I think steps are not as innocuous as as we think they are, and because of that, I, I don't know, I tend to lean a little bit more as a primary to do a Bianchi, and if I have to redo something, I might, I might do it as a step then
I think steps are not as innocuous as as we think they are, and because of that, I, I don't know, I tend to lean a little bit more as a primary to do a Bianchi, and if I have to redo something, I might, I might do it as a step then
In looking for mechanisms as to how this occurs, we sought to determine whether bile acids or the site of intestinal resection would really make a difference in terms of the liver injury.
I would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should, you know, back off on your enteral feeding.
I would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should, you know, back off on your enteral feeding.
You have to remove what's dead, and you intentionally would never remove anything that wasn't. You want to preserve as much and And I think that's really important to highlight.
clinicalIntestinal 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↗
▶Ep 18 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 18 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10 to 15 centimeters of small intestine is a ballpark figure for salvageability↗
▶Ep 18 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15 to 20 centimeters would be a ballpark figure for salvageability↗
▶Ep 18 · 4:51
epidemiologicalIn adults with less than 50 centimeters of intestine, about 40% will not be alive after 5 to 10 years↗
▶Ep 18 · 5:56
epidemiologicalFor a patient with 15 centimeters of bowel and ileocecal valve, long term 50% should be able to wean from TPN, 25% would require transplant, and 25% would die↗
▶Ep 18 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection↗
▶Ep 18 · 8:30
guidelineStool outputs of up to 40 ccs per kilo per day are acceptable when advancing enteral feeding↗
▶Ep 18 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should back off on your enteral feeding.↗
▶Ep 18 · 10:22
guidelineFor TPN, shoot for about 100 to 120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein↗
▶Ep 18 · 10:45
guidelineGenerally shoot for about 2 to 3 g of protein per kilo per day and about 2 to 3 g of fat per kilo per day in TPN↗
▶Ep 18 · 12:05
clinicalA baby should gain about 20 to 30 g a day, which approximates in utero progression for a newborn↗
▶Ep 18 · 12:53
guidelineLipid reduction strategy takes patients from 2 to 3 g per kilo per day of fat delivered daily down to about 1 g per kilo per day delivered twice or 3 times a week to reduce cholestasis↗
▶Ep 18 · 14:03
clinicalOmegaven is a fish oil-based fat primarily containing omega 3 fatty acids that are anti-inflammatory, compared to soybean-based intralipid with omega 6 fatty acids that are pro-inflammatory↗
▶Ep 18 · 15:08
clinicalSMOF lipid contains soybean (essential fatty acids), medium chain triglycerides (easily digested), olive oil, and fish oil, and has become the most commonly used lipid in Canada↗
▶Ep 18 · 18:11
opinionBreast milk is the best choice for neonates because it contains growth factors like EGF and IGF, milk oligosaccharides that enhance adaptation, and other beneficial components↗
▶Ep 18 · 19:26
clinicalComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 18 · 21:19
clinicalThere is a threshold percentage of enteral calories that prevents onset of liver damage from TPN, though the exact number is unknown↗
▶Ep 18 · 22:33
guidelineTime to consider surgical intervention is when patient hits a plateau enterally and starts backing away, or if going backward rather than forward in enteral tolerance↗
▶Ep 18 · 23:01
guidelineMultiple episodes of sepsis along with abdominal distention and dilated bowel loops is an indication for surgical intervention↗
▶Ep 18 · 23:18
clinicalIf child is starting to get jaundiced, there is a role to evaluate the gut for subclinical portal bacteremia arising from dilated bowel loops↗
▶Ep 18 · 23:53
clinicalDilated bowel loops cause bacterial overgrowth leading to secretory diarrhea that is not related to digestion-absorption capacity but to enzyme dysfunction↗
▶Ep 18 · 25:43
guidelineMore than 4 to 5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention↗
▶Ep 18 · 26:07
opinionIn a child who is completely stable after 3 years but not progressing, would interrogate bowel and if dilated would proceed with lengthening↗
▶Ep 18 · 27:53
clinicalIf a child has over 100 centimeters of intestine, less than 5 or 10% should require TPN, suggesting possible underlying motility or mucosal problem↗
▶Ep 18 · 28:37
guidelineWith less than 50 centimeters of intestine and bowel at least 4 to 5 centimeters dilated, there is an option for either Bianchi or STEP procedure↗
▶Ep 18 · 29:31
clinicalThe STEP procedure has emerged to be the most commonly performed lengthening operation because it is easier to do with less risk of injuring mesenteric blood supply↗
▶Ep 18 · 32:54
clinicalSTEP procedures can redilate requiring redo procedures, and outcomes are not as good if a redo STEP is needed compared to never needing a redo↗
▶Ep 18 · 33:26
clinicalYou 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↗
▶Ep 18 · 35:04
clinicalSTEP procedures can cause dysmotility acting as a brake on intestinal transit↗
▶Ep 18 · 38:21
opinionWould taper a child with dilated bowel who had at least 90 to 100 centimeters of intestinal length rather than performing a lengthening procedure↗
▶Ep 18 · 39:00
clinicalChenodeoxycholic acid bile salts can be used to improve bile flow in TPN cholestasis↗
▶Ep 18 · 39:23
clinicalCholecystokinin administration to promote bile flow and mitigate TPN cholestasis did not work in clinical trials↗
▶Ep 18 · 41:54
clinicalGut bacteria in short gut syndrome become more efficient and help adapt by encouraging greater absorption and digestion, similar to an obesogenic microbiome↗
▶Ep 18 · 42:19
clinicalIn mouse models, oral vancomycin to knock out gram positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 18 · 43:45
clinicalTeduglutide, a GLP-2 analog, has been demonstrated in randomized trials to reduce TPN requirements by about 1-2 liters per week in adults with short gut syndrome↗
▶Ep 18 · 44:34
clinicalTeduglutide is not yet approved for children in the United States due to concerns about malignancy risk from promoting proliferation↗
▶Ep 18 · 45:40
clinicalGrowth hormone and glutamine combinations have shown primarily mixed results and have not been a huge advance in TPN weaning↗
▶Ep 18 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50 to 60% at 5 years, with one year survivals now above 70 to 80%↗
▶Ep 18 · 47:11
clinicalThe intestine is an immunogenic organ filled with white cells and macrophages that mount a huge graft versus host response requiring industrial strength immunosuppression↗
▶Ep 18 · 49:22
clinicalEthanol locks for central lines have reduced significantly the number of sepsis episodes in patients with short gut syndrome↗
▶Ep 18 · 50:37
quoteYou're taking someone who's stable and doing fine and now putting them in a category of 50% 5 year survival.↗
▶Ep 18 · 51:16
clinicalMultidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID, radiology, and interventional radiology improve survival of intestinal failure patients↗
▶Ep 18 · 51:20
quoteThis is a team sport in taking care of these patients.↗
clinicalIntestinal 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↗
▶Ep 75 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 75 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10 to 15 centimeters of small intestine is a ballpark figure for salvageability↗
▶Ep 75 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15 to 20 centimeters would be a ballpark figure for salvageability↗
▶Ep 75 · 4:51
epidemiologicalIn adults with less than 50 centimeters of intestine, about 40% will not be alive after 5 to 10 years↗
▶Ep 75 · 5:56
epidemiologicalFor a patient with 15 centimeters of bowel and ileocecal valve, long term 50% should be able to wean from TPN, 25% would require transplant, and 25% would die↗
▶Ep 75 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection↗
▶Ep 75 · 8:30
guidelineStool outputs of up to 40 ccs per kilo per day are acceptable when advancing enteral feeding↗
▶Ep 75 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should back off on your enteral feeding.↗
▶Ep 75 · 10:22
guidelineFor TPN, shoot for about 100 to 120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein↗
▶Ep 75 · 10:45
guidelineGenerally shoot for about 2 to 3 g of protein per kilo per day and about 2 to 3 g of fat per kilo per day in TPN↗
▶Ep 75 · 12:05
clinicalA baby should gain about 20 to 30 g a day, which approximates in utero progression for a newborn↗
▶Ep 75 · 12:53
guidelineLipid reduction strategy takes patients from 2 to 3 g per kilo per day of fat delivered daily down to about 1 g per kilo per day delivered twice or 3 times a week to reduce cholestasis↗
▶Ep 75 · 14:03
clinicalOmegaven is a fish oil-based fat primarily containing omega 3 fatty acids that are anti-inflammatory, compared to soybean-based intralipid with omega 6 fatty acids that are pro-inflammatory↗
▶Ep 75 · 15:08
clinicalSMOF lipid contains soybean (essential fatty acids), medium chain triglycerides (easily digested), olive oil, and fish oil, and has become the most commonly used lipid in Canada↗
▶Ep 75 · 18:11
opinionBreast milk is the best choice for neonates because it contains growth factors like EGF and IGF, milk oligosaccharides that enhance adaptation, and other beneficial components↗
▶Ep 75 · 19:26
clinicalComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 75 · 21:19
clinicalThere is a threshold percentage of enteral calories that prevents onset of liver damage from TPN, though the exact number is unknown↗
▶Ep 75 · 22:33
guidelineTime to consider surgical intervention is when patient hits a plateau enterally and starts backing away, or if going backward rather than forward in enteral tolerance↗
▶Ep 75 · 23:01
guidelineMultiple episodes of sepsis along with abdominal distention and dilated bowel loops is an indication for surgical intervention↗
▶Ep 75 · 23:18
clinicalIf child is starting to get jaundiced, there is a role to evaluate the gut for subclinical portal bacteremia arising from dilated bowel loops↗
▶Ep 75 · 23:53
clinicalDilated bowel loops cause bacterial overgrowth leading to secretory diarrhea that is not related to digestion-absorption capacity but to enzyme dysfunction↗
▶Ep 75 · 25:43
guidelineMore than 4 to 5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention↗
▶Ep 75 · 26:07
opinionIn a child who is completely stable after 3 years but not progressing, would interrogate bowel and if dilated would proceed with lengthening↗
▶Ep 75 · 27:53
clinicalIf a child has over 100 centimeters of intestine, less than 5 or 10% should require TPN, suggesting possible underlying motility or mucosal problem↗
▶Ep 75 · 28:37
guidelineWith less than 50 centimeters of intestine and bowel at least 4 to 5 centimeters dilated, there is an option for either Bianchi or STEP procedure↗
▶Ep 75 · 29:31
clinicalThe STEP procedure has emerged to be the most commonly performed lengthening operation because it is easier to do with less risk of injuring mesenteric blood supply↗
▶Ep 75 · 32:54
clinicalSTEP procedures can redilate requiring redo procedures, and outcomes are not as good if a redo STEP is needed compared to never needing a redo↗
▶Ep 75 · 33:26
clinicalYou 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↗
▶Ep 75 · 35:04
clinicalSTEP procedures can cause dysmotility acting as a brake on intestinal transit↗
▶Ep 75 · 38:21
opinionWould taper a child with dilated bowel who had at least 90 to 100 centimeters of intestinal length rather than performing a lengthening procedure↗
▶Ep 75 · 39:00
clinicalChenodeoxycholic acid bile salts can be used to improve bile flow in TPN cholestasis↗
▶Ep 75 · 39:23
clinicalCholecystokinin administration to promote bile flow and mitigate TPN cholestasis did not work in clinical trials↗
▶Ep 75 · 41:54
clinicalGut bacteria in short gut syndrome become more efficient and help adapt by encouraging greater absorption and digestion, similar to an obesogenic microbiome↗
▶Ep 75 · 42:19
clinicalIn mouse models, oral vancomycin to knock out gram positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 75 · 43:45
clinicalTeduglutide, a GLP-2 analog, has been demonstrated in randomized trials to reduce TPN requirements by about 1-2 liters per week in adults with short gut syndrome↗
▶Ep 75 · 44:34
clinicalTeduglutide is not yet approved for children in the United States due to concerns about malignancy risk from promoting proliferation↗
▶Ep 75 · 45:40
clinicalGrowth hormone and glutamine combinations have shown primarily mixed results and have not been a huge advance in TPN weaning↗
▶Ep 75 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50 to 60% at 5 years, with one year survivals now above 70 to 80%↗
▶Ep 75 · 47:11
clinicalThe intestine is an immunogenic organ filled with white cells and macrophages that mount a huge graft versus host response requiring industrial strength immunosuppression↗
▶Ep 75 · 49:22
clinicalEthanol locks for central lines have reduced significantly the number of sepsis episodes in patients with short gut syndrome↗
▶Ep 75 · 50:37
quoteYou're taking someone who's stable and doing fine and now putting them in a category of 50% 5 year survival.↗
▶Ep 75 · 51:16
clinicalMultidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID, radiology, and interventional radiology improve survival of intestinal failure patients↗
▶Ep 75 · 51:20
quoteThis is a team sport in taking care of these patients.↗
clinicalIntestinal 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↗
▶Ep 25 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 25 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10 to 15 centimeters of small intestine is a ballpark figure for salvageability↗
▶Ep 25 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15 to 20 centimeters would be a ballpark figure for salvageability↗
▶Ep 25 · 4:51
epidemiologicalIn adults with less than 50 centimeters of intestine, about 40% will not be alive after 5 to 10 years↗
▶Ep 25 · 5:56
epidemiologicalFor a patient with 15 centimeters of bowel and ileocecal valve, long term 50% should be able to wean from TPN, 25% would require transplant, and 25% would die↗
▶Ep 25 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection↗
▶Ep 25 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should back off on your enteral feeding.↗
▶Ep 25 · 8:30
guidelineStool outputs of up to 40 ccs per kilo per day are acceptable when advancing enteral feeding↗
▶Ep 25 · 10:22
guidelineFor TPN, shoot for about 100 to 120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein↗
▶Ep 25 · 10:45
guidelineGenerally shoot for about 2 to 3 g of protein per kilo per day and about 2 to 3 g of fat per kilo per day in TPN↗
▶Ep 25 · 12:05
clinicalA baby should gain about 20 to 30 g a day, which approximates in utero progression for a newborn↗
▶Ep 25 · 12:53
guidelineLipid reduction strategy takes patients from 2 to 3 g per kilo per day of fat delivered daily down to about 1 g per kilo per day delivered twice or 3 times a week to reduce cholestasis↗
▶Ep 25 · 14:03
clinicalOmegaven is a fish oil-based fat primarily containing omega 3 fatty acids that are anti-inflammatory, compared to soybean-based intralipid with omega 6 fatty acids that are pro-inflammatory↗
▶Ep 25 · 15:08
clinicalSMOF lipid contains soybean (essential fatty acids), medium chain triglycerides (easily digested), olive oil, and fish oil, and has become the most commonly used lipid in Canada↗
▶Ep 25 · 18:11
opinionBreast milk is the best choice for neonates because it contains growth factors like EGF and IGF, milk oligosaccharides that enhance adaptation, and other beneficial components↗
▶Ep 25 · 19:26
clinicalComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 25 · 21:19
clinicalThere is a threshold percentage of enteral calories that prevents onset of liver damage from TPN, though the exact number is unknown↗
▶Ep 25 · 22:33
guidelineTime to consider surgical intervention is when patient hits a plateau enterally and starts backing away, or if going backward rather than forward in enteral tolerance↗
▶Ep 25 · 23:01
guidelineMultiple episodes of sepsis along with abdominal distention and dilated bowel loops is an indication for surgical intervention↗
▶Ep 25 · 23:18
clinicalIf child is starting to get jaundiced, there is a role to evaluate the gut for subclinical portal bacteremia arising from dilated bowel loops↗
▶Ep 25 · 23:53
clinicalDilated bowel loops cause bacterial overgrowth leading to secretory diarrhea that is not related to digestion-absorption capacity but to enzyme dysfunction↗
▶Ep 25 · 25:43
guidelineMore than 4 to 5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention↗
▶Ep 25 · 26:07
opinionIn a child who is completely stable after 3 years but not progressing, would interrogate bowel and if dilated would proceed with lengthening↗
▶Ep 25 · 27:53
clinicalIf a child has over 100 centimeters of intestine, less than 5 or 10% should require TPN, suggesting possible underlying motility or mucosal problem↗
▶Ep 25 · 28:37
guidelineWith less than 50 centimeters of intestine and bowel at least 4 to 5 centimeters dilated, there is an option for either Bianchi or STEP procedure↗
▶Ep 25 · 29:31
clinicalThe STEP procedure has emerged to be the most commonly performed lengthening operation because it is easier to do with less risk of injuring mesenteric blood supply↗
▶Ep 25 · 32:54
clinicalSTEP procedures can redilate requiring redo procedures, and outcomes are not as good if a redo STEP is needed compared to never needing a redo↗
▶Ep 25 · 33:26
clinicalYou 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↗
▶Ep 25 · 35:04
clinicalSTEP procedures can cause dysmotility acting as a brake on intestinal transit↗
▶Ep 25 · 38:21
opinionWould taper a child with dilated bowel who had at least 90 to 100 centimeters of intestinal length rather than performing a lengthening procedure↗
▶Ep 25 · 39:00
clinicalChenodeoxycholic acid bile salts can be used to improve bile flow in TPN cholestasis↗
▶Ep 25 · 39:23
clinicalCholecystokinin administration to promote bile flow and mitigate TPN cholestasis did not work in clinical trials↗
▶Ep 25 · 41:54
clinicalGut bacteria in short gut syndrome become more efficient and help adapt by encouraging greater absorption and digestion, similar to an obesogenic microbiome↗
▶Ep 25 · 42:19
clinicalIn mouse models, oral vancomycin to knock out gram positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 25 · 43:45
clinicalTeduglutide, a GLP-2 analog, has been demonstrated in randomized trials to reduce TPN requirements by about 1-2 liters per week in adults with short gut syndrome↗
▶Ep 25 · 44:34
clinicalTeduglutide is not yet approved for children in the United States due to concerns about malignancy risk from promoting proliferation↗
▶Ep 25 · 45:40
clinicalGrowth hormone and glutamine combinations have shown primarily mixed results and have not been a huge advance in TPN weaning↗
▶Ep 25 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50 to 60% at 5 years, with one year survivals now above 70 to 80%↗
▶Ep 25 · 47:11
clinicalThe intestine is an immunogenic organ filled with white cells and macrophages that mount a huge graft versus host response requiring industrial strength immunosuppression↗
▶Ep 25 · 49:22
clinicalEthanol locks for central lines have reduced significantly the number of sepsis episodes in patients with short gut syndrome↗
▶Ep 25 · 50:37
quoteYou're taking someone who's stable and doing fine and now putting them in a category of 50% 5 year survival.↗
▶Ep 25 · 51:16
clinicalMultidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID, radiology, and interventional radiology improve survival of intestinal failure patients↗
▶Ep 25 · 51:20
quoteThis is a team sport in taking care of these patients.↗
clinicalIntestinal 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↗
▶Ep 2 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 2 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10 to 15 centimeters of small intestine would be a ballpark salvageable figure↗
▶Ep 2 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15 to 20 cm range would be a ballpark salvageable figure↗
▶Ep 2 · 4:51
epidemiologicalIn adult studies, adults with less than 50 centimeters of intestine, about 40% will not be alive after 5 to 10 years↗
▶Ep 2 · 5:56
epidemiologicalLong term, 50% of kids with 15 cm intestinal length and entire colon should be able to wean from TPN, 25% would require intestinal and/or liver transplant, and 25% would probably die↗
▶Ep 2 · 7:11
clinicalCauses of death in short gut syndrome include liver failure, septic episodes from central line or bacterial overgrowth, variceal bleeding from liver disease, and loss of IV access↗
▶Ep 2 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two↗
▶Ep 2 · 8:30
clinicalWould accept stool outputs of up to 40 ccs per kilo per day as the limit before backing off on enteral feeding↗
▶Ep 2 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should, you know, back off on your enteral feeding.↗
▶Ep 2 · 9:15
epidemiologicalTop causes of short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias↗
▶Ep 2 · 10:22
clinicalFor TPN, shoot for about 100 to 120 calories per kilo per day for total calories, about 50% glucose calories, with 2 to 3 g protein per kilo per day and 2 to 3 g fat per kilo per day↗
▶Ep 2 · 12:05
clinicalWant a baby to gain about 20 to 30 g a day, which approximates in utero aggression for a newborn↗
▶Ep 2 · 12:53
clinicalLipid reduction strategy takes patients from 2 to 3 g per kilo per day of fat delivered every day 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↗
▶Ep 2 · 13:46
clinicalOmegaven is a fish oil-based fat primarily containing omega 3 fatty acids considered anti-inflammatory, versus intralipid which is soybean-based with omega 6 fatty acids considered pro-inflammatory↗
▶Ep 2 · 15:08
clinicalSMOF lipid contains soybean-based lipid (essential fatty acids), medium chain triglycerides (more easily digested), olive oil, and fish oil, and has become the most commonly used lipid in Canada with recent FDA approval in the United States↗
▶Ep 2 · 18:11
opinionBreast milk is the best choice for neonates because it contains proper fat, growth factors like EGF and insulin-like growth factors that promote adaptation, and milk oligosaccharides that enhance adaptation↗
▶Ep 2 · 19:26
opinionComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 2 · 20:56
clinicalThere is a threshold percentage of enteral calories that prevents onset of liver damage from TPN, though the exact number is not known↗
opinionWould start thinking about surgical intervention if patient hits a point enterally and starts backing away, or if going backward rather than forward in enteral tolerance↗
▶Ep 2 · 23:01
clinicalMultiple episodes of sepsis with abdominal distention and dilated bowel loops would be another reason to consider surgical intervention↗
▶Ep 2 · 23:18
clinicalIf child is starting to get jaundiced, should evaluate the gut because there could be subclinical portal bacteremia arising from dilated bowel loops↗
▶Ep 2 · 23:53
clinicalDilated bowel loops can cause bacterial overgrowth leading to secretory diarrhea that affects digestion and absorption capacity↗
▶Ep 2 · 25:43
clinicalWould use more than 4 to 5 centimeters of bowel dilation as threshold for surgical intervention when patient is not advancing or going backward with enteral feeds↗
▶Ep 2 · 27:53
clinicalIf child has over 100 centimeters of intestine, less than 5 or 10% should require TPN, suggesting possible underlying motility or mucosal problem if still TPN-dependent↗
▶Ep 2 · 28:37
clinicalWith less than 50 cm intestine and bowel at least 4 to 5 cm dilated, have option of either Bianchi intestinal lengthening or STEP procedure↗
▶Ep 2 · 29:31
epidemiologicalThe STEP procedure has emerged to be the most commonly performed lengthening operation↗
▶Ep 2 · 30:00
clinicalBianchi procedure takes advantage of bifurcating blood supply to bowel wall, creating two tubes of bowel each supplied by one arm of the V-shaped vessels↗
▶Ep 2 · 31:45
clinicalSTEP procedure cuts partially across bowel alternating from each side, creating channels that increase length of mucosal contact and reduce caliber↗
▶Ep 2 · 32:54
clinicalSTEP can redilate requiring redo procedures, and outcomes are not as good if you have to redo a STEP compared to never needing redo↗
▶Ep 2 · 33:26
clinicalCan do a Bianchi and then go back and do a STEP on top of a Bianchi, but cannot do a Bianchi once a STEP has been done↗
▶Ep 2 · 33:26
quoteYou can do a Bianchi and then go back in and do another step on top of a Bianchi. You can't do a Bianchi once a step has been done.↗
▶Ep 2 · 35:04
clinicalSTEP procedures can cause dysmotility and act as a brake on intestinal transit↗
▶Ep 2 · 35:40
quoteI think steps are not as innocuous as as we think they are, and because of that, I, I don't know, I tend to lean a little bit more as a primary to do a Bianchi, and if I have to redo something, I might, I might do it as a step then↗
▶Ep 2 · 38:21
opinionWould taper a child with dilated bowel who had at least 90 to 100 centimeters of intestinal length↗
▶Ep 2 · 39:00
clinicalStrategies for TPN cholestasis include bile salts like chenodeoxycholic acid, changing lipid composition, and increasing enteral feeds↗
▶Ep 2 · 39:23
clinicalCholecystokinin trial by Dan Teitelbaum to promote bile flow and mitigate TPN cholestasis did not work↗
▶Ep 2 · 39:38
clinicalDilated bowel is a nidus for infection and encourages translocation of bacteria and endotoxin into portal circuit, damaging the liver↗
▶Ep 2 · 40:21
clinicalFor bacterial overgrowth, people try oral antibiotics like Cipro and Flagyl, probiotics with lactobacilli, prebiotics, or fecal transplantation↗
▶Ep 2 · 41:32
clinicalGut bacteria in short gut syndrome become more efficient and help adapt by encouraging greater absorption and digestion, similar to an obesogenic microbiome↗
▶Ep 2 · 42:19
clinicalIn mouse models, oral vancomycin to knock out gram positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 2 · 42:57
clinicalMice with TLR-4 deficiency (endotoxin receptor knockout) also prevented hepatic steatosis after intestinal resection↗
▶Ep 2 · 43:45
clinicalTeduglutide, a GLP-2 analog, has been shown in randomized trials to reduce TPN requirements in adults by about 1-2 liters per week↗
▶Ep 2 · 44:29
clinicalTeduglutide is not yet approved for children in the United States, with concerns about malignancy risk from growth factor-induced proliferation↗
▶Ep 2 · 45:40
clinicalGrowth hormone and glutamine combinations have shown primarily mixed results and are expensive↗
▶Ep 2 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50 to 60% at 5 years, with one-year survivals above 70 to 80%↗
▶Ep 2 · 47:11
clinicalThe intestine is highly immunogenic, filled with white cells and macrophages that mount a huge graft versus host response, requiring industrial strength immunosuppression↗
▶Ep 2 · 49:12
opinionShould not go to transplant without trying everything possible to avoid it, including lengthening procedures and strategies to mitigate liver damage↗
▶Ep 2 · 49:22
clinicalEthanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome↗
▶Ep 2 · 50:33
quoteYou're taking someone who's stable and doing fine and now putting them in a category of 50% 5 year survival.↗
▶Ep 2 · 51:16
clinicalMultidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID specialists, and interventional radiologists improve survival of short gut patients↗
▶Ep 2 · 51:16
quoteThis is a team sport in taking care of these patients.↗
Intestinal Failure with Dr. Brad Warner
▶Ep 6 · 1:42
clinicalIntestinal 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↗
▶Ep 6 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 6 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10 to 15 centimeters of small intestine is a ballpark figure for salvageability↗
▶Ep 6 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15 to 20 centimeters would be a ballpark figure for salvageability↗
▶Ep 6 · 4:51
epidemiologicalIn adults with less than 50 centimeters of intestine, about 40% will not be alive after 5 to 10 years↗
▶Ep 6 · 5:56
epidemiologicalFor a patient with 15 centimeters of bowel and ileocecal valve, long term 50% should be able to wean from TPN, 25% would require transplant, and 25% would die↗
▶Ep 6 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection↗
▶Ep 6 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should back off on your enteral feeding.↗
▶Ep 6 · 8:30
guidelineStool outputs of up to 40 ccs per kilo per day are acceptable when advancing enteral feeding↗
▶Ep 6 · 10:22
guidelineFor TPN, shoot for about 100 to 120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein↗
▶Ep 6 · 10:45
guidelineGenerally shoot for about 2 to 3 g of protein per kilo per day and about 2 to 3 g of fat per kilo per day in TPN↗
▶Ep 6 · 12:05
clinicalA baby should gain about 20 to 30 g a day, which approximates in utero progression for a newborn↗
▶Ep 6 · 12:53
guidelineLipid reduction strategy takes patients from 2 to 3 g per kilo per day of fat delivered daily down to about 1 g per kilo per day delivered twice or 3 times a week to reduce cholestasis↗
▶Ep 6 · 14:03
clinicalOmegaven is a fish oil-based fat primarily containing omega 3 fatty acids that are anti-inflammatory, compared to soybean-based intralipid with omega 6 fatty acids that are pro-inflammatory↗
▶Ep 6 · 15:08
clinicalSMOF lipid contains soybean (essential fatty acids), medium chain triglycerides (easily digested), olive oil, and fish oil, and has become the most commonly used lipid in Canada↗
▶Ep 6 · 18:11
opinionBreast milk is the best choice for neonates because it contains growth factors like EGF and IGF, milk oligosaccharides that enhance adaptation, and other beneficial components↗
▶Ep 6 · 19:26
clinicalComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 6 · 21:19
clinicalThere is a threshold percentage of enteral calories that prevents onset of liver damage from TPN, though the exact number is unknown↗
▶Ep 6 · 22:33
guidelineTime to consider surgical intervention is when patient hits a plateau enterally and starts backing away, or if going backward rather than forward in enteral tolerance↗
▶Ep 6 · 23:01
guidelineMultiple episodes of sepsis along with abdominal distention and dilated bowel loops is an indication for surgical intervention↗
▶Ep 6 · 23:18
clinicalIf child is starting to get jaundiced, there is a role to evaluate the gut for subclinical portal bacteremia arising from dilated bowel loops↗
▶Ep 6 · 23:53
clinicalDilated bowel loops cause bacterial overgrowth leading to secretory diarrhea that is not related to digestion-absorption capacity but to enzyme dysfunction↗
▶Ep 6 · 25:43
guidelineMore than 4 to 5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention↗
▶Ep 6 · 26:07
opinionIn a child who is completely stable after 3 years but not progressing, would interrogate bowel and if dilated would proceed with lengthening↗
▶Ep 6 · 27:53
clinicalIf a child has over 100 centimeters of intestine, less than 5 or 10% should require TPN, suggesting possible underlying motility or mucosal problem↗
▶Ep 6 · 28:37
guidelineWith less than 50 centimeters of intestine and bowel at least 4 to 5 centimeters dilated, there is an option for either Bianchi or STEP procedure↗
▶Ep 6 · 29:31
clinicalThe STEP procedure has emerged to be the most commonly performed lengthening operation because it is easier to do with less risk of injuring mesenteric blood supply↗
▶Ep 6 · 32:54
clinicalSTEP procedures can redilate requiring redo procedures, and outcomes are not as good if a redo STEP is needed compared to never needing a redo↗
▶Ep 6 · 33:26
clinicalYou 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↗
▶Ep 6 · 35:04
clinicalSTEP procedures can cause dysmotility acting as a brake on intestinal transit↗
▶Ep 6 · 38:21
opinionWould taper a child with dilated bowel who had at least 90 to 100 centimeters of intestinal length rather than performing a lengthening procedure↗
▶Ep 6 · 39:00
clinicalChenodeoxycholic acid bile salts can be used to improve bile flow in TPN cholestasis↗
▶Ep 6 · 39:23
clinicalCholecystokinin administration to promote bile flow and mitigate TPN cholestasis did not work in clinical trials↗
▶Ep 6 · 41:54
clinicalGut bacteria in short gut syndrome become more efficient and help adapt by encouraging greater absorption and digestion, similar to an obesogenic microbiome↗
▶Ep 6 · 42:19
clinicalIn mouse models, oral vancomycin to knock out gram positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 6 · 43:45
clinicalTeduglutide, a GLP-2 analog, has been demonstrated in randomized trials to reduce TPN requirements by about 1-2 liters per week in adults with short gut syndrome↗
▶Ep 6 · 44:34
clinicalTeduglutide is not yet approved for children in the United States due to concerns about malignancy risk from promoting proliferation↗
▶Ep 6 · 45:40
clinicalGrowth hormone and glutamine combinations have shown primarily mixed results and have not been a huge advance in TPN weaning↗
▶Ep 6 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50 to 60% at 5 years, with one year survivals now above 70 to 80%↗
▶Ep 6 · 47:11
clinicalThe intestine is an immunogenic organ filled with white cells and macrophages that mount a huge graft versus host response requiring industrial strength immunosuppression↗
▶Ep 6 · 49:22
clinicalEthanol locks for central lines have reduced significantly the number of sepsis episodes in patients with short gut syndrome↗
▶Ep 6 · 50:37
quoteYou're taking someone who's stable and doing fine and now putting them in a category of 50% 5 year survival.↗
▶Ep 6 · 51:16
clinicalMultidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID, radiology, and interventional radiology improve survival of intestinal failure patients↗
▶Ep 6 · 51:20
quoteThis is a team sport in taking care of these patients.↗
clinicalIntestinal 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↗
▶Ep 15 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 15 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10 to 15 centimeters of small intestine would be a ballpark salvageable figure↗
▶Ep 15 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15 to 20 cm range would be a ballpark salvageable figure↗
▶Ep 15 · 4:51
epidemiologicalIn adult studies, adults with less than 50 centimeters of intestine, about 40% will not be alive after 5 to 10 years↗
▶Ep 15 · 5:56
epidemiologicalLong term, 50% of kids with 15 cm intestinal length and entire colon should be able to wean from TPN, 25% would require intestinal and/or liver transplant, and 25% would probably die↗
▶Ep 15 · 7:11
clinicalCauses of death in short gut syndrome include liver failure, septic episodes from central line or bacterial overgrowth, variceal bleeding from liver disease, and loss of IV access↗
▶Ep 15 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two↗
▶Ep 15 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should, you know, back off on your enteral feeding.↗
▶Ep 15 · 8:30
clinicalWould accept stool outputs of up to 40 ccs per kilo per day as the limit before backing off on enteral feeding↗
▶Ep 15 · 9:15
epidemiologicalTop causes of short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias↗
▶Ep 15 · 10:22
clinicalFor TPN, shoot for about 100 to 120 calories per kilo per day for total calories, about 50% glucose calories, with 2 to 3 g protein per kilo per day and 2 to 3 g fat per kilo per day↗
▶Ep 15 · 12:05
clinicalWant a baby to gain about 20 to 30 g a day, which approximates in utero aggression for a newborn↗
▶Ep 15 · 12:53
clinicalLipid reduction strategy takes patients from 2 to 3 g per kilo per day of fat delivered every day 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↗
▶Ep 15 · 13:46
clinicalOmegaven is a fish oil-based fat primarily containing omega 3 fatty acids considered anti-inflammatory, versus intralipid which is soybean-based with omega 6 fatty acids considered pro-inflammatory↗
▶Ep 15 · 15:08
clinicalSMOF lipid contains soybean-based lipid (essential fatty acids), medium chain triglycerides (more easily digested), olive oil, and fish oil, and has become the most commonly used lipid in Canada with recent FDA approval in the United States↗
▶Ep 15 · 18:11
opinionBreast milk is the best choice for neonates because it contains proper fat, growth factors like EGF and insulin-like growth factors that promote adaptation, and milk oligosaccharides that enhance adaptation↗
▶Ep 15 · 19:26
opinionComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 15 · 20:56
clinicalThere is a threshold percentage of enteral calories that prevents onset of liver damage from TPN, though the exact number is not known↗
opinionWould start thinking about surgical intervention if patient hits a point enterally and starts backing away, or if going backward rather than forward in enteral tolerance↗
▶Ep 15 · 23:01
clinicalMultiple episodes of sepsis with abdominal distention and dilated bowel loops would be another reason to consider surgical intervention↗
▶Ep 15 · 23:18
clinicalIf child is starting to get jaundiced, should evaluate the gut because there could be subclinical portal bacteremia arising from dilated bowel loops↗
▶Ep 15 · 23:53
clinicalDilated bowel loops can cause bacterial overgrowth leading to secretory diarrhea that affects digestion and absorption capacity↗
▶Ep 15 · 25:43
clinicalWould use more than 4 to 5 centimeters of bowel dilation as threshold for surgical intervention when patient is not advancing or going backward with enteral feeds↗
▶Ep 15 · 27:53
clinicalIf child has over 100 centimeters of intestine, less than 5 or 10% should require TPN, suggesting possible underlying motility or mucosal problem if still TPN-dependent↗
▶Ep 15 · 28:37
clinicalWith less than 50 cm intestine and bowel at least 4 to 5 cm dilated, have option of either Bianchi intestinal lengthening or STEP procedure↗
▶Ep 15 · 29:31
epidemiologicalThe STEP procedure has emerged to be the most commonly performed lengthening operation↗
▶Ep 15 · 30:00
clinicalBianchi procedure takes advantage of bifurcating blood supply to bowel wall, creating two tubes of bowel each supplied by one arm of the V-shaped vessels↗
▶Ep 15 · 31:45
clinicalSTEP procedure cuts partially across bowel alternating from each side, creating channels that increase length of mucosal contact and reduce caliber↗
▶Ep 15 · 32:54
clinicalSTEP can redilate requiring redo procedures, and outcomes are not as good if you have to redo a STEP compared to never needing redo↗
▶Ep 15 · 33:26
clinicalCan do a Bianchi and then go back and do a STEP on top of a Bianchi, but cannot do a Bianchi once a STEP has been done↗
▶Ep 15 · 33:26
quoteYou can do a Bianchi and then go back in and do another step on top of a Bianchi. You can't do a Bianchi once a step has been done.↗
▶Ep 15 · 35:04
clinicalSTEP procedures can cause dysmotility and act as a brake on intestinal transit↗
▶Ep 15 · 35:40
quoteI think steps are not as innocuous as as we think they are, and because of that, I, I don't know, I tend to lean a little bit more as a primary to do a Bianchi, and if I have to redo something, I might, I might do it as a step then↗
▶Ep 15 · 38:21
opinionWould taper a child with dilated bowel who had at least 90 to 100 centimeters of intestinal length↗
▶Ep 15 · 39:00
clinicalStrategies for TPN cholestasis include bile salts like chenodeoxycholic acid, changing lipid composition, and increasing enteral feeds↗
▶Ep 15 · 39:23
clinicalCholecystokinin trial by Dan Teitelbaum to promote bile flow and mitigate TPN cholestasis did not work↗
▶Ep 15 · 39:38
clinicalDilated bowel is a nidus for infection and encourages translocation of bacteria and endotoxin into portal circuit, damaging the liver↗
▶Ep 15 · 40:21
clinicalFor bacterial overgrowth, people try oral antibiotics like Cipro and Flagyl, probiotics with lactobacilli, prebiotics, or fecal transplantation↗
▶Ep 15 · 41:32
clinicalGut bacteria in short gut syndrome become more efficient and help adapt by encouraging greater absorption and digestion, similar to an obesogenic microbiome↗
▶Ep 15 · 42:19
clinicalIn mouse models, oral vancomycin to knock out gram positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 15 · 42:57
clinicalMice with TLR-4 deficiency (endotoxin receptor knockout) also prevented hepatic steatosis after intestinal resection↗
▶Ep 15 · 43:45
clinicalTeduglutide, a GLP-2 analog, has been shown in randomized trials to reduce TPN requirements in adults by about 1-2 liters per week↗
▶Ep 15 · 44:29
clinicalTeduglutide is not yet approved for children in the United States, with concerns about malignancy risk from growth factor-induced proliferation↗
▶Ep 15 · 45:40
clinicalGrowth hormone and glutamine combinations have shown primarily mixed results and are expensive↗
▶Ep 15 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50 to 60% at 5 years, with one-year survivals above 70 to 80%↗
▶Ep 15 · 47:11
clinicalThe intestine is highly immunogenic, filled with white cells and macrophages that mount a huge graft versus host response, requiring industrial strength immunosuppression↗
▶Ep 15 · 49:12
opinionShould not go to transplant without trying everything possible to avoid it, including lengthening procedures and strategies to mitigate liver damage↗
▶Ep 15 · 49:22
clinicalEthanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome↗
▶Ep 15 · 50:33
quoteYou're taking someone who's stable and doing fine and now putting them in a category of 50% 5 year survival.↗
▶Ep 15 · 51:16
clinicalMultidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID specialists, and interventional radiologists improve survival of short gut patients↗
▶Ep 15 · 51:16
quoteThis is a team sport in taking care of these patients.↗
Intestinal Failure with Dr. Brad Warner
▶Ep 34 · 1:42
clinicalIntestinal 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↗
▶Ep 34 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 34 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10 to 15 centimeters of small intestine is a ballpark figure for salvageability↗
▶Ep 34 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15 to 20 centimeters would be a ballpark figure for salvageability↗
▶Ep 34 · 4:51
epidemiologicalIn adults with less than 50 centimeters of intestine, about 40% will not be alive after 5 to 10 years↗
▶Ep 34 · 5:56
epidemiologicalFor a patient with 15 centimeters of bowel and ileocecal valve, long term 50% should be able to wean from TPN, 25% would require transplant, and 25% would die↗
▶Ep 34 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection↗
▶Ep 34 · 8:30
guidelineStool outputs of up to 40 ccs per kilo per day are acceptable when advancing enteral feeding↗
▶Ep 34 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should back off on your enteral feeding.↗
▶Ep 34 · 10:22
guidelineFor TPN, shoot for about 100 to 120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein↗
▶Ep 34 · 10:45
guidelineGenerally shoot for about 2 to 3 g of protein per kilo per day and about 2 to 3 g of fat per kilo per day in TPN↗
▶Ep 34 · 12:05
clinicalA baby should gain about 20 to 30 g a day, which approximates in utero progression for a newborn↗
▶Ep 34 · 12:53
guidelineLipid reduction strategy takes patients from 2 to 3 g per kilo per day of fat delivered daily down to about 1 g per kilo per day delivered twice or 3 times a week to reduce cholestasis↗
▶Ep 34 · 14:03
clinicalOmegaven is a fish oil-based fat primarily containing omega 3 fatty acids that are anti-inflammatory, compared to soybean-based intralipid with omega 6 fatty acids that are pro-inflammatory↗
▶Ep 34 · 15:08
clinicalSMOF lipid contains soybean (essential fatty acids), medium chain triglycerides (easily digested), olive oil, and fish oil, and has become the most commonly used lipid in Canada↗
▶Ep 34 · 18:11
opinionBreast milk is the best choice for neonates because it contains growth factors like EGF and IGF, milk oligosaccharides that enhance adaptation, and other beneficial components↗
▶Ep 34 · 19:26
clinicalComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 34 · 21:19
clinicalThere is a threshold percentage of enteral calories that prevents onset of liver damage from TPN, though the exact number is unknown↗
▶Ep 34 · 22:33
guidelineTime to consider surgical intervention is when patient hits a plateau enterally and starts backing away, or if going backward rather than forward in enteral tolerance↗
▶Ep 34 · 23:01
guidelineMultiple episodes of sepsis along with abdominal distention and dilated bowel loops is an indication for surgical intervention↗
▶Ep 34 · 23:18
clinicalIf child is starting to get jaundiced, there is a role to evaluate the gut for subclinical portal bacteremia arising from dilated bowel loops↗
▶Ep 34 · 23:53
clinicalDilated bowel loops cause bacterial overgrowth leading to secretory diarrhea that is not related to digestion-absorption capacity but to enzyme dysfunction↗
▶Ep 34 · 25:43
guidelineMore than 4 to 5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention↗
▶Ep 34 · 26:07
opinionIn a child who is completely stable after 3 years but not progressing, would interrogate bowel and if dilated would proceed with lengthening↗
▶Ep 34 · 27:53
clinicalIf a child has over 100 centimeters of intestine, less than 5 or 10% should require TPN, suggesting possible underlying motility or mucosal problem↗
▶Ep 34 · 28:37
guidelineWith less than 50 centimeters of intestine and bowel at least 4 to 5 centimeters dilated, there is an option for either Bianchi or STEP procedure↗
▶Ep 34 · 29:31
clinicalThe STEP procedure has emerged to be the most commonly performed lengthening operation because it is easier to do with less risk of injuring mesenteric blood supply↗
▶Ep 34 · 32:54
clinicalSTEP procedures can redilate requiring redo procedures, and outcomes are not as good if a redo STEP is needed compared to never needing a redo↗
▶Ep 34 · 33:26
clinicalYou 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↗
▶Ep 34 · 35:04
clinicalSTEP procedures can cause dysmotility acting as a brake on intestinal transit↗
▶Ep 34 · 38:21
opinionWould taper a child with dilated bowel who had at least 90 to 100 centimeters of intestinal length rather than performing a lengthening procedure↗
▶Ep 34 · 39:00
clinicalChenodeoxycholic acid bile salts can be used to improve bile flow in TPN cholestasis↗
▶Ep 34 · 39:23
clinicalCholecystokinin administration to promote bile flow and mitigate TPN cholestasis did not work in clinical trials↗
▶Ep 34 · 41:54
clinicalGut bacteria in short gut syndrome become more efficient and help adapt by encouraging greater absorption and digestion, similar to an obesogenic microbiome↗
▶Ep 34 · 42:19
clinicalIn mouse models, oral vancomycin to knock out gram positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 34 · 43:45
clinicalTeduglutide, a GLP-2 analog, has been demonstrated in randomized trials to reduce TPN requirements by about 1-2 liters per week in adults with short gut syndrome↗
▶Ep 34 · 44:34
clinicalTeduglutide is not yet approved for children in the United States due to concerns about malignancy risk from promoting proliferation↗
▶Ep 34 · 45:40
clinicalGrowth hormone and glutamine combinations have shown primarily mixed results and have not been a huge advance in TPN weaning↗
▶Ep 34 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50 to 60% at 5 years, with one year survivals now above 70 to 80%↗
▶Ep 34 · 47:11
clinicalThe intestine is an immunogenic organ filled with white cells and macrophages that mount a huge graft versus host response requiring industrial strength immunosuppression↗
▶Ep 34 · 49:22
clinicalEthanol locks for central lines have reduced significantly the number of sepsis episodes in patients with short gut syndrome↗
▶Ep 34 · 50:37
quoteYou're taking someone who's stable and doing fine and now putting them in a category of 50% 5 year survival.↗
▶Ep 34 · 51:16
clinicalMultidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID, radiology, and interventional radiology improve survival of intestinal failure patients↗
▶Ep 34 · 51:20
quoteThis is a team sport in taking care of these patients.↗
clinicalIntestinal 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↗
▶Ep 3 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 3 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10 to 15 centimeters of small intestine is a ballpark figure for salvageability↗
▶Ep 3 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15 to 20 centimeters would be a ballpark figure for salvageability↗
▶Ep 3 · 4:51
epidemiologicalIn adults with less than 50 centimeters of intestine, about 40% will not be alive after 5 to 10 years↗
▶Ep 3 · 5:56
epidemiologicalFor a patient with 15 centimeters of bowel and ileocecal valve, long term 50% should be able to wean from TPN, 25% would require transplant, and 25% would die↗
▶Ep 3 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection↗
▶Ep 3 · 8:30
guidelineStool outputs of up to 40 ccs per kilo per day are acceptable when advancing enteral feeding↗
▶Ep 3 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should back off on your enteral feeding.↗
▶Ep 3 · 10:22
guidelineFor TPN, shoot for about 100 to 120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein↗
▶Ep 3 · 10:45
guidelineGenerally shoot for about 2 to 3 g of protein per kilo per day and about 2 to 3 g of fat per kilo per day in TPN↗
▶Ep 3 · 12:05
clinicalA baby should gain about 20 to 30 g a day, which approximates in utero progression for a newborn↗
▶Ep 3 · 12:53
guidelineLipid reduction strategy takes patients from 2 to 3 g per kilo per day of fat delivered daily down to about 1 g per kilo per day delivered twice or 3 times a week to reduce cholestasis↗
▶Ep 3 · 14:03
clinicalOmegaven is a fish oil-based fat primarily containing omega 3 fatty acids that are anti-inflammatory, compared to soybean-based intralipid with omega 6 fatty acids that are pro-inflammatory↗
▶Ep 3 · 15:08
clinicalSMOF lipid contains soybean (essential fatty acids), medium chain triglycerides (easily digested), olive oil, and fish oil, and has become the most commonly used lipid in Canada↗
▶Ep 3 · 18:11
opinionBreast milk is the best choice for neonates because it contains growth factors like EGF and IGF, milk oligosaccharides that enhance adaptation, and other beneficial components↗
▶Ep 3 · 19:26
clinicalComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 3 · 21:19
clinicalThere is a threshold percentage of enteral calories that prevents onset of liver damage from TPN, though the exact number is unknown↗
▶Ep 3 · 22:33
guidelineTime to consider surgical intervention is when patient hits a plateau enterally and starts backing away, or if going backward rather than forward in enteral tolerance↗
▶Ep 3 · 23:01
guidelineMultiple episodes of sepsis along with abdominal distention and dilated bowel loops is an indication for surgical intervention↗
▶Ep 3 · 23:18
clinicalIf child is starting to get jaundiced, there is a role to evaluate the gut for subclinical portal bacteremia arising from dilated bowel loops↗
▶Ep 3 · 23:53
clinicalDilated bowel loops cause bacterial overgrowth leading to secretory diarrhea that is not related to digestion-absorption capacity but to enzyme dysfunction↗
▶Ep 3 · 25:43
guidelineMore than 4 to 5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention↗
▶Ep 3 · 26:07
opinionIn a child who is completely stable after 3 years but not progressing, would interrogate bowel and if dilated would proceed with lengthening↗
▶Ep 3 · 27:53
clinicalIf a child has over 100 centimeters of intestine, less than 5 or 10% should require TPN, suggesting possible underlying motility or mucosal problem↗
▶Ep 3 · 28:37
guidelineWith less than 50 centimeters of intestine and bowel at least 4 to 5 centimeters dilated, there is an option for either Bianchi or STEP procedure↗
▶Ep 3 · 29:31
clinicalThe STEP procedure has emerged to be the most commonly performed lengthening operation because it is easier to do with less risk of injuring mesenteric blood supply↗
▶Ep 3 · 32:54
clinicalSTEP procedures can redilate requiring redo procedures, and outcomes are not as good if a redo STEP is needed compared to never needing a redo↗
▶Ep 3 · 33:26
clinicalYou 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↗
▶Ep 3 · 35:04
clinicalSTEP procedures can cause dysmotility acting as a brake on intestinal transit↗
▶Ep 3 · 38:21
opinionWould taper a child with dilated bowel who had at least 90 to 100 centimeters of intestinal length rather than performing a lengthening procedure↗
▶Ep 3 · 39:00
clinicalChenodeoxycholic acid bile salts can be used to improve bile flow in TPN cholestasis↗
▶Ep 3 · 39:23
clinicalCholecystokinin administration to promote bile flow and mitigate TPN cholestasis did not work in clinical trials↗
▶Ep 3 · 41:54
clinicalGut bacteria in short gut syndrome become more efficient and help adapt by encouraging greater absorption and digestion, similar to an obesogenic microbiome↗
▶Ep 3 · 42:19
clinicalIn mouse models, oral vancomycin to knock out gram positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 3 · 43:45
clinicalTeduglutide, a GLP-2 analog, has been demonstrated in randomized trials to reduce TPN requirements by about 1-2 liters per week in adults with short gut syndrome↗
▶Ep 3 · 44:34
clinicalTeduglutide is not yet approved for children in the United States due to concerns about malignancy risk from promoting proliferation↗
▶Ep 3 · 45:40
clinicalGrowth hormone and glutamine combinations have shown primarily mixed results and have not been a huge advance in TPN weaning↗
▶Ep 3 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50 to 60% at 5 years, with one year survivals now above 70 to 80%↗
▶Ep 3 · 47:11
clinicalThe intestine is an immunogenic organ filled with white cells and macrophages that mount a huge graft versus host response requiring industrial strength immunosuppression↗
▶Ep 3 · 49:22
clinicalEthanol locks for central lines have reduced significantly the number of sepsis episodes in patients with short gut syndrome↗
▶Ep 3 · 50:37
quoteYou're taking someone who's stable and doing fine and now putting them in a category of 50% 5 year survival.↗
▶Ep 3 · 51:16
clinicalMultidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID, radiology, and interventional radiology improve survival of intestinal failure patients↗
▶Ep 3 · 51:20
quoteThis is a team sport in taking care of these patients.↗
Journal of Pediatric Article Review: June 2023, AAP Issue
▶Ep 10 · 2:22
quoteIn looking for mechanisms as to how this occurs, we sought to determine whether bile acids or the site of intestinal resection would really make a difference in terms of the liver injury.↗
▶Ep 10 · 3:28
clinicalThe ileocecal region may not be important to preserve and may actually be injurious↗
▶Ep 10 · 3:28
quoteTwo takeaways here, one of which is the ileocecal region. May not be important to preserve and may actually be injurious.↗
▶Ep 10 · 3:37
clinicalAdministration of a specific bile acid that is more lipophilic and hepatoprotective could be potential therapy for patients with cholestatic liver disease after massive intestinal resection↗
▶Ep 10 · 4:13
clinicalIn clinical practice, surgeons cannot choose which segment of intestine to remove - they must remove what's dead and preserve as much as possible↗
▶Ep 10 · 4:16
quoteYou have to remove what's dead, and you intentionally would never remove anything that wasn't. You want to preserve as much and And I think that's really important to highlight.↗
clinicalIntestinal 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↗
▶Ep 1 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 1 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10 to 15 centimeters of small intestine is a ballpark figure for salvageability↗
▶Ep 1 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15 to 20 centimeters would be a ballpark figure for salvageability↗
▶Ep 1 · 4:51
epidemiologicalIn adults with less than 50 centimeters of intestine, about 40% will not be alive after 5 to 10 years↗
▶Ep 1 · 5:56
epidemiologicalFor a patient with 15 centimeters of bowel and ileocecal valve, long term 50% should be able to wean from TPN, 25% would require transplant, and 25% would die↗
▶Ep 1 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection↗
▶Ep 1 · 8:30
guidelineStool outputs of up to 40 ccs per kilo per day are acceptable when advancing enteral feeding↗
▶Ep 1 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should back off on your enteral feeding.↗
▶Ep 1 · 10:22
guidelineFor TPN, shoot for about 100 to 120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein↗
▶Ep 1 · 10:45
guidelineGenerally shoot for about 2 to 3 g of protein per kilo per day and about 2 to 3 g of fat per kilo per day in TPN↗
▶Ep 1 · 12:05
clinicalA baby should gain about 20 to 30 g a day, which approximates in utero progression for a newborn↗
▶Ep 1 · 12:53
guidelineLipid reduction strategy takes patients from 2 to 3 g per kilo per day of fat delivered daily down to about 1 g per kilo per day delivered twice or 3 times a week to reduce cholestasis↗
▶Ep 1 · 14:03
clinicalOmegaven is a fish oil-based fat primarily containing omega 3 fatty acids that are anti-inflammatory, compared to soybean-based intralipid with omega 6 fatty acids that are pro-inflammatory↗
▶Ep 1 · 15:08
clinicalSMOF lipid contains soybean (essential fatty acids), medium chain triglycerides (easily digested), olive oil, and fish oil, and has become the most commonly used lipid in Canada↗
▶Ep 1 · 18:11
opinionBreast milk is the best choice for neonates because it contains growth factors like EGF and IGF, milk oligosaccharides that enhance adaptation, and other beneficial components↗
▶Ep 1 · 19:26
clinicalComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 1 · 21:19
clinicalThere is a threshold percentage of enteral calories that prevents onset of liver damage from TPN, though the exact number is unknown↗
▶Ep 1 · 22:33
guidelineTime to consider surgical intervention is when patient hits a plateau enterally and starts backing away, or if going backward rather than forward in enteral tolerance↗
▶Ep 1 · 23:01
guidelineMultiple episodes of sepsis along with abdominal distention and dilated bowel loops is an indication for surgical intervention↗
▶Ep 1 · 23:18
clinicalIf child is starting to get jaundiced, there is a role to evaluate the gut for subclinical portal bacteremia arising from dilated bowel loops↗
▶Ep 1 · 23:53
clinicalDilated bowel loops cause bacterial overgrowth leading to secretory diarrhea that is not related to digestion-absorption capacity but to enzyme dysfunction↗
▶Ep 1 · 25:43
guidelineMore than 4 to 5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention↗
▶Ep 1 · 26:07
opinionIn a child who is completely stable after 3 years but not progressing, would interrogate bowel and if dilated would proceed with lengthening↗
▶Ep 1 · 27:53
clinicalIf a child has over 100 centimeters of intestine, less than 5 or 10% should require TPN, suggesting possible underlying motility or mucosal problem↗
▶Ep 1 · 28:37
guidelineWith less than 50 centimeters of intestine and bowel at least 4 to 5 centimeters dilated, there is an option for either Bianchi or STEP procedure↗
▶Ep 1 · 29:31
clinicalThe STEP procedure has emerged to be the most commonly performed lengthening operation because it is easier to do with less risk of injuring mesenteric blood supply↗
▶Ep 1 · 32:54
clinicalSTEP procedures can redilate requiring redo procedures, and outcomes are not as good if a redo STEP is needed compared to never needing a redo↗
▶Ep 1 · 33:26
clinicalYou 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↗
▶Ep 1 · 35:04
clinicalSTEP procedures can cause dysmotility acting as a brake on intestinal transit↗
▶Ep 1 · 38:21
opinionWould taper a child with dilated bowel who had at least 90 to 100 centimeters of intestinal length rather than performing a lengthening procedure↗
▶Ep 1 · 39:00
clinicalChenodeoxycholic acid bile salts can be used to improve bile flow in TPN cholestasis↗
▶Ep 1 · 39:23
clinicalCholecystokinin administration to promote bile flow and mitigate TPN cholestasis did not work in clinical trials↗
▶Ep 1 · 41:54
clinicalGut bacteria in short gut syndrome become more efficient and help adapt by encouraging greater absorption and digestion, similar to an obesogenic microbiome↗
▶Ep 1 · 42:19
clinicalIn mouse models, oral vancomycin to knock out gram positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 1 · 43:45
clinicalTeduglutide, a GLP-2 analog, has been demonstrated in randomized trials to reduce TPN requirements by about 1-2 liters per week in adults with short gut syndrome↗
▶Ep 1 · 44:34
clinicalTeduglutide is not yet approved for children in the United States due to concerns about malignancy risk from promoting proliferation↗
▶Ep 1 · 45:40
clinicalGrowth hormone and glutamine combinations have shown primarily mixed results and have not been a huge advance in TPN weaning↗
▶Ep 1 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50 to 60% at 5 years, with one year survivals now above 70 to 80%↗
▶Ep 1 · 47:11
clinicalThe intestine is an immunogenic organ filled with white cells and macrophages that mount a huge graft versus host response requiring industrial strength immunosuppression↗
▶Ep 1 · 49:22
clinicalEthanol locks for central lines have reduced significantly the number of sepsis episodes in patients with short gut syndrome↗
▶Ep 1 · 50:37
quoteYou're taking someone who's stable and doing fine and now putting them in a category of 50% 5 year survival.↗
▶Ep 1 · 51:16
clinicalMultidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID, radiology, and interventional radiology improve survival of intestinal failure patients↗
▶Ep 1 · 51:20
quoteThis is a team sport in taking care of these patients.↗
clinicalIntestinal 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↗
▶Ep 1 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 1 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10 to 15 centimeters of small intestine is a ballpark figure for salvageability↗
▶Ep 1 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15 to 20 centimeters would be a ballpark figure for salvageability↗
▶Ep 1 · 4:51
epidemiologicalIn adults with less than 50 centimeters of intestine, about 40% will not be alive after 5 to 10 years↗
▶Ep 1 · 5:56
epidemiologicalFor a patient with 15 centimeters of bowel and ileocecal valve, long term 50% should be able to wean from TPN, 25% would require transplant, and 25% would die↗
▶Ep 1 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection↗
▶Ep 1 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should back off on your enteral feeding.↗
▶Ep 1 · 8:30
guidelineStool outputs of up to 40 ccs per kilo per day are acceptable when advancing enteral feeding↗
▶Ep 1 · 10:22
guidelineFor TPN, shoot for about 100 to 120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein↗
▶Ep 1 · 10:45
guidelineGenerally shoot for about 2 to 3 g of protein per kilo per day and about 2 to 3 g of fat per kilo per day in TPN↗
▶Ep 1 · 12:05
clinicalA baby should gain about 20 to 30 g a day, which approximates in utero progression for a newborn↗
▶Ep 1 · 12:53
guidelineLipid reduction strategy takes patients from 2 to 3 g per kilo per day of fat delivered daily down to about 1 g per kilo per day delivered twice or 3 times a week to reduce cholestasis↗
▶Ep 1 · 14:03
clinicalOmegaven is a fish oil-based fat primarily containing omega 3 fatty acids that are anti-inflammatory, compared to soybean-based intralipid with omega 6 fatty acids that are pro-inflammatory↗
▶Ep 1 · 15:08
clinicalSMOF lipid contains soybean (essential fatty acids), medium chain triglycerides (easily digested), olive oil, and fish oil, and has become the most commonly used lipid in Canada↗
▶Ep 1 · 18:11
opinionBreast milk is the best choice for neonates because it contains growth factors like EGF and IGF, milk oligosaccharides that enhance adaptation, and other beneficial components↗
▶Ep 1 · 19:26
clinicalComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 1 · 21:19
clinicalThere is a threshold percentage of enteral calories that prevents onset of liver damage from TPN, though the exact number is unknown↗
▶Ep 1 · 22:33
guidelineTime to consider surgical intervention is when patient hits a plateau enterally and starts backing away, or if going backward rather than forward in enteral tolerance↗
▶Ep 1 · 23:01
guidelineMultiple episodes of sepsis along with abdominal distention and dilated bowel loops is an indication for surgical intervention↗
▶Ep 1 · 23:18
clinicalIf child is starting to get jaundiced, there is a role to evaluate the gut for subclinical portal bacteremia arising from dilated bowel loops↗
▶Ep 1 · 23:53
clinicalDilated bowel loops cause bacterial overgrowth leading to secretory diarrhea that is not related to digestion-absorption capacity but to enzyme dysfunction↗
▶Ep 1 · 25:43
guidelineMore than 4 to 5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention↗
▶Ep 1 · 26:07
opinionIn a child who is completely stable after 3 years but not progressing, would interrogate bowel and if dilated would proceed with lengthening↗
▶Ep 1 · 27:53
clinicalIf a child has over 100 centimeters of intestine, less than 5 or 10% should require TPN, suggesting possible underlying motility or mucosal problem↗
▶Ep 1 · 28:37
guidelineWith less than 50 centimeters of intestine and bowel at least 4 to 5 centimeters dilated, there is an option for either Bianchi or STEP procedure↗
▶Ep 1 · 29:31
clinicalThe STEP procedure has emerged to be the most commonly performed lengthening operation because it is easier to do with less risk of injuring mesenteric blood supply↗
▶Ep 1 · 32:54
clinicalSTEP procedures can redilate requiring redo procedures, and outcomes are not as good if a redo STEP is needed compared to never needing a redo↗
▶Ep 1 · 33:26
clinicalYou 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↗
▶Ep 1 · 35:04
clinicalSTEP procedures can cause dysmotility acting as a brake on intestinal transit↗
▶Ep 1 · 38:21
opinionWould taper a child with dilated bowel who had at least 90 to 100 centimeters of intestinal length rather than performing a lengthening procedure↗
▶Ep 1 · 39:00
clinicalChenodeoxycholic acid bile salts can be used to improve bile flow in TPN cholestasis↗
▶Ep 1 · 39:23
clinicalCholecystokinin administration to promote bile flow and mitigate TPN cholestasis did not work in clinical trials↗
▶Ep 1 · 41:54
clinicalGut bacteria in short gut syndrome become more efficient and help adapt by encouraging greater absorption and digestion, similar to an obesogenic microbiome↗
▶Ep 1 · 42:19
clinicalIn mouse models, oral vancomycin to knock out gram positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 1 · 43:45
clinicalTeduglutide, a GLP-2 analog, has been demonstrated in randomized trials to reduce TPN requirements by about 1-2 liters per week in adults with short gut syndrome↗
▶Ep 1 · 44:34
clinicalTeduglutide is not yet approved for children in the United States due to concerns about malignancy risk from promoting proliferation↗
▶Ep 1 · 45:40
clinicalGrowth hormone and glutamine combinations have shown primarily mixed results and have not been a huge advance in TPN weaning↗
▶Ep 1 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50 to 60% at 5 years, with one year survivals now above 70 to 80%↗
▶Ep 1 · 47:11
clinicalThe intestine is an immunogenic organ filled with white cells and macrophages that mount a huge graft versus host response requiring industrial strength immunosuppression↗
▶Ep 1 · 49:22
clinicalEthanol locks for central lines have reduced significantly the number of sepsis episodes in patients with short gut syndrome↗
▶Ep 1 · 50:37
quoteYou're taking someone who's stable and doing fine and now putting them in a category of 50% 5 year survival.↗
▶Ep 1 · 51:16
clinicalMultidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID, radiology, and interventional radiology improve survival of intestinal failure patients↗
▶Ep 1 · 51:20
quoteThis is a team sport in taking care of these patients.↗
