PostOp Leak

Hello everyone. Welcome back to the bariatric surgery team on Behind the Knife subspecialty series. I'm Matt Martin. I'm a trauma and bariatric surgeon at the University of Southern California. Here with the rest of our team. I'm Adrian Dan. I'm from Akron, Ohio. I'm the fellowship director for MIS Bariatric and Foregout Surgery Fellowship at a place called SUMA Health System, Northeast Ohio Medical University.

So I'm Crystal Johnson Mann. I'm a bariatric and foregut surgeon at the University of Florida in Gainesville, Florida, where I, we don't have a fellowship, but I'm our fourth year surgery department director. And my name is Paul Vishnevsky. I am the fifth year general surgery resident at the University of Southern California.

So, for this scenario, we're going to be seeing a 42 year old female in the emergency room who underwent a laparoscopic gastric bypass about 11 days ago. The operation, at least per the report, was uneventful, and she had a negative air leak test. The post

operative course was again uneventful and she was put on a discharge on post op day one.

Her medical history is significant for hypertension and hyperlipidemia and she has no other surgical history. So at home she's been able to keep up with a clear liquid diet but she complains that this morning she experienced abdominal pain and palpitations. You note that her vital signs show a mildly elevated blood pressure and her latest heart rate is in the 120s.

Dr. Dan, when I hear something like this my mind jumps to the worst conclusions. If you were seeing this patient in the emergency room, how would you go about assessing them? Well, unfortunately, Paul, my mind jumps to worse conclusions. Also, I think as a surgeon, you have to consider the worst case scenario.

I agree that these findings are concerning, but you know, you've got to interpret them in the context of the clinical situation. So before jumping to that conclusion, I would want to make sure that I get a full picture of the situation. I'd start with a physical exam. assess her abdominal pain trying to

discern whether it was focal, generalized, how it came on, is there distension is the pain related to something different, like maybe an abdominal wall infection or hematoma.

Then I would ask if she's having any additional complaints. I think it's important to determine if the patient is nausea, vomiting, if they have the hiccups, something could irritate the diaphragm, fevers, anxiety. dysuria, obstipation, all those things are important to consider. And lastly, I would want to check labs and ensure that there's no significant findings.

Of course. So you see the patient just to get a better understanding of their clinical stability and their symptoms, but say over the next two hours, her heart rate fluctuates between 110 and 120 beats per minute, despite fluid resuscitation. And she develops a fever while waiting up to a 38.

1 centigrade. Dr. Mann, does this change your differential diagnosis on this patient? So, you know, when we're thinking about, Things that can be going wrong heart rate is one of the strongest

predictors, as well as fever. So, sustained tachycardia more than 120 beats per minute is a strong predictor for post operative leak.

So, patients that may have a post operative leak obviously can present in these sort of varying formats from sort of insidious abdominal pain to frank peritonitis and septic shock. Oftentimes, patients will complain of abdominal pain with fever and tachycardia, but that's not a given. So, not everyone will do that.

I may just be tachycardia and fever. So in this patient that has a new favor and sustained heart cardia, I am suspicious really at this point, but there are also some other things that could be leading to this presentation, such as internal hernias, pancreatitis, gallbladder disease, small bowel obstruction, and so on.

Got it. So we're suspicious for a postoperative lead, but we can't rule out other etiologies at this point. I think here, with the clinical stability of the patient, it determines the next course of action. Dr. Martin, what would you do next? Yeah, I think you have a couple options. But I think the most important point that a couple of you already

said was, No, I'm going to assume the worst.

And I think where people get in trouble with these, is they go down the pathway of trying to prove it's everything except for the worst thing which usually is a leak. So your top three things on your differential in this patient should be leak, leak, leak. And in your mind, you're trying to rule it out.

First rule out what will kill them. If you'll miss it, then what's common, then the rare zebras. And I think if you take that approach, you will generally be safe. If the patient's stable I would get a CT scan of the abdomen with oral and IV contrasts. You have to remember there are multiple locations.

You can have a leak with a gastric bypass and some of them that the contrast won't reach. You can have a leak from the gastrointestinal anastomosis. You can have a leak from the pouch. You can have a leak from the remnant. And you can have a leak from the jejunum jejunostomy. Some physicians advocate for an upper GI.

It will partially be dependent on your system,

but the data is pretty convincingly showed upper GI alone has a much lower sensitivity than either a CAT scan with a Oral contrast or a combined upper GI CAT scan. So, so I would go for a CAT scan or the combined upper GI immediately followed by a CAT scan.

You really can't hang your hat on an upper GI contrast study. And there's actually literature, a nice study recently has shown that there's improved sensitivity and specificity with a CT scan with oral contrast. As a matter of fact, an upper GI contrast study can give you a false sense of security immediately post op.

All too often I hear upper GI is fine, doesn't necessarily mean everything is fine or will be fine. You also have to know who is likely to get these leaks, you know, certain things can predispose patients a large amount of intra abdominal obesity, as you can see in men. operations that are difficult, whether it may be tension of the gastrointestinal me, all those are things that

you as the surgeon should should know about and help out your local radiologist.

They don't know the patient. They haven't seen the patient or looking at the study, typically not the patient. Plus you can add a CT of the chest to rule out a pulmonary embolus, pneumonia an effusion, intra abdominal bleeding, bleeding in the in the abdominal wall. things that, that may point towards other diagnoses.

Also remember that not every radiologist is experienced at evaluating the anatomy after gastric bypass or other bariatric procedures. Their experience and their comfort level plays a very significant role in their ability to accurately pick up these leaks and these complications. You as the bariatric surgeon have to take a look at every study and you have to help your radiologist out.

And just to kind of add on to the imaging thing, so I do think as we're, you know, as Matt was talking about, you got to roll up the things that will kill patients first, obviously that's sleep followed by PE. And let's just face it, our patients are high risk for PEs as well, so I totally agree

with adding on a CT scan of the chest.

If you're going to be scanning, if the patient is able enough to get a CT scan, period, to be doing the oral contrast scan to rule out a leak, and evaluate the bypass anatomy, but also making sure they don't have a massive PE causing symptoms. And then the other thing about imaging is, remember, their pouch is very small, and so the volume of contrast that they can take in is very limited, and so I usually ask for on table contrast.

So that patients are not in the ED trying to drink an entire Gatorade bottle worth of contrast, because it's just not going to happen. I think it's, you know, worth mentioning that exploration, whether that's laparoscopic or open, depending on the surgeon and scenario, is very reasonable if you're not able to get imaging, especially if you have a very high suspicion for a leak.

And so, We oftentimes associate that operations that have higher mobility often start with nonoperative approaches. However, there's been multiple studies that have shown that there is a benefit to re exploring patients earlier versus delaying expiration for diagnostic or treatment purposes, which when you delay treatment

and worse than the inflammatory response.

And so if I have a very high suspicion for a leak, I would just take them to the operating room without any additional workup. Let's say for our scenario the ED has already ordered the scan before they called surgery, which is sometimes not uncommon. And it shows that contrast is extravasating from the gastro digionostomy into a four centimeter air and fluid collection in the left upper quadrant.

The patient's tachycardic and febrile with evidence of a leak. Are we rushing off to the OR? Yeah I think people would be split on this. And again this totally depends on your system. and where you are and the clinical status of the patient. In my current practice, I would usually be taking these patients to the OR.

The most important thing you need to get is good source control, especially if they're manifesting a septic response. Once you get into the abdomen, obviously you want to do a complete exploration. Sometimes the CT scan has helped guide you, but you don't want to just look at one

area, assume that's the problem.

And miss some other problem, for example, like a distal obstruction that caused your gastrointestinal leak. So it's always important to do a full exploration, even if you've localized the area of the problem. I go in and I just start top down. So I go up to the gastrointestinal ostomy, look at that, run the Roux limb down to the JJ, look at the gastric remnant, and then I'll do a exploration of the abdomen if I haven't found the source.

The most important thing is getting wide drainage of that leak. If you can, do a repair which is usually if it's a small disruption in the anastomosis you can often attempt a suture repair, although even if you do, assume that's going to leak and your main therapeutic intervention here is drains.

The alternative approach some centers would do is go for, non operative management or endoscopic management with a stent plus minus a perc drain if there's a fluid collection. And again, I think that's perfectly reasonable if that's what your system is set up to

do. Yeah, man, I love the fact that you mentioned that the leak may not be the root problem.

There's another problem that has led to distal obstruction, increased pressure and a subsequent leak. So a leak is not a leak is not a leak. There's different types of of leaks and you can have the ones that are contained that are amenable to certain less invasive treatments and the ones where you really have to pull the trigger and perform an exploration and try to figure out how you can get the white drainage in the access to the GI tract for Enteral feedings, etc.

But it's important to mention that in certain situations, in selected situations where it's clinically appropriate to proceed with an endoscopic approach, there's quite a few things in the tool bag of the bariatric surgeon and the advanced endoscopist. There may be the possibility to use internal drainage with double pigtail catheters.

So instead of an interventional radiologist putting a drain from the

anterior approach, you can actually drain these contained, leaks right back into the GI tract. We'll talk about stents a little bit later, but they're notoriously hard to deploy in this anatomy. And they're often poorly tolerated by patients, typically not a very attractive option, but certainly an option.

I also just kind of want to bring up that there had been some other more recent case reports that have reported on non operative management of GJ leaks after a bypass. With the same basic management principles which are adequate drainage, antibiotics, adequate nutrition, bowel arrest. However, that data is somewhat heterogeneous and there's been no recommendations for non operative management of GI leaks after a gastric bypass, but it may be suitable in select patients that are clinically stable, especially in the settings of contained leak.

They're not systemically sick. Maybe a plus or minus a hostile abdomen that you want to be careful about going back into. Thank you. So in these patient cells that we're generally going to explore and try and fix it, but for this patient, we mentioned that there

was a negative intraoperative leak test.

Is there anything that we could do to prevent postoperative leaks in these cases or anything that is done? And do you guys normally get any routine postoperative imaging? The most important thing to begin with is good technique, right, and patient selection. There are some studies that have attempted to utilize reinforcement techniques to prevent leaks, such as reinforced staple loads, over sewing the staple line, and use of biological sealants.

I will say that very few of these have actually been proven to decrease or have even come close to showing a benefit to decreased leaks, but they may have decreased bleeding. And there's more and more evidence that bleeding subsequently may lead to leaks as a hematoma or infected hematoma attempts to drain somewhere in the GI tract and the body finds, finds a path back to the staple line.

But really there have been no high quality studies to demonstrate any benefit from any of these additional

interventions. I think it's useful to perform a leak test with endoscopy once you finish your anastomosis at the end of your bariatric procedures. Although, again, there's a lot of variability amongst bariatric surgeons with regards to intraoperative endoscopy and postoperative radiologic imaging.

Certainly, it's been shown to be beneficial when you can actually identify a leak and fix it, but it does not seem to be beneficial in terms of the post operative leaks that are and the rate that, that occur. Some surgeons have left drains at the gastrogynostomy. And in, in our own practice, in my group, what we've seen is that all too often we would identify, especially when you're worried and you leave that drain in there a little, a little longer, that continuous negative pressure can actually itself create a leak between the lumen of the anastomosis and the continuous pressure into the

negative pressure created by the drain itself.

And we've seen leaks that Initially, we're not there. We studied the patients again, and there's a little wisp of contrast going from the staple line, guess where, directly to where the drain was. At this time, really, there's no high quality evidence that anything beyond the common principles of good technique and avoiding ischemia and tension on urinastimosis would prevent the leak.

Probably the most important thing to understand is the techniques, the training and specialization in bariatric surgery and the technology, especially stapler technology has advanced so much and it's just so reliable that your leak rate should be, you know, 1 percent or less. So if you're dealing with a problem that uncommon, you need studies with thousands of patients in each arm.

to be able to sort out any of that. Well, does this actually help my leak rate or hurt my leak rate? So I think that's important to consider. So these series of there were a hundred patients, you know, in each

arm, that doesn't tell you a whole lot. And my practice evolved. I think probably like most of yours did when I started, I leak tested everyone.

I left a JP drain in everyone. I got a post update one contrast swallow and everyone. And now I still do a leak test for bypass. just an air leak test with a, an NG. I do not leave a drain and I don't do routine post op imaging. And magically they all seem to just do fine. I'm a little bit more junior than y'all, so I will say in my practice, that's kind of how it's been.

Actually, I trained with surgeons who did methylene blue leak testing interop, which is Very helpful if there's a leak, because then the methylene blue goes everywhere, which can be a mess when you're trying to then retest, actually. Versus surgeons who air leak test. My personal practice, I air leak test every single bypass.

And it's helpful if there is, you know, a positive test, because there's a technical issue that you can correct in the moment. Thankfully, that's a very rare occasion. I mean, those

patients do fine. But I tell all my patients, I'm like, the whole purpose of the leak test is to see if there's a technical reason that you should have a leak.

It does not mean that you will not have a leak in the future. It's just, you're looking for a technical reason, like a bad staple fires, like that, so it's helpful when it's positive. It's not super helpful when it's not, it doesn't necessarily prevent or predict. And as Matt said, like your leak rate should be 1 percent or less.

That is the standard of care. Patients need to really understand all of the complications that can occur with a gastric bypass. If there's a leak that this will add additional time to their recovery from anywhere from a few weeks to a few months, depending on the severity and their systemic response and it can change their expectations of their recovery pretty significantly.

So they just need to kind of understand that. This will be a process and it's not a sprint. It's a marathon. It will take some time. So, so you lead test everyone, but are you leaving a drain and are you doing routine? No, sorry. I admitted that I do not lead drains. I can count on the number of drains I've left in the six years

I've been in practice on one hand.

The drains not stay in very long for the reasons that we've already kind of discussed. And then I do not do routine postoperative imaging. I think that was a great review of the management of leaks for these for gastric bypass patients. But to switch it up a little bit, say that for our previous example, we had a similar patient with identical symptoms that came in, but gastrectomy 10 days ago.

Would you do anything differently for this patient? I think your initial management is going to be the same. I mean, high on my deferential basically is the same things as with a gastric with the prior patient. I'm thinking leak, leak, leak. And then secondary to that, I'm thinking PE and everything else that can come out of that.

You're going to evaluate the patient and you're going to kind of see what their complaints are. You're going to kind of try to sort out exactly what is happening. Again, like I said, I would be concerned if you have sustained postoperative psychicardia in the setting of a fever. It would be helpful to start with imaging in this patient though so I would get a CT out of him and pelvis provided the patient is clinically stable to

go to radiology with oral and IV contrast.

And like I said before, add on a CT of the chest. So let's say for in this case it also showed a leak similar to the other patient, Dr. Martin, any any differences in your management? Well, you start by taking out your pen from your pocket and stab yourself in the eye several times.

And this is probably a real important point for people to understand, especially who bariatric surgery is I'll take 10 bypass leaks before I'll take a sleeve leak. These are harder to manage. They almost always have a much longer course, a much more difficult course, and they're just torture, and It's because of the location, it's because of the treatment options, it's because of the response to therapy.

So sleeve leaks are a big problem, and thank God we have the leak rate down to less than 1%, again, with modern technique and technology. It's almost always at the GE junction, or right below it, so the worst place to have it. It's similar to a bypass

leak in terms of your management priorities. You want to get source control.

So you want to get drainage. If there's a fluid collection or abscess cavity, you want to get that drained. Oftentimes, though, that can be done nonoperatively with an interventional radiology drain, and then you start down the pathway of what am I going to do for this leak? Am I going to try endoscopic interventions?

Do I need to try and do a laparoscopy and try to repair it or get direct drainage? But again, and they this will really vary depending on the support you have and whether you have a good advanced endoscopist who has experience managing these, cause these are tough, tough problems. Yeah, and to your point earlier, Matt, I think you also have to consider why you're getting a leak.

It's not always because of a staple line issue. It could be bleeding. It could be most commonly a tie to insessura and our residents and fellows can now appreciate why we look

absolutely insane when we measure millimeters as we try to find the perfect leak. Perfect angle for our staplers. And they're looking at me thinking, what's the difference between those two?

And we all sometimes joke around about how how many ways there are to, to mess up a sleeve. You also have to keep in mind in this situation, it may be a little bit easier to get your GI colleagues involved in with the gastric bypass. They're pretty savvy about some of their stent placements double pigtail catheters into a contained leak again.

And this may allow for the patient to support their nutritional needs with actual oral intake. As it's difficult sometimes to get enteral access in the sleeve patient with a limited antrum and, as we all know, jejunostomy tubes are a disease in and of themselves. But placement of the stents the success rates are pretty high.

But it does require buy in from the gastroenterologist because it does involve multiple

endoscopies, replacements et cetera. And it also involves buy in from the patient. I think it's important to keep an eye on the stents to make sure they don't kink. They themselves can cause an obstruction, they can cause an erosion, migration, and sometimes they're very poorly tolerated by the patient, sometimes causing horrible reflux.

Yeah, I think these are all great options. I think the basic sort of tenet is to get on top of these early because chronic leaks can fistulize to the chest, which becomes a really bad problem with gastroploidal fistulas. When you're talking about sort of weighing the risks and morbidity and that sort of thing and re operating on these patients, it is recommended to allow at least three months.

before not offered management can be deemed unsuccessful. And the reason for that is leaks after a sleeve are challenging because of the high pressures in the sleeve stomach, which can lead to persistent leak, which just never seal. If you're in a situation where

there's a persistent fistula, you've tried everything, you've optimized nutrition, drainage, et cetera, and it's not closed after about three months.

It's likely to require some kind of operative interventions. And you know, there's certainly reports of surgical options that have been described open. Sometimes an open approach is necessary. The robotic approach has made things a little more feasible, given the dexterity and the visual visualization that's provided.

And laparoscopic approaches also of course, conversion to a gastric bypass. If it's feasible even creating a loop gastric jejunostomy to allow drainage of the leak or the fistula into the jejunum and control that. And then come back to fight another day when things are less inflamed or in some instances, a total gastrectomy with esophageal jejunostomy is necessary.

Another option is placement of a T tube to decrease intraluminal pressure of the sleeve for fibrosis around the tube to

occur, subsequent closure of that fistula. When these are treated, even with good surgical therapy the leaks in the fistulas tend to persist in nearly half the cases. Got it.

So the initial management for these patients, I believe we would mostly agree, is non operative especially, mostly if they're stable with percutaneous drainage, antibiotics, ensuring that they have appropriate nutrition, and utilizing endoscopic options if if some other non operative management fails.

If the leak persists, then there are surgical options like Dr. Dr. Dan had mentioned. This patient presented about 10 days after the, their initial operation, which can be a challenging. time to go back in. No, going through the literature, they usually define an acute presentation as under five days. Say if this patient had this happen post op day one where you notice they had sustained tachycardia, fever, abdominal pain, would you proceed any differently?

Oh yeah, I would. So, so

post op day one, you know, if I have a problem, either bypass or sleeve, and it's looking like a leak, then it's a technical failure. Right, your staple line failed or you stapled across something that you shouldn't have. Those I think you should take them back and see what caused the problem.

And usually you have a decent chance of being able to fix it right there. At a minimum, obtain adequate drainage. What you don't want to do is hem and haw and now you're at post op day five to seven and you try to go back in there and everything's inflamed and it's a disaster. So if it was post op day one or, you know, anywhere from kind of one to three to four, I will take them back to find the problem.

And usually you can fix it either staple again across the area where the leak is or suture it or. Put a T tube in it and control the fistula.

Yeah, and I think it's important to, to mention there's been a significant decline in the leak rates. When you take a sleeve gastrectomy historically the sleeve came into vogue as the gastric band fell out of favor.

Initially the procedure was not standardized at all. It's kind of the wild west, different techniques. People would figure out how tight they could make it because back then we used to think that restriction was the mechanism of action. Certainly, we've debunked that people were doing these over 32 French bougies as tight as you could get.

And of course, you'd get a. Dumbbell sleeve with a large fondus that would dilate and eventually blow out. Well, I could tell you my sleeve today isn't anything like my sleeve in 2010 or 2008. It's evolved a lot and we're very careful about ensuring that we leave the right shape. ample room at the insura so that a proximal

dilation does not occur.

That's about three out of four leaks. That's where they occur. It may take a few days for that to happen. And often these are not diagnosed until seven to 10 days after the procedure itself. Matter of fact, in one study, 80 percent of the leaks were diagnosed 10 days after the discharge. Primarily talking about primary sleeves here.

We're not talking about conversions to sleeves which pretends a different leak rate in different pictures, especially if you're talking about bands to sleeves which is a whole other can of worms. But overall, the risk of leak for primary sleeves post operatively has significantly decreased. But they still occur.

And there's been many options that have been proposed to help address these leak rates, such as over, over sewing staple line, using biologic sealants, using reinforced staple loads and such. However, many studies evaluating these options have led to mixed results thus limiting recommendations for their use.

And even with the interoperative leak test, which we often do to

identify a leak, has not been shown to prevent leaks. Yeah, if you want to, if you want to turn the setting into utter chaos, take a group of radiologic surgeons and ask them who uses staple line reinforcement and what benefit it has.

And you'll see utter chaos ensue. You know, I was trained to do it a certain way and that is how I still do it. So I do a linear stapler to create sort of the anastomosis and then I close everything else in two layers with absorbable suture. Yeah. For bypass you mean? Yeah. I do a linear, linear, totally stapled.

So linear stapled asthmosis and then linear stapler to close the. the common defect. Now I'm doing all my cases with residents who can range from an R2 to, you know, an R5. So I try to keep it a simple reproducible approach. Personally, I've started with the EA and switched to a linear stapler. And currently I do hand sewn robotic, but there's some opinions out there amongst bariatric surgeons as to which one is best with regards to leaks and

bleeding.

And I don't know that there's enough data to be able to substantiate those opinions. I mean, I agree with that. I think that there's probably more data relevant to the structure formation rate than there is on leak data. But for the sleeve too, I think the other definite trend I've noticed is surgeons going to lower staple height and being comfortable with that on the sleeves.

Cause I remember again, when we started doing sleeves, it was like all green loads. Then I went to all blue loads and now people are even using white loads for a good portion of it. So I think that's probably as important as, you know, do you use reinforcement or not, do you oversaw or not, using the correct staple height.

Probably the most important thing. And I can tell you from my own experience, I've become more comfortable with using a lower a smaller staple height as we've had more technology, whether a handheld

laparoscopic staplers or in the robotic stapler. To give you some feedback with regards to the thickness of the tissue, looking at how everything else in the world is moving to more technology and artificial intelligence, we have to trust that.

And yeah there's a lot of people using white loads all the way across. I'm not sure I'm quite there yet, but. What staple loads are you using on your sleeves, Crystal? So I don't know what kind of stuff staples, you know, not staples, but stomachs y'all are encountering, but my stomach. I mean, I'm having to force fire black loads sometimes on these stomachs robotically.

So I tend to, what I do is I typically start with a black load in the entrance. I also use tapewound reinforcement, which will add just a hair of thickness. So I have to size up accordingly for that. And then I decrease based off of how many pauses there are on The short form stapler. But what if you're doing a laparoscopic?

Same thing. Singles apply, though. I start with the black load. I feel you see my reinforcement and I listen to how much the stapler is struggling. And that makes my

determination as to, do I stay with this load or do I go down a load? So the stapler talks to you. The stapler talks to me. You know, actually I learned that trick of listening to the stapler laparoscopically in fellowship.

Listening to Bruce Scharmer and Peter Halliwell. Because that, that was how they would determine to kind of drop the load. Based off of how much the sound of the stapler and how it actually was going through the tissue would help them determine, Is this the appropriate load? Can I go down a load? So on and so forth.

It whispers. It whispers. It whispers. All right, well, to close this out we all do leak tests on our bypasses. How about your sleeves? And I'll just start by saying I completely stopped doing leak tests on my sleeves. I found them to be useless. There's several studies actually shown the leak rates were a little higher in patients who had a leak test.

So I've stopped doing it. No leak test. No drain. How about Improperly. Intraoperative leak test, yes. So, you know, I recently changed, I used to do it on every one of them and found very little

benefit from it, especially in the sleeve over a some kind of calibrating instrument where everything went perfectly.

There's just really nothing there and it tends to stretch out the staple line a little bit and cause some bleeding. I will be the outlier here. So I create my sleeves over 40 French. A tube, not a bougie, but the other two, so I won't say what it is for sake of industry things. And I leak test with that tube.

When was the last time you had a positive leak test? I've never had a positive leak test on a sleeve in six years. To wrap this up takeaway points, two different management strategies, I guess, but overall themes are going to be source control, adequate nutrition, antibiotics, and fluid resuscitation for all of these patients.

But for bypasses, you want to hedge or edge towards an operative approach versus the sleeve where you can edmores towards percutaneous drainage and attempting to close the leak or manage the leak non

operatively with varying degrees of success for both. All right. Well, that was great discussion, everyone.

Thanks for tuning in. As always, this is behind the knife. So we have to end with the dominate the day. Although I feel this one, we're going to end with dominate the leak. That's right. To dominate the day and dominate the leak. Dominate the day and dominate the leak.