Fuld transskription af The Laser's Edge: Revolutionizing Endometriosis Treatment

You tell me if I'm right or wrong and then slew after that. 00:02:17.956 --> 00:02:20.242 So st louis university began a center there. 00:02:20.361 --> 00:02:26.911 I was there for 10 years very now private practice here at st luke's, and you and don summers work closely together. 00:02:26.911 --> 00:02:27.370 Is that right? 00:02:27.411 --> 00:02:38.165 yeah, I have an independent but we operate here at St Luke's for mostly the deep endo or advanced endo cases that can involve the bowel, sometimes the bowel resection. 00:02:38.165 --> 00:02:39.936 Those are done with Dr Summers, who's here. 00:02:40.016 --> 00:02:46.094 Yes, so my understanding is you know you have this the lining of the uterus. 00:02:46.094 --> 00:03:02.326 It's this thin layer of cells called the endometrium and they slough off and go out of the fallopian tubes and into the pelvis and grow into these, sometimes masses, that cause trouble with the anatomy and inflammation in the pelvis. 00:03:02.326 --> 00:03:02.728 Is that? 00:03:03.310 --> 00:03:03.510 Okay. 00:03:03.510 --> 00:03:06.498 So a two-word definition is ectopic endometrium Okay? 00:03:06.498 --> 00:03:08.665 Is ectopic endometrium Okay? 00:03:08.665 --> 00:03:14.534 Which means cells that are normally in the lining shed during the period, found in the wrong place, outside the uterus. 00:03:14.534 --> 00:03:18.319 So now, how do they get there, is the question. 00:03:18.319 --> 00:03:20.817 So again, they're, by definition, outside the uterus. 00:03:21.189 --> 00:03:22.657 The number one symptom is painless periods. 00:03:22.657 --> 00:03:26.221 It can affect or cause pain and infertility. 00:03:26.221 --> 00:03:41.438 The number one theory of how they get outside the uterus is this backflow theory that you described, or the retrograde menstruation theory of SAMHSA, which is when a woman is having her period she bleeds backwards through the tubes in those cells and plant. 00:03:41.438 --> 00:03:45.099 That is still the most common and traditional theory. 00:03:45.289 --> 00:04:11.733 But there's a lot of problems with the theory, like endo has been found before the very first period, after the last period, outside the pelvis, lungs, brain, back of the eye in men, places where backflow cannot reach, and it leads to a lot of endo myths, things that aren't true, like if you take out the uterus, you're going to take out the source of endo, based upon the backflow theory, so that you cannot have endo without a uterus. 00:04:12.915 --> 00:04:21.331 That is a hundred percent not true, especially if you've left the ovaries, which can stimulate the endo again, which is, by definition outside the uterus, you've done nothing to the endo. 00:04:21.331 --> 00:04:33.822 If you just remove the uterus or they're going to say, well, if you can stop the periods, that's going to turn off the tap, stop the, and so you can't have endo after having no periods for a long time Also, 100% not true. 00:04:33.822 --> 00:04:42.355 People have

said that the number one thing we can do to really help women with endo is to get rid of the bad theory because it leads to endomus. 00:04:42.355 --> 00:04:46.187 So modern day theories include stem cells metaplasia. 00:04:46.187 --> 00:04:52.654 The cells just change and that may be at a particular window in a woman's development, so it doesn't keep happening. 00:04:52.654 --> 00:04:55.260 It's not an ongoing process, which? 00:04:55.260 --> 00:05:01.302 So then, if you can cut out the endo and do that well, you can have great outcomes, which is what we're showing. 00:05:01.710 --> 00:05:16.494 Yeah, I got you and so, and like everything in science and medicine, it's always way more complicated than you think, and so that's fascinating to hear kind of the competing theories right, and hopefully in time we learn more and more about it. 00:05:16.494 --> 00:05:45.356 And so what you do which is very unique and there's only a few doctors like you in the country, is my understanding you go in with your CO2 laser and remove these pockets of ectopic endometrium that are in the pelvis, that are causing pain or changing the anatomy of the uterus and the fallopian tubes and the ovaries, causing infertility, and sometimes these are really tedious, meticulous surgeries that last a long time, right? 00:05:45.376 --> 00:05:47.221 So this disease starts off on the surface. 00:05:47.221 --> 00:05:51.750 As the disease progresses it can go deeper. 00:05:51.750 --> 00:05:55.821 You can get a ball of it in the ovary, called a chocolate cyst or endometrioma. 00:05:55.821 --> 00:05:59.918 You can get a ball of it in the bowel or the bowel wall, called the bowel nodule. 00:05:59.918 --> 00:06:00.981 That can make things stick. 00:06:00.981 --> 00:06:03.775 In fact the disease can make all the anatomy stick. 00:06:03.775 --> 00:06:10.822 So in advanced cases you can get what's called a frozen pelvis, where uterus, bowel tubes and ovaries are all stuck together. 00:06:12.289 --> 00:06:18.441 So I like to start by saying there's a TED talk called the most common disease you've never heard of. 00:06:18.441 --> 00:06:19.783 I love that title. 00:06:19.783 --> 00:06:20.225 That's endo. 00:06:20.409 --> 00:06:27.582 Everybody knows somebody with endo and the common phrase out there or thinking is you know, it's one in ten, hashtag it. 00:06:27.582 --> 00:06:31.572 That's the rate of endo, but it's much more than that. 00:06:31.572 --> 00:06:37.203 Okay, the two main things that endo is associated with or causes is pain and infertility. 00:06:37.203 --> 00:06:40.697 So if you have infertility, no pain, it's at least 50%. 00:06:40.697 --> 00:06:49.345 Pain that does not feel better with hormonal suppression or birth control pills over 80% Pain and infertility it's over 90%. 00:06:49.345 --> 00:06:50.749 So it's so common. 00:06:50.749 --> 00:06:52.032 Everybody knows somebody with endo. 00:06:52.032 --> 00:07:11.744 The usual treatments the status quo I like to call it is band-aid therapy for pain, hormonal suppression of some kind, whether it be chemical pregnancy with birth control pills or chemical menopause or all the newer medications for pain bypass therapy for fertility. 00:07:11.744 --> 00:07:15.297 I call it like IVF bypass the problem, you know. 00:07:15.297 --> 00:07:20.255 Make a baby in a test tube or this idea that you're going to have to have surgery every couple of years for the rest of your life. 00:07:20.255 --> 00:07:25.014 That status quo, that usual treatment, is not satisfactory to most women. 00:07:25.956 --> 00:07:29.903 At Restore Center for Endo our approach is to remove the actual disease. 00:07:29.903 --> 00:07:32.234 We call that root cause treatment. 00:07:32.234 --> 00:07:47.773 Remove the disease to avoid the need for long-term suppression, basically because it's gone to lead to natural fertility and hopefully recurring natural fertility, and for the hope of one and done surgery, which no one thinks is possible but we're showing is possible. 00:07:47.773 --> 00:07:54.552 We just published our 10-year study from our experience at SLU, st Louis University, and our rate of repeat surgery was very low. 00:07:54.552 --> 00:08:09.937 It was under 5% in 10 years and even without most patients taking any long-term suppression post op, the usual rates of repeat surgery after the burning, which is what most people do, is 50, 60, 80%. 00:08:09.937 --> 00:08:11.351 That's great In two years. 00:08:11.351 --> 00:08:28.201 So again, we're showing a very low rate of repeat surgery and so we're saying one and done surgery is possible and we would say the way to get there, which should be the goal of all centers of endo, is to try to offer to patients one and done surgery. 00:08:29.023 --> 00:08:30.975 I think you know surgery surgeons have kind of given up. 00:08:30.975 --> 00:08:37.057 They're going to burn what they can, but if it's near a vital structure they're going to put them on long-term suppression, post-op. 00:08:37.057 --> 00:08:47.274 They don't have to remove it all, or for fertility, they don't have to optimize the anatomy because they're just going to bypass the pelvis and refer to IVF or just come back and do it again in two years. 00:08:47.274 --> 00:08:57.176 That's a very different surgical mindset versus trying to remove it all and optimize the anatomy now, and so I think that's a very different surgical mindset on behalf of the surgeon. 00:08:57.176 --> 00:09:02.277 But also we're showing, I think, a very different surgical result for the patient. 00:09:02.277 --> 00:09:06.053 And so we're trying to combine the best of cutting it all out. 00:09:06.053 --> 00:09:09.442 We call that optimal excision and adhesion prevention, so very few cut it all out. 00:09:09.442 --> 00:09:12.272 We call that optimal excision and adhesion prevention, so very few cut it all out. 00:09:12.272 --> 00:09:21.523 Well, but the other half is to prevent adhesions and that's how we would say you achieve

such great results or achieve the goal of one and done surgery. 00:09:22.492 --> 00:09:24.399 Yeah, and you use the CO2 laser to do that. 00:09:24.430 --> 00:09:30.903 So my cutting tool of choice, as you say yes, is this free beam, non-contact CO2 laser. 00:09:30.903 --> 00:09:33.579 So I don't have to touch the tissue to cut the tissue. 00:09:33.579 --> 00:09:34.835 It's very precise. 00:09:34.835 --> 00:09:36.858 It's literally cutting one layer at a time. 00:09:36.858 --> 00:09:42.699 You can see the layers separate and so there's not that kind of danger of pushing too far. 00:09:42.699 --> 00:09:44.315 People ask why I don't use the robot. 00:09:44.315 --> 00:09:45.720 I used to use the robot. 00:09:45.720 --> 00:09:50.481 I think well, the robot doesn't have this type of laser. 00:09:51.552 --> 00:09:53.790 Do you do your surgeries open or laparoscopic? 00:09:53.790 --> 00:09:55.416 So they're all laparoscopic, minimally invasive. 00:09:55.557 --> 00:09:57.154 Okay, less holes than a robot. 00:09:57.375 --> 00:09:57.576 Yeah. 00:09:58.151 --> 00:10:00.197 Less visible holes than the robot. 00:10:00.197 --> 00:10:06.537 The robot's only been shown to really, you know, not improve outcomes but only increase time and cost in benign surgery. 00:10:06.537 --> 00:10:13.079 So I don't use it for what I do, and especially surface endo or stage one to three. 00:10:13.079 --> 00:10:17.455 I wouldn't use it Now, stage four maybe. 00:10:17.455 --> 00:10:18.980 Why is that? 00:10:18.980 --> 00:10:27.197 Just because by then it's not really delicate surface endo, it's more just deep endo and maybe the robot would be fine for that. 00:10:28.412 --> 00:10:33.278 What are the side effects from the surgery or potential side effects from the surgery? 00:10:34.321 --> 00:10:48.951 So the main criticism of surgery or excision, cutting it out, is that you're going to create all these raw surfaces which will promote adhesions, so it's going to make things worse for fertility. 00:10:48.951 --> 00:10:49.835 That's a theory. 00:10:49.835 --> 00:10:54.432 That's a theory that has not been shown to be true. 00:10:54.432 --> 00:11:10.050 With our anatomy optimization and non-surgical optimizations for patients with fertility, when you treat the endo, they feel better and they have improved chances of fertility, and I think they actually go hand in hand. 00:11:10.050 --> 00:11:13.950 Feeling better and chances of pregnancy go hand in hand, yeah for sure. 00:11:13.950 --> 00:11:15.127 What are the rates of fertility? 00:11:15.127 --> 00:11:18.555 So the national average for IVF is 32%. 00:11:18.555 --> 00:11:31.701 When you're talking about root cause treatment and restorative reproductive medicine, or optimizing the anatomy and the non-surgical factors for fertility, the rates of pregnancy can be up to 70% in one to two years. 00:11:33.024 --> 00:11:34.306 Did you in the study? 00:11:34.306 --> 00:11:36.968 You guys did, did you guys measure that as an endpoint? 00:11:37.908 --> 00:11:39.951 fertility- In the 10-year study. 00:11:39.951 --> 00:11:43.913 Yeah Well, it was a database, and so we had different endpoints, gotcha. 00:11:43.913 --> 00:11:46.195 This one was focused on rates of repeat surgery. 00:11:46.375 --> 00:11:46.536 Yeah. 00:11:46.556 --> 00:11:54.362 There are other studies, yes, that show up to 70% fertility rates, even in advanced endo. 00:11:54.362 --> 00:12:02.997 Yeah, so it's very effective and, again, patients are feeling better and it can lead to recurring fertility and if it's one and done surgery, it's very cost effective. 00:12:03.177 --> 00:12:08.956 Yeah, for sure, yeah, and and yeah, and there's the and there's, it's a big picture. 00:12:08.956 --> 00:12:25.156 I mean, you're not only looking at fertility, you're not only looking at pain obviously significant psychological benefits if you're not in pain, if you're not having to, you know, continuing to have surgeries and so, you know, seems like a lot of positives on a lot of fronts. 00:12:25.485 --> 00:12:37.555 Yeah, the real reason why, you know, I began Restore Center of Endo was to enter the conversation among centers of endo to say that what we're doing is different and here's how you can try to get to one and done surgery. 00:12:37.555 --> 00:12:41.606 But really it's also to pay it forward and here's how you can try to get to one and done surgery, but really it's also to pay it forward. 00:12:41.606 --> 00:12:44.893 That is the real reason for Restore Center for Endo. 00:12:44.893 --> 00:12:48.059 So my wife had painful periods her whole life. 00:12:48.059 --> 00:12:51.508 We tried from day one to get pregnant. 00:12:51.508 --> 00:12:53.632 After a year of trying she said maybe I have endo. 00:12:53.632 --> 00:12:54.815 I said no way. 00:12:54.815 --> 00:12:56.177 She had bad endo. 00:12:56.177 --> 00:13:00.699 She had one surgery to remove the endo and then multiple surgeries for adhesions. 00:13:00.699 --> 00:13:04.394 She's now pain-free and we've had recurring fertility. 00:13:06.128 --> 00:13:09.086 I saw your five beautiful kids on your website Praise God. 00:13:09.086 --> 00:13:09.687 Yes, thank you. 00:13:10.690 --> 00:13:34.255 So you know, but going through the journey with her and again we're trying to pay that forward and in our story preventing adhesions was as important as removing all the disease but going through the the the journey with her, not knowing why somebody is not getting pregnant is as bad as not having a baby, or at least adds insult to injury. 00:13:34.255 --> 00:13:58.570 Yeah, to be told you have unexplained infertility, which you know again, mainstream would say 30 of infertility, which you know again, mainstream would say 30% of infertility is unexplained, is a slap in the face. 00:13:58.570 --> 00:14:14.921 A woman knows that her body is designed to get pregnant and if you look hard enough you will probably find an answer to why, or a factor that is, often multiple factors that are

leading the woman to not be able to get pregnant and many of those women have endo. 00:14:14.921 --> 00:14:20.427 So again, a normal ultrasound and a normal exam do not rule out surface endo. 00:14:21.516 --> 00:14:22.097 Yeah, I mean. 00:14:22.097 --> 00:14:46.147 So I look at a lot of scans and things like that and I would assume that a focus of endometriosis would have about the same Hounsfield units as fluid or anything else, and so it would be kind of hard to see on a scan, I would think Well, if it's advanced endo, again it's gone beyond the surface and it's now a ball of it in the ovary, that's stage three endo. 00:14:46.267 --> 00:14:47.256 that's an endometrioma. 00:14:47.256 --> 00:14:49.299 If it's in the bowel, that's stage four endo. 00:14:49.299 --> 00:14:53.626 You can see advanced endo when there's some thickness to it. 00:14:53.746 --> 00:14:56.951 And then it's deflecting other tissue and misshaping it. 00:14:57.395 --> 00:15:02.655 But if it's just surface endo, stage one to two, that's not going to be picked up on exam or imaging. 00:15:02.655 --> 00:15:08.040 But stage one to two endo or surface endo can still affect pain and fertility and treating it will help both. 00:15:08.040 --> 00:15:18.248 So, again, a lot of this unexplained infertility disappears when you actually look for and treat underlying conditions or root cause treatment. 00:15:18.248 --> 00:15:32.111 And again, having an answer, having that disease removed from your body, is so important in the healing process of a woman who's not getting pregnant. 00:15:32.771 --> 00:15:47.799 Yeah, and, like you said, like a lot of diseases, it has a ripple effect not only in the individual's life but also you know their spouse and you know whatever it is, whether it's cancer, endometriosis or whatever and so well, that's great. 00:15:47.799 --> 00:15:48.119 This is. 00:15:48.119 --> 00:15:52.545 It sounds like kind of an avant-garde, you know, this is it sounds like kind of an avant garde. 00:15:52.545 --> 00:16:11.097 You know advanced technique and practice that you have here and sometimes with that comes, you know, if you're kind of pushing the status quo. 00:16:11.117 --> 00:16:12.318 Sometimes you can get a little bit of headwinds. 00:16:12.318 --> 00:16:15.601 Yes, is that the case with your practice, or not so much. 00:16:16.682 --> 00:16:24.489 Well, I would say it's really a return to trying to focus on treating the patient. 00:16:24.489 --> 00:16:27.752 Yeah, again, this is not to bash on IVF. 00:16:27.752 --> 00:16:32.454 It has its role, but I would say it this way. 00:16:32.454 --> 00:16:39.009 Okay, the director of an IVF center asked me who is the most important person in the IVF center. 00:16:39.009 --> 00:16:40.579 Okay, you get to guess. 00:16:41.763 --> 00:16:48.524 Well, I mean, you know we're supposed to be patient first oriented, so you could say the patient Okay common answer, great answer. 00:16:48.985 --> 00:16:52.802 Well, first off to say it's not the director of the clinic. 00:16:52.802 --> 00:16:55.748 Okay, it's not the person who got into med school. 00:16:55.748 --> 00:16:57.816 We love our administrators, but that's right. 00:16:57.816 --> 00:16:59.778 Completed med school. 00:16:59.778 --> 00:17:05.740 Did residency training, subspecialty fellowship training to become an REI reproductive endocrinologist and infertility specialist. 00:17:05.740 --> 00:17:07.102 Which is a difficult field to get into. 00:17:07.142 --> 00:17:10.664 Right and now owns and runs the IVF center. 00:17:10.664 --> 00:17:15.027 It's not that person and it's not even the patient she posed the question. 00:17:15.027 --> 00:17:15.948 She gave the answer. 00:17:15.948 --> 00:17:19.410 Which is the most important person is the embryologist. 00:17:19.410 --> 00:17:23.813 It's the person that runs the lab, because that's where the action is. 00:17:24.174 --> 00:17:24.455 Okay. 00:17:25.356 --> 00:17:32.970 So just to say the woman is not being treated to help produce the baby. 00:17:32.970 --> 00:17:35.758 So women? 00:17:35.758 --> 00:17:44.102 This to me was just mind blowing, or at least highlighted the point that you know, women want to be treated as patients. 00:17:44.102 --> 00:17:49.541 Women want to be healed to have the baby, and that's as important as having the baby. 00:17:49.541 --> 00:17:50.825 They want to be restored. 00:17:50.825 --> 00:17:56.042 So this title Restore Center for Endo is my wife. 00:17:56.102 --> 00:17:56.722 Great title. 00:17:57.084 --> 00:18:08.039 But again, having lived through it, there's a real desire there by women to get answers to be restored as much as having the baby, or at least that's a very important part of the healing process. 00:18:08.039 --> 00:18:09.879 Yeah, okay, is this? 00:18:09.879 --> 00:18:16.683 So this issue is, I would say, an issue for our time. 00:18:16.683 --> 00:18:41.931 I really think this idea of restorative reproductive medicine as an alternative or as a way to try to get pregnant without bypassing the problem and really offering root cause treatment is really an issue that is a great moment in our society and that cuts across the political spectrum. 00:18:41.931 --> 00:19:24.061 People come at it from both sides, but people are wanting root cause treatment kind of to be more organic or natural, to lead to natural fertility for a patient, without big pharma, without just suppressive Band-Aid treatments or treatments that end up with a lot of hormones in the environment but that flood your body in a very artificial way, or bypass therapy with big fertility, we'll call it, and so I think it's really there's a lot of grassroots movement or desire for options for fertility that are not just the usual. 00:19:24.562 --> 00:19:34.562 Yeah, yeah and it and if it seems like if you have, you know, very significant endometriosis, it's, it's something that would probably give people hope. 00:19:34.562 --> 00:19:52.222 And I'm sure it's a gratifying field

to be in, you know, to see patients who may have kind of given up on things or maybe didn't want to take you know a certain route, and they come into your clinic and you get to see, you know them and their spouse and how it changes. 00:19:52.222 --> 00:19:54.051 I mean, is that right? 00:19:54.051 --> 00:19:54.953 Can you talk about? 00:19:54.974 --> 00:19:56.478 that, yeah, I love what I do. 00:19:56.478 --> 00:20:01.755 Again, I'm a slow learner and I went through all that, but I love what I do every day and I steal my wife's phrase all the time. 00:20:01.755 --> 00:20:14.361 But to help a woman get her life back, get answers or be a part of having a baby, I mean it has eternal value. 00:20:14.361 --> 00:20:15.984 I love it. 00:20:16.585 --> 00:20:18.589 Yeah's great, that's great. 00:20:18.589 --> 00:20:29.149 Well, um, how can patients if they were interested in just kind of taking that first step and um kind of looking into this? 00:20:29.149 --> 00:20:31.538 You have a website, is that right? 00:20:31.858 --> 00:20:36.244 yes, so it's called restore center for Endometriosis is the name of the practice. 00:20:36.244 --> 00:20:42.151 The website is restore-endocom or restoreendocom. 00:20:42.151 --> 00:20:46.418 There's a lot of information on there, but you know. 00:20:46.418 --> 00:20:48.305 So we're here in St Louis, we're based here. 00:20:48.305 --> 00:21:01.602 There are very few centers in the country that are really focused on this type of root cause treatment and can do this type of surgery to restore the anatomy, especially for advanced endo. 00:21:01.602 --> 00:21:04.156 We're going to often take a team like we have here. 00:21:04.156 --> 00:21:11.037 You know, some places really do believe in cutting out the endo but don't have a good bowel surgeon to work with. 00:21:11.037 --> 00:21:13.561 I feel so blessed to be able to work with Dr Summers. 00:21:14.000 --> 00:21:29.639 We've been together now for 10 years and um yeah you know, you guys have a reputation for being meticulous and and doing what it takes to get the job done, because these are not easy surgeries. 00:21:29.639 --> 00:21:42.747 I mean, for people who don't know, doing surgery in the pelvis is kind of like doing surgery in an upside down traffic cone, Like the deeper you get, the more narrow it is, and so this is a highly specialized treatment. 00:21:42.747 --> 00:22:07.544 And that's one of the great things about health care in St Louis is you have these kind of super specialists that are available and you know all the systems have, you know, really great doctors, and so I always say with St Luke's we have incredible competition, you know, because there's really good hospitals all around, but we're fortunate to have you know something like this, and I know a lot of your patients fly in from other places to get their treatment. 00:22:07.625 --> 00:22:08.167 Yeah, thank you. 00:22:08.167 --> 00:22:15.847 Now we actually see more patients out of state than in state and very few places can do this Well, people come from all over. 00:22:15.847 --> 00:22:22.524 It's very humbling, but I hesitated there because I was going to say so. 00:22:22.524 --> 00:22:31.926 I learned I hope it's okay to say Don, but Dr Summers, when he graduated residence day, I think it was you know they roast you, yeah, sure. 00:22:31.926 --> 00:22:40.717 So when he graduated he got the OCD award, which, when you're dealing with endo, is exactly the guy you want. 00:22:40.938 --> 00:22:48.160 He is meticulous and for these advanced endo cases that can involve the bowel, where things can be stuck, might include a bowel resection. 00:22:48.160 --> 00:22:49.643 We allow all day. 00:22:49.643 --> 00:23:22.035 We do one case all day, yeah, so we're not rushed, we can do what needs to be done and St Luke's has been so supportive no-transcript. 00:23:22.416 --> 00:23:24.263 If you're doing whatever it takes to get the job done. 00:23:24.263 --> 00:23:29.355 It could be a 10 hour surgery if necessary, and and, and and you know the. 00:23:29.355 --> 00:23:43.134 The truth of it is that's a stress on the staff and it's a stress on the system, and um, and so it's it makes a big difference to have that support Right. 00:23:49.394 --> 00:24:20.276 No, and St Luke's, you know they I think at first they weren't sure to be fair, but they've seen over the years the outcomes for the patient first and foremost, and that you know the patients do well and it's, you know it's really helping people, and so they, they've seen that I would call our practice a mission-based practice and I really think, you know St Luke's is on mission together with us and, first and foremost, patients are benefiting and again, their support has been wonderful. 00:24:20.998 --> 00:24:35.039 Well, patrick, we're fortunate to have you and Dr Donald Summers on staff here and or your practice here, and I want to thank you for the not only the work you do, but I want to thank you for being here at St Luke's. 00:24:35.039 --> 00:24:38.065 We appreciate you and the website's. 00:24:38.065 --> 00:24:46.243 Restoreendocom and check it out and reach out to Dr Yeung and his staff if you think he may be able to help you. 00:24:46.584 --> 00:24:47.166 Thanks so much. 00:24:47.166 --> 00:24:48.792 Thanks, patrick, thank you.