# Short Gut Syndrome — GCMD Library living collection

Updated: n/a · 3 episodes · 118 cited statements

## Episodes
### Resources
- [Intestinal Failure with Dr. Brad Warner](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296) — podcast · 52:46 · [machine version](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296.md)
- [Intestinal Failure with Dr. Brad Warner](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927) — podcast · 52:46 · [machine version](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927.md)
- [Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 1](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141) — podcast · 16:18 · [machine version](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=0) Introduction and Episode Overview (Ep 1)
- [1:39](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=99) Definition and Prognostic Factors in Intestinal Failure (Ep 1)
- [5:29](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=329) Natural History and Outcomes in Short Gut Syndrome (Ep 1)
- [10:22](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=622) Medical Management and TPN Strategy (Ep 1)
- [17:51](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1071) Enteral Feeding Strategy and Intestinal Adaptation (Ep 1)
- [21:48](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1308) Indications for Surgical Intervention (Ep 1)
- [26:01](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1561) Surgical Techniques: Bianchi and STEP Procedures (Ep 1)
- [36:00](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2160) Bowel Tapering and Technical Considerations (Ep 1)
- [41:31](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2491) Management of TPN-Related Cholestasis and Bacterial Overgrowth (Ep 1)
- [43:35](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2615) Growth Factors and Future Therapies (Ep 1)
- [46:31](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2791) Intestinal Transplantation: Indications and Outcomes (Ep 1)
- [51:21](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=3081) Multidisciplinary Care and Closing Remarks (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=0) Introduction and Definition of Intestinal Failure (Ep 2)
- [1:39](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=99) Prognostic Factors and Bowel Length Thresholds (Ep 2)
- [6:38](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=398) Causes of Mortality and Timing of Transplant Evaluation (Ep 2)
- [9:42](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=582) Medical Management and TPN Strategies (Ep 2)
- [16:15](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=975) Enteral Feeding Advancement Protocol (Ep 2)
- [20:09](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1209) Indications for Surgical Intervention (Ep 2)
- [26:01](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1561) Surgical Lengthening Procedures: Bianchi vs STEP (Ep 2)
- [35:59](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2159) Management of TPN-Related Cholestasis (Ep 2)
- [41:32](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2492) Bacterial Overgrowth and Growth Factor Therapy (Ep 2)
- [46:30](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2790) Intestinal Transplantation and Multidisciplinary Care (Ep 2)
- [52:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=3123) Closing Remarks (Ep 2)
- [0:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=4) Introduction and Defining Adaptation (Ep 3)
- [1:37](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=97) Mechanisms of Intestinal Adaptation (Ep 3)
- [3:27](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=207) Anatomy and Regional Gut Function (Ep 3)
- [5:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=331) Defining Enteral Autonomy (Ep 3)
- [7:36](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=456) Evolution of Enteral Autonomy Outcomes (Ep 3)
- [9:41](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=581) Anatomical Predictors of Adaptation (Ep 3)
- [12:32](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=752) Microbiota in Adaptation (Ep 3)
- [13:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=804) Timing and Surgical Strategy (Ep 3)
- [15:02](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=902) Closing and Webinar Announcement (Ep 3)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Intestinal failure is an umbrella term for when the small intestine is unable to absorb or digest enough nutrition to support the patient entirely by oral or enteral feeding. — Brad Warner (clinical) [Ep 2 · 1:42](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=102)
- The intestine of a newborn or fetus doubles in length in the last trimester of gestation. — Brad Warner (clinical) [Ep 2 · 3:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=183)
- For a neonate with an ileocecal valve and entire colon, 10 to 15 centimeters of small intestine is a ballpark figure for potential salvageability. — Brad Warner (clinical) [Ep 2 · 4:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=243)
- Without the colon and ileocecal valve, at least 15 to 20 centimeters of small intestine would be needed for potential salvageability in neonates. — Brad Warner (clinical) [Ep 2 · 4:37](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=277)
- In adult studies, adults with less than 50 centimeters of intestine have about 40% mortality after 5 to 10 years. — Brad Warner (epidemiological) [Ep 2 · 4:51](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=291)
- According to Pediatric Intestinal Failure Research Consortium data, approximately 25% of children with short gut syndrome die, 25% need a transplant, and 50% can wean off TPN. — Brad Warner (epidemiological) [Ep 2 · 6:38](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=398)
- The most common causes of death in intestinal failure include liver failure, septic episodes from central line or bacterial overgrowth, variceal bleeding from liver disease, and loss of IV access. — Brad Warner (clinical) [Ep 2 · 7:11](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=431)
- Intestinal adaptation in humans probably takes place over about a year or two after small bowel resection. — Brad Warner (clinical) [Ep 2 · 7:49](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=469)
- Stool outputs of up to 40 cc per kilo per day are acceptable when advancing enteral feeding; beyond that threshold, enteral feeding should be reduced. — Brad Warner (clinical) [Ep 2 · 8:30](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=510)
- The most common causes of short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias, with trauma and inflammatory bowel disease further down the list. — Brad Warner (epidemiological) [Ep 2 · 9:22](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=562)
- For TPN, the goal is about 100 to 120 calories per kilo per day for total calories, with about 50% from glucose and the remainder from fat and protein. — Brad Warner (clinical) [Ep 2 · 10:22](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=622)
- TPN should provide about 2 to 3 grams of protein per kilo per day and about 2 to 3 grams of fat per kilo per day. — Brad Warner (clinical) [Ep 2 · 10:45](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=645)
- Babies should gain about 20 to 30 grams a day, which approximates in utero weight gain for a newborn. — Brad Warner (clinical) [Ep 2 · 12:05](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=725)
- Lipid reduction strategy involves reducing fat from 2-3 g/kg/day given daily down to about 1 g/kg/day delivered twice or three times a week, which has been effective in reducing TPN-associated cholestasis. — Brad Warner (clinical) [Ep 2 · 12:53](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=773)
- Omegaven is a fish oil-based fat containing primarily omega-3 fatty acids that are anti-inflammatory, in contrast to soybean-based intralipid which contains pro-inflammatory omega-6 fatty acids. — Brad Warner (clinical) [Ep 2 · 13:46](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=826)
- SMOF lipid contains soybean-based lipid (essential fatty acids), medium chain triglycerides (more easily digested), olive oil, and fish oil, and has recently been FDA approved in the United States. — Brad Warner (clinical) [Ep 2 · 15:08](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=908)
- Breast milk is the best choice for neonates because it contains proper fat composition plus growth factors such as epidermal growth factor and insulin-like growth factors that promote adaptation. — Brad Warner (opinion) [Ep 2 · 18:11](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1091)
- Complex formulas fed enterally may stimulate adaptation better than elemental formulas because they cause secretion of enterotrophic hormones to a greater extent. — Brad Warner (opinion) [Ep 2 · 19:26](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1166)
- There is a threshold percentage of enteral calories that prevents the onset of TPN-related liver damage, though the exact number is unknown; 90% enteral feeding carries far less risk than 10% enteral feeding. — Brad Warner (clinical) [Ep 2 · 20:56](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1256)
- Surgical intervention should be considered when patients regress in enteral tolerance (e.g., tolerating 50% enteral a month ago but now down to 20%), when there are multiple episodes of sepsis with abdominal distention and dilated bowel loops, or when the child develops jaundice. — Brad Warner (clinical) [Ep 2 · 22:33](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1353)
- Dilated bowel loops greater than 4 to 5 centimeters in diameter, combined with failure to advance enteral feeds or regression, is an indication for surgical intervention. — Brad Warner (clinical) [Ep 2 · 25:43](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1543)
- Less than 5 to 10% of patients with over 100 centimeters of intestine should require TPN, suggesting an underlying motility or mucosal problem if they remain TPN-dependent. — Brad Warner (clinical) [Ep 2 · 27:53](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1673)
- The STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation because it is easier to perform with less risk of injuring the mesenteric blood supply. — Brad Warner (clinical) [Ep 2 · 29:31](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1771)
- The Bianchi procedure takes advantage of the bifurcating blood supply to the bowel wall, allowing longitudinal division to create two tubes of bowel, effectively doubling the length. — Brad Warner (clinical) [Ep 2 · 30:00](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1800)
- STEP procedures can redilate and require redo operations, and outcomes are not as good when a STEP needs to be redone compared to never needing a redo. — Brad Warner (clinical) [Ep 2 · 32:54](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1974)
- A Bianchi can be performed first, then a STEP can be done later if needed, but a Bianchi cannot be done after a STEP has been performed (unless the STEP was inadequate). — Brad Warner (clinical) [Ep 2 · 33:26](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2006)
- Tapering should be considered for children with dilated bowel who have at least 90 to 100 centimeters of intestinal length. — Brad Warner (clinical) [Ep 2 · 38:21](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2301)
- Teduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1 to 2 liters per week. — Brad Warner (clinical) [Ep 2 · 43:45](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2625)
- Growth hormone and glutamine combinations have been administered to patients, but results are primarily mixed and it hasn't been a huge advance in weaning TPN. — Brad Warner (clinical) [Ep 2 · 45:40](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2740)
- Current survival for small bowel transplant is about 50 to 60% at 5 years, with one-year survivals now above 70 to 80%. — Brad Warner (epidemiological) [Ep 2 · 46:51](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2811)
- The intestine is an immunogenic organ filled with white cells and macrophages that mount a huge graft-versus-host response, requiring industrial strength immunosuppression that increases risk for malignancies and infections. — Brad Warner (clinical) [Ep 2 · 47:11](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2831)
- Ethanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters. — Brad Warner (clinical) [Ep 2 · 49:22](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2962)
- Multidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID specialists, and interventional radiologists improve survival in intestinal failure patients, as demonstrated in series from Boston, Michigan, and Texas. — Brad Warner (clinical) [Ep 2 · 51:16](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=3076)
- Intestinal failure is an umbrella term for when the small intestine is unable to absorb or digest enough nutrition to support the patient entirely by oral or enteral feeding — Brad Warner (clinical) [Ep 1 · 1:42](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=102)
- The intestine of a newborn or fetus doubles in length in the last trimester of gestation — Brad Warner (clinical) [Ep 1 · 3:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=183)
- A 24-25 week premature infant with 20-25 cm of bowel will likely increase to at least 50 cm just on the basis of growth alone — Brad Warner (clinical) [Ep 1 · 3:13](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=193)
- For a neonate with ileocecal valve and entire colon, 10-15 cm of small intestine is a ballpark figure for potential viability — Brad Warner (clinical) [Ep 1 · 4:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=243)
- Without the colon and ileocecal valve, at least 15-20 cm of small intestine would be needed for potential viability in a neonate — Brad Warner (clinical) [Ep 1 · 4:37](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=277)
- In adult studies, patients with less than 50 cm of intestine have about 40% mortality after 5-10 years — Brad Warner (epidemiological) [Ep 1 · 4:51](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=291)
- According to Pediatric Intestinal Failure Research Consortium data, of children on TPN for more than several months due to short gut syndrome: 25% die, 25% need transplant, and 50% can wean off TPN — Brad Warner (epidemiological) [Ep 1 · 6:38](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=398)
- Common causes of death in intestinal failure include liver failure, septic episodes from central line or bacterial overgrowth, variceal bleeding from liver disease, and loss of IV access — Brad Warner (clinical) [Ep 1 · 7:11](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=431)
- Intestinal adaptation in humans probably takes place over about a year or two after small bowel resection — Brad Warner (clinical) [Ep 1 · 7:49](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=469)
- The goal of management is to wean TPN and push enteral feeding, accepting stool outputs of up to 40 cc per kilo per day as the limit — Brad Warner (clinical) [Ep 1 · 8:19](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=499)
- The most common reasons children develop short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias — Brad Warner (epidemiological) [Ep 1 · 9:22](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=562)
- For TPN, target about 100-120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein — Brad Warner (clinical) [Ep 1 · 10:22](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=622)
- Shoot for about 2-3 g of protein per kilo per day and about 2-3 g of fat per kilo per day in TPN — Brad Warner (clinical) [Ep 1 · 10:45](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=645)
- Begin enteral feeding as soon as feasible after resection and reanastomosis when they start stooling, generally starting with slow continuous drip — Brad Warner (clinical) [Ep 1 · 11:06](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=666)
- With continuous drip feeding, nutrient transporters are upregulated and ability to get more nutrition in may be advantageous — Brad Warner (opinion) [Ep 1 · 11:23](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=683)
- Want a baby to gain about 20-30 g a day, which approximates in utero progression for a newborn — Brad Warner (clinical) [Ep 1 · 12:05](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=725)
- Lipid reduction strategy takes fat from 2-3 g per kilo per day given daily down to about 1 g per kilo per day delivered twice or 3 times a week, which has been effective in reducing TPN-associated cholestasis — Brad Warner (clinical) [Ep 1 · 12:53](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=773)
- Omegaven is a fish oil-based fat containing primarily omega-3 fatty acids that are anti-inflammatory, compared to soybean-based intralipid with omega-6 fatty acids that are pro-inflammatory — Brad Warner (clinical) [Ep 1 · 14:03](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=843)
- When fish oil (omegaven) is introduced to children getting jaundiced, there has been demonstrated significant fall in their jaundice levels — Brad Warner (clinical) [Ep 1 · 14:38](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=878)
- SMOF lipid contains soybean-based lipid (essential fatty acids), medium chain triglycerides (more easily digested), olive oil, and fish oil, and has recently been FDA approved in the United States — Brad Warner (clinical) [Ep 1 · 15:08](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=908)
- Breast milk is the best choice for neonates because it contains proper fat, growth factors like EGF and IGF, and milk oligosaccharides that enhance adaptation — Brad Warner (opinion) [Ep 1 · 18:11](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1091)
- Complex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent — Brad Warner (opinion) [Ep 1 · 19:26](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1166)
- There is a threshold percentage of enteral calories that prevents onset of liver damage from TPN, with 90% enteral feeding having far less risk of TPN-related cholestasis than 10% enteral — Brad Warner (clinical) [Ep 1 · 21:19](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1279)
- Time to consider surgical intervention is when enteral tolerance plateaus and then declines (going backward rather than forward), or with multiple sepsis episodes plus abdominal distention and dilated bowel loops, or when child starts getting jaundiced — Brad Warner (clinical) [Ep 1 · 22:33](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1353)
- Dilated bowel loops can cause subclinical portal bacteremia contributing to jaundice, and bacterial overgrowth causes secretory diarrhea that impairs enzyme function — Brad Warner (clinical) [Ep 1 · 23:28](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1408)
- More than 4-5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention — Brad Warner (clinical) [Ep 1 · 25:43](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1543)
- If a child has over 100 centimeters of intestine, less than 5-10% should require TPN, suggesting there may be an underlying motility or mucosal problem — Brad Warner (clinical) [Ep 1 · 27:53](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1673)
- For bowel lengthening, need less than 100 cm (ideally less than 50 cm) of intestine and bowel that is at least 4-5 cm dilated — Brad Warner (clinical) [Ep 1 · 28:37](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1717)
- The STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation — Brad Warner (epidemiological) [Ep 1 · 29:31](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1771)
- The Bianchi procedure takes advantage of the V-shaped blood supply bifurcation before reaching the bowel wall, allowing creation of two tubes each supplied by one arm of the V — Brad Warner (clinical) [Ep 1 · 30:00](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1800)
- STEP procedure is easier to perform with less risk of injuring mesenteric blood supply because you only cut partially across the bowel at right angles — Brad Warner (clinical) [Ep 1 · 32:30](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1950)
- STEP can redilate requiring redo procedures, and outcomes are not as good if you have to redo a STEP compared to never needing a redo — Brad Warner (clinical) [Ep 1 · 32:54](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1974)
- You can do a Bianchi and then later do a STEP on top of it, but you cannot do a Bianchi once a STEP has been done — Brad Warner (clinical) [Ep 1 · 33:26](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2006)
- In a case where a STEP was acting as a brake causing dysmotility, removing the distal stepped bowel allowed the patient to completely wean off TPN — Brad Warner (clinical) [Ep 1 · 35:04](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2104)
- Would taper a child with dilated bowel who had at least 90-100 centimeters of intestinal length — Brad Warner (clinical) [Ep 1 · 38:23](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2303)
- Strategies for TPN cholestasis include bile salts (chenodeoxycholic acid), changing lipid composition, and increasing enteral feeds — Brad Warner (clinical) [Ep 1 · 39:00](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2340)
- Dan Teitelbaum's trial of cholecystokinin to promote bile flow and mitigate TPN cholestasis did not work — Brad Warner (clinical) [Ep 1 · 39:23](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2363)
- Dilated bowel is a nidus for infection encouraging translocation of bacteria and endotoxin into portal circulation, damaging the liver — Brad Warner (clinical) [Ep 1 · 39:51](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2391)
- Medical management of bacterial overgrowth includes oral antibiotics (Cipro, Flagyl), probiotics (lactobacilli), prebiotics, and potentially fecal transplantation — Brad Warner (clinical) [Ep 1 · 40:26](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2426)
- The gut bacteria in short gut syndrome become more efficient, creating an obesogenic-like microbiome that helps adapt by encouraging greater absorption and digestion — Brad Warner (clinical) [Ep 1 · 41:54](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2514)
- In mouse studies, oral vancomycin to knock out gram-positive organisms completely prevented hepatic steatosis after bowel resection — Brad Warner (clinical) [Ep 1 · 42:19](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2539)
- Teduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1-2 liters per week — Brad Warner (clinical) [Ep 1 · 43:57](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2637)
- Teduglutide is not yet approved for children in the United States, with concerns about malignancy risk due to promoting proliferation — Brad Warner (clinical) [Ep 1 · 44:34](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2674)
- Growth factors shown to promote adaptation in animal studies include EGF, HB-EGF (demonstrated by Gail Bessner), interleukins, and growth hormone with glutamine — Brad Warner (clinical) [Ep 1 · 45:13](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2713)
- Growth hormone and glutamine combinations in patients have shown primarily mixed results and are expensive — Brad Warner (clinical) [Ep 1 · 45:46](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2746)
- Survival for small bowel transplant is about 50-60% at 5 years, with one-year survivals now above 70-80% — Brad Warner (epidemiological) [Ep 1 · 46:51](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2811)
- The intestine is highly immunogenic, filled with white cells and macrophages that mount a huge graft-versus-host response, requiring industrial strength immunosuppression — Brad Warner (clinical) [Ep 1 · 47:11](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2831)
- Ethanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters — Brad Warner (clinical) [Ep 1 · 49:22](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2962)
- Multidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID specialists, and interventional radiologists improve survival in intestinal failure patients, as demonstrated in series from Boston, Michigan, and Texas — Brad Warner (clinical) [Ep 1 · 51:20](https://library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=3080)
- Adaptation is defined as developing and strengthening gut function, occurring naturally in infants during in utero development and the first few years of life, or as a regenerative response to damage in older children. — Michael Helmrath (clinical) [Ep 3 · 0:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=55)
- Adaptation generally takes months and years, not weeks and days, and requires enteral nutrition in all situations. — Michael Helmrath (clinical) [Ep 3 · 1:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=85)
- In short gut syndrome, residual intestine undergoes adaptation to compensate and reestablish function to absorb enough nutrients and fluids to maintain survival. — Paul Wales (clinical) [Ep 3 · 2:02](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=122)
- The adaptive process is driven by the presence of intraluminal nutrients and their interaction with gut secretions (pancreatic, biliary) and trophic gut peptides. — Paul Wales (clinical) [Ep 3 · 2:16](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=136)
- Structural changes during adaptation include mucosal hypertrophy (increased villous length), increased blood supply through angiogenesis, bowel dilation, and in younger children, gut lengthening—all increasing surface area for nutrient absorption. — Paul Wales (clinical) [Ep 3 · 2:42](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=162)
- Functional changes during adaptation include slowed motility to allow more contact time and up-regulation of enterocyte transporters to move nutrients across cells more efficiently. — Paul Wales (clinical) [Ep 3 · 3:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=184)
- The duodenum senses caloric intake, monitors sugars, receives hepatobiliary secretions, takes up iron, and functions as an endocrine engine recognizing meal initiation. — Michael Helmrath (clinical) [Ep 3 · 3:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=214)
- The jejunum is largely a source of fluid secretion needed for digestion, with random back-and-forth sloshing motion like a washing machine. — Michael Helmrath (clinical) [Ep 3 · 3:54](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=234)
- The ileum secretes different hormones including the incretins GLP-2, GLP-1, and PYY, which stop gastric emptying and slow motility when excess liquid is detected in the distal bowel and proximal colon. — Michael Helmrath (clinical) [Ep 3 · 4:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=246)
- The distal ileum's ability to take up bile sends a signal to the liver, the metabolic engine that helps regulate the whole metabolism of the patient. — Michael Helmrath (clinical) [Ep 3 · 4:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=271)
- In short gut patients, the colon becomes a source of energy uptake when exposed to free fatty acids, which requires the presence of bacteria. — Michael Helmrath (clinical) [Ep 3 · 4:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=290)
- Colonic adaptation does not occur in most normal patients because energy is already reclaimed before reaching the colon. — Michael Helmrath (clinical) [Ep 3 · 5:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=301)
- Adaptation is highly influenced by modifiable factors including formula type, H2 blockers, antibiotics, illness episodes, and motility changes. — Michael Helmrath (clinical) [Ep 3 · 5:13](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=313)
- Until very recently, there was no standardized definition for enteral autonomy, and most intestinal failure outcomes have poor definitions. — Paul Wales (clinical) [Ep 3 · 5:35](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=335)
- The current ASPEN guidelines define enteral autonomy as independence from parenteral support for 12 weeks with maintenance of adequate growth and hydration during that time period. — Paul Wales (guideline) [Ep 3 · 6:39](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=399)
- A patient is not truly off TPN unless they can actually grow off TPN; stopping TPN without achieving growth is a mistake. — Paul Wales (clinical) [Ep 3 · 6:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=413)
- Healthy growth is the underlying driver of successful TPN weaning, not time off TPN. — Michael Helmrath (clinical) [Ep 3 · 7:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=426)
- The last thing a patient needs to come off TPN is fluid; without adequate hydration, the baby will not grow and will not efficiently absorb nutrition, losing energy and decreasing their growth trajectory. — Michael Helmrath (clinical) [Ep 3 · 7:13](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=433)
- In the 2012 Squires/PIFCO paper, 50% of patients achieved enteral autonomy over 5-6 years, 25% died, and 25% received transplants. — Paul Wales (epidemiological) [Ep 3 · 7:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=477)
- Recent papers from the last 5-6 years show that 60-80% of patients now achieve enteral autonomy, representing improved outcomes compared to historical data. — Paul Wales (epidemiological) [Ep 3 · 8:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=505)
- Higher proportions of patients are now surviving to have the ability to reach enteral autonomy due to better management of TPN complications such as line infections, liver disease, and vascular thrombosis. — Paul Wales (clinical) [Ep 3 · 6:10](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=370)
- In the past, patients were lost to complications such as liver disease before they could reach their adaptive potential; current management is much better at preventing these complications. — Paul Wales (clinical) [Ep 3 · 6:20](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=380)
- Small bowel length is an independently significant variable predicting adaptive capacity, which is intuitive since the majority of nutrient digestion and fluid absorption occurs in the small bowel. — Paul Wales (clinical) [Ep 3 · 9:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=595)
- The ileum has a much greater capacity to adapt than the jejunum; patients with predominant ileal anatomy do better than those with predominant jejunal anatomy. — Paul Wales (clinical) [Ep 3 · 10:18](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=618)
- A full-term baby is born with approximately 160 centimeters of small bowel, which grows to about 425 centimeters by age 5 years, with the steepest growth rate between 35 weeks gestation and 6 months postnatal. — Paul Wales (clinical) [Ep 3 · 10:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=634)
- The presence or absence of the ileocecal valve is a predictor of adaptation, though the valve itself may not be the important factor; rather, loss of the valve typically accompanies loss of the terminal ileum, which is the bigger factor affecting adaptive potential. — Paul Wales (opinion) [Ep 3 · 11:13](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=673)
- When a patient has the majority of their small bowel, it almost does not matter how much colon they have—probability of enteral autonomy is 85-100%. — Paul Wales (clinical) [Ep 3 · 11:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=713)
- When small bowel remnant is less than 50% of expected length, the colon becomes vitally important, assuming an increasing role in energy absorption from short-chain fatty acids and fluid/salt absorption. — Paul Wales (clinical) [Ep 3 · 12:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=726)
- Lab data from Cincinnati shows a shift in microbiota to more acid-producing bacteria in an acidotic state, with increased bile due to lack of reclamation. — Michael Helmrath (clinical) [Ep 3 · 12:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=760)
- Bacterial colonization differences from normal are part of the adaptive response and should not automatically be considered pathological; they need to be studied and taken into context. — Michael Helmrath (opinion) [Ep 3 · 13:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=786)
- NEC is an acquired condition; infants are born, start eating (often reaching near-full feeds), then have an incident usually at 2-3 weeks of life, meaning they have not been using their gut during the critical 35-week-to-6-months adaptive window. — Michael Helmrath (clinical) [Ep 3 · 13:26](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=806)
- Whether a child has been fed before makes them different from one who has never been fed, affecting their adaptive potential. — Michael Helmrath (clinical) [Ep 3 · 13:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=825)
- Surgical planning for short gut patients is like a game of chess requiring consideration of the second, third, and fourth steps ahead. — Michael Helmrath (opinion) [Ep 3 · 13:58](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=838)
- The sooner a child can be fed safely and bowel access achieved without exposing them to surgical risk, the more the adaptive process can be leveraged. — Michael Helmrath (clinical) [Ep 3 · 14:09](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=849)
- Cincinnati strategies were developed to take advantage of the easiest, safest way to use the bowel early without needing to return immediately to surgery. — Michael Helmrath (clinical) [Ep 3 · 14:23](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=863)
- Surgery puts children in harm's way regardless of surgeon talent, so balancing surgical intervention with optimization of adaptation has led to improved outcomes. — Michael Helmrath (opinion) [Ep 3 · 14:48](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=888)

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