# Intestinal Failure — GCMD Library living collection

Also covered as: necrotizing enterocolitis · short bowel syndrome · gastroschisis · cholestasis · Hirschsprung disease · bacterial overgrowth · midgut volvulus · intestinal atresia

Experts: Dr. Paul Wales, Dr. Michael Helmrath, Dr. Ellen Encisco, Dr. Rod Gerardo

Updated: n/a · 29 episodes · 838 cited statements

## Episodes
### Foundations
- [Multidisciplinary Approach: Intestinal Failure Innovations](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036) — video · 97:52 · [machine version](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036.md)
- [Intestinal rehabilitation: What is intestinal rehab? - Episode 1](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741) — video · 14:33 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741.md)
- [Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742) — podcast · 14:33 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742.md)
- [Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 1](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141) — podcast · 16:18 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141.md)

### Acute Management
- [Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 1](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954) — podcast · 13:27 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954.md)

### Nutritional Management
- [Intestinal Failure - Feeding Access and Nutrition](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740) — video · 118:06 · [machine version](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740.md)
- [Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 2](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240) — podcast · 13:37 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240.md)
- [Intestinal Rehabilitation, Episode 7: Refeeding in a neonatal patient](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209) — podcast · 16:09 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209.md)
- [Intestinal Rehabilitation Episode 8: Refeeding of an Older Patient](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227) — podcast · 12:05 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227.md)

### Surgical Management
- [Practical Approach: Intestinal Failure Innovations](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035) — video · 116:52 · [machine version](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035.md)
- [Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 2](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993) — podcast · 17:21 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993.md)
- [Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909) — video · 19:07 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909.md)
- [Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913) — podcast · 19:07 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913.md)

### Complications
- [Pediatric Vascular Access in Brief: Preoperative, Operative, and Postoperative Considerations](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870) — video · 13:54 · [machine version](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870.md)
- [Intestinal Rehabilitation, Episode 4: Surgical Management, Part 2](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099) — podcast · 12:24 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099.md)
- [Intestinal Rehabilitation, Episode 6: Cholestasis](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734) — podcast · 15:25 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734.md)

### Evidence & Research
- [Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929) — podcast · 44:19 · [machine version](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929.md)
- [Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308) — podcast · 44:19 · [machine version](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308.md)
- [CAPS - The use of urine sodium to creatinine ratio as a marker of total body sodium in infants with intestinal failure - Sara Choi](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432) — video · 8:40 · [machine version](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432.md)
- [Journal of Pediatric Surgery Article Review: June 2022, AAP Issue](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878) — video · 15:54 · [machine version](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878.md)
- [Journal of Pediatric Surgery Article Review: June 2022, AAP Issue](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881) — podcast · 15:54 · [machine version](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881.md)
- [Outcomes of Children With Short Bowel Syndrome: Experiences in a Multidisciplinary Intestinal Rehabilitation Unit Over Two Decades](https://library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027) — video · 0:45 · [machine version](https://library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027.md)
- [Impact of social determinants of health on outcomes in pediatric short bowel syndrome...](https://library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896) — video · 0:43 · [machine version](https://library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896.md)

### In-Depth Reviews
- [Intestinal Failure with Dr. Brad Warner](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927) — podcast · 52:46 · [machine version](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927.md)
- [Intestinal Failure with Dr. Brad Warner](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296) — podcast · 52:46 · [machine version](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296.md)
- [Intestinal Rehabilitation Webinar 2023 - Top 5 Key Takeaways](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768) — video · 12:14 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768.md)
- [Advancements in Pediatric Intestinal Failure: Innovative Therapies and Improved Outcomes](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892) — video · 17:45 · [machine version](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892.md)

### Patient & Family Education
- [Reliance on total parenteral nutrition (TPN) and travelling abroad](https://library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804) — video · 1:42 · [machine version](https://library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804.md)

### Long-Term Care
- [Care transition from a pediatric intestinal rehabilitation program to adult care and the risk of all-cause mortality: A retrospective cohort study](https://library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901) — video · 1:01 · [machine version](https://library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901.md)

## Chapters
- [0:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=5) Introduction and Patient Population (Ep 23)
- [1:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=110) Dietary Strategy for Refeeding (Ep 23)
- [3:43](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=223) Fluid Management and Hydration (Ep 23)
- [5:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=351) Growth Through Puberty and Team Approach (Ep 23)
- [8:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=514) Growth Monitoring and Assessment (Ep 23)
- [0:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=4) Introduction and Program Context (Ep 9)
- [1:46](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=106) Defining Intestinal Failure (Ep 9)
- [4:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=290) Three Categories of Intestinal Failure (Ep 9)
- [8:19](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=499) Timing of Diagnosis and Referral (Ep 9)
- [10:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=604) Multidisciplinary Team Approach (Ep 9)
- [12:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=754) Outcomes and Future Challenges (Ep 9)
- [0:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=0) Introduction and Nutritional Fundamentals (Ep 13)
- [1:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=115) Feeding Protocols and Surgical Access Strategies (Ep 13)
- [4:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=261) Managing High Output and Gastric Losses (Ep 13)
- [6:42](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=402) Pharmacotherapy Considerations (Ep 13)
- [7:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=470) Surgical Interventions for Adaptation (Ep 13)
- [11:22](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=682) Decision-Making Principles and Conclusion (Ep 13)
- [0:07](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=7) STEP Procedure Indications and Expected Outcomes (Ep 20)
- [2:29](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=149) Postoperative Timeline and Staged Approach (Ep 20)
- [5:35](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=335) Staple-Line Ulcer Complications and Pathophysiology (Ep 20)
- [9:18](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=558) Surgical Management Philosophy and Long-term Care (Ep 20)
- [0:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=0) Historical Context and Preoperative Philosophy (Ep 19)
- [4:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=257) Surgical Decision-Making at Birth (Ep 19)
- [7:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=423) Diagnosis-Specific Considerations (Ep 19)
- [10:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=645) STEP Procedure Technical Details (Ep 19)
- [17:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=1073) Summary and Conclusion (Ep 19)
- [0:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=5) Defining Cholestasis (Ep 21)
- [1:37](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=97) Epidemiology and Risk Factors (Ep 21)
- [3:44](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=224) Prevention Strategies (Ep 21)
- [7:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=420) TPN Lipid Management (Ep 21)
- [9:13](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=553) Expected Post-Surgical Changes (Ep 21)
- [10:37](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=637) Surgical Considerations (Ep 21)
- [12:43](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=763) Long-Term Monitoring (Ep 21)
- [0:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=5) Introduction and Goals of Refeeding (Ep 22)
- [2:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=125) Initiating Feeds with High Stoma Output (Ep 22)
- [3:30](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=210) Formula Selection and Composition (Ep 22)
- [5:47](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=347) Volume Management and TPN Weaning (Ep 22)
- [7:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=437) Feeding Methods and Oral Skill Development (Ep 22)
- [9:22](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=562) Managing Gastric Dysmotility and Distal Refeeding (Ep 22)
- [11:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=710) G-tube Placement Strategy (Ep 22)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "Older children (8-16 years) who experience volvulus can lose 90+% of their bowel" — Michael Helmrath (clinical) [Ep 23 · 1:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=71)
- "Older patients who have established eating behavior before bowel loss have both a benefit and curse in that they know how to eat" — Paul Wales (opinion) [Ep 23 · 1:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=84)
- "In older children, normal feeding behavior is important for social aspects of life beyond nutrition" — Cecilia Gigena (clinical) [Ep 23 · 1:30](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=90)
- "Even if a patient cannot be cured and weaned off TPN, compromises should be made to optimize quality of life" — Paul Wales (opinion) [Ep 23 · 1:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=110)
- "The general strategy is to push macronutrient modules of protein and fat which are well tolerated" — Paul Wales (clinical) [Ep 23 · 2:14](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=134)
- "Most short bowel patients don't tolerate simple sugars very well" — Paul Wales (clinical) [Ep 23 · 2:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=141)
- "Pushing solids and minimizing fluid intake helps reduce dumping" — Paul Wales (clinical) [Ep 23 · 2:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=145)
- "Smaller meals more frequently of solids separated from liquids and minimization of simple sugars is the recommended approach" — Paul Wales (clinical) [Ep 23 · 2:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=151)
- "Patients who have transitioned off TPN often come back with problems when diet history reveals they have gotten loose with diet choices" — Paul Wales (clinical) [Ep 23 · 2:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=172)
- "Increase in sugars can create problems with absorption and changes in stool output" — Cecilia Gigena (clinical) [Ep 23 · 3:12](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=192)
- "Minimizing sugars reduces symptoms related to bacterial overgrowth such as bloating and gas" — Paul Wales (clinical) [Ep 23 · 3:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=211)
- "Fluid losses whether by stoma or other source must be replaced" — Paul Wales (clinical) [Ep 23 · 3:48](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=228)
- "If patients are on IV support, some fluid can be replaced intravenously" — Paul Wales (clinical) [Ep 23 · 3:56](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=236)
- "When trying to wean off IV support, keeping patients hydrated through enteral replacements is important" — Paul Wales (clinical) [Ep 23 · 4:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=241)
- "Fluid transport requires sodium and glucose, so replacement solution must contain both" — Paul Wales (clinical) [Ep 23 · 4:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=251)
- "Gatorade doesn't work well for rehydration because it has too much sugar" — Paul Wales (clinical) [Ep 23 · 4:48](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=288)
- "Some patients can come off TPN but still need a central line for IV fluids" — Michael Helmrath (clinical) [Ep 23 · 4:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=295)
- "Without adequate IV fluids, patients end up sleeping most of the day and don't have energy" — Michael Helmrath (clinical) [Ep 23 · 4:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=295)
- "Being in a hydrated state is extremely important to making the bowel work well" — Michael Helmrath (clinical) [Ep 23 · 5:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=308)
- "Sometimes patients can't drink rehydration solution but the GI tract can use it via G-tube" — Michael Helmrath (clinical) [Ep 23 · 5:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=331)
- "Energy use goes up dramatically during puberty" — Michael Helmrath (clinical) [Ep 23 · 5:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=351)
- "Children doing well often hit the wall when they start puberty because energy needs overcome nutrient input" — Michael Helmrath (clinical) [Ep 23 · 5:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=351)
- "Some kids end up back on parenteral support to get through puberty" — Paul Wales (clinical) [Ep 23 · 6:28](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=388)
- "When not growing anymore as an adult, borderline or marginal gut function is often enough to sustain them" — Paul Wales (clinical) [Ep 23 · 6:33](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=393)
- "There are very few conditions with intestinal failure that have restricted growth" — Michael Helmrath (clinical) [Ep 23 · 6:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=417)
- "A 3rd percentile growth should not be accepted for most intestinal failure patients" — Michael Helmrath (opinion) [Ep 23 · 6:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=417)
- "After getting off TPN, patients often get into trouble with micronutrient deficiencies" — Paul Wales (clinical) [Ep 23 · 7:22](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=442)
- "Weight must be balanced with height as a growth metric" — Paul Wales (clinical) [Ep 23 · 8:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=531)
- "This population commonly shows round babies where weight for height is elevated" — Paul Wales (clinical) [Ep 23 · 8:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=537)
- "There is increasing data looking at quality of weight - how much is fat weight versus lean body mass" — Paul Wales (clinical) [Ep 23 · 9:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=541)
- "For any child not meeting growth potential, numerous other diagnoses must be considered including endocrine issues, pancreatic insufficiency, and micronutrient deficiencies" — Michael Helmrath (clinical) [Ep 23 · 9:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=574)
- "After addressing growth issues, improvements should be assessed on the order of weeks not months" — Michael Helmrath (clinical) [Ep 23 · 9:54](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=594)
- "Growth monitoring can be done remotely and should not wait until the next appointment" — Michael Helmrath (clinical) [Ep 23 · 10:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=615)
- "Intestinal failure is defined as insufficient gut function to absorb enough nutrients, fluids, and calories to support survival and, in children, growth" — Paul Wales (clinical) [Ep 9 · 2:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=125)
- "For a patient to be defined as having intestinal failure, they must have inadequate intestinal function necessitating parenteral support for at least 60 days" — Rod Gerardo (guideline) [Ep 9 · 2:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=144)
- "An intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm that brings coordinated care for children with intestinal failure through comprehensive management of their specialized nutrition and associated needs" — Paul Wales (clinical) [Ep 9 · 3:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=183)
- "Short bowel syndrome is by far the most common category of intestinal failure in pediatric patients" — Paul Wales (epidemiological) [Ep 9 · 4:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=290)
- "Causes of short bowel syndrome include congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, and long segment Hirschsprung's disease" — Paul Wales (clinical) [Ep 9 · 5:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=306)
- "Acquired diseases of the newborn such as necrotizing enterocolitis can cause short bowel syndrome" — Paul Wales (clinical) [Ep 9 · 5:18](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=318)
- "Motility disorders occur when the bowel is unable to push contents through in a coordinated way due to abnormalities of the muscle itself or the nerves that control that muscle" — Paul Wales (clinical) [Ep 9 · 5:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=345)
- "Congenital enteropathies are conditions where the patient has all of their bowel but the mucosa does not work, leading to hypersecretion and profuse fluid losses" — Paul Wales (clinical) [Ep 9 · 6:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=377)
- "Some patients will have elements of two or three categories of intestinal failure in the way they present" — Paul Wales (clinical) [Ep 9 · 7:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=431)
- "A child with gastroschisis could have short bowel because it was not all viable, inflammation affecting absorption, and motility issues" — Ellen Encisco (clinical) [Ep 9 · 7:22](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=442)
- "Older pediatric patients can develop intestinal failure from inflammatory bowel disease or Crohn's disease where they have lost gut as a result of complications" — Paul Wales (clinical) [Ep 9 · 7:56](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=476)
- "Trauma, malignancy, and vascular thrombosis leading to gut loss are diagnoses seen more in older patients or adult series and less in pediatrics" — Paul Wales (epidemiological) [Ep 9 · 8:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=484)
- "There are three time points where families reach intestinal rehabilitation programs: prenatal diagnosis, postnatal acquired problems, and later presentations after discharge" — Michael Helmrath (clinical) [Ep 9 · 8:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=533)
- "Prenatal diagnoses that lead to intestinal rehabilitation typically include atresia with cystic fibrosis and gastroschisis" — Michael Helmrath (clinical) [Ep 9 · 9:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=555)
- "Postnatal acquired problems leading to intestinal rehabilitation include volvulus and necrotizing enterocolitis" — Ellen Encisco (clinical) [Ep 9 · 9:29](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=569)
- "Dietitians play a key role in understanding the nutritional needs of children in intestinal rehabilitation" — Michael Helmrath (opinion) [Ep 9 · 11:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=712)
- "Social work is a key component of the intestinal rehabilitation team" — Michael Helmrath (opinion) [Ep 9 · 12:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=721)
- "The survival overall in big intestinal rehabilitation programs is usually over 90% long-term survival" — Rod Gerardo (epidemiological) [Ep 9 · 12:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=754)
- "Children with intestinal failure who survive long-term now develop chronic comorbidities including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues" — Paul Wales (clinical) [Ep 9 · 12:46](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=766)
- "Earlier recognition and taking advantage of the biology of the gut to adapt are time dependent" — Michael Helmrath (clinical) [Ep 9 · 2:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=160)
- "Intestinal rehabilitation streamlines care and improves communication with families and between care providers and team members" — Paul Wales (opinion) [Ep 9 · 3:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=235)
- "Intestinal rehabilitation comes down to key factors that drive the process: nutrition in the gut, nutrition in the body, and healing" — Michael Helmrath (clinical) [Ep 9 · 4:07](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=247)
- "Pattern recognition from multiple eyes on a baby who have seen them over time is important in intestinal rehabilitation" — Michael Helmrath (opinion) [Ep 9 · 4:19](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=259)
- "A paper from Chris Duggan's group at Boston demonstrated that implementation of a feeding protocol is associated with achieving full autonomy in a shorter time period" — Wales (clinical) [Ep 13 · 1:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=115)
- "Bowel heals with adhesions that bring blood supply to the bowel and help it heal" — Helmuth (clinical) [Ep 13 · 2:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=165)
- "Very high outputs can occur initially in damaged bowel that requires luminal nutrition to start getting the bowel to learn how to reabsorb fluid" — Helmuth (clinical) [Ep 13 · 3:56](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=236)
- "High outputs without feeding are an indication to feed, as long as the child can be hydrated" — Helmuth (clinical) [Ep 13 · 4:10](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=250)
- "After massive resection and loss of distal bowel, patients can be hypergastrinemic and have elevated acid secretion for 6 to 12 months due to loss of hormonal feedback messaging" — Wales (clinical) [Ep 13 · 4:35](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=275)
- "Acid blockade with H2 blockers or PPIs can decrease gastric volume in the short term" — Wales (clinical) [Ep 13 · 4:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=297)
- "Acid blockade carries a counter risk of bacterial overgrowth by losing the acid barrier" — Wales (clinical) [Ep 13 · 5:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=311)
- "Increased secretions occur because of a thick, leaky mucosa, and the way to improve that is to heal the mucosa, which requires delivery of luminal nutrients" — Wales (clinical) [Ep 13 · 5:59](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=359)
- "If serum bicarbonate is kept above 20, feeding is generally safe even with high cc per kilo output" — Helmuth (clinical) [Ep 13 · 6:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=377)
- "Cycled antibiotics for bacterial overgrowth are often done very empiric and ad hoc" — Wales (clinical) [Ep 13 · 6:49](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=409)
- "Closing a stoma immediately recruits more bowel and restores continuity" — Wales (clinical) [Ep 13 · 7:58](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=478)
- "As bowel becomes increasingly dilated, its motility becomes impaired" — Wales (clinical) [Ep 13 · 8:36](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=516)
- "In dilated bowel with impaired motility, stool doesn't move, leading to mucosal inflammation, damage to the mucosal barrier allowing bacterial translocation, potential sepsis, and malabsorption" — Rod (clinical) [Ep 13 · 8:41](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=521)
- "Restoring bowel caliber to something more normal can improve motility, provide better stool clearance, decrease bacterial overgrowth, allow mucosa to heal, and improve absorptive function" — Wales (clinical) [Ep 13 · 9:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=541)
- "The Bianchi procedure (longitudinal intestinal lengthening) has been around since 1980" — Wales (clinical) [Ep 13 · 9:33](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=573)
- "One of the most important factors for efficacy of both Bianchi and STEP procedures is that you're tapering the bowel" — Wales (clinical) [Ep 13 · 9:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=585)
- "STEP differs from anti-mesenteric tapering or resection in that it preserves all available mucosa without removing any" — Wales (clinical) [Ep 13 · 9:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=591)
- "Bowel lengthening procedures primarily redistribute surface area rather than truly increasing it" — Rod (clinical) [Ep 13 · 10:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=655)
- "It takes about 6 months to see any changes in absorption after bowel lengthening procedures" — Ellen (clinical) [Ep 13 · 11:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=665)
- "Cincinnati published experience showing absorption changes over time using fecal fat, alpha-1 antitrypsin clearance, xylose as measures of macronutrient absorption, and citrulline rise" — Wales (clinical) [Ep 13 · 11:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=668)
- "An upper GI can only rule in a problem; it does not rule out a problem" — Ellen (clinical) [Ep 13 · 11:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=694)
- "A normal upper GI does not rule out an anatomical problem" — Helmuth (clinical) [Ep 13 · 11:48](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=708)
- "The new ASPEN guidelines define enteral autonomy as independence from parenteral support for 12 weeks" — Ellen (guideline) [Ep 13 · 12:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=725)
- "The biggest benefit of the STEP procedure is tapering the bowel and reestablishing a more normal caliber to improve motility" — Paul Wales (clinical) [Ep 20 · 1:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=112)
- "The STEP procedure redistributes bowel rather than creating new bowel, helping to reestablish normal caliber which improves motility" — Ellen Encisco (clinical) [Ep 20 · 2:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=124)
- "It can take up to 6 months before significant improvement in absorptive capacity is seen after STEP" — Paul Wales (clinical) [Ep 20 · 3:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=184)
- "Absorptive capacity improvement is measured with fecal fat, alpha-1 antitrypsin clearance, xylose absorption, and citrulline levels" — Paul Wales (clinical) [Ep 20 · 3:12](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=192)
- "The delay in improvement is due to inflamed, sick, leaky mucosa in the setting of bacterial overgrowth needing time to heal" — Paul Wales (clinical) [Ep 20 · 3:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=204)
- "About 50% reduction in parental nutrition support can be expected after STEP" — Ellen Encisco (clinical) [Ep 20 · 3:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=214)
- "Half of patients who have a STEP will have progression of improved enteral tolerance, while half will have worsening" — Michael Helmrath (clinical) [Ep 20 · 3:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=220)
- "Before performing STEP, other anatomical problems must be ruled out by laying out the bowel and getting the mesentery completely oriented" — Michael Helmrath (clinical) [Ep 20 · 4:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=248)
- "There is nothing wrong with staging surgical procedures in intestinal failure patients" — Michael Helmrath (opinion) [Ep 20 · 5:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=300)
- "Ulcers at STEP staple lines are not uncommon and can cause recurrent bleeding requiring monthly transfusions for years" — Michael Helmrath (clinical) [Ep 20 · 5:39](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=339)
- "Chronic blood loss at the STEP line is an absolute indication to operate" — Michael Helmrath (clinical) [Ep 20 · 6:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=361)
- "Staple-line ulcer bleeding is an underreported complication that is difficult to manage" — Paul Wales (clinical) [Ep 20 · 6:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=384)
- "There is a spectrum of bleeding from staple-line ulcers ranging from specks of blood in stool to requiring transfusion every week and a half" — Ellen Encisco (clinical) [Ep 20 · 6:32](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=392)
- "Staple-line ulcers tend to occur in type 2 anatomy (small bowel to colonic remnant in the absence of an intact colon ileocecal valve)" — Paul Wales (clinical) [Ep 20 · 6:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=412)
- "Pathology of staple-line ulcers shows non-specific inflammation with no vasculitis, viral elements, or obvious ischemia" — Paul Wales (clinical) [Ep 20 · 7:12](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=432)
- "Medical management attempts for staple-line bleeding have included enteral omega 3 lipid supplements, cycled antibiotics, probiotics, 5ASA, budesonide, and immune modulators like Remicade, but none have been the perfect remedy" — Ellen Encisco (clinical) [Ep 20 · 7:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=441)
- "The underlying issue in staple-line bleeding is mesenteric inflammation and scarring that creates obstruction to venous outflow, not primary bowel pathology" — Michael Helmrath (clinical) [Ep 20 · 7:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=472)
- "Mesenteric inflammation causes venous hypertension along the staple lines" — Michael Helmrath (clinical) [Ep 20 · 8:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=483)
- "Mesenteric scarring causes enlarged veins, venous hypertension, and large lymph nodes from lymphatic obstruction visible on the bowel" — Ellen Encisco (clinical) [Ep 20 · 8:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=497)
- "During surgery for staple-line bleeding, vessels the size of your thumb and really big adenopathy can be seen due to lymphatic obstruction" — Michael Helmrath (clinical) [Ep 20 · 8:33](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=513)
- "Once mesenteric scar is freed up, the enlarged vessels come right back to normal" — Michael Helmrath (clinical) [Ep 20 · 8:42](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=522)
- "Venous hypertension is what leads to the bleeding from staple lines" — Michael Helmrath (clinical) [Ep 20 · 8:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=533)
- "Staple line revision is typically done with hand-sewn stitch to reconnect the bowel" — Michael Helmrath (clinical) [Ep 20 · 9:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=545)
- "The key to managing staple-line bleeding is to look at the mesentery and free up the mesentery, not just look at the bowel" — Michael Helmrath (clinical) [Ep 20 · 9:09](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=549)
- "Mesenteric pathology causing staple-line bleeding is obvious if you are looking for it" — Michael Helmrath (opinion) [Ep 20 · 9:27](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=567)
- "Most referrals for intestinal failure have had multiple operations before coming to a specialized center" — Paul Wales (clinical) [Ep 20 · 10:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=605)
- "Surgical planning may not be conducive to just one operation and may require setting up for the next case" — Paul Wales (opinion) [Ep 20 · 10:09](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=609)
- "Doing things in a staged fashion is typical for the intestinal failure patient population" — Ellen Encisco (clinical) [Ep 20 · 10:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=625)
- "Detailed operative notes documenting orientation, landmarks, and what was done are important for future operations" — Michael Helmrath (opinion) [Ep 20 · 10:33](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=633)
- "Surgeons should try not to be the hero and try not to do everything, especially in the first week of life" — Michael Helmrath (opinion) [Ep 20 · 10:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=652)
- "The surgeon plays a huge role in intestinal failure management even when patients are doing well, because progress must be monitored" — Michael Helmrath (opinion) [Ep 20 · 11:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=665)
- "Intestinal failure is a lifelong issue requiring long-term multidisciplinary follow-up" — Ellen Encisco (clinical) [Ep 20 · 11:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=675)
- "Adrian Bianchi first reported the longitudinal intestinal lengthening procedure (Bianchi procedure) that divides bowel along its two leaves and tubularizes it" — Michael Helmrath (clinical) [Ep 19 · 1:23](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=83)
- "In the 1980s and 1990s, babies with intestinal failure had poor outcomes primarily due to liver progression to inflammation and fibrosis associated with parenteral nutrition, lipids, and phytosterols" — Ellen Encisco (epidemiological) [Ep 19 · 1:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=110)
- "Rising direct bilirubin was recognized as a sign that children with intestinal failure would not do well" — Michael Helmrath (clinical) [Ep 19 · 2:13](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=133)
- "The first 4 months of life is when care for intestinal failure patients is most uncoordinated and surgical decisions have the most profound effect on long-term outcome" — Em Tombash (clinical) [Ep 19 · 2:29](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=149)
- "The gut doubles in length during the last trimester and the first year of life" — Michael Helmrath (clinical) [Ep 19 · 2:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=175)
- "Intestinal maturation occurs when the baby is fed; healthy growth of the intestine requires nutrition" — Michael Helmrath (clinical) [Ep 19 · 2:58](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=178)
- "Disrupting the feeding and maturation process affects not only the intestine's ability to absorb and digest but also peristalsis and function" — Michael Helmrath (clinical) [Ep 19 · 3:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=186)
- "Absorptive surface area comes from the waves of peristalsis moving over the villi, not from the exposed length of bowel" — Em Tombash (clinical) [Ep 19 · 3:32](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=212)
- "Lengthening bowel that doesn't have peristalsis does not increase absorption; it's just more static water" — Michael Helmrath (clinical) [Ep 19 · 3:46](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=226)
- "Very short bowel children can sometimes come off TPN because their motility is so good" — Michael Helmrath (clinical) [Ep 19 · 3:59](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=239)
- "The majority of pediatric short bowel syndrome cases present at birth due to neonatal causes: congenital GI anomalies or acquired conditions like necrotizing enterocolitis" — Paul Wales (epidemiological) [Ep 19 · 4:18](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=258)
- "When reestablishing bowel continuity, size discrepancy between bowel ends must be addressed or a functional obstruction will result even if the anastomosis is patent" — Paul Wales (clinical) [Ep 19 · 5:42](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=342)
- "If adequate bowel length exists, size discrepancy can be managed by resection back to appropriate caliber or tapering enteroplasty" — Paul Wales (clinical) [Ep 19 · 6:02](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=362)
- "In short bowel cases, serial transverse enteroplasty (STEP) can address size discrepancy without resecting mucosa" — Paul Wales (clinical) [Ep 19 · 6:28](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=388)
- "Gastroschisis patients don't tend to do as well regardless of intervention; STEP procedures in gastroschisis patients consistently underperform" — Paul Wales (clinical) [Ep 19 · 7:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=428)
- "Gastroschisis patients have inherent dysmotility from enteric nervous system damage due to amniotic fluid exposure" — Em Tombash (clinical) [Ep 19 · 7:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=441)
- "The enteric nervous system in gastroschisis must go through a healing and recovery phase that is attenuated by dysmotility and stasis" — Michael Helmrath (clinical) [Ep 19 · 7:32](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=452)
- "Atresia patients may have good peristalsis from bowel working against obstruction, and longitudinal stapling procedures may benefit them" — Michael Helmrath (clinical) [Ep 19 · 7:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=475)
- "Children who undergo STEP procedures in the first year of life sometimes never progress and are labeled as poor motility patients unable to tolerate enteral feeds" — Michael Helmrath (clinical) [Ep 19 · 8:19](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=499)
- "Necrotizing enterocolitis patients do better than other intestinal failure etiologies because they have been fed before disease onset, initiating GI motility and maturation" — Michael Helmrath (opinion) [Ep 19 · 8:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=520)
- "STEP procedure requires bowel diameter of at least 5 centimeters to be worthwhile" — Paul Wales (clinical) [Ep 19 · 9:09](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=549)
- "At birth, neonatal bowel is usually not dilated enough to apply the STEP procedure" — Ellen Encisco (clinical) [Ep 19 · 9:36](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=576)
- "In scenarios where immediate anastomosis is not prudent, distal bowel can be accessed with a feeding tube to provide distal feeding and grow the bowel in caliber before a subsequent operation" — Paul Wales (clinical) [Ep 19 · 9:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=590)
- "Stepping the duodenum in non-rotated children is fraught with problems and causes significant issues later in life" — Michael Helmrath (opinion) [Ep 19 · 10:22](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=622)
- "The STEP procedure was originally described by HP Kim and Tom Jackson" — Paul Wales (clinical) [Ep 19 · 10:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=645)
- "Maintaining bowel alignment during STEP is critical; there is risk of longitudinal twisting if alignment is not maintained" — Paul Wales (clinical) [Ep 19 · 11:29](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=689)
- "An endo GIA stapler with vascular (white) load cartridge (2.5mm crimping to 1mm) is preferred over open GIA and prevents leaks better than the classic blue load" — Paul Wales (clinical) [Ep 19 · 12:26](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=746)
- "Target bowel caliber after STEP is 1.5 cm in babies and 2 to 2.5 cm in older infants or children" — Paul Wales (clinical) [Ep 19 · 13:23](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=803)
- "Making the bowel too narrow during STEP can cause obstruction, especially in patients with borderline motility" — Paul Wales (clinical) [Ep 19 · 13:36](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=816)
- "A U-stitch with 4-0 PDS should be placed in the crotch of each staple line to prevent potential leaks" — Paul Wales (clinical) [Ep 19 · 14:35](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=875)
- "Dog ears (blind loops) can form at the top and bottom of the STEP segment where bowel transitions in and out, and these can dilate over time" — Paul Wales (clinical) [Ep 19 · 15:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=908)
- "Dilated segments in STEP can allow the stepped segments to rotate away from each other and twist, forming a functional obstruction" — Ellen Encisco (clinical) [Ep 19 · 15:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=952)
- "STEP staple lines should be oriented perpendicular to the mesentery at 90 and 270 degrees (3 o'clock and 9 o'clock positions)" — Paul Wales (clinical) [Ep 19 · 12:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=754)
- "The duodenum should not be stepped; STEP should start where the bowel begins to dilate, usually distal to the duodenum" — Paul Wales (clinical) [Ep 19 · 16:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=1011)
- "If duodenal narrowing is needed, a stapler should be used on the lateral side away from the bile duct and ampulla; plication sutures usually fail" — Paul Wales (clinical) [Ep 19 · 17:20](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=1040)
- "The duodenum has no mesentery, making it impossible to orient staple lines at 3 and 9 o'clock positions as in the jejunum" — Michael Helmrath (clinical) [Ep 19 · 17:32](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=1052)
- "Cholestasis is institutionally defined as conjugated bilirubin greater than 3 mg/dL or 50 micromoles/L sustained for 2 weeks and not associated with a septic event" — Paul Wales (guideline) [Ep 21 · 1:09](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=69)
- "A 2021 JPN publication defines cholestasis as conjugated bilirubin around 2 mg/dL or 34 micromoles/L for 2 weeks, not associated with a septic event" — Paul Wales (guideline) [Ep 21 · 1:20](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=80)
- "Advanced liver disease is defined as conjugated bilirubin above 5 or 6 mg/dL" — Cecilia Gigena (guideline) [Ep 21 · 1:48](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=108)
- "Cholestasis is now more an indicator of underlying diseases that need to be addressed rather than a direct morbidity/mortality factor" — Michael Helmrath (opinion) [Ep 21 · 1:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=117)
- "Historically 25-50% of intestinal failure patients died because of associated liver disease; now it is less than 2%" — Cecilia Gigena (epidemiological) [Ep 21 · 2:36](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=156)
- "In young children, intestinal failure causes cholestatic liver disease, whereas in adolescents and adults it tends to cause steatosis (fatty deposition)" — Paul Wales (clinical) [Ep 21 · 2:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=177)
- "Risk factors for intestinal failure-associated liver disease include prematurity, lack of enteral feeding, sepsis, and TPN components" — Cecilia Gigena (clinical) [Ep 21 · 3:19](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=199)
- "Prematurity is not modifiable by the clinical team, but other risk factors (enteral feeding, sepsis, TPN components) are modifiable" — Paul Wales (clinical) [Ep 21 · 3:30](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=210)
- "Prevention requires aggressive introduction of enteral feeding and surgical procedures to optimize anatomy for feed delivery" — Paul Wales (clinical) [Ep 21 · 4:09](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=249)
- "Limiting fat in TPN to 1 g/kg/day can help prevent cholestasis" — Michael Helmrath (clinical) [Ep 21 · 5:12](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=312)
- "New lipid emulsions (Omegaven first in US, then SMOF in Europe/Canada and now US over last 3-4 years) can reverse or prevent cholestasis" — Michael Helmrath (clinical) [Ep 21 · 5:20](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=320)
- "SMOF lipids allow provision of more calories from fat, as much as 2-2.5 g/kg" — Michael Helmrath (clinical) [Ep 21 · 6:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=375)
- "Conventional intralipid (soybean-based) when metabolized leads to production of prostaglandins and eicosanoids that are pro-inflammatory" — Paul Wales (clinical) [Ep 21 · 7:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=428)
- "SMOF lipid promotes bile flow, is hepatoprotective, and can be delivered at conventional dose while supporting somatic growth and neurologic development" — Paul Wales (clinical) [Ep 21 · 7:19](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=439)
- "SMOF lipid does not have enough arachidonic acid, so dose restriction can lead to essential fatty acid deficiency" — Paul Wales (clinical) [Ep 21 · 7:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=465)
- "When SMOF is delivered at conventional dosing, nobody develops essential fatty acid deficiency" — Paul Wales (clinical) [Ep 21 · 7:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=477)
- "Recommended lipid dosing is settling around 2.5 g/kg, but nutrition guidelines for preterms and babies state 3-4 g/kg/day" — Paul Wales (guideline) [Ep 21 · 8:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=486)
- "A bilirubin of 2 mg/dL is not advanced liver disease, is not dangerous, and is usually transient; approximately 90% of patients will improve with observation alone" — Paul Wales (opinion) [Ep 21 · 8:29](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=509)
- "When refeeding a cholestatic liver after jejunostomy takedown, direct bilirubin and liver enzymes (GGT, AST, ALT) will initially rise in the first 1-2 weeks as bile acid pool is reintroduced and liver becomes more active" — Michael Helmrath (clinical) [Ep 21 · 9:38](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=578)
- "It may take several weeks for bilirubin and liver enzyme levels to come back down after refeeding" — Ellen Encisco (clinical) [Ep 21 · 10:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=617)
- "Proximal blockage puts pressure in the biliary system at a much higher level and speeds up the cholestatic process" — Michael Helmrath (clinical) [Ep 21 · 11:18](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=678)
- "G-tubes do not decompress the duodenum" — Michael Helmrath (clinical) [Ep 21 · 11:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=691)
- "Liver biopsy is commonly performed during secondary surgical or autologous reconstruction procedures to provide an up-to-date microscopic snapshot" — Paul Wales (clinical) [Ep 21 · 12:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=731)
- "Prophylactic cholecystectomy is not recommended because the gallbladder helps with enterohepatic circulation and many patients will not need it" — Cecilia Gigena (guideline) [Ep 21 · 12:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=744)
- "Elastography or fibroscan is available for monitoring but is good for mild/no fibrosis or very advanced fibrosis; it is less sensitive for patients in the middle range" — Paul Wales (clinical) [Ep 21 · 13:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=780)
- "Outpatient follow-up frequency for children on TPN at home ranges from every 1-4 months depending on patient stability" — Paul Wales (clinical) [Ep 21 · 13:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=811)
- "Refeeding goals include establishing normal feeding habits to promote gut function and optimize quality of life and social aspects of eating" — Paul Wales (clinical) [Ep 22 · 0:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=57)
- "Damaged bowel is in a secretory phase even when not fed" — Michael Helmrath (clinical) [Ep 22 · 2:37](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=157)
- "Starting to feed the bowel transitions it to an absorptive state because luminal nutrition stimulates absorption, resulting in decreased stoma volume over time" — Michael Helmrath (clinical) [Ep 22 · 2:46](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=166)
- "Breast milk is the ideal first choice for feeding due to nutritional value, immunomodulatory effects, and growth healing effects not present in typical formulas" — Michael Helmrath (clinical) [Ep 22 · 3:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=220)
- "Donor breast milk is the second choice when maternal breast milk is unavailable" — Michael Helmrath (guideline) [Ep 22 · 4:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=248)
- "Breast milk has lower protein levels than desired and likely requires supplementation" — Cecilia Gigena (clinical) [Ep 22 · 4:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=261)
- "In short bowel syndrome, protein absorption is fairly well preserved, so the benefit of hydrolyzed or amino acid formulas is primarily from an allergy perspective" — Paul Wales (clinical) [Ep 22 · 4:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=274)
- "Long-chain fat is a stronger driver for intestinal adaptation than MCT" — Paul Wales (clinical) [Ep 22 · 5:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=304)
- "Long-chain fatty acids have developmental and immune properties" — Michael Helmrath (clinical) [Ep 22 · 5:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=321)
- "It is a common mistake to decrease TPN by the same volume that enteral feeds are increased, assuming the child will absorb all those calories, which results in stunted growth" — Michael Helmrath (clinical) [Ep 22 · 5:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=351)
- "One milliliter of parenteral nutrition is not isocaloric with one milliliter of formula" — Paul Wales (clinical) [Ep 22 · 6:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=366)
- "Advancing enteral feeds beyond 100-120 mL/kg can cause problems with sodium and calcium in addition to calorie and protein deficits, because milk composition differs from parenteral solution" — Paul Wales (clinical) [Ep 22 · 6:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=371)
- "If the child tolerates it and does not have lung issues, total daily volume can be expanded from 140 to 160, 170, or occasionally 180 mL/kg" — Michael Helmrath (clinical) [Ep 22 · 6:44](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=404)
- "Children with sick intestines will not absorb all the calories provided" — Cecilia Gigena (clinical) [Ep 22 · 7:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=420)
- "Bolus feeds are preferred as the default feeding method; patients should fail bolus feeds before transitioning to continuous feeds as the sole delivery mode" — Paul Wales (guideline) [Ep 22 · 8:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=485)
- "Continuous feeds can be used as a supplemental approach, with bolus feeds during the day and continuous feeds overnight" — Paul Wales (guideline) [Ep 22 · 8:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=485)
- "Oral feeding is important for skill development even when non-nutritive; children who never learn to suck, swallow, and process food by mouth will not eat solids later and will remain tube-dependent" — Paul Wales (clinical) [Ep 22 · 8:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=520)
- "The stomach is the most complicated part of the GI tract because it must coordinate both back-and-forth mixing and coordinated squeezing with pyloric relaxation several times per minute" — Michael Helmrath (clinical) [Ep 22 · 9:28](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=568)
- "When children have not been fed and have had an injury, gastric coordination is commonly disrupted" — Michael Helmrath (clinical) [Ep 22 · 9:28](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=568)
- "Gastric dysmotility after intestinal injury requires time and stimulation to resolve" — Michael Helmrath (clinical) [Ep 22 · 10:02](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=602)
- "Post-pyloric feeding with simultaneous gastric decompression allows distal bowel stimulation, which produces hormones that signal the stomach to start functioning and break the dysmotility cycle" — Michael Helmrath (clinical) [Ep 22 · 10:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=615)
- "Post-pyloric refeeding can be done as a bolus or over a pump; bolus is preferred, but running it over a pump for one hour works well at Cincinnati Children's" — Michael Helmrath (clinical) [Ep 22 · 11:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=663)
- "The Cincinnati Children's protocol typically starts post-pyloric feeds at 5 mL/kg, then 10 mL/kg, and advances based on tolerance" — Michael Helmrath (guideline) [Ep 22 · 11:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=663)
- "Feeding the distal colon reduces stoma output due to hormonal effects of the distal bowel, and often the stomach will start to work" — Michael Helmrath (clinical) [Ep 22 · 11:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=685)
- "Refeeding the distal intestine stimulates the proximal portion to absorb more" — Cecilia Gigena (clinical) [Ep 22 · 11:38](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=698)
- "When distal bowel has been functionally used through refeeding, the time to start feeding postoperatively after anastomosis is made easier" — Michael Helmrath (clinical) [Ep 22 · 11:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=710)
- "Distally fed bowel has improved size discrepancy at the time of anastomosis because the bowel has been used" — Paul Wales (clinical) [Ep 22 · 12:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=737)
- "Undigested formula in the colon is a trigger that can cause stress to the bowel and may not be the healthiest approach" — Michael Helmrath (opinion) [Ep 22 · 12:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=754)
- "Placing a feeding tube into the stomach at the time of surgery does not commit the child to a lifelong G-tube or even for the first year" — Michael Helmrath (clinical) [Ep 22 · 12:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=773)
- "A gastric tube can be directed out of the pylorus into the proximal small bowel as a source of feeding to overcome unpredictable obstacles" — Michael Helmrath (clinical) [Ep 22 · 13:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=786)
- "When a gastric tube is no longer needed, it can be removed and the hole heals quickly like any other tube site" — Michael Helmrath (clinical) [Ep 22 · 13:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=804)
- "A gastric tube provides versatility for nutrition supplementation, medication delivery, and venting for gassy or bloated patients to improve enteral tolerance" — Paul Wales (clinical) [Ep 22 · 13:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=831)
- "The morbidity from a gastric tube is extremely low and the benefit can be very high" — Michael Helmrath (opinion) [Ep 22 · 14:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=845)
- "In Toronto, ultra-short gut is classified as less than 20% of expected bowel length for age" — Paul Wales (clinical) [Ep 11 · 1:37](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=97)
- "In a term baby, ultra-short gut corresponds to 20 to 30 centimeters of bowel" — Paul Wales (clinical) [Ep 11 · 1:42](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=102)
- "Overall survival in ultra-short gut patients in the current era is over 90%" — Paul Wales (clinical) [Ep 11 · 1:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=112)
- "Survival in ultra-short gut is actually 90 to 95%" — Ellen (clinical) [Ep 11 · 2:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=121)
- "Ultra-short gut patients don't die of liver failure anymore and rarely get transplanted" — Ellen (clinical) [Ep 11 · 2:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=123)
- "Ultra-short gut patients who reached autonomy required multiple nutritional supplements" — Paul Wales (clinical) [Ep 11 · 2:10](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=130)
- "Ultra-short gut patients with remnant ileum as part of residual bowel tended to do better" — Paul Wales (clinical) [Ep 11 · 2:26](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=146)
- "Ultra-short gut patients with longer colonic remnants tended to adapt and get off TPN" — Paul Wales (clinical) [Ep 11 · 2:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=170)
- "The ileum reclaims bile and tells the liver what to do" — Michael Helmrath (clinical) [Ep 11 · 2:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=175)
- "The ileum produces hormones like GLP-2, PYY and others that slow motility and tell the jejunum to reabsorb fluid" — Michael Helmrath (clinical) [Ep 11 · 2:58](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=178)
- "The colon can account for a third to half of the caloric needs of babies when exposed to undigested nutrients" — Michael Helmrath (clinical) [Ep 11 · 3:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=195)
- "Short bowel syndrome kids are largely neurologically fine, running and playing" — Michael Helmrath (clinical) [Ep 11 · 3:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=204)
- "Bowel removed is bowel never to be used" — Michael Helmrath (clinical) [Ep 11 · 4:26](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=266)
- "Most necrotizing enterocolitis kids don't have overwhelming totalis; NEC totalis is fairly rare" — Michael Helmrath (epidemiological) [Ep 11 · 4:48](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=288)
- "Cincinnati has a dozen or more NEC totalis kids that are off TPN and have done remarkably" — Michael Helmrath (clinical) [Ep 11 · 4:54](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=294)
- "If a baby grows well with protein growth, linear growth and head growth, that's brain growth" — Michael Helmrath (clinical) [Ep 11 · 6:49](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=409)
- "A baby will not grow well with an unhealthy liver" — Michael Helmrath (clinical) [Ep 11 · 6:59](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=419)
- "An unhealthy liver is not providing the protein for neurocognitive development" — Michael Helmrath (clinical) [Ep 11 · 6:59](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=419)
- "Lipid restriction was never a practice subscribed to by the Toronto program" — Paul Wales (opinion) [Ep 11 · 7:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=460)
- "Premature babies in the first year of life have caloric needs of 80, 100, 120 per kilo because they're growing and developing" — Michael Helmrath (clinical) [Ep 11 · 7:43](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=463)
- "When critically ill, babies no longer grow and develop; they can be fed 150 kcals per kilo but will not grow because their livers are catabolic" — Michael Helmrath (clinical) [Ep 11 · 7:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=472)
- "A transverse incision gives the least problems over time for patients requiring multiple operations" — Michael Helmrath (clinical) [Ep 11 · 8:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=505)
- "An 8 or 10 French Blake drain is placed through bowel just beyond what is expected to heal, advanced retrograde to the pylorus" — Michael Helmrath (clinical) [Ep 11 · 8:37](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=517)
- "A purse string is placed at the drain insertion site and secured to the skin, essentially creating a stoma to the abdominal wall" — Michael Helmrath (clinical) [Ep 11 · 9:10](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=550)
- "A 5 to 7 French feeding tube can be placed into the proximal bowel via the stomach using a purse string technique" — Michael Helmrath (clinical) [Ep 11 · 9:29](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=569)
- "Significant dissection of the distal ileum should be avoided to preserve blood supply and allow collateralization to recover proximal bowel" — Michael Helmrath (clinical) [Ep 11 · 10:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=608)
- "A refeeding tube can be placed in the distal bowel to allow intermediate bowel to heal" — Michael Helmrath (clinical) [Ep 11 · 10:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=653)
- "The volume of fluid output from injured bowel is very high initially; as bowel heals and regenerates reabsorptive capacity, output decreases" — Michael Helmrath (clinical) [Ep 11 · 11:19](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=679)
- "Intraoperative decisions in short bowel syndrome have a lifelong impact" — Paul Wales (opinion) [Ep 11 · 12:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=720)
- "Decisions made at the time of intraabdominal catastrophe can make the difference between staying on or getting off TPN or whether the child survives" — Paul Wales (opinion) [Ep 11 · 12:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=728)
- "Many kids who appear critically sick preoperatively are not as sick as believed once proximal bowel is controlled and decompressed" — Michael Helmrath (clinical) [Ep 11 · 13:22](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=802)
- "Kids may look worse over the first 24-36 hours postoperatively, then stop getting worse before they start improving" — Paul Wales (clinical) [Ep 11 · 14:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=861)
- "Blake tubes have linear cuts on the outside so they won't get obstructed when secretions accumulate" — Michael Helmrath (clinical) [Ep 11 · 14:49](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=889)
- "Blake tubes cannot be changed over a wire like JP drains with side holes" — Michael Helmrath (clinical) [Ep 11 · 14:58](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=898)
- "Blake tubes are soft and don't tend to put pressure on damaged bowel" — Michael Helmrath (clinical) [Ep 11 · 15:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=906)
- "Blake tubes can be connected to a bulb syringe and cut to size" — Michael Helmrath (clinical) [Ep 11 · 15:09](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=909)
- "The inflection point of bowel loss requiring prolonged TPN is about 50%" — Michael Helmrath (clinical) [Ep 10 · 9:27](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=567)
- "Intestinal transplant is not experimental therapy but part of the continuum of therapy for a child with short bowel syndrome" — Paul Wales (guideline) [Ep 10 · 2:38](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=158)
- "Babies born with duodenal atresia or very proximal jejunal atresia are born with elevated direct or conjugated bilirubins" — Paul Wales (clinical) [Ep 10 · 6:14](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=374)
- "A 30-week-old baby's gut is in a highly developmental phase and its ability to regenerate is much more profound than a full term baby and certainly a one year old baby" — Michael Helmrath (clinical) [Ep 10 · 7:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=454)
- "The distal bowel, the ileum, can be salvaged by ileocecal blood flow" — Michael Helmrath (clinical) [Ep 10 · 8:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=484)
- "Bowel regeneration with proximal control occurs over 6, 8, 12 weeks based on the liver getting better" — Michael Helmrath (clinical) [Ep 10 · 8:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=497)
- "When the liver is inflamed and has high bilirubin, it's in a catabolic state" — Michael Helmrath (clinical) [Ep 10 · 5:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=357)
- "Decompressing the duodenum is needed to protect the liver" — Michael Helmrath (clinical) [Ep 10 · 5:49](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=349)
- "Giving fish oils and just trying to improve the bilirubin is not enough to protect the liver" — Ellen (clinical) [Ep 10 · 5:32](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=332)
- "In the very acute time after bowel infarction, the risk is dying of sepsis and multi-organ failure" — Paul Wales (clinical) [Ep 10 · 4:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=271)
- "Intermediate and longer term complications include intestinal failure associated liver disease, recurrent sepsis, or line problems" — Paul Wales (clinical) [Ep 10 · 4:44](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=284)
- "Success in the last two decades is because we're way better at preventing sepsis and liver disease" — Paul Wales (epidemiological) [Ep 10 · 5:02](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=302)
- "Factors affecting liver function include prematurity, sepsis, choice of TPN, and presence or absence of enteral nutrition" — Paul Wales (clinical) [Ep 10 · 6:42](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=402)
- "If bowel necrosis is focal and less than 50%, the best option is to remove that bowel" — Michael Helmrath (clinical) [Ep 10 · 9:35](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=575)
- "The adaptive potential for a child with less than 50% bowel loss is really great, especially if they have preserved ileum" — Michael Helmrath (clinical) [Ep 10 · 9:44](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=584)
- "When bowel appears dead in a mosaic pattern with parts terrible, parts bad, and maybe a little good, proximal control with a drain and time to heal gives opportunity to come back later" — Michael Helmrath (clinical) [Ep 10 · 10:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=600)
- "Not all bowel will survive and it will become islands of mucosa that need to be tubularized and put back together again" — Michael Helmrath (clinical) [Ep 10 · 10:14](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=614)
- "Stomas lose abdominal domain and lose bowel down the road" — Michael Helmrath (clinical) [Ep 10 · 10:59](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=659)
- "The percentage of kids that do well with proximal drain therapy when looking at dead gut is more than 70 to 80%" — Michael Helmrath (clinical) [Ep 10 · 11:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=671)
- "Kids with necrotizing enterocolitis have the best outcomes because it's a microvascular disease" — Michael Helmrath (clinical) [Ep 10 · 11:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=705)
- "There is an algorithm of children that have overwhelming sepsis where surgery cannot salvage these patients and there is no life saving option" — Michael Helmrath (clinical) [Ep 10 · 3:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=214)
- "Many babies will rally without having their bowel removed, which allows them an opportunity" — Michael Helmrath (clinical) [Ep 10 · 3:41](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=221)
- "Mistakes are commonly made because surgeons think they can predict the future with their eyes" — Michael Helmrath (opinion) [Ep 10 · 3:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=191)
- "The first line of treating a baby with overwhelming catastrophe is to allow the clinical scenario to drive the direction of care and not predetermining care based on what surgeons believe will happen" — Michael Helmrath (opinion) [Ep 10 · 3:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=191)
- "The outlook has changed and what's gone hand in hand with that is a bit more of an aggressive approach to surgical resection" — Paul Wales (opinion) [Ep 10 · 1:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=77)
- "Comorbidities such as neurologic status, pulmonary function, cardiac function, or significant genetic or chromosomal anomaly factor into decision making about how to proceed" — Paul Wales (clinical) [Ep 10 · 1:39](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=99)
- "The conversation with the family and understanding of the family's wishes is important to figure out if the baby is salvageable or not salvageable" — Rod Gerardo (clinical) [Ep 10 · 2:20](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=140)
- "Adaptation is a natural process occurring in all infants during uterine development and the first few years of life, or as a regenerative response to damage in older children" — Michael Helmrath (clinical) [Ep 12 · 1:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=61)
- "Adaptation takes time measured in months and years, not weeks and days, and requires enteral nutrition in all situations" — Michael Helmrath (clinical) [Ep 12 · 1:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=85)
- "Adaptation is driven by intraluminal nutrients and their interaction with pancreatic biliary secretions and trophic gut peptides" — Paul Wales (clinical) [Ep 12 · 2:16](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=136)
- "Structural changes during adaptation include mucosal hypertrophy with increased villous length, increased blood supply through angiogenesis, bowel dilation, and gut lengthening in younger children, all increasing surface area for absorption" — Paul Wales (clinical) [Ep 12 · 2:42](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=162)
- "Functional changes during adaptation include slowed motility to allow more contact time and upregulation of enterocyte transporters" — Paul Wales (clinical) [Ep 12 · 3:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=184)
- "The duodenum is where caloric intake and sugars are sensed, hepatobiliary secretions occur, iron is absorbed, and it functions as an endocrine engine recognizing meal initiation" — Michael Helmrath (clinical) [Ep 12 · 3:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=214)
- "The jejunum is largely a source of secretion of large amounts of fluid needed for digestion, with random back-and-forth sloshing motion" — Michael Helmrath (clinical) [Ep 12 · 3:54](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=234)
- "The ileum secretes incretins GLP-2, GLP-1, and PYY that stop gastric emptying and slow motility when there is too much liquid in the distal bowel" — Michael Helmrath (clinical) [Ep 12 · 4:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=246)
- "Distal ileum bile uptake sends a signal to the liver, which regulates the whole metabolism of the patient" — Michael Helmrath (clinical) [Ep 12 · 4:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=271)
- "The colon, specifically the right colon, is a source of energy uptake from free fatty acids in short gut patients, which requires the presence of bacteria" — Michael Helmrath (clinical) [Ep 12 · 4:46](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=286)
- "Colonic adaptation does not occur in most patients because energy is reclaimed before reaching the colon" — Michael Helmrath (clinical) [Ep 12 · 5:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=301)
- "Until recently there was no standardized definition for enteral autonomy" — Paul Wales (clinical) [Ep 12 · 5:35](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=335)
- "TPN complications include line infections, liver disease, and vascular thrombosis" — Paul Wales (clinical) [Ep 12 · 6:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=364)
- "In the past, patients were lost to complications such as liver disease before they could reach their adaptive potential; management of these complications has improved significantly" — Paul Wales (clinical) [Ep 12 · 6:20](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=380)
- "Current ASPEN guidelines define enteral autonomy as independence of parenteral support for 12 weeks with maintenance of adequate growth and hydration" — Paul Wales (guideline) [Ep 12 · 6:39](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=399)
- "Healthy growth is the underlying driver of autonomy, not time off TPN" — Michael Helmrath (opinion) [Ep 12 · 7:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=426)
- "The last thing needed to come off TPN is fluid, and without hydration the baby will not grow or efficiently absorb nutrition" — Michael Helmrath (clinical) [Ep 12 · 7:13](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=433)
- "A 2012 PIFCO paper by Squires showed 50% of patients achieved enteral autonomy over 5-6 years, 25% died, and 25% got transplanted" — Paul Wales (epidemiological) [Ep 12 · 7:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=470)
- "Recent papers in the last 5-6 years show 60-80% of patients achieve enteral autonomy, with a higher proportion surviving to reach autonomy" — Paul Wales (epidemiological) [Ep 12 · 8:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=505)
- "Small bowel length is an independently significant variable for adaptation capacity" — Paul Wales (clinical) [Ep 12 · 9:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=595)
- "The ileum has a much greater capacity to adapt than the jejunum" — Paul Wales (clinical) [Ep 12 · 10:18](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=618)
- "A full-term baby is born with approximately 160 centimeters of small bowel" — Rod Gerardo (clinical) [Ep 12 · 10:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=634)
- "At 5 years old, a child has about 425 centimeters of small bowel, with the steepest growth rate between 35 weeks gestation to about 6 months postnatal" — Paul Wales (clinical) [Ep 12 · 10:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=640)
- "80 centimeters of small bowel represents about 50% of small intestine in a term baby but about 80% in a 30-week infant" — Ellen (clinical) [Ep 12 · 10:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=652)
- "The ileocecal valve itself is not the important factor; most people who lose their ileocecal valve also lose their terminal ileum, which is the bigger factor for adaptive potential" — Paul Wales (opinion) [Ep 12 · 11:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=685)
- "If a patient has the majority of their small bowel, it almost does not matter how much colon they have; probability of enteral autonomy is 85-100%" — Paul Wales (clinical) [Ep 12 · 11:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=713)
- "When small bowel remnant is less than 50% of expected length, the colon becomes vitally important for energy absorption from short-chain fatty acids and fluid/salt absorption" — Ellen (clinical) [Ep 12 · 12:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=726)
- "Lab data shows a shift in microbiota to one that is more acid-producing in an acidotic state, likely more full of bile because it is not being reclaimed" — Michael Helmrath (clinical) [Ep 12 · 12:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=760)
- "Bacterial colonization of the intestines is part of the adaptive response" — Rod Gerardo (clinical) [Ep 12 · 12:58](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=778)
- "NEC is an acquired condition; infants are born, start eating, often get up to full feeds, then have an incident usually at 2-3 weeks of life" — Michael Helmrath (clinical) [Ep 12 · 13:26](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=806)
- "NEC patients have not been using their gut in utero during the critical period of 35 weeks to 6 months, making them different from children who have been fed before" — Michael Helmrath (clinical) [Ep 12 · 13:38](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=818)
- "The sooner a child can be fed safely and bowel access obtained without exposing them to surgical risk, the more advantage can be taken of the adaptive process" — Michael Helmrath (opinion) [Ep 12 · 14:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=845)
- "Surgery puts kids in harm's way no matter how talented the surgeon, so balancing operative risk with the ability to optimize feeding has led to improved outcomes" — Michael Helmrath (opinion) [Ep 12 · 14:48](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=888)
- "Intestinal failure is defined as insufficient gut function to absorb enough nutrients, fluids, and calories to support survival and, in children, growth" — Paul Wales (clinical) [Ep 8 · 2:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=125)
- "New guidelines define intestinal failure as requiring parental support for at least 60 days" — Rod Gerardo (guideline) [Ep 8 · 2:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=144)
- "An intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm providing coordinated care for children with intestinal failure through comprehensive management of specialized nutrition and associated needs" — Paul Wales (clinical) [Ep 8 · 3:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=183)
- "Short bowel syndrome is by far the most common category of intestinal failure in pediatric patients" — Paul Wales (epidemiological) [Ep 8 · 4:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=290)
- "Causes of short bowel syndrome include congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, and long segment Hirschsprung's disease" — Paul Wales (clinical) [Ep 8 · 5:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=306)
- "Acquired diseases of the newborn such as necrotizing enterocolitis cause short bowel syndrome" — Paul Wales (clinical) [Ep 8 · 5:18](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=318)
- "Motility disorders occur when abnormalities of the intestinal muscle itself or the nerves that control that muscle prevent coordinated movement of food and stool" — Paul Wales (clinical) [Ep 8 · 5:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=345)
- "Children with motility disorders are dependent on intravenous support" — Paul Wales (clinical) [Ep 8 · 6:10](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=370)
- "Enteropathies or congenital diarrheas are conditions where the patient has all of their bowel but the mucosal lining that digests and absorbs does not work" — Paul Wales (clinical) [Ep 8 · 6:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=377)
- "Mucosal defects lead to hypersecretion and profuse fluid losses such that the bowel is unable to tolerate or absorb nutrients" — Ellen (clinical) [Ep 8 · 6:30](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=390)
- "Some patients will have elements of one, two, or all three categories of intestinal failure" — Paul Wales (clinical) [Ep 8 · 7:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=431)
- "A child with gastroschisis could have short bowel because it was not all viable, inflammation affecting absorption, and motility issues" — Ellen (clinical) [Ep 8 · 7:22](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=442)
- "Most intestinal failure patients are infants or babies, but some older kids develop intestinal failure" — Paul Wales (epidemiological) [Ep 8 · 7:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=465)
- "Inflammatory bowel disease or Crohn's disease can lead to gut loss and intestinal failure in older patients" — Paul Wales (clinical) [Ep 8 · 7:56](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=476)
- "Trauma, malignancy, and vascular thrombosis leading to gut loss are diagnoses seen more in older patients or adult series and less in pediatrics" — Paul Wales (epidemiological) [Ep 8 · 8:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=484)
- "There are three time points when families reach intestinal rehab programs: prenatal diagnosis, postnatal acquired problems, and later diagnosis after discharge" — Rod Gerardo (clinical) [Ep 8 · 8:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=531)
- "Prenatal diagnoses that lead to intestinal rehab referral include atresia with cystic fibrosis and gastroschisis" — Michael Helmrath (clinical) [Ep 8 · 9:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=555)
- "Postnatal acquired problems leading to intestinal rehab referral include volvulus and necrotizing enterocolitis" — Ellen (clinical) [Ep 8 · 9:29](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=569)
- "The intestinal rehab team includes surgeons, GI doctors, neonatologists, dietitians, social work, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology" — Michael Helmrath (clinical) [Ep 8 · 11:43](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=703)
- "Survival overall in big intestinal rehab programs is usually over 90% long-term survival" — Rod Gerardo (epidemiological) [Ep 8 · 12:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=754)
- "Long-term survivors now develop chronic comorbidities including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues" — Paul Wales (clinical) [Ep 8 · 12:46](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=766)
- "Earlier recognition and taking advantage of the gut's biology to adapt are time dependent" — Michael Helmrath (opinion) [Ep 8 · 2:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=160)
- "Intestinal rehabilitation comes down to key factors: nutrition in the gut, nutrition in the body, and healing" — Michael Helmrath (clinical) [Ep 8 · 4:07](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=247)
- "Pattern recognition from multiple experienced providers seeing patients over time is essential in intestinal rehabilitation" — Michael Helmrath (opinion) [Ep 8 · 4:19](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=259)
- "Families living within the region can benefit from understanding that delivery at an intestinal rehab center from the beginning is probably beneficial" — Michael Helmrath (opinion) [Ep 8 · 8:30](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=510)
- "Access and availability to an intestinal rehab program is still very rare" — Rod Gerardo (epidemiological) [Ep 8 · 8:41](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=521)
- "Innovation comes from multiple approaches to the problem and different visions, with more expertise bringing better outcomes" — Michael Helmrath (opinion) [Ep 8 · 10:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=625)
- "Transitioning older children with intestinal failure into their late teen years and later is a major obstacle that needs to be addressed" — Michael Helmrath (clinical) [Ep 8 · 10:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=651)
- "The gut doubles in length in the last trimester and the first year of life" — Michael Helmrath (clinical) [Ep 18 · 2:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=175)
- "Maturation of the intestine occurs when you feed the baby" — Michael Helmrath (clinical) [Ep 18 · 2:58](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=178)
- "Healthy growth of the intestine requires nutrition" — Michael Helmrath (clinical) [Ep 18 · 3:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=183)
- "Anything done to disrupt feeding affects the maturation of the intestine's ability to absorb, digest, and peristalse" — Michael Helmrath (clinical) [Ep 18 · 3:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=186)
- "It's the waves of peristalsis going over the villi that give absorptive surface area, not the length of exposed bowel" — Em Tombash (clinical) [Ep 18 · 3:32](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=212)
- "Lengthening bowel that doesn't peristalse doesn't increase absorption - it's just more static water" — Michael Helmrath (clinical) [Ep 18 · 3:46](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=226)
- "Very short bowel kids sometimes come off TPN because their motility is so good" — Michael Helmrath (clinical) [Ep 18 · 3:59](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=239)
- "The point of intake for the majority of short bowel syndrome patients is at birth because etiologies are usually neonatal causes" — Paul Wales (epidemiological) [Ep 18 · 4:18](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=258)
- "Congenital anomalies of the GI tract or acquired conditions like necrotizing enterocolitis are the main causes" — Paul Wales (epidemiological) [Ep 18 · 4:36](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=276)
- "If reestablishing bowel continuity, you must deal with size discrepancy between the two ends" — Paul Wales (clinical) [Ep 18 · 5:42](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=342)
- "Even if an anastomosis is patent, disparate diameter will result in functional obstruction" — Ellen Encisco (clinical) [Ep 18 · 5:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=352)
- "Gastroschisis patients don't tend to do as well regardless of intervention" — Paul Wales (clinical) [Ep 18 · 7:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=428)
- "STEP procedures tend to not work as well in gastroschisis patients" — Paul Wales (clinical) [Ep 18 · 7:12](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=432)
- "Gastroschisis patients have inherent dysmotility" — Em Tombash (clinical) [Ep 18 · 7:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=441)
- "The enteric nervous system is damaged in gastroschisis from exposure to amniotic fluid" — Michael Helmrath (clinical) [Ep 18 · 7:32](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=452)
- "The enteric nervous system in gastroschisis has to go through a healing and recovery phase" — Michael Helmrath (clinical) [Ep 18 · 7:32](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=452)
- "When exposed to more dysmotility and stasis, regeneration and healing of the enteric nervous system is attenuated" — Michael Helmrath (clinical) [Ep 18 · 7:46](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=466)
- "A baby with atresia may have really good peristalsis that has been working against an obstruction" — Michael Helmrath (clinical) [Ep 18 · 7:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=475)
- "Children who have STEP procedures in the first year of life sometimes never progress and are labeled poor motility children" — Michael Helmrath (clinical) [Ep 18 · 8:19](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=499)
- "Babies with necrotizing enterocolitis do better when they heal because they've been fed before and already have GI motility starting" — Michael Helmrath (opinion) [Ep 18 · 8:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=520)
- "The STEP procedure requires bowel diameter of about 5 centimeters to be worthwhile" — Paul Wales (clinical) [Ep 18 · 9:09](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=549)
- "The length gained from STEP depends on the starting diameter of the bowel and the width of the stapler cuts" — Em Tombash (clinical) [Ep 18 · 9:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=561)
- "At birth, bowel is usually not dilated enough to apply the STEP procedure" — Ellen Encisco (clinical) [Ep 18 · 9:36](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=576)
- "It's critical to record bowel measurements before and after the procedure" — Em Tombash (guideline) [Ep 18 · 11:22](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=682)
- "There is a risk of bowel twisting in longitudinal orientation if alignment is not maintained during STEP" — Paul Wales (clinical) [Ep 18 · 11:29](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=689)
- "Target caliber for STEP in a baby is about 1.5 centimeters, and for older infant or child is 2 to 2.5 centimeters" — Paul Wales (guideline) [Ep 18 · 13:23](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=803)
- "Making the bowel too narrow during STEP can obstruct the patient, especially in someone with borderline motility" — Paul Wales (clinical) [Ep 18 · 13:36](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=816)
- "A proposed advantage of STEP is that the surgeon can maintain caliber all the way from top to bottom by careful measurements" — Paul Wales (clinical) [Ep 18 · 14:19](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=859)
- "There is potential for leak in the crotch of the staple line if not reinforced" — Paul Wales (clinical) [Ep 18 · 14:35](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=875)
- "Dog ears at the top and bottom of the STEP segment can dilate over time and form blind loops" — Paul Wales (clinical) [Ep 18 · 15:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=908)
- "If one part of the bowel becomes dilated, the STEP segments can rotate away from each other and form a functional obstruction" — Ellen Encisco (clinical) [Ep 18 · 15:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=957)
- "The duodenum doesn't have a mesentery, making it difficult to orient staple lines at 3 and 9 o'clock" — Michael Helmrath (clinical) [Ep 18 · 17:32](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=1052)
- "This was a retrospective cohort study of children with short bowel syndrome in an intestinal rehabilitation program, followed from 2006 to 2019." — Lizzie Lee (epidemiological) [Ep 29 · 0:07](https://library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896?t=7)
- "The study asked whether social determinants of health predict outcomes like bloodstream infections, liver disease, and achieving enteral autonomy." — Lizzie Lee (epidemiological) [Ep 29 · 0:16](https://library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896?t=16)
- "Social determinants of health do predict outcomes in pediatric short bowel syndrome." — Lizzie Lee (epidemiological) [Ep 29 · 0:24](https://library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896?t=24)
- "Distance from the hospital was associated with higher risks of serious complications in children with short bowel syndrome." — Lizzie Lee (epidemiological) [Ep 29 · 0:27](https://library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896?t=27)
- "Parental education was linked with fewer central line infections in children with short bowel syndrome." — Lizzie Lee (epidemiological) [Ep 29 · 0:33](https://library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896?t=33)
- "Clinicians need to consider social determinants of health to better support families of children with short bowel syndrome." — Lizzie Lee (opinion) [Ep 29 · 0:37](https://library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896?t=37)
- "Intestinal failure is defined as reduction of functioning intestinal mass below that which can sustain life, resulting in dependence on supplemental parenteral support for a minimum of 60 days within a 74 consecutive day interval" — Stephanie Oliveira (clinical) [Ep 28 · 0:26](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=26)
- "More than 50% of intestinal failure cases are related to short bowel syndrome, with some mucosal enteropathies and dysmotility disorders" — Stephanie Oliveira (epidemiological) [Ep 28 · 0:43](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=43)
- "Most causes of short bowel syndrome in pediatrics happen during the neonatal period, including gastroschisis, necrotizing enterocolitis, bowel atresia, and intestinal volvulus" — Stephanie Oliveira (clinical) [Ep 28 · 0:55](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=55)
- "The field is starting to focus on neurocognitive outcomes, quality of life, and caregiver burnout" — Stephanie Oliveira (opinion) [Ep 28 · 1:18](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=78)
- "Chronic intestinal inflammation resembling Crohn's disease is now seen in intestinal failure patients, requiring management with inflammatory bowel disease therapies like biologics" — Lizzie Lee (clinical) [Ep 28 · 1:24](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=84)
- "The cause of chronic intestinal inflammation in intestinal failure patients is not known" — Stephanie Oliveira (clinical) [Ep 28 · 1:37](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=97)
- "Intestinal adaptation is an active compensatory process that starts happening right after bowel resection" — Stephanie Oliveira (clinical) [Ep 28 · 2:30](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=150)
- "Food, bacteria, and hormones in the gut are important for enhancing intestinal adaptation" — Stephanie Oliveira (clinical) [Ep 28 · 2:42](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=162)
- "Enteral autonomy is achieved when a patient gets off TPN and has all nutrition going to the gut, either by mouth or by feeding tube" — Stephanie Oliveira (clinical) [Ep 28 · 3:11](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=191)
- "A 2012 Pediatric Intestinal Failure Consortium report showed 50% of intestinal failure patients achieved enteral autonomy, and 25% either passed away or had an intestinal transplant" — Lizzie Lee (epidemiological) [Ep 28 · 3:19](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=199)
- "From 2010 to 2015, a repeat study with double the number of patients showed about 50% reached enteral autonomy, but the number of transplants and deaths significantly decreased" — Stephanie Oliveira (epidemiological) [Ep 28 · 3:33](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=213)
- "The establishment of multidisciplinary teams changed outcomes in intestinal failure" — Stephanie Oliveira (clinical) [Ep 28 · 3:46](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=226)
- "Studies from Canada, Michigan, and Spain show that a multidisciplinary intestinal rehab team improves survival" — Lizzie Lee (epidemiological) [Ep 28 · 3:51](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=231)
- "Predictors of reaching enteral autonomy include greater residual bowel length, follow-up at an institution with an intestinal rehabilitation program, and no-step procedure" — Stephanie Oliveira (clinical) [Ep 28 · 4:03](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=243)
- "The number of intestinal transplants has significantly decreased over the last several decades" — Stephanie Oliveira (epidemiological) [Ep 28 · 4:56](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=296)
- "Liver disease in intestinal failure ranges from mild cholestasis to profound steatosis in older children or adolescents and adults, with ongoing inflammation, fibrosis, and ultimately cirrhosis" — Paul Wales (clinical) [Ep 28 · 5:23](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=323)
- "Risk factors for intestinal failure-associated liver disease include prematurity, lack of enteral feeding, inability to feed due to anatomy, recurrent infections, sepsis, and components of TPN" — Paul Wales (clinical) [Ep 28 · 5:41](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=341)
- "Intestinal rehab programs improve outcomes through integration of care, improved communication, and better continuity" — Paul Wales (clinical) [Ep 28 · 6:12](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=372)
- "Literature shows improvement of outcomes with intestinal rehab programs including improved survival related to liver dysfunction, decreased septic episodes, reduction in central line complications, reduced ICU admissions, and patients coming off transplant lists" — Paul Wales (epidemiological) [Ep 28 · 7:25](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=445)
- "Lipids are a source of essential fatty acids, a non-protein energy source important for growth, and fatty acids have a major role in cellular pathways" — Paul Wales (clinical) [Ep 28 · 8:02](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=482)
- "Soybean-based lipid emulsions have high phytosterol content, high omega-6 long chain polyunsaturated fatty acid content, and low antioxidant content" — Paul Wales (clinical) [Ep 28 · 8:15](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=495)
- "Prolonged soybean-based lipid exposure is associated with deterioration of liver dysfunction, specifically cholestasis" — Paul Wales (clinical) [Ep 28 · 8:31](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=511)
- "For every day an infant is exposed to soybean lipid dosed at greater than 2.5 g per kilo per day, there is a 3% increase in the odds ratio of developing advanced liver disease" — Paul Wales (clinical) [Ep 28 · 8:51](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=531)
- "Omega-6 lipids are metabolized to arachidonic acid, which produces leukotrienes and prostaglandins with a more pro-inflammatory profile" — Paul Wales (clinical) [Ep 28 · 9:51](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=591)
- "Omega-3 lipids are metabolized through EPA and DHA and lead to production of cytokines with a less inflammatory profile" — Paul Wales (clinical) [Ep 28 · 10:01](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=601)
- "Omega-3 lipids improve bile flow by decreasing lithogenicity of bile, decreasing steatosis, stimulating improved beta oxidation and clearance, lowering oxidative stress, and supporting immune function" — Paul Wales (clinical) [Ep 28 · 10:15](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=615)
- "Restricting soybean lipid exposure improves cholestasis when dosed at 1 g per kilo per day or less" — Paul Wales (clinical) [Ep 28 · 10:42](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=642)
- "In preterm babies, fat is important for growth, especially for neurocognitive development, and there is risk of essential fatty acid deficiency if lipid dosing is restricted too much" — Paul Wales (clinical) [Ep 28 · 11:00](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=660)
- "DHA and arachidonic acid are important for retinal and brain development" — Paul Wales (clinical) [Ep 28 · 11:22](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=682)
- "None of the current lipid emulsions were designed for premature babies; they were all designed for adults in a critical care setting" — Paul Wales (clinical) [Ep 28 · 11:26](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=686)
- "There are approximately 240,000 central line-associated bloodstream infections in the United States annually, with each costing about $30,000, totaling about $2 billion per year nationwide" — Paul Wales (epidemiological) [Ep 28 · 12:24](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=744)
- "4% tetrasodium EDTA (kite lock) is an antithrombotic, anti-fibrinolytic, and antimicrobial that satisfies all three criteria important for a good lock solution" — Paul Wales (clinical) [Ep 28 · 12:48](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=768)
- "Kite lock is licensed in Europe and Australia but not available in the United States" — Paul Wales (clinical) [Ep 28 · 13:23](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=803)
- "A multi-center randomized trial of kite lock versus heparin went live 4 weeks ago and is actively recruiting patients" — Paul Wales (clinical) [Ep 28 · 13:29](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=809)
- "In short bowel syndrome, there are 3 anatomical subtypes: Type 1 is high jejunostomy, Type 2 has lost distal small bowel and ileum with small bowel-colonic anastomosis, and Type 3 has lost mid-small bowel but retains some ileum and intact colon" — Paul Wales (clinical) [Ep 28 · 13:58](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=838)
- "Patients with Type 3 short bowel syndrome have the best prognosis because they still have residual ileum" — Lizzie Lee (clinical) [Ep 28 · 14:19](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=859)
- "The most common anatomical subtype of short bowel syndrome in pediatrics is Type 2" — Paul Wales (epidemiological) [Ep 28 · 14:26](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=866)
- "Type 1 and Type 2 short bowel syndrome patients struggle because they lack an ileum, which is where GLP-2 is naturally produced" — Paul Wales (clinical) [Ep 28 · 14:33](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=873)
- "Native GLP-2 hormone has a half-life of 7 minutes, making it impractical for clinical use" — Paul Wales (clinical) [Ep 28 · 14:53](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=893)
- "Teduglutide is a GLP-2 analog with one amino acid alteration that has a half-life of 2 hours and is given once daily by subcutaneous injection" — Paul Wales (clinical) [Ep 28 · 14:58](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=898)
- "Patients receiving teduglutide show a 40% reduction in TPN fluid and calorie requirements over a six-month period" — Paul Wales (clinical) [Ep 28 · 15:23](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=923)
- "70% of patients receiving teduglutide achieved the study endpoint of a 20% reduction in TPN requirements" — Paul Wales (clinical) [Ep 28 · 15:32](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=932)
- "Teduglutide is licensed for children greater than 1 year of age" — Paul Wales (clinical) [Ep 28 · 15:48](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=948)
- "Apraglutide is another GLP-2 analog with a longer half-life that can be given once a week and works even better than teduglutide, producing more bowel lengthening" — Paul Wales (clinical) [Ep 28 · 16:02](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=962)
- "These interventions have led to a decrease in transplantation since 2008, largely because of the successes of intestinal rehabilitation" — Paul Wales (epidemiological) [Ep 28 · 16:36](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=996)
- "Outcomes of intestinal transplant at 5 years are about 65%" — Paul Wales (epidemiological) [Ep 28 · 16:41](https://library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=1001)
- "Intestinal failure is an umbrella term for when the small intestine is unable to absorb or digest enough nutrition to support the patient entirely by oral or enteral feeding" — Brad Warner (clinical) [Ep 6 · 1:42](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=102)
- "The intestine of a newborn or fetus doubles in length in the last trimester of gestation" — Brad Warner (clinical) [Ep 6 · 3:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=183)
- "For a neonate with ileocecal valve and entire colon, 10 to 15 centimeters of small intestine is a ballpark figure for salvageability" — Brad Warner (clinical) [Ep 6 · 4:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=243)
- "Without the colon and ileocecal valve, at least 15 to 20 centimeters would be a ballpark figure for salvageability" — Brad Warner (clinical) [Ep 6 · 4:37](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=277)
- "In adults with less than 50 centimeters of intestine, about 40% will not be alive after 5 to 10 years" — Brad Warner (epidemiological) [Ep 6 · 4:51](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=291)
- "For a patient with 15 centimeters of bowel and ileocecal valve, long term 50% should be able to wean from TPN, 25% would require transplant, and 25% would die" — Brad Warner (epidemiological) [Ep 6 · 5:56](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=356)
- "Intestinal adaptation in humans probably takes place over about a year or two after small bowel resection" — Brad Warner (clinical) [Ep 6 · 7:49](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=469)
- "Stool outputs of up to 40 ccs per kilo per day are acceptable when advancing enteral feeding" — Brad Warner (guideline) [Ep 6 · 8:30](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=510)
- "For TPN, shoot for about 100 to 120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein" — Brad Warner (guideline) [Ep 6 · 10:22](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=622)
- "Generally shoot for about 2 to 3 g of protein per kilo per day and about 2 to 3 g of fat per kilo per day in TPN" — Brad Warner (guideline) [Ep 6 · 10:45](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=645)
- "A baby should gain about 20 to 30 g a day, which approximates in utero progression for a newborn" — Brad Warner (clinical) [Ep 6 · 12:05](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=725)
- "Lipid reduction strategy takes patients from 2 to 3 g per kilo per day of fat delivered daily down to about 1 g per kilo per day delivered twice or 3 times a week to reduce cholestasis" — Brad Warner (guideline) [Ep 6 · 12:53](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=773)
- "Omegaven is a fish oil-based fat primarily containing omega 3 fatty acids that are anti-inflammatory, compared to soybean-based intralipid with omega 6 fatty acids that are pro-inflammatory" — Brad Warner (clinical) [Ep 6 · 14:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=843)
- "SMOF lipid contains soybean (essential fatty acids), medium chain triglycerides (easily digested), olive oil, and fish oil, and has become the most commonly used lipid in Canada" — Brad Warner (clinical) [Ep 6 · 15:08](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=908)
- "Breast milk is the best choice for neonates because it contains growth factors like EGF and IGF, milk oligosaccharides that enhance adaptation, and other beneficial components" — Brad Warner (opinion) [Ep 6 · 18:11](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1091)
- "Complex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent" — Brad Warner (clinical) [Ep 6 · 19:26](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1166)
- "There is a threshold percentage of enteral calories that prevents onset of liver damage from TPN, though the exact number is unknown" — Brad Warner (clinical) [Ep 6 · 21:19](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1279)
- "Time to consider surgical intervention is when patient hits a plateau enterally and starts backing away, or if going backward rather than forward in enteral tolerance" — Brad Warner (guideline) [Ep 6 · 22:33](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1353)
- "Multiple episodes of sepsis along with abdominal distention and dilated bowel loops is an indication for surgical intervention" — Brad Warner (guideline) [Ep 6 · 23:01](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1381)
- "If child is starting to get jaundiced, there is a role to evaluate the gut for subclinical portal bacteremia arising from dilated bowel loops" — Brad Warner (clinical) [Ep 6 · 23:18](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1398)
- "Dilated bowel loops cause bacterial overgrowth leading to secretory diarrhea that is not related to digestion-absorption capacity but to enzyme dysfunction" — Brad Warner (clinical) [Ep 6 · 23:53](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1433)
- "More than 4 to 5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention" — Brad Warner (guideline) [Ep 6 · 25:43](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1543)
- "In a child who is completely stable after 3 years but not progressing, would interrogate bowel and if dilated would proceed with lengthening" — Brad Warner (opinion) [Ep 6 · 26:07](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1567)
- "If a child has over 100 centimeters of intestine, less than 5 or 10% should require TPN, suggesting possible underlying motility or mucosal problem" — Brad Warner (clinical) [Ep 6 · 27:53](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1673)
- "With less than 50 centimeters of intestine and bowel at least 4 to 5 centimeters dilated, there is an option for either Bianchi or STEP procedure" — Brad Warner (guideline) [Ep 6 · 28:37](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1717)
- "The STEP procedure has emerged to be the most commonly performed lengthening operation because it is easier to do with less risk of injuring mesenteric blood supply" — Brad Warner (clinical) [Ep 6 · 29:31](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1771)
- "STEP procedures can redilate requiring redo procedures, and outcomes are not as good if a redo STEP is needed compared to never needing a redo" — Brad Warner (clinical) [Ep 6 · 32:54](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1974)
- "You can do a Bianchi and then later do a STEP on top of it, but you cannot do a Bianchi once a STEP has been done" — Brad Warner (clinical) [Ep 6 · 33:26](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2006)
- "STEP procedures can cause dysmotility acting as a brake on intestinal transit" — Brad Warner (clinical) [Ep 6 · 35:04](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2104)
- "Would taper a child with dilated bowel who had at least 90 to 100 centimeters of intestinal length rather than performing a lengthening procedure" — Brad Warner (opinion) [Ep 6 · 38:21](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2301)
- "Chenodeoxycholic acid bile salts can be used to improve bile flow in TPN cholestasis" — Brad Warner (clinical) [Ep 6 · 39:00](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2340)
- "Cholecystokinin administration to promote bile flow and mitigate TPN cholestasis did not work in clinical trials" — Brad Warner (clinical) [Ep 6 · 39:23](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2363)
- "Gut bacteria in short gut syndrome become more efficient and help adapt by encouraging greater absorption and digestion, similar to an obesogenic microbiome" — Brad Warner (clinical) [Ep 6 · 41:54](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2514)
- "In mouse models, oral vancomycin to knock out gram positive organisms completely prevented hepatic steatosis after bowel resection" — Brad Warner (clinical) [Ep 6 · 42:19](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2539)
- "Teduglutide, a GLP-2 analog, has been demonstrated in randomized trials to reduce TPN requirements by about 1-2 liters per week in adults with short gut syndrome" — Brad Warner (clinical) [Ep 6 · 43:45](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2625)
- "Teduglutide is not yet approved for children in the United States due to concerns about malignancy risk from promoting proliferation" — Brad Warner (clinical) [Ep 6 · 44:34](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2674)
- "Growth hormone and glutamine combinations have shown primarily mixed results and have not been a huge advance in TPN weaning" — Brad Warner (clinical) [Ep 6 · 45:40](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2740)
- "Survival for small bowel transplant is about 50 to 60% at 5 years, with one year survivals now above 70 to 80%" — Brad Warner (epidemiological) [Ep 6 · 46:51](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2811)
- "The intestine is an immunogenic organ filled with white cells and macrophages that mount a huge graft versus host response requiring industrial strength immunosuppression" — Brad Warner (clinical) [Ep 6 · 47:11](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2831)
- "Ethanol locks for central lines have reduced significantly the number of sepsis episodes in patients with short gut syndrome" — Brad Warner (clinical) [Ep 6 · 49:22](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2962)
- "Multidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID, radiology, and interventional radiology improve survival of intestinal failure patients" — Brad Warner (clinical) [Ep 6 · 51:16](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=3076)
- "Advances in medicine have dramatically improved survival rates for children with intestinal failure" — Julian Goddard (clinical) [Ep 27 · 0:00](https://library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=0)
- "The study tracked 46 patients who turned 20 to evaluate outcomes during care transition" — Julian Goddard (epidemiological) [Ep 27 · 0:13](https://library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=13)
- "59% of patients transitioned to adult focused programs while the rest continued receiving care at Cincinnati Children's" — Julian Goddard (epidemiological) [Ep 27 · 0:23](https://library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=23)
- "Patients who transitioned to adult care had a 33% mortality rate" — Julian Goddard (epidemiological) [Ep 27 · 0:29](https://library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=29)
- "Patients who stayed in pediatric care had a 5% mortality rate" — Julian Goddard (epidemiological) [Ep 27 · 0:29](https://library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=29)
- "The two groups showed no obvious differences in medical complexity or disease burden" — Julian Goddard (clinical) [Ep 27 · 0:29](https://library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=29)
- "The median time from transition to death was approximately 12 months" — Julian Goddard (epidemiological) [Ep 27 · 0:42](https://library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=42)
- "Young adults with a history of intestinal failure aging out of pediatric care remain a critically vulnerable population" — Julian Goddard (opinion) [Ep 27 · 0:46](https://library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=46)
- "Structured transition programs need to be developed and widely implemented for this population" — Julian Goddard (opinion) [Ep 27 · 0:46](https://library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=46)
- "Young infants, babies, and young children have tremendous gut growth potential, with the gut growing for the first several years of life" — Paul Weil (clinical) [Ep 25 · 0:49](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=49)
- "A term baby will have 160 centimeters of small bowel, and by age 5 years it almost triples to about 425 to 450 centimeters" — Paul Weil (clinical) [Ep 25 · 1:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=77)
- "You can have as low as 10% expected gut length and still achieve enteral autonomy if you have the majority of your colon in continuity" — Paul Weil (clinical) [Ep 25 · 1:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=111)
- "The more important factor is the presence or absence of the distal small bowel or ileum and right colon that can act as reclamation of bile and support enterohepatic circulation" — Michael Helmrath (clinical) [Ep 25 · 2:30](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=150)
- "GLP-2, GLP-1, and hormones like PYY are produced in the distal ileum, not because of the ileocecal valve but because of the distal ileum itself" — Michael Helmrath (clinical) [Ep 25 · 2:43](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=163)
- "Strategy at the first operation should provide a pathway forward that allows early interval feeding" — Michael Helmrath (clinical) [Ep 25 · 3:29](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=209)
- "It is sometimes better to stage reconstruction under more controlled conditions rather than attempt immediate continuity" — Michael Helmrath (opinion) [Ep 25 · 3:38](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=218)
- "Many segments of bowel deemed non-usable actually have potential to heal in this population and can make a huge difference in the lifetime of the child" — Michael Helmrath (clinical) [Ep 25 · 4:02](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=242)
- "As long as you can divert proximally and the baby is stable, you can leave questionable bowel for potential use at later secondary reconstructive procedures" (clinical) [Ep 25 · 4:26](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=266)
- "The overarching principle is to deliver adequate nutrition to have normal growth within normal parameters, ideally enterally" — Paul Weil (clinical) [Ep 25 · 5:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=308)
- "As much as possible, we should try to establish normal feeding behavior, realizing that enteral nutrition is more than just nutrition" — Paul Weil (clinical) [Ep 25 · 5:28](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=328)
- "If a patient needs tube support from the beginning, bolus feeding should be tried rather than defaulting to continuous feeding" — Paul Weil (clinical) [Ep 25 · 5:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=352)
- "If the child fails gastric approach (bolus then continuous), the strategy is to feed beyond the stomach and decompress the stomach through an NG tube" — Paul Weil (clinical) [Ep 25 · 6:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=375)
- "Breast milk is the formula of choice, not only for nutritional benefits but for all the other components within breast milk" — Michael Helmrath (clinical) [Ep 25 · 6:42](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=402)
- "Single amino acid level protein is the generalized preference to avoid high stool output, high fluid losses, wound breakdown, rashes, and emesis" — Michael Helmrath (clinical) [Ep 25 · 7:28](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=448)
- "Long chain fat is the preferred fat module rather than MCT, as long chain fat is a much stronger stimulus for GLP-2 release, which drives adaptation" — Paul Weil (clinical) [Ep 25 · 8:07](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=487)
- "Not every child needs to be on SMOF lipid emulsion" — Paul Weil (opinion) [Ep 25 · 9:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=540)
- "For preterm babies, SMOF is not the ideal lipid emulsion but is the best currently available" — Paul Weil (clinical) [Ep 25 · 9:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=543)
- "SMOF does not have enough arachidonic acid, which is really important for brain development" — Paul Weil (clinical) [Ep 25 · 9:16](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=556)
- "Two strategies to treat cholestasis are to reduce the total amount of fat or to change the composition to introduce SMOF lipids or omegaven" (clinical) [Ep 25 · 9:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=574)
- "Lipid restrictions that reduce dose to 1 g/kg/day can reverse cholestasis but result in reduced calorie delivery that can impair growth and potentially impact neurocognitive development" (clinical) [Ep 25 · 9:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=590)
- "Omegaven is essentially pure fish oil with omega-3 and is dosed at 1 g/kg, so babies take a calorie hit" (clinical) [Ep 25 · 10:07](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=607)
- "SMOF lipids are a more well-balanced emulsion with an omega-3 to omega-6 ratio of 2.5 to 1, being less inflammatory than intralipid and promoting bile flow" (clinical) [Ep 25 · 10:28](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=628)
- "SMOF lipids should not be restricted and must be given at no less than 2 or 2.5 g/kg/day" (clinical) [Ep 25 · 10:28](https://library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=628)
- "This is a retrospective study examining pediatric patients with short bowel syndrome" — Lizzie Lee (clinical) [Ep 26 · 0:10](https://library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=10)
- "The study included 64 pediatric patients with short bowel syndrome" — Lizzie Lee (epidemiological) [Ep 26 · 0:10](https://library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=10)
- "Patients were managed by a multidisciplinary intestinal rehab program" — Lizzie Lee (clinical) [Ep 26 · 0:10](https://library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=10)
- "The study period was between 2001 and 2022" — Lizzie Lee (epidemiological) [Ep 26 · 0:10](https://library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=10)
- "89% of patients survived" — Lizzie Lee (epidemiological) [Ep 26 · 0:22](https://library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=22)
- "78% of patients were able to wean off parenteral nutrition" — Lizzie Lee (epidemiological) [Ep 26 · 0:22](https://library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=22)
- "Survival rates improved over time" — Lizzie Lee (epidemiological) [Ep 26 · 0:22](https://library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=22)
- "Fish oil-based parenteral nutrition was introduced in 2007" — Lizzie Lee (clinical) [Ep 26 · 0:31](https://library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=31)
- "Introduction of fish oil-based parenteral nutrition improved survival" — Lizzie Lee (clinical) [Ep 26 · 0:31](https://library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=31)
- "Intestinal failure associated liver disease was a factor that affected survival" — Lizzie Lee (clinical) [Ep 26 · 0:31](https://library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=31)
- "Breast milk provides significant benefit to time to wean off parenteral nutrition in gastroschisis and necrotizing enterocolitis patients compared to formula only" — Michael Helmrath (clinical) [Ep 1 · 59:57](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=3597)
- "Donor breast milk is less advantageous than maternal breast milk because it is typically from mothers 10-14 months postpartum with lower caloric density and protein levels" — Sam Kocoshis (clinical) [Ep 1 · 62:48](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=3768)
- "Continuous drip feeding improves absorption coefficient from 60% to 85% in adults with short bowel syndrome compared to ad lib feeding" — Sam Kocoshis (clinical) [Ep 1 · 17:44](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1064)
- "Combining daytime oral feeding with nighttime drip feeds achieves approximately 75% absorption, balancing benefits of both approaches" — Sam Kocoshis (clinical) [Ep 1 · 18:08](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1088)
- "Micronutrient deficiency occurs in approximately 60% of patients weaned off TPN" — Sam Kocoshis (epidemiological) [Ep 1 · 71:51](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=4311)
- "Patients with 50% of estimated bowel length are expected to come off parenteral nutrition" — Michael Helmrath (clinical) [Ep 1 · 28:11](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1691)
- "The one thing that makes the bowel adapt is feeding the bowel; procedures that cause problems in reinitiating feeds cause damage to the patient" — Michael Helmrath (clinical) [Ep 1 · 30:20](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1820)
- "STEP procedures done in the first year of life in patients who have not progressed with enteral feeds are not beneficial unless specifically avoiding line infections and bacterial overgrowth" — Michael Helmrath (opinion) [Ep 1 · 29:35](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1775)
- "In a neonatal STEP registry study, only 3 patients came off parenteral nutrition, whereas natural data shows 80-90% of similar patients come off TPN at 12 months without STEP" — Michael Helmrath (clinical) [Ep 1 · 31:32](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1892)
- "Dilated bowel does not become motile because you did a STEP procedure on it if the patient has never been able to advance feeds" — Michael Helmrath (clinical) [Ep 1 · 29:53](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1793)
- "Placing a balloon catheter directly into the jejunal lumen is obstructing; creating a chimney with a Roux limb allows easy family-managed tube changes" — Michael Helmrath (clinical) [Ep 1 · 4:36](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=276)
- "GJ tubes in small infants are very stiff, not durable long-term, and require families to return for radiographic exchange when displaced" — Michael Helmrath (clinical) [Ep 1 · 12:21](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=741)
- "In patients with mega duodenum and dysmotility, GJ tube tips invariably flip back into the stomach, requiring almost weekly replacement" — Sam Kocoshis (clinical) [Ep 1 · 13:16](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=796)
- "Patients with surgical jejunal feeding access have been successfully managed for 12-18 months with eventual return of gastric function" — Sam Kocoshis (clinical) [Ep 1 · 13:42](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=822)
- "Two-thirds of bloodstream infections occurred in patients on prophylactic Flagyl because it knocks out anaerobes and facilitates aerobic overgrowth" — Sam Kocoshis (clinical) [Ep 1 · 90:48](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=5448)
- "Metronidazole is the wrong choice for bacterial overgrowth because it has limited spectrum, knocks off anaerobes, and facilitates growth of aerobes" — Sam Kocoshis (opinion) [Ep 1 · 92:11](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=5531)
- "Breast milk contains non-nutrient oligosaccharides (2FL, 3FL) that affect microflora and dysbiosis, with 80% of donors having secretor status producing 2FL" — Michael Helmrath (clinical) [Ep 1 · 86:39](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=5199)
- "H2 blockers and antibiotics further dysbiosis in intestinal failure patients" — Michael Helmrath (clinical) [Ep 1 · 87:01](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=5221)
- "Elemental formulas at 20 kilocalories have osmolarity around 350-360; going higher increases osmolarity risk" — Sam Kocoshis (clinical) [Ep 1 · 64:35](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=3875)
- "In jejunum-only patients with no ileum, isotonic formulas at 15-17 calories per ounce are preferred because jejunum cannot absorb against concentration gradient" — Simon (clinical) [Ep 1 · 65:34](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=3934)
- "Patients handle volume much better than concentration when they don't have upper GI dysmotility" — Simon (clinical) [Ep 1 · 66:10](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=3970)
- "Introduction of baby foods, meats, and vegetables is remarkably helpful in the adaptation process once patients are older" — Simon (clinical) [Ep 1 · 66:18](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=3978)
- "Cholestyramine doses effective in firming stool will bind nutrients, fat-soluble vitamins, and fats, with risk of hyperchloremic acidosis and bezoars" — Sam Kocoshis (clinical) [Ep 1 · 106:00](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6360)
- "Pancreatic enzymes in distal areas of bowel, especially with stomas, can cause strictures or stoma problems when they sit in areas of stenosis and dysmotility" — Michael Helmrath (clinical) [Ep 1 · 109:07](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6547)
- "Physiologically, only pancreatic proteases are present in adult quantities in young infants; amylases appear at 6-12 months and lipase reaches adult levels by end of first year" — Sam Kocoshis (clinical) [Ep 1 · 109:38](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6578)
- "Short gut patients have very high trypsinogen levels because they lack sufficient enterokinase" — Sam Kocoshis (clinical) [Ep 1 · 110:07](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6607)
- "Pancreatic enzymes go through short gut before they've released, resulting in perianal excoriation" — Simon (clinical) [Ep 1 · 111:01](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6661)
- "GLP-2 analog reduces fecal output such that TPN can be reduced by 20% in 60-70% of adult patients, with 20% achieving complete TPN independence in extension studies" — Sam Kocoshis (clinical) [Ep 1 · 114:00](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6840)
- "Some patients regress when GLP-2 analog is discontinued" — Sam Kocoshis (clinical) [Ep 1 · 114:49](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6889)
- "Stoma output of 40-50 cc/kg is acceptable if electrolyte profile is maintained and patient is not acidotic with CO2 in the teens" — Michael Helmrath (clinical) [Ep 1 · 111:30](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6690)
- "Knee-jerk reactions to volume of output without considering overall pattern, acidosis, and electrolytes leads to variable feeding amounts over longer periods, which is detrimental" — Michael Helmrath (opinion) [Ep 1 · 112:26](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6746)
- "Stoma output is more relevant for guiding fluid and electrolyte replacement than for making decisions about stopping or decreasing feeds" — Michael Helmrath (clinical) [Ep 1 · 112:53](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6773)
- "Anti-inflammatory agents including 5-ASA products and steroid-based enemas can help manage hypermotility when inflammation is documented on endoscopy" — Michael Helmrath (clinical) [Ep 1 · 104:08](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6248)
- "In challenging Hirschsprung's patients with dysbiosis and high stool frequency not responding to antibiotics or formula changes, anti-inflammatories have been remarkably successful" — Michael Helmrath (clinical) [Ep 1 · 104:43](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6283)
- "Octreotide has not been found very useful for high output and raises concerns about growth hormone suppression in children trying to gain weight" — Simon (opinion) [Ep 1 · 102:49](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6169)
- "Proton pump inhibitors may decrease gastric secretion in patients with high gastric output" — Simon (clinical) [Ep 1 · 103:21](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6201)
- "First consideration in high output is whether the gut is being overtaxed and whether an osmotic diarrhea is occurring from pushing feeds too hard or fast" — Simon (clinical) [Ep 1 · 101:32](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6092)
- "Loperamide becomes helpful when colon is involved in managing high output" — Simon (clinical) [Ep 1 · 102:21](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6141)
- "Soluble fibers help decrease output" — Simon (clinical) [Ep 1 · 102:35](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6155)
- "Lactobacillus species from probiotics are extremely hard to clear when they infect central lines" — Simon (clinical) [Ep 1 · 100:01](https://library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6001)
- "The START trial randomized 140 infants with biliary atresia to high-dose steroids (13-week course) versus placebo after Kasai portoenterostomy" — Daniel von Allmen (clinical) [Ep 3 · 2:56](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=176)
- "High-dose steroid therapy following Kasai did not result in statistically significant treatment difference in bile drainage at 6 months: 58.6% treatment group versus 48.6% placebo" — Daniel von Allmen (clinical) [Ep 3 · 4:01](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=241)
- "Survival without liver transplant at 24 months was not statistically different: 58.7% steroid group versus 49.4% placebo group" — Daniel von Allmen (clinical) [Ep 3 · 4:39](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=279)
- "Adverse events occurred in near 80% of patients in both steroid and placebo groups, attributed largely to severe underlying liver dysfunction" — Daniel von Allmen (clinical) [Ep 3 · 4:55](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=295)
- "Steroid treatment was associated with earlier onset of serious adverse events in children with biliary atresia" — Daniel von Allmen (clinical) [Ep 3 · 5:10](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=310)
- "The study was powered to detect a 25% absolute treatment difference in outcomes" — Daniel von Allmen (clinical) [Ep 3 · 3:46](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=226)
- "Steroids are proposed to work through two mechanisms: reducing ongoing inflammation to preserve bile ductules, and acting as a choleretic to maintain bile flow" — Daniel von Allmen (clinical) [Ep 3 · 8:59](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=539)
- "Washington State registry study included over 50 hospitals and analyzed clean-contaminated operations over 18 months beginning January 2011" — Whit Holcomb (clinical) [Ep 3 · 12:02](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=722)
- "Overall surgical site infection rate was 4.6%, varying by procedure: 6.6% colorectal, 1.4% bariatric, 1.5% other" — Whit Holcomb (epidemiological) [Ep 3 · 13:05](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=785)
- "No single antiseptic agent was associated with lower risk of surgical site infection than any other agent" — Whit Holcomb (clinical) [Ep 3 · 13:39](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=819)
- "Isopropyl alcohol provided no benefit: 4.5% SSI rate without alcohol versus 4.6% with alcohol" — Whit Holcomb (clinical) [Ep 3 · 13:49](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=829)
- "Registry data could not identify surgical site infections diagnosed after discharge, likely underestimating true SSI rate" — Whit Holcomb (clinical) [Ep 3 · 14:20](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=860)
- "Recent reports show 50% or more surgical site infections are diagnosed after discharge" — Whit Holcomb (epidemiological) [Ep 3 · 14:40](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=880)
- "Most surgical site infections occur 3 to 10 days after operation" — Whit Holcomb (clinical) [Ep 3 · 14:48](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=888)
- "Chlorhexidine prep dries faster than betadine, allowing cases to start sooner" — Whit Holcomb (clinical) [Ep 3 · 18:33](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1113)
- "Appendicitis pilot RCT enrolled 50 patients aged 5-15 years with non-perforated appendicitis: 26 randomized to operation, 24 to antibiotics" — Whit Holcomb (clinical) [Ep 3 · 22:58](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1378)
- "Of 24 patients randomized to non-operative treatment, 2 underwent appendectomy during primary treatment course and 1 had appendectomy at 9 months for recurrent appendicitis" — Whit Holcomb (clinical) [Ep 3 · 23:14](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1394)
- "An additional 6 patients in the non-operative group underwent appendectomy for recurrent abdominal pain or parental desire during 1-year follow-up, with no appendicitis found on histology" — Whit Holcomb (clinical) [Ep 3 · 23:32](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1412)
- "Total of 9 of 24 patients (38%) initially randomized to antibiotic therapy underwent appendectomy within first year, making success rate 62%" — Whit Holcomb (clinical) [Ep 3 · 24:10](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1450)
- "Median time to discharge was significantly shorter in surgical group than non-operative group, possibly due to stipulated 48-hour minimum hospitalization for non-operative patients" — Whit Holcomb (clinical) [Ep 3 · 24:35](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1475)
- "Cost for initial inpatient stay was significantly lower in non-operative treatment group despite longer hospitalizations" — Whit Holcomb (clinical) [Ep 3 · 24:55](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1495)
- "Immunosuppressed cancer patients with typhlitis are sometimes treated non-operatively and most resolve with antibiotics" — Whit Holcomb (clinical) [Ep 3 · 27:00](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1620)
- "PIFCON study included 272 patients from 14 multidisciplinary intestinal rehab programs with median 33-month follow-up" — Aaron Lipskar (clinical) [Ep 3 · 32:32](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1952)
- "Enteral autonomy was achieved in 43% of intestinal failure cohort, 13% remained PN-dependent, and 43% died or underwent transplantation" — Aaron Lipskar (epidemiological) [Ep 3 · 32:40](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1960)
- "Necrotizing enterocolitis diagnosis, care at intestinal rehab facility without transplant center, and presence of ileocecal valve were associated with statistically significant higher rates of enteral autonomy" — Aaron Lipskar (clinical) [Ep 3 · 32:58](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1978)
- "Residual small bowel length was a statistically significant but less impressive predictor of enteral autonomy" — Aaron Lipskar (clinical) [Ep 3 · 33:19](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1999)
- "The protective effect of necrotizing enterocolitis on enteral autonomy goes against understanding of that inflammatory illness" — Aaron Lipskar (opinion) [Ep 3 · 33:55](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2035)
- "A companion paper in same journal showed necrotizing enterocolitis was a poor predictor of growth outcome in infants with short bowel syndrome" — Aaron Lipskar (clinical) [Ep 3 · 35:12](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2112)
- "FDA established SmartTots partnership with International Anesthesia Research Society in 2009 to study anesthesia-related neurotoxicity" — Aaron Lipskar (guideline) [Ep 3 · 37:19](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2239)
- "SmartTots 2012 consensus statement recommended avoiding elective surgical procedures under anesthesia in children less than 3 years when possible" — Aaron Lipskar (guideline) [Ep 3 · 37:34](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2254)
- "Commonly used anesthetics including propofol, etomidate, sevoflurane, isoflurane, and ketamine produce profound neurotoxic effects in laboratory animals from nematodes to nonhuman primates" — Aaron Lipskar (clinical) [Ep 3 · 38:09](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2289)
- "Observational studies in children undergoing early anesthesia offer conflicting results but suggest some children may have deficits, though causation difficult to establish" — Aaron Lipskar (clinical) [Ep 3 · 38:43](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2323)
- "June 2014 SmartTots statement concluded animal data sufficiently convincing that large-scale clinical studies are warranted" — Aaron Lipskar (guideline) [Ep 3 · 39:06](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2346)
- "Updated recommendation is to avoid surgical procedures under anesthesia in children under 3 years unless situation is urgent or potentially harmful if not attended to" — Aaron Lipskar (guideline) [Ep 3 · 39:14](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2354)
- "Regional anesthesia blocks can diminish amount of potentially neurotoxic medications in almost every laparoscopic, thoracoscopic, or open operation" — Aaron Lipskar (clinical) [Ep 3 · 42:00](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2520)
- "Rule of two suggested: defer elective operations until after age 2 and try not to have two anesthetics in one year" — Todd Ponsky (opinion) [Ep 3 · 42:16](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2536)
- "Survey of 150 parents in primary care pediatrics office found vast majority did not know anesthetic neurotoxicity was a major issue" — Aaron Lipskar (epidemiological) [Ep 3 · 43:17](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2597)
- "Intestinal failure is an umbrella term for when the small intestine is unable to absorb or digest enough nutrition to support the patient entirely by oral or enteral feeding" — Brad Warner (clinical) [Ep 2 · 1:42](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=102)
- "The intestine of a newborn or fetus doubles in length in the last trimester of gestation" — Brad Warner (clinical) [Ep 2 · 3:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=183)
- "For a neonate with ileocecal valve and entire colon, 10 to 15 centimeters of small intestine would be a ballpark salvageable figure" — Brad Warner (clinical) [Ep 2 · 4:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=243)
- "Without the colon and ileocecal valve, at least 15 to 20 cm range would be a ballpark salvageable figure" — Brad Warner (clinical) [Ep 2 · 4:37](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=277)
- "In adult studies, adults with less than 50 centimeters of intestine, about 40% will not be alive after 5 to 10 years" — Brad Warner (epidemiological) [Ep 2 · 4:51](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=291)
- "Long term, 50% of kids with 15 cm intestinal length and entire colon should be able to wean from TPN, 25% would require intestinal and/or liver transplant, and 25% would probably die" — Brad Warner (epidemiological) [Ep 2 · 5:56](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=356)
- "Causes of death in short gut syndrome include liver failure, septic episodes from central line or bacterial overgrowth, variceal bleeding from liver disease, and loss of IV access" — Brad Warner (clinical) [Ep 2 · 7:11](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=431)
- "Intestinal adaptation in humans probably takes place over about a year or two" — Brad Warner (clinical) [Ep 2 · 7:49](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=469)
- "Would accept stool outputs of up to 40 ccs per kilo per day as the limit before backing off on enteral feeding" — Brad Warner (clinical) [Ep 2 · 8:30](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=510)
- "Top causes of short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias" — Brad Warner (epidemiological) [Ep 2 · 9:15](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=555)
- "For TPN, shoot for about 100 to 120 calories per kilo per day for total calories, about 50% glucose calories, with 2 to 3 g protein per kilo per day and 2 to 3 g fat per kilo per day" — Brad Warner (clinical) [Ep 2 · 10:22](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=622)
- "Want a baby to gain about 20 to 30 g a day, which approximates in utero aggression for a newborn" — Brad Warner (clinical) [Ep 2 · 12:05](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=725)
- "Lipid reduction strategy takes patients from 2 to 3 g per kilo per day of fat delivered every day down to about 1 g per kilo per day delivered twice or 3 times a week, which has been effective in reducing TPN-associated cholestasis" — Brad Warner (clinical) [Ep 2 · 12:53](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=773)
- "Omegaven is a fish oil-based fat primarily containing omega 3 fatty acids considered anti-inflammatory, versus intralipid which is soybean-based with omega 6 fatty acids considered pro-inflammatory" — Brad Warner (clinical) [Ep 2 · 13:46](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=826)
- "SMOF lipid contains soybean-based lipid (essential fatty acids), medium chain triglycerides (more easily digested), olive oil, and fish oil, and has become the most commonly used lipid in Canada with recent FDA approval in the United States" — Brad Warner (clinical) [Ep 2 · 15:08](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=908)
- "Breast milk is the best choice for neonates because it contains proper fat, growth factors like EGF and insulin-like growth factors that promote adaptation, and milk oligosaccharides that enhance adaptation" — Brad Warner (opinion) [Ep 2 · 18:11](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1091)
- "Complex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent" — Brad Warner (opinion) [Ep 2 · 19:26](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1166)
- "There is a threshold percentage of enteral calories that prevents onset of liver damage from TPN, though the exact number is not known" — Brad Warner (clinical) [Ep 2 · 20:56](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1256)
- "Would start thinking about surgical intervention if patient hits a point enterally and starts backing away, or if going backward rather than forward in enteral tolerance" — Brad Warner (opinion) [Ep 2 · 22:33](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1353)
- "Multiple episodes of sepsis with abdominal distention and dilated bowel loops would be another reason to consider surgical intervention" — Brad Warner (clinical) [Ep 2 · 23:01](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1381)
- "If child is starting to get jaundiced, should evaluate the gut because there could be subclinical portal bacteremia arising from dilated bowel loops" — Brad Warner (clinical) [Ep 2 · 23:18](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1398)
- "Dilated bowel loops can cause bacterial overgrowth leading to secretory diarrhea that affects digestion and absorption capacity" — Brad Warner (clinical) [Ep 2 · 23:53](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1433)
- "Would use more than 4 to 5 centimeters of bowel dilation as threshold for surgical intervention when patient is not advancing or going backward with enteral feeds" — Brad Warner (clinical) [Ep 2 · 25:43](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1543)
- "If child has over 100 centimeters of intestine, less than 5 or 10% should require TPN, suggesting possible underlying motility or mucosal problem if still TPN-dependent" — Brad Warner (clinical) [Ep 2 · 27:53](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1673)
- "With less than 50 cm intestine and bowel at least 4 to 5 cm dilated, have option of either Bianchi intestinal lengthening or STEP procedure" — Brad Warner (clinical) [Ep 2 · 28:37](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1717)
- "The STEP procedure has emerged to be the most commonly performed lengthening operation" — Brad Warner (epidemiological) [Ep 2 · 29:31](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1771)
- "Bianchi procedure takes advantage of bifurcating blood supply to bowel wall, creating two tubes of bowel each supplied by one arm of the V-shaped vessels" — Brad Warner (clinical) [Ep 2 · 30:00](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1800)
- "STEP procedure cuts partially across bowel alternating from each side, creating channels that increase length of mucosal contact and reduce caliber" — Brad Warner (clinical) [Ep 2 · 31:45](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1905)
- "STEP can redilate requiring redo procedures, and outcomes are not as good if you have to redo a STEP compared to never needing redo" — Brad Warner (clinical) [Ep 2 · 32:54](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1974)
- "Can do a Bianchi and then go back and do a STEP on top of a Bianchi, but cannot do a Bianchi once a STEP has been done" — Brad Warner (clinical) [Ep 2 · 33:26](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2006)
- "STEP procedures can cause dysmotility and act as a brake on intestinal transit" — Brad Warner (clinical) [Ep 2 · 35:04](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2104)
- "Would taper a child with dilated bowel who had at least 90 to 100 centimeters of intestinal length" — Brad Warner (opinion) [Ep 2 · 38:21](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2301)
- "Strategies for TPN cholestasis include bile salts like chenodeoxycholic acid, changing lipid composition, and increasing enteral feeds" — Brad Warner (clinical) [Ep 2 · 39:00](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2340)
- "Cholecystokinin trial by Dan Teitelbaum to promote bile flow and mitigate TPN cholestasis did not work" — Brad Warner (clinical) [Ep 2 · 39:23](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2363)
- "Dilated bowel is a nidus for infection and encourages translocation of bacteria and endotoxin into portal circuit, damaging the liver" — Brad Warner (clinical) [Ep 2 · 39:38](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2378)
- "For bacterial overgrowth, people try oral antibiotics like Cipro and Flagyl, probiotics with lactobacilli, prebiotics, or fecal transplantation" — Brad Warner (clinical) [Ep 2 · 40:21](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2421)
- "Gut bacteria in short gut syndrome become more efficient and help adapt by encouraging greater absorption and digestion, similar to an obesogenic microbiome" — Brad Warner (clinical) [Ep 2 · 41:32](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2492)
- "In mouse models, oral vancomycin to knock out gram positive organisms completely prevented hepatic steatosis after bowel resection" — Brad Warner (clinical) [Ep 2 · 42:19](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2539)
- "Mice with TLR-4 deficiency (endotoxin receptor knockout) also prevented hepatic steatosis after intestinal resection" — Brad Warner (clinical) [Ep 2 · 42:57](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2577)
- "Teduglutide, a GLP-2 analog, has been shown in randomized trials to reduce TPN requirements in adults by about 1-2 liters per week" — Brad Warner (clinical) [Ep 2 · 43:45](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2625)
- "Teduglutide is not yet approved for children in the United States, with concerns about malignancy risk from growth factor-induced proliferation" — Brad Warner (clinical) [Ep 2 · 44:29](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2669)
- "Growth hormone and glutamine combinations have shown primarily mixed results and are expensive" — Brad Warner (clinical) [Ep 2 · 45:40](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2740)
- "Survival for small bowel transplant is about 50 to 60% at 5 years, with one-year survivals above 70 to 80%" — Brad Warner (epidemiological) [Ep 2 · 46:51](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2811)
- "The intestine is highly immunogenic, filled with white cells and macrophages that mount a huge graft versus host response, requiring industrial strength immunosuppression" — Brad Warner (clinical) [Ep 2 · 47:11](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2831)
- "Ethanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome" — Brad Warner (clinical) [Ep 2 · 49:22](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2962)
- "Should not go to transplant without trying everything possible to avoid it, including lengthening procedures and strategies to mitigate liver damage" — Brad Warner (opinion) [Ep 2 · 49:12](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2952)
- "Multidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID specialists, and interventional radiologists improve survival of short gut patients" — Brad Warner (clinical) [Ep 2 · 51:16](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=3076)
- "Team approach to intestinal failure reduced 1-year mortality from 30-40% to approximately 5% per year at University of Michigan" — Sam (clinical) [Ep 4 · 2:23](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=143)
- "Cincinnati's intestinal failure program was started in 1984" — Sam (clinical) [Ep 4 · 2:51](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=171)
- "Intestinal failure is defined by inadequate bowel length OR bowel that doesn't absorb nutrition and fluid adequately to maintain growth" — Monique (clinical) [Ep 4 · 3:47](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=227)
- "Almost 30% of patients leaving NICU without rotavirus vaccination were readmitted with rotavirus infection" (epidemiological) [Ep 4 · 16:56](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1016)
- "Joint weekly rounds with surgeons, gastroenterologists, dietitians, and neonatologists help identify protocol deviations and build family rapport" — Sam (clinical) [Ep 4 · 18:11](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1091)
- "Breast milk provides not just immunostimulatory benefits but motility effects through oligosaccharides and healing properties" (clinical) [Ep 4 · 30:13](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1813)
- "PIFCON study data showing 25% mortality or transplant referral are now archaic; outcomes have improved dramatically in past 5 years" — Sam (opinion) [Ep 4 · 33:36](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2016)
- "Cincinnati reduced catheter-related bloodstream infections from 12 per 1000 catheter-days to 2 per 1000, approaching <1 per 1000" (clinical) [Ep 4 · 37:31](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2251)
- "Standardized central line bundles and multi-hospital communication networks have reduced line infections across pediatric populations" (clinical) [Ep 4 · 38:54](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2334)
- "Intestinal failure patients have unique propensity for line infections and different infection types compared to general pediatric population" (clinical) [Ep 4 · 39:45](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2385)
- "Toronto experience paper in JPGN examined PICC lines for TPN administration" (clinical) [Ep 4 · 41:13](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2473)
- "Complication-free survival of PICC lines is approximately half that of broviacs according to IR literature" — Sam (clinical) [Ep 4 · 44:58](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2698)
- "Subclavian approach for central lines carries higher risk of stenosis compared to jugular approach" — Valerie (clinical) [Ep 4 · 46:26](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2786)
- "Lack of vascular access is no longer a common indication for intestinal transplant in past 3 years at some centers" (clinical) [Ep 4 · 50:04](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3004)
- "Ethanol locks use 70% concentration with 2-6 hour dwell time, can be given 3 times weekly (Monday/Wednesday/Friday) with good results" — Sam (clinical) [Ep 4 · 60:20](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3620)
- "Ethanol locks work better with 6.6 French catheters than smaller catheters; smaller PICC lines tend to occlude" — Sam (clinical) [Ep 4 · 61:04](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3664)
- "Younger NPO infants often cannot tolerate TPN windows required for ethanol locks" — Sam (clinical) [Ep 4 · 61:28](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3688)
- "UK predominantly uses taurolidine locks rather than ethanol locks for line infection prevention" — Girish (clinical) [Ep 4 · 63:55](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3835)
- "Line care education is crucial; recurrent infections warrant revisiting line care practices before implementing locks" — Girish (clinical) [Ep 4 · 64:23](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3863)
- "Fungal line infections are pulled more promptly, but some centers now treat through even fungal infections in patients with limited vascular access" (clinical) [Ep 4 · 65:32](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3932)
- "Phytosterols in soy-based lipids are cleared poorly, share cholesterol transporter (down-regulated by endotoxemia), and reduce FXR receptor expression causing hepatocyte damage" — Sam (clinical) [Ep 4 · 68:34](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4114)
- "Limiting lipid intake to 1 g/kg/day reduces cholestasis rate to less than 5% of patients" — Sam (clinical) [Ep 4 · 69:42](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4182)
- "Fish oil-based lipid (Omegaven) may have anti-inflammatory advantage and benefit patients who don't respond to lipid restriction" — Sam (clinical) [Ep 4 · 70:43](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4243)
- "Neonatologists often maintain higher lipid doses (2-3 g/kg/day) due to concern about depriving infants of linoleic acid and affecting brain development" — Sam (clinical) [Ep 4 · 71:50](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4310)
- "With lipid restriction protocols, cholestasis rarely emerges from Cincinnati NICU" (clinical) [Ep 4 · 72:39](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4359)
- "Standard metrics for essential fatty acid deficiency are based on malnourished children not on TPN, so altered triene:tetraene ratios may not apply the same way" (opinion) [Ep 4 · 74:14](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4454)
- "Symptomatic essential fatty acid deficiency is not seen in practice with lipid restriction protocols" (clinical) [Ep 4 · 74:41](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4481)
- "Higher glucose infusion rates become less efficient as caloric source and are pushed toward fatty acid and fat deposition" (clinical) [Ep 4 · 75:16](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4516)
- "Age-based glucose infusion rate limits: generally 15-16 in premature/infants, gradually decreasing with age" (guideline) [Ep 4 · 75:41](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4541)
- "Intestinal failure patients may not need to maintain 50th percentile growth; unclear what appropriate growth curve should be for this population" (opinion) [Ep 4 · 76:04](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4564)
- "Neurodevelopmental outcomes in intestinal failure are multifactorial (prolonged hospitalization, recurrent admissions, neonatal insults), not solely attributable to lipid strategies" — Girish (clinical) [Ep 4 · 79:31](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4771)
- "Babies with spontaneous intestinal perforation (no functional bowel removed) still require 2-3 months of parenteral nutrition" (clinical) [Ep 4 · 82:03](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4923)
- "Feed absorption and ability to progress feeds are the best measures of bowel function, not absolute bowel length" — Girish (clinical) [Ep 4 · 85:29](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5129)
- "Ability to wean TPN while maintaining good growth is the most important functional measure" (opinion) [Ep 4 · 86:18](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5178)
- "Upper GI studies can identify problems but cannot rule them out; absence of findings does not exclude anastomotic issues" (clinical) [Ep 4 · 88:16](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5296)
- "Delayed contrast films may reveal that barium flows into anastomosis but doesn't flow out well, suggesting functional problem" (clinical) [Ep 4 · 88:43](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5323)
- "Some anastomoses are not strictured but kinked or twisted, creating functional rather than anatomic obstruction" (clinical) [Ep 4 · 88:43](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5323)
- "Endoscopy is valuable for visualizing anastomosis diameter; sometimes can get scope on both sides but cannot see anastomosis itself" — Sam (clinical) [Ep 4 · 90:45](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5445)
- "Motility abnormalities in short bowel syndrome are not well described; manometric assessment is less helpful in this population" — Sam (opinion) [Ep 4 · 94:28](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5668)
- "Post-gastric tube feeding with gastric decompression can demonstrate distal bowel function and avoid unnecessary surgeries" (clinical) [Ep 4 · 95:24](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5724)
- "Infants with intestinal failure have compromised intestinal function, putting them at increased risk of malabsorption and electrolyte and fluid deficits" — Sarah Choi (clinical) [Ep 14 · 0:36](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=36)
- "Sodium depletion can go unrecognized, resulting in poor growth refractory to increased caloric intake" — Sarah Choi (clinical) [Ep 14 · 0:45](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=45)
- "Sodium supplementation has been shown to be associated with weight gain and overall growth in infants with intestinal failure" — Sarah Choi (clinical) [Ep 14 · 1:00](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=60)
- "Serum sodium does not reflect total sodium stores" — Sarah Choi (clinical) [Ep 14 · 1:04](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=64)
- "Fractional excretion of sodium is the optimum measure of total body sodium but is inconvenient in the pediatric population as it requires a paired urine and blood sample" — Sarah Choi (clinical) [Ep 14 · 1:14](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=74)
- "At BC Women's Hospital, urine sodium is used as a non-invasive marker to estimate total body sodium in infants with intestinal failure, with a value above 30 suggesting sodium sufficiency" — Sarah Choi (guideline) [Ep 14 · 1:29](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=89)
- "Urine sodium doesn't account for volume status, therefore can result in oversupplementation or under supplementation with sodium" — Sarah Choi (clinical) [Ep 14 · 1:44](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=104)
- "The urine sodium to urine creatinine ratio offers a non-invasive measure which accounts for variable urine flow and has shown to be strongly correlated with fractional excretion of sodium" — Sarah Choi (clinical) [Ep 14 · 1:57](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=117)
- "The use of the urine sodium to creatinine ratio has not yet been validated in the intestinal failure population" — Sarah Choi (clinical) [Ep 14 · 2:13](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=133)
- "The study included 22 infants with median gestational age of 31 weeks, median birth weight of 1.9 kg, and median age of enrollment at 8 days" — Sarah Choi (epidemiological) [Ep 14 · 3:18](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=198)
- "Gastroschisis was the most common etiology of intestinal failure in the study cohort" — Sarah Choi (epidemiological) [Ep 14 · 3:30](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=210)
- "There was no significant correlation between either urine sodium or the ratio with daily weight gain when evaluating the entire data set" — Sarah Choi (clinical) [Ep 14 · 3:41](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=221)
- "The ratio was more strongly associated with sodium intake when compared to urine sodium alone" — Sarah Choi (clinical) [Ep 14 · 4:04](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=244)
- "Urine sodium values above 29 and ratio values above 35 best predicted adequate weight gain" — Sarah Choi (clinical) [Ep 14 · 4:18](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=258)
- "It is generally accepted that urine sodium values above 30 is suggestive of sodium sufficiency" — Sarah Choi (guideline) [Ep 14 · 4:28](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=268)
- "In 19% of the time, urine sodium and ratio values were discordant" — Sarah Choi (clinical) [Ep 14 · 4:54](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=294)
- "Urine sodium to creatinine ratio significantly correlated with sodium intake" — Sarah Choi (clinical) [Ep 14 · 5:10](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=310)
- "Urine sodium to creatinine values above 35 best predicted adequate weight gain, therefore suggesting sufficient sodium stores" — Sarah Choi (clinical) [Ep 14 · 5:21](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=321)
- "Patients with stomas, even those without intestinal failure, run the risk of sodium depletion which has a significant impact on their growth" — Paul Wales (clinical) [Ep 14 · 6:08](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=368)
- "Stomas and high stool losses are a large source of sodium bicarb as well as magnesium loss" — Paul Wales (clinical) [Ep 14 · 6:19](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=379)
- "When we replace sodium, it does help restore growth, but it doesn't allow catch up growth" — Paul Wales (clinical) [Ep 14 · 6:38](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=398)
- "If potassium level is higher than sodium level in urine, that often will tell you that the aldosterone pathway is turned on" — Paul Wales (clinical) [Ep 14 · 7:41](https://library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=461)
- "An estimated 5 million central venous catheter lines are placed in the United States annually, with several in pediatric surgical patients" — Rod (epidemiological) [Ep 15 · 0:13](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=13)
- "Cincinnati Children's Hospital handles the bulk of complex vascular access and all catheter-based access for dialysis" — Alex Bondoc (clinical) [Ep 15 · 0:26](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=26)
- "Central venous catheters are not tunneled and typically for temporary hospital use with 1 to 3 lumens" — Rod (clinical) [Ep 15 · 1:00](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=60)
- "Ports are for long-term access on the order of months to years, with tunneled catheters and totally implantable reservoirs, often used for chemotherapy" (clinical) [Ep 15 · 1:10](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=70)
- "Broviac catheters are tunneled lines with cuffs used for months to years for chemotherapy, parenteral nutrition, and frequent blood transfusions" — Rod (clinical) [Ep 15 · 1:25](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=85)
- "Hemodialysis or pheresis catheters can be temporary if uncuffed or permanent if cuffed" (clinical) [Ep 15 · 1:40](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=100)
- "Chest and neck central venous access is preferred from a purely logistical standpoint" — Alex Bondoc (opinion) [Ep 15 · 2:09](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=129)
- "There is fair evidence suggesting an increased rate of complications and infection with femoral access" (clinical) [Ep 15 · 2:17](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=137)
- "Indications for central access include need for total parenteral nutrition, resuscitation, or hemodialysis" (clinical) [Ep 15 · 2:29](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=149)
- "Contraindications for central access include thrombosis, collateralization, and central stenosis of the SVC" — Alex Bondoc (clinical) [Ep 15 · 2:39](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=159)
- "Routine ultrasound is not necessary unless the patient has a congenital anomaly, usually cardiovascular" — Alex Bondoc (opinion) [Ep 15 · 3:09](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=189)
- "For patients with multiple prior lines, Doppler venous ultrasound of the jugulars is the preferred first screening test" — Alex Bondoc (clinical) [Ep 15 · 3:20](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=200)
- "Imaging may escalate to contrast-enhanced MR or CT venogram, and sometimes intraoperative venography with fluoroscopy" — Alex Bondoc (clinical) [Ep 15 · 3:37](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=217)
- "Positioning over a vertically oriented shoulder roll is the most versatile approach for neonates and infants" — Alex Bondoc (clinical) [Ep 15 · 4:02](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=242)
- "A vertical shoulder roll provides hyperextension of the neck and allows shoulders to drop posteriorly, giving access to bilateral subclavians and jugulars" — Alex Bondoc (clinical) [Ep 15 · 4:12](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=252)
- "For really small babies, many surgeons prefer a cut-down approach" — Rod (opinion) [Ep 15 · 4:43](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=283)
- "A micropuncture kit with a 21 gauge finder needle is preferred over the 18 gauge needle in standard kits for small neonates" — Alex Bondoc (clinical) [Ep 15 · 4:55](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=295)
- "Using ultrasound for internal jugular central line placement is the number one preferred method, with lowest risk of pneumothorax and carotid injury" — Alex Bondoc (clinical) [Ep 15 · 5:25](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=325)
- "For large bore access like dialysis catheters, sticking the patient as low as possible on the neck is recommended" — Alex Bondoc (opinion) [Ep 15 · 5:52](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=352)
- "Levering the ultrasound probe (12mm diameter) against the clavicle provides a reasonable low puncture site" — Alex Bondoc (clinical) [Ep 15 · 6:00](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=360)
- "Sticking low on the neck leaves less catheter to curve in the neck, reducing problems with catheter displacement when patients turn their heads" — Alex Bondoc (opinion) [Ep 15 · 6:22](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=382)
- "Catheters have been observed to spit out of the SVC with excessive laxity in the neck" — Alex Bondoc (clinical) [Ep 15 · 6:36](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=396)
- "Subclavian line placement is more anatomic and considered when IJ access is lost or patient is in cervical collar" (clinical) [Ep 15 · 6:42](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=402)
- "For subclavian access, puncture at least 1 finger breadth (almost 1cm) inferior and lateral to the junction of median and medial aspects of the clavicle" — Alex Bondoc (clinical) [Ep 15 · 6:56](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=416)
- "When approaching the clavicle during subclavian access, keep the needle flat and push down on skin rather than angling at 30 degrees" — Alex Bondoc (clinical) [Ep 15 · 7:14](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=434)
- "For subclavian access, aim directly at the sternal notch, then angle wider toward the angle of mandible in a radial motion if unsuccessful" — Alex Bondoc (clinical) [Ep 15 · 7:34](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=454)
- "The catheter tip should be positioned at the junction between the right atrium and superior vena cava" (clinical) [Ep 15 · 7:46](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=466)
- "The right triangle technique uses the trachea as midline and the right mainstem bronchus as hypotenuse; catheter tip in this triangle will always be at the atrial-caval junction" — Alex Bondoc (clinical) [Ep 15 · 8:04](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=484)
- "Routine post-procedural X-rays are not ordered for single-stick, uncomplicated procedures using fluoroscopy" — Alex Bondoc (opinion) [Ep 15 · 8:38](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=518)
- "The practice of not routinely ordering X-rays is based on data from Children's Mercy Hospital Kansas City" — Rod (clinical) [Ep 15 · 8:45](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=525)
- "Post-procedural complications include pneumothorax, hemothorax, arterial injury (subclavian or carotid), and rarely chylothorax or thoracic duct injury" — Alex Bondoc (clinical) [Ep 15 · 9:06](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=546)
- "Long-term complications include thrombosis, catheter displacement, kinking, and eventual line degradation" — Rod (clinical) [Ep 15 · 9:21](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=561)
- "The first clinical decision for line infection is determining if the patient is septic from the line" — Alex Bondoc (clinical) [Ep 15 · 9:41](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=581)
- "If the patient is septic from the line, source control requires bedside removal under light sedation" — Alex Bondoc (clinical) [Ep 15 · 9:46](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=586)
- "For non-septic line-dependent patients with complex vascular access, treatment involves identifying the organism, assessing sensitivity, and performing serial blood cultures to achieve sustained culture negativity for line salvage" — Alex Bondoc (clinical) [Ep 15 · 10:04](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=604)
- "Antibiotic locking solutions have been around for a long time but predominantly develop resistance" — Paul Wales (clinical) [Ep 15 · 10:35](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=635)
- "Ethanol locks are antimicrobial without resistance and kill both planktonic bacteria (floating in lumen) and sessile bacteria (embedded in biofilm)" — Paul Wales (clinical) [Ep 15 · 10:56](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=656)
- "The price of ethanol in locking solutions skyrocketed, prompting search for alternatives" — Rod (clinical) [Ep 15 · 11:12](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=672)
- "Kite lock is a 4% tetrasodium EDTA chemical found in Canada" — Paul Wales (clinical) [Ep 15 · 11:24](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=684)
- "Kite lock is antimicrobial without resistance, antifibrinolytic, and antithrombotic" — Paul Wales (clinical) [Ep 15 · 11:36](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=696)
- "Kite lock has been licensed in Canada for pediatric use, and is now licensed in Europe and Australia" — Paul Wales (clinical) [Ep 15 · 11:59](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=719)
- "Translumbar line placement through back musculature into intrahepatic IVC is considered when femoral, IJ, and subclavian options are exhausted" — Alex Bondoc (clinical) [Ep 15 · 12:19](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=739)
- "Emergency facial vein cutdown involves horizontal incision lateral to sternocleidomastoid at angle of mandible with the head turned" — Alex Bondoc (clinical) [Ep 15 · 12:48](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=768)
- "For facial vein cutdown, beveling the catheter hard helps it follow a path when blindly passing without a wire" — Alex Bondoc (clinical) [Ep 15 · 13:04](https://library.globalcastmd.com/watch/pediatric-vascular-access-in-brief-preoperative-operative-and-postoperative-considerations-5870?t=784)
- "The Midwest Pediatric Surgery Research Consortium was established by departments of Pediatric Surgery from 11 children's hospitals" — Ellen Incisco and M. Tom Bash (epidemiological) [Ep 17 · 2:15](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=135)
- "Non-accidental trauma rates initially dropped during stay-at-home orders but subsequently increased above expected levels" — Nicole Chandler (epidemiological) [Ep 17 · 4:16](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=256)
- "Patients disproportionately affected by increased non-accidental trauma were older children (>5 years), minority children, and lower socioeconomic groups as determined by social vulnerability index" — Nicole Chandler (epidemiological) [Ep 17 · 4:31](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=271)
- "CDC Social Vulnerability Index was created to assess neighborhood vulnerability during times of crises" — Ellen Incisco and M. Tom Bash (guideline) [Ep 17 · 5:12](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=312)
- "During public health crises, it is important to maintain systems of protection for children who lose normal protections from school" — Nicole Chandler (opinion) [Ep 17 · 5:37](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=337)
- "Trauma registry data and ICD-10 codes have limitations that require caution in drawing strong conclusions" — Ellen Incisco and M. Tom Bash (clinical) [Ep 17 · 5:56](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=356)
- "Very few cell lines are available to study hepatoblastoma, and some cell lines labeled as hepatoblastoma are actually hepatocellular carcinoma" — Ellen Incisco and M. Tom Bash (clinical) [Ep 17 · 6:47](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=407)
- "Management of metastatic hepatoblastoma continues to pose significant treatment challenges" — Nicole Chandler (clinical) [Ep 17 · 7:13](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=433)
- "The new metastatic hepatoblastoma cell line was created by serial passage through mouse lungs, harvesting lung tissue, culturing surviving cells, and repeating the process" — Ellen Incisco and M. Tom Bash (clinical) [Ep 17 · 7:24](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=444)
- "The new hepatoblastoma cell line exhibited increased tumorigenicity, invasiveness, and increased resistance to chemotherapy compared to the original human cell line" — Nicole Chandler (clinical) [Ep 17 · 8:14](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=494)
- "PSORC (Pediatric Surgical Oncology Research Collaborative) is a multi-institutional consortium of North American pediatric surgeons focused on advancing care of children with cancer" — Marcus Malik (clinical) [Ep 17 · 9:46](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=586)
- "There has been no consistency in localization techniques for small pulmonary nodules across institutions" — Marcus Malik (clinical) [Ep 17 · 10:19](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=619)
- "The most common localization techniques for pulmonary nodules are wire and methylene blue dye, followed by methylene blue dye only" — Nicole Chandler (clinical) [Ep 17 · 10:49](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=649)
- "There was no difference in successful IR localization or successful resection of pulmonary nodules between different localization techniques" — Nicole Chandler (clinical) [Ep 17 · 10:56](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=656)
- "Time under anesthesia for nodule localization can be long and variable depending on institutional setup (hybrid OR vs separate IR suite)" — Marcus Malik (clinical) [Ep 17 · 11:10](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=670)
- "Experience is probably more important than the actual localization technique itself, given all techniques were wildly successful" — Nicole Chandler (opinion) [Ep 17 · 12:06](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=726)
- "Pediatric intestinal failure was defined as requirement of parenteral nutrition for 60 days or more at any time before 8 years of age" — Todd Ponsky and Dr. Biran Modi (clinical) [Ep 17 · 12:52](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=772)
- "Puberty is at least partially dependent on having good nutritional stores based on hormonal drivers" — Todd Ponsky and Dr. Biran Modi (clinical) [Ep 17 · 13:38](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=818)
- "The hypothesis was that chronic pediatric intestinal failure would delay puberty and potentially dull the sharp spike of peak height velocity" — Todd Ponsky and Dr. Biran Modi (clinical) [Ep 17 · 13:45](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=825)
- "Peak height velocity occurred at significantly younger ages for both males and females with intestinal failure" — Nicole Chandler (clinical) [Ep 17 · 14:00](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=840)
- "Puberty onset occurred significantly earlier compared to established norms for males with intestinal failure, reaching pubertal onset earlier than the CDC 50th percentile" — Nicole Chandler (clinical) [Ep 17 · 14:00](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=840)
- "There is a high incidence of short stature in chronic intestinal failure" — Todd Ponsky and Dr. Biran Modi (clinical) [Ep 17 · 14:37](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=877)
- "The finding that short stature is not due to missing pubertal timing suggests the need to do a better job at setting up intestinal failure patients for puberty by working on their height and linear growth beforehand" — Todd Ponsky and Dr. Biran Modi (opinion) [Ep 17 · 14:37](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=877)
- "The Midwest Pediatric Surgery Research Consortium was established by departments of Pediatric Surgery from 11 children's hospitals" — Ellen Incisco and M. Tom Bash (clinical) [Ep 16 · 2:15](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=135)
- "The study used historical patterns of NAT captured by trauma registries to predict what the volume should have been during the initial COVID time period and compared that to observed rates" — Ellen Incisco and M. Tom Bash (clinical) [Ep 16 · 3:42](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=222)
- "NAT rates initially dropped slightly but then increased above expected levels during stay-at-home orders" — Todd Ponsky and Dr. Biran Modi (clinical) [Ep 16 · 4:07](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=247)
- "Patients disproportionately affected were older children over 5 years who would commonly be in school, minority children, and lower socioeconomic groups as determined by social vulnerability index" — Nicole Chandler (epidemiological) [Ep 16 · 4:27](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=267)
- "The CDC Social Vulnerability Index was created to assess a neighborhood's vulnerability during times of crises" — Ellen Incisco and M. Tom Bash (clinical) [Ep 16 · 5:12](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=312)
- "During public health crises, it is important to maintain systems of protection for children, particularly when they are not afforded normal protections from school" — Nicole Chandler (opinion) [Ep 16 · 5:37](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=337)
- "One must be careful not to make too strong conclusions based on trauma registry data and ICD-10 codes, regardless of the number of institutions or evaluation period length" — Ellen Incisco and M. Tom Bash (opinion) [Ep 16 · 6:07](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=367)
- "Very few cell lines are available to study hepatoblastoma, and some cell lines touted as hepatoblastoma are actually hepatocellular carcinoma" — Ellen Incisco and M. Tom Bash (clinical) [Ep 16 · 6:47](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=407)
- "Management of metastatic hepatoblastoma continues to pose significant treatment challenges" — Nicole Chandler (clinical) [Ep 16 · 7:13](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=433)
- "The new metastatic hepatoblastoma cell line was created by labeling cells with luciferase, injecting them into mouse tail veins where they preferentially metastasized to lungs, harvesting and culturing surviving cells, and repeating the process until establishing a reliable metastatic cell line" — Ellen Incisco and M. Tom Bash (clinical) [Ep 16 · 7:24](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=444)
- "The new cell line exhibited increased tumorigenicity, invasiveness, and increased resistance to chemotherapy compared to the original human cell line" — Nicole Chandler (clinical) [Ep 16 · 8:14](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=494)
- "There was no hepatoblastoma cell line mouse model available before this study" — Todd Ponsky and Dr. Biran Modi (clinical) [Ep 16 · 8:29](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=509)
- "PSORC is the Pediatric Surgical Oncology Research Collaborative, a multi-institutional consortium of North American pediatric surgeons focused on advancing care of children with cancer" — Marcus Malik (clinical) [Ep 16 · 9:46](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=586)
- "PSORC was founded to amalgamate data from multiple institutions to better study surgical questions in pediatric cancer" — Marcus Malik (clinical) [Ep 16 · 10:05](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=605)
- "There has not been consistency in localization techniques for small pulmonary nodules across North American institutions" — Marcus Malik (clinical) [Ep 16 · 10:19](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=619)
- "The most common localization techniques were wire and methylene blue dye, followed by methylene blue dye only" — Nicole Chandler (clinical) [Ep 16 · 10:49](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=649)
- "There was no difference in successful IR localization or successful resection of pulmonary nodules between different localization techniques" — Nicole Chandler (clinical) [Ep 16 · 10:56](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=656)
- "Time under anesthesia for localization procedures can be long and variable depending on institutional setup, with some using hybrid ORs for immediate transition from localization to operation" — Marcus Malik (clinical) [Ep 16 · 11:10](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=670)
- "Experience is probably more important than the actual localization technique itself, given that all techniques were wildly successful despite significant variation" — Nicole Chandler (opinion) [Ep 16 · 12:06](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=726)
- "Pediatric intestinal failure was defined as requirement of parenteral nutrition for 60 days or more at any time, with diagnosis before 8 years of age" — Todd Ponsky and Dr. Biran Modi (clinical) [Ep 16 · 12:52](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=772)
- "Puberty is at least partially dependent on having good nutritional stores based on hormonal drivers of puberty" — Todd Ponsky and Dr. Biran Modi (clinical) [Ep 16 · 13:38](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=818)
- "The hypothesis was that chronic pediatric intestinal failure would delay puberty and potentially dull the sharp spike of peak height velocity" — Todd Ponsky and Dr. Biran Modi (clinical) [Ep 16 · 13:45](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=825)
- "Peak height velocity occurred at significantly younger ages for both males and females with intestinal failure" — Nicole Chandler (clinical) [Ep 16 · 14:00](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=840)
- "Puberty onset occurred significantly earlier compared to established norms for males, reaching pubertal onset earlier than the CDC 50th percentile" — Nicole Chandler (clinical) [Ep 16 · 14:00](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=840)
- "There is a high incidence of short stature in chronic intestinal failure" — Todd Ponsky and Dr. Biran Modi (clinical) [Ep 16 · 14:37](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=877)
- "The finding that short stature is not due to missing pubertal timing or peak height velocity suggests the need to better optimize height and linear growth before puberty" — Todd Ponsky and Dr. Biran Modi (clinical) [Ep 16 · 14:37](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=877)
- "Children reliant on TPN and their families may face challenges when traveling abroad" (clinical) [Ep 24 · 0:21](https://library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=21)
- "Medication and appropriate medical supplies must accompany the child on their travels" (guideline) [Ep 24 · 0:30](https://library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=30)
- "Parents and families may have concerns about not having access to specialist emergency care for their child whilst abroad" (clinical) [Ep 24 · 0:37](https://library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=37)
- "ERNICA has developed an online map tool to identify specialist centers across Europe that are able to administer TPN and meet particular criteria" (clinical) [Ep 24 · 0:46](https://library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=46)
- "The map tool can be accessed from the publicly available ERNICA website" (clinical) [Ep 24 · 0:58](https://library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=58)
- "Users can search for specialist centers per country and access detailed information on each center" (clinical) [Ep 24 · 1:04](https://library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=64)
- "A holiday checklist document is available for download on the ERNICA website" (clinical) [Ep 24 · 1:11](https://library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=71)
- "Templates are available for local healthcare providers to provide a written record of the child's medical history and clinical precautions" (clinical) [Ep 24 · 1:18](https://library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=78)
- "Medical documentation templates can accompany families on trips abroad in case emergency care is required" (guideline) [Ep 24 · 1:28](https://library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=88)
- "The START trial randomized 140 infants with biliary atresia to high-dose steroids (13-week course) versus placebo after Kasai portoenterostomy" — Daniel von Allmen (clinical) [Ep 7 · 2:56](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=176)
- "High-dose steroid therapy following Kasai did not result in statistically significant treatment difference in bile drainage at 6 months: 58.6% treatment group versus 48.6% placebo" — Daniel von Allmen (clinical) [Ep 7 · 4:01](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=241)
- "Survival without liver transplant at 24 months was not statistically different: 58.7% steroid group versus 49.4% placebo group" — Daniel von Allmen (clinical) [Ep 7 · 4:39](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=279)
- "Adverse events occurred in near 80% of patients in both steroid and placebo groups, attributed largely to severe underlying liver dysfunction" — Daniel von Allmen (clinical) [Ep 7 · 4:55](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=295)
- "Steroid treatment was associated with earlier onset of serious adverse events in children with biliary atresia" — Daniel von Allmen (clinical) [Ep 7 · 5:10](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=310)
- "The study was powered to detect a 25% absolute treatment difference in outcomes" — Daniel von Allmen (clinical) [Ep 7 · 3:46](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=226)
- "Steroids are proposed to work through two mechanisms: reducing ongoing inflammation to preserve bile ductules, and acting as a choleretic to maintain bile flow" — Daniel von Allmen (clinical) [Ep 7 · 8:59](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=539)
- "Washington State registry study included over 50 hospitals and analyzed clean-contaminated operations over 18 months beginning January 2011" — Whit Holcomb (clinical) [Ep 7 · 12:02](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=722)
- "Overall surgical site infection rate was 4.6%, varying by procedure: 6.6% colorectal, 1.4% bariatric, 1.5% other" — Whit Holcomb (epidemiological) [Ep 7 · 13:05](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=785)
- "No single antiseptic agent was associated with lower risk of surgical site infection than any other agent" — Whit Holcomb (clinical) [Ep 7 · 13:39](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=819)
- "Isopropyl alcohol provided no benefit: 4.5% SSI rate without alcohol versus 4.6% with alcohol" — Whit Holcomb (clinical) [Ep 7 · 13:49](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=829)
- "Registry data could not identify surgical site infections diagnosed after discharge, likely underestimating true SSI rate" — Whit Holcomb (clinical) [Ep 7 · 14:20](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=860)
- "Recent reports show 50% or more surgical site infections are diagnosed after discharge" — Whit Holcomb (epidemiological) [Ep 7 · 14:40](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=880)
- "Most surgical site infections occur 3 to 10 days after operation" — Whit Holcomb (clinical) [Ep 7 · 14:48](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=888)
- "Chlorhexidine prep dries faster than betadine, allowing cases to start sooner" — Whit Holcomb (clinical) [Ep 7 · 18:33](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1113)
- "Appendicitis pilot RCT enrolled 50 patients aged 5-15 years with non-perforated appendicitis: 26 randomized to operation, 24 to antibiotics" — Whit Holcomb (clinical) [Ep 7 · 22:58](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1378)
- "Of 24 patients randomized to non-operative treatment, 2 underwent appendectomy during primary treatment course and 1 had appendectomy at 9 months for recurrent appendicitis" — Whit Holcomb (clinical) [Ep 7 · 23:14](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1394)
- "An additional 6 patients in the non-operative group underwent appendectomy for recurrent abdominal pain or parental desire during 1-year follow-up, with no appendicitis found on histology" — Whit Holcomb (clinical) [Ep 7 · 23:32](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1412)
- "Total of 9 of 24 patients (38%) initially randomized to antibiotic therapy underwent appendectomy within first year, making success rate 62%" — Whit Holcomb (clinical) [Ep 7 · 24:10](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1450)
- "Median time to discharge was significantly shorter in surgical group than non-operative group, possibly due to stipulated 48-hour minimum hospitalization for non-operative patients" — Whit Holcomb (clinical) [Ep 7 · 24:35](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1475)
- "Cost for initial inpatient stay was significantly lower in non-operative treatment group despite longer hospitalizations" — Whit Holcomb (clinical) [Ep 7 · 24:55](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1495)
- "Immunosuppressed cancer patients with typhlitis are sometimes treated non-operatively and most resolve with antibiotics" — Whit Holcomb (clinical) [Ep 7 · 27:00](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1620)
- "PIFCON study included 272 patients from 14 multidisciplinary intestinal rehab programs with median 33-month follow-up" — Aaron Lipskar (clinical) [Ep 7 · 32:32](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1952)
- "Enteral autonomy was achieved in 43% of intestinal failure cohort, 13% remained PN-dependent, and 43% died or underwent transplantation" — Aaron Lipskar (epidemiological) [Ep 7 · 32:40](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1960)
- "Necrotizing enterocolitis diagnosis, care at intestinal rehab facility without transplant center, and presence of ileocecal valve were associated with statistically significant higher rates of enteral autonomy" — Aaron Lipskar (clinical) [Ep 7 · 32:58](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1978)
- "Residual small bowel length was a statistically significant but less impressive predictor of enteral autonomy" — Aaron Lipskar (clinical) [Ep 7 · 33:19](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1999)
- "The protective effect of necrotizing enterocolitis on enteral autonomy goes against understanding of that inflammatory illness" — Aaron Lipskar (opinion) [Ep 7 · 33:55](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2035)
- "A companion paper in same journal showed necrotizing enterocolitis was a poor predictor of growth outcome in infants with short bowel syndrome" — Aaron Lipskar (clinical) [Ep 7 · 35:12](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2112)
- "FDA established SmartTots partnership with International Anesthesia Research Society in 2009 to study anesthesia-related neurotoxicity" — Aaron Lipskar (guideline) [Ep 7 · 37:19](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2239)
- "SmartTots 2012 consensus statement recommended avoiding elective surgical procedures under anesthesia in children less than 3 years when possible" — Aaron Lipskar (guideline) [Ep 7 · 37:34](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2254)
- "Commonly used anesthetics including propofol, etomidate, sevoflurane, isoflurane, and ketamine produce profound neurotoxic effects in laboratory animals from nematodes to nonhuman primates" — Aaron Lipskar (clinical) [Ep 7 · 38:09](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2289)
- "Observational studies in children undergoing early anesthesia offer conflicting results but suggest some children may have deficits, though causation difficult to establish" — Aaron Lipskar (clinical) [Ep 7 · 38:43](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2323)
- "June 2014 SmartTots statement concluded animal data sufficiently convincing that large-scale clinical studies are warranted" — Aaron Lipskar (guideline) [Ep 7 · 39:06](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2346)
- "Updated recommendation is to avoid surgical procedures under anesthesia in children under 3 years unless situation is urgent or potentially harmful if not attended to" — Aaron Lipskar (guideline) [Ep 7 · 39:14](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2354)
- "Regional anesthesia blocks can diminish amount of potentially neurotoxic medications in almost every laparoscopic, thoracoscopic, or open operation" — Aaron Lipskar (clinical) [Ep 7 · 42:00](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2520)
- "Rule of two suggested: defer elective operations until after age 2 and try not to have two anesthetics in one year" — Todd Ponsky (opinion) [Ep 7 · 42:16](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2536)
- "Survey of 150 parents in primary care pediatrics office found vast majority did not know anesthetic neurotoxicity was a major issue" — Aaron Lipskar (epidemiological) [Ep 7 · 43:17](https://library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2597)
- "Breast milk provides significant benefit to time to wean off parenteral nutrition in gastroschisis and necrotizing enterocolitis patients compared to formula-only feeding" — Mike (clinical) [Ep 5 · 59:42](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3582)
- "Spontaneous intestinal perforation patients do not show the same benefit from breast milk as necrotizing enterocolitis patients" — Mike (clinical) [Ep 5 · 60:19](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3619)
- "Patients with 50% of estimated bowel length are expected to come off parenteral nutrition" — Mike (clinical) [Ep 5 · 28:07](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1687)
- "STEP procedures done in the first year of life in patients who have not progressed with enteral feeds are not beneficial unless specifically avoiding line infections and bacterial overgrowth" — Mike (opinion) [Ep 5 · 29:20](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1760)
- "Only 3 of the neonates who had early STEP procedures in the registry study came off parenteral nutrition, whereas natural data shows 80-90% of similar patients come off TPN at 12 months without STEP" — Mike (clinical) [Ep 5 · 31:25](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1885)
- "Donor breast milk is less advantageous than maternal breast milk because it is usually from mothers 10-14 months postpartum with lower caloric density and protein levels" — Mike (clinical) [Ep 5 · 62:33](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3753)
- "Continuous drip feeding improves absorption coefficient from 60% to 85% in adults with short bowel syndrome, while combined daytime eating plus overnight drip achieves 75% absorption" — Mike (clinical) [Ep 5 · 17:29](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1049)
- "Micronutrient deficiency is extremely common, occurring in about 60% of patients weaned off TPN" — Mike (clinical) [Ep 5 · 71:36](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4296)
- "Human milk oligosaccharides (2FL, 3FL) are non-nutrient components that affect microflora and dysbiosis, with 80% of secretor mothers producing 2FL which is immunomodulatory" — Mike (clinical) [Ep 5 · 86:24](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5184)
- "Two-thirds of bloodstream infections occurred in patients on prophylactic Flagyl, suggesting it knocks out anaerobes and facilitates aerobic overgrowth" — Mike (clinical) [Ep 5 · 90:33](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5433)
- "Metronidazole has limited spectrum, knocks off anaerobes, and facilitates growth of aerobes, making it potentially the wrong choice for bacterial overgrowth" — Mike (opinion) [Ep 5 · 91:58](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5518)
- "GLP-2 analog can reduce fecal output allowing 20% reduction in TPN in 60-70% of adult patients, with 20% achieving complete TPN independence in extension studies" — Mike (clinical) [Ep 5 · 114:02](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6842)
- "Pancreatic enzymes are not physiologic in humans until 5-7 months of age; lipase doesn't reach adult levels until end of first year" — Mike (clinical) [Ep 5 · 109:36](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6576)
- "Cholestyramine doses effective for firming stool will bind nutrients, fat-soluble vitamins, and fats, with risk of hyperchloremic acidosis and bezoar formation" — Mike (clinical) [Ep 5 · 106:03](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6363)
- "There is no hard upper limit for acceptable stoma output; decisions should be based on electrolyte profile and acidosis rather than volume alone" — Mike (opinion) [Ep 5 · 111:19](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6679)

## Changelog
- Aug 31: 29 doctors auto-found from episode dossiers
- Aug 30: 29 doctors auto-found from episode dossiers
- Aug 30: 29 doctors auto-found from episode dossiers
- Aug 30: Members-only episodes removed from this collection
- Aug 29: 32 doctors auto-found from episode dossiers
- Aug 29: 32 doctors auto-found from episode dossiers
- Aug 29: Collection generated from campaign corpus: 35 items, 34 dossiers, summaries for 2 audience(s)
- Aug 29: Collection reviewed and published
- Aug 29: Collection generated from campaign corpus: 21 items, 21 dossiers, summaries for 2 audience(s)
- Aug 29: Collection generated from campaign corpus: 21 items, 21 dossiers, summaries for 2 audience(s)

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