# Intestinal Rehabilitation Fundamentals — GCMD Library living collection

Updated: n/a · 16 episodes · 229 cited statements

## Episodes
### Introduction to Intestinal Rehabilitation
- [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)
- [Introduction to intestinal rehabilitation and intestinal failure in pediatric surgery](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526) — podcast · 14:33 · [machine version](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526.md)

### Clinical Management
- [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)
- [Managing overwhelming intestinal catastrophe in neonates: when to operate](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525) — podcast · 17:21 · [machine version](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525.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 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 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)

### Program Management & Outcomes
- [Management of Pediatric Intestinal Failure](https://library.globalcastmd.com/watch/management-of-pediatric-intestinal-failure-16383) — article · [machine version](https://library.globalcastmd.com/watch/management-of-pediatric-intestinal-failure-16383.md)
- [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-11734) — article · [machine version](https://library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-11734.md)
- [Parenteral nutrition weaning in pediatric intestinal failure patients enrolled in remote patient monitoring: A descriptive study](https://library.globalcastmd.com/watch/parenteral-nutrition-weaning-in-pediatric-intestinal-failure-patients-enrolled-i-16348) — article · [machine version](https://library.globalcastmd.com/watch/parenteral-nutrition-weaning-in-pediatric-intestinal-failure-patients-enrolled-i-16348.md)
- [Factors associated with accelerated parenteral weaning in children with intestinal failure: A descriptive cohort study](https://library.globalcastmd.com/watch/factors-associated-with-accelerated-parenteral-weaning-in-children-with-intestin-16351) — article · [machine version](https://library.globalcastmd.com/watch/factors-associated-with-accelerated-parenteral-weaning-in-children-with-intestin-16351.md)

### Patient Stories & Education
- [Xavier's journey from short bowel syndrome to eating again](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338) — video · 3:12 · [machine version](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338.md)
- [A Tree for Dr. Helmrath](https://library.globalcastmd.com/watch/a-tree-for-dr-helmrath-16339) — article · [machine version](https://library.globalcastmd.com/watch/a-tree-for-dr-helmrath-16339.md)
- [Intestinal rehabilitation in pediatric short bowel syndrome: expert strategies for autonomy](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524) — podcast · 12:14 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524.md)
- [Patient and Family Resources](https://library.globalcastmd.com/watch/patient-and-family-resources-15230) — article · [machine version](https://library.globalcastmd.com/watch/patient-and-family-resources-15230.md)
- [Resources for Healthcare Professionals](https://library.globalcastmd.com/watch/resources-for-healthcare-professionals-15231) — article · [machine version](https://library.globalcastmd.com/watch/resources-for-healthcare-professionals-15231.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=0) Introduction to the intestinal rehabilitation series and guest experts (Ep 1)
- [1:46](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=106) Defining intestinal failure and the need for intestinal rehabilitation (Ep 1)
- [3:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=183) What is intestinal rehabilitation and the multidisciplinary team approach (Ep 1)
- [4:39](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=279) Three categories of intestinal failure causes (Ep 1)
- [8:30](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=510) Three time points for diagnosis and referral to intestinal rehabilitation (Ep 1)
- [10:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=604) Building the Cincinnati Children's intestinal rehabilitation program (Ep 1)
- [12:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=754) Long-term survival outcomes and emerging chronic comorbidities (Ep 1)
- [0:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=1) Introduction and recap of episode 1 (Ep 3)
- [1:23](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=83) Outcomes in ultra-short gut and the role of ileum and colon (Ep 3)
- [4:02](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=242) Timing of intervention, inflammation, and neurocognitive outcomes (Ep 3)
- [7:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=431) Operative technique: proximal diversion with Blake drain and gastrostomy (Ep 3)
- [10:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=608) Management of distal bowel and refeeding strategy (Ep 3)
- [11:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=713) Surgeon's role, team approach, and postoperative expectations (Ep 3)
- [14:37](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=877) Blake drain characteristics and episode summary (Ep 3)
- [0:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=0) Introduction and nutritional principles for enteral autonomy (Ep 7)
- [1:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=115) Feeding protocols and surgical considerations for feeding access (Ep 7)
- [4:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=261) Managing high gastric output and fluid balance (Ep 7)
- [6:42](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=402) Pharmacotherapy and antibiotic use (Ep 7)
- [7:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=470) Surgical procedures to promote adaptation (Ep 7)
- [10:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=655) Outcomes and timing of surgical intervention (Ep 7)
- [11:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=711) Episode summary and webinar announcement (Ep 7)
- [0:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=0) Historical Context and Natural History of Intestinal Failure Surgery (Ep 6)
- [4:18](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=258) Preoperative Decision-Making and Timing Considerations (Ep 6)
- [7:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=426) Diagnosis-Specific Considerations: Gastroschisis vs Atresia vs NEC (Ep 6)
- [10:09](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=609) STEP Procedure: Detailed Operative Technique (Ep 6)
- [17:54](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=1074) Summary and Preview of Part 2 (Ep 6)
- [0:07](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=7) Introduction and STEP Procedure Overview (Ep 5)
- [1:43](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=103) STEP Outcomes and Timeline for Improvement (Ep 5)
- [3:54](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=234) Preoperative Assessment and Staged Surgical Approach (Ep 5)
- [5:35](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=335) Complications: Bleeding at Staple Lines (Ep 5)
- [7:43](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=463) Mesenteric Pathology and Surgical Management of Bleeding (Ep 5)
- [10:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=625) Long-term Management Philosophy and Episode Summary (Ep 5)
- [0:05](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=5) Xavier's birth defect and initial diagnosis (Ep 12)
- [0:45](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=45) Years of TPN dependence and hospital care (Ep 12)
- [1:33](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=93) Second opinion and surgical reconstruction (Ep 12)
- [2:07](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=127) Post-surgical outcomes and ongoing care (Ep 12)
- [0:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=0) Introduction and webinar context (Ep 14)
- [0:44](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=44) Principle 1: Infant gut growth potential and measurement (Ep 14)
- [2:18](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=138) Principle 2: Importance of distal ileum and functional bowel (Ep 14)
- [3:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=201) Principle 3: Surgical strategy for staged reconstruction (Ep 14)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Until recently, there was no standardized definition for intestinal failure. — Paul Wales (guideline) [Ep 1 · 1:56](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=116)
- Intestinal failure is a functional problem where gut function is insufficient to absorb enough nutrients, fluids, and calories to support survival and, in children, growth. — Paul Wales (clinical) [Ep 1 · 2:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=123)
- Earlier recognition and taking advantage of the gut's adaptive biology are time dependent. — Michael Helmrath (clinical) [Ep 1 · 2:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=160)
- 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 other associated needs, as defined in recent ASPEN guidelines. — Paul Wales (guideline) [Ep 1 · 3:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=183)
- Intestinal rehabilitation streamlines care and improves communication between family and care providers through an amalgamation of experts providing holistic, comprehensive, coordinated care. — Paul Wales (clinical) [Ep 1 · 3:44](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=224)
- Intestinal rehabilitation depends on key factors: nutrition in the gut, nutrition in the body, and healing. — Michael Helmrath (clinical) [Ep 1 · 4:07](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=247)
- Pattern recognition from multiple expert eyes observing a patient over time is essential in intestinal rehabilitation. — Michael Helmrath (clinical) [Ep 1 · 4:19](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=259)
- Short bowel syndrome is by far the most common category of intestinal failure in pediatric patients. — Paul Wales (epidemiological) [Ep 1 · 4:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=290)
- Causes of short bowel syndrome are usually related to neonatal disorders including congenital anomalies (intestinal atresia, malrotation, volvulus, gastroschisis, long segment Hirschsprung disease) or acquired diseases (necrotizing enterocolitis). — Paul Wales (clinical) [Ep 1 · 4:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=290)
- Motility disorders occur when abnormalities of the intestinal muscle itself or the nerves controlling that muscle prevent coordinated propulsion of food and stool, making patients dependent on intravenous support. — Paul Wales (clinical) [Ep 1 · 5:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=345)
- 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, leading to hypersecretion and profuse fluid losses. — Paul Wales (clinical) [Ep 1 · 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 all three categories of intestinal failure; for example, gastroschisis can involve short bowel, inflammation affecting absorption, and motility issues. — Paul Wales (clinical) [Ep 1 · 7:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=431)
- Although most intestinal failure patients are infants or babies, older pediatric patients can develop intestinal failure from inflammatory bowel disease, Crohn's disease complications, trauma, malignancy, or vascular thrombosis leading to gut loss. — Paul Wales (clinical) [Ep 1 · 7:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=465)
- Families reach intestinal rehabilitation programs at three time points: prenatal diagnosis (typically atresia with cystic fibrosis or gastroschisis), postnatal acquired problems (volvulus or NEC), and later diagnosis after discharge when patients fail to progress. — Michael Helmrath (clinical) [Ep 1 · 8:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=533)
- Innovation comes from multiple approaches to a problem and different visions; bringing in more expertise leads to better outcomes. — Michael Helmrath (opinion) [Ep 1 · 10:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=615)
- Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being met. — Michael Helmrath (clinical) [Ep 1 · 10:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=651)
- The intestinal rehabilitation team includes dietitians (understanding nutritional needs), social work, nurse practitioners, pharmacy, interventional radiology, pathology, and subspecialties including endocrinology and nephrology. — Michael Helmrath (clinical) [Ep 1 · 11:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=712)
- Improved survival has revealed chronic comorbidities not previously seen to the same extent because patients did not live long enough, including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life concerns. — Paul Wales (clinical) [Ep 1 · 12:46](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=766)
- 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 6 · 1:23](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=83)
- Rising direct bilirubin was recognized as a sign that children with intestinal failure would not do well. — Michael Helmrath (clinical) [Ep 6 · 2:13](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=133)
- The gut doubles in length during the last trimester and the first year of life, and this maturation process occurs when the baby is fed. — Michael Helmrath (clinical) [Ep 6 · 2:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=175)
- Healthy growth of the intestine requires nutrition; anything that disrupts this affects maturation of both absorptive/digestive capacity and peristalsis. — Michael Helmrath (clinical) [Ep 6 · 3:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=183)
- Lengthening bowel that doesn't have peristalsis does not increase absorption; very short bowel children can sometimes come off TPN because their motility is good. — Michael Helmrath (clinical) [Ep 6 · 3:46](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=226)
- 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 6 · 4:18](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?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 6 · 5:42](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=342)
- Size discrepancy can be managed by resection to a more appropriate caliber, tapering enteroplasty, or serial transverse enteroplasty (STEP) depending on available bowel length. — Paul Wales (clinical) [Ep 6 · 6:02](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=362)
- Gastroschisis patients tend to not do as well with STEP procedures regardless of whether atresia is present; among STEP procedures performed over the years, gastroschisis cases consistently had worse outcomes. — Paul Wales (epidemiological) [Ep 6 · 7:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=428)
- The enteric nervous system in gastroschisis is damaged from exposure to amniotic fluid and requires a healing and recovery phase; this regeneration is attenuated by dysmotility and stasis, not enhanced. — Michael Helmrath (clinical) [Ep 6 · 7:32](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=452)
- In atresia without gastroschisis, the bowel may have good peristalsis from working against an obstruction, and when done correctly with proper orientation, a longitudinal lengthening procedure may benefit the child. — Michael Helmrath (opinion) [Ep 6 · 7:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=475)
- Children who undergo STEP procedures in their first year of life sometimes never progress and are labeled as poor motility patients unable to tolerate enteral feeds. — Michael Helmrath (clinical) [Ep 6 · 8:19](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=499)
- Among patients with limited gut, necrotizing enterocolitis patients do best because they have been fed before, have established GI motility, and the maturation phase has already been initiated. — Michael Helmrath (opinion) [Ep 6 · 8:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=520)
- STEP procedure is not usually performed unless bowel is at least 5 centimeters dilated to make it worthwhile. — Paul Wales (clinical) [Ep 6 · 9:09](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=549)
- In scenarios where bowel is not adequately dilated, options include resecting bulbs with tapering enteroplasty, establishing continuity if possible, or leaving bowel disconnected with distal feeding tube access to grow the distal bowel before reconnection. — Paul Wales (clinical) [Ep 6 · 9:41](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=581)
- The STEP procedure was originally described by HP Kim and Tom Jackson. — Paul Wales (clinical) [Ep 6 · 10:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=645)
- For STEP, a transverse supraumbilical abdominal incision is used, all adhesions are lysed, and the entire intestinal tract is laid out from top to bottom to understand anatomy and maximize mobility. — Paul Wales (clinical) [Ep 6 · 11:02](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=662)
- The anti-mesenteric surface of the bowel is marked with surgical pen after drying with a lap sponge; maintaining this alignment prevents longitudinal twisting of the bowel during stapling. — Paul Wales (clinical) [Ep 6 · 11:29](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=689)
- Bowel length is measured before the procedure using 30 silk dipped in mineral oil; caliber and length of the dilated segment to be stepped are also recorded. — Paul Wales (clinical) [Ep 6 · 11:58](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=718)
- An endo-GIA stapler is preferred over an open GIA stapler because the smaller cartridge head is more amenable in smaller patients. — Paul Wales (opinion) [Ep 6 · 12:20](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=740)
- Staple lines are applied perpendicular to the mesentery at 90° and 270° (3 o'clock and 9 o'clock positions if mesenteric vessels are at 0°). — Paul Wales (clinical) [Ep 6 · 12:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=754)
- A vascular (white) cartridge with 2.5 mm staples that crimp to 1 mm is used; this is more appropriate for younger patients' bowel thickness and prevents leaks that occurred with classic blue loads in early experience. — Paul Wales (clinical) [Ep 6 · 12:58](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=778)
- Target caliber for STEP is 1.5 cm in babies and 2 to 2.5 cm in older infants or children; making it too narrow risks obstruction, especially in patients with borderline motility. — Paul Wales (clinical) [Ep 6 · 13:23](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=803)
- Before firing the stapler, measurements are taken to both the end of the bowel and to the side to ensure proper caliber is maintained throughout the length. — Paul Wales (clinical) [Ep 6 · 14:09](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=849)
- A U-stitch with 4-0 PDS is placed in the crotch of each staple line to prevent potential leaks at that point. — Paul Wales (clinical) [Ep 6 · 14:28](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=868)
- The procedure is performed with a partner, alternating sides of the bowel, working down the length; 45 mm cartridges are most versatile, but 30 mm and 60 mm cartridges may be needed depending on bowel diameter. — Paul Wales (clinical) [Ep 6 · 14:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=890)
- At the top and bottom of the STEP segment, an additional oblique staple line is fired to taper the transition and avoid a 'dog ear' blind loop that can dilate over time. — Paul Wales (clinical) [Ep 6 · 15:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=908)
- The STEP procedure is performed with staple lines perpendicular to the mesentery (90° and 270°), not in the anti-mesenteric to mesenteric orientation (180° and 0°). — Paul Wales (clinical) [Ep 6 · 16:23](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=983)
- The duodenum is not stepped; the STEP procedure starts where the bowel begins to dilate, usually distal to the duodenum. — Paul Wales (clinical) [Ep 6 · 16:56](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=1016)
- Avoiding staple lines in the duodenum allows proximal access if emergency reoperation is needed for a leak. — Paul Wales (opinion) [Ep 6 · 17:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=1023)
- If duodenal narrowing is needed, a stapler is used to partially narrow the lateral side away from the bile duct and ampulla; plication sutures are not used because they usually fail. — Paul Wales (clinical) [Ep 6 · 17:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=1035)
- The duodenum has no mesentery, making it impossible to orient 90° and 270° positions; surgeons who STEP the duodenum end up entering the bowel at inconsistent orientations. — Michael Helmrath (clinical) [Ep 6 · 17:32](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=1052)
- The biggest benefit of the STEP procedure is tapering the bowel and reestablishing a more normal caliber to improve motility. — Paul Wales (clinical) [Ep 5 · 1:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=112)
- It can take up to 6 months before you actually start to see a significant improvement in absorptive capacity after STEP. — Paul Wales (clinical) [Ep 5 · 3:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=184)
- Improvements in absorptive capacity are measured with fecal fat, alpha-1 antitrypsin clearance, xylose absorption, and citrulline levels as they rise over time. — Paul Wales (clinical) [Ep 5 · 3:16](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=196)
- The reason absorptive improvement takes time is that inflamed, sick, leaky mucosa in the setting of bacterial overgrowth needs to heal. — Paul Wales (clinical) [Ep 5 · 3:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=204)
- Half of the people that have a STEP will have progression of improved enteral tolerance, and half will actually have a worsening. — Michael Helmrath (clinical) [Ep 5 · 3:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=220)
- The six month postoperative period is very critical for analyzing how the patient is moving forward after STEP. — Michael Helmrath (clinical) [Ep 5 · 3:46](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=226)
- Before operating for a STEP procedure, you need to first rule out other anatomical problems by laying out the bowel and getting the mesentery completely oriented. — Michael Helmrath (clinical) [Ep 5 · 4:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=248)
- If you only focus on the STEP without examining the complete anatomy, you will miss some of the reasons why these kids aren't getting better. — Michael Helmrath (clinical) [Ep 5 · 4:14](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=254)
- The management of these kids is not a one-stop shopping that you're going to fix with your operation; there is nothing wrong with staging. — Michael Helmrath (opinion) [Ep 5 · 4:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=293)
- Recurrent bleeding from STEP staple lines is an absolute indication to operate. — Michael Helmrath (clinical) [Ep 5 · 6:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=361)
- Bleeding at STEP staple lines is an underreported complication that is really difficult to manage in some cases. — Paul Wales (clinical) [Ep 5 · 6:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=384)
- Staple line bleeding is hypothesized to be a microbiome problem occurring in a pro-inflammatory environment. — Paul Wales (opinion) [Ep 5 · 6:49](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=409)
- Staple line bleeding tends to occur in type 2 anatomy, which is small bowel to colonic remnant in the absence of an intact colon ileocecal valve. — Paul Wales (clinical) [Ep 5 · 6:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=415)
- Pathology of staple line ulcers shows non-specific inflammation with no vasculitis, no viral elements, and no obvious ischemia. — Paul Wales (clinical) [Ep 5 · 7:12](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=432)
- Mesenteric inflammation and scarring creates an obstruction to venous outflow, resulting in venous hypertension along the staple lines. — Michael Helmrath (clinical) [Ep 5 · 8:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=483)
- During operation for staple line bleeding, you can see vessels the size of your thumb and really big adenopathy because the lymphatics are also obstructed. — Michael Helmrath (clinical) [Ep 5 · 8:33](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=513)
- It is very important to free up the mesentery from scar, which is a dense scar. — Michael Helmrath (clinical) [Ep 5 · 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 at staple lines. — Michael Helmrath (clinical) [Ep 5 · 8:56](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=536)
- The key in 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 5 · 9:09](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=549)
- Mesenteric scarring causing venous hypertension is obvious if you're looking for it during operation. — Michael Helmrath (opinion) [Ep 5 · 9:27](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=567)
- Most referrals for intestinal rehabilitation have had multiple operations before coming to the specialist center. — Paul Wales (clinical) [Ep 5 · 10:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=605)
- Optimizing a child's anatomy may not be conducive to just one operation; you have to set yourself up sometimes planning for the next case. — Paul Wales (opinion) [Ep 5 · 10:09](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=609)
- Dr. Helmrath documents detailed operative notes for himself describing orientation, landmarks, and what was done to guide future operations. — Michael Helmrath (clinical) [Ep 5 · 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; understand that biology, physiology, and growth are a spectrum. — Michael Helmrath (opinion) [Ep 5 · 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 rehabilitation even when patients are doing well, because you have to see the progress. — Michael Helmrath (opinion) [Ep 5 · 11:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=668)
- In Toronto, ultra-short gut is classified as less than 20% of expected bowel length for age; in a term baby that corresponds to 20–30 centimeters. — Paul Wales (clinical) [Ep 3 · 1:37](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=97)
- Overall survival in the ultra-short gut population in the current era of management is over 90%, actually 90–95%. — Paul Wales (epidemiological) [Ep 3 · 1:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=112)
- Ultra-short gut patients who reached enteral autonomy required multiple nutritional supplements but were able to grow within normal parameters. — Paul Wales (clinical) [Ep 3 · 2:07](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=127)
- Long-term risks of death from liver disease or sepsis in ultra-short gut patients have been transformed in the current era of management. — Paul Wales (clinical) [Ep 3 · 2:13](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=133)
- Ultra-short gut patients who did better tended to have some remnant ileum and longer colonic remnants. — Paul Wales (clinical) [Ep 3 · 2:26](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=146)
- The ileum reclaims bile, tells the liver what to do, and produces hormones like GLP-2, PYY, and others that slow motility and signal the jejunum to reabsorb fluid. — Michael Helmrath (clinical) [Ep 3 · 2:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=175)
- The colon can account for one-third to one-half of the caloric needs of these babies when exposed to undigested nutrients. — Michael Helmrath (clinical) [Ep 3 · 3:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=195)
- These children with overwhelming intestinal catastrophe are largely neurologically fine—they are running and playing—and their life expectancy is not associated with lifelong care needs that most parents would not want. — Michael Helmrath (clinical) [Ep 3 · 3:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=204)
- The child should be the one driving the care, not the surgeon's expectations or lack thereof; without changing that early paradigm, nothing else can improve in this population. — Michael Helmrath (opinion) [Ep 3 · 3:48](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=228)
- Bowel removed is bowel never to be used; the fear that delayed surgery drives neurocognitive harm needs to be supported with data. — Michael Helmrath (opinion) [Ep 3 · 4:26](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=266)
- NEC totalis in NEC patients is fairly rare; most NEC patients do not have overwhelming totalis. — Michael Helmrath (epidemiological) [Ep 3 · 4:48](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=288)
- A dozen or more children with NEC totalis at Cincinnati have survived, are off TPN, and have done remarkably well; the comparative group is dead children who have no neurological function. — Michael Helmrath (clinical) [Ep 3 · 4:54](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=294)
- Once these patients survive the acute phase, the opportunities to rehabilitate the bowel and the new tools that will be developed in the next decade are going to be profound. — Michael Helmrath (opinion) [Ep 3 · 5:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=325)
- The opportunity given to the child is made at the time the surgeon opens the belly and sees catastrophe; removing all bowel eliminates all future potential based on clinical acumen that the outcome will be bad. — Michael Helmrath (opinion) [Ep 3 · 5:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=334)
- The first team that must be convinced of this approach is the neonatology team, because historically they are the ones who removed breathing tubes and allowed these babies to pass. — Michael Helmrath (clinical) [Ep 3 · 5:49](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=349)
- Neonatologists see some of the survivors—ex-premature infants with intestinal failure—return to their follow-up clinics, which informs their perspective. — Paul Wales (clinical) [Ep 3 · 5:59](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=359)
- Not every child needs to die with a laparotomy decision; the data will tell whether the unoperated septic/inflammatory response leads to negative outcomes. — Paul Wales (opinion) [Ep 3 · 6:10](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=370)
- Long-term neurocognitive tracking of this population is part of the program's responsibility and is beneficial to patients. — Paul Wales (opinion) [Ep 3 · 6:29](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=389)
- If you see protein growth, linear growth, and head growth in the baby, that is brain growth; a baby will not grow well with an unhealthy liver or poor management. — Michael Helmrath (clinical) [Ep 3 · 6:47](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=407)
- An unhealthy liver does not provide the protein necessary for neurocognitive development; liver health is the number one priority early in management. — Michael Helmrath (clinical) [Ep 3 · 6:59](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=419)
- Lipid restriction as a way of controlling liver disease was never a practice subscribed to by the speakers. — Paul Wales (opinion) [Ep 3 · 7:20](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=440)
- Babies, especially premature babies in the first year of life, have caloric needs of 80–120 kcal/kg because they are growing and developing; when critically ill they are no longer growing and their livers are catabolic, so feeding 150 kcal/kg will not result in growth. — Michael Helmrath (clinical) [Ep 3 · 7:43](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=463)
- For a 30-week baby with extensive NEC and a long segment of dead bowel, the surgeon knows the baby will need multiple operations, so a transverse incision is used because it causes the least problems over time. — Michael Helmrath (clinical) [Ep 3 · 8:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=501)
- The surgeon finds a segment of bowel just beyond what is expected to heal (1–2 cm margin) and brings in an 8 or 10 French Blake drain, often from the left lower quadrant if normally rotated, placing it through bowel that is not expected to do well and advancing it retrograde to the pylorus. — Michael Helmrath (clinical) [Ep 3 · 8:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=511)
- A loose tie is placed around the most healthy part of the bowel around the drain to control secretions, and a purse-string is placed at the insertion site and secured to the skin, essentially stemming the bowel to the abdominal wall; this takes minutes. — Michael Helmrath (clinical) [Ep 3 · 8:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=533)
- If the stomach is visible, a purse-string is placed in the stomach and a 5–7 French feeding tube is inserted into the proximal bowel and tied, taking one to two minutes; this avoids having to access the left upper quadrant later for a G-tube. — Michael Helmrath (clinical) [Ep 3 · 9:29](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=569)
- The surgeon tries to close the abdomen primarily, but if there is concern about dead bowel, Alloderm is placed; if very worried, a drain is placed in the abdomen to allow drainage. — Michael Helmrath (clinical) [Ep 3 · 9:54](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=594)
- The surgeon tries to avoid significant dissection of the distal ileum to preserve blood supply and allow collateralization to recover as much proximal bowel as possible. — Michael Helmrath (clinical) [Ep 3 · 10:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=608)
- If the distal diverted bowel is baggy and filled with bloody enteric fluid, and there are distal perforations with patchy necrosis, the surgeon may place stitches distal to proximal to bring the bowel together to preserve muscle, planning to manage it later. — Michael Helmrath (clinical) [Ep 3 · 10:30](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=630)
- A refeeding tube is placed in the distal bowel to allow refeeding and let the intermediate bowel hang out and heal; this depends on the amount of proximal bowel and whether feeding is feasible. — Michael Helmrath (clinical) [Ep 3 · 10:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=653)
- In one current case with 40 cm of proximal bowel, refeeding is allowing the surgeon to wait longer for intervening bowel to heal, and the baby's liver is fine, buying time because the fluid output from injured bowel is very high. — Michael Helmrath (clinical) [Ep 3 · 11:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=666)
- The surgeon's intraoperative decisions—what is done and what is not done—have a lifelong impact and are critically important; these decisions can determine whether the child stays on or gets off TPN or whether they survive. — Paul Wales (opinion) [Ep 3 · 11:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=713)
- These conversations about approach need to be had with neonatologists and dietitians in the room, not just surgical colleagues, because they must be on board. — Michael Helmrath (opinion) [Ep 3 · 12:33](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=753)
- Families are not able to make decisions in these situations; once the family is told that the baby is the one driving decisions moving forward, it makes things easier for them when outcomes are bad. — Michael Helmrath (opinion) [Ep 3 · 12:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=765)
- Many babies taken to the OR are not as critically sick as believed; once proximal bowel is controlled and everything is decompressed, many will slowly improve. — Michael Helmrath (clinical) [Ep 3 · 13:22](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=802)
- Traditional teaching is to remove obviously dead and infarcted bowel, leave suspicious or questionable bowel, and return in 24–48 hours to let it demarcate; the approach described is a departure from that teaching. — Paul Wales (clinical) [Ep 3 · 13:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=832)
- Some of these children look worse over the next 24–36 hours, then start to stabilize—they may not get better, but they stop getting worse. — Paul Wales (clinical) [Ep 3 · 14:20](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=860)
- Long-term, if all bowel is removed, many patients will heal but there is no opportunity for rehabilitation; that experiment has been done. — Michael Helmrath (opinion) [Ep 3 · 14:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=871)
- Blake tubes have linear cuts on the outside so they do not get obstructed when secretions accumulate; they are soft and do not put pressure on damaged bowel; they can be connected to a bulb syringe and cut to size. — Michael Helmrath (clinical) [Ep 3 · 14:47](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=887)
- The downside of Blake tubes is that they cannot be changed over a wire like JP drains with side holes; the ideal tube would be a Blake with a central hole for wire passage. — Michael Helmrath (opinion) [Ep 3 · 14:59](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=899)
- Nutritional choices including elemental versus semi-elemental versus intact macronutrient diet selection are guided by residual anatomy and functional status — Wales (clinical) [Ep 7 · 1:09](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=69)
- Inadequate caloric support results in poor growth, impaired healing, and diminished adaptive response — Wales (clinical) [Ep 7 · 1:38](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=98)
- Bowel heals with adhesions which bring blood supply to the bowel and help it heal — Helmuth (clinical) [Ep 7 · 2:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=165)
- Placing a tube beyond the pylorus at time of surgery while allowing NG decompression of the stomach, later changed to gastrostomy tube, has been beneficial at Cincinnati Children's — Helmuth (clinical) [Ep 7 · 3:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=185)
- Refeeding through a tube is done best and allows standardized nursing feeding practices — Helmuth (opinion) [Ep 7 · 3:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=201)
- High ostomy outputs without feeding are an indication to feed, as long as the child can be hydrated, though this presents a clinical challenge — Helmuth (clinical) [Ep 7 · 3:56](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=236)
- After massive bowel resection, patients can be hypergastrinemic with elevated acid secretion for 6 to 12 months due to loss of distal bowel and hormonal feedback — Wales (clinical) [Ep 7 · 4:35](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=275)
- Acid blockade (H2 blocker or PPI) can decrease gastric volume in the short term — Wales (clinical) [Ep 7 · 4:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=297)
- Acid blockade carries risk of bacterial overgrowth by losing the acid barrier — Wales (clinical) [Ep 7 · 5:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=311)
- Prokinetic therapy options include intravenous agents (metoclopramide, erythromycin) or enteral agents (domperidone, cisapride) to improve gastric emptying and motility — Wales (clinical) [Ep 7 · 5:20](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=320)
- Increased secretions result from thick, leaky mucosa which requires delivery of luminal nutrients to heal — Wales (clinical) [Ep 7 · 5:59](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=359)
- Serum bicarbonate above 20 indicates feeding is generally safe even with high ostomy outputs (40-60 cc/kg), and acetate can be added to TPN for hydration support — Helmuth (clinical) [Ep 7 · 6:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=377)
- Enteral antibiotics are often cycled for bacterial overgrowth treatment in an empiric and ad hoc manner — Wales (clinical) [Ep 7 · 6:49](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=409)
- Anti-secretory or anti-diarrheal medications to decrease losses include octreotide, clonidine, and loperamide — Wales (clinical) [Ep 7 · 6:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=417)
- Antibiotic treatment should have defined endpoints and duration rather than empiric two-week courses when the child is not showing clinical signs of illness — Helmuth (opinion) [Ep 7 · 7:38](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=458)
- Surgical procedures to promote adaptation fall into three categories: restoring continuity, affecting motility, and lengthening the bowel — Wales (clinical) [Ep 7 · 7:58](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=478)
- Closing a stoma immediately recruits more bowel — Wales (clinical) [Ep 7 · 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 7 · 8:36](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=516)
- Restoring bowel caliber to normal improves motility, clearance, decreases bacterial overgrowth, allows mucosal healing, and improves absorption — Wales (clinical) [Ep 7 · 9:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=541)
- Bowel tapering can be performed on the anti-mesenteric side or the dilated segment can be resected if the patient has adequate length — Wales (clinical) [Ep 7 · 9:14](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=554)
- Bowel lengthening procedures include the Bianchi procedure (longitudinal intestinal lengthening, available since 1980) and the serial transverse enteroplasty (STEP) — Wales (clinical) [Ep 7 · 9:33](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=573)
- The most important factor for efficacy of both Bianchi and STEP procedures is that they taper the bowel — Wales (clinical) [Ep 7 · 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 by preserving all available mucosa without removing any — Wales (clinical) [Ep 7 · 9:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=591)
- In patients who are shorter with dilated bowel segments where resection is undesirable, STEP or Bianchi become options to preserve all mucosa while addressing dilatation — Wales (clinical) [Ep 7 · 10:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=601)
- Bowel lengthening procedures redistribute rather than increase surface area; ongoing dilatation and bowel growth in infants and young children eventually result in more surface area through downstream adaptive responses — Wales (clinical) [Ep 7 · 10:38](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=638)
- It takes approximately 6 months to see changes in absorption after bowel lengthening procedures, as demonstrated in published absorption studies measuring fecal fat, alpha-1 antitrypsin clearance, xylose, and citrulline — Wales (clinical) [Ep 7 · 11:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=665)
- An upper GI study can rule in a problem but does not rule out a problem; a normal upper GI does not exclude an anatomical problem — Helmuth (clinical) [Ep 7 · 11:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=694)
- Initial repair was performed at birth for the gastroschisis. (clinical) [Ep 12 · 0:26](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=26)
- At five weeks, exploratory surgery revealed that all intestines that were on the outside of his body were not viable and had to be removed. (clinical) [Ep 12 · 0:30](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=30)
- Short bowel syndrome diagnosis was made at five weeks of age following removal of non-viable intestinal tissue. (clinical) [Ep 12 · 0:40](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=40)
- Patients with these conditions often require prolonged medical system involvement with multiple operations and very complicated care. (clinical) [Ep 12 · 0:58](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=58)
- Xavier spent more time in the hospital than at home during his first three years. (clinical) [Ep 12 · 1:09](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=69)
- Dr. Helmrath and team at Cincinnati Children's presented an alternative treatment option that offered hope. (clinical) [Ep 12 · 1:33](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=93)
- Xavier was incapable of taking anything by mouth and was essentially completely obstructed. — Helmrath (clinical) [Ep 12 · 1:46](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=106)
- The surgical goal was to reconstruct the intestine in a way that prevents obstruction that can happen with complex surgeries. (clinical) [Ep 12 · 1:52](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=112)
- Xavier had ice cream for the first time at 10 years old following the surgery. (clinical) [Ep 12 · 2:13](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=133)
- Young infants, babies, infants, and young children have tremendous gut growth potential, with the gut growing for the first several years of life. — Paul Well (clinical) [Ep 14 · 0:49](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=49)
- A term baby will have 160 centimeters of small bowel, and by the time the child is 5 years old, it almost triples to about 425 to 450 centimeters. — Paul Well (clinical) [Ep 14 · 1:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=77)
- Residual bowel should be discussed as a percentage of what is normal for a child of that age, not in absolute centimeters. — Paul Well (clinical) [Ep 14 · 1:02](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=62)
- A patient can achieve enteral autonomy with as low as 10% expected gut length if they have the majority of their colon in continuity. — Paul Well (clinical) [Ep 14 · 1:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?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 a reclamation of bile and support the enterohepatic circulation. — Michael Helmrath (clinical) [Ep 14 · 2:30](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=150)
- The distal ileum produces hormones and incretins like GLP-2, GLP-1, and PYY. — Michael Helmrath (clinical) [Ep 14 · 2:43](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=163)
- The importance is not the ileocecal valve itself, but rather the distal ileum and proximal colon where bile recirculation occurs and hormones that help intestinal growth and absorption are produced. — Michael Helmrath (opinion) [Ep 14 · 2:43](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=163)
- The strategy at the first operation should provide a pathway forward that allows early enteral feeding, and it is sometimes better to stage reconstruction under more controlled conditions. — Michael Helmrath (clinical) [Ep 14 · 3:29](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=209)
- In situations of overwhelming intestinal loss, the strategy is to provide proximal control that allows feeding to occur without the enteral stream going through, and to leave questionable bowel with the understanding that many segments deemed non-usable have potential to heal. — Michael Helmrath (clinical) [Ep 14 · 3:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=233)
- As long as proximal diversion is achieved and the baby is stable, questionable bowel can be left for potential use in later secondary reconstructive procedures. (clinical) [Ep 14 · 4:26](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=266)
- The overarching principle is to deliver adequate nutrition to have normal growth within normal parameters, ideally enterally. — Paul Well (clinical) [Ep 14 · 5:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=308)
- As much as possible, the goal is to establish normal feeding behavior, recognizing that enteral nutrition is more than just nutrition. — Paul Well (clinical) [Ep 14 · 5:28](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=328)
- If a patient needs tube support from the beginning, bolus feeding should be tried rather than defaulting to continuous feeding. — Paul Well (clinical) [Ep 14 · 5:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=352)
- When motility issues or delayed gastric emptying prevent tolerance of food into the stomach, the strategy is to feed beyond the stomach and decompress the stomach through an NG tube if the child fails both bolus and continuous gastric feeding. — Paul Well (clinical) [Ep 14 · 6:02](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=362)
- Breast milk is the formula of choice, not only for its nutritional benefits but for all the other beneficial components within breast milk. — Michael Helmrath (clinical) [Ep 14 · 6:42](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=402)
- Formulas can be categorized as intact formulas or semi-elemental/elemental formulas, with protein and fat modules being particularly important. — Paul Well (clinical) [Ep 14 · 7:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=426)
- Single amino acid level protein is the generalized preference, ensuring patients are not having high stool output, high fluid losses, wound breakdown, rashes, or emesis. — Michael Helmrath (clinical) [Ep 14 · 7:28](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=448)
- Long chain fat is the preferred fat module rather than MCT fat, even though there is a feeling that MCT fat is better tolerated in short bowel syndrome. — Paul Well (opinion) [Ep 14 · 7:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=477)
- Long chain fat is a much stronger stimulus for GLP-2 release compared to MCT, which is important when trying to drive adaptation. — Paul Well (clinical) [Ep 14 · 8:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=495)
- Not every child needs to be on SMOFlipid for parenteral nutrition. — Paul Well (opinion) [Ep 14 · 9:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=540)
- For preterm babies, SMOFlipid is not the ideal lipid emulsion but is the best currently available option. — Paul Well (opinion) [Ep 14 · 9:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=543)
- SMOFlipid does not have enough arachidonic acid, which is important for brain development. — Paul Well (clinical) [Ep 14 · 9:16](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=556)
- There are two strategies to treat cholestasis: reduce the total amount of fat or change the composition to introduce SMOFlipid or omegaven. (clinical) [Ep 14 · 9:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=574)
- Reducing lipid dose to 1 g per kg per day can reverse cholestasis but results in reduced calorie delivery that can impair growth and potentially impact neurocognitive development. (clinical) [Ep 14 · 9:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=590)
- Omegaven is essentially pure fish oil with omega-3 and is dosed at 1 g/kg, so babies take a calorie deficit. (clinical) [Ep 14 · 10:07](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=607)
- SMOFlipid is a better choice than omegaven as it is a more well-balanced emulsion with an omega-3 to omega-6 ratio of 2.5 to 1, is less inflammatory than intralipid, and promotes bile flow. (opinion) [Ep 14 · 10:28](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=628)
- SMOFlipid should not be restricted and must be given at no less than 2 or 2.1 g per kg per day. (clinical) [Ep 14 · 10:28](https://library.globalcastmd.com/watch/intestinal-rehabilitation-in-pediatric-short-bowel-syndrome-expert-strategies-fo-16524?t=628)
- Until recently, there was no standardized definition for intestinal failure. — Paul Wales (clinical) [Ep 2 · 1:56](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=116)
- Intestinal failure is when someone's gut function is insufficient to absorb enough nutrients, fluids, and calories to support survival and, in children, growth. — Paul Wales (clinical) [Ep 2 · 2:05](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=125)
- Earlier recognition and taking advantage of the biology of the gut that wants to adapt and meet the needs of the child are time dependent. — Michael Helmrath (clinical) [Ep 2 · 2:40](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=160)
- An intestinal rehabilitation program is a multidisciplinary or interdisciplinary collaborative patient care paradigm that brings coordinated care for children with intestinal failure through comprehensive management of their specialized nutrition and other associated needs. — Paul Wales (clinical) [Ep 2 · 3:03](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=183)
- 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 2 · 4:07](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=247)
- The causes of intestinal failure can be divided into three categories: short bowel syndrome, motility disorders, and mucosal enteropathies or congenital diarrheas. — Paul Wales (clinical) [Ep 2 · 4:39](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=279)
- Short bowel syndrome is by far the most common category in pediatric patients with intestinal failure. — Paul Wales (epidemiological) [Ep 2 · 4:50](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=290)
- Causes of short bowel syndrome are usually related to congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, or long segment Hirschsprung's disease, or acquired diseases of the newborn such as necrotizing enterocolitis. — Paul Wales (clinical) [Ep 2 · 4:50](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=290)
- In motility disorders, the bowel is unable to push things through in a coordinated way due to abnormalities of the muscle itself or of the nerves that control that muscle. — Paul Wales (clinical) [Ep 2 · 5:45](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=345)
- In mucosal enteropathies or congenital diarrheas, the patient has all of their bowel, but the mucosa (the inside lining that digests and absorbs) doesn't work. — Paul Wales (clinical) [Ep 2 · 6:17](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=377)
- Some patients will have elements of one, two, or all three categories of intestinal failure. — Paul Wales (clinical) [Ep 2 · 7:11](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=431)
- Although most patients referred to intestinal rehab programs are infants or babies, there are some older kids that develop intestinal failure. — Paul Wales (epidemiological) [Ep 2 · 7:45](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=465)
- Older pediatric patients can develop intestinal failure from inflammatory bowel disease or Crohn's disease (where they've lost gut as a result of complications), trauma, malignancy, or vascular thrombosis leading to gut loss. — Paul Wales (clinical) [Ep 2 · 7:56](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=476)
- Diagnoses like inflammatory bowel disease, trauma, malignancy, and vascular thrombosis are seen more in older patients or in adult series, and less so in pediatrics. — Paul Wales (epidemiological) [Ep 2 · 8:04](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=484)
- Prenatal diagnoses that lead to intestinal rehab referral typically include atresia (which could be with cystic fibrosis) and gastroschisis. — Michael Helmrath (clinical) [Ep 2 · 9:15](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=555)
- Innovation comes from multiple approaches to the problem and different visions of the problem; the more expertise you bring in, the better the outcome is. — Michael Helmrath (opinion) [Ep 2 · 10:25](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=625)
- How to take the older child who's had intestinal failure into their late teen years and later is a major obstacle that needs to be addressed and is currently not being met. — Michael Helmrath (opinion) [Ep 2 · 10:51](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=651)
- Dietitians and understanding the nutritional needs of a child are critical components of the intestinal rehabilitation team. — Michael Helmrath (clinical) [Ep 2 · 11:52](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=712)
- Social work is a really key part of the intestinal rehabilitation team. — Michael Helmrath (clinical) [Ep 2 · 12:01](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=721)
- Extended providers including nurse practitioners are fantastic and essential to the intestinal rehabilitation team. — Michael Helmrath (opinion) [Ep 2 · 12:03](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=723)
- Pharmacy, social work, interventional radiology, pathology, endocrinology, and nephrology are all important components of the intestinal rehabilitation team. — Paul Wales (clinical) [Ep 2 · 12:15](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=735)
- Kids with intestinal failure who survive long-term have developed chronic comorbidities that weren't seen to the same extent before because they didn't live long enough. — Paul Wales (epidemiological) [Ep 2 · 12:46](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=766)
- Long-term survivors of intestinal failure are now seeing diseases like renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues. — Paul Wales (clinical) [Ep 2 · 12:55](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=775)
- Having a coordinated team that can track chronic comorbidity problems long-term is vital for intestinal failure patients. — Paul Wales (opinion) [Ep 2 · 13:10](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=790)
- In babies with ultra-short gut managed with current era approaches, overall survival is over 90% — Paul Wales (epidemiological) [Ep 4 · 1:52](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=112)
- Ultra-short gut is defined as less than 20% of expected bowel length for age, which in a term baby is 20-30 centimeters or less — Paul Wales (clinical) [Ep 4 · 1:37](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=97)
- Ultra-short gut patients who did better tended to have remnant ileum as part of residual bowel and longer colonic remnants — Paul Wales (clinical) [Ep 4 · 2:26](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=146)
- The ileum produces hormones like GLP-2, PYY and others that slow motility and signal the jejunum to reabsorb fluid — Michael Helmrath (clinical) [Ep 4 · 2:55](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=175)
- The colon can account for a third to half of caloric needs in these babies when exposed to undigested nutrients — Michael Helmrath (clinical) [Ep 4 · 3:15](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=195)
- These children with intestinal failure are largely neurologically fine, running and playing, with normal life expectancy — Michael Helmrath (clinical) [Ep 4 · 3:24](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=204)
- Bowel removed is bowel never to be used — Michael Helmrath (clinical) [Ep 4 · 4:26](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=266)
- The fear that inflammatory response from delayed surgery affects neurocognitive outcomes needs to be supported with data — Michael Helmrath (opinion) [Ep 4 · 4:29](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=269)
- NEC totalis in NEC kids is fairly rare — Michael Helmrath (epidemiological) [Ep 4 · 4:48](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=288)
- A dozen or more kids with NEC totalis have survived, gotten off TPN, and done remarkably well — Michael Helmrath (clinical) [Ep 4 · 4:54](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=294)
- If a baby grows well with protein growth, linear growth, and head growth, that represents brain growth — Michael Helmrath (clinical) [Ep 4 · 6:49](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=409)
- A baby will not grow well with an unhealthy liver that is not managed well — Michael Helmrath (clinical) [Ep 4 · 6:54](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=414)
- An unhealthy liver does not provide the protein needed for neurocognitive development — Michael Helmrath (clinical) [Ep 4 · 6:59](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=419)
- Lipid restriction was never a practice subscribed to by the Cincinnati program for managing these patients — Paul Wales (clinical) [Ep 4 · 7:40](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=460)
- Premature babies in the first year of life have caloric needs of 80-120 kcal/kg because they are growing and developing — Michael Helmrath (clinical) [Ep 4 · 7:43](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=463)
- When critically ill, babies no longer grow and develop; they can be fed 150 kcal/kg but will not grow because their livers are catabolic — Michael Helmrath (clinical) [Ep 4 · 7:52](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=472)
- A transverse incision is preferred because it will cause the least problems over time with multiple operations — Michael Helmrath (clinical) [Ep 4 · 8:25](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=505)
- An 8 or 10 French Blake drain is placed through bowel that is not expected to heal well, advanced retrograde to the pylorus, with a tie around healthy bowel to control secretions — Michael Helmrath (clinical) [Ep 4 · 8:42](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=522)
- A 5-7 French feeding tube can be placed in the stomach through a purse string to enable early feeding access — Michael Helmrath (clinical) [Ep 4 · 9:29](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?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 4 · 10:08](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=608)
- A refeeding tube can be placed in distal bowel to allow intermediate bowel to heal while maintaining liver health — Michael Helmrath (clinical) [Ep 4 · 10:53](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=653)
- Intraoperative decisions by the surgeon have a lifelong impact on whether a child with short bowel syndrome stays on or gets off TPN or whether they survive — Paul Wales (clinical) [Ep 4 · 12:00](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=720)
- Many kids who appear critically sick preoperatively are not as critically sick as believed once proximal bowel is controlled and decompressed — Michael Helmrath (clinical) [Ep 4 · 13:22](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=802)
- Often these kids look worse over the next 24-36 hours after surgery, then stop getting worse before they start improving — Paul Wales (clinical) [Ep 4 · 14:21](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=861)
- Blake tubes have linear cuts on the outside so they do not get obstructed when secretions accumulate around them — Michael Helmrath (clinical) [Ep 4 · 14:49](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=889)
- Blake tubes are soft and do not put much pressure on damaged bowel, and can be connected to a bulb syringe — Michael Helmrath (clinical) [Ep 4 · 15:06](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=906)
- The downside of Blake tubes is they cannot be changed over a wire like JP drains with side holes — Michael Helmrath (clinical) [Ep 4 · 14:59](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=899)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- New guidelines define intestinal failure as inadequate intestinal function requiring parenteral support for at least 60 days. — Rod Gerardo summarizing the discussion [Ep 1 · 2:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=144)
- Intestinal rehabilitation requires managing comorbidities including sepsis and liver disease that challenge infant growth. — Rod Gerardo summarizing the discussion [Ep 1 · 3:33](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=213)
- Overall survival in big intestinal rehabilitation programs is usually over 90% long-term. — Rod Gerardo summarizing the discussion [Ep 1 · 12:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=754)
- 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 summarizing the discussion [Ep 6 · 1:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=110)
- The first 4 months of life is when care for intestinal failure patients is most uncoordinated, and surgical decisions made during this period have the most profound effect on long-term outcome. — Todd Ponsky summarizing the discussion [Ep 6 · 2:29](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=149)
- Absorptive surface area comes from the waves of peristalsis moving over the villi, not from the exposed length of bowel. — Todd Ponsky summarizing the discussion [Ep 6 · 3:32](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=212)
- Gastroschisis patients have inherent dysmotility. — Todd Ponsky summarizing the discussion [Ep 6 · 7:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=441)
- At birth, neonatal bowel is usually not dilated enough to apply the STEP procedure. — Ellen Encisco summarizing the discussion [Ep 6 · 9:36](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=576)
- If one part of the stepped bowel becomes dilated, the STEP segments can rotate away from each other separately, causing twisting and functional obstruction. — Ellen Encisco summarizing the discussion [Ep 6 · 15:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=957)
- After completing the STEP, the length of stepped bowel, new total bowel length, and final caliber (2-2.5 cm) are recorded. — Todd Ponsky summarizing the discussion [Ep 6 · 16:13](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=973)
- STEP does not create new bowel but redistributes it to reestablish more normal caliber bowel, which helps improve motility overall. — Ellen Encisco summarizing the discussion [Ep 5 · 2:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=124)
- About 50% reduction in parental nutrition support can be expected after STEP. — Ellen Encisco summarizing the discussion [Ep 5 · 3:33](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=213)
- Ulcers at STEP staple lines are not uncommon, and many kids have been transfused every month for years because of that. — Anton Bash summarizing the discussion [Ep 5 · 5:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=353)
- There is a whole spectrum of findings from ulcers at staple lines, from just having specks of blood in the stool to enough bleeding that kids might have to be transfused every week and a half. — Ellen Encisco summarizing the discussion [Ep 5 · 6:32](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=392)
- Staple line ulcers can recur after treatment. — Ellen Encisco summarizing the discussion [Ep 5 · 6:47](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=407)
- Teams have tried enteral omega 3 lipid supplements, bacterial overgrowth management with cycled antibiotics or probiotics, 5ASA, budesonide, and immune modulators like Remicade for staple line bleeding, but none have been the perfect remedy. — Ellen Encisco summarizing the discussion [Ep 5 · 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 not in the bowel but actually in the mesentery. — Ellen Encisco summarizing the discussion [Ep 5 · 7:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=472)
- Mesenteric inflammation causes scarring and obstructs venous outflow, leading to enlarged veins and venous hypertension on the bowel, and even large lymph nodes from lymphatic obstruction. — Ellen Encisco summarizing the discussion [Ep 5 · 8:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=497)
- Once you free up the mesenteric scar, those big vessels come right back to normal. — Anton Bash summarizing the discussion [Ep 5 · 8:47](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=527)
- Dr. Helmrath typically revises the staple line with a hand sewn stitch when mesenteric scarring and venous hypertension are present. — Ellen Encisco summarizes what Dr. Michael Helmrath said [Ep 5 · 9:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=540)
- Doing things in a staged fashion is typical for the intestinal rehabilitation patient population. — Ellen Encisco summarizing the discussion [Ep 5 · 10:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=625)
- As intestinal rehabilitation patients grow and develop, more issues might arise requiring additional operations. — Ellen Encisco summarizing the discussion [Ep 5 · 10:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=645)
- Intestinal rehabilitation is a lifelong issue, and surgeons typically follow these patients for a long time. — Ellen Encisco summarizing the discussion [Ep 5 · 11:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=675)
- Ultra-short gut patients in the current era do not die of liver failure anymore and are rarely transplanted. — The host summarizing the discussion [Ep 3 · 2:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=123)
- When damaged bowel weeps and secretes fluids, the volume of output is high; as it heals and regenerates the ability to reabsorb fluid, the drain output will decrease, signaling that the bowel is healing. — The host summarizing the discussion [Ep 3 · 11:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=685)
- Implementation of a feeding protocol is associated with achieving full enteral autonomy in a shorter time period, based on literature from Chris Duggan's group at Boston — Rod summarizing the discussion [Ep 7 · 1:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=115)
- Dilated bowel with impaired motility leads to stool stasis, mucosal inflammation, barrier damage allowing bacterial translocation, potential sepsis, and malabsorption — Rod summarizing the discussion [Ep 7 · 8:41](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=521)
- The new ASPEN guidelines define enteral autonomy as independence from parenteral support for 12 weeks — Ellen summarizing the discussion [Ep 7 · 12:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=725)
- Xavier was born with gastroschisis, a condition causing his intestines to be on the outside of his body. — The host summarizing the discussion [Ep 12 · 0:18](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=18)
- Xavier was unable to get nourishment through traditional feedings and required total parenteral nutrition (TPN) intravenously. — The host summarizing the discussion [Ep 12 · 0:45](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=45)
- After years of TPN and multiple operations, the hometown hospital stated that other than transplant, there was nothing else they could do. — The host summarizing the discussion [Ep 12 · 1:17](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=77)
- Dr. Helmrath successfully rebuilt Xavier's small intestine, enabling him to eat. — The host summarizing the discussion [Ep 12 · 2:07](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=127)
- Xavier still needs TPN for supplemental nutrition as he grows. — The host summarizing the discussion [Ep 12 · 2:24](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=144)
- Xavier will continue to be closely monitored by his care team at Cincinnati Children's. — The host summarizing the discussion [Ep 12 · 2:24](https://library.globalcastmd.com/watch/xavier-s-journey-from-short-bowel-syndrome-to-eating-again-16338?t=144)
- 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 summarizing the discussion [Ep 2 · 2:24](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=144)
- Mucosal defects lead to hypersecretion and profuse fluid losses, such that the bowel is unable to tolerate or absorb nutrients. — Ellen summarizing the discussion [Ep 2 · 6:30](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=390)
- A child with gastroschisis could have short bowel (because not all bowel was viable), inflamed bowel (so it doesn't absorb well), and motility issues. — Ellen summarizing the discussion [Ep 2 · 7:22](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=442)
- There are three general time points when families reach intestinal rehab programs: prenatal diagnosis, postnatal acquired problems, and later presentations after discharge when patients fail to progress. — Rod Gerardo summarizing the discussion [Ep 2 · 8:53](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=533)
- Postnatal acquired problems leading to intestinal rehab referral include volvulus and necrotizing enterocolitis. — Ellen summarizing the discussion [Ep 2 · 9:29](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=569)
- The survival overall in big intestinal rehabilitation programs is usually over 90% long-term survival. — Rod Gerardo summarizing the discussion [Ep 2 · 12:34](https://library.globalcastmd.com/watch/introduction-to-intestinal-rehabilitation-and-intestinal-failure-in-pediatric-su-16526?t=754)
- Ultra-short gut patients with survival rates of 90-95% rarely die of liver failure anymore and rarely get transplanted — Ellen summarizing the discussion [Ep 4 · 2:01](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=121)
- When damaged bowel weeps and secretes fluids, the volume of output is initially high; as it heals and regenerates reabsorptive capacity, drain output decreases as a sign of healing — Ellen summarizing the discussion [Ep 4 · 11:25](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=685)
- 50% bowel length is the cutoff used to determine salvageability in overwhelming intestinal catastrophe — The host summarizing the discussion [Ep 4 · 15:45](https://library.globalcastmd.com/watch/managing-overwhelming-intestinal-catastrophe-in-neonates-when-to-operate-16525?t=945)

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