Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
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Laparoscopic Jejunal Atresia Repair - Technique
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Dr. Steven Rothenberg describes his technique for laparoscopic repair of jejunal atresia with apple peel defect. Key steps to the procedure include Veress entry, identification of the proximal and distal segments of jejunum, mobilization a
video5:55 · Nov 2018
Laparoscopic Jejunal Atresia Repair - Technique
Watch →
Dr. Steven Rothenberg describes his technique for laparoscopic repair of jejunal atresia with apple peel defect. Key steps to the procedure include Veress entry, identification of the proximal and distal segments of jejunum, mobilization a
video5:55 · Nov 2018
Practical Approach: Intestinal Failure Innovations
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Dr. Michael Helmrath leads a discussion in alternative feeding techniques for intestinal failure, distal feeding, button insertion, the significant of small bowel length, liver disease, international patient management, breast milk therapy,
video1:56:52 · Jan 2019
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Jejunal atresia is a condition where a baby is born with a blockage in part of the small intestine called the jejunum [e748-c1, e751-c1]. Doctors often discover this before birth during prenatal ultrasounds [e748-c1, e751-c1]. Sometimes the blockage involves a twist in the bowel called an "apple peel defect," where the intestine spirals around its blood supply [e748-c6, e748-c8, e751-c7, e751-c8]. Surgeons repair this by removing the blocked or overly stretched section of bowel and reconnecting the healthy parts [e748-c10, e748-c15, e751-c10, e751-c15]. The operation can be done using small instruments and a camera through tiny incisions [e748-c3, e751-c3]. After surgery, babies gradually start tolerating feeds as their bowel begins working again [e748-c23, e751-c23]. Doctors check that the repair is healing properly with imaging studies about a week after surgery [e748-c24, e751-c24]. Most infants recover well from the procedure [e748-c22, e751-c22]. The surgical team works carefully to ensure no kinks or problems remain that could interfere with the bowel's ability to move food through .
Jejunal atresia is a condition where a baby is born with a blockage in part of the small intestine called the jejunum [e748-c1, e751-c1]. Doctors often discover this before birth during prenatal ultrasounds [e748-c1, e751-c1]. Sometimes the blockage involves a twist in the bowel called an "apple peel defect," where the intestine spirals around its blood supply [e748-c6, e748-c8, e751-c7, e751-c8]. Surgeons repair this by removing the blocked or overly stretched section of bowel and reconnecting the healthy parts [e748-c10, e748-c15, e751-c10, e751-c15]. The operation can be done using small instruments and a camera through tiny incisions [e748-c3, e751-c3]. After surgery, babies gradually start tolerating feeds as their bowel begins working again [e748-c23, e751-c23]. Doctors check that the repair is healing properly with imaging studies about a week after surgery [e748-c24, e751-c24]. Most infants recover well from the procedure [e748-c22, e751-c22]. The surgical team works carefully to ensure no kinks or problems remain that could interfere with the bowel's ability to move food through .
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Practical Approach: Intestinal Failure Innovations
Jejunostomy chimney technique involves dividing bowel 2-3 cm distal to ligament of Treitz, bringing distal limb up as chimney over splenic flexure with side-to-end anastomosis, allowing Mickey button placement without luminal obstruction
clinical3:00 ↗
Placing balloon catheter directly in jejunal lumen creates obstruction; chimney technique avoids this by creating separate access limb
clinical4:21 ↗
Distal feeding can be provided through 3-4 French feeding tube placed in distal bowel and brought out as stent rather than matured mucous fistula, allowing easy refeeding without catheter access issues
clinical0:57 ↗
Refeeding distal bowel provides significant benefit for fluid/electrolyte absorption and allows bowel to dilate and mature, potentially decreasing technical problems at takedown
clinical1:45 ↗
When proximal and distal stomas are placed close together, takedown is less stressful on patient and surgeon than complete laparotomy to find and reconnect distant bowel segments
opinion8:02 ↗
Gastrostomy tubes in very small premature infants (700 grams) can be deferred by placing 3 French feeding tube coiled in stomach, then later dilating tract with wire and interventional radiology to place primary tube without second surgery
clinical14:46 ↗
Gastrostomy tube placement has costs including leakage issues if placed against costal margin in small infants; timing and location require careful consideration
clinical20:41 ↗
Prolapsed gastrostomy tubes can cause significant formula loss during feeds; removing dysfunctional gastrostomy allows some children to thrive better
clinical22:46 ↗
In 2-month-old with jejunal atresia unable to advance feeds beyond 20 mL/kg, if anastomosis appears patent at reoperation, would still revise it rather than leave it alone
clinical24:16 ↗
At end of intestinal failure operation, must ensure no kinking, restriction, or potential problems remain - cannot tolerate leaving anything that 'could be a problem but is probably all right'
clinical25:29 ↗
STEP procedure in first year of life, especially in infant who has not progressed with enteral feeds, is not beneficial unless specifically avoiding line infections and bacterial overgrowth
clinical29:20 ↗
Dysmotile bowel does not become motile because you did a STEP procedure on it; if bowel hasn't been fed and isn't functioning, STEP won't make it work
clinical29:32 ↗
The one thing that makes bowel adapt is feeding the bowel; procedures causing problems reinitiating feeds cause damage to patient
clinical30:06 ↗
In patient with 50% estimated bowel length, expectation is they will come off parenteral nutrition; should not overtry to salvage bad bowel when good bowel exists
clinical28:07 ↗
STEP registry paper showing procedures can be done safely in early neonatal period found only 3 patients came off parenteral nutrition, whereas natural data shows 80-90% of such patients off TPN at 12 months just by being fed
epidemiological31:18 ↗
Kids who had early STEP procedures have often redilated, undergone second STEPs, and had mechanical obstructions very detrimental to feeding ability
clinical31:43 ↗
Indication for lengthening procedure is complications from bacterial overgrowth (d-lactic acidosis) or ultra-short bowel with very dilated segment where tapering doesn't make sense - generally not decisions made at 2-3 months old but after first birthday
clinical33:21 ↗
Expectation of going from 10 mL/kg enteral feeds to off TPN in 3 months after STEP is a fairy tale that doesn't exist
opinion34:06 ↗
Surgical techniques for intestinal failure are not out of realm of any pediatric surgeon, but outcomes differ when done in isolation without multidisciplinary team consideration
opinion34:46 ↗
Since maturing multidisciplinary program, transplant candidates declined by 75% and internal transplants almost non-existent
epidemiological40:47 ↗
Patients should be referred to intestinal rehabilitation programs as soon as identified as needing comprehensive approach, not when complications exhausted local knowledge
opinion44:23 ↗
Programs do far better with children who do not already have complications of their disease than patients who come already suffering from current management
clinical44:34 ↗
In gastroschisis and surgical necrotizing enterocolitis, significant benefit to time to wean off parenteral nutrition based solely on breast milk (fortified or not) versus formula only
clinical59:42 ↗
Breast milk is not just formula but really a therapy with components that are anti-inflammatory and promotile
clinical1:00:19 ↗
Benefit to kids with spontaneous intestinal perforation is not seen with breast milk, suggesting specific anti-inflammatory and promotile components important for other conditions
clinical1:00:20 ↗
Donor breast milk is less advantageous than maternal breast milk; usually taken from mothers 10-14 months postpartum before weaning, has lower caloric density and protein, and freezing may inactivate trophic factors
clinical1:02:25 ↗
Express maternal breast milk is favorite approach; when patient predicted to do badly, go to elemental formulas as second line
clinical1:03:19 ↗
Free amino acid formulas are relatively hyperosmolar at 20 kcal/oz (osmolarity around 350-360); going higher increases osmolarity, so tend to avoid high caloric density formulas in very young infants
clinical1:04:20 ↗
In study by Joly et al in French adult cohort, hyperphagic adults with short bowel had 60% absorption coefficient with ad lib eating, 85% with continuous drip feeds, and 75% with half calories by mouth during day plus overnight drip feeds
Host summaryThe host summarizing the discussion — not the host's own clinical position17:01 ↗
Continuous drip feeding improves absorptive index, but combining daytime oral intake with nighttime drip feeds may offer best of both approaches
Host summaryThe host summarizing the discussion — not the host's own clinical position17:40 ↗
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