# Necrotizing Enterocolitis — GCMD Library living collection

Updated: n/a · 23 episodes · 502 cited statements

## Episodes
### Resources
- [Necrotizing Enterocolitis](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636) — video · 35:06 · [machine version](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636.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)
- [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)
- [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)
- [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)
- [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)
- [Multidisciplinary Approach: Intestinal Failure Innovations](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036) — video · 1:37:52 · [machine version](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036.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)
- [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)
- [Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 2](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993) — podcast · 17:21 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993.md)
- [Intestinal Rehabilitation, Episode 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)
- [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)
- [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)
- [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)
- [Practical Approach: Intestinal Failure Innovations](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035) — video · 1:56:52 · [machine version](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035.md)
- [Necrotizing Enterocolitis with Dr. Gail Besner](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297) — podcast · 46:29 · [machine version](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297.md)
- [Should we be checking gastric residuals in premature infants?](https://library.globalcastmd.com/watch/should-we-be-checking-gastric-residuals-in-premature-infants-1998) — video · [machine version](https://library.globalcastmd.com/watch/should-we-be-checking-gastric-residuals-in-premature-infants-1998.md)
- [#APSA 50: Robert E. Gross Debate](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510) — video · 59:33 · [machine version](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510.md)
- [#APSA 50: Robert E. Gross Debate](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512) — podcast · 59:33 · [machine version](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=0) Introduction and Research Background (Ep 20)
- [2:33](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=153) Initial Evaluation and Medical Management (Ep 20)
- [8:45](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=525) Medical Management Protocol (Ep 20)
- [11:44](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=704) Duration of Medical Management and Stricture Surveillance (Ep 20)
- [15:05](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=905) Surgical Indications and Decision-Making (Ep 20)
- [19:10](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1150) Peritoneal Drainage versus Laparotomy (Ep 20)
- [23:48](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1428) Peritoneal Drain Technique (Ep 20)
- [27:46](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1666) Management After Drain Placement (Ep 20)
- [31:00](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1860) Laparotomy Technique and Principles (Ep 20)
- [34:43](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2083) Stoma Creation Technique (Ep 20)
- [36:52](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2212) Management of Indeterminate and Skip Lesions (Ep 20)
- [39:07](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2347) Stoma Reversal and Refeeding (Ep 20)
- [42:05](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2525) NEC Totalis Management (Ep 20)
- [44:06](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2646) Special Considerations and Closing (Ep 20)
- [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/necrotizing-enterocolitis-with-dr-gail-besner-930?t=0) Introduction and Case Presentation (Ep 7)
- [3:23](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=203) Initial Evaluation and Diagnostic Workup (Ep 7)
- [8:45](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=525) Imaging and Medical Management (Ep 7)
- [11:44](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=704) Indications for Surgery (Ep 7)
- [17:45](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1065) Drain versus Laparotomy Debate (Ep 7)
- [24:56](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1496) Peritoneal Drain Technique and Management (Ep 7)
- [31:00](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1860) Laparotomy Technique and Stoma Creation (Ep 7)
- [36:52](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2212) Challenging Intraoperative Scenarios (Ep 7)
- [42:05](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2525) NEC Totalis and Stoma Reversal (Ep 7)
- [44:06](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2646) Special Scenarios and Closing (Ep 7)
- [0:00](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=0) Surgical feeding access techniques and stoma management (Ep 19)
- [9:20](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=560) Gastrostomy tube indications and timing in intestinal failure (Ep 19)
- [22:46](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1366) Dilated bowel management and lengthening procedure indications (Ep 19)
- [34:06](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2046) Intestinal rehabilitation program structure and referral patterns (Ep 19)
- [46:16](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2776) Feeding strategies: breast milk, formula selection, and concentration (Ep 19)
- [59:30](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3570) Laboratory monitoring protocols and micronutrient surveillance (Ep 19)
- [72:00](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4320) Bacterial overgrowth management: antibiotics versus prebiotics (Ep 19)
- [87:00](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5220) Probiotic use and central line infection risk (Ep 19)
- [100:50](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6050) Hypermotility management and anti-inflammatory strategies (Ep 19)
- [111:26](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6686) Emerging therapeutics and future directions (Ep 19)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Dr. Mina Yeina discussed lipid nanoparticle delivery of microRNA 148A and attenuation of intestinal inflammation during NEC (clinical) [Ep 15 · 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 15 · 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 15 · 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 15 · 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 15 · 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 15 · 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 15 · 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)
- 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)
- 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)
- 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)
- 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)
- Most U.S. institutions do not routinely use probiotics despite evidence, due to uncertainty about formulation and dosing. (epidemiological) [Ep 9 · 3:31](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=211)
- Focal abdominal wall erythema is one of the most sensitive indicators for underlying dead bowel. (clinical) [Ep 9 · 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 9 · 11:16](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=676)
- Transporting a 600-g infant to the OR increases risk of demise due to ventilatory instability, fluid shifts, and PDA complications. — Tim (clinical) [Ep 9 · 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 9 · 15:03](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=903)
- 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 9 · 22:44](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1364)
- 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 10 · 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 10 · 2:19](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=139)
- 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 8:05](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=485)
- 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 10 · 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 10 · 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 10 · 11:59](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=719)
- 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 10 · 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 10 · 13:19](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=799)
- 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 10 · 16:26](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=986)
- 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 7:00](https://library.globalcastmd.com/watch/dr-colleen-nofi-best-of-the-best-in-pediatric-surgery-2025-10047?t=420)
- Abdominal X-rays for NEC have high specificity but very low sensitivity, with studies showing sensitivity between 13 and 25% — Augusto Zani (clinical) [Ep 6 · 1:56](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=116)
- Ultrasound can assess bowel wall thickening, thinning, perfusion, peristalsis, intra-abdominal contents, peritoneum, and liver — Augusto Zani (clinical) [Ep 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 4:47](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=287)
- Data shows primary anastomosis is better than stoma in appropriate cases — Todd Ponsky (clinical) [Ep 6 · 5:06](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=306)
- Hemodynamic markers to guide second-look decisions include lactate correction, thrombocytopenia correction, and weaning off inotropes — Todd Ponsky (clinical) [Ep 6 · 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 6 · 6:19](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=379)
- 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 40:48](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2448)
- 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 64:20](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3860)
- 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 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 19 · 113:12](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6792)
- Some patients do fine on GLP-2 analog while on it but regress when they come off, so jury still out (clinical) [Ep 19 · 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 19 · 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 19 · 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 19 · 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 11 · 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 11 · 1:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=112)
- Ultra-short gut patients who reached enteral autonomy required multiple nutritional supplements but were able to grow within normal parameters. — Paul Wales (clinical) [Ep 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 11:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=666)
- The surgeon's intraoperative decisions—what is done and what is not done—have a lifelong impact and are critically important; these decisions can determine whether the child stays on or gets off TPN or whether they survive. — Paul Wales (opinion) [Ep 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 12 · 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 12 · 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 12 · 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 12 · 2:16](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=136)
- Structural changes during adaptation include mucosal hypertrophy (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 12 · 2:42](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=162)
- Functional changes during adaptation include slowed motility to allow more contact time and up-regulation of enterocyte transporters to move nutrients across cells more efficiently. — Paul Wales (clinical) [Ep 12 · 3:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=184)
- The duodenum senses caloric intake, monitors sugars, receives hepatobiliary secretions, takes up iron, and functions as an endocrine engine recognizing meal initiation. — Michael Helmrath (clinical) [Ep 12 · 3:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=214)
- The jejunum is largely a source of fluid secretion needed for digestion, with random back-and-forth sloshing motion like a washing machine. — Michael Helmrath (clinical) [Ep 12 · 3:54](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=234)
- The ileum secretes 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 9:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=595)
- The ileum has a much greater capacity to adapt than the jejunum; patients with predominant ileal anatomy do better than those with predominant jejunal anatomy. — Paul Wales (clinical) [Ep 12 · 10:18](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=618)
- A full-term baby is born with approximately 160 centimeters of small bowel, 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 12 · 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 12 · 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 12 · 11:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=713)
- When small bowel remnant is less than 50% of expected length, the colon becomes vitally important, assuming an increasing role in energy absorption from short-chain fatty acids and fluid/salt absorption. — Paul Wales (clinical) [Ep 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 40:41](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2441)
- 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 45:00](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2700)
- Despite 6 decades of research, the exact cause of necrotizing enterocolitis is unknown and there is no absolute cure for the disease. — Gail Besner (clinical) [Ep 20 · 2:11](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=131)
- Indomethacin administration predisposes babies to both isolated ileal perforation and necrotizing enterocolitis. — Gail Besner (clinical) [Ep 20 · 3:53](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=233)
- PPIs, H2 blockers, and other acid suppression medications predispose to or increase chances of NEC development; gastric acid neutralization should be avoided. — Gail Besner (clinical) [Ep 20 · 4:44](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=284)
- In premature babies with patent processus vaginalis, intestinal contents leaking into the abdomen can cause scrotal swelling and discoloration. — Gail Besner (clinical) [Ep 20 · 5:29](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=329)
- Neutropenia and low white blood cell count are more concerning than elevated white count in NEC, suggesting overwhelming sepsis that the patient is not compensating for. — Gail Besner (clinical) [Ep 20 · 7:17](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=437)
- Thrombocytopenia can result from endotoxemia and gram-negative septicemia in NEC; low platelet count is important to know before surgery to optimize patient condition. — Gail Besner (clinical) [Ep 20 · 7:33](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=453)
- Cross-table lateral or lateral decubitus X-ray films are essential in addition to plain films because free air can be quite subtle and easily missed. — Gail Besner (clinical) [Ep 20 · 8:50](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=530)
- Pneumoperitoneum (free air) is an absolute indication for surgical intervention, either drain placement or laparotomy. — Gail Besner (clinical) [Ep 20 · 9:38](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=578)
- Clinical deterioration in the face of maximum medical management is an indication for surgery. — Gail Besner (clinical) [Ep 20 · 9:54](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?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 improving. — Gail Besner (clinical) [Ep 20 · 10:02](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?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 20 · 10:16](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=616)
- Medical management of NEC includes withholding feeds, inserting orogastric tube for gastric decompression, starting broad-spectrum antibiotic therapy, and performing serial abdominal exams, labs, and X-rays. — Gail Besner (clinical) [Ep 20 · 10:58](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=658)
- Small French feeding tubes are not adequate for gastric decompression in NEC; feeding tube should be removed and replaced with orogastric tube. — Gail Besner (clinical) [Ep 20 · 12:05](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=725)
- There is tremendous diversity in antibiotic regimens for NEC across the United States; broad-spectrum coverage is critical but specific regimen may depend on bacterial colonization of the intensive care unit environment. — Gail Besner (clinical) [Ep 20 · 12:33](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=753)
- At Nationwide Children's Hospital, abdominal X-rays are obtained at intervals (approximately every 8 hours) rather than waiting 12-24 hours between films. — Gail Besner (clinical) [Ep 20 · 13:37](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=817)
- Medical management (NPO, decompression, antibiotics) should continue for at least 1 week to 10 days, preferably a week and a half, before starting feeds. — Gail Besner (clinical) [Ep 20 · 14:15](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=855)
- Some babies have repeated episodes of necrotizing enterocolitis. — Gail Besner (clinical) [Ep 20 · 14:29](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=869)
- Post-NEC stricture formation typically occurs in the colon, usually near the splenic flexure in the left colon, but can occur anywhere. — Gail Besner (clinical) [Ep 20 · 14:40](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=880)
- For suspected post-NEC stricture, contrast enema is preferred as initial study over upper GI with small bowel follow-through because strictures are more common in colon and contrast from below avoids long wait time if patient is partially obstructed. — Gail Besner (clinical) [Ep 20 · 15:17](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=917)
- Serial abdominal exams are important for surgical decision-making; worsening distention, signs of peritoneal irritation, hemodynamic instability with increasing pressor support, and renal shutdown with no urine production build up to indicate need for surgery. — Gail Besner (clinical) [Ep 20 · 16:23](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=983)
- Two randomized controlled trials (MOSS trial in US and PIERO trial in Europe) of peritoneal drainage versus laparotomy showed no difference in overall mortality. — Gail Besner (clinical) [Ep 20 · 19:44](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1184)
- MOSS and PIERO trials looked at early endpoints rather than delayed endpoints of neurological recovery. — Gail Besner (clinical) [Ep 20 · 20:04](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1204)
- Babies who have peritoneal drains instead of laparotomy may do worse from neurological standpoint if neurological outcomes are examined 1-2 years after recovery from NEC. — Gail Besner (clinical) [Ep 20 · 20:14](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1214)
- The ongoing NEST trial (necrotizing enterocolitis surgery trial) in the United States has randomized 300 babies to peritoneal drainage versus laparotomy and will examine neurological outcomes at 18-22 months after recovery from NEC with detailed neurological assessments. — Gail Besner (clinical) [Ep 20 · 20:34](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?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 expected to be better in babies who undergo laparotomy with removal of inflammatory necrotic tissue. — Gail Besner (opinion) [Ep 20 · 21:44](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1304)
- Babies with peritoneal drains can have striking degree of dead bowel remaining in abdomen, as seen when some drain patients subsequently undergo laparotomy. — Gail Besner (clinical) [Ep 20 · 22:09](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1329)
- Systemic inflammatory response syndrome can make patients just as sick and hemodynamically unstable from isolated intestinal perforation as from necrotizing enterocolitis. — Gail Besner (clinical) [Ep 20 · 24:15](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1455)
- Peritoneal drain placement is a bedside procedure performed with small amount of local anesthesia using small transverse incision in right lower quadrant; incision must not be too large to prevent subsequent hernia. — Gail Besner (clinical) [Ep 20 · 26:15](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1575)
- Quarter-inch Penrose drain is used for peritoneal drainage; drain is passed gently multiple times without forcing to avoid bleeding, then sutured in place. — Gail Besner (clinical) [Ep 20 · 26:41](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1601)
- After peritoneal drain placement, significant proportion of patients continue to decline and require subsequent laparotomy. — Gail Besner (clinical) [Ep 20 · 25:46](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1546)
- Operating during peak inflammatory process (e.g., 2 weeks after drain with ongoing stool output) can result in severe adhesions, serosal tears, and enterotomies; sometimes smartest decision is to stop operation, create proximal diverting stoma if possible, and avoid making situation worse. — Gail Besner (clinical) [Ep 20 · 28:43](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1723)
- After successful drain placement with patient recovery, drain should be advanced out over several days starting at 7-10 days post-operation rather than withdrawing all at once. — Gail Besner (clinical) [Ep 20 · 29:48](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1788)
- Continual leakage of stool at drain site is concerning; upper GI small bowel follow-through should be considered before drain removal if ongoing stool leakage present. — Gail Besner (clinical) [Ep 20 · 30:09](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1809)
- If feeds are started after drain removal without contrast study and patient doesn't tolerate feeds, contrast study becomes mandatory to ensure everything is intact. — Gail Besner (clinical) [Ep 20 · 30:49](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1849)
- For laparotomy, if baby is too hemodynamically unstable or on very high oscillator settings to safely transport to OR, operation can be performed at bedside in ICU with surgical team and anesthesiologists. — Gail Besner (clinical) [Ep 20 · 31:24](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1884)
- Laparotomy uses supraumbilical transverse incision; extreme care needed due to thin skin and underlying dilated bowel to avoid immediate enterotomy. — Gail Besner (clinical) [Ep 20 · 31:43](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1903)
- Patient should be resuscitated preoperatively with at least partial correction of platelet and coagulation abnormalities; blood products (packed red blood cells, platelets, fresh frozen plasma) must be available for operation. — Gail Besner (clinical) [Ep 20 · 32:05](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1925)
- It is critically important not to injure liver or spleen in premature babies during laparotomy; even minimal trauma can cause subcapsular hematoma that baby can exsanguinate from. — Gail Besner (clinical) [Ep 20 · 32:27](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1947)
- Spontaneous intestinal perforation (SIP) presents as one small localized area of perforation, while NEC is more diffuse disease with pneumatosis involving more than one tiny area; differentiation can be difficult preoperatively. — Gail Besner (clinical) [Ep 20 · 33:21](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2001)
- Some surgeons worldwide perform primary anastomosis after limited NEC resection; in the United States, surgeons are less likely to do primary anastomosis due to concern about anastomotic healing in these patients. — Gail Besner (clinical) [Ep 20 · 34:04](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2044)
- Dr. Besner typically performs resection with stoma and mucous fistula rather than primary anastomosis, with stoma closure when patient is bigger (at least 2000g) and stable. — Gail Besner (clinical) [Ep 20 · 34:20](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2060)
- Stomas are brought out through laparotomy incision with functional end and mucous fistula positioned close together to facilitate limited reoperation for closure; stomas are tacked to fascia but not matured. — Gail Besner (clinical) [Ep 20 · 35:07](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2107)
- Distal end of stoma must protrude slightly because it can slough off; leaving small distal end prevents recession under fascia. — Gail Besner (clinical) [Ep 20 · 35:50](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2150)
- When bowel appears injured but not clearly necrotic (thin-walled, brownish discoloration, pneumatosis but not dead), acceptable approach is to not resect and perform second-look operation in 24-48 hours. — Gail Besner (clinical) [Ep 20 · 37:12](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2232)
- Abdomen may be left open if there are many dilated loops of bowel to avoid adding pressure that may compromise blood flow. — Gail Besner (clinical) [Ep 20 · 37:35](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2255)
- For multiple skip lesions that are very close together, can resect all without creating short bowel syndrome rather than having multiple anastomoses. — Gail Besner (clinical) [Ep 20 · 38:07](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2287)
- For separated skip lesions, can perform multiple anastomoses with proximal diverted stoma so anastomoses are distal to diversion; if anastomotic healing problem occurs, it won't be major issue because of proximal diversion. — Gail Besner (clinical) [Ep 20 · 38:19](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2299)
- Clip and drop technique (resecting dead bowel, clipping ends, replacing in abdomen, returning for anastomosis when baby more stable) can be life-saving maneuver in very unstable patients without time for multiple anastomoses. — Gail Besner (clinical) [Ep 20 · 38:46](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2326)
- Stoma reversal typically performed when baby is stable, well, hopefully feeding, and approximately 2000g in size; anastomosis is easier when baby is bigger. — Gail Besner (clinical) [Ep 20 · 39:32](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2372)
- Earlier stoma reversal is indicated if baby develops TPN-induced cholestasis or cannot be nourished due to very high stoma output. — Gail Besner (clinical) [Ep 20 · 39:56](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2396)
- Mucous fistula refeeding is done selectively rather than routinely, particularly for very high output stomas where any nourishment given comes directly out the stoma. — Gail Besner (clinical) [Ep 20 · 40:48](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2448)
- Mucous fistula often strictures post-operatively, losing opportunity for refeeding; if serious about refeeding (e.g., after massive resection with very high stoma), consider leaving small soft catheter in mucous fistula post-op to maintain access. — Gail Besner (clinical) [Ep 20 · 41:22](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2482)
- NEC totalis is one of most tragic findings on exploratory laparotomy for NEC; chance of baby living to be old enough for small bowel-liver transplant is very close to zero. — Gail Besner (clinical) [Ep 20 · 42:15](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2535)
- For very small premature baby with NEC totalis, current technology cannot get baby through this devastating problem; no one would be criticized for explaining severity to parents and providing comfort care after closing abdomen. — Gail Besner (opinion) [Ep 20 · 42:56](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2576)
- In Dr. Besner's experience, chance of baby with NEC totalis surviving months-to-years of required TPN is very low; TPN will irreversibly injure liver, and even if baby lives to transplant size, small bowel transplant results remain suboptimal. — Gail Besner (opinion) [Ep 20 · 43:42](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2622)
- Small subset of premature patients with severe lung disease can develop pneumothorax that dissects through diaphragm into abdomen, causing pneumoperitoneum; must confirm problem is in abdomen rather than chest. — Gail Besner (clinical) [Ep 20 · 44:28](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2668)
- For extremely unstable patient (e.g., 800g on jet ventilation and pressors) with pneumoperitoneum and severe distention, angiocatheter can be inserted through abdominal wall to release pneumoperitoneum as temporizing maneuver while mobilizing for definitive operation. — Gail Besner (clinical) [Ep 20 · 45:06](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2706)
- At London NEC conference, 100% of European surgeons polled perform laparotomy for NEC and no one places peritoneal drains. — Gail Besner (epidemiological) [Ep 20 · 19:10](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=1150)
- Between 2015 and 2030, the pediatric surgery workforce will increase by 45% while index case numbers remain flat or decline — Kathy Burnwhite (epidemiological) [Ep 22 · 3:35](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=215)
- In 1987 there were 22 pediatric surgery training programs; now there are upwards of 60 — Kathy Burnwhite (epidemiological) [Ep 22 · 4:20](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=260)
- In a recent 4-year period, pediatric urology increased 53% and pediatric ENT increased 73% — Kathy Burnwhite (epidemiological) [Ep 22 · 5:30](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=330)
- Pediatric surgery training requires 4 years medical school, 5 years general surgery, 2 years research, and 2 years fellowship for total of 9+ years — Kathy Burnwhite (guideline) [Ep 22 · 7:10](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=430)
- Applicants spend an average of $20,000 (more than half their after-tax income) to apply for pediatric surgery fellowship, and 50% fail to match — Kathy Burnwhite (epidemiological) [Ep 22 · 7:40](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=460)
- One in five pediatric surgery fellows fail their boards — Kathy Burnwhite (epidemiological) [Ep 22 · 8:15](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=495)
- Every pediatric surgery operation saves not just one life but lifetimes and generations, unlike adult surgery which saves one person who has already reproduced — Andrea Hayes-Jordan (opinion) [Ep 22 · 10:20](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=620)
- Millennials and Gen Z require immediate gratification, and pediatric surgery cases like ECMO cannulation provide this (blue baby with 30% saturation becomes 100% and pink immediately) — Andrea Hayes-Jordan (opinion) [Ep 22 · 12:10](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=730)
- One-third of pediatric surgery cases come from being on call — Dan Ostlie (epidemiological) [Ep 22 · 14:10](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=850)
- 93% of all pediatric surgeons in the United States depend on hospital support through affiliation agreements, directorships, or call contracts — Dan Ostlie (epidemiological) [Ep 22 · 16:20](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=980)
- Hospital reimbursement is DRG-based (tied to Medicare), but pediatric surgeons operate in a Medicaid world where uninsured/Medicaid patients have increased from 30% to 70% in Miami over 25 years — Dan Ostlie (epidemiological) [Ep 22 · 17:00](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=1020)
- Phoenix Children's Hospital Medicaid percentage increased from 45% to 54% in just 4 years — Dan Ostlie (epidemiological) [Ep 22 · 17:45](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=1065)
- There are 18 pediatric surgeons per 1 million children in the United States nationally, but in rural states like North Dakota, South Dakota, and Montana there is sometimes one pediatric surgeon per 5 million people — Andrea Hayes-Jordan (epidemiological) [Ep 22 · 30:40](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=1840)
- Patients now research surgeons online and ask how many of a specific operation the surgeon has performed, making subspecialization inevitable — Andrea Hayes-Jordan (opinion) [Ep 22 · 31:35](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=1895)
- RRC approves programs algorithmically based on criteria with minimal interest in pediatric surgery workforce health (0-5% interest level) — Dan Ostlie (opinion) [Ep 22 · 26:20](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=1580)
- American Board of Surgery only certifies whether individuals are safe surgeons, without regard to training program characteristics or workforce needs — Dan Ostlie (clinical) [Ep 22 · 26:55](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=1615)
- Resident case volumes have not changed as fellowships have been added, though significant variation exists between high and low volume programs — Doug Barnhart (epidemiological) [Ep 22 · 43:00](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=2580)
- Not every pediatric surgeon should do abdominal neuroblastoma with vascular encasement or long-gap esophageal atresia; subspecialization based on outcomes is appropriate — Doug Barnhart (opinion) [Ep 22 · 44:00](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=2640)
- 80% of general surgery residents now go into subspecialties, with programs begging people to become general surgeons — Andrea Hayes-Jordan (epidemiological) [Ep 22 · 45:00](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=2700)
- Many general surgery residents training in non-fellowship programs will become colorectal or bariatric surgeons and never perform pediatric cases, making that training time arguably wasted — Andrea Hayes-Jordan (opinion) [Ep 22 · 45:30](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=2730)
- The United States culture does not support centralization of care; parents will seek immediate repair rather than wait 18 months as accepted in Canada — Andrea Hayes-Jordan (opinion) [Ep 22 · 46:40](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=2800)
- Bad outcomes in children carry unique emotional toll compared to elderly patients because of truncated lifetime, similar to obstetrics — Kathy Burnwhite (opinion) [Ep 22 · 47:30](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=2850)
- Academic success per capita in pediatric surgery is very high compared to other surgical specialties — Dan Ostlie (opinion) [Ep 22 · 48:20](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=2900)
- Two years of research during training helps trainees identify whether they have passion for academic work and is necessary to answer unanswered questions like NEC prevention and biliary atresia prediction — Kathy Burnwhite (opinion) [Ep 22 · 48:40](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=2920)
- When APSA was founded 50 years ago, similar challenges existed: local general surgeons opposed pediatric surgeons, surgeons took call every night, pediatric surgery boards had failed twice, Medicaid had just passed, and CHIP was 20 years in the future — Doug Barnhart (epidemiological) [Ep 22 · 50:20](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=3020)
- The pediatric surgery board, ACGME, and program directors now meet regularly to work through workforce and training issues — Doug Barnhart (clinical) [Ep 22 · 52:20](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=3140)
- Between 2015 and 2030, the pediatric surgery workforce will increase by 45% — Kathy Burnwhite (epidemiological) [Ep 23 · 3:35](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=215)
- The number of index cases is staying the same and in some entities actually dropping — Kathy Burnwhite (epidemiological) [Ep 23 · 4:40](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=280)
- In a recent 4-year period, the number of pediatric urologists increased 53% — Kathy Burnwhite (epidemiological) [Ep 23 · 5:30](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=330)
- In the same 4 years, pediatric ENT increased 73% — Kathy Burnwhite (epidemiological) [Ep 23 · 6:00](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=360)
- Clear-cut scientific evidence shows that volume increases quality — Kathy Burnwhite (clinical) [Ep 23 · 6:50](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=410)
- Applicants spend an average of $20,000 to apply for pediatric surgery fellowship, more than half their after-tax income for a year — Kathy Burnwhite (epidemiological) [Ep 23 · 7:50](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=470)
- 50% of pediatric surgery fellowship applicants fail to match — Kathy Burnwhite (epidemiological) [Ep 23 · 8:05](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=485)
- 1 in 5 pediatric surgery fellows fail their pediatric surgery boards — Kathy Burnwhite (epidemiological) [Ep 23 · 8:20](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=500)
- Every single pediatric surgery operation saves lives - if the surgeon weren't there, the child would die — Andrea Hayes-Jordan (clinical) [Ep 23 · 10:50](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=650)
- Saving a child saves generations - that child goes on to have children who have children — Andrea Hayes-Jordan (opinion) [Ep 23 · 11:40](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=700)
- VA ECMO provides immediate gratification - you take a baby with 30% sats who is blue, put in cannulas, and achieve 100% sats with the baby pinking up — Andrea Hayes-Jordan (clinical) [Ep 23 · 12:50](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=770)
- One-third of pediatric surgery cases come from being on call — Dan Ostlie (epidemiological) [Ep 23 · 14:10](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=850)
- 93% of all pediatric surgeons in the United States are dependent on some sort of hospital support through affiliation agreements, directorships, or call contracts — Dan Ostlie (epidemiological) [Ep 23 · 15:50](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=950)
- Hospital reimbursement is DRG-based, not professional fees, and DRGs are based on Medicare — Dan Ostlie (clinical) [Ep 23 · 16:20](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=980)
- In Miami, uninsured Medicaid patients in children's hospitals have gone from 30% to 70% over the last 25 years — Dan Ostlie (epidemiological) [Ep 23 · 17:10](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=1030)
- Phoenix Children's Hospital Medicaid population increased from 45% to 54% in the last 4 years, an 18% increase — Dan Ostlie (epidemiological) [Ep 23 · 17:40](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=1060)
- There is no reason fellows can't participate in a national curriculum with one or two lectures a week taught by national experts — Doug Barnhart (opinion) [Ep 23 · 21:00](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=1260)
- This year's class of fellows is the first group required to submit a case log with requirements by area and complexity to sit for pediatric surgery boards — Doug Barnhart (clinical) [Ep 23 · 23:30](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=1410)
- In 20 years, concerns about fellowship numbers growing have been heard at program directors meetings and from the RRC and American Board of Surgery, but nothing has been done — Dan Ostlie (epidemiological) [Ep 23 · 25:00](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=1500)
- The RRC approves programs based on algorithmic criteria with 0-5% interest in the health of pediatric surgery as a specialty — Dan Ostlie (opinion) [Ep 23 · 26:20](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=1580)
- The American Board of Surgery's entire goal is to certify whether individuals are safe surgeons, regardless of where or how they trained — Dan Ostlie (clinical) [Ep 23 · 26:45](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=1605)
- In the United States, there are 18 pediatric surgeons per 1 million children nationally — Andrea Hayes-Jordan (epidemiological) [Ep 23 · 30:00](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=1800)
- In states like North Dakota, South Dakota, and Montana, sometimes there is one pediatric surgeon for 5 million people — Andrea Hayes-Jordan (epidemiological) [Ep 23 · 30:15](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=1815)
- Resident case volumes have not changed as fellowships have been added, according to RRC data — Doug Barnhart (epidemiological) [Ep 23 · 43:40](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=2620)
- There is significant variation between high volume and low volume training programs, and the distribution has not changed as programs have been added — Doug Barnhart (epidemiological) [Ep 23 · 44:00](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=2640)
- 80% of general surgery residents are going into subspecialties, with programs begging people to be general surgeons — Andrea Hayes-Jordan (epidemiological) [Ep 23 · 45:50](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=2750)
- The pediatric surgery board, ACGME, and program directors now meet on a regular basis to work through training and workforce issues — Doug Barnhart (clinical) [Ep 23 · 52:00](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=3120)
- The Cincinnati intestinal failure program was started in 1984. — Sam (clinical) [Ep 8 · 2:48](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=168)
- Almost 30% of patients who left the NICU without receiving rotavirus vaccinations were readmitted with rotavirus infection. (epidemiological) [Ep 8 · 16:56](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1016)
- By monitoring patients and administering rotavirus vaccination in the hospital with isolation protocols, rotavirus readmissions were reduced to almost zero. (clinical) [Ep 8 · 17:13](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1033)
- At Cincinnati, the infection rate was 12 per 1000 catheter days in the 3 years prior to team implementation, and as of last year it was 2 per 1000, approaching less than 1 per 1000 this year. (epidemiological) [Ep 8 · 37:31](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2251)
- IR colleagues state that PICC lines should be much more damaging to vessels because there's far more contact with the vessel, but empirically infants appear to do better with PICC lines when in the hospital. — Sam (opinion) [Ep 8 · 45:09](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2709)
- Subclavian approach for central lines is probably inferior to a jugular approach for risk of stenosis. — Valerie (clinical) [Ep 8 · 46:35](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2795)
- Within the last 3 years at Pittsburgh, no child has been transplanted because of limitations of vascular access. (epidemiological) [Ep 8 · 50:04](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3004)
- Ethanol locks use 70% ethanol, though Pittsburgh now cuts it down to 35% ethanol. — Sam (clinical) [Ep 8 · 60:20](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3620)
- Ethanol locks are used as a dwell when the patient has a TPN window, requiring the patient to be on cycled TPN. — Sam (clinical) [Ep 8 · 60:40](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3640)
- Better results are seen with ethanol locks when using a 6.6 catheter than when using a smaller catheter; smaller PICC lines tend to occlude when using ethanol. — Sam (clinical) [Ep 8 · 61:04](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3664)
- In the UK, there is predominant use of taurolidine locks to prevent line infections, with a planned multi-center study to prove efficacy. — Girish (clinical) [Ep 8 · 63:55](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3835)
- Line care is the crucial thing; if a child is getting recurrent line infections, revisiting line care is critically important before proceeding to any kind of locks. — Girish (opinion) [Ep 8 · 64:23](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3863)
- Soy-based lipids are laced with phytosterols which are cleared very poorly, share the cholesterol heterodimer transporter in the hepatocyte (which is down-regulated by endotoxemia), and reduce expression of the FXR nuclear receptor instrumental in maintaining bile acid homeostasis. — Sam (clinical) [Ep 8 · 68:45](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4125)
- Patients at risk for long-term TPN have a much lower risk of cholestasis if lipid intake is limited to 1 g per kilo per day. — Sam (clinical) [Ep 8 · 69:33](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4173)
- If patients develop cholestasis on 1 g/kg/day lipids, the dose may be reduced to 1 g per kilo per day every other day, recognizing they may become essential fatty acid deficient. — Sam (clinical) [Ep 8 · 69:54](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4194)
- Using lipid restriction, the cholestasis rate has been reduced to less than 5% of patients, and it is extraordinarily rare to see a patient cholestatic for more than a week or two. — Sam (epidemiological) [Ep 8 · 70:10](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4210)
- Omegaven (fish oil-based lipid) may have the theoretical advantage of being anti-inflammatory. — Sam (clinical) [Ep 8 · 70:43](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4243)
- Some patients who don't respond to lipid restriction can achieve benefit from fish oil-based lipid. — Sam (clinical) [Ep 8 · 71:02](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4262)
- With lipid restriction protocols, cholestasis does not come out of the Cincinnati NICU. (epidemiological) [Ep 8 · 72:56](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4376)
- The standard metrics for essential fatty acid deficiency are based on malnourished children not on TPN, so high mead acid to tetraene ratios may not necessarily apply the same way to patients supplemented with abnormal mixes of essential fatty acids. (opinion) [Ep 8 · 74:14](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4454)
- Symptomatic essential fatty acid deficiency is not seen in Seattle's practice. (epidemiological) [Ep 8 · 74:41](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4481)
- The higher the glucose infusion rate, the less efficient glucose is used as a caloric source, and the more it's pushed towards fatty acid and fat deposition. (clinical) [Ep 8 · 75:16](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4516)
- The goal of an intestinal failure patient on chronic TPN is not maintaining the 50th percentile for growth or a normal growth pattern; it's unclear what the growth curve of a kid with intestinal failure should look like. (opinion) [Ep 8 · 76:04](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4564)
- The most important thing is that patients continue to advance along a growth curve. (opinion) [Ep 8 · 76:35](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4595)
- By restricting lipids and being limited with glucose, growth can sometimes be affected, but for the most part kids can be made to grow, though they are a smaller population than standard growth charts portray. (clinical) [Ep 8 · 76:43](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4603)
- In the UK, small lipids (SMOFlipid) are usually accessible, so symptomatic essential fatty acid deficiency is not usually seen. — Girish (clinical) [Ep 8 · 79:44](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4784)
- Measuring essential fatty acid profiles is much more difficult in the UK than in the US because of NHS restrictions. — Girish (clinical) [Ep 8 · 80:06](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4806)
- Kids with 50% of bowel remaining will do well, and even those with as low as 20-10% of estimated bowel length can do significantly well; some might be able to get off TPN. (clinical) [Ep 8 · 28:36](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1716)
- It doesn't matter whether the ileocecal valve is present; what matters is whether they have a colon. (clinical) [Ep 8 · 28:58](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1738)
- Kids with spontaneous intestinal perforation (no functional bowel removed) versus resections less than 10% up to 50% versus greater than 50% of estimated bowel length are still on parenteral nutrition at Cincinnati for 2-3 months. (epidemiological) [Ep 8 · 82:36](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4956)
- Feed absorption is the best measure of bowel function; the amount of feed the child will tolerate and the ability to progress that feed. — Girish (opinion) [Ep 8 · 85:33](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5133)
- The ability to manage fluid balance appropriately to wean the child from TPN or give nights off TPN while advancing enteral feeds can be used as a marker of function. — Girish (opinion) [Ep 8 · 85:49](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5149)
- The ability to wean down TPN while maintaining good growth is the most important functional measure. (opinion) [Ep 8 · 86:18](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5178)
- Kids are now growing with linear growth above the 50th percentile consistently for those with genetic potential; excessively fat kids with poor linear growth are not seen. (epidemiological) [Ep 8 · 86:28](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5188)
- Liver disease and recurrent infection were crucial to poor growth; now much better growth is seen. (clinical) [Ep 8 · 86:51](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5211)
- In the majority of cases, upper GI will pick up mechanical problems, but the absence of findings does not mean there's not an issue, particularly with low-down anastomotic strictures. (clinical) [Ep 8 · 88:16](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5296)
- Sometimes the anastomosis is not necessarily strictured but kinked or not quite grown in alignment and slightly twisted; these functional anastomotic problems resolve with revision. (clinical) [Ep 8 · 88:43](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5323)
- Endoscopy is valuable for actually visualizing an anastomosis to ascertain the diameter. — Sam (opinion) [Ep 8 · 90:45](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5445)
- Motility abnormalities seen in short bowel syndrome are not well described in the literature or in practice; manometric assessment is less and less requested in children with dilated bowel. — Sam (opinion) [Ep 8 · 94:28](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5668)
- The best functional study of the ability to feed a child is sometimes a post-gastric tube dripping in, because the rate-limiting step in some kids is foregut dysmotility. (opinion) [Ep 8 · 95:30](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5730)
- Decompressing the stomach at the time of distal feeding without worrying about gastric residuals has demonstrated the ability to feed the distal bowel; there's probably a feedback mechanism that improves foregut emptying over time. (clinical) [Ep 8 · 95:52](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5752)
- Evaluating gastric residuals has been standard of care in most NICUs probably for decades — Arun Thanain (clinical) [Ep 21 · 0:40](https://library.globalcastmd.com/watch/should-we-be-checking-gastric-residuals-in-premature-infants-1998?t=40)
- There doesn't really seem to be much supporting evidence in the literature for checking gastric residuals — Arun Thanain (opinion) [Ep 21 · 0:49](https://library.globalcastmd.com/watch/should-we-be-checking-gastric-residuals-in-premature-infants-1998?t=49)
- High gastric residuals were presumed to be a risk for aspiration or ventilator associated pneumonia — Arun Thanain (clinical) [Ep 21 · 0:55](https://library.globalcastmd.com/watch/should-we-be-checking-gastric-residuals-in-premature-infants-1998?t=55)
- Gastric residuals were thought to be an early sign of necrotizing enterocolitis — Arun Thanain (clinical) [Ep 21 · 1:09](https://library.globalcastmd.com/watch/should-we-be-checking-gastric-residuals-in-premature-infants-1998?t=69)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- Rate of feeding advancement does not correlate with development of necrotizing enterocolitis. — Todd Ponsky summarizing the discussion [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. — The host summarizing the discussion [Ep 1 · 3:35](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=215)
- Approximately 30% of infants treated with peritoneal drainage alone do not require subsequent laparotomy. — The host summarizing the discussion [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 summarizing the discussion [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 summarizing the discussion [Ep 1 · 19:06](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1146)
- 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 summarizing the discussion [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 summarizing the discussion [Ep 1 · 22:01](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1321)
- 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 summarizing the discussion [Ep 1 · 26:32](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1592)
- There are no clear predictive factors to identify which premature infants with early NEC will progress to require surgical intervention. — The host summarizing the discussion [Ep 9 · 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. — The host summarizing the discussion [Ep 9 · 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. — The host summarizing the discussion [Ep 9 · 3:14](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=194)
- Free air (pneumoperitoneum) is the only single factor that would universally prompt surgical intervention in NEC. — Todd summarizing the discussion [Ep 9 · 12:16](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=736)
- In the Moss trial comparing drainage to laparotomy in ELBW infants, approximately 30% of drained patients never required subsequent laparotomy. — Todd summarizing the discussion [Ep 9 · 15:37](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=937)
- 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 summarizing the discussion [Ep 9 · 21:19](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1279)
- 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 summarizing the discussion [Ep 9 · 25:48](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1548)
- Complete metadata for medical education content includes title, description, summary, keywords, duration, content type, specialty area, target audience level, and language. — Rod Gerardo summarizing the discussion [Ep 10 · 2:50](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=170)
- We currently do not have objective clinical markers, whether clinical features or novel biomarkers, to help make earlier surgical decisions in NEC. — Rod Gerardo summarizing the discussion [Ep 10 · 8:32](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=512)
- After one year in the bowel management program, 30% of patients still struggled with fecal incontinence despite intensive resources. — Ellen Encisco summarizing the discussion [Ep 10 · 12:12](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=732)
- The Italian anorectal malformation study was a retrospective review of 350 patients between 1999 and 2019, representing one of the largest series. — Ellen Encisco summarizing the discussion [Ep 10 · 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 summarizing the discussion [Ep 10 · 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 summarizing the discussion [Ep 10 · 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 summarizing the discussion [Ep 10 · 16:01](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-october-2021-4661?t=961)
- 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 summarizing the discussion [Ep 10 · 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 summarizing a resource [Ep 13 · 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 summarizing a resource [Ep 13 · 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 summarizing a resource [Ep 13 · 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 summarizing a resource [Ep 13 · 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 summarizing a resource [Ep 13 · 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 summarizing a resource [Ep 13 · 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 summarizing a resource [Ep 13 · 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 summarizing a resource [Ep 13 · 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 summarizing a resource [Ep 14 · 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 summarizing a resource [Ep 14 · 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 summarizing a resource [Ep 14 · 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 summarizing a resource [Ep 14 · 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 summarizing a resource [Ep 14 · 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 summarizing a resource [Ep 14 · 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 summarizing a resource [Ep 14 · 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 summarizing a resource [Ep 14 · 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 summarizing a resource [Ep 14 · 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 summarizing a resource [Ep 14 · 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 summarizing a resource [Ep 16 · 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 summarizing a resource [Ep 16 · 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 summarizing a resource [Ep 16 · 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 summarizing a resource [Ep 16 · 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 summarizing a resource [Ep 16 · 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 summarizing a resource [Ep 16 · 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 summarizing a resource [Ep 16 · 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 summarizing a resource [Ep 17 · 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 summarizing a resource [Ep 17 · 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 summarizing a resource [Ep 17 · 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 summarizing a resource [Ep 17 · 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 summarizing a resource [Ep 17 · 0:40](https://library.globalcastmd.com/watch/conservative-management-of-necrotizing-enterocolitis-in-newborns-incidence-and-management-of-intestinal-strictures-9738?t=40)
- RIC has been shown to decrease rates of necrotizing enterocolitis in a rat model. — Alex Halpern summarizing a resource [Ep 4 · 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 summarizing a resource [Ep 4 · 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 summarizing a resource [Ep 4 · 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 summarizing a resource [Ep 4 · 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 summarizing a resource [Ep 4 · 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 summarizing a resource [Ep 4 · 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 summarizing a resource [Ep 4 · 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 summarizing a resource [Ep 4 · 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 summarizing a resource [Ep 4 · 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 summarizing a resource [Ep 18 · 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 summarizing a resource [Ep 18 · 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 summarizing a resource [Ep 18 · 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 summarizing a resource [Ep 18 · 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 summarizing a resource [Ep 18 · 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 summarizing a resource [Ep 18 · 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 summarizing a resource [Ep 18 · 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 summarizing a resource [Ep 5 · 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 summarizing a resource [Ep 5 · 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 summarizing a resource [Ep 5 · 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 summarizing a resource [Ep 5 · 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 summarizing a resource [Ep 5 · 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 summarizing a resource [Ep 5 · 0:46](https://library.globalcastmd.com/watch/availability-utilization-and-barriers-to-bowel-ultrasound-for-necrotizing-enterocolitis-13575?t=46)
- 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 summarizing the discussion [Ep 6 · 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 summarizing the discussion [Ep 6 · 2:15](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=135)
- The benefit of primary anastomosis may not be seen in immediate survival but appears in the long run — Lizzie Lee summarizing the discussion [Ep 6 · 5:00](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=300)
- 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 summarizing the discussion [Ep 6 · 5:18](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=318)
- In the SAT trial, mortality was similar between primary anastomosis and stoma groups — Lizzie Lee summarizing the discussion [Ep 6 · 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 summarizing the discussion [Ep 6 · 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 summarizing the discussion [Ep 6 · 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 summarizing the discussion [Ep 6 · 7:52](https://library.globalcastmd.com/watch/update-course-rewind-2025-updates-in-nec-management-13612?t=472)
- A recent Journal of Pediatric Surgery article showed substantial decrease in TPN use with mucous fistula refeeding. — Todd Ponsky summarizes what Dr. Gail Besner said [Ep 7 · 41:06](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2466)
- 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 — The host summarizing the discussion [Ep 19 · 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 — The host summarizing the discussion [Ep 19 · 17:40](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1060)
- 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 — The host summarizing the discussion [Ep 19 · 113:45](https://library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6825)
- Ultra-short gut patients in the current era do not die of liver failure anymore and are rarely transplanted. — The host summarizing the discussion [Ep 11 · 2:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=123)
- When damaged bowel weeps and secretes fluids, the volume of output is high; as it heals and regenerates the ability to reabsorb fluid, the drain output will decrease, signaling that the bowel is healing. — The host summarizing the discussion [Ep 11 · 11:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=685)
- A recent Journal of Pediatric Surgery article showed substantial decrease in TPN use with mucous fistula refeeding. — Todd Ponsky summarizes what Dr. Gail Besner said [Ep 2 · 41:06](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2466)
- The NEST trial results published in fall 2021 showed no overall difference in death or neurodevelopmental impairment between laparotomy and drainage groups. — Rod Gerardo summarizes what Dr. Gail Besner said [Ep 2 · 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 summarizes what Dr. Gail Besner said [Ep 2 · 47:00](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2820)
- Recent Journal of Pediatric Surgery article showed substantial decrease in TPN use with mucous fistula refeeding. — Todd Ponsky summarizes what Dr. Gail Besner said [Ep 20 · 41:06](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-297?t=2466)
- Scientific evidence shows volume increases quality in surgical outcomes — Kathy Burnwhite summarizing the discussion [Ep 22 · 6:30](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=390)
- A survey of 19,000 physicians found 44-58% experienced burnout depending on specialty, with 15% having suicidal ideation — Andrea Hayes-Jordan summarizing the discussion [Ep 22 · 29:10](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=1750)
- Among 39,000 surgeons surveyed, trauma surgeons had the highest burnout rate and pediatric surgeons had the lowest — Andrea Hayes-Jordan summarizing the discussion [Ep 22 · 29:45](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=1785)
- Audience polling showed 80% opposed the resolution before debate and 60% opposed after, indicating pro arguments convinced 20% of attendees — Alexander Gibbons summarizing the discussion [Ep 22 · 59:00](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1510?t=3540)
- Pediatric surgery training is 9 years for most people: 4 years medical school, 5 years general surgery, 2 years fellowship, with 2 years of research required to match — Doug Barnhart summarizing the discussion [Ep 23 · 20:00](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=1200)
- Between 44% and 58% of physicians, depending on specialty, have experienced burnout according to a 2019 American Physicians survey of 19,000 physicians — Andrea Hayes-Jordan summarizing the discussion [Ep 23 · 28:20](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=1700)
- About 15% of surveyed physicians had either thought about or knew somebody else that wanted to commit suicide — Andrea Hayes-Jordan summarizing the discussion [Ep 23 · 28:40](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=1720)
- Among 39,000 surgeons surveyed in the Journal of the American College of Surgeons, trauma surgeons have the highest burnout rate and pediatric surgeons have the lowest — Andrea Hayes-Jordan summarizing the discussion [Ep 23 · 29:10](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=1750)
- The audience poll shifted from 80% opposed to the resolution before the debate to 60% opposed afterward — Alexander Gibbons summarizing the discussion [Ep 23 · 59:00](https://library.globalcastmd.com/watch/apsa-50-robert-e-gross-debate-1512?t=3540)
- Dan Teitelbaum at University of Michigan showed that when each surgeon or gastroenterologist managed 2-3 patients individually, 1-year mortality was 30-40%, but after developing a team approach, mortality dropped to about 5% per year. — Sam summarizing the discussion [Ep 8 · 2:16](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=136)
- The PIFCON study reported line infection rates of well over 8 infections per 1000 catheter days. — The host summarizing the discussion [Ep 8 · 37:22](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2242)
- The complication-free survival of a PICC line is only about half that of a Broviac, based on IR literature including adults and children. — Sam summarizing the discussion [Ep 8 · 44:58](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2698)
- Some centers have shown very good results utilizing ethanol locks 3 times weekly (Monday, Wednesday, Friday). — Sam summarizing the discussion [Ep 8 · 61:47](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3707)
- From Clayton's work in the UK 25 years ago, the strongest association with irreversible liver disease is with administration of high doses of soy-based lipid preparations. — Sam summarizing the discussion [Ep 8 · 68:13](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4093)
- Neonatologists often use high lipids (2-3 g/kg/day) because they find it easier to manage glucose control instead of giving adequate energy as glucose, avoiding frequent insulin use. — The host summarizing the discussion [Ep 8 · 72:26](https://library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4346)
- The Parker et al. study was a prospective randomized control trial in a level 4 NICU with about 140 patients — Arun Thanain summarizing the discussion [Ep 21 · 1:28](https://library.globalcastmd.com/watch/should-we-be-checking-gastric-residuals-in-premature-infants-1998?t=88)
- Half the group continued to check gastric residuals right before each feeding and the other group stopped checking them — Arun Thanain summarizing the discussion [Ep 21 · 1:39](https://library.globalcastmd.com/watch/should-we-be-checking-gastric-residuals-in-premature-infants-1998?t=99)
- Babies were followed for 6 weeks to determine how quickly they increased feeding on a daily and weekly basis — Arun Thanain summarizing the discussion [Ep 21 · 1:48](https://library.globalcastmd.com/watch/should-we-be-checking-gastric-residuals-in-premature-infants-1998?t=108)
- The group in which they didn't check gastric residuals advanced feeds much quicker — Arun Thanain summarizing the discussion [Ep 21 · 2:00](https://library.globalcastmd.com/watch/should-we-be-checking-gastric-residuals-in-premature-infants-1998?t=120)
- The no-check group got to full feeds quicker, usually by 5 weeks — Arun Thanain summarizing the discussion [Ep 21 · 2:00](https://library.globalcastmd.com/watch/should-we-be-checking-gastric-residuals-in-premature-infants-1998?t=120)
- The no-check group got discharged from the NICU about 8 days earlier on average — Arun Thanain summarizing the discussion [Ep 21 · 2:08](https://library.globalcastmd.com/watch/should-we-be-checking-gastric-residuals-in-premature-infants-1998?t=128)
- There was no difference in odds of developing necrotizing enterocolitis or ventilator associated pneumonia between the two groups — Arun Thanain summarizing the discussion [Ep 21 · 2:08](https://library.globalcastmd.com/watch/should-we-be-checking-gastric-residuals-in-premature-infants-1998?t=128)
- The study excluded babies that had any GI conditions or cardiac disease or were post-op — Arun Thanain summarizing the discussion [Ep 21 · 2:39](https://library.globalcastmd.com/watch/should-we-be-checking-gastric-residuals-in-premature-infants-1998?t=159)
- Study subjects were very low birth weight infants who might be on the ventilator or have respiratory issues but were otherwise fine — Arun Thanain summarizing the discussion [Ep 21 · 2:48](https://library.globalcastmd.com/watch/should-we-be-checking-gastric-residuals-in-premature-infants-1998?t=168)

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