# Necrotizing Enterocolitis — GCMD Library living collection Updated: n/a · 12 episodes · 213 cited statements ## Episodes ### Resources - [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) - [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) - [Necrotizing Enterocolitis](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636) — video · 35:06 · [machine version](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636.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) - [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) - [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) - [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) - [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) - [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) ## Chapters - [0:00](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=0) Introduction and Prevention Strategies (Ep 3) - [4:20](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=260) Indications for Surgical Intervention (Ep 3) - [10:40](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=640) Drainage versus Laparotomy in Extremely Low Birth Weight Infants (Ep 3) - [19:30](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1170) Ethical Considerations and Pan-Intestinal Necrosis (Ep 3) - [24:40](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1480) Stoma Creation and Timing of Reversal (Ep 3) - [29:47](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-636?t=1787) Full-Thickness Necrosis and Intestinal Transplant (Ep 3) - [0:00](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=0) Introduction and Case Presentation (Ep 4) - [3:23](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=203) Initial Evaluation and Diagnostic Workup (Ep 4) - [8:45](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=525) Imaging and Medical Management (Ep 4) - [11:44](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=704) Indications for Surgery (Ep 4) - [17:45](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1065) Drain versus Laparotomy Debate (Ep 4) - [24:56](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1496) Peritoneal Drain Technique and Management (Ep 4) - [31:00](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=1860) Laparotomy Technique and Stoma Creation (Ep 4) - [36:52](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2212) Challenging Intraoperative Scenarios (Ep 4) - [42:05](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2525) NEC Totalis and Stoma Reversal (Ep 4) - [44:06](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2646) Special Scenarios and Closing (Ep 4) - [0:00](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=0) Predictive factors and case introduction (Ep 5) - [2:24](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=144) Prevention strategies: probiotics and feeding protocols (Ep 5) - [5:10](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=310) Surgical indications and thresholds (Ep 5) - [8:28](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=508) Drainage versus laparotomy in ELBW infants (Ep 5) - [15:00](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=900) Ethical considerations: severe IVH and surgical decision-making (Ep 5) - [19:54](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1194) Resection strategies: stoma configuration and anastomosis (Ep 5) - [24:00](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1440) Timing of stoma takedown (Ep 5) - [29:00](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1740) Pan-intestinal necrosis and totalis management (Ep 5) - [0:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=1) Introduction and recap of episode 1 (Ep 6) - [1:23](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=83) Outcomes in ultra-short gut and the role of ileum and colon (Ep 6) - [4:02](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=242) Timing of intervention, inflammation, and neurocognitive outcomes (Ep 6) - [7:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=431) Operative technique: proximal diversion with Blake drain and gastrostomy (Ep 6) - [10:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=608) Management of distal bowel and refeeding strategy (Ep 6) - [11:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=713) Surgeon's role, team approach, and postoperative expectations (Ep 6) - [14:37](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=877) Blake drain characteristics and episode summary (Ep 6) - [0:00](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=0) Introduction and NEC Awareness Day Context (Ep 7) - [1:13](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=73) Guest Introduction and Research Focus (Ep 7) - [3:21](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=201) Initial Evaluation of Suspected NEC (Ep 7) - [7:08](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=428) Laboratory and Imaging Workup (Ep 7) - [9:16](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=556) Indications for Surgery and Medical Management (Ep 7) - [11:46](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=706) Medical Management Details and Duration (Ep 7) - [15:06](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=906) Stricture Evaluation and Surgical Decision-Making (Ep 7) - [17:14](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1034) Surgical Options: Drain versus Laparotomy (Ep 7) - [19:29](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=1169) Neurological Outcomes and Drain Concerns (Ep 7) ## Statements Every statement is attributed, typed, and timestamped; the link is the citation. - There are no clear predictive factors to identify which premature infants with early NEC will progress to require surgical intervention. — Jose Zinter (clinical) [Ep 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 5 · 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 5 · 11:40](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=700) - A fixed loop on serial X-rays usually indicates dead bowel at exploration, but does not always dictate immediate operative timing. — Todd (clinical) [Ep 5 · 11:16](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=676) - Transporting a 600-g infant to the OR increases risk of demise due to ventilatory instability, fluid shifts, and PDA complications. — Tim (clinical) [Ep 5 · 14:20](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=860) - Peritoneal drainage was originally conceptualized as a temporizing measure to stabilize the baby before definitive laparotomy, but has evolved into definitive therapy in some centers. (clinical) [Ep 5 · 15:03](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=903) - The 'shish-kebab' technique (Pittsburgh paper) involves threading a tube through multiple necrotic segments with simple sutures, bringing both ends out as stomas, and diverting proximally. (clinical) [Ep 5 · 22:44](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1364) - Bringing stomas out side-by-side in the same incision (rather than separated) allows easier re-exploration without disturbing the entire abdominal cavity. (clinical) [Ep 5 · 26:23](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1583) - Waiting 6 weeks for stoma takedown allows inflammatory response to subside and adhesions to become more flimsy. (clinical) [Ep 5 · 28:17](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1697) - In pan-intestinal necrosis, decompressing distended bowel may reduce ischemia and salvage additional segments. (clinical) [Ep 5 · 31:05](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1865) - As of one year ago, no child with NEC totalis has successfully survived small bowel transplant; transplant survivors with NEC typically have short-gut syndrome, not complete necrosis. (epidemiological) [Ep 5 · 33:20](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=2000) - The minimum viable bowel length threshold has dropped to approximately 20 cm of small bowel, particularly if the colon is intact. (clinical) [Ep 5 · 33:40](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=2020) - 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 9 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 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 4 · 45:06](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2706) - 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 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 6 · 14:59](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=899) - Despite six decades of research, the exact cause of necrotizing enterocolitis remains unknown and there is no absolute cure. — Gail Besner (clinical) [Ep 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 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 7 · 45:00](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2700) ## 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 3 · 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 5 · 1:09](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=69) - Probiotics are the only preventative strategy with Cochrane database support for reducing NEC incidence. — The host summarizing the discussion [Ep 5 · 2:59](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=179) - Rate of feeding and timing of feeding initiation do not impact NEC incidence. — The host summarizing the discussion [Ep 5 · 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 5 · 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 5 · 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 5 · 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 5 · 25:48](https://library.globalcastmd.com/watch/nec-update-course-2013-1060?t=1548) - 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 1 · 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 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 8 · 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 8 · 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 8 · 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 8 · 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 8 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 10 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 2 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 11 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 12 · 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 4 · 41:06](https://library.globalcastmd.com/watch/necrotizing-enterocolitis-with-dr-gail-besner-930?t=2466) - 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 6 · 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 6 · 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 7 · 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 7 · 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 7 · 47:00](https://library.globalcastmd.com/watch/stay-current-throwbacks-necrotizing-enterocolitis-with-dr-gail-besner-5402?t=2820) --- Educational content from recorded physician discussions — not medical advice. 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