TSARKOV emicolectomia dx

Good morning, ladies and gentlemen, I'm glad to see you, to hear you, and today, first

of all, I would like to say many thanks to our organizing committee for inviting us,

our clinic to demonstrate our specific for Western countries surgery, our experience

for lateral lymph node dissection.

You hear and can see the presentation.

The patient is really difficult.

but you saw that the tumor was very difficult also, and we start early this morning and do these procedures previously, before the lateral lymph node dissection.

It was almost complete total mesorectal excision. We call it extrafacial resection of the rectum.

with partial rejection of seminal vesicles from the right side

and also with rejection of pre-sacral fascia from the posterior,

mostly part right side also, part of pre-sacral fascia.

and you also can see that

here is the

peritoneum covered

bladder

here it was very close

and it was connected with

tumor, tumor is

here you can see

it is a huge tumor

And if you look at the distal margin, the distal margin is okay.

And you can see that here is the end of the mesorectal.

That's why I think that we made a complete mesocollic mesorectal excision.

And also you can see that the distal margin is okay, because it is around 10 cm, you can see this, maybe a bit less, but this specimen looks very nice, I think.

And you also can see the aortic area without 253 groups, because we removed it separately.

Separately, here is the intermediate part of the mesocolic misorectum lymph nodes, and here is the paratumor location of the mesocolon.

You also can see that it is an extra-fascial type of resection.

You can see that here, right after promontorium, we include to the resection margin,

we include pre-sacral, hypogastric and pre-sacral fascia too.

Here you can see a huge fibrosis after radiation therapy, and we need to remove it together with the specimen.

If you have any questions about the tumor, I can answer it.

Do we have any questions?

Can they hear me?

If you have any questions, I can answer.

Here you can see seminal vesicles from the right side. I also can show you how it was.

Because there is a pre-hypogastric fascia here with a hypogastric nerve from this side.

I should stop this very small bleeding, but it is necessary because if you have small bleeding, it will be not convenient to see.

Okay, I think it's okay.

And you can also see the left branch of hypogastric nerve with pre-hypogastric fascia.

And we should resect the distal part of this fascia together with pelvic plexus

Yes, from this side and from that side also, especially from this side, because it was the tumor penetration.

It made the perspective of our patients for his good sexual function very, very controversial.

But we have no choice in this case.

If you have no question about the previous part of procedure, we will start our procedure for lateral lymph nodes.

As you can hear from our demonstration, there are some lymph nodes, one of them is very

species for metastasis, that's why we need to do bilaterals, bilaterals, this is my

Let's start with the left ureter in this case, because we need to move hypogastric vesicle

fascia and find our first plane of dissection.

It's going around the ureter and also hypogastric nerves and you can see that we have here some

kind of plan of dissection looking as embryological plan during the TME, you can see.

And we should go deep and deep, because we need to reach the end of this space, going to the end of the pelvic plexus,

for exposition of lymph nodes

located around the internal part of internal iliac vessels.

First of all artery.

We have small bleeding here.

Okay.

If you can, Volodya, put it there.

Do you have another one?

specimen will be not, the planned dissection will be not good looking.

It is not so easy to go here, even if you know that it is exactly an embryological plan of dissection, because fibrosis is right here.

Okay, I think we can stop to go here, and the next step of our practice is going around the external iliac vessels.

very important, and usually it is a good-looking anatomical landmark, and usually it is simply

to reach this anatomical structure and go around.

We are not to try to remove all lymph nodes around the external iliac, because from the

external side of the external iliac, there are some lymph vessels and lymph nodes going

going from the leg, that's why we do not try.

It doesn't matter for us, for our pathology, I mean for rectal carcinoma.

It is important for gynecologists or for urologists, but not for colorectal surgery.

That's why we never remove lymph nodes from the external part of the external ILEC artery.

Here you can see that it is internal ILEC also.

And also we can see the external ILEC VN, which is going here, and so we reach the external ILEC VN,

it gives us the possibility to operate from the external side.

It is not so usual anatomy, you can see musculus ptolus,

it's located a bit laterally than usual.

Usually we have the artery just above the vein,

but not in this case here it is some anatomical variation and next our step

we should go deep to the obturator space to the direction of psoas muscle

Okay, we enter to the operator space.

Here you can see the border of the musculus psoas, psoas muscle.

and we go around it to the arcus tendineus from the left side.

going from the external iliac, and if you damage it, it will be a bit bloody.

Maybe not a bit, it depends.

That's why in every step of this procedure, you should go very carefully,

and you should remember also about the variations of this anatomy,

because the vessel anatomy of this area has some variations.

Not so often, but here you can see that the vessels which I damaged right now was very small, but the bleeding was very, very, very small, but the picture changed.

So, step by step, we should go to the direction to the pubic bone.

Here you can see Arcus tendineus, and this is the internal obturator muscle.

We need to expose a bit this peritoneum.

And we should be very careful with this.

Yes, yes, yes.

In this direction, in the direction of the bubble.

The space, operator space of these patients is not so wide,

but right now we should...

This is a very important structure for our procedure because this is the obturator vein.

Today we use Storz equipment, HD.

And you can see that visualization with this equipment are very good.

It is not modern equipment, we are waiting for the next generation, which is going to

which are going to be this December in our clinic.

But you can see that HD is also very good.

Because you can see that the blade is very

narrow, and you can use it like an electric coagulation.

Maybe even better.

Here is the obturator nerve, or VN, I'm sorry, and usually we, it's possible to just cut this for preventing of bleeding, because if we do not do this, it will be very difficult to go down.

I damaged some accessories branch of operator wing and it's bleed. Right now it's stopped and we can go further.

You can see that the operator space is very deep, and we should do some exposition for going to the deepest part of this operator space.

The better way to go from the site of the urinary bladder, here you can see also some

kind of embryological plan of dissection.

And here, the main vessels which go in here is the umbilical artery.

I can say that not just in Italy, there are many, you can see this procedure.

Today, we also translate our procedure for our Russian colleagues, and I cannot hear

the Italian part of the audience, auditorium, that's why I asked our Russian colleagues

Maybe they have some question at this moment.

Yes, please.

Practically, I can say that not a single vessel,

except for the lateral and subarachnoid arteries,

does not lead to a fatal situation.

If you cross, if there is a proliferation of the process in the outer air vein,

then its intersection, as a rule, is not accompanied by life-threatening complications,

There is a serious syndrome, a violation of the venous flow from the lower limb, but it does not pose any life threat.

It does not pose any life threat.

Arteria, if you cross the artery, then I will ask you to translate for the Italian audience.

If you cross the artery, then the situation is more serious here, and if you yourself own the technique of the vascular seam, then it will require you to fix this artery, because then, in the opposite case...

As for such arteries as the parietal artery, the parietal vein, the visceral branches of the internal subarachnoid artery,

their intersection, as a rule, will not entail any consequences,

because they are well compensated by other vessels.

I must say that even a two-way intersection of the visceral branches of the internal pituitary artery does not cause damage to the internal organs.

You can see that we almost reach the deepest part of the operator space.

The deepest part of the operator space is Alcock Canal.

Now, pudendal vessels go in, and we have to remove these lymph nodes from this area, because it is very important for low rectal carcinoma.

It is the usual way for low lateral recurrence in this area.

If you remember, this patient was radiated.

That's why you can see the special idioma after radiation therapy.

Let's be silent with the Italians.

Traumatic?

Ah, traumatic.

It will be translated into Italian, yes, the question?

I will answer in Russian, then I will translate it into English.

I cannot exactly answer the number.

We have already joined the line of rejection from the side of the rectum.

This means that we have reached the desired point.

Here we have the Alcock Canal, and here we will now plunge into the locking system.

intersect pelvic plexus together with hypogastric fascia.

That's why here you can see the hole

which connected this space with perirectal space.

And now we can go from the other side to the same place.

The patient with whom we reconstructed the subcutaneous artery together with our vascular surgeons was yesterday.

There is a very interesting anatomical situation.

The patient came to us about hardoma and we met for the first time.

Yes, for the first time, our vascular surgeons have also confirmed that it is a rather rare situation when the division of the outer subcutaneous vein occurred at the level of the third sacroiliac.

Excuse me, yes, the outer one, the internal one, and, excuse me, not the outer one, but the total subcutaneous vein occurred at the level of the internal one.

The previous patient with a complete intersection of the vein is still in the clinic.

There is a fourth relapse.

Before that, there was already an attempt to resect the external subcutaneous vein of this patient.

The fourth relapse was operated in several oncological and pathological departments.

For our Italian colleague, I can translate.

I have a question about the resection of the vessels in this particular area, I mean lateral area of the pelvis.

If we reject any branches of internal iliac, it doesn't matter.

There is no any specific disadvantages after this.

But the question was also about the major vessels like external iliac and vein and artery.

and we discussed the indication and contraindication for this resection.

For example, in our clinic yesterday was a patient with resection of external eyelid artery.

And our vascular surgeons made a prosthesis after this resection.

It was for her doma.

Unfortunately, these vessels and this specimen

is very, very, how to say, specific.

There is no strong fascia around the vessels, around the fat tissue.

That's why it is possible to have bleeding during this dissection.

We should clear our dissector.

I like harmonic scalpel very much because it's very easy to do the procedure,

especially around the vessels.

It's really easy, easy to train, easy to operate.

rate, the incidence of damage using this scalpel is not really high, that's why I prefer this.

And I can recommend this instrument for all of you, because if you are not experienced

Experienced surgeons, it is easiest way to do, to start major surgery.

Well, they don't wash the rubber band like that.

Only the rubber band, they don't need to put it there.

This patient, I'm not sure 100%, but I'm sure at 70% that this patient has the positive

lateral lymph nodes.

And if you left it, even after radiation therapy, the recurrence will happen 100%.

If we remove this, we can have from 60% to 70% of five-year recurrence-free survival rate.

In our series, which is more than 150 patients, we have 75% of recurrence-free 5-year survival.

We had the same oncological result.

I understand what to do we were asked a question about tactics with lateral

relapses sometimes they can be operated if not very late they are late for when I

When I say late, for lateral reflux, it means that this reflux is already beginning to grow in the sacroiliac nerves, in the muscles, in the esophageal muscles, then you can't do anything anymore.

And if this is not there, then, in principle, it is possible, quite possible, such an operation.

Recently, from one of our regional centers, we were sent a patient who had a complete response after the radiation of the anal canal cancer, but there was a relapse in the lumbar lymphatic node.

There is no way to say that there was a previous relapse.

We had to resect almost all the branches of the internal arterial artery in order to remove it.

Nevertheless, we managed to do it.

We have now reached the same level of our lymphodissection as we did at the top.

and we take the rest of our fat tissue from the distal part of the

Now we reach the distal part of the obturator canal from the medial side and we remove all head tissue from the bladder wall.

Let's pray.

Although the questioner, in principle, is not far from the truth,

that, in principle, it does not have any...

Well, we need to stabilize it, because you are disturbing me now.

Unfortunately, there were, but it is accompanied, and you should know that it is always accompanied by quite pronounced violations of the function of the lower limbs.

Here, in particular, in our patient, who we resuscitated the vein, we had to remove and resuscitate the sciatic nerve.

And, unfortunately, this is still accompanied by certain functional violations.

Let's get in from there and start lifting.

You can see that we reach the lower part of our dissection.

You distract him, you started to deal with others, and this one tore up.

That's why we should a bit free our specimen from the proximal part of the obturator area.

There was a question whether we crossed the clavicle nerve. We crossed the clavicle nerve many times. When we started our activity, we even had one attempt to reconstruct it together with our plastic surgeons, with whom we worked in the RNCH, in particular, Ruben Tatevosovich Adamyan.

совершенно потрясающий микрохирург пластический хирург мы восстановили его соответствии с

правилами микрохирургии но надо сказать что в последующем когда мы и не восстанавливали

результаты у нас были абсолютно аналогичные через несколько недель определенных ограничений

in the lower limbs, we then had a compensation, that is, the

lumbar nerve itself does not carry such a special load on the leg, that is,

there are no special violations of the lower limbs, the other thing is the

sedation nerve sedation nerves are more complicated but we had

options for rejection some patients experienced serious

difficulties but also by rehabilitation events in the future

managed to restore their activity now we are approaching the proximal

and you should find the nerve of the proximal part.

Here is a rather unpleasant area.

There is definitely a lymph node.

And there, you see, there are also veins.

And if you are not careful here,

then you can get quite unpleasant bleeding,

tечение при остановке которого как раз очень часто и происходит повреждение

запирательного нерва ну вот мы достигли его мы уже помним что мы с вами отсекли

конечном итоге запирательная артерия вопросите вена у нас еще сохранена не

it or not, but in any case, we will now wash the camera and it will be a little clearer where we are and who we still have

is not easy to reach this point, but we are lucky, we are almost finished with this area.

Also, our listeners are absolutely right, you can also do it from the umbilical artery, it can also be crossed, and then it is much easier to work without arteries when you cross them.

Well, today we have an opportunity to demonstrate, to show how we can work through the preservation of these vessels.

Take it like this.

I explained to our Russian audience that it is possible to cut the umbilical artery without any functional disorders.

But today we try to demonstrate how it is possible to preserve.

So, we removed the main fat tissue from the obturator space.

And now we should complete our dissection just from the, we call it second space, between

hypogastric, pre-hypogastric fascia and internal islet branches.

I think there is nothing

there is just

we should

unfortunately right now

we cannot use

ICG maybe a bit

later

it will be possible in Russia

because there are some

logistical

problem with this

equipment right now

but

Liquid here.

That's why we should use a bit more than usual.

As I said, this is really nothing.

There is nothing here.

Let's try.

What else is good about the ultrasonic scalpel is that you can work freely in the area of the nerve.

Literally on Wednesday, we did robotic lateral lymphodissection.

There, the preference is given to electrocoagulation.

Well, today there is no mobile arm for the ultrasonic scalpel.

Well, there, the moment of release of the lumbar nerve is accompanied by the twitching of the leg.

But also not very long.

Okay, so I think we finished here, we just, let's put something here, I think while we are working on the second space, it will stop.

So, now we have to remove the lymphatic nodes from the second space.

Put it down, put your clamp, put it here, very high, yes, here, in place, yes, yes, yes, that's great, good, that's it.

Now we go to the same space, but from the inside, from the side of the vessels.

Accordingly, we need to remove this bandage.

Sometimes it happens, such a challenge is accompanied in order to eventually stop.

Is it dry here? What is it?

There are bubbles.

Let me take it from there.

There it is.

There it is.

We came to it from there,

but we still can't get to the end,

you see, we still can't get to it.

Here we have

the remains of the pelvic weave.

It is not all preserved,

especially the distal part,

under such a question

about preservation.

But we need to remove the gap between the pelvis and the internal air vessels.

Here, unfortunately, we have a fairly pronounced sclerosis.

And I don't think that this is only connected with urinary therapy, but also, in all likelihood, with the inflammation that was in this zone.

Here you can see the hypogastral nerve, we need to separate the fascia, because if we go now outside the fascia, here we have, you see, there was also already removal, but it was done during the operation on the rectum, here, since there was already an extra-fascial situation.

You see, I'll show you now, we even resized here, this is our piriformis.

Here is the piriformis muscle, the gluteus maximus muscle.

This was done during the removal of the rectum.

Accordingly, in this direction, it is not quite usual to have to go down.

See, I can't pass here from here because of the inflammation that was here, because of the fixation that was here.

Now it's more or less opening for us, it's all.

So, if you show me.

Not up there, but on the contrary, take it here and not here.

I have the maximum.

The upper part of it is a wolf.

Well, what is it? A wolf.

And this is a very serious zone,

because here we have, right under the artery,

and sometimes outside of it,

there is a vein, an internal subarachnoid.

Very often it happens that we speak

and discuss at our coloproctological conferences

The blood flow from the so-called prosacral veins is very often the blood flow from these vessels.

You see, the changed tissue, I don't know what character it is, you have to cut it off.

Only here the unfiltered, healthy tissue appeared.

But, unfortunately, here is very serious inflammation, and we have to do it.

Unfortunately, this is a very serious inflammation,

which we found during the rectal cancer therapy.

It's very, I'm trying to find a convenient way to do it.

Humor mass here, we don't know really what is it.

That's why we should remove it.

Second space, I'm telling you.

Did you get it? Is there something?

We definitely threw it.

Here it is, there is no space between inflamed tissues and normal tissues.

together with the with the vessels not possible to remove without vessels and i think it's

oncologically

Take the clip.

Take the clip.

You have the left one there.

Give it to me, please.

Press it.

Try the oligarch.

This is the reading one.

Let's go.

This is a bad clip.

Here it is.

I'll take it off at the bottom while I hold it.

Do the maximum.

This is not usual, but a possible situation when you are working during resection, are

working for the resection of internal iliac.

This is inferior cystic artery and vein.

Why are you giving me all this?

And we should resect this also.

Clean this vacuum cleaner for me.

Yes, yes.

Give me a big clip.

The thing is that it bleeds on both sides.

It doesn't work for me, it disconnected.

It doesn't spin.

For what reason we received this blood loss during this procedure?

But I hope this will be a bit easier than previous.

This is the, this arterial trunk and the venous trunk is inferior cystical artery.

Okay.

Now it is complete.

Unfortunately, we have to do the reduction of all visceral branches of inferior mesenteric artery and vein in this area.

together with all sacral nerve in this area.

Our, for his urination, connected with right side pelvic wall,

wall, because there are some branches there, which maybe help him urinate after the operation.

Unfortunately, this advanced case needs to remove all branches of the wall.

Okay. You can see that here it's also artery, which we dissect during the rectal cancer surgery. Okay. Are there any questions for this side?

The anatomy, this is left ureter, this is the hypogastric nerve, but unfortunately, just

it going to the rest of the pelvic plexus,

bladder wall, umbilical artery.

Here it is the alcochal channel

where going the pudendal nerve,

the pudendal artery and nerves.

There is obturator vessels, and we should clear a bit of them.

muscle levator ani muscle what else can i do if there is no question questions we should go

to the other side сколько времени а сколько времени сколько сколько 12 22 да то есть у

нас еще осталось там полчаса на следующую да ну давайте сторону на эту сторону поверните

This operator space we put here in reason not to change the place of this for pathologists.

And we start with the same maneuver from the other side.

There is the obturator space.

Maybe just these branches.

We'll see going from the other side.

You will need to...

Let me close the window.

Just press it.

Now I will intercept it.

And how is it with you?

What did you do?

I held it from the side.

It feels like you are tearing it.

Petya, take it away.

And also you saw the method of deciding this problem, I hope.

Really, today it is a difficult case for demonstration, unfortunately, but very often in Western surgery, we have such kind of patients with big tumors, with enlarged lymph node, with big fibrosis after radiation.

therapy, not so easy, pelvis, looking at the anatomy, but anyway, this is our world, our

Maybe accessories, circumflexor, maybe operator.

Sometimes it happens.

But anyway, we should cut it.

Because with this, with this vane, it is not possible to reach this part of the rotor space.

Okay, finally, this is for dissection, and I hope you will have less problems.

Well, then it's over, I don't want to do it.

In the case of the experiment of remodeling, as you said, in Brest,

you want to make a statement about the local residents, even if it is a problem.

At the same time, if the experiment is located in this area,

What is more important is that the rate of local recidivism was 25% and the majority of these recidivisms were in the side wall area of the total number of patients.

The rate of local recidivism was only 6%.

These data confirm that the initial increase in the number of patients was 34% or more.

we left some branches here, some branches of sacral nerve, this is inferior cystic artery,

This is the last, maybe third and fourth branches of sacral nerves.

And maybe it gives him the possibility to urinate after surgery.

Okay, it means that we finished our bilateral lymph node dissection.

It was a very extensive today's surgery.

It's complicated, but it's possible to do.

Yuri Yevgenievich, maybe we should say goodbye to our Italian colleagues.

I think the procedure is almost finished.

We just should remove our specimen.

You can see.

And create anastomosis.

And I think it is the other procedure.

It is anterior resection procedure, not low rectal, not lateral node dissection.

I would like to say all of our Italian colleagues goodbye.

If you have any questions, I don't know how, because there was no one question from the floor.

Please, do it. If not, we finish our translation. Thank you very much. See you.

Professor Kitsenko? Can you hear me?

No, he is asking you, he is asking you to finish Russia. I think it is technical. Hello, hello.

Hello, congratulations for the wonderful operation demonstration of technical skills.

Can you hear?

Thank you, thank you.

Yes, it was a very, very high challenging situation and we have appreciated all the steps

And in particular, the unexpected situation that we can meet during this operation.

So it was a very, very useful demonstration.

But in your experience, how is the percentage of this procedure?

I don't remember, and what are the most important outcomes that you have in your theory?

I'm sorry, I don't understand the question.

In my theory, what question?

The percentage of this operation for all the rectal surgery that more or less you have.

Okay, okay, okay, I understand, okay, I understand.

You know, since 2006, we made, until now, we made 150 lateral lymph node dissection.

Not always bilateral, maybe 10 or 15% of them were unilateral.

Since that time, we try to use selective policy,

because previously we did a study for prophylactic lateral lymph node dissection.

We did 950 rectal cancer cases.

It means that around 15% of our patients need selective lateral lymph node dissection.

It's especially for low rectal carcinoma.

This case is not usual because it is mid-rectal carcinoma, but this patient had mucin-producing carcinoma.

It is a very strong indication for lateral lymph node dissection.

And even if that is located in the middle rectum, it is often metastasized to the lateral area.

area. What else?

Around 15%

of our patients need this procedure.

We calculate the

incidence. You know, we have

two periods in our practice for lateral lymph node

dissection. First was till

until 2017, when we found a beautiful calculation scale, and now we use it for selection of patients.

Before this, we made 120 patients, and the incidence of lateral lymph node metastasis was around 30%.

29 and something, I don't remember exactly.

Around 30%.

What was interesting in our series, the incidence of metastatic lateral lymph node was the same in both groups, after neodevant hemeradiation therapy and without neodevant hemeradiation therapy.

Moreover, the five-year survival was also exactly the same.

Unfortunately, we can say till this moment that in our series,

the connection with neoadjuvant chemotherapy,

this aggressive surgery doesn't help us to improve results.

in terms of overall survival and in terms of local recurrence.

Now we use, as I said, the special calculation scale for finding of these patients

and the incidence of finding the positive lymph nodes is 70% in the last 28 patients.

Hello?

It's a very nice, very important experience here, and what about the indication,

Because I lost the first part of your presentation, we are discussing the case.

Do you use the MRI only, or the PET scan to evaluate or to select the cases for this operation?

That's why we didn't have MRI before neoadjuvant chemoradiation therapy.

But after chemoradiation therapy, they did MRI in this regional hospital and found out that there is serum plus patient after chemoradiation therapy.

and they also found that these patients had bilateral lymph nodes, enlarged lymph nodes.

That's why they sent these patients to us to ask to do this kind of procedure.

I don't know, did you see the specimen before lateral lymph node dissection?

I demonstrated this.

It was extra-facial anterior resection with removing of hypogastric fascia, pre-sacral fascia,

and also partial resection of piriformis muscle from the left side

and seminal vesicles and partial resection of pelvic plexus from the right side.

Just after that, we connect with you and demonstrate that

that even it was really complicated part of procedure,

but lateral lymph node dissection was also not simple, as you saw.

It was a bit bloody.

It needs resection of internal islet branches from both sides

and removing pelvic plexus from the left side

and partial resection of it from the right side.

It's really, how to say, a very, very difficult case

with not good prognosis.

If we look at our data, I can say that if we receive bilateral lymph node metastasis

and we receive more than three lateral lymph node metastasis, there is no chance for these

patients for survival but we never know how many and where it will be located I mean lateral lymph node metastasis and we do what we can in this case.

It's extensive surgery, but it is the only chance for cure, if the disease will be not aggressive.

Maybe some of the enlarged lymph nodes will be not metastatic.

Yes, I agree completely.

The last question is, have you ever used a robotic surgery,

and do you think that may be useful, or maybe for this challenging situation, useful in some part of the operation,

for example the vessel repair or other steps? What do you think?

that's why we

decide to show you

laparoscopic

because I know that robotic

surgery in Italy

is not

widespread

not widespread

I think

that

I recommend

for that surgeons

but

you know we have one

One trainee here from Bari, Antonio Arcangelo Piccarello, he is from Donato Altamara Clinic.

He spent here almost one year, and right now he can do lateral lymph node dissection using our style, using laparoscopic and open techniques.

I recommend to start this complicated procedure with complicated and unusual anatomy for usual colorectal surgeon.

I recommend to start with some open cases and then step by step start to do this laparoscopically.

Maybe your skills will be for not these advanced cases, but maybe for more simple cases.

And I was lucky I started when radiation therapy was not so widespread in our country.

That's why it was a period when I can train without radiation therapy.

You can see that after radiation therapy, a lot of fibrotic tissue, a lot of edema, liquid in operating field, and also a bit bloody in these cases.

But anyway, it's possible to do.

Yeah.

Congratulations again, and good job.

Thank you very much.

Good luck.

See you.

See you.