getting your partners involved, it could be very helpful to help you with that emotional decision. Yeah, I completely agree. I think that's a real salient point that you don't wanna mess up the mess up. You know, it, it is very emotional and getting a second set of eyes is often really helpful because you can easily try to talk yourself in or outta something when you're unsure. Usually the right decision is to go back to the operating room and create an ostomy when you're on the, when you're on the fence. But also remember that the patient's clinical condition is really the driving force of how to manage these anastomotic leaks. Alright, really great discussion guys. That's all for this episode. Thanks to everyone who is listening and dominate the day.