# Necrotizing Enterocolitis — GCMD Library living collection

Everything in the library about NEC — built automatically from dossiers that name it.

Updated: n/a · 19 episodes · 387 cited statements

## Episodes
### Nutritional Management
- [Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 1](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141) — podcast · 16:18 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141.md)

### Surgical 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)
- [Update Course Rewind 2025: Updates in NEC Management](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612) — video · 11:03 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612.md)

### Complications
- [Conservative Management of Necrotizing Enterocolitis in Newborns: Incidence and Management of Intestinal Strictures](https://library.globalcastmd.com/watch/conservative-management-of-necrotizing-enterocolitis-in-newborns-incidence-and-management-of-intestinal-strictures-9738) — video · 0:50 · [machine version](https://library.globalcastmd.com/watch/conservative-management-of-necrotizing-enterocolitis-in-newborns-incidence-and-management-of-intestinal-strictures-9738.md)

### Evidence & Research
- [Journal of Pediatric Surgery Article Review: October 2021](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661) — podcast · 19:10 · [machine version](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661.md)
- [Routine contrast enema prior to stoma reversal seems only required following treatment for necrotizing enterocolitis: An evaluation of the diagnostic accuracy of the contrast enema](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603) — video · 0:56 · [machine version](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603.md)
- [Expectant Management or Early Ibuprofen for Patent Ductus Arteriosus](https://library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075) — video · 1:14 · [machine version](https://library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075.md)
- [Heat 3 Winner: Shruthi Srinivas, MD - Best of the Best in Pediatric Surgery 2024](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018) — video · 1:47 · [machine version](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018.md)
- [Association of Exclusive Breast Milk Intake and Outcomes in Infants With Uncomplicated Gastroschisis: A National Cohort Study](https://library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037) — video · 0:56 · [machine version](https://library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037.md)
- [Dr. Colleen Nofi - Best of the Best in Pediatric Surgery 2025](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047) — video · 8:06 · [machine version](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047.md)
- [Remote Ischemic Conditioning (RIC) Decreases the Incidence and Severity of Necrotizing Enterocolitis (NEC) - Validation in a Large Animal Model](https://library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417) — video · 0:59 · [machine version](https://library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417.md)
- [STAT trial: stoma or intestinal anastomosis for necrotizing enterocolitis: a multicentre randomized controlled trial](https://library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427) — video · 0:57 · [machine version](https://library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427.md)
- [Availability, utilization, and barriers to bowel ultrasound for necrotizing enterocolitis...](https://library.globalcastmd.com/watch/availability-utilization-and-barriers-to-bowel-ultrasound-for-necrotizing-enterocolitis-13575) — video · 0:55 · [machine version](https://library.globalcastmd.com/watch/availability-utilization-and-barriers-to-bowel-ultrasound-for-necrotizing-enterocolitis-13575.md)

### Case-Based Learning
- [Necrotizing Enterocolitis](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636) — video · 35:06 · [machine version](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636.md)
- [NEC: Update Course 2013](https://library.globalcastmd.com/watch/nec-update-course-2013-1060) — video · 34:22 · [machine version](https://library.globalcastmd.com/watch/nec-update-course-2013-1060.md)

### In-Depth Reviews
- [Necrotizing Enterocolitis with Dr. Gail Besner](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930) — podcast · 46:29 · [machine version](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930.md)
- [Practical Approach: Intestinal Failure Innovations](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035) — video · 116:52 · [machine version](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035.md)
- [Stay Current Throwbacks Necrotizing Enterocolitis with Dr. Gail Besner](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402) — podcast · 47:54 · [machine version](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402.md)

### Long-Term Care
- [Multidisciplinary Approach: Intestinal Failure Innovations](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036) — video · 97:52 · [machine version](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=0) Defining Team-Based Care Models (Ep 4)
- [10:00](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=600) Patient Identification and Early Intervention (Ep 4)
- [20:00](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1200) Central Line Management and Infection Prevention (Ep 4)
- [40:00](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2400) TPN Composition and Lipid Management (Ep 4)
- [60:00](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3600) Growth, Nutrition, and Functional Assessment (Ep 4)
- [80:00](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4800) Feeding Challenges and Surgical Decision-Making (Ep 4)
- [0:00](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018?t=0) Heat 3 Recap (Ep 12)
- [0:50](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018?t=50) Winner Announcement (Ep 12)
- [0:00](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=0) Introduction and Prevention Strategies (Ep 1)
- [4:20](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=260) Indications for Surgical Intervention (Ep 1)
- [10:40](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=640) Drainage versus Laparotomy in Extremely Low Birth Weight Infants (Ep 1)
- [19:30](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1170) Ethical Considerations and Pan-Intestinal Necrosis (Ep 1)
- [24:40](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1480) Stoma Creation and Timing of Reversal (Ep 1)
- [29:47](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1787) Full-Thickness Necrosis and Intestinal Transplant (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=0) Predictive factors and case introduction (Ep 5)
- [2:24](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=144) Prevention strategies: probiotics and feeding protocols (Ep 5)
- [5:10](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=310) Surgical indications and thresholds (Ep 5)
- [8:28](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=508) Drainage versus laparotomy in ELBW infants (Ep 5)
- [15:00](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=900) Ethical considerations: severe IVH and surgical decision-making (Ep 5)
- [19:54](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1194) Resection strategies: stoma configuration and anastomosis (Ep 5)
- [24:00](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1440) Timing of stoma takedown (Ep 5)
- [29:00](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1740) Pan-intestinal necrosis and totalis management (Ep 5)
- [0:05](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=5) Longitudinal Care Needs After Child Physical Abuse (Ep 6)
- [4:39](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=279) Surgical Timing and Outcomes in Necrotizing Enterocolitis (Ep 6)
- [9:59](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=599) One-Year Outcomes of Bowel Management Programs for Anorectal Malformations (Ep 6)
- [13:46](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=826) Spinal Imaging in Anorectal Malformations (Ep 6)
- [0:00](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=0) Diagnostic accuracy of contrast enema before stoma reversal in pediatric patients (Ep 10)
- [0:00](https://library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=0) Non-inferiority trial of expectant management versus early ibuprofen for PDA in preterm infants (Ep 11)
- [0:00](https://library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037?t=0) Breast milk versus formula in uncomplicated gastroschisis outcomes (Ep 13)
- [0:00](https://library.globalcastmd.com/watch/conservative-management-of-necrotizing-enterocolitis-in-newborns-incidence-and-management-of-intestinal-strictures-9738?t=0) Incidence of Intestinal Strictures After Conservative NEC Management (Ep 14)
- [0:00](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=0) Introduction and Background on eCIRP in NEC (Ep 15)
- [2:05](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=125) CIRP Knockout Results in Murine NEC Model (Ep 15)
- [4:10](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=250) MOP3 Therapeutic Intervention Results (Ep 15)
- [5:42](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=342) Conclusions and Q&A (Ep 15)
- [0:00](https://library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=0) Remote Ischemic Conditioning for NEC Prevention in a Piglet Model (Ep 16)
- [0:00](https://library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427?t=0) STAT trial: anastomosis versus stoma for necrotizing enterocolitis (Ep 17)
- [0:00](https://library.globalcastmd.com/watch/availability-utilization-and-barriers-to-bowel-ultrasound-for-necrotizing-enterocolitis-13575?t=0) Survey findings on bowel ultrasound availability and barriers for NEC diagnosis (Ep 18)
- [0:00](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=0) Introduction and Case Presentation: Diagnostic Challenges in NEC (Ep 19)
- [1:51](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=111) Ultrasound vs X-ray: Improving Diagnostic Sensitivity (Ep 19)
- [3:25](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=205) Operative Decision-Making: Drain vs Laparotomy, Stoma vs Anastomosis (Ep 19)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "Team approach to intestinal failure reduced 1-year mortality from 30-40% to approximately 5% per year at University of Michigan" — Sam (clinical) [Ep 4 · 2:23](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=143)
- "Cincinnati's intestinal failure program was started in 1984" — Sam (clinical) [Ep 4 · 2:51](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=171)
- "Intestinal failure is defined by inadequate bowel length OR bowel that doesn't absorb nutrition and fluid adequately to maintain growth" — Monique (clinical) [Ep 4 · 3:47](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=227)
- "Almost 30% of patients leaving NICU without rotavirus vaccination were readmitted with rotavirus infection" (epidemiological) [Ep 4 · 16:56](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1016)
- "Joint weekly rounds with surgeons, gastroenterologists, dietitians, and neonatologists help identify protocol deviations and build family rapport" — Sam (clinical) [Ep 4 · 18:11](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1091)
- "Breast milk provides not just immunostimulatory benefits but motility effects through oligosaccharides and healing properties" (clinical) [Ep 4 · 30:13](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1813)
- "PIFCON study data showing 25% mortality or transplant referral are now archaic; outcomes have improved dramatically in past 5 years" — Sam (opinion) [Ep 4 · 33:36](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2016)
- "Cincinnati reduced catheter-related bloodstream infections from 12 per 1000 catheter-days to 2 per 1000, approaching <1 per 1000" (clinical) [Ep 4 · 37:31](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2251)
- "Standardized central line bundles and multi-hospital communication networks have reduced line infections across pediatric populations" (clinical) [Ep 4 · 38:54](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2334)
- "Intestinal failure patients have unique propensity for line infections and different infection types compared to general pediatric population" (clinical) [Ep 4 · 39:45](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2385)
- "Toronto experience paper in JPGN examined PICC lines for TPN administration" (clinical) [Ep 4 · 41:13](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2473)
- "Complication-free survival of PICC lines is approximately half that of broviacs according to IR literature" — Sam (clinical) [Ep 4 · 44:58](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2698)
- "Subclavian approach for central lines carries higher risk of stenosis compared to jugular approach" — Valerie (clinical) [Ep 4 · 46:26](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2786)
- "Lack of vascular access is no longer a common indication for intestinal transplant in past 3 years at some centers" (clinical) [Ep 4 · 50:04](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3004)
- "Ethanol locks use 70% concentration with 2-6 hour dwell time, can be given 3 times weekly (Monday/Wednesday/Friday) with good results" — Sam (clinical) [Ep 4 · 60:20](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3620)
- "Ethanol locks work better with 6.6 French catheters than smaller catheters; smaller PICC lines tend to occlude" — Sam (clinical) [Ep 4 · 61:04](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3664)
- "Younger NPO infants often cannot tolerate TPN windows required for ethanol locks" — Sam (clinical) [Ep 4 · 61:28](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3688)
- "UK predominantly uses taurolidine locks rather than ethanol locks for line infection prevention" — Girish (clinical) [Ep 4 · 63:55](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3835)
- "Line care education is crucial; recurrent infections warrant revisiting line care practices before implementing locks" — Girish (clinical) [Ep 4 · 64:23](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3863)
- "Fungal line infections are pulled more promptly, but some centers now treat through even fungal infections in patients with limited vascular access" (clinical) [Ep 4 · 65:32](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3932)
- "Phytosterols in soy-based lipids are cleared poorly, share cholesterol transporter (down-regulated by endotoxemia), and reduce FXR receptor expression causing hepatocyte damage" — Sam (clinical) [Ep 4 · 68:34](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4114)
- "Limiting lipid intake to 1 g/kg/day reduces cholestasis rate to less than 5% of patients" — Sam (clinical) [Ep 4 · 69:42](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4182)
- "Fish oil-based lipid (Omegaven) may have anti-inflammatory advantage and benefit patients who don't respond to lipid restriction" — Sam (clinical) [Ep 4 · 70:43](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4243)
- "Neonatologists often maintain higher lipid doses (2-3 g/kg/day) due to concern about depriving infants of linoleic acid and affecting brain development" — Sam (clinical) [Ep 4 · 71:50](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4310)
- "With lipid restriction protocols, cholestasis rarely emerges from Cincinnati NICU" (clinical) [Ep 4 · 72:39](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4359)
- "Standard metrics for essential fatty acid deficiency are based on malnourished children not on TPN, so altered triene:tetraene ratios may not apply the same way" (opinion) [Ep 4 · 74:14](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4454)
- "Symptomatic essential fatty acid deficiency is not seen in practice with lipid restriction protocols" (clinical) [Ep 4 · 74:41](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4481)
- "Higher glucose infusion rates become less efficient as caloric source and are pushed toward fatty acid and fat deposition" (clinical) [Ep 4 · 75:16](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4516)
- "Age-based glucose infusion rate limits: generally 15-16 in premature/infants, gradually decreasing with age" (guideline) [Ep 4 · 75:41](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4541)
- "Intestinal failure patients may not need to maintain 50th percentile growth; unclear what appropriate growth curve should be for this population" (opinion) [Ep 4 · 76:04](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4564)
- "Neurodevelopmental outcomes in intestinal failure are multifactorial (prolonged hospitalization, recurrent admissions, neonatal insults), not solely attributable to lipid strategies" — Girish (clinical) [Ep 4 · 79:31](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4771)
- "Babies with spontaneous intestinal perforation (no functional bowel removed) still require 2-3 months of parenteral nutrition" (clinical) [Ep 4 · 82:03](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4923)
- "Feed absorption and ability to progress feeds are the best measures of bowel function, not absolute bowel length" — Girish (clinical) [Ep 4 · 85:29](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5129)
- "Ability to wean TPN while maintaining good growth is the most important functional measure" (opinion) [Ep 4 · 86:18](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5178)
- "Upper GI studies can identify problems but cannot rule them out; absence of findings does not exclude anastomotic issues" (clinical) [Ep 4 · 88:16](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5296)
- "Delayed contrast films may reveal that barium flows into anastomosis but doesn't flow out well, suggesting functional problem" (clinical) [Ep 4 · 88:43](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5323)
- "Some anastomoses are not strictured but kinked or twisted, creating functional rather than anatomic obstruction" (clinical) [Ep 4 · 88:43](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5323)
- "Endoscopy is valuable for visualizing anastomosis diameter; sometimes can get scope on both sides but cannot see anastomosis itself" — Sam (clinical) [Ep 4 · 90:45](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5445)
- "Motility abnormalities in short bowel syndrome are not well described; manometric assessment is less helpful in this population" — Sam (opinion) [Ep 4 · 94:28](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5668)
- "Post-gastric tube feeding with gastric decompression can demonstrate distal bowel function and avoid unnecessary surgeries" (clinical) [Ep 4 · 95:24](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5724)
- "Dr. Mina Yeina discussed lipid nanoparticle delivery of microRNA 148A and attenuation of intestinal inflammation during NEC" (clinical) [Ep 12 · 0:04](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018?t=4)
- "Dr. Joseph Davidson presented on sexual function and fertility outcomes in Hirschsprung's disease patients" (clinical) [Ep 12 · 0:20](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018?t=20)
- "Dr. Shruthi Srinivas presented outcomes from colonic pull-through for cloacal atrophy" (clinical) [Ep 12 · 0:25](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018?t=25)
- "Dr. Kala presented on single-cell guided prenatal derivation of fetal organoids" (clinical) [Ep 12 · 0:31](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018?t=31)
- "Dr. Zheng presented on clinical characteristics and MMP-7 levels for biliary atresia" (clinical) [Ep 12 · 0:40](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018?t=40)
- "Dr. Shruthi Srinivas won Heat 3 with her presentation on outcomes from colonic pull-through for cloacal atrophy, differentiated by colon length, in a multi-institutional study" (clinical) [Ep 12 · 1:15](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018?t=75)
- "The competition between the second and third presentations was very tight" (opinion) [Ep 12 · 0:50](https://library.globalcastmd.com/watch/heat-3-winner-shruthi-srinivas-md-best-of-the-best-in-pediatric-surgery-2024-8018?t=50)
- "There are no clear predictive factors to identify which premature infants with early NEC will progress to require surgical intervention." — Jose Zinter (clinical) [Ep 1 · 1:54](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=114)
- "Rate of feeding advancement does not correlate with development of necrotizing enterocolitis." — Todd Ponsky (host_summary) [Ep 1 · 3:11](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=191)
- "Probiotics have the most evidence for NEC prevention, supported by Cochrane database review." (host_summary) [Ep 1 · 3:35](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=215)
- "Many U.S. institutions do not routinely use probiotics despite evidence, due to uncertainty about formulation and dosing." — Jose Zinter (clinical) [Ep 1 · 4:19](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=259)
- "Pneumoperitoneum is the only single factor that would prompt operation; otherwise a constellation of findings (pneumatosis, hemodynamic instability, fixed loop, worsening acidosis/ventilation) is required." — Todd Ponsky (clinical) [Ep 1 · 7:17](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=437)
- "Focal abdominal wall erythema is one of the most sensitive indicators for underlying dead bowel in NEC." (clinical) [Ep 1 · 12:24](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=744)
- "In a 600-g infant with pneumoperitoneum, transport to the OR increases risk of demise; bedside intervention (drainage or laparotomy) is preferred." — Tim (clinical) [Ep 1 · 15:08](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=908)
- "Approximately 30% of infants treated with peritoneal drainage alone do not require subsequent laparotomy." (host_summary) [Ep 1 · 16:21](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=981)
- "The Moss New England Journal trial showed no difference in outcomes between peritoneal drainage and laparotomy in extremely low birth weight infants with NEC, but the study population was heterogeneous." — Todd Ponsky (host_summary) [Ep 1 · 17:44](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1064)
- "Most panelists use 1 kg as the weight threshold above which they favor laparotomy over peritoneal drainage." — Todd Ponsky (host_summary) [Ep 1 · 19:06](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1146)
- "Bilateral grade 4 intraventricular hemorrhage does not alter surgical decision-making unless the family requests comfort measures only." (opinion) [Ep 1 · 20:10](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1210)
- "Primary anastomosis at initial NEC operation is rarely performed (8–10% of audience) due to inability to detect anastomotic leak in a sick neonate." — Todd Ponsky (host_summary) [Ep 1 · 21:55](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1315)
- "Dr. Miguel Guelfand presented impressive results with primary anastomosis in NEC at a prior conference." — Todd Ponsky (host_summary) [Ep 1 · 22:01](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1321)
- "The 'Shishka baby' technique involves placing a tube through multiple necrotic segments with a few stitches to hold them together, then bringing both ends out as stomas with proximal diversion." (clinical) [Ep 1 · 23:29](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1409)
- "Stoma takedown is typically performed at 4–6 weeks postoperatively and 2 kg body weight, though recent data (Andrew Badillo) suggest earlier reversal may be safe." — Todd Ponsky (host_summary) [Ep 1 · 26:32](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1592)
- "Bringing stomas out side-by-side in the incision (rather than separated) facilitates easier takedown without disturbing the entire abdominal cavity." (opinion) [Ep 1 · 27:00](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1620)
- "In pan-intestinal necrosis, decompressing distended bowel may reduce ischemia and salvage additional segments." (clinical) [Ep 1 · 31:41](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1901)
- "As of one year ago, no child with true NEC totalis (complete small bowel and colonic necrosis) has successfully survived intestinal transplant." — Jose Zinter (epidemiological) [Ep 1 · 33:54](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=2034)
- "The threshold for viable bowel length has dropped to approximately 20 cm of small bowel, with better outcomes if the colon is intact." — Jose Zinter (clinical) [Ep 1 · 34:23](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=2063)
- "There are no clear predictive factors to identify which premature infants with early NEC will progress to require surgical intervention." (host_summary) [Ep 5 · 1:09](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=69)
- "Probiotics are the only preventative strategy with Cochrane database support for reducing NEC incidence." (host_summary) [Ep 5 · 2:59](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=179)
- "Rate of feeding and timing of feeding initiation do not impact NEC incidence." (host_summary) [Ep 5 · 3:14](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=194)
- "Most U.S. institutions do not routinely use probiotics despite evidence, due to uncertainty about formulation and dosing." (epidemiological) [Ep 5 · 3:31](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=211)
- "Free air (pneumoperitoneum) is the only single factor that would universally prompt surgical intervention in NEC." — Todd (host_summary) [Ep 5 · 12:16](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=736)
- "Focal abdominal wall erythema is one of the most sensitive indicators for underlying dead bowel." (clinical) [Ep 5 · 11:40](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=700)
- "A fixed loop on serial X-rays usually indicates dead bowel at exploration, but does not always dictate immediate operative timing." — Todd (clinical) [Ep 5 · 11:16](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=676)
- "In the Moss trial comparing drainage to laparotomy in ELBW infants, approximately 30% of drained patients never required subsequent laparotomy." — Todd (host_summary) [Ep 5 · 15:37](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=937)
- "Transporting a 600-g infant to the OR increases risk of demise due to ventilatory instability, fluid shifts, and PDA complications." — Tim (clinical) [Ep 5 · 14:20](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=860)
- "Peritoneal drainage was originally conceptualized as a temporizing measure to stabilize the baby before definitive laparotomy, but has evolved into definitive therapy in some centers." (clinical) [Ep 5 · 15:03](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=903)
- "Primary anastomosis in NEC is rarely performed; Miguel Gil presented impressive results at a prior conference, but most surgeons avoid it due to inability to assess for leak in a sick infant." — Todd (host_summary) [Ep 5 · 21:19](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1279)
- "The 'shish-kebab' technique (Pittsburgh paper) involves threading a tube through multiple necrotic segments with simple sutures, bringing both ends out as stomas, and diverting proximally." (clinical) [Ep 5 · 22:44](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1364)
- "Stoma takedown timing: minimum 4 weeks if infant is failing to thrive on TPN; 6–8 weeks and 2 kg are traditional thresholds, but recent data (Andrew Badillo) support earlier reversal." — Todd (host_summary) [Ep 5 · 25:48](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1548)
- "Bringing stomas out side-by-side in the same incision (rather than separated) allows easier re-exploration without disturbing the entire abdominal cavity." (clinical) [Ep 5 · 26:23](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1583)
- "Waiting 6 weeks for stoma takedown allows inflammatory response to subside and adhesions to become more flimsy." (clinical) [Ep 5 · 28:17](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1697)
- "In pan-intestinal necrosis, decompressing distended bowel may reduce ischemia and salvage additional segments." (clinical) [Ep 5 · 31:05](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1865)
- "As of one year ago, no child with NEC totalis has successfully survived small bowel transplant; transplant survivors with NEC typically have short-gut syndrome, not complete necrosis." (epidemiological) [Ep 5 · 33:20](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=2000)
- "The minimum viable bowel length threshold has dropped to approximately 20 cm of small bowel, particularly if the colon is intact." (clinical) [Ep 5 · 33:40](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=2020)
- "The Texas Children's Hospital study tracked non-accidental trauma patients using their trauma database, examining hospital course, injuries, consults, discharge instructions, and one-year follow-up compliance with recommended visits." — Brittany Johnson (clinical) [Ep 6 · 1:44](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=104)
- "Follow-up rates for child physical abuse victims were actually quite high, with patients not following up as recommended but rates not being low, representing an opportunity as families are trying to make appointments." — Brittany Johnson (clinical) [Ep 6 · 2:19](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=139)
- "Complete metadata for medical education content includes title, description, summary, keywords, duration, content type, specialty area, target audience level, and language." — Rod Gerardo (host_summary) [Ep 6 · 2:50](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=170)
- "Pediatric surgery could adopt the model used for children with complex medical conditions where all appointments are scheduled on one day to decrease burden on families." — Brittany Johnson (opinion) [Ep 6 · 3:18](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=198)
- "The 85% follow-up rate in child abuse victims is surprising and encouraging." — Todd Ponsky (opinion) [Ep 6 · 3:58](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=238)
- "The UK NEC study was a secondary analysis of prospectively collected observational data from all 27 pediatric surgery centers in the UK, representing a whole population-based study over one year." — Nigel Hall (clinical) [Ep 6 · 5:15](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=315)
- "Primary outcomes in the NEC study were death or parenteral nutrition requirement at 28 days after surgery, examining the relationship between surgical indication, timing from presentation to surgery, and outcomes." — Nigel Hall (clinical) [Ep 6 · 5:47](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=347)
- "Of approximately 130 babies with surgical NEC, about half had bowel perforation; of the remaining half, one-third were critically ill and proceeded quickly to surgery, while two-thirds eventually had surgery for failed medical treatment." — Nigel Hall (epidemiological) [Ep 6 · 6:57](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=417)
- "Babies with NEC who had surgery for failed medical treatment had the longest time from presentation to operation and the worst outcomes compared to those operated for perforation or clinical deterioration." — Nigel Hall (clinical) [Ep 6 · 7:30](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=450)
- "In NEC, it is easy to make surgical decisions when there is free air, but without definitive protocol for other presentations, surgeons hedge and delay daily about whether to operate." — Todd Ponsky (opinion) [Ep 6 · 8:05](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=485)
- "We currently do not have objective clinical markers, whether clinical features or novel biomarkers, to help make earlier surgical decisions in NEC." — Rod Gerardo (host_summary) [Ep 6 · 8:32](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=512)
- "The Nationwide Children's Hospital bowel management program started recording outcomes in a standardized way in 2015 using standardized definitions and patient-reported outcome and experience measures." — Richard Wood (clinical) [Ep 6 · 10:37](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=637)
- "The bowel management study measured outcomes at one year rather than one week because one-week outcomes represent an artificial environment, and one-year measurement demonstrates sustained changes within the patient's normal environment." — Richard Wood (clinical) [Ep 6 · 11:32](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=692)
- "In the bowel management program, children who achieved continence had significantly improved quality of life, while those who remained incontinent had no quality of life improvement." — Richard Wood (clinical) [Ep 6 · 11:59](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=719)
- "After one year in the bowel management program, 30% of patients still struggled with fecal incontinence despite intensive resources." — Ellen Encisco (host_summary) [Ep 6 · 12:12](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=732)
- "In the bowel management study, 70% of children achieve good outcomes, allowing focus on understanding and improving outcomes for the remaining 30%." — Richard Wood (clinical) [Ep 6 · 12:56](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=776)
- "Many surgeons who see the value of bowel management programs lack the volume or resources to build formal programs, making it reasonable to refer patients to nearby established programs." — Todd Ponsky (opinion) [Ep 6 · 13:19](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=799)
- "The Italian anorectal malformation study was a retrospective review of 350 patients between 1999 and 2019, representing one of the largest series." — Ellen Encisco (host_summary) [Ep 6 · 14:46](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=886)
- "The Italian study demonstrated a close relationship between spinal cord abnormalities and spinal bone anomalies in anorectal malformation patients." — Ellen Encisco (host_summary) [Ep 6 · 15:29](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=929)
- "Despite correlation between spinal bone and cord abnormalities, many patients without sacral or vertebral anomalies still had spinal cord abnormalities, making MRI necessary for screening." — Ellen Encisco (host_summary) [Ep 6 · 15:44](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=944)
- "In typical US practice for anorectal malformations, ultrasound shortly after birth is usually sufficient to look for spinal cord abnormalities, whereas the Italian practice finds MRI necessary." — Ellen Encisco (host_summary) [Ep 6 · 16:01](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=961)
- "There is variability in the use of ultrasound versus MRI for detecting tethered cord in anorectal malformation patients, and radiographs are not a good substitute." — Todd Ponsky (clinical) [Ep 6 · 16:26](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=986)
- "The Italian study provides sufficient evidence to convince clinicians who are not doing routine spinal cord and spine assessment in anorectal malformation patients that they should be more serious with imaging." — Rod Gerardo (host_summary) [Ep 6 · 17:03](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=1023)
- "A retrospective study was conducted in the Netherlands between 1998 and 2018 examining contrast enema use prior to stoma reversal." — Cecilia Gigena (host_summary) [Ep 10 · 0:13](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=13)
- "The study included patients under three years old who underwent stoma reversal." — Cecilia Gigena (host_summary) [Ep 10 · 0:24](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=24)
- "The study gathered 244 patients." — Cecilia Gigena (host_summary) [Ep 10 · 0:38](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=38)
- "10% of patients developed strictures." — Cecilia Gigena (host_summary) [Ep 10 · 0:40](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=40)
- "95% of patients with strictures had necrotizing enterocolitis." — Cecilia Gigena (host_summary) [Ep 10 · 0:43](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=43)
- "Only 68% of all patients had a contrast enema prior to stoma reversal." — Cecilia Gigena (host_summary) [Ep 10 · 0:47](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=47)
- "Contrast enema was able to detect 92% of strictures." — Cecilia Gigena (host_summary) [Ep 10 · 0:51](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=51)
- "Contrast enema prior to stoma reversal is only useful if patients had necrotizing enterocolitis." — Cecilia Gigena (opinion) [Ep 10 · 0:54](https://library.globalcastmd.com/watch/routine-contrast-enema-prior-to-stoma-reversal-seems-only-required-following-treatment-for-necrotizing-enterocolitis-an-evaluation-of-the-diagnostic-accuracy-of-the-contrast-enema-6603?t=54)
- "A multi-center non-inferiority trial compared preterm infants treated with expectant management versus early ibuprofen for PDA" — Cecilia Gigena (host_summary) [Ep 11 · 0:09](https://library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=9)
- "The trial enrolled 273 infants total" — Cecilia Gigena (host_summary) [Ep 11 · 0:22](https://library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=22)
- "136 infants were treated with expectant management and 137 with early ibuprofen" — Cecilia Gigena (host_summary) [Ep 11 · 0:25](https://library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=25)
- "In the expectant management group, 17.6% developed necrotizing enterocolitis" — Cecilia Gigena (host_summary) [Ep 11 · 0:31](https://library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=31)
- "In the expectant management group, 33% developed bronchopulmonary dysplasia" — Cecilia Gigena (host_summary) [Ep 11 · 0:31](https://library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=31)
- "In the expectant management group, the death rate was 14%" — Cecilia Gigena (host_summary) [Ep 11 · 0:31](https://library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=31)
- "In the ibuprofen group, 15.4% developed necrotizing enterocolitis" — Cecilia Gigena (host_summary) [Ep 11 · 0:43](https://library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=43)
- "In the ibuprofen group, 50% developed bronchopulmonary dysplasia" — Cecilia Gigena (host_summary) [Ep 11 · 0:43](https://library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=43)
- "In the ibuprofen group, the death rate was 80%" — Cecilia Gigena (host_summary) [Ep 11 · 0:43](https://library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=43)
- "Expectant management is non-inferior to early ibuprofen in preterm patients with PDA" — Cecilia Gigena (host_summary) [Ep 11 · 1:01](https://library.globalcastmd.com/watch/expectant-management-or-early-ibuprofen-for-patent-ductus-arteriosus-7075?t=61)
- "McMaster University team performed a retrospective review of infants born between 2014 and 2022 with uncomplicated gastroschisis examining feeding outcomes." — Alex Halpern (host_summary) [Ep 13 · 0:13](https://library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037?t=13)
- "Infants with exclusive breast milk intake and those with supplemental or exclusive formula intake had similar outcomes in uncomplicated gastroschisis." — Alex Halpern (host_summary) [Ep 13 · 0:24](https://library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037?t=24)
- "No significant differences were found between exclusive breast milk and formula groups in time to reach full enteral feeds in infants with uncomplicated gastroschisis." — Alex Halpern (host_summary) [Ep 13 · 0:24](https://library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037?t=24)
- "No significant differences were found between exclusive breast milk and formula groups in duration of parenteral nutrition in infants with uncomplicated gastroschisis." — Alex Halpern (host_summary) [Ep 13 · 0:24](https://library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037?t=24)
- "No significant differences were found between exclusive breast milk and formula groups in rates of necrotizing enterocolitis in infants with uncomplicated gastroschisis." — Alex Halpern (host_summary) [Ep 13 · 0:24](https://library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037?t=24)
- "No significant differences were found between exclusive breast milk and formula groups in length of hospital stay in infants with uncomplicated gastroschisis." — Alex Halpern (host_summary) [Ep 13 · 0:24](https://library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037?t=24)
- "Formula intake versus exclusive breast milk intake does not appear to affect outcomes in uncomplicated gastroschisis." — Alex Halpern (host_summary) [Ep 13 · 0:44](https://library.globalcastmd.com/watch/association-of-exclusive-breast-milk-intake-and-outcomes-in-infants-with-uncomplicated-gastroschisis-a-national-cohort-study-9037?t=44)
- "A retrospective review by Men et al examined all patients who underwent conservative management of modified Bell stage 2A or greater NEC at a single institution from 2011 to 2022." — Alex Halpern (host_summary) [Ep 14 · 0:13](https://library.globalcastmd.com/watch/conservative-management-of-necrotizing-enterocolitis-in-newborns-incidence-and-management-of-intestinal-strictures-9738?t=13)
- "126 patients underwent conservative management of NEC in the study period." — Alex Halpern (host_summary) [Ep 14 · 0:27](https://library.globalcastmd.com/watch/conservative-management-of-necrotizing-enterocolitis-in-newborns-incidence-and-management-of-intestinal-strictures-9738?t=27)
- "24 of 126 patients (19%) who underwent conservative management of NEC eventually required surgery for a post-NEC stricture." — Alex Halpern (host_summary) [Ep 14 · 0:27](https://library.globalcastmd.com/watch/conservative-management-of-necrotizing-enterocolitis-in-newborns-incidence-and-management-of-intestinal-strictures-9738?t=27)
- "Primary resection and anastomosis was performed in all cases of post-NEC stricture requiring surgery." — Alex Halpern (host_summary) [Ep 14 · 0:36](https://library.globalcastmd.com/watch/conservative-management-of-necrotizing-enterocolitis-in-newborns-incidence-and-management-of-intestinal-strictures-9738?t=36)
- "Post-NEC strictures are a common occurrence after conservative management of NEC." — Alex Halpern (host_summary) [Ep 14 · 0:40](https://library.globalcastmd.com/watch/conservative-management-of-necrotizing-enterocolitis-in-newborns-incidence-and-management-of-intestinal-strictures-9738?t=40)
- "Necrotizing enterocolitis is a devastating gastrointestinal disease impacting premature infants whose pathophysiology is driven by complex pathways that are not completely understood" — Colleen Nofi (clinical) [Ep 15 · 0:39](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=39)
- "NEC has limited treatment options and an unacceptably high morbidity and mortality risk" — Colleen Nofi (clinical) [Ep 15 · 0:52](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=52)
- "Under biologic conditions, CIRP is found inside the cell where it acts as an RNA chaperone protein" — Colleen Nofi (clinical) [Ep 15 · 1:06](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=66)
- "In states of cellular stress such as sepsis, CIRP escapes outside the cell" — Colleen Nofi (clinical) [Ep 15 · 1:12](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=72)
- "Once released from the cell, extracellular CIRP acts as a DAMP by enhancing the release of cytokines and chemokines and amplifying the inflammatory cascade" — Colleen Nofi (clinical) [Ep 15 · 1:19](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=79)
- "MOP3 (MFGE8 derived oligopeptide 3) is an eCIRP scavenging peptide that removes eCIRP from circulation to reduce inflammation" — Colleen Nofi (clinical) [Ep 15 · 1:33](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=93)
- "CIRP knockout protected pups from NEC severity with preservation of intestinal villi architecture" — Colleen Nofi (clinical) [Ep 15 · 2:30](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=150)
- "CIRP knockout mice subjected to NEC showed reduced intestinal inflammation as measured by mRNA levels of IL-6 and TNF-alpha in the small bowel" — Colleen Nofi (clinical) [Ep 15 · 2:59](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=179)
- "CIRP knockout pups had reduced fluorescent dextran leakage indicating preserved intestinal barrier function compared to wild-type NEC pups" — Colleen Nofi (clinical) [Ep 15 · 3:36](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=216)
- "CIRP knockout pups subjected to NEC had 100% survival whereas wild-type pups had only 65% survival in the same model under the same conditions" — Colleen Nofi (clinical) [Ep 15 · 3:57](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=237)
- "MOP3 treatment reduced circulating eCIRP levels in NEC pups compared to vehicle" — Colleen Nofi (clinical) [Ep 15 · 4:18](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=258)
- "Reduction in eCIRP with MOP3 treatment correlated with reduction in systemic inflammatory markers including IL-6 and TNF-alpha" — Colleen Nofi (clinical) [Ep 15 · 4:27](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=267)
- "MOP3 treatment protected against NEC severity with preservation of intestinal villi" — Colleen Nofi (clinical) [Ep 15 · 4:37](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=277)
- "MOP3 treatment reduced intestinal inflammation in NEC as measured by mRNA levels of IL-6 and TNF-alpha" — Colleen Nofi (clinical) [Ep 15 · 4:55](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=295)
- "MOP3-treated pups had significantly reduced fluorescence intensity indicating protection of the intestinal barrier compared to vehicle-treated NEC pups" — Colleen Nofi (clinical) [Ep 15 · 5:05](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=305)
- "Murine pups subjected to NEC and treated with MOP3 had 80% survival compared to only 50% survival in vehicle-treated pups" — Colleen Nofi (clinical) [Ep 15 · 5:22](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=322)
- "eCIRP exacerbates NEC pathogenesis by increasing inflammation and intestinal injury" — Colleen Nofi (clinical) [Ep 15 · 5:42](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=342)
- "MOP3 protects against NEC pathogenesis by scavenging eCIRP and preventing deleterious downstream impacts" — Colleen Nofi (clinical) [Ep 15 · 5:42](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=342)
- "The murine NEC model uses a 4-day protocol with continuous stressors including LPS, formula gavage, and hypoxia" — Colleen Nofi (clinical) [Ep 15 · 7:34](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=454)
- "MOP3 treatment was administered once per day at the beginning of the model, ongoing with the NEC insult" — Colleen Nofi (clinical) [Ep 15 · 7:49](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=469)
- "MOP3 is effective in other models of ischemia-reperfusion injury in the gut" — Colleen Nofi (clinical) [Ep 15 · 6:53](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=413)
- "The therapeutic benefit of MOP3 is not at the same level as complete CIRP knockdown" — Colleen Nofi (clinical) [Ep 15 · 7:00](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=420)
- "RIC has been shown to decrease rates of necrotizing enterocolitis in a rat model." — Alex Halpern (host_summary) [Ep 16 · 0:00](https://library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=0)
- "Gadal used an established piglet NEC model to test RIC." — Alex Halpern (host_summary) [Ep 16 · 0:16](https://library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=16)
- "Piglets were randomly assigned to receive RIC or serve as controls." — Alex Halpern (host_summary) [Ep 16 · 0:20](https://library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=20)
- "RIC was initiated at 24 hours of life and consisted of 4 cycles of 4 minutes of arterial occlusion followed by reperfusion." — Alex Halpern (host_summary) [Ep 16 · 0:24](https://library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=24)
- "Cycles were repeated every 24 hours in the low frequency group and every 12 hours in the high frequency group." — Alex Halpern (host_summary) [Ep 16 · 0:31](https://library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=31)
- "38 piglets were randomized into the control group, 26 into the low frequency group, and 22 into the high frequency group." — Alex Halpern (host_summary) [Ep 16 · 0:37](https://library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=37)
- "High frequency RIC significantly reduced the incidence of NEC when compared to controls." — Alex Halpern (host_summary) [Ep 16 · 0:45](https://library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=45)
- "Low frequency RIC did not significantly reduce the incidence of NEC." — Alex Halpern (host_summary) [Ep 16 · 0:50](https://library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=50)
- "High frequency RIC protects against NEC in a piglet model." — Alex Halpern (host_summary) [Ep 16 · 0:53](https://library.globalcastmd.com/watch/remote-ischemic-conditioning-decreases-the-incidence-and-severity-of-necrotizing-enterocolitis-validation-in-a-large-animal-model-10417?t=53)
- "The STAT trial was a randomized controlled trial in 12 centers worldwide." — Lizzie Lee (host_summary) [Ep 17 · 0:13](https://library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427?t=13)
- "The STAT trial looked at newborns who underwent laparotomy for necrotizing enterocolitis requiring intestinal resection from 2010 to 2020." — Lizzie Lee (host_summary) [Ep 17 · 0:13](https://library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427?t=13)
- "Infants were randomized to two surgical approaches: either anastomosis or stoma formation." — Lizzie Lee (host_summary) [Ep 17 · 0:26](https://library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427?t=26)
- "Infants undergoing primary anastomosis had a significantly less duration of requiring parenteral nutrition compared to those with stoma formation." — Lizzie Lee (host_summary) [Ep 17 · 0:31](https://library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427?t=31)
- "There was no difference in mortality between primary anastomosis and stoma formation groups." — Lizzie Lee (host_summary) [Ep 17 · 0:31](https://library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427?t=31)
- "There was no difference in unplanned surgeries between primary anastomosis and stoma formation groups." — Lizzie Lee (host_summary) [Ep 17 · 0:31](https://library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427?t=31)
- "Primary anastomosis is superior for enhancing recovery from necrotizing enterocolitis in infants and does not increase adverse outcomes." — Lizzie Lee (host_summary) [Ep 17 · 0:43](https://library.globalcastmd.com/watch/stat-trial-stoma-or-intestinal-anastomosis-for-necrotizing-enterocolitis-a-multicentre-randomized-controlled-trial-10427?t=43)
- "Bowel ultrasound is becoming an important tool for diagnosing necrotizing enterocolitis (NEC)." — Lizzie Lee (host_summary) [Ep 18 · 0:08](https://library.globalcastmd.com/watch/availability-utilization-and-barriers-to-bowel-ultrasound-for-necrotizing-enterocolitis-13575?t=8)
- "A national survey included more than 100 neonatologists, surgeons, and radiologists from 42 children's hospitals." — Lizzie Lee (host_summary) [Ep 18 · 0:19](https://library.globalcastmd.com/watch/availability-utilization-and-barriers-to-bowel-ultrasound-for-necrotizing-enterocolitis-13575?t=19)
- "Bowel ultrasound was available in 83% of level 4 NICUs." — Lizzie Lee (host_summary) [Ep 18 · 0:26](https://library.globalcastmd.com/watch/availability-utilization-and-barriers-to-bowel-ultrasound-for-necrotizing-enterocolitis-13575?t=26)
- "Clinicians reported using bowel ultrasound inconsistently, most often only when X-rays were inconclusive." — Lizzie Lee (host_summary) [Ep 18 · 0:26](https://library.globalcastmd.com/watch/availability-utilization-and-barriers-to-bowel-ultrasound-for-necrotizing-enterocolitis-13575?t=26)
- "The biggest barriers to bowel ultrasound use were lack of standardized protocols, limited provider training, and uncertainty about how bowel ultrasound should guide treatment decisions." — Lizzie Lee (host_summary) [Ep 18 · 0:36](https://library.globalcastmd.com/watch/availability-utilization-and-barriers-to-bowel-ultrasound-for-necrotizing-enterocolitis-13575?t=36)
- "Wider adoption of bowel ultrasound for NEC will depend on better evidence, standardized guidelines, and improved clinician training." — Lizzie Lee (host_summary) [Ep 18 · 0:46](https://library.globalcastmd.com/watch/availability-utilization-and-barriers-to-bowel-ultrasound-for-necrotizing-enterocolitis-13575?t=46)
- "Abdominal X-rays for NEC have high specificity but very low sensitivity, with studies showing sensitivity between 13 and 25%" — Augusto Zani (clinical) [Ep 19 · 1:56](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=116)
- "For every 10 babies with surgical NEC, an X-ray might only catch one or two in the early stages (based on 13% sensitivity)" — Lizzie Lee (host_summary) [Ep 19 · 2:06](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=126)
- "A 2023 study in Pediatric Radiology suggests ultrasound can detect bowel wall thinning, perfusion abnormalities, and silent fluid collections that X-ray misses" — Lizzie Lee (host_summary) [Ep 19 · 2:15](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=135)
- "Ultrasound can assess bowel wall thickening, thinning, perfusion, peristalsis, intra-abdominal contents, peritoneum, and liver" — Augusto Zani (clinical) [Ep 19 · 2:30](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=150)
- "High-risk ultrasound findings for bowel perforation include pneumoperitoneum, focal fluid collections, and complex fluid" — Augusto Zani (clinical) [Ep 19 · 2:59](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=179)
- "Intermediate-risk ultrasound findings include increased bowel wall echogenicity, absent perfusion, portal venous gas, and bowel thinning and thickening" — Augusto Zani (clinical) [Ep 19 · 3:07](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=187)
- "The majority of surgeons would perform laparotomy rather than drain placement for perforated NEC" — Augusto Zani (opinion) [Ep 19 · 3:56](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=236)
- "Babies are sick post-operatively whether you perform anastomosis or not" — Todd Ponsky (clinical) [Ep 19 · 4:18](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=258)
- "In NEC, diseased bowel is a symptom or result of the illness, not the cause of the illness" — Todd Ponsky (clinical) [Ep 19 · 4:28](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=268)
- "The disease still progresses even after resection, which is the problem of operating too early" — Todd Ponsky (clinical) [Ep 19 · 4:34](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=274)
- "In stable babies where approximately 10 cm of necrotic segment is removed for source control, they do not necessarily do poorly afterwards and there is long-term benefit" — Augusto Zani (clinical) [Ep 19 · 4:47](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=287)
- "The benefit of primary anastomosis may not be seen in immediate survival but appears in the long run" — Lizzie Lee (host_summary) [Ep 19 · 5:00](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=300)
- "Data shows primary anastomosis is better than stoma in appropriate cases" — Todd Ponsky (clinical) [Ep 19 · 5:06](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=306)
- "In clip-and-drop technique, surgeon removes necrotic segment, staples the ends, and returns in 24-48 hours to check gut hemodynamics before committing to stoma or anastomosis" — Lizzie Lee (host_summary) [Ep 19 · 5:18](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=318)
- "Hemodynamic markers to guide second-look decisions include lactate correction, thrombocytopenia correction, and weaning off inotropes" — Todd Ponsky (clinical) [Ep 19 · 5:45](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=345)
- "The SAT trial was a randomized controlled trial where final eligibility decision was made by the surgeon during laparotomy based on hemodynamic stability" — Simon Eaton (clinical) [Ep 19 · 6:19](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=379)
- "In the SAT trial, mortality was similar between primary anastomosis and stoma groups" — Lizzie Lee (host_summary) [Ep 19 · 6:55](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=415)
- "Babies who received primary anastomosis got off parenteral nutrition significantly sooner than those with stoma" — Lizzie Lee (host_summary) [Ep 19 · 6:56](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=416)
- "Babies with primary anastomosis were able to return to enteral feeds more quickly and had fewer intestinal complications than those with stoma" — Lizzie Lee (host_summary) [Ep 19 · 7:06](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=426)
- "Mucous fistula refeeding involves recycling upper stoma output into the lower bowel to keep it healthy" — Lizzie Lee (host_summary) [Ep 19 · 7:52](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=472)
- "A systematic review and meta-analysis by Bonnie Jasani from Toronto Sick Kids shows the evidence for mucous fistula refeeding is not strong so far" — Simon Eaton (clinical) [Ep 19 · 8:10](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=490)
- "There is an ongoing randomized controlled trial of mucous fistula refeeding measuring time to full enteral feeds" — Simon Eaton (clinical) [Ep 19 · 8:21](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=501)
- "A recent paper in Journal of Surgical Research shows early stoma closure (before 8 weeks) appears to be safe" — Simon Eaton (clinical) [Ep 19 · 8:41](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=521)
- "The early stoma closure study was very underpowered, and in the less-than-8-weeks group there were 2 infants who had repeat episodes of NEC" — Simon Eaton (clinical) [Ep 19 · 8:54](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=534)
- "There is an ongoing preparation for a randomized trial on stoma closure timing in the UK (SKIN mixed methods study)" — Simon Eaton (clinical) [Ep 19 · 9:06](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=546)
- "Surgeons need to be prepared to have some negative laparotomies when clinical suspicion is high despite equivocal imaging" — Augusto Zani (opinion) [Ep 19 · 9:45](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=585)
- "Despite 6 decades of research, we don't know exactly what causes NEC and are still quite some ways from finding an absolute cure." — Gail Besner (clinical) [Ep 2 · 2:11](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=131)
- "Indomethacin predisposes babies to both isolated ileal perforation and necrotizing enterocolitis." — Gail Besner (clinical) [Ep 2 · 4:14](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=254)
- "PPIs, H2 blockers, and other acid suppression medications predispose to or increase chances of NEC development; you don't want to neutralize gastric acid." — Gail Besner (clinical) [Ep 2 · 4:44](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=284)
- "In premature babies with NEC, intestinal contents can leak into the scrotum through a patent processus vaginalis, causing scrotal swelling and discoloration." — Gail Besner (clinical) [Ep 2 · 5:29](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=329)
- "Neutropenia (low white blood cell count) is more worrisome than elevated WBC in NEC because it suggests overwhelming sepsis that the patient is not compensating for." — Gail Besner (clinical) [Ep 2 · 7:17](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=437)
- "Thrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC, and knowledge of platelet count is important for optimizing patient condition prior to surgery." — Gail Besner (clinical) [Ep 2 · 7:33](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=453)
- "There is no single test that shows whether you have ischemic or necrotic bowel, but taking all tests in combination gives a sense of how sick the patient is." — Gail Besner (clinical) [Ep 2 · 8:33](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=513)
- "For imaging in suspected NEC, you need plain film plus either cross-table lateral or lateral decubitus film because free air can be quite subtle and you don't want to miss it." — Gail Besner (clinical) [Ep 2 · 8:50](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=530)
- "Free air on imaging is an absolute indication for surgical intervention (either drain or laparotomy)." — Gail Besner (clinical) [Ep 2 · 9:38](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=578)
- "Clinical deterioration in the face of maximum medical management is an indication for surgery." — Gail Besner (clinical) [Ep 2 · 9:54](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=594)
- "Fixed loops of intestine on serial X-rays are not an absolute indication for surgery but are a worrisome sign that the patient is not going in the right direction." — Gail Besner (clinical) [Ep 2 · 10:02](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=602)
- "Portal venous air is a concerning and worrisome sign but not an absolute indication for surgery; some patients with portal venous air improve with medical management and don't need operation." — Gail Besner (clinical) [Ep 2 · 10:16](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=616)
- "Medical management of NEC includes: withholding feeds, inserting orogastric tube for gastric decompression, starting broad-spectrum antibiotics, and performing serial abdominal exams, labs, and X-rays." — Gail Besner (clinical) [Ep 2 · 10:58](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=658)
- "Small French feeding tubes are not adequate for gastric decompression in NEC; they should be replaced with an orogastric tube." — Gail Besner (clinical) [Ep 2 · 12:05](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=725)
- "There is tremendous diversity in antibiotic regimens for NEC across the United States, possibly depending on bacterial colonization of the ICU environment." — Gail Besner (epidemiological) [Ep 2 · 12:43](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=763)
- "For serial X-rays in NEC, obtaining them every 8 hours is reasonable; getting them too frequently makes no sense, but waiting 12-24 hours is too long." — Gail Besner (opinion) [Ep 2 · 13:37](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=817)
- "Patients with NEC should be kept NPO with NG decompression and antibiotics for at least 1 week to 10 days (preferably a week and a half) before starting feeds." — Gail Besner (clinical) [Ep 2 · 14:15](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=855)
- "Some babies have repeated episodes of necrotizing enterocolitis." — Gail Besner (clinical) [Ep 2 · 14:29](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=869)
- "Stricture formation is a complication of medical NEC that should be suspected in babies not tolerating feeds post-NEC; strictures typically occur in the colon, usually near the splenic flexure, but can occur anywhere." — Gail Besner (clinical) [Ep 2 · 14:40](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=880)
- "For suspected stricture post-NEC, starting with contrast enema is preferred over upper GI with small bowel follow-through because strictures are more common in the colon and contrast from above takes long to transit, especially if partially obstructed." — Gail Besner (opinion) [Ep 2 · 15:17](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=917)
- "Serial abdominal exams are critical for determining when to operate on NEC patients without absolute indications; worsening distention, peritoneal signs, hemodynamic instability with increasing pressor needs, and renal shutdown build up like building blocks to indicate need for surgery." — Gail Besner (clinical) [Ep 2 · 16:23](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=983)
- "Two surgical options for NEC are exploratory laparotomy and peritoneal drain placement." — Gail Besner (clinical) [Ep 2 · 18:16](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1096)
- "The ongoing NEST trial (necrotizing enterocolitis surgery trial) is concluding and will provide results in the next 1-2 years comparing peritoneal drainage versus laparotomy." — Gail Besner (clinical) [Ep 2 · 18:22](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1102)
- "Mortality difference between peritoneal drainage and laparotomy for NEC is indecipherable; survival chance is about the same with either procedure." — Gail Besner (clinical) [Ep 2 · 18:39](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1119)
- "At a NEC conference in London, 100% of surgeons polled do laparotomy and no one puts in a drain in Europe." — Gail Besner (epidemiological) [Ep 2 · 19:10](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1150)
- "The MOSS trial (United States) and PIERO trial (Europe) showed no difference in overall mortality between peritoneal drainage and laparotomy for NEC, but these studies looked at early endpoints rather than delayed neurological outcomes." — Gail Besner (clinical) [Ep 2 · 19:44](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1184)
- "Babies who have peritoneal drains instead of laparotomy may do worse neurologically if you look at outcomes 1-2 years after recovery from NEC." — Gail Besner (clinical) [Ep 2 · 20:14](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1214)
- "The NEST trial will randomize 300 babies to peritoneal drainage versus laparotomy and assess neurological outcomes at 18-22 months after NEC recovery with detailed neurological assessments." — Gail Besner (clinical) [Ep 2 · 20:34](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1234)
- "Dr. Besner predicts that in the next 1-2 years practice will move towards laparotomy versus peritoneal drainage for the majority of NEC babies, with neurological outcomes likely better in babies who undergo laparotomy with removal of inflammatory necrotic tissue." — Gail Besner (opinion) [Ep 2 · 21:44](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1304)
- "When peritoneal drains are placed and babies subsequently undergo laparotomy, the degree of dead bowel actually present is often quite striking and it's inconceivable the baby could get over that insult." — Gail Besner (clinical) [Ep 2 · 22:09](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1329)
- "There are no criteria that help decide between laparotomy or drain for NEC; with current information you can't be faulted for doing either one." — Gail Besner (opinion) [Ep 2 · 22:58](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1378)
- "You can get just as sick and hemodynamically unstable from systemic inflammatory response syndrome with an isolated intestinal perforation as from necrotizing enterocolitis." — Gail Besner (clinical) [Ep 2 · 24:15](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1455)
- "Peritoneal drain placement is a bedside procedure with tiny amount of local anesthesia, using a small transverse incision in the right lower quadrant for a 1/4 inch Penrose drain." — Gail Besner (clinical) [Ep 2 · 26:15](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1575)
- "If the incision for peritoneal drain is made too big, it's a problem because the patient can get a hernia once the drain is out." — Gail Besner (clinical) [Ep 2 · 26:34](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1594)
- "When placing peritoneal drain, pass it several times gently without forcing to avoid bleeding; it's hard to achieve the drain curving to all four quadrants as shown in published pictures." — Gail Besner (clinical) [Ep 2 · 27:01](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1621)
- "After peritoneal drain placement, if baby continues producing stool from drain for weeks and you convert to laparotomy, you may be forced to operate at the wrong time when inflammatory process is at its worst, resulting in extensive adhesions and serosal tears." — Gail Besner (clinical) [Ep 2 · 28:43](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1723)
- "One of the smartest surgical decisions is knowing when to get out and stop; if you're getting serosal tears and making the situation worse during difficult NEC laparotomy, it's time to stop." — Gail Besner (opinion) [Ep 2 · 29:03](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1743)
- "In difficult NEC laparotomy with extensive adhesions, try to make a proximal diverting stoma to control the area of perforation, but don't keep going if making multiple enterotomies and serosal injuries." — Gail Besner (clinical) [Ep 2 · 29:13](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1753)
- "For successful peritoneal drain management, advance the drain out over several days starting at 7-10 days post-operation rather than withdrawing it all at once." — Gail Besner (clinical) [Ep 2 · 29:48](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1788)
- "Don't advance peritoneal drain out if there's continual leakage of stool at the drain site; this suggests ongoing area of leakage." — Gail Besner (clinical) [Ep 2 · 30:09](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1809)
- "There is difference of opinion about whether to get upper GI small bowel follow-through before removing peritoneal drain; it should be considered if there's ongoing stool leakage." — Gail Besner (opinion) [Ep 2 · 30:22](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1822)
- "If baby does well after drain removal without contrast study but doesn't tolerate feeds, then contrast study is compelled to ensure everything is OK." — Gail Besner (clinical) [Ep 2 · 30:49](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1849)
- "For NEC laparotomy, if baby is hemodynamically unstable or on very high oscillator settings and can't be safely moved to OR, bring the OR to bedside and operate in the ICU." — Gail Besner (clinical) [Ep 2 · 31:19](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1879)
- "For NEC laparotomy, make supraumbilical transverse incision; skin is extraordinarily thin so be careful entering abdomen, especially with underlying dilated bowel loops." — Gail Besner (clinical) [Ep 2 · 31:43](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1903)
- "For NEC laparotomy, have blood products available (packed RBCs, platelets, fresh frozen plasma) and partially correct platelet and coagulation abnormalities preoperatively." — Gail Besner (clinical) [Ep 2 · 32:08](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1928)
- "In premature babies undergoing NEC laparotomy, it's incredibly important not to hurt the liver or spleen; even looking at or touching the liver wrong can cause subcapsular hematoma that a baby can exsanguinate from." — Gail Besner (clinical) [Ep 2 · 32:27](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1947)
- "Liver and spleen injuries can occur with peritoneal drain insertion as well." — Gail Besner (clinical) [Ep 2 · 32:53](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1973)
- "Spontaneous intestinal perforation (SIP) is one small localized area of perforation; NEC is more diffuse disease with pneumatosis involving more than one tiny area. These can be hard to differentiate preoperatively." — Gail Besner (clinical) [Ep 2 · 33:21](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2001)
- "Some surgeons around the world resect limited NEC and do primary anastomosis; this is less common in the United States where surgeons typically make stomas due to concern about anastomotic healing." — Gail Besner (epidemiological) [Ep 2 · 34:04](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2044)
- "For NEC stomas, bring functional end and mucous fistula out through the laparotomy incision close to each other (facilitating later closure), tack to fascia without maturation." — Gail Besner (clinical) [Ep 2 · 35:07](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2107)
- "No matter how carefully NEC stomas are made, sometimes the distal end will slough off, so leave a little distal end sticking out so it doesn't recede under the fascia." — Gail Besner (clinical) [Ep 2 · 35:50](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2150)
- "High-quality enterostomal therapists can manage stomas brought out through the incision; the problem gets more complicated if the wound opens." — Gail Besner (opinion) [Ep 2 · 36:19](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2179)
- "For indeterminate bowel viability during NEC laparotomy (injured but not necrotic, diffusely the same appearance), it's acceptable to not resect, leave abdomen open to avoid pressure compromising blood flow, and return for second-look operation in 24-48 hours." — Gail Besner (clinical) [Ep 2 · 37:12](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2232)
- "For multiple skip lesions in NEC, if very close together and can resect without creating short bowel syndrome, do that rather than multiple anastomoses; otherwise do multiple anastomoses with proximal diverted stoma so anastomoses are distal to diversion." — Gail Besner (clinical) [Ep 2 · 38:07](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2287)
- "Clip-and-drop technique (resect dead bowel, clip ends, put back in, return another day) can be life-saving in very unstable NEC patients without time for multiple anastomoses." — Gail Besner (clinical) [Ep 2 · 38:46](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2326)
- "The 'putting green' approach (bringing out multiple stomas throughout abdomen) can get really confusing and messy; try to avoid if possible." — Gail Besner (opinion) [Ep 2 · 39:15](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2355)
- "For stoma reversal timing, typically wait until baby is stable, well, hopefully being fed, and about 2000g (anastomosis is easier when baby is bigger); go in sooner if TPN-induced cholestasis develops or can't nourish baby due to very high stoma." — Gail Besner (clinical) [Ep 2 · 39:32](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2372)
- "Stoma reversal timing is more about weight gain, clinical appearance, and TPN sequelae than a mandatory 2-month waiting period." — Gail Besner (opinion) [Ep 2 · 40:21](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2421)
- "Refeeding mucous fistula is done selectively (not routinely) for very high-output stomas where any nourishment given comes right out the stoma." — Gail Besner (clinical) [Ep 2 · 40:48](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2448)
- "A recent Journal of Pediatric Surgery article showed substantial decrease in TPN use with mucous fistula refeeding." — Todd Ponsky (host_summary) [Ep 2 · 41:06](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2466)
- "Mucous fistulas often stricture and you lose the opportunity to refeed; if serious about refeeding (e.g., massive resection, very high stoma), consider leaving a small soft catheter in the mucous fistula post-op to maintain access." — Gail Besner (clinical) [Ep 2 · 41:22](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2482)
- "NEC totalis is one of the most tragic findings on exploratory laparotomy for NEC; the chance of a baby with true NEC totalis living to be old enough for small bowel-liver transplant is very close to zero." — Gail Besner (clinical) [Ep 2 · 42:15](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2535)
- "For very small premature baby with NEC totalis, we don't have the technology to get that baby through this devastating problem; no one would be criticized for explaining severity to parents and closing abdomen with comfort care." — Gail Besner (opinion) [Ep 2 · 42:56](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2576)
- "For NEC totalis, the chance of the baby living through months to years of required TPN will irreversibly injure their liver, and even if they live to be big enough, results of small bowel transplant are still suboptimal." — Gail Besner (clinical) [Ep 2 · 43:42](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2622)
- "There is a very small subset of premature patients with horrible lung disease who get pneumothorax that dissects through the diaphragm into the abdomen, presenting as free air; make sure the problem is in the abdomen and not in the chest." — Gail Besner (clinical) [Ep 2 · 44:28](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2668)
- "For hemodynamically unstable baby with free air and abdominal distention, put an angiocatheter through the abdominal wall to release pneumoperitoneum as a temporizing maneuver while mobilizing for surgery." — Gail Besner (clinical) [Ep 2 · 45:06](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2706)
- "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" (clinical) [Ep 3 · 3:00](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=180)
- "Placing balloon catheter directly in jejunal lumen creates obstruction; chimney technique avoids this by creating separate access limb" (clinical) [Ep 3 · 4:21](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=261)
- "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" (clinical) [Ep 3 · 0:57](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=57)
- "Refeeding distal bowel provides significant benefit for fluid/electrolyte absorption and allows bowel to dilate and mature, potentially decreasing technical problems at takedown" (clinical) [Ep 3 · 1:45](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=105)
- "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" (opinion) [Ep 3 · 8:02](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=482)
- "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" (clinical) [Ep 3 · 14:46](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=886)
- "Gastrostomy tube placement has costs including leakage issues if placed against costal margin in small infants; timing and location require careful consideration" (clinical) [Ep 3 · 20:41](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1241)
- "Prolapsed gastrostomy tubes can cause significant formula loss during feeds; removing dysfunctional gastrostomy allows some children to thrive better" (clinical) [Ep 3 · 22:46](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1366)
- "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" (clinical) [Ep 3 · 24:16](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1456)
- "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'" (clinical) [Ep 3 · 25:29](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1529)
- "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" (clinical) [Ep 3 · 29:20](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1760)
- "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" (clinical) [Ep 3 · 29:32](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1772)
- "The one thing that makes bowel adapt is feeding the bowel; procedures causing problems reinitiating feeds cause damage to patient" (clinical) [Ep 3 · 30:06](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1806)
- "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" (clinical) [Ep 3 · 28:07](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1687)
- "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" (epidemiological) [Ep 3 · 31:18](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1878)
- "Kids who had early STEP procedures have often redilated, undergone second STEPs, and had mechanical obstructions very detrimental to feeding ability" (clinical) [Ep 3 · 31:43](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1903)
- "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" (clinical) [Ep 3 · 33:21](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2001)
- "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" (opinion) [Ep 3 · 34:06](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2046)
- "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" (opinion) [Ep 3 · 34:46](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2086)
- "Since maturing multidisciplinary program, transplant candidates declined by 75% and internal transplants almost non-existent" (epidemiological) [Ep 3 · 40:47](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2447)
- "Patients should be referred to intestinal rehabilitation programs as soon as identified as needing comprehensive approach, not when complications exhausted local knowledge" (opinion) [Ep 3 · 44:23](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2663)
- "Programs do far better with children who do not already have complications of their disease than patients who come already suffering from current management" (clinical) [Ep 3 · 44:34](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2674)
- "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" (clinical) [Ep 3 · 59:42](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3582)
- "Breast milk is not just formula but really a therapy with components that are anti-inflammatory and promotile" (clinical) [Ep 3 · 60:19](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3619)
- "Benefit to kids with spontaneous intestinal perforation is not seen with breast milk, suggesting specific anti-inflammatory and promotile components important for other conditions" (clinical) [Ep 3 · 60:20](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3620)
- "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" (clinical) [Ep 3 · 62:25](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3745)
- "Express maternal breast milk is favorite approach; when patient predicted to do badly, go to elemental formulas as second line" (clinical) [Ep 3 · 63:19](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3799)
- "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" (clinical) [Ep 3 · 64:20](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3860)
- "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_summary) [Ep 3 · 17:01](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1021)
- "Continuous drip feeding improves absorptive index, but combining daytime oral intake with nighttime drip feeds may offer best of both approaches" (host_summary) [Ep 3 · 17:40](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1060)
- "Prefer isotonic formulas (15-17 cal/oz) because digestion changes osmolarity in jejunum, and most bad kids don't have ileum so jejunum has no ability to absorb against concentration gradient" (clinical) [Ep 3 · 65:20](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3920)
- "Kids without upper GI dysmotility handle volume much better than concentration, so keep concentration low and advance volume" (clinical) [Ep 3 · 65:55](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3955)
- "Introduction of baby foods, meats, and vegetables remarkably helpful in adaptation process once kids get older" (clinical) [Ep 3 · 66:03](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3963)
- "TPN panel includes renal panel, liver panel, calcium/phosphorus/magnesium; no longer follow prealbumin or RBP as money-saving strategy, follow albumin instead for chronic changes" (clinical) [Ep 3 · 70:04](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4204)
- "Follow essential fatty acids monthly or every other month if on low lipid TPN; iron, ferritin, TIBC every 2-3 months; zinc, copper, ceruloplasmin every 3-6 months; selenium every 6 months" (clinical) [Ep 3 · 70:43](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4243)
- "About 60% of patients weaned off TPN have deficiencies in one micronutrient or another" (epidemiological) [Ep 3 · 71:36](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4296)
- "Follow B12 annually plus methylmalonic acid and homocysteine as more sensitive surrogate markers, since B12 can be synthesized by bacteria or falsely elevated with liver disease" (clinical) [Ep 3 · 72:03](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4323)
- "Breast milk has non-nutrient oligosaccharides (2FL, 3FL) that are not nutrient source to humans but affect microflora and dysbiosis; 80% of secretor mothers make 2FL which is immunomodulatory" (clinical) [Ep 3 · 85:56](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5156)
- "Dysbiosis in intestinal failure patients is profound and furthered by H2 blockers and antibiotics; how this affects adaptive process not well understood" (clinical) [Ep 3 · 86:24](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5184)
- "Older patient recommends prebiotics more and antibiotics less; almost all patients with substantial resection and lost ileocecal valve have element of small bowel contamination with colonic flora" (opinion) [Ep 3 · 83:13](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4993)
- "Want to encourage right flora (anaerobes) and discourage wrong flora (putrefactive bacteria like E. coli, Klebsiella); too many antibiotics kill bacteria you want present to break down starches into butyric acid" (clinical) [Ep 3 · 83:59](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5039)
- "Use antibiotics selectively: for d-lactic acidosis, hyperammonemia, or older child no longer thriving on previously adequate caloric intake; if used, finite period 2-3 weeks, and abandon if no improved growth velocity" (clinical) [Ep 3 · 85:06](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5106)
- "In recent data, probably 2/3 of bloodstream infections seen in patients on prophylactic Flagyl, because knocking out anaerobes facilitates aerobic overgrowth and presumably translocation" (clinical) [Ep 3 · 90:33](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5433)
- "Metronidazole has limited spectrum, knocks off anaerobes, facilitates growth of aerobes - absolutely the wrong choice for bacterial overgrowth" (opinion) [Ep 3 · 91:56](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5516)
- "If desperate for antibiotics, might use selective decontamination with non-absorbable aminoglycoside (Tobramycin) and Colistin" (clinical) [Ep 3 · 92:16](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5536)
- "Rifaximin may have role but not well studied in bacterial overgrowth, appropriate dose unknown, and no stable suspension available" (clinical) [Ep 3 · 92:37](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5557)
- "Use metronidazole to promote motility by decreasing overgrowth, improving mucosal quality, decreasing inflammation, and increasing tolerance and absorption - not to prevent bacterial infection" (clinical) [Ep 3 · 93:26](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5606)
- "When culture most bacteria causing overgrowth, get anaerobes qualitatively, which is reason for metronidazole use" (clinical) [Ep 3 · 94:29](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5669)
- "Lack of knowledge about microbiome in children with intestinal failure; tend to use antibiotics based on clinical findings - gram negatives or cholestasis suggests non-absorbable aminoglycoside; sudden distension with frothy diarrhea or lactic acidosis suggests Flagyl" (clinical) [Ep 3 · 95:24](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5724)
- "Patients seem to advance well once on solid food, likely due to more physiological exposure to complex proteins and oligosaccharides, but can't identify single causative factor yet" (clinical) [Ep 3 · 96:45](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5805)
- "Use antibiotics and not probiotics, only when forced to (d-lactic acidosis, stalling feeds with distension); metronidazole used because anaerobes are gas producers and cause lactic acidosis" (clinical) [Ep 3 · 97:56](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5876)
- "Metronidazole doesn't work for everyone; with lactic acidosis, very specific antibiotics seem to work and must find best one; try not to cycle, use once and see how long before recurrence" (clinical) [Ep 3 · 98:47](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5927)
- "Worry about probiotics getting in central lines through external contamination more than translocation; lactobacillus species extremely hard to clear, may require line removal" (clinical) [Ep 3 · 99:41](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5981)
- "One case established blood infection with same genotype as lactobacillus given as probiotic, which turned program away from probiotics in all kids with central lines" (clinical) [Ep 3 · 100:06](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6006)
- "First consideration with increased output is whether overfeeding and overtaxing gut, providing elements for osmotic diarrhea" (clinical) [Ep 3 · 101:17](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6077)
- "Reanastomosing colon helps with output; when colon involved, anti-motility drugs like loperamide become helpful" (clinical) [Ep 3 · 101:51](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6111)
- "Use soluble fibers to decrease high output; have tried octreotide but not found very useful and worry about chronic use with growth hormone suppression" (clinical) [Ep 3 · 102:20](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6140)
- "For patients with lot of gastric output, might use proton pump inhibitor to decrease gastric secretions, but must balance with potential medication risks" (clinical) [Ep 3 · 103:12](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6192)
- "Documented inflammation found on endoscopy in some kids; using anti-inflammatory agents (5-ASA products) seems to have impact, sometimes steroid-based enemas helpful depending on location" (clinical) [Ep 3 · 103:50](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6230)
- "Anti-inflammatories really helpful in challenging Hirschsprung's patients with dysbiosis and high stool frequency not well managed with other interventions" (clinical) [Ep 3 · 104:29](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6269)
- "Successfully managed some Hirschsprung's patients (8-9 years old, stooling 12 times daily, not responding to antibiotic cycling or prebiotics/formulas) with long-term anti-inflammatories and 5-ASA with remarkable success" (clinical) [Ep 3 · 104:49](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6289)
- "Avoid cholestyramine as much as possible; doses effective in firming stool usually bind nutrients, fat-soluble vitamins, and fats; slight risk for hyperchloremic acidosis and cholestyramine bezos" (clinical) [Ep 3 · 105:42](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6342)
- "Encountered patients on almost homeopathic cholestyramine doses whose parents/physicians believed stools looked better, but not sure stool volume actually declined" (clinical) [Ep 3 · 106:30](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6390)
- "Ursodiol in child with very short gut can contribute to diarrhea due to osmotic component with no real benefit preventing cholestasis" (clinical) [Ep 3 · 107:10](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6430)
- "Pancreatic enzymes not physiologic in humans until 5-7 months of age; worry about enzymes in dysmotile bowel areas especially with stomas - have seen strictures/stoma problems related to enzymes sitting in stenotic areas" (clinical) [Ep 3 · 108:12](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6492)
- "Only pancreatic enzyme present in adult quantities in young infants are proteases; amylases don't appear until 6-12 months, lipase doesn't reach adult levels until end of first year" (clinical) [Ep 3 · 109:23](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6563)
- "Short gut patients have high trypsinogen levels because they don't have enough enterokinase, but formal pancreatic stimulation shows proteases do appear" (clinical) [Ep 3 · 109:52](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6592)
- "Problem with pancreatic enzymes in short gut is they go through before releasing" (clinical) [Ep 3 · 110:47](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6647)
- "No upper number for acceptable stoma output that is hard and fast; have many patients with 40-50 cc/kg stoma output who continue feeding based on electrolyte profile" (clinical) [Ep 3 · 111:14](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6674)
- "Don't want patients acidotic (CO2 dropping to teens despite maximizing acetate) - that's the limit, not volume; electrolytes and acidosis drive decision, not volume" (clinical) [Ep 3 · 111:29](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6689)
- "Knee-jerk reactions to volume of output (unless otherwise sick with acidosis/abnormal electrolytes) should not be made; using nurse-callable number for output leads to variable feeding over longer time, very detrimental to weaning program" (opinion) [Ep 3 · 111:45](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6705)
- "Stoma output or stool output more relevant in guiding fluid and electrolyte replacement than making decisions about stopping or decreasing feeds" (clinical) [Ep 3 · 112:36](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6756)
- "Patients receiving GLP-2 analog therapies have dramatically decreased stomal output with benefit in fluid and electrolytes, though whether this gives sustainable benefit and whether use in kids is indicated not yet determined" (clinical) [Ep 3 · 113:12](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6792)
- "Adult GLP-2 analog studies suggest it is beneficial: can reduce fecal output in 60-70% of patients allowing 20% TPN reduction, and in extension study 20% of patients totally emancipated from TPN" (host_summary) [Ep 3 · 113:45](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6825)
- "Some patients do fine on GLP-2 analog while on it but regress when they come off, so jury still out" (clinical) [Ep 3 · 114:35](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6875)
- "Studies waiting until children have late intestinal failure not likely to give needed insight; multi-institutional trials following patients in areas where they can be monitored will provide better outcomes and insight for next 5-10 years" (opinion) [Ep 3 · 114:53](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6893)
- "Major advancements made in intestinal failure field in last 5-6 years not fully recognized; trajectory suggests remarkably different treatment paradigm in very short time" (opinion) [Ep 3 · 115:31](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6931)
- "When patients on long-term TPN, must monitor not just growth (weight and length) but micronutrient status - impacts neurodevelopmental/cognitive outcome and bone health" (clinical) [Ep 3 · 116:10](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6970)
- "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 7 · 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 7 · 1:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=112)
- "Ultra-short gut patients in the current era do not die of liver failure anymore and are rarely transplanted." (host_summary) [Ep 7 · 2:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=123)
- "Ultra-short gut patients who reached enteral autonomy required multiple nutritional supplements but were able to grow within normal parameters." — Paul Wales (clinical) [Ep 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 11:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=666)
- "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." (host_summary) [Ep 7 · 11:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=685)
- "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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 14:59](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=899)
- "Adaptation is defined as developing and strengthening gut function, occurring naturally in infants during in utero development and the first few years of life, or as a regenerative response to damage in older children." — Michael Helmrath (clinical) [Ep 8 · 0:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=55)
- "Adaptation generally takes months and years, not weeks and days, and requires enteral nutrition in all situations." — Michael Helmrath (clinical) [Ep 8 · 1:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=85)
- "In short gut syndrome, residual intestine undergoes adaptation to compensate and reestablish function to absorb enough nutrients and fluids to maintain survival." — Paul Wales (clinical) [Ep 8 · 2:02](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=122)
- "The adaptive process is driven by the presence of intraluminal nutrients and their interaction with gut secretions (pancreatic, biliary) and trophic gut peptides." — Paul Wales (clinical) [Ep 8 · 2:16](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=136)
- "Structural changes during adaptation include mucosal hypertrophy (increased villous length), increased blood supply through angiogenesis, bowel dilation, and in younger children, gut lengthening—all increasing surface area for nutrient absorption." — Paul Wales (clinical) [Ep 8 · 2:42](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=162)
- "Functional changes during adaptation include slowed motility to allow more contact time and up-regulation of enterocyte transporters to move nutrients across cells more efficiently." — Paul Wales (clinical) [Ep 8 · 3:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=184)
- "The duodenum senses caloric intake, monitors sugars, receives hepatobiliary secretions, takes up iron, and functions as an endocrine engine recognizing meal initiation." — Michael Helmrath (clinical) [Ep 8 · 3:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=214)
- "The jejunum is largely a source of fluid secretion needed for digestion, with random back-and-forth sloshing motion like a washing machine." — Michael Helmrath (clinical) [Ep 8 · 3:54](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=234)
- "The ileum secretes different hormones including the incretins GLP-2, GLP-1, and PYY, which stop gastric emptying and slow motility when excess liquid is detected in the distal bowel and proximal colon." — Michael Helmrath (clinical) [Ep 8 · 4:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=246)
- "The distal ileum's ability to take up bile sends a signal to the liver, the metabolic engine that helps regulate the whole metabolism of the patient." — Michael Helmrath (clinical) [Ep 8 · 4:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=271)
- "In short gut patients, the colon becomes a source of energy uptake when exposed to free fatty acids, which requires the presence of bacteria." — Michael Helmrath (clinical) [Ep 8 · 4:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=290)
- "Colonic adaptation does not occur in most normal patients because energy is already reclaimed before reaching the colon." — Michael Helmrath (clinical) [Ep 8 · 5:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=301)
- "Adaptation is highly influenced by modifiable factors including formula type, H2 blockers, antibiotics, illness episodes, and motility changes." — Michael Helmrath (clinical) [Ep 8 · 5:13](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=313)
- "Until very recently, there was no standardized definition for enteral autonomy, and most intestinal failure outcomes have poor definitions." — Paul Wales (clinical) [Ep 8 · 5:35](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=335)
- "The current ASPEN guidelines define enteral autonomy as independence from parenteral support for 12 weeks with maintenance of adequate growth and hydration during that time period." — Paul Wales (guideline) [Ep 8 · 6:39](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=399)
- "A patient is not truly off TPN unless they can actually grow off TPN; stopping TPN without achieving growth is a mistake." — Paul Wales (clinical) [Ep 8 · 6:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=413)
- "Healthy growth is the underlying driver of successful TPN weaning, not time off TPN." — Michael Helmrath (clinical) [Ep 8 · 7:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=426)
- "The last thing a patient needs to come off TPN is fluid; without adequate hydration, the baby will not grow and will not efficiently absorb nutrition, losing energy and decreasing their growth trajectory." — Michael Helmrath (clinical) [Ep 8 · 7:13](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=433)
- "In the 2012 Squires/PIFCO paper, 50% of patients achieved enteral autonomy over 5-6 years, 25% died, and 25% received transplants." — Paul Wales (epidemiological) [Ep 8 · 7:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=477)
- "Recent papers from the last 5-6 years show that 60-80% of patients now achieve enteral autonomy, representing improved outcomes compared to historical data." — Paul Wales (epidemiological) [Ep 8 · 8:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=505)
- "Higher proportions of patients are now surviving to have the ability to reach enteral autonomy due to better management of TPN complications such as line infections, liver disease, and vascular thrombosis." — Paul Wales (clinical) [Ep 8 · 6:10](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=370)
- "In the past, patients were lost to complications such as liver disease before they could reach their adaptive potential; current management is much better at preventing these complications." — Paul Wales (clinical) [Ep 8 · 6:20](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=380)
- "Small bowel length is an independently significant variable predicting adaptive capacity, which is intuitive since the majority of nutrient digestion and fluid absorption occurs in the small bowel." — Paul Wales (clinical) [Ep 8 · 9:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=595)
- "The ileum has a much greater capacity to adapt than the jejunum; patients with predominant ileal anatomy do better than those with predominant jejunal anatomy." — Paul Wales (clinical) [Ep 8 · 10:18](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=618)
- "A full-term baby is born with approximately 160 centimeters of small bowel, which grows to about 425 centimeters by age 5 years, with the steepest growth rate between 35 weeks gestation and 6 months postnatal." — Paul Wales (clinical) [Ep 8 · 10:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=634)
- "The presence or absence of the ileocecal valve is a predictor of adaptation, though the valve itself may not be the important factor; rather, loss of the valve typically accompanies loss of the terminal ileum, which is the bigger factor affecting adaptive potential." — Paul Wales (opinion) [Ep 8 · 11:13](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=673)
- "When a patient has the majority of their small bowel, it almost does not matter how much colon they have—probability of enteral autonomy is 85-100%." — Paul Wales (clinical) [Ep 8 · 11:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=713)
- "When small bowel remnant is less than 50% of expected length, the colon becomes vitally important, assuming an increasing role in energy absorption from short-chain fatty acids and fluid/salt absorption." — Paul Wales (clinical) [Ep 8 · 12:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=726)
- "Lab data from Cincinnati shows a shift in microbiota to more acid-producing bacteria in an acidotic state, with increased bile due to lack of reclamation." — Michael Helmrath (clinical) [Ep 8 · 12:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=760)
- "Bacterial colonization differences from normal are part of the adaptive response and should not automatically be considered pathological; they need to be studied and taken into context." — Michael Helmrath (opinion) [Ep 8 · 13:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=786)
- "NEC is an acquired condition; infants are born, start eating (often reaching near-full feeds), then have an incident usually at 2-3 weeks of life, meaning they have not been using their gut during the critical 35-week-to-6-months adaptive window." — Michael Helmrath (clinical) [Ep 8 · 13:26](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=806)
- "Whether a child has been fed before makes them different from one who has never been fed, affecting their adaptive potential." — Michael Helmrath (clinical) [Ep 8 · 13:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=825)
- "Surgical planning for short gut patients is like a game of chess requiring consideration of the second, third, and fourth steps ahead." — Michael Helmrath (opinion) [Ep 8 · 13:58](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=838)
- "The sooner a child can be fed safely and bowel access achieved without exposing them to surgical risk, the more the adaptive process can be leveraged." — Michael Helmrath (clinical) [Ep 8 · 14:09](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=849)
- "Cincinnati strategies were developed to take advantage of the easiest, safest way to use the bowel early without needing to return immediately to surgery." — Michael Helmrath (clinical) [Ep 8 · 14:23](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=863)
- "Surgery puts children in harm's way regardless of surgeon talent, so balancing surgical intervention with optimization of adaptation has led to improved outcomes." — Michael Helmrath (opinion) [Ep 8 · 14:48](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=888)
- "Despite six decades of research, the exact cause of necrotizing enterocolitis remains unknown and there is no absolute cure." — Gail Besner (clinical) [Ep 9 · 1:53](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=113)
- "Indomethacin administration predisposes babies to both isolated ileal perforation and necrotizing enterocolitis." — Gail Besner (clinical) [Ep 9 · 3:21](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=201)
- "Acid suppression medications (PPIs, H2 blockers) should be avoided in at-risk neonates because neutralizing gastric acid may increase NEC risk." — Gail Besner (clinical) [Ep 9 · 4:46](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=286)
- "In premature babies with patent processus vaginalis, intestinal contents leaking into the abdomen can cause scrotal swelling and discoloration." — Gail Besner (clinical) [Ep 9 · 5:24](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=324)
- "Neutropenia (low white blood cell count) in a baby with suspected NEC is more concerning than leukocytosis because it may indicate overwhelming sepsis that the baby cannot compensate for." — Gail Besner (clinical) [Ep 9 · 7:14](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=434)
- "Thrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC, and platelet count is important to know before surgery to optimize the patient's condition." — Gail Besner (clinical) [Ep 9 · 7:14](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=434)
- "Cross-table lateral or lateral decubitus films are essential in addition to plain films because free air can be quite subtle and easily missed." — Gail Besner (clinical) [Ep 9 · 8:48](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=528)
- "Free air on imaging is an absolute indication for surgical intervention (either drain or laparotomy) in NEC." — Gail Besner (clinical) [Ep 9 · 9:24](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=564)
- "Fixed loops of intestine on serial x-rays are not an absolute indication for surgery but are a concerning sign that the patient is not improving." — Gail Besner (opinion) [Ep 9 · 9:50](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=590)
- "Portal venous air is a worrisome sign but not an absolute indication for surgery; some patients with portal venous air improve with medical management." — Gail Besner (clinical) [Ep 9 · 10:25](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=625)
- "Medical management of NEC includes withholding feeds, orogastric tube decompression, broad-spectrum antibiotics, and serial monitoring (exams, labs, x-rays)." — Gail Besner (guideline) [Ep 9 · 11:01](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=661)
- "Small French feeding tubes are inadequate for gastric decompression in NEC; they should be replaced with larger orogastric tubes." — Gail Besner (clinical) [Ep 9 · 11:46](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=706)
- "There is likely tremendous diversity in antibiotic regimens for NEC across the United States, possibly depending on bacterial colonization patterns in individual ICU environments." — Gail Besner (opinion) [Ep 9 · 12:35](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=755)
- "Abdominal x-rays should be obtained at regular intervals (approximately every 8 hours) during medical NEC management, not waiting 12-24 hours between films." — Gail Besner (opinion) [Ep 9 · 13:39](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=819)
- "Babies should remain NPO for at least 7-10 days (preferably a week and a half) after medical NEC treatment before attempting to restart feeds." — Gail Besner (opinion) [Ep 9 · 14:16](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=856)
- "Stricture formation after medical NEC typically occurs in the colon, usually near the splenic flexure, but can occur anywhere." — Gail Besner (clinical) [Ep 9 · 14:45](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=885)
- "When evaluating for post-NEC stricture, contrast enema should be performed before upper GI with small bowel follow-through because strictures are more common in the colon and waiting for contrast to pass through obstructed small bowel is time-consuming." — Gail Besner (clinical) [Ep 9 · 15:18](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=918)
- "Serial abdominal examinations over time are more valuable than a single examination for determining need for surgery in NEC without absolute indications." — Gail Besner (opinion) [Ep 9 · 16:22](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=982)
- "The MOSS and PIERO randomized controlled trials showed no difference in overall mortality between peritoneal drainage and laparotomy for NEC." — Gail Besner (epidemiological) [Ep 9 · 19:42](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1182)
- "Babies who receive peritoneal drains instead of laparotomy may have worse neurological outcomes at 1-2 years post-NEC, though early mortality is similar." — Gail Besner (epidemiological) [Ep 9 · 20:20](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1220)
- "The NEST trial randomized 300 babies to peritoneal drainage versus laparotomy and will assess neurological outcomes at 18-22 months, with results expected in 1-2 years (from 2017)." — Gail Besner (epidemiological) [Ep 9 · 21:00](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1260)
- "At a recent NEC conference in London, 100% of European surgeons reported performing laparotomy for NEC; none use peritoneal drainage." — Gail Besner (epidemiological) [Ep 9 · 19:29](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1169)
- "Spontaneous intestinal perforation (SIP) can cause hemodynamic instability similar to NEC through systemic inflammatory response syndrome, making clinical differentiation difficult." — Gail Besner (clinical) [Ep 9 · 24:07](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1447)
- "Peritoneal drain placement can be performed at bedside with local anesthesia through a small right lower quadrant transverse incision using a quarter-inch Penrose drain." — Gail Besner (clinical) [Ep 9 · 26:17](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1577)
- "Making the drain incision too large can lead to hernia formation after drain removal." — Gail Besner (clinical) [Ep 9 · 27:00](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1620)
- "Some babies with peritoneal drains continue to produce stool from the drain for weeks, and if this persists for approximately two weeks, conversion to laparotomy should be considered." — Todd Ponsky (clinical) [Ep 9 · 28:14](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1694)
- "When operating on a baby with extensive adhesions after drain placement, surgeons should know when to stop if causing multiple serosal tears and enterotomies, as continuing may worsen the outcome." — Gail Besner (opinion) [Ep 9 · 28:38](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1718)
- "Creating a proximal diverting stoma is helpful when extensive adhesions prevent safe complete exploration, as it controls the perforation and diverts the fecal stream." — Gail Besner (clinical) [Ep 9 · 29:20](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1760)
- "Peritoneal drains should be advanced out gradually over several days starting at 7-10 days post-placement, rather than removing all at once." — Gail Besner (opinion) [Ep 9 · 29:50](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1790)
- "For laparotomy in NEC, a supraumbilical transverse incision is used, with extreme care required to avoid liver and spleen injury in premature infants." — Gail Besner (clinical) [Ep 9 · 31:18](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1878)
- "Even minimal trauma to the liver in premature babies can cause subcapsular hematomas that can lead to exsanguination." — Gail Besner (clinical) [Ep 9 · 32:00](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1920)
- "NEC is differentiated from SIP intraoperatively: SIP presents as one small localized perforation, while NEC shows more diffuse disease with pneumatosis involving more than one area." — Gail Besner (clinical) [Ep 9 · 33:10](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1990)
- "Some surgeons internationally perform primary anastomosis after NEC resection, but many US surgeons create stomas due to concern about anastomotic healing in critically ill premature infants." — Gail Besner (clinical) [Ep 9 · 34:00](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2040)
- "Bringing stoma and mucous fistula out close together through the main incision allows for more limited reoperation at stoma closure compared to separate sites." — Gail Besner (clinical) [Ep 9 · 35:03](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2103)
- "Stomas should be tacked to fascia (not matured) and a small distal end should protrude to prevent recession under the fascia, though sloughing of the distal end can still occur." — Gail Besner (clinical) [Ep 9 · 35:45](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2145)
- "When bowel appears injured but not clearly necrotic (thin-walled, brownish, with pneumatosis but diffusely similar), it may be appropriate to not resect, leave the abdomen open to reduce pressure, and return for second-look operation in 24-48 hours." — Gail Besner (opinion) [Ep 9 · 37:13](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2233)
- "For multiple skip lesions in NEC, if they are close together and can be resected without creating short bowel syndrome, resecting all may be preferable to multiple anastomoses." — Gail Besner (opinion) [Ep 9 · 38:06](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2286)
- "Multiple anastomoses can be performed with proximal diversion so that if one anastomosis fails to heal, it is distal to the diversion and less problematic." — Gail Besner (clinical) [Ep 9 · 38:30](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2310)
- "Clip-and-drop technique (resecting dead bowel, clipping ends, replacing in abdomen for later definitive surgery) can be lifesaving in very unstable patients when time does not permit multiple anastomoses." — Gail Besner (clinical) [Ep 9 · 38:48](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2328)
- "Stoma reversal is typically performed when the baby reaches approximately 2000 grams, though earlier reversal is indicated for TPN-induced cholestasis or inability to nourish due to high stoma output." — Gail Besner (opinion) [Ep 9 · 39:28](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2368)
- "Refeeding through mucous fistula is done selectively (not routinely), primarily for very high-output stomas where most nutrition is lost through the stoma." — Gail Besner (opinion) [Ep 9 · 40:41](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2441)
- "A recent Journal of Pediatric Surgery article showed substantial decrease in TPN use with mucous fistula refeeding." — Todd Ponsky (host_summary) [Ep 9 · 41:06](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2466)
- "Mucous fistulas often stricture, preventing refeeding access; leaving a small soft catheter in the mucous fistula post-operatively can maintain access for refeeding." — Gail Besner (clinical) [Ep 9 · 41:23](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2483)
- "The chance of a premature baby with NEC totalis surviving long enough to receive small bowel-liver transplant is very close to zero." — Gail Besner (clinical) [Ep 9 · 42:06](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2526)
- "Babies with NEC totalis who survive on TPN for months to years will develop irreversible liver injury, and even if they reach transplant size, small bowel transplant outcomes remain suboptimal." — Gail Besner (clinical) [Ep 9 · 43:39](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2619)
- "Pneumothorax can dissect through the diaphragm into the abdomen in premature babies with severe lung disease, mimicking intra-abdominal free air; this must be ruled out before attributing pneumoperitoneum to bowel perforation." — Gail Besner (clinical) [Ep 9 · 44:22](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2662)
- "In a hemodynamically unstable baby with pneumoperitoneum, inserting an angiocatheter through the abdominal wall to release pressure is a useful temporizing measure while mobilizing the OR." — Gail Besner (clinical) [Ep 9 · 45:00](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2700)
- "The NEST trial results published in fall 2021 showed no overall difference in death or neurodevelopmental impairment between laparotomy and drainage groups." — Rod Gerardo (host_summary) [Ep 9 · 46:18](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2778)
- "In the NEST trial, neonates with a preoperative diagnosis of necrotizing enterocolitis (versus isolated intestinal perforation) had approximately 20% decrease in death rate with laparotomy compared to drainage." — Rod Gerardo (host_summary) [Ep 9 · 47:00](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2820)

## Changelog
- Sep 9: 1 item added automatically
- Sep 7: Published again automatically — condition is back above threshold
- Sep 7: 12 items added automatically
- Sep 7: Unpublished automatically — folded or below threshold
- Sep 7: Audit reverted — short clips unhidden
- Sep 7: 6 items added automatically

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