Michael Helmrath

652 timestamped statements across 7 collections — auto-found in recorded discussions, each timestamp jumps to the exact moment.

Abdominal Wall Defects · guest expert Colorectal / ARM & Hirschsprung · guest expert Etiologies (Gastroschisis/NEC/Atresia/Volvulus) · guest expert Intestinal Failure · guest expert Intestinal Rehab · guest expert Motility / Pseudo-obstruction · guest expert Short Bowel Syndrome · guest expert

Featured diaries

▶ Ep 22 · 9:28
By far the most complicated part of our GI tract is the stomach, because it does both the back and forth, uh, sloshing around that the small bowel does, but in addition, it has to coordinate a squeeze with the relaxation of the pylorus several. Times a minute to induce small amounts of gastric emptying, and so it's not uncommon that when children haven't been fed and they've had an injury, the coordination of the stomach is completely off.
quote · Intestinal Failure
▶ Ep 79 · 9:28
By far the most complicated part of our GI tract is the stomach, because it does both the back and forth, uh, sloshing around that the small bowel does, but in addition, it has to coordinate a squeeze with the relaxation of the pylorus several. Times a minute to induce small amounts of gastric emptying, and so it's not uncommon that when children haven't been fed and they've had an injury, the coordination of the stomach is completely off.
quote · Intestinal Rehab
▶ Ep 11 · 3:24
These kids largely are neurologically fine. They're running and playing, and the, the thought that you would be salvaging a baby to have a lifelong care need and their, their life expectancy would not be associated with things that most parents would want for their children is not what we see in the clinic.
quote · Intestinal Failure
▶ Ep 49 · 3:24
These kids largely are neurologically fine. They're running and playing, and the, the thought that you would be salvaging a baby to have a lifelong care need and their, their life expectancy would not be associated with things that most parents would want for their children is not what we see in the clinic.
quote · Intestinal Rehab
▶ Ep 36 · 3:11
Mistakes I believe are commonly made because we think we can predict the future with our eyes, and that the first line of treating a baby with overwhelming catastrophe is to allow the clinical scenario to drive the direction of care and not us predicting.
quote · Etiologies (Gastroschisis/NEC/Atresia/Volvulus)
▶ Ep 5 · 8:19
I have seen many a child with a first operation at that time that included steps that have just never gone forward and then have been labeled a poor motility child and accepted to not be able to tolerate enteral feeds, which I have challenges with.
quote · Short Bowel Syndrome

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Abdominal Wall Defects 23 entries

Intestinal rehabilitation: What is intestinal rehab? - Episode 1

▶ Ep 23 · 2:40
opinion Earlier recognition and taking advantage of the gut's biology to adapt are time dependent ↗
▶ Ep 23 · 4:07
clinical Intestinal rehabilitation comes down to key factors: nutrition in the gut, nutrition in the body, and healing ↗
▶ Ep 23 · 4:07
quote What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing. ↗
▶ Ep 23 · 4:19
opinion Pattern recognition from multiple experienced providers seeing patients over time is essential in intestinal rehabilitation ↗
▶ Ep 23 · 4:24
quote So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time. ↗
▶ Ep 23 · 8:30
opinion Families living within the region can benefit from understanding that delivery at an intestinal rehab center from the beginning is probably beneficial ↗
▶ Ep 23 · 9:15
clinical Prenatal diagnoses that lead to intestinal rehab referral include atresia with cystic fibrosis and gastroschisis ↗
▶ Ep 23 · 10:15
quote I've long believed that your ideas that first come to your head always have ways to improve, and that, that you only see things through one way. ↗
▶ Ep 23 · 10:25
opinion Innovation comes from multiple approaches to the problem and different visions, with more expertise bringing better outcomes ↗
▶ Ep 23 · 10:25
quote Innovation comes from multiple approaches to the problem and Different visions of the problem, the more expertise you bring in, um, the better the outcome is. ↗
▶ Ep 23 · 10:51
clinical Transitioning older children with intestinal failure into their late teen years and later is a major obstacle that needs to be addressed ↗
▶ Ep 23 · 11:43
clinical The intestinal rehab team includes surgeons, GI doctors, neonatologists, dietitians, social work, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology ↗
▶ Ep 23 · 13:21
quote I think the big key to a person watching the podcast is that they get hope. These are wonderful children. They're, they're opportunities to grow up and to live the lives that their families want is really in front of them. ↗

Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?

▶ Ep 24 · 2:40
clinical Earlier recognition and taking advantage of the biology of the gut to adapt are time dependent ↗
▶ Ep 24 · 4:07
clinical Intestinal rehabilitation comes down to key factors that drive the process: nutrition in the gut, nutrition in the body, and healing ↗
▶ Ep 24 · 4:19
opinion Pattern recognition from multiple eyes on a baby who have seen them over time is important in intestinal rehabilitation ↗
▶ Ep 24 · 8:53
clinical There are three time points where families reach intestinal rehabilitation programs: prenatal diagnosis, postnatal acquired problems, and later presentations after discharge ↗
▶ Ep 24 · 9:15
clinical Prenatal diagnoses that lead to intestinal rehabilitation typically include atresia with cystic fibrosis and gastroschisis ↗
▶ Ep 24 · 10:25
quote Innovation comes from multiple approaches to the problem and Different visions of the problem, the more expertise you bring in, um, the better the outcome is ↗
▶ Ep 24 · 11:52
opinion Dietitians play a key role in understanding the nutritional needs of children in intestinal rehabilitation ↗
▶ Ep 24 · 12:01
opinion Social work is a key component of the intestinal rehabilitation team ↗
▶ Ep 24 · 13:21
quote I think the big key to a person watching the podcast is that they get hope ↗
▶ Ep 24 · 13:51
quote there's nothing that puts more energy back into you wanting to go better uh than that hug. Um, like I said, we work for hugs ↗
Colorectal / ARM & Hirschsprung 23 entries

Intestinal rehabilitation: What is intestinal rehab? - Episode 1

▶ Ep 112 · 2:40
opinion Earlier recognition and taking advantage of the gut's biology to adapt are time dependent ↗
▶ Ep 112 · 4:07
quote What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing. ↗
▶ Ep 112 · 4:07
clinical Intestinal rehabilitation comes down to key factors: nutrition in the gut, nutrition in the body, and healing ↗
▶ Ep 112 · 4:19
opinion Pattern recognition from multiple experienced providers seeing patients over time is essential in intestinal rehabilitation ↗
▶ Ep 112 · 4:24
quote So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time. ↗
▶ Ep 112 · 8:30
opinion Families living within the region can benefit from understanding that delivery at an intestinal rehab center from the beginning is probably beneficial ↗
▶ Ep 112 · 9:15
clinical Prenatal diagnoses that lead to intestinal rehab referral include atresia with cystic fibrosis and gastroschisis ↗
▶ Ep 112 · 10:15
quote I've long believed that your ideas that first come to your head always have ways to improve, and that, that you only see things through one way. ↗
▶ Ep 112 · 10:25
quote Innovation comes from multiple approaches to the problem and Different visions of the problem, the more expertise you bring in, um, the better the outcome is. ↗
▶ Ep 112 · 10:25
opinion Innovation comes from multiple approaches to the problem and different visions, with more expertise bringing better outcomes ↗
▶ Ep 112 · 10:51
clinical Transitioning older children with intestinal failure into their late teen years and later is a major obstacle that needs to be addressed ↗
▶ Ep 112 · 11:43
clinical The intestinal rehab team includes surgeons, GI doctors, neonatologists, dietitians, social work, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology ↗
▶ Ep 112 · 13:21
quote I think the big key to a person watching the podcast is that they get hope. These are wonderful children. They're, they're opportunities to grow up and to live the lives that their families want is really in front of them. ↗

Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?

▶ Ep 113 · 2:40
clinical Earlier recognition and taking advantage of the biology of the gut to adapt are time dependent ↗
▶ Ep 113 · 4:07
clinical Intestinal rehabilitation comes down to key factors that drive the process: nutrition in the gut, nutrition in the body, and healing ↗
▶ Ep 113 · 4:19
opinion Pattern recognition from multiple eyes on a baby who have seen them over time is important in intestinal rehabilitation ↗
▶ Ep 113 · 8:53
clinical There are three time points where families reach intestinal rehabilitation programs: prenatal diagnosis, postnatal acquired problems, and later presentations after discharge ↗
▶ Ep 113 · 9:15
clinical Prenatal diagnoses that lead to intestinal rehabilitation typically include atresia with cystic fibrosis and gastroschisis ↗
▶ Ep 113 · 10:25
quote Innovation comes from multiple approaches to the problem and Different visions of the problem, the more expertise you bring in, um, the better the outcome is ↗
▶ Ep 113 · 11:52
opinion Dietitians play a key role in understanding the nutritional needs of children in intestinal rehabilitation ↗
▶ Ep 113 · 12:01
opinion Social work is a key component of the intestinal rehabilitation team ↗
▶ Ep 113 · 13:21
quote I think the big key to a person watching the podcast is that they get hope ↗
▶ Ep 113 · 13:51
quote there's nothing that puts more energy back into you wanting to go better uh than that hug. Um, like I said, we work for hugs ↗
Etiologies (Gastroschisis/NEC/Atresia/Volvulus) 43 entries

Intestinal rehabilitation: What is intestinal rehab? - Episode 1

▶ Ep 34 · 2:40
opinion Earlier recognition and taking advantage of the gut's biology to adapt are time dependent ↗
▶ Ep 34 · 4:07
clinical Intestinal rehabilitation comes down to key factors: nutrition in the gut, nutrition in the body, and healing ↗
▶ Ep 34 · 4:07
quote What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing. ↗
▶ Ep 34 · 4:19
opinion Pattern recognition from multiple experienced providers seeing patients over time is essential in intestinal rehabilitation ↗
▶ Ep 34 · 4:24
quote So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time. ↗
▶ Ep 34 · 8:30
opinion Families living within the region can benefit from understanding that delivery at an intestinal rehab center from the beginning is probably beneficial ↗
▶ Ep 34 · 9:15
clinical Prenatal diagnoses that lead to intestinal rehab referral include atresia with cystic fibrosis and gastroschisis ↗
▶ Ep 34 · 10:15
quote I've long believed that your ideas that first come to your head always have ways to improve, and that, that you only see things through one way. ↗
▶ Ep 34 · 10:25
opinion Innovation comes from multiple approaches to the problem and different visions, with more expertise bringing better outcomes ↗
▶ Ep 34 · 10:25
quote Innovation comes from multiple approaches to the problem and Different visions of the problem, the more expertise you bring in, um, the better the outcome is. ↗
▶ Ep 34 · 10:51
clinical Transitioning older children with intestinal failure into their late teen years and later is a major obstacle that needs to be addressed ↗
▶ Ep 34 · 11:43
clinical The intestinal rehab team includes surgeons, GI doctors, neonatologists, dietitians, social work, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology ↗
▶ Ep 34 · 13:21
quote I think the big key to a person watching the podcast is that they get hope. These are wonderful children. They're, they're opportunities to grow up and to live the lives that their families want is really in front of them. ↗

Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?

▶ Ep 35 · 2:40
clinical Earlier recognition and taking advantage of the biology of the gut to adapt are time dependent ↗
▶ Ep 35 · 4:07
clinical Intestinal rehabilitation comes down to key factors that drive the process: nutrition in the gut, nutrition in the body, and healing ↗
▶ Ep 35 · 4:19
opinion Pattern recognition from multiple eyes on a baby who have seen them over time is important in intestinal rehabilitation ↗
▶ Ep 35 · 8:53
clinical There are three time points where families reach intestinal rehabilitation programs: prenatal diagnosis, postnatal acquired problems, and later presentations after discharge ↗
▶ Ep 35 · 9:15
clinical Prenatal diagnoses that lead to intestinal rehabilitation typically include atresia with cystic fibrosis and gastroschisis ↗
▶ Ep 35 · 10:25
quote Innovation comes from multiple approaches to the problem and Different visions of the problem, the more expertise you bring in, um, the better the outcome is ↗
▶ Ep 35 · 11:52
opinion Dietitians play a key role in understanding the nutritional needs of children in intestinal rehabilitation ↗
▶ Ep 35 · 12:01
opinion Social work is a key component of the intestinal rehabilitation team ↗
▶ Ep 35 · 13:21
quote I think the big key to a person watching the podcast is that they get hope ↗
▶ Ep 35 · 13:51
quote there's nothing that puts more energy back into you wanting to go better uh than that hug. Um, like I said, we work for hugs ↗

Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 1

▶ Ep 36 · 3:11
opinion The first line of treating a baby with overwhelming catastrophe is to allow the clinical scenario to drive the direction of care and not predetermining care based on what surgeons believe will happen ↗
▶ Ep 36 · 3:11
quote Mistakes I believe are commonly made because we think we can predict the future with our eyes, and that the first line of treating a baby with overwhelming catastrophe is to allow the clinical scenario to drive the direction of care and not us predicting. ↗
▶ Ep 36 · 3:11
opinion Mistakes are commonly made because surgeons think they can predict the future with their eyes ↗
▶ Ep 36 · 3:34
clinical There is an algorithm of children that have overwhelming sepsis where surgery cannot salvage these patients and there is no life saving option ↗
▶ Ep 36 · 3:41
clinical Many babies will rally without having their bowel removed, which allows them an opportunity ↗
▶ Ep 36 · 5:14
quote The first goal that drives me when I see these kids is protecting the liver. ↗
▶ Ep 36 · 5:49
clinical Decompressing the duodenum is needed to protect the liver ↗
▶ Ep 36 · 5:57
clinical When the liver is inflamed and has high bilirubin, it's in a catabolic state ↗
▶ Ep 36 · 7:34
clinical A 30-week-old baby's gut is in a highly developmental phase and its ability to regenerate is much more profound than a full term baby and certainly a one year old baby ↗
▶ Ep 36 · 8:04
clinical The distal bowel, the ileum, can be salvaged by ileocecal blood flow ↗
▶ Ep 36 · 8:17
clinical Bowel regeneration with proximal control occurs over 6, 8, 12 weeks based on the liver getting better ↗
▶ Ep 36 · 9:27
clinical The inflection point of bowel loss requiring prolonged TPN is about 50% ↗
▶ Ep 36 · 9:35
clinical If bowel necrosis is focal and less than 50%, the best option is to remove that bowel ↗
▶ Ep 36 · 9:44
clinical The adaptive potential for a child with less than 50% bowel loss is really great, especially if they have preserved ileum ↗
▶ Ep 36 · 10:00
quote It's not like when you look at it, it's all dead. We all know it's patchy. ↗
▶ Ep 36 · 10:00
clinical When bowel appears dead in a mosaic pattern with parts terrible, parts bad, and maybe a little good, proximal control with a drain and time to heal gives opportunity to come back later ↗
▶ Ep 36 · 10:14
clinical Not all bowel will survive and it will become islands of mucosa that need to be tubularized and put back together again ↗
▶ Ep 36 · 10:59
clinical Stomas lose abdominal domain and lose bowel down the road ↗
▶ Ep 36 · 11:11
clinical The percentage of kids that do well with proximal drain therapy when looking at dead gut is more than 70 to 80% ↗
▶ Ep 36 · 11:45
clinical Kids with necrotizing enterocolitis have the best outcomes because it's a microvascular disease ↗
Intestinal Failure 249 entries

Intestinal Failure - Feeding Access and Nutrition

▶ Ep 1 · 4:36
clinical Placing a balloon catheter directly into the jejunal lumen is obstructing; creating a chimney with a Roux limb allows easy family-managed tube changes ↗
▶ Ep 1 · 12:21
clinical GJ tubes in small infants are very stiff, not durable long-term, and require families to return for radiographic exchange when displaced ↗
▶ Ep 1 · 28:11
clinical Patients with 50% of estimated bowel length are expected to come off parenteral nutrition ↗
▶ Ep 1 · 29:35
opinion STEP procedures done in the first year of life in patients who have not progressed with enteral feeds are not beneficial unless specifically avoiding line infections and bacterial overgrowth ↗
▶ Ep 1 · 29:53
clinical Dilated bowel does not become motile because you did a STEP procedure on it if the patient has never been able to advance feeds ↗
▶ Ep 1 · 30:20
clinical The one thing that makes the bowel adapt is feeding the bowel; procedures that cause problems in reinitiating feeds cause damage to the patient ↗
▶ Ep 1 · 30:20
quote The one thing that makes the bowel adapt is feeding the bowel and procedures in which you have problems in reinitiating feeds have really caused damage to that patient. ↗
▶ Ep 1 · 31:32
clinical In a neonatal STEP registry study, only 3 patients came off parenteral nutrition, whereas natural data shows 80-90% of similar patients come off TPN at 12 months without STEP ↗
▶ Ep 1 · 33:22
quote Just because you can do something doesn't necessarily mean that you should. ↗
▶ Ep 1 · 34:21
quote The expectation of going from 10 per kilo of enteral feeds, you're doing a step and that kid's gonna be off a TPN in 3 months is a fairy tale that belongs in Disney World because that doesn't exist. ↗
▶ Ep 1 · 59:57
clinical Breast milk provides significant benefit to time to wean off parenteral nutrition in gastroschisis and necrotizing enterocolitis patients compared to formula only ↗
▶ Ep 1 · 1:26:39
clinical Breast milk contains non-nutrient oligosaccharides (2FL, 3FL) that affect microflora and dysbiosis, with 80% of donors having secretor status producing 2FL ↗
▶ Ep 1 · 1:27:01
clinical H2 blockers and antibiotics further dysbiosis in intestinal failure patients ↗
▶ Ep 1 · 1:44:08
clinical Anti-inflammatory agents including 5-ASA products and steroid-based enemas can help manage hypermotility when inflammation is documented on endoscopy ↗
▶ Ep 1 · 1:44:43
clinical In challenging Hirschsprung's patients with dysbiosis and high stool frequency not responding to antibiotics or formula changes, anti-inflammatories have been remarkably successful ↗
▶ Ep 1 · 1:49:07
clinical Pancreatic enzymes in distal areas of bowel, especially with stomas, can cause strictures or stoma problems when they sit in areas of stenosis and dysmotility ↗
▶ Ep 1 · 1:51:30
clinical Stoma output of 40-50 cc/kg is acceptable if electrolyte profile is maintained and patient is not acidotic with CO2 in the teens ↗
▶ Ep 1 · 1:52:26
opinion Knee-jerk reactions to volume of output without considering overall pattern, acidosis, and electrolytes leads to variable feeding amounts over longer periods, which is detrimental ↗
▶ Ep 1 · 1:52:53
clinical Stoma output is more relevant for guiding fluid and electrolyte replacement than for making decisions about stopping or decreasing feeds ↗

Intestinal rehabilitation: What is intestinal rehab? - Episode 1

▶ Ep 8 · 2:40
opinion Earlier recognition and taking advantage of the gut's biology to adapt are time dependent ↗
▶ Ep 8 · 4:07
quote What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing. ↗
▶ Ep 8 · 4:07
clinical Intestinal rehabilitation comes down to key factors: nutrition in the gut, nutrition in the body, and healing ↗
▶ Ep 8 · 4:19
opinion Pattern recognition from multiple experienced providers seeing patients over time is essential in intestinal rehabilitation ↗
▶ Ep 8 · 4:24
quote So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time. ↗
▶ Ep 8 · 8:30
opinion Families living within the region can benefit from understanding that delivery at an intestinal rehab center from the beginning is probably beneficial ↗
▶ Ep 8 · 9:15
clinical Prenatal diagnoses that lead to intestinal rehab referral include atresia with cystic fibrosis and gastroschisis ↗
▶ Ep 8 · 10:15
quote I've long believed that your ideas that first come to your head always have ways to improve, and that, that you only see things through one way. ↗
▶ Ep 8 · 10:25
opinion Innovation comes from multiple approaches to the problem and different visions, with more expertise bringing better outcomes ↗
▶ Ep 8 · 10:25
quote Innovation comes from multiple approaches to the problem and Different visions of the problem, the more expertise you bring in, um, the better the outcome is. ↗
▶ Ep 8 · 10:51
clinical Transitioning older children with intestinal failure into their late teen years and later is a major obstacle that needs to be addressed ↗
▶ Ep 8 · 11:43
clinical The intestinal rehab team includes surgeons, GI doctors, neonatologists, dietitians, social work, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology ↗
▶ Ep 8 · 13:21
quote I think the big key to a person watching the podcast is that they get hope. These are wonderful children. They're, they're opportunities to grow up and to live the lives that their families want is really in front of them. ↗

Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?

▶ Ep 9 · 2:40
clinical Earlier recognition and taking advantage of the biology of the gut to adapt are time dependent ↗
▶ Ep 9 · 4:07
clinical Intestinal rehabilitation comes down to key factors that drive the process: nutrition in the gut, nutrition in the body, and healing ↗
▶ Ep 9 · 4:19
opinion Pattern recognition from multiple eyes on a baby who have seen them over time is important in intestinal rehabilitation ↗
▶ Ep 9 · 8:53
clinical There are three time points where families reach intestinal rehabilitation programs: prenatal diagnosis, postnatal acquired problems, and later presentations after discharge ↗
▶ Ep 9 · 9:15
clinical Prenatal diagnoses that lead to intestinal rehabilitation typically include atresia with cystic fibrosis and gastroschisis ↗
▶ Ep 9 · 10:25
quote Innovation comes from multiple approaches to the problem and Different visions of the problem, the more expertise you bring in, um, the better the outcome is ↗
▶ Ep 9 · 11:52
opinion Dietitians play a key role in understanding the nutritional needs of children in intestinal rehabilitation ↗
▶ Ep 9 · 12:01
opinion Social work is a key component of the intestinal rehabilitation team ↗
▶ Ep 9 · 13:21
quote I think the big key to a person watching the podcast is that they get hope ↗
▶ Ep 9 · 13:51
quote there's nothing that puts more energy back into you wanting to go better uh than that hug. Um, like I said, we work for hugs ↗

Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 1

▶ Ep 10 · 3:11
opinion The first line of treating a baby with overwhelming catastrophe is to allow the clinical scenario to drive the direction of care and not predetermining care based on what surgeons believe will happen ↗
▶ Ep 10 · 3:11
opinion Mistakes are commonly made because surgeons think they can predict the future with their eyes ↗
▶ Ep 10 · 3:11
quote Mistakes I believe are commonly made because we think we can predict the future with our eyes, and that the first line of treating a baby with overwhelming catastrophe is to allow the clinical scenario to drive the direction of care and not us predicting. ↗
▶ Ep 10 · 3:34
clinical There is an algorithm of children that have overwhelming sepsis where surgery cannot salvage these patients and there is no life saving option ↗
▶ Ep 10 · 3:41
clinical Many babies will rally without having their bowel removed, which allows them an opportunity ↗
▶ Ep 10 · 5:14
quote The first goal that drives me when I see these kids is protecting the liver. ↗
▶ Ep 10 · 5:49
clinical Decompressing the duodenum is needed to protect the liver ↗
▶ Ep 10 · 5:57
clinical When the liver is inflamed and has high bilirubin, it's in a catabolic state ↗
▶ Ep 10 · 7:34
clinical A 30-week-old baby's gut is in a highly developmental phase and its ability to regenerate is much more profound than a full term baby and certainly a one year old baby ↗
▶ Ep 10 · 8:04
clinical The distal bowel, the ileum, can be salvaged by ileocecal blood flow ↗
▶ Ep 10 · 8:17
clinical Bowel regeneration with proximal control occurs over 6, 8, 12 weeks based on the liver getting better ↗
▶ Ep 10 · 9:27
clinical The inflection point of bowel loss requiring prolonged TPN is about 50% ↗
▶ Ep 10 · 9:35
clinical If bowel necrosis is focal and less than 50%, the best option is to remove that bowel ↗
▶ Ep 10 · 9:44
clinical The adaptive potential for a child with less than 50% bowel loss is really great, especially if they have preserved ileum ↗
▶ Ep 10 · 10:00
clinical When bowel appears dead in a mosaic pattern with parts terrible, parts bad, and maybe a little good, proximal control with a drain and time to heal gives opportunity to come back later ↗
▶ Ep 10 · 10:00
quote It's not like when you look at it, it's all dead. We all know it's patchy. ↗
▶ Ep 10 · 10:14
clinical Not all bowel will survive and it will become islands of mucosa that need to be tubularized and put back together again ↗
▶ Ep 10 · 10:59
clinical Stomas lose abdominal domain and lose bowel down the road ↗
▶ Ep 10 · 11:11
clinical The percentage of kids that do well with proximal drain therapy when looking at dead gut is more than 70 to 80% ↗
▶ Ep 10 · 11:45
clinical Kids with necrotizing enterocolitis have the best outcomes because it's a microvascular disease ↗

Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 2

▶ Ep 11 · 2:55
clinical The ileum reclaims bile and tells the liver what to do ↗
▶ Ep 11 · 2:58
clinical The ileum produces hormones like GLP-2, PYY and others that slow motility and tell the jejunum to reabsorb fluid ↗
▶ Ep 11 · 3:15
clinical The colon can account for a third to half of the caloric needs of babies when exposed to undigested nutrients ↗
▶ Ep 11 · 3:24
quote These kids largely are neurologically fine. They're running and playing, and the, the thought that you would be salvaging a baby to have a lifelong care need and their, their life expectancy would not be associated with things that most parents would want for their children is not what we see in the clinic. ↗
▶ Ep 11 · 3:24
clinical Short bowel syndrome kids are largely neurologically fine, running and playing ↗
▶ Ep 11 · 3:50
quote And again, I think the take home message of this is the child should be the one driving the care, not your expectations or the lack thereof. ↗
▶ Ep 11 · 4:26
quote Well, I mean, obviously bowel removed is bowel never to be used. ↗
▶ Ep 11 · 4:26
clinical Bowel removed is bowel never to be used ↗
▶ Ep 11 · 4:48
epidemiological Most necrotizing enterocolitis kids don't have overwhelming totalis; NEC totalis is fairly rare ↗
▶ Ep 11 · 4:54
clinical Cincinnati has a dozen or more NEC totalis kids that are off TPN and have done remarkably ↗
▶ Ep 11 · 4:54
quote The comparative group to that patient is in a cemetery. As, as rude as that sounds, um, a dead child has no neurological function. ↗
▶ Ep 11 · 5:25
quote Once they live, the opportunities for us to move forward in this field and rehabilitate the bowel, the new tools that we will make in the next decade are going to be profound. ↗
▶ Ep 11 · 5:39
quote So you remove all the potential that we have in the future. Based on your clinical acumen that this is gonna have a bad outcome, and that it's time to withdraw. ↗
▶ Ep 11 · 6:49
clinical If a baby grows well with protein growth, linear growth and head growth, that's brain growth ↗
▶ Ep 11 · 6:49
quote If you see protein growth and linear growth of your baby and head growth, that's brain growth, and a baby will not grow well with a, with an unhealthy liver and is not managed well. ↗
▶ Ep 11 · 6:59
clinical A baby will not grow well with an unhealthy liver ↗
▶ Ep 11 · 6:59
clinical An unhealthy liver is not providing the protein for neurocognitive development ↗
▶ Ep 11 · 7:43
clinical Premature babies in the first year of life have caloric needs of 80, 100, 120 per kilo because they're growing and developing ↗
▶ Ep 11 · 7:52
clinical When critically ill, babies no longer grow and develop; they can be fed 150 kcals per kilo but will not grow because their livers are catabolic ↗
▶ Ep 11 · 7:52
quote When you're critically ill, you no longer are growing and developing. You can feed these babies 150 k cals per kilo, but they will not grow because their livers are catabolic. ↗
▶ Ep 11 · 8:21
quote So I know this baby is going to need multiple operations. So the incision is a transverse incision because I know over time that's the one that's going to give me the least problems. ↗
▶ Ep 11 · 8:25
clinical A transverse incision gives the least problems over time for patients requiring multiple operations ↗
▶ Ep 11 · 8:37
clinical An 8 or 10 French Blake drain is placed through bowel just beyond what is expected to heal, advanced retrograde to the pylorus ↗
▶ Ep 11 · 9:10
clinical A purse string is placed at the drain insertion site and secured to the skin, essentially creating a stoma to the abdominal wall ↗
▶ Ep 11 · 9:29
clinical A 5 to 7 French feeding tube can be placed into the proximal bowel via the stomach using a purse string technique ↗
▶ Ep 11 · 10:08
quote I try to avoid doing significant dissection of the distal ileum one because I wanna preserve the blood. So I wanna let the collateralization happen to recover as much of that proximal bowel as possible. ↗
▶ Ep 11 · 10:08
clinical Significant dissection of the distal ileum should be avoided to preserve blood supply and allow collateralization to recover proximal bowel ↗
▶ Ep 11 · 10:53
clinical A refeeding tube can be placed in the distal bowel to allow intermediate bowel to heal ↗
▶ Ep 11 · 11:19
clinical The volume of fluid output from injured bowel is very high initially; as bowel heals and regenerates reabsorptive capacity, output decreases ↗
▶ Ep 11 · 12:45
quote Once you explain to the family that the individual making the decisions moving forward is a baby, and you explain that to them, when things go bad, it actually makes it easier for them. ↗
▶ Ep 11 · 13:22
clinical Many kids who appear critically sick preoperatively are not as sick as believed once proximal bowel is controlled and decompressed ↗
▶ Ep 11 · 13:22
quote I think you'd be surprised at the number of kids who are sick, taken to the OR, but they're not as critically sick as we believe they're going to be. ↗
▶ Ep 11 · 14:31
quote Long term, if you take everything out, there are many of them that will heal, and then we have no opportunity. That Experiment's been done. ↗
▶ Ep 11 · 14:49
clinical Blake tubes have linear cuts on the outside so they won't get obstructed when secretions accumulate ↗
▶ Ep 11 · 14:58
clinical Blake tubes cannot be changed over a wire like JP drains with side holes ↗
▶ Ep 11 · 15:06
clinical Blake tubes are soft and don't tend to put pressure on damaged bowel ↗
▶ Ep 11 · 15:09
clinical Blake tubes can be connected to a bulb syringe and cut to size ↗

Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 1

▶ Ep 12 · 0:55
quote The word adaptation is to develop and to strengthen function. ↗
▶ Ep 12 · 1:01
clinical Adaptation is a natural process occurring in all infants during uterine development and the first few years of life, or as a regenerative response to damage in older children ↗
▶ Ep 12 · 1:25
clinical Adaptation takes time measured in months and years, not weeks and days, and requires enteral nutrition in all situations ↗
▶ Ep 12 · 3:34
clinical The duodenum is where caloric intake and sugars are sensed, hepatobiliary secretions occur, iron is absorbed, and it functions as an endocrine engine recognizing meal initiation ↗
▶ Ep 12 · 3:54
clinical The jejunum is largely a source of secretion of large amounts of fluid needed for digestion, with random back-and-forth sloshing motion ↗
▶ Ep 12 · 4:06
clinical The ileum secretes incretins GLP-2, GLP-1, and PYY that stop gastric emptying and slow motility when there is too much liquid in the distal bowel ↗
▶ Ep 12 · 4:31
clinical Distal ileum bile uptake sends a signal to the liver, which regulates the whole metabolism of the patient ↗
▶ Ep 12 · 4:46
clinical The colon, specifically the right colon, is a source of energy uptake from free fatty acids in short gut patients, which requires the presence of bacteria ↗
▶ Ep 12 · 5:01
clinical Colonic adaptation does not occur in most patients because energy is reclaimed before reaching the colon ↗
▶ Ep 12 · 7:06
opinion Healthy growth is the underlying driver of autonomy, not time off TPN ↗
▶ Ep 12 · 7:06
quote Healthy growth is the underlying. Driver, not time off TPN. ↗
▶ Ep 12 · 7:13
quote The last thing you need to come off a TPN is fluid. And so without hydration, the baby won't grow. ↗
▶ Ep 12 · 7:13
clinical The last thing needed to come off TPN is fluid, and without hydration the baby will not grow or efficiently absorb nutrition ↗
▶ Ep 12 · 12:40
clinical Lab data shows a shift in microbiota to one that is more acid-producing in an acidotic state, likely more full of bile because it is not being reclaimed ↗
▶ Ep 12 · 13:26
clinical NEC is an acquired condition; infants are born, start eating, often get up to full feeds, then have an incident usually at 2-3 weeks of life ↗
▶ Ep 12 · 13:38
clinical NEC patients have not been using their gut in utero during the critical period of 35 weeks to 6 months, making them different from children who have been fed before ↗
▶ Ep 12 · 13:58
quote It's really important that when you do a procedure on this child that you understand the 2nd and the 3rd and the 4th step. You, this is a game of chess. You really have to plan ahead. ↗
▶ Ep 12 · 14:05
opinion The sooner a child can be fed safely and bowel access obtained without exposing them to surgical risk, the more advantage can be taken of the adaptive process ↗
▶ Ep 12 · 14:48
opinion Surgery puts kids in harm's way no matter how talented the surgeon, so balancing operative risk with the ability to optimize feeding has led to improved outcomes ↗
▶ Ep 12 · 14:48
quote You put kids in harm's way when you go to the operating room, no matter how talented you are. ↗

Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1

▶ Ep 18 · 2:55
clinical The gut doubles in length in the last trimester and the first year of life ↗
▶ Ep 18 · 2:58
clinical Maturation of the intestine occurs when you feed the baby ↗
▶ Ep 18 · 3:03
clinical Healthy growth of the intestine requires nutrition ↗
▶ Ep 18 · 3:06
clinical Anything done to disrupt feeding affects the maturation of the intestine's ability to absorb, digest, and peristalse ↗
▶ Ep 18 · 3:21
quote The outcome is one that should benefit the child for 80, 90 years, not just the next 2 months. ↗
▶ Ep 18 · 3:46
quote The better the waves going over the villa, The more exposure of nutrients and removal of waste that you have is not increased by lengthening the bowel that doesn't peristals. That's just more static water. ↗
▶ Ep 18 · 3:46
clinical Lengthening bowel that doesn't peristalse doesn't increase absorption - it's just more static water ↗
▶ Ep 18 · 3:59
clinical Very short bowel kids sometimes come off TPN because their motility is so good ↗
▶ Ep 18 · 7:32
clinical The enteric nervous system in gastroschisis has to go through a healing and recovery phase ↗
▶ Ep 18 · 7:32
clinical The enteric nervous system is damaged in gastroschisis from exposure to amniotic fluid ↗
▶ Ep 18 · 7:46
clinical When exposed to more dysmotility and stasis, regeneration and healing of the enteric nervous system is attenuated ↗
▶ Ep 18 · 7:55
clinical A baby with atresia may have really good peristalsis that has been working against an obstruction ↗
▶ Ep 18 · 8:19
quote I have seen many a child with a first operation at that time that included steps that have just never gone forward and then have been labeled a poor motility child and accepted to not be able to tolerate enteral feeds, which I have challenges with. ↗
▶ Ep 18 · 8:19
clinical Children who have STEP procedures in the first year of life sometimes never progress and are labeled poor motility children ↗
▶ Ep 18 · 8:40
opinion Babies with necrotizing enterocolitis do better when they heal because they've been fed before and already have GI motility starting ↗
▶ Ep 18 · 8:43
quote They just do better when they heal. Most of them because they've been fed before. They already have geo immertility starting. That maturation phase has already been turned on because they didn't get neck the day they were born. ↗
▶ Ep 18 · 8:54
quote Tresia's 2, and I run from gastroschisis. ↗
▶ Ep 18 · 8:58
quote Anything that creates a potential worsening of motility and gastroschisis, especially in the first year of Life should be something you should strongly think about before doing. ↗
▶ Ep 18 · 17:32
clinical The duodenum doesn't have a mesentery, making it difficult to orient staple lines at 3 and 9 o'clock ↗

Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1

▶ Ep 19 · 1:23
clinical Adrian Bianchi first reported the longitudinal intestinal lengthening procedure (Bianchi procedure) that divides bowel along its two leaves and tubularizes it ↗
▶ Ep 19 · 2:13
clinical Rising direct bilirubin was recognized as a sign that children with intestinal failure would not do well ↗
▶ Ep 19 · 2:55
quote The gut doubles in length the last trimester in the first year of life. That maturation process occurs when you feed the baby. ↗
▶ Ep 19 · 2:55
clinical The gut doubles in length during the last trimester and the first year of life ↗
▶ Ep 19 · 2:58
clinical Intestinal maturation occurs when the baby is fed; healthy growth of the intestine requires nutrition ↗
▶ Ep 19 · 3:06
clinical Disrupting the feeding and maturation process affects not only the intestine's ability to absorb and digest but also peristalsis and function ↗
▶ Ep 19 · 3:21
quote The outcome is one that should benefit the child for 80, 90 years, not just the next 2 months. ↗
▶ Ep 19 · 3:46
quote The better the waves going over the villa, The more exposure of nutrients and removal of waste that you have is not increased by lengthening the bowel that doesn't peristals. That's just more static water. ↗
▶ Ep 19 · 3:46
clinical Lengthening bowel that doesn't have peristalsis does not increase absorption; it's just more static water ↗
▶ Ep 19 · 3:59
clinical Very short bowel children can sometimes come off TPN because their motility is so good ↗
▶ Ep 19 · 7:32
clinical The enteric nervous system in gastroschisis must go through a healing and recovery phase that is attenuated by dysmotility and stasis ↗
▶ Ep 19 · 7:55
clinical Atresia patients may have good peristalsis from bowel working against obstruction, and longitudinal stapling procedures may benefit them ↗
▶ Ep 19 · 8:19
clinical Children who undergo STEP procedures in the first year of life sometimes never progress and are labeled as poor motility patients unable to tolerate enteral feeds ↗
▶ Ep 19 · 8:19
quote I have seen many a child with a first operation at that time that included steps that have just never gone forward and then have been labeled a poor motility child and accepted to not be able to tolerate enteral feeds, which I have challenges with. ↗
▶ Ep 19 · 8:40
opinion Necrotizing enterocolitis patients do better than other intestinal failure etiologies because they have been fed before disease onset, initiating GI motility and maturation ↗
▶ Ep 19 · 8:43
quote They just do better when they heal. Most of them because they've been fed before. They already have geo immertility starting. That maturation phase has already been turned on because they didn't get neck the day they were born. ↗
▶ Ep 19 · 8:54
quote Tresia's 2, and I run from gastroschisis. ↗
▶ Ep 19 · 10:22
opinion Stepping the duodenum in non-rotated children is fraught with problems and causes significant issues later in life ↗
▶ Ep 19 · 17:32
clinical The duodenum has no mesentery, making it impossible to orient staple lines at 3 and 9 o'clock positions as in the jejunum ↗

Intestinal Rehabilitation, Episode 4: Surgical Management, Part 2

▶ Ep 20 · 3:40
quote Half of the people that have a step will have progression of improved animal tolerance. Half will have actually a worsening. ↗
▶ Ep 20 · 3:40
clinical Half of patients who have a STEP will have progression of improved enteral tolerance, while half will have worsening ↗
▶ Ep 20 · 4:08
quote If you're going to operate on a kid for a step procedure, you need to first rule out other anatomical problems. ↗
▶ Ep 20 · 4:08
clinical Before performing STEP, other anatomical problems must be ruled out by laying out the bowel and getting the mesentery completely oriented ↗
▶ Ep 20 · 5:00
quote There is nothing wrong with staging. ↗
▶ Ep 20 · 5:00
opinion There is nothing wrong with staging surgical procedures in intestinal failure patients ↗
▶ Ep 20 · 5:39
clinical Ulcers at STEP staple lines are not uncommon and can cause recurrent bleeding requiring monthly transfusions for years ↗
▶ Ep 20 · 5:39
quote One of the things that we've seen as a complication here is that the kids have done really well with step procedures, but they have continued loss from either they lose protein in the stool or we see recurrent bleeding. ↗
▶ Ep 20 · 6:01
quote And that's an absolute indication to operate. ↗
▶ Ep 20 · 6:01
clinical Chronic blood loss at the STEP line is an absolute indication to operate ↗
▶ Ep 20 · 7:52
clinical The underlying issue in staple-line bleeding is mesenteric inflammation and scarring that creates obstruction to venous outflow, not primary bowel pathology ↗
▶ Ep 20 · 8:03
clinical Mesenteric inflammation causes venous hypertension along the staple lines ↗
▶ Ep 20 · 8:03
quote And so that mesenteric fire that Causes inflammation and scarring, creates an obstruction to venous outflow. ↗
▶ Ep 20 · 8:33
quote And when you operate. You can see vessels the size of your thumb, and you'll see really big adenopathy because the lymphatics are also obstructed. ↗
▶ Ep 20 · 8:33
clinical During surgery for staple-line bleeding, vessels the size of your thumb and really big adenopathy can be seen due to lymphatic obstruction ↗
▶ Ep 20 · 8:42
clinical Once mesenteric scar is freed up, the enlarged vessels come right back to normal ↗
▶ Ep 20 · 8:53
clinical Venous hypertension is what leads to the bleeding from staple lines ↗
▶ Ep 20 · 9:05
clinical Staple line revision is typically done with hand-sewn stitch to reconnect the bowel ↗
▶ Ep 20 · 9:09
quote So the key to me in that situation of bleeding is look at the mesentery. Make sure you free up the mesentery. Don't just look at the bowel. ↗
▶ Ep 20 · 9:09
clinical The key to managing staple-line bleeding is to look at the mesentery and free up the mesentery, not just look at the bowel ↗
▶ Ep 20 · 9:27
opinion Mesenteric pathology causing staple-line bleeding is obvious if you are looking for it ↗
▶ Ep 20 · 9:27
quote It's so obvious if you're looking for it. ↗
▶ Ep 20 · 10:33
opinion Detailed operative notes documenting orientation, landmarks, and what was done are important for future operations ↗
▶ Ep 20 · 10:52
opinion Surgeons should try not to be the hero and try not to do everything, especially in the first week of life ↗
▶ Ep 20 · 10:52
quote Try not to be the hero. Try not to do everything, especially the first week in life. ↗
▶ Ep 20 · 11:05
quote These are families that you need to grow up with. ↗
▶ Ep 20 · 11:05
opinion The surgeon plays a huge role in intestinal failure management even when patients are doing well, because progress must be monitored ↗

Intestinal Rehabilitation, Episode 6: Cholestasis

▶ Ep 21 · 1:57
quote I believe though that as we've gotten better and we've learned how to use lipid emulgens differently and nutrition differently and our approaches. That the definition of cholestasis is not as much as a morbidity mortality as much as it is an indicator of underlying diseases that we need to address. ↗
▶ Ep 21 · 1:57
opinion Cholestasis is now more an indicator of underlying diseases that need to be addressed rather than a direct morbidity/mortality factor ↗
▶ Ep 21 · 3:53
quote So when you talk about the kid that's cholestatic, it really starts at the very beginning. So the first question that I always ask is, has this child ever been enterally fed, and where did we start with our cholestasis and, and where are we at in gestational age and progress? ↗
▶ Ep 21 · 5:12
clinical Limiting fat in TPN to 1 g/kg/day can help prevent cholestasis ↗
▶ Ep 21 · 5:20
clinical New lipid emulsions (Omegaven first in US, then SMOF in Europe/Canada and now US over last 3-4 years) can reverse or prevent cholestasis ↗
▶ Ep 21 · 6:15
clinical SMOF lipids allow provision of more calories from fat, as much as 2-2.5 g/kg ↗
▶ Ep 21 · 6:15
quote One of the major advantages I think of the addition of SMP is the ability to provide more calories from fat, as much as 2 2.5 g per kilo. ↗
▶ Ep 21 · 9:38
clinical When refeeding a cholestatic liver after jejunostomy takedown, direct bilirubin and liver enzymes (GGT, AST, ALT) will initially rise in the first 1-2 weeks as bile acid pool is reintroduced and liver becomes more active ↗
▶ Ep 21 · 9:38
quote One of the first things that you'll get your neonatologist telling you about when you start feeding is they'll get worried because the direct bilirubin goes up. That's normal. ↗
▶ Ep 21 · 10:46
quote So I think it's really important to try to provide proximal drainage of the duodenum. ↗
▶ Ep 21 · 11:18
clinical Proximal blockage puts pressure in the biliary system at a much higher level and speeds up the cholestatic process ↗
▶ Ep 21 · 11:31
quote G tubes do not decompress the duodenum. ↗
▶ Ep 21 · 11:31
clinical G-tubes do not decompress the duodenum ↗

Intestinal Rehabilitation, Episode 7: Refeeding in a neonatal patient

▶ Ep 22 · 2:37
clinical Damaged bowel is in a secretory phase even when not fed ↗
▶ Ep 22 · 2:37
quote Yeah, remember that especially if there's been damaged bowel, it's gonna be in a secretory phase, even if it's not fed, and people are scared then to feed. ↗
▶ Ep 22 · 2:46
clinical Starting to feed the bowel transitions it to an absorptive state because luminal nutrition stimulates absorption, resulting in decreased stoma volume over time ↗
▶ Ep 22 · 2:46
quote And feeling like it's gonna be totally uncontrollable, whereas what happens is the exact opposite, as you start to feed the bowel, then gets in an absorptive state, because the nutrition that's present in the luminal stimulate it to do so, and you'll actually start to see less volume out the stoma in time. ↗
▶ Ep 22 · 3:40
clinical Breast milk is the ideal first choice for feeding due to nutritional value, immunomodulatory effects, and growth healing effects not present in typical formulas ↗
▶ Ep 22 · 3:54
quote Mom's breast milk is ideal, not just because of the nutritional value, but certainly because it has all the immunomodulatory beneficial effects, growth healing effects. ↗
▶ Ep 22 · 4:08
guideline Donor breast milk is the second choice when maternal breast milk is unavailable ↗
▶ Ep 22 · 5:21
clinical Long-chain fatty acids have developmental and immune properties ↗
▶ Ep 22 · 5:51
clinical It is a common mistake to decrease TPN by the same volume that enteral feeds are increased, assuming the child will absorb all those calories, which results in stunted growth ↗
▶ Ep 22 · 5:51
quote It's a common mistake to increase enteral feeds by X volume that you decrease TPN by, and what you end up doing is you're assuming that the child. And absorb all those calories, and you end up stunting the growth. ↗
▶ Ep 22 · 6:44
clinical If the child tolerates it and does not have lung issues, total daily volume can be expanded from 140 to 160, 170, or occasionally 180 mL/kg ↗
▶ Ep 22 · 9:28
clinical When children have not been fed and have had an injury, gastric coordination is commonly disrupted ↗
▶ Ep 22 · 9:28
quote By far the most complicated part of our GI tract is the stomach, because it does both the back and forth, uh, sloshing around that the small bowel does, but in addition, it has to coordinate a squeeze with the relaxation of the pylorus several. Times a minute to induce small amounts of gastric emptying, and so it's not uncommon that when children haven't been fed and they've had an injury, the coordination of the stomach is completely off. ↗
▶ Ep 22 · 9:28
clinical The stomach is the most complicated part of the GI tract because it must coordinate both back-and-forth mixing and coordinated squeezing with pyloric relaxation several times per minute ↗
▶ Ep 22 · 10:02
clinical Gastric dysmotility after intestinal injury requires time and stimulation to resolve ↗
▶ Ep 22 · 10:15
clinical Post-pyloric feeding with simultaneous gastric decompression allows distal bowel stimulation, which produces hormones that signal the stomach to start functioning and break the dysmotility cycle ↗
▶ Ep 22 · 11:03
clinical Post-pyloric refeeding can be done as a bolus or over a pump; bolus is preferred, but running it over a pump for one hour works well at Cincinnati Children's ↗
▶ Ep 22 · 11:03
guideline The Cincinnati Children's protocol typically starts post-pyloric feeds at 5 mL/kg, then 10 mL/kg, and advances based on tolerance ↗
▶ Ep 22 · 11:25
quote Interestingly, by feeding the colon, one of the things you'll notice quickly is that the output from the stoma actually goes down, speaking to all the hormonal effects of the distal bowel, and often the stomach will start to work. ↗
▶ Ep 22 · 11:25
clinical Feeding the distal colon reduces stoma output due to hormonal effects of the distal bowel, and often the stomach will start to work ↗
▶ Ep 22 · 11:50
clinical When distal bowel has been functionally used through refeeding, the time to start feeding postoperatively after anastomosis is made easier ↗
▶ Ep 22 · 12:34
opinion Undigested formula in the colon is a trigger that can cause stress to the bowel and may not be the healthiest approach ↗
▶ Ep 22 · 12:53
clinical Placing a feeding tube into the stomach at the time of surgery does not commit the child to a lifelong G-tube or even for the first year ↗
▶ Ep 22 · 13:06
clinical A gastric tube can be directed out of the pylorus into the proximal small bowel as a source of feeding to overcome unpredictable obstacles ↗
▶ Ep 22 · 13:24
clinical When a gastric tube is no longer needed, it can be removed and the hole heals quickly like any other tube site ↗
▶ Ep 22 · 14:05
opinion The morbidity from a gastric tube is extremely low and the benefit can be very high ↗

Intestinal Rehabilitation Episode 8: Refeeding of an Older Patient

▶ Ep 23 · 1:11
clinical Older children (8-16 years) who experience volvulus can lose 90+% of their bowel ↗
▶ Ep 23 · 4:55
clinical Without adequate IV fluids, patients end up sleeping most of the day and don't have energy ↗
▶ Ep 23 · 4:55
clinical Some patients can come off TPN but still need a central line for IV fluids ↗
▶ Ep 23 · 5:08
clinical Being in a hydrated state is extremely important to making the bowel work well ↗
▶ Ep 23 · 5:31
clinical Sometimes patients can't drink rehydration solution but the GI tract can use it via G-tube ↗
▶ Ep 23 · 5:32
quote Sometimes they can't drink it, but the GI tract can use it. ↗
▶ Ep 23 · 5:51
clinical Children doing well often hit the wall when they start puberty because energy needs overcome nutrient input ↗
▶ Ep 23 · 5:51
clinical Energy use goes up dramatically during puberty ↗
▶ Ep 23 · 5:51
quote The other key point to remember is that the energy use goes up dramatically during puberty ↗
▶ Ep 23 · 6:57
clinical There are very few conditions with intestinal failure that have restricted growth ↗
▶ Ep 23 · 6:57
opinion A 3rd percentile growth should not be accepted for most intestinal failure patients ↗
▶ Ep 23 · 6:57
quote I can't emphasize enough to look at the growth chart, both the weight, but also the height, and don't accept a 3rd percentile. ↗
▶ Ep 23 · 7:06
quote There are very few conditions with intestinal failure that have restricted growth ↗
▶ Ep 23 · 9:34
clinical For any child not meeting growth potential, numerous other diagnoses must be considered including endocrine issues, pancreatic insufficiency, and micronutrient deficiencies ↗
▶ Ep 23 · 9:54
clinical After addressing growth issues, improvements should be assessed on the order of weeks not months ↗
▶ Ep 23 · 10:15
clinical Growth monitoring can be done remotely and should not wait until the next appointment ↗

Intestinal Rehabilitation Webinar 2023 - Top 5 Key Takeaways

▶ Ep 25 · 2:30
clinical The more important factor is the presence or absence of the distal small bowel or ileum and right colon that can act as reclamation of bile and support enterohepatic circulation ↗
▶ Ep 25 · 2:30
quote So, to me, I believe the more important fact is the presence or absence of the distal small bowel or the ileum and even right colon that can act as a reclamation of bile and get the inneroppatic circulation. ↗
▶ Ep 25 · 2:43
clinical GLP-2, GLP-1, and hormones like PYY are produced in the distal ileum, not because of the ileocecal valve but because of the distal ileum itself ↗
▶ Ep 25 · 3:29
clinical Strategy at the first operation should provide a pathway forward that allows early interval feeding ↗
▶ Ep 25 · 3:29
quote I think sometimes strategy at the first operation is to be able to provide a pathway forward that allows early interval feeding. ↗
▶ Ep 25 · 3:38
opinion It is sometimes better to stage reconstruction under more controlled conditions rather than attempt immediate continuity ↗
▶ Ep 25 · 4:02
clinical Many segments of bowel deemed non-usable actually have potential to heal in this population and can make a huge difference in the lifetime of the child ↗
▶ Ep 25 · 6:42
clinical Breast milk is the formula of choice, not only for nutritional benefits but for all the other components within breast milk ↗
▶ Ep 25 · 6:42
quote Obviously, formula of choice coming from the breast, breast milk, always mess. ↗
▶ Ep 25 · 7:28
clinical Single amino acid level protein is the generalized preference to avoid high stool output, high fluid losses, wound breakdown, rashes, and emesis ↗
Intestinal Rehab 249 entries

Intestinal Failure - Feeding Access and Nutrition

▶ Ep 8 · 4:36
clinical Placing a balloon catheter directly into the jejunal lumen is obstructing; creating a chimney with a Roux limb allows easy family-managed tube changes ↗
▶ Ep 8 · 12:21
clinical GJ tubes in small infants are very stiff, not durable long-term, and require families to return for radiographic exchange when displaced ↗
▶ Ep 8 · 28:11
clinical Patients with 50% of estimated bowel length are expected to come off parenteral nutrition ↗
▶ Ep 8 · 29:35
opinion STEP procedures done in the first year of life in patients who have not progressed with enteral feeds are not beneficial unless specifically avoiding line infections and bacterial overgrowth ↗
▶ Ep 8 · 29:53
clinical Dilated bowel does not become motile because you did a STEP procedure on it if the patient has never been able to advance feeds ↗
▶ Ep 8 · 30:20
quote The one thing that makes the bowel adapt is feeding the bowel and procedures in which you have problems in reinitiating feeds have really caused damage to that patient. ↗
▶ Ep 8 · 30:20
clinical The one thing that makes the bowel adapt is feeding the bowel; procedures that cause problems in reinitiating feeds cause damage to the patient ↗
▶ Ep 8 · 31:32
clinical In a neonatal STEP registry study, only 3 patients came off parenteral nutrition, whereas natural data shows 80-90% of similar patients come off TPN at 12 months without STEP ↗
▶ Ep 8 · 33:22
quote Just because you can do something doesn't necessarily mean that you should. ↗
▶ Ep 8 · 34:21
quote The expectation of going from 10 per kilo of enteral feeds, you're doing a step and that kid's gonna be off a TPN in 3 months is a fairy tale that belongs in Disney World because that doesn't exist. ↗
▶ Ep 8 · 59:57
clinical Breast milk provides significant benefit to time to wean off parenteral nutrition in gastroschisis and necrotizing enterocolitis patients compared to formula only ↗
▶ Ep 8 · 1:26:39
clinical Breast milk contains non-nutrient oligosaccharides (2FL, 3FL) that affect microflora and dysbiosis, with 80% of donors having secretor status producing 2FL ↗
▶ Ep 8 · 1:27:01
clinical H2 blockers and antibiotics further dysbiosis in intestinal failure patients ↗
▶ Ep 8 · 1:44:08
clinical Anti-inflammatory agents including 5-ASA products and steroid-based enemas can help manage hypermotility when inflammation is documented on endoscopy ↗
▶ Ep 8 · 1:44:43
clinical In challenging Hirschsprung's patients with dysbiosis and high stool frequency not responding to antibiotics or formula changes, anti-inflammatories have been remarkably successful ↗
▶ Ep 8 · 1:49:07
clinical Pancreatic enzymes in distal areas of bowel, especially with stomas, can cause strictures or stoma problems when they sit in areas of stenosis and dysmotility ↗
▶ Ep 8 · 1:51:30
clinical Stoma output of 40-50 cc/kg is acceptable if electrolyte profile is maintained and patient is not acidotic with CO2 in the teens ↗
▶ Ep 8 · 1:52:26
opinion Knee-jerk reactions to volume of output without considering overall pattern, acidosis, and electrolytes leads to variable feeding amounts over longer periods, which is detrimental ↗
▶ Ep 8 · 1:52:53
clinical Stoma output is more relevant for guiding fluid and electrolyte replacement than for making decisions about stopping or decreasing feeds ↗

Intestinal rehabilitation: What is intestinal rehab? - Episode 1

▶ Ep 46 · 2:40
opinion Earlier recognition and taking advantage of the gut's biology to adapt are time dependent ↗
▶ Ep 46 · 4:07
quote What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing. ↗
▶ Ep 46 · 4:07
clinical Intestinal rehabilitation comes down to key factors: nutrition in the gut, nutrition in the body, and healing ↗
▶ Ep 46 · 4:19
opinion Pattern recognition from multiple experienced providers seeing patients over time is essential in intestinal rehabilitation ↗
▶ Ep 46 · 4:24
quote So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time. ↗
▶ Ep 46 · 8:30
opinion Families living within the region can benefit from understanding that delivery at an intestinal rehab center from the beginning is probably beneficial ↗
▶ Ep 46 · 9:15
clinical Prenatal diagnoses that lead to intestinal rehab referral include atresia with cystic fibrosis and gastroschisis ↗
▶ Ep 46 · 10:15
quote I've long believed that your ideas that first come to your head always have ways to improve, and that, that you only see things through one way. ↗
▶ Ep 46 · 10:25
quote Innovation comes from multiple approaches to the problem and Different visions of the problem, the more expertise you bring in, um, the better the outcome is. ↗
▶ Ep 46 · 10:25
opinion Innovation comes from multiple approaches to the problem and different visions, with more expertise bringing better outcomes ↗
▶ Ep 46 · 10:51
clinical Transitioning older children with intestinal failure into their late teen years and later is a major obstacle that needs to be addressed ↗
▶ Ep 46 · 11:43
clinical The intestinal rehab team includes surgeons, GI doctors, neonatologists, dietitians, social work, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology ↗
▶ Ep 46 · 13:21
quote I think the big key to a person watching the podcast is that they get hope. These are wonderful children. They're, they're opportunities to grow up and to live the lives that their families want is really in front of them. ↗

Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?

▶ Ep 47 · 2:40
clinical Earlier recognition and taking advantage of the biology of the gut to adapt are time dependent ↗
▶ Ep 47 · 4:07
clinical Intestinal rehabilitation comes down to key factors that drive the process: nutrition in the gut, nutrition in the body, and healing ↗
▶ Ep 47 · 4:19
opinion Pattern recognition from multiple eyes on a baby who have seen them over time is important in intestinal rehabilitation ↗
▶ Ep 47 · 8:53
clinical There are three time points where families reach intestinal rehabilitation programs: prenatal diagnosis, postnatal acquired problems, and later presentations after discharge ↗
▶ Ep 47 · 9:15
clinical Prenatal diagnoses that lead to intestinal rehabilitation typically include atresia with cystic fibrosis and gastroschisis ↗
▶ Ep 47 · 10:25
quote Innovation comes from multiple approaches to the problem and Different visions of the problem, the more expertise you bring in, um, the better the outcome is ↗
▶ Ep 47 · 11:52
opinion Dietitians play a key role in understanding the nutritional needs of children in intestinal rehabilitation ↗
▶ Ep 47 · 12:01
opinion Social work is a key component of the intestinal rehabilitation team ↗
▶ Ep 47 · 13:21
quote I think the big key to a person watching the podcast is that they get hope ↗
▶ Ep 47 · 13:51
quote there's nothing that puts more energy back into you wanting to go better uh than that hug. Um, like I said, we work for hugs ↗

Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 1

▶ Ep 48 · 3:11
opinion The first line of treating a baby with overwhelming catastrophe is to allow the clinical scenario to drive the direction of care and not predetermining care based on what surgeons believe will happen ↗
▶ Ep 48 · 3:11
quote Mistakes I believe are commonly made because we think we can predict the future with our eyes, and that the first line of treating a baby with overwhelming catastrophe is to allow the clinical scenario to drive the direction of care and not us predicting. ↗
▶ Ep 48 · 3:11
opinion Mistakes are commonly made because surgeons think they can predict the future with their eyes ↗
▶ Ep 48 · 3:34
clinical There is an algorithm of children that have overwhelming sepsis where surgery cannot salvage these patients and there is no life saving option ↗
▶ Ep 48 · 3:41
clinical Many babies will rally without having their bowel removed, which allows them an opportunity ↗
▶ Ep 48 · 5:14
quote The first goal that drives me when I see these kids is protecting the liver. ↗
▶ Ep 48 · 5:49
clinical Decompressing the duodenum is needed to protect the liver ↗
▶ Ep 48 · 5:57
clinical When the liver is inflamed and has high bilirubin, it's in a catabolic state ↗
▶ Ep 48 · 7:34
clinical A 30-week-old baby's gut is in a highly developmental phase and its ability to regenerate is much more profound than a full term baby and certainly a one year old baby ↗
▶ Ep 48 · 8:04
clinical The distal bowel, the ileum, can be salvaged by ileocecal blood flow ↗
▶ Ep 48 · 8:17
clinical Bowel regeneration with proximal control occurs over 6, 8, 12 weeks based on the liver getting better ↗
▶ Ep 48 · 9:27
clinical The inflection point of bowel loss requiring prolonged TPN is about 50% ↗
▶ Ep 48 · 9:35
clinical If bowel necrosis is focal and less than 50%, the best option is to remove that bowel ↗
▶ Ep 48 · 9:44
clinical The adaptive potential for a child with less than 50% bowel loss is really great, especially if they have preserved ileum ↗
▶ Ep 48 · 10:00
clinical When bowel appears dead in a mosaic pattern with parts terrible, parts bad, and maybe a little good, proximal control with a drain and time to heal gives opportunity to come back later ↗
▶ Ep 48 · 10:00
quote It's not like when you look at it, it's all dead. We all know it's patchy. ↗
▶ Ep 48 · 10:14
clinical Not all bowel will survive and it will become islands of mucosa that need to be tubularized and put back together again ↗
▶ Ep 48 · 10:59
clinical Stomas lose abdominal domain and lose bowel down the road ↗
▶ Ep 48 · 11:11
clinical The percentage of kids that do well with proximal drain therapy when looking at dead gut is more than 70 to 80% ↗
▶ Ep 48 · 11:45
clinical Kids with necrotizing enterocolitis have the best outcomes because it's a microvascular disease ↗

Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 2

▶ Ep 49 · 2:55
clinical The ileum reclaims bile and tells the liver what to do ↗
▶ Ep 49 · 2:58
clinical The ileum produces hormones like GLP-2, PYY and others that slow motility and tell the jejunum to reabsorb fluid ↗
▶ Ep 49 · 3:15
clinical The colon can account for a third to half of the caloric needs of babies when exposed to undigested nutrients ↗
▶ Ep 49 · 3:24
clinical Short bowel syndrome kids are largely neurologically fine, running and playing ↗
▶ Ep 49 · 3:24
quote These kids largely are neurologically fine. They're running and playing, and the, the thought that you would be salvaging a baby to have a lifelong care need and their, their life expectancy would not be associated with things that most parents would want for their children is not what we see in the clinic. ↗
▶ Ep 49 · 3:50
quote And again, I think the take home message of this is the child should be the one driving the care, not your expectations or the lack thereof. ↗
▶ Ep 49 · 4:26
quote Well, I mean, obviously bowel removed is bowel never to be used. ↗
▶ Ep 49 · 4:26
clinical Bowel removed is bowel never to be used ↗
▶ Ep 49 · 4:48
epidemiological Most necrotizing enterocolitis kids don't have overwhelming totalis; NEC totalis is fairly rare ↗
▶ Ep 49 · 4:54
quote The comparative group to that patient is in a cemetery. As, as rude as that sounds, um, a dead child has no neurological function. ↗
▶ Ep 49 · 4:54
clinical Cincinnati has a dozen or more NEC totalis kids that are off TPN and have done remarkably ↗
▶ Ep 49 · 5:25
quote Once they live, the opportunities for us to move forward in this field and rehabilitate the bowel, the new tools that we will make in the next decade are going to be profound. ↗
▶ Ep 49 · 5:39
quote So you remove all the potential that we have in the future. Based on your clinical acumen that this is gonna have a bad outcome, and that it's time to withdraw. ↗
▶ Ep 49 · 6:49
clinical If a baby grows well with protein growth, linear growth and head growth, that's brain growth ↗
▶ Ep 49 · 6:49
quote If you see protein growth and linear growth of your baby and head growth, that's brain growth, and a baby will not grow well with a, with an unhealthy liver and is not managed well. ↗
▶ Ep 49 · 6:59
clinical An unhealthy liver is not providing the protein for neurocognitive development ↗
▶ Ep 49 · 6:59
clinical A baby will not grow well with an unhealthy liver ↗
▶ Ep 49 · 7:43
clinical Premature babies in the first year of life have caloric needs of 80, 100, 120 per kilo because they're growing and developing ↗
▶ Ep 49 · 7:52
clinical When critically ill, babies no longer grow and develop; they can be fed 150 kcals per kilo but will not grow because their livers are catabolic ↗
▶ Ep 49 · 7:52
quote When you're critically ill, you no longer are growing and developing. You can feed these babies 150 k cals per kilo, but they will not grow because their livers are catabolic. ↗
▶ Ep 49 · 8:21
quote So I know this baby is going to need multiple operations. So the incision is a transverse incision because I know over time that's the one that's going to give me the least problems. ↗
▶ Ep 49 · 8:25
clinical A transverse incision gives the least problems over time for patients requiring multiple operations ↗
▶ Ep 49 · 8:37
clinical An 8 or 10 French Blake drain is placed through bowel just beyond what is expected to heal, advanced retrograde to the pylorus ↗
▶ Ep 49 · 9:10
clinical A purse string is placed at the drain insertion site and secured to the skin, essentially creating a stoma to the abdominal wall ↗
▶ Ep 49 · 9:29
clinical A 5 to 7 French feeding tube can be placed into the proximal bowel via the stomach using a purse string technique ↗
▶ Ep 49 · 10:08
quote I try to avoid doing significant dissection of the distal ileum one because I wanna preserve the blood. So I wanna let the collateralization happen to recover as much of that proximal bowel as possible. ↗
▶ Ep 49 · 10:08
clinical Significant dissection of the distal ileum should be avoided to preserve blood supply and allow collateralization to recover proximal bowel ↗
▶ Ep 49 · 10:53
clinical A refeeding tube can be placed in the distal bowel to allow intermediate bowel to heal ↗
▶ Ep 49 · 11:19
clinical The volume of fluid output from injured bowel is very high initially; as bowel heals and regenerates reabsorptive capacity, output decreases ↗
▶ Ep 49 · 12:45
quote Once you explain to the family that the individual making the decisions moving forward is a baby, and you explain that to them, when things go bad, it actually makes it easier for them. ↗
▶ Ep 49 · 13:22
quote I think you'd be surprised at the number of kids who are sick, taken to the OR, but they're not as critically sick as we believe they're going to be. ↗
▶ Ep 49 · 13:22
clinical Many kids who appear critically sick preoperatively are not as sick as believed once proximal bowel is controlled and decompressed ↗
▶ Ep 49 · 14:31
quote Long term, if you take everything out, there are many of them that will heal, and then we have no opportunity. That Experiment's been done. ↗
▶ Ep 49 · 14:49
clinical Blake tubes have linear cuts on the outside so they won't get obstructed when secretions accumulate ↗
▶ Ep 49 · 14:58
clinical Blake tubes cannot be changed over a wire like JP drains with side holes ↗
▶ Ep 49 · 15:06
clinical Blake tubes are soft and don't tend to put pressure on damaged bowel ↗
▶ Ep 49 · 15:09
clinical Blake tubes can be connected to a bulb syringe and cut to size ↗

Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 1

▶ Ep 52 · 0:55
quote The word adaptation is to develop and to strengthen function. ↗
▶ Ep 52 · 1:01
clinical Adaptation is a natural process occurring in all infants during uterine development and the first few years of life, or as a regenerative response to damage in older children ↗
▶ Ep 52 · 1:25
clinical Adaptation takes time measured in months and years, not weeks and days, and requires enteral nutrition in all situations ↗
▶ Ep 52 · 3:34
clinical The duodenum is where caloric intake and sugars are sensed, hepatobiliary secretions occur, iron is absorbed, and it functions as an endocrine engine recognizing meal initiation ↗
▶ Ep 52 · 3:54
clinical The jejunum is largely a source of secretion of large amounts of fluid needed for digestion, with random back-and-forth sloshing motion ↗
▶ Ep 52 · 4:06
clinical The ileum secretes incretins GLP-2, GLP-1, and PYY that stop gastric emptying and slow motility when there is too much liquid in the distal bowel ↗
▶ Ep 52 · 4:31
clinical Distal ileum bile uptake sends a signal to the liver, which regulates the whole metabolism of the patient ↗
▶ Ep 52 · 4:46
clinical The colon, specifically the right colon, is a source of energy uptake from free fatty acids in short gut patients, which requires the presence of bacteria ↗
▶ Ep 52 · 5:01
clinical Colonic adaptation does not occur in most patients because energy is reclaimed before reaching the colon ↗
▶ Ep 52 · 7:06
opinion Healthy growth is the underlying driver of autonomy, not time off TPN ↗
▶ Ep 52 · 7:06
quote Healthy growth is the underlying. Driver, not time off TPN. ↗
▶ Ep 52 · 7:13
quote The last thing you need to come off a TPN is fluid. And so without hydration, the baby won't grow. ↗
▶ Ep 52 · 7:13
clinical The last thing needed to come off TPN is fluid, and without hydration the baby will not grow or efficiently absorb nutrition ↗
▶ Ep 52 · 12:40
clinical Lab data shows a shift in microbiota to one that is more acid-producing in an acidotic state, likely more full of bile because it is not being reclaimed ↗
▶ Ep 52 · 13:26
clinical NEC is an acquired condition; infants are born, start eating, often get up to full feeds, then have an incident usually at 2-3 weeks of life ↗
▶ Ep 52 · 13:38
clinical NEC patients have not been using their gut in utero during the critical period of 35 weeks to 6 months, making them different from children who have been fed before ↗
▶ Ep 52 · 13:58
quote It's really important that when you do a procedure on this child that you understand the 2nd and the 3rd and the 4th step. You, this is a game of chess. You really have to plan ahead. ↗
▶ Ep 52 · 14:05
opinion The sooner a child can be fed safely and bowel access obtained without exposing them to surgical risk, the more advantage can be taken of the adaptive process ↗
▶ Ep 52 · 14:48
opinion Surgery puts kids in harm's way no matter how talented the surgeon, so balancing operative risk with the ability to optimize feeding has led to improved outcomes ↗
▶ Ep 52 · 14:48
quote You put kids in harm's way when you go to the operating room, no matter how talented you are. ↗

Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1

▶ Ep 66 · 2:55
clinical The gut doubles in length in the last trimester and the first year of life ↗
▶ Ep 66 · 2:58
clinical Maturation of the intestine occurs when you feed the baby ↗
▶ Ep 66 · 3:03
clinical Healthy growth of the intestine requires nutrition ↗
▶ Ep 66 · 3:06
clinical Anything done to disrupt feeding affects the maturation of the intestine's ability to absorb, digest, and peristalse ↗
▶ Ep 66 · 3:21
quote The outcome is one that should benefit the child for 80, 90 years, not just the next 2 months. ↗
▶ Ep 66 · 3:46
quote The better the waves going over the villa, The more exposure of nutrients and removal of waste that you have is not increased by lengthening the bowel that doesn't peristals. That's just more static water. ↗
▶ Ep 66 · 3:46
clinical Lengthening bowel that doesn't peristalse doesn't increase absorption - it's just more static water ↗
▶ Ep 66 · 3:59
clinical Very short bowel kids sometimes come off TPN because their motility is so good ↗
▶ Ep 66 · 7:32
clinical The enteric nervous system is damaged in gastroschisis from exposure to amniotic fluid ↗
▶ Ep 66 · 7:32
clinical The enteric nervous system in gastroschisis has to go through a healing and recovery phase ↗
▶ Ep 66 · 7:46
clinical When exposed to more dysmotility and stasis, regeneration and healing of the enteric nervous system is attenuated ↗
▶ Ep 66 · 7:55
clinical A baby with atresia may have really good peristalsis that has been working against an obstruction ↗
▶ Ep 66 · 8:19
quote I have seen many a child with a first operation at that time that included steps that have just never gone forward and then have been labeled a poor motility child and accepted to not be able to tolerate enteral feeds, which I have challenges with. ↗
▶ Ep 66 · 8:19
clinical Children who have STEP procedures in the first year of life sometimes never progress and are labeled poor motility children ↗
▶ Ep 66 · 8:40
opinion Babies with necrotizing enterocolitis do better when they heal because they've been fed before and already have GI motility starting ↗
▶ Ep 66 · 8:43
quote They just do better when they heal. Most of them because they've been fed before. They already have geo immertility starting. That maturation phase has already been turned on because they didn't get neck the day they were born. ↗
▶ Ep 66 · 8:54
quote Tresia's 2, and I run from gastroschisis. ↗
▶ Ep 66 · 8:58
quote Anything that creates a potential worsening of motility and gastroschisis, especially in the first year of Life should be something you should strongly think about before doing. ↗
▶ Ep 66 · 17:32
clinical The duodenum doesn't have a mesentery, making it difficult to orient staple lines at 3 and 9 o'clock ↗

Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1

▶ Ep 67 · 1:23
clinical Adrian Bianchi first reported the longitudinal intestinal lengthening procedure (Bianchi procedure) that divides bowel along its two leaves and tubularizes it ↗
▶ Ep 67 · 2:13
clinical Rising direct bilirubin was recognized as a sign that children with intestinal failure would not do well ↗
▶ Ep 67 · 2:55
quote The gut doubles in length the last trimester in the first year of life. That maturation process occurs when you feed the baby. ↗
▶ Ep 67 · 2:55
clinical The gut doubles in length during the last trimester and the first year of life ↗
▶ Ep 67 · 2:58
clinical Intestinal maturation occurs when the baby is fed; healthy growth of the intestine requires nutrition ↗
▶ Ep 67 · 3:06
clinical Disrupting the feeding and maturation process affects not only the intestine's ability to absorb and digest but also peristalsis and function ↗
▶ Ep 67 · 3:21
quote The outcome is one that should benefit the child for 80, 90 years, not just the next 2 months. ↗
▶ Ep 67 · 3:46
quote The better the waves going over the villa, The more exposure of nutrients and removal of waste that you have is not increased by lengthening the bowel that doesn't peristals. That's just more static water. ↗
▶ Ep 67 · 3:46
clinical Lengthening bowel that doesn't have peristalsis does not increase absorption; it's just more static water ↗
▶ Ep 67 · 3:59
clinical Very short bowel children can sometimes come off TPN because their motility is so good ↗
▶ Ep 67 · 7:32
clinical The enteric nervous system in gastroschisis must go through a healing and recovery phase that is attenuated by dysmotility and stasis ↗
▶ Ep 67 · 7:55
clinical Atresia patients may have good peristalsis from bowel working against obstruction, and longitudinal stapling procedures may benefit them ↗
▶ Ep 67 · 8:19
clinical Children who undergo STEP procedures in the first year of life sometimes never progress and are labeled as poor motility patients unable to tolerate enteral feeds ↗
▶ Ep 67 · 8:19
quote I have seen many a child with a first operation at that time that included steps that have just never gone forward and then have been labeled a poor motility child and accepted to not be able to tolerate enteral feeds, which I have challenges with. ↗
▶ Ep 67 · 8:40
opinion Necrotizing enterocolitis patients do better than other intestinal failure etiologies because they have been fed before disease onset, initiating GI motility and maturation ↗
▶ Ep 67 · 8:43
quote They just do better when they heal. Most of them because they've been fed before. They already have geo immertility starting. That maturation phase has already been turned on because they didn't get neck the day they were born. ↗
▶ Ep 67 · 8:54
quote Tresia's 2, and I run from gastroschisis. ↗
▶ Ep 67 · 10:22
opinion Stepping the duodenum in non-rotated children is fraught with problems and causes significant issues later in life ↗
▶ Ep 67 · 17:32
clinical The duodenum has no mesentery, making it impossible to orient staple lines at 3 and 9 o'clock positions as in the jejunum ↗

Intestinal Rehabilitation, Episode 4: Surgical Management, Part 2

▶ Ep 68 · 3:40
clinical Half of patients who have a STEP will have progression of improved enteral tolerance, while half will have worsening ↗
▶ Ep 68 · 3:40
quote Half of the people that have a step will have progression of improved animal tolerance. Half will have actually a worsening. ↗
▶ Ep 68 · 4:08
quote If you're going to operate on a kid for a step procedure, you need to first rule out other anatomical problems. ↗
▶ Ep 68 · 4:08
clinical Before performing STEP, other anatomical problems must be ruled out by laying out the bowel and getting the mesentery completely oriented ↗
▶ Ep 68 · 5:00
opinion There is nothing wrong with staging surgical procedures in intestinal failure patients ↗
▶ Ep 68 · 5:00
quote There is nothing wrong with staging. ↗
▶ Ep 68 · 5:39
quote One of the things that we've seen as a complication here is that the kids have done really well with step procedures, but they have continued loss from either they lose protein in the stool or we see recurrent bleeding. ↗
▶ Ep 68 · 5:39
clinical Ulcers at STEP staple lines are not uncommon and can cause recurrent bleeding requiring monthly transfusions for years ↗
▶ Ep 68 · 6:01
quote And that's an absolute indication to operate. ↗
▶ Ep 68 · 6:01
clinical Chronic blood loss at the STEP line is an absolute indication to operate ↗
▶ Ep 68 · 7:52
clinical The underlying issue in staple-line bleeding is mesenteric inflammation and scarring that creates obstruction to venous outflow, not primary bowel pathology ↗
▶ Ep 68 · 8:03
quote And so that mesenteric fire that Causes inflammation and scarring, creates an obstruction to venous outflow. ↗
▶ Ep 68 · 8:03
clinical Mesenteric inflammation causes venous hypertension along the staple lines ↗
▶ Ep 68 · 8:33
quote And when you operate. You can see vessels the size of your thumb, and you'll see really big adenopathy because the lymphatics are also obstructed. ↗
▶ Ep 68 · 8:33
clinical During surgery for staple-line bleeding, vessels the size of your thumb and really big adenopathy can be seen due to lymphatic obstruction ↗
▶ Ep 68 · 8:42
clinical Once mesenteric scar is freed up, the enlarged vessels come right back to normal ↗
▶ Ep 68 · 8:53
clinical Venous hypertension is what leads to the bleeding from staple lines ↗
▶ Ep 68 · 9:05
clinical Staple line revision is typically done with hand-sewn stitch to reconnect the bowel ↗
▶ Ep 68 · 9:09
clinical The key to managing staple-line bleeding is to look at the mesentery and free up the mesentery, not just look at the bowel ↗
▶ Ep 68 · 9:09
quote So the key to me in that situation of bleeding is look at the mesentery. Make sure you free up the mesentery. Don't just look at the bowel. ↗
▶ Ep 68 · 9:27
opinion Mesenteric pathology causing staple-line bleeding is obvious if you are looking for it ↗
▶ Ep 68 · 9:27
quote It's so obvious if you're looking for it. ↗
▶ Ep 68 · 10:33
opinion Detailed operative notes documenting orientation, landmarks, and what was done are important for future operations ↗
▶ Ep 68 · 10:52
quote Try not to be the hero. Try not to do everything, especially the first week in life. ↗
▶ Ep 68 · 10:52
opinion Surgeons should try not to be the hero and try not to do everything, especially in the first week of life ↗
▶ Ep 68 · 11:05
quote These are families that you need to grow up with. ↗
▶ Ep 68 · 11:05
opinion The surgeon plays a huge role in intestinal failure management even when patients are doing well, because progress must be monitored ↗

Intestinal Rehabilitation, Episode 6: Cholestasis

▶ Ep 73 · 1:57
opinion Cholestasis is now more an indicator of underlying diseases that need to be addressed rather than a direct morbidity/mortality factor ↗
▶ Ep 73 · 1:57
quote I believe though that as we've gotten better and we've learned how to use lipid emulgens differently and nutrition differently and our approaches. That the definition of cholestasis is not as much as a morbidity mortality as much as it is an indicator of underlying diseases that we need to address. ↗
▶ Ep 73 · 3:53
quote So when you talk about the kid that's cholestatic, it really starts at the very beginning. So the first question that I always ask is, has this child ever been enterally fed, and where did we start with our cholestasis and, and where are we at in gestational age and progress? ↗
▶ Ep 73 · 5:12
clinical Limiting fat in TPN to 1 g/kg/day can help prevent cholestasis ↗
▶ Ep 73 · 5:20
clinical New lipid emulsions (Omegaven first in US, then SMOF in Europe/Canada and now US over last 3-4 years) can reverse or prevent cholestasis ↗
▶ Ep 73 · 6:15
quote One of the major advantages I think of the addition of SMP is the ability to provide more calories from fat, as much as 2 2.5 g per kilo. ↗
▶ Ep 73 · 6:15
clinical SMOF lipids allow provision of more calories from fat, as much as 2-2.5 g/kg ↗
▶ Ep 73 · 9:38
clinical When refeeding a cholestatic liver after jejunostomy takedown, direct bilirubin and liver enzymes (GGT, AST, ALT) will initially rise in the first 1-2 weeks as bile acid pool is reintroduced and liver becomes more active ↗
▶ Ep 73 · 9:38
quote One of the first things that you'll get your neonatologist telling you about when you start feeding is they'll get worried because the direct bilirubin goes up. That's normal. ↗
▶ Ep 73 · 10:46
quote So I think it's really important to try to provide proximal drainage of the duodenum. ↗
▶ Ep 73 · 11:18
clinical Proximal blockage puts pressure in the biliary system at a much higher level and speeds up the cholestatic process ↗
▶ Ep 73 · 11:31
clinical G-tubes do not decompress the duodenum ↗
▶ Ep 73 · 11:31
quote G tubes do not decompress the duodenum. ↗

Intestinal Rehabilitation, Episode 7: Refeeding in a neonatal patient

▶ Ep 79 · 2:37
clinical Damaged bowel is in a secretory phase even when not fed ↗
▶ Ep 79 · 2:37
quote Yeah, remember that especially if there's been damaged bowel, it's gonna be in a secretory phase, even if it's not fed, and people are scared then to feed. ↗
▶ Ep 79 · 2:46
quote And feeling like it's gonna be totally uncontrollable, whereas what happens is the exact opposite, as you start to feed the bowel, then gets in an absorptive state, because the nutrition that's present in the luminal stimulate it to do so, and you'll actually start to see less volume out the stoma in time. ↗
▶ Ep 79 · 2:46
clinical Starting to feed the bowel transitions it to an absorptive state because luminal nutrition stimulates absorption, resulting in decreased stoma volume over time ↗
▶ Ep 79 · 3:40
clinical Breast milk is the ideal first choice for feeding due to nutritional value, immunomodulatory effects, and growth healing effects not present in typical formulas ↗
▶ Ep 79 · 3:54
quote Mom's breast milk is ideal, not just because of the nutritional value, but certainly because it has all the immunomodulatory beneficial effects, growth healing effects. ↗
▶ Ep 79 · 4:08
guideline Donor breast milk is the second choice when maternal breast milk is unavailable ↗
▶ Ep 79 · 5:21
clinical Long-chain fatty acids have developmental and immune properties ↗
▶ Ep 79 · 5:51
clinical It is a common mistake to decrease TPN by the same volume that enteral feeds are increased, assuming the child will absorb all those calories, which results in stunted growth ↗
▶ Ep 79 · 5:51
quote It's a common mistake to increase enteral feeds by X volume that you decrease TPN by, and what you end up doing is you're assuming that the child. And absorb all those calories, and you end up stunting the growth. ↗
▶ Ep 79 · 6:44
clinical If the child tolerates it and does not have lung issues, total daily volume can be expanded from 140 to 160, 170, or occasionally 180 mL/kg ↗
▶ Ep 79 · 9:28
clinical When children have not been fed and have had an injury, gastric coordination is commonly disrupted ↗
▶ Ep 79 · 9:28
quote By far the most complicated part of our GI tract is the stomach, because it does both the back and forth, uh, sloshing around that the small bowel does, but in addition, it has to coordinate a squeeze with the relaxation of the pylorus several. Times a minute to induce small amounts of gastric emptying, and so it's not uncommon that when children haven't been fed and they've had an injury, the coordination of the stomach is completely off. ↗
▶ Ep 79 · 9:28
clinical The stomach is the most complicated part of the GI tract because it must coordinate both back-and-forth mixing and coordinated squeezing with pyloric relaxation several times per minute ↗
▶ Ep 79 · 10:02
clinical Gastric dysmotility after intestinal injury requires time and stimulation to resolve ↗
▶ Ep 79 · 10:15
clinical Post-pyloric feeding with simultaneous gastric decompression allows distal bowel stimulation, which produces hormones that signal the stomach to start functioning and break the dysmotility cycle ↗
▶ Ep 79 · 11:03
clinical Post-pyloric refeeding can be done as a bolus or over a pump; bolus is preferred, but running it over a pump for one hour works well at Cincinnati Children's ↗
▶ Ep 79 · 11:03
guideline The Cincinnati Children's protocol typically starts post-pyloric feeds at 5 mL/kg, then 10 mL/kg, and advances based on tolerance ↗
▶ Ep 79 · 11:25
quote Interestingly, by feeding the colon, one of the things you'll notice quickly is that the output from the stoma actually goes down, speaking to all the hormonal effects of the distal bowel, and often the stomach will start to work. ↗
▶ Ep 79 · 11:25
clinical Feeding the distal colon reduces stoma output due to hormonal effects of the distal bowel, and often the stomach will start to work ↗
▶ Ep 79 · 11:50
clinical When distal bowel has been functionally used through refeeding, the time to start feeding postoperatively after anastomosis is made easier ↗
▶ Ep 79 · 12:34
opinion Undigested formula in the colon is a trigger that can cause stress to the bowel and may not be the healthiest approach ↗
▶ Ep 79 · 12:53
clinical Placing a feeding tube into the stomach at the time of surgery does not commit the child to a lifelong G-tube or even for the first year ↗
▶ Ep 79 · 13:06
clinical A gastric tube can be directed out of the pylorus into the proximal small bowel as a source of feeding to overcome unpredictable obstacles ↗
▶ Ep 79 · 13:24
clinical When a gastric tube is no longer needed, it can be removed and the hole heals quickly like any other tube site ↗
▶ Ep 79 · 14:05
opinion The morbidity from a gastric tube is extremely low and the benefit can be very high ↗

Intestinal Rehabilitation Episode 8: Refeeding of an Older Patient

▶ Ep 80 · 1:11
clinical Older children (8-16 years) who experience volvulus can lose 90+% of their bowel ↗
▶ Ep 80 · 4:55
clinical Some patients can come off TPN but still need a central line for IV fluids ↗
▶ Ep 80 · 4:55
clinical Without adequate IV fluids, patients end up sleeping most of the day and don't have energy ↗
▶ Ep 80 · 5:08
clinical Being in a hydrated state is extremely important to making the bowel work well ↗
▶ Ep 80 · 5:31
clinical Sometimes patients can't drink rehydration solution but the GI tract can use it via G-tube ↗
▶ Ep 80 · 5:32
quote Sometimes they can't drink it, but the GI tract can use it. ↗
▶ Ep 80 · 5:51
clinical Children doing well often hit the wall when they start puberty because energy needs overcome nutrient input ↗
▶ Ep 80 · 5:51
quote The other key point to remember is that the energy use goes up dramatically during puberty ↗
▶ Ep 80 · 5:51
clinical Energy use goes up dramatically during puberty ↗
▶ Ep 80 · 6:57
opinion A 3rd percentile growth should not be accepted for most intestinal failure patients ↗
▶ Ep 80 · 6:57
clinical There are very few conditions with intestinal failure that have restricted growth ↗
▶ Ep 80 · 6:57
quote I can't emphasize enough to look at the growth chart, both the weight, but also the height, and don't accept a 3rd percentile. ↗
▶ Ep 80 · 7:06
quote There are very few conditions with intestinal failure that have restricted growth ↗
▶ Ep 80 · 9:34
clinical For any child not meeting growth potential, numerous other diagnoses must be considered including endocrine issues, pancreatic insufficiency, and micronutrient deficiencies ↗
▶ Ep 80 · 9:54
clinical After addressing growth issues, improvements should be assessed on the order of weeks not months ↗
▶ Ep 80 · 10:15
clinical Growth monitoring can be done remotely and should not wait until the next appointment ↗

Intestinal Rehabilitation Webinar 2023 - Top 5 Key Takeaways

▶ Ep 83 · 2:30
clinical The more important factor is the presence or absence of the distal small bowel or ileum and right colon that can act as reclamation of bile and support enterohepatic circulation ↗
▶ Ep 83 · 2:30
quote So, to me, I believe the more important fact is the presence or absence of the distal small bowel or the ileum and even right colon that can act as a reclamation of bile and get the inneroppatic circulation. ↗
▶ Ep 83 · 2:43
clinical GLP-2, GLP-1, and hormones like PYY are produced in the distal ileum, not because of the ileocecal valve but because of the distal ileum itself ↗
▶ Ep 83 · 3:29
quote I think sometimes strategy at the first operation is to be able to provide a pathway forward that allows early interval feeding. ↗
▶ Ep 83 · 3:29
clinical Strategy at the first operation should provide a pathway forward that allows early interval feeding ↗
▶ Ep 83 · 3:38
opinion It is sometimes better to stage reconstruction under more controlled conditions rather than attempt immediate continuity ↗
▶ Ep 83 · 4:02
clinical Many segments of bowel deemed non-usable actually have potential to heal in this population and can make a huge difference in the lifetime of the child ↗
▶ Ep 83 · 6:42
clinical Breast milk is the formula of choice, not only for nutritional benefits but for all the other components within breast milk ↗
▶ Ep 83 · 6:42
quote Obviously, formula of choice coming from the breast, breast milk, always mess. ↗
▶ Ep 83 · 7:28
clinical Single amino acid level protein is the generalized preference to avoid high stool output, high fluid losses, wound breakdown, rashes, and emesis ↗
Motility / Pseudo-obstruction 23 entries

Intestinal rehabilitation: What is intestinal rehab? - Episode 1

▶ Ep 5 · 2:40
opinion Earlier recognition and taking advantage of the gut's biology to adapt are time dependent ↗
▶ Ep 5 · 4:07
quote What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing. ↗
▶ Ep 5 · 4:07
clinical Intestinal rehabilitation comes down to key factors: nutrition in the gut, nutrition in the body, and healing ↗
▶ Ep 5 · 4:19
opinion Pattern recognition from multiple experienced providers seeing patients over time is essential in intestinal rehabilitation ↗
▶ Ep 5 · 4:24
quote So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time. ↗
▶ Ep 5 · 8:30
opinion Families living within the region can benefit from understanding that delivery at an intestinal rehab center from the beginning is probably beneficial ↗
▶ Ep 5 · 9:15
clinical Prenatal diagnoses that lead to intestinal rehab referral include atresia with cystic fibrosis and gastroschisis ↗
▶ Ep 5 · 10:15
quote I've long believed that your ideas that first come to your head always have ways to improve, and that, that you only see things through one way. ↗
▶ Ep 5 · 10:25
quote Innovation comes from multiple approaches to the problem and Different visions of the problem, the more expertise you bring in, um, the better the outcome is. ↗
▶ Ep 5 · 10:25
opinion Innovation comes from multiple approaches to the problem and different visions, with more expertise bringing better outcomes ↗
▶ Ep 5 · 10:51
clinical Transitioning older children with intestinal failure into their late teen years and later is a major obstacle that needs to be addressed ↗
▶ Ep 5 · 11:43
clinical The intestinal rehab team includes surgeons, GI doctors, neonatologists, dietitians, social work, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology ↗
▶ Ep 5 · 13:21
quote I think the big key to a person watching the podcast is that they get hope. These are wonderful children. They're, they're opportunities to grow up and to live the lives that their families want is really in front of them. ↗

Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?

▶ Ep 6 · 2:40
clinical Earlier recognition and taking advantage of the biology of the gut to adapt are time dependent ↗
▶ Ep 6 · 4:07
clinical Intestinal rehabilitation comes down to key factors that drive the process: nutrition in the gut, nutrition in the body, and healing ↗
▶ Ep 6 · 4:19
opinion Pattern recognition from multiple eyes on a baby who have seen them over time is important in intestinal rehabilitation ↗
▶ Ep 6 · 8:53
clinical There are three time points where families reach intestinal rehabilitation programs: prenatal diagnosis, postnatal acquired problems, and later presentations after discharge ↗
▶ Ep 6 · 9:15
clinical Prenatal diagnoses that lead to intestinal rehabilitation typically include atresia with cystic fibrosis and gastroschisis ↗
▶ Ep 6 · 10:25
quote Innovation comes from multiple approaches to the problem and Different visions of the problem, the more expertise you bring in, um, the better the outcome is ↗
▶ Ep 6 · 11:52
opinion Dietitians play a key role in understanding the nutritional needs of children in intestinal rehabilitation ↗
▶ Ep 6 · 12:01
opinion Social work is a key component of the intestinal rehabilitation team ↗
▶ Ep 6 · 13:21
quote I think the big key to a person watching the podcast is that they get hope ↗
▶ Ep 6 · 13:51
quote there's nothing that puts more energy back into you wanting to go better uh than that hug. Um, like I said, we work for hugs ↗
Short Bowel Syndrome 42 entries

Intestinal rehabilitation: What is intestinal rehab? - Episode 1

▶ Ep 3 · 2:40
opinion Earlier recognition and taking advantage of the gut's biology to adapt are time dependent ↗
▶ Ep 3 · 4:07
quote What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing. ↗
▶ Ep 3 · 4:07
clinical Intestinal rehabilitation comes down to key factors: nutrition in the gut, nutrition in the body, and healing ↗
▶ Ep 3 · 4:19
opinion Pattern recognition from multiple experienced providers seeing patients over time is essential in intestinal rehabilitation ↗
▶ Ep 3 · 4:24
quote So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time. ↗
▶ Ep 3 · 8:30
opinion Families living within the region can benefit from understanding that delivery at an intestinal rehab center from the beginning is probably beneficial ↗
▶ Ep 3 · 9:15
clinical Prenatal diagnoses that lead to intestinal rehab referral include atresia with cystic fibrosis and gastroschisis ↗
▶ Ep 3 · 10:15
quote I've long believed that your ideas that first come to your head always have ways to improve, and that, that you only see things through one way. ↗
▶ Ep 3 · 10:25
quote Innovation comes from multiple approaches to the problem and Different visions of the problem, the more expertise you bring in, um, the better the outcome is. ↗
▶ Ep 3 · 10:25
opinion Innovation comes from multiple approaches to the problem and different visions, with more expertise bringing better outcomes ↗
▶ Ep 3 · 10:51
clinical Transitioning older children with intestinal failure into their late teen years and later is a major obstacle that needs to be addressed ↗
▶ Ep 3 · 11:43
clinical The intestinal rehab team includes surgeons, GI doctors, neonatologists, dietitians, social work, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology ↗
▶ Ep 3 · 13:21
quote I think the big key to a person watching the podcast is that they get hope. These are wonderful children. They're, they're opportunities to grow up and to live the lives that their families want is really in front of them. ↗

Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?

▶ Ep 4 · 2:40
clinical Earlier recognition and taking advantage of the biology of the gut to adapt are time dependent ↗
▶ Ep 4 · 4:07
clinical Intestinal rehabilitation comes down to key factors that drive the process: nutrition in the gut, nutrition in the body, and healing ↗
▶ Ep 4 · 4:19
opinion Pattern recognition from multiple eyes on a baby who have seen them over time is important in intestinal rehabilitation ↗
▶ Ep 4 · 8:53
clinical There are three time points where families reach intestinal rehabilitation programs: prenatal diagnosis, postnatal acquired problems, and later presentations after discharge ↗
▶ Ep 4 · 9:15
clinical Prenatal diagnoses that lead to intestinal rehabilitation typically include atresia with cystic fibrosis and gastroschisis ↗
▶ Ep 4 · 10:25
quote Innovation comes from multiple approaches to the problem and Different visions of the problem, the more expertise you bring in, um, the better the outcome is ↗
▶ Ep 4 · 11:52
opinion Dietitians play a key role in understanding the nutritional needs of children in intestinal rehabilitation ↗
▶ Ep 4 · 12:01
opinion Social work is a key component of the intestinal rehabilitation team ↗
▶ Ep 4 · 13:21
quote I think the big key to a person watching the podcast is that they get hope ↗
▶ Ep 4 · 13:51
quote there's nothing that puts more energy back into you wanting to go better uh than that hug. Um, like I said, we work for hugs ↗

Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1

▶ Ep 5 · 1:23
clinical Adrian Bianchi first reported the longitudinal intestinal lengthening procedure (Bianchi procedure) that divides bowel along its two leaves and tubularizes it ↗
▶ Ep 5 · 2:13
clinical Rising direct bilirubin was recognized as a sign that children with intestinal failure would not do well ↗
▶ Ep 5 · 2:55
quote The gut doubles in length the last trimester in the first year of life. That maturation process occurs when you feed the baby. ↗
▶ Ep 5 · 2:55
clinical The gut doubles in length during the last trimester and the first year of life ↗
▶ Ep 5 · 2:58
clinical Intestinal maturation occurs when the baby is fed; healthy growth of the intestine requires nutrition ↗
▶ Ep 5 · 3:06
clinical Disrupting the feeding and maturation process affects not only the intestine's ability to absorb and digest but also peristalsis and function ↗
▶ Ep 5 · 3:21
quote The outcome is one that should benefit the child for 80, 90 years, not just the next 2 months. ↗
▶ Ep 5 · 3:46
quote The better the waves going over the villa, The more exposure of nutrients and removal of waste that you have is not increased by lengthening the bowel that doesn't peristals. That's just more static water. ↗
▶ Ep 5 · 3:46
clinical Lengthening bowel that doesn't have peristalsis does not increase absorption; it's just more static water ↗
▶ Ep 5 · 3:59
clinical Very short bowel children can sometimes come off TPN because their motility is so good ↗
▶ Ep 5 · 7:32
clinical The enteric nervous system in gastroschisis must go through a healing and recovery phase that is attenuated by dysmotility and stasis ↗
▶ Ep 5 · 7:55
clinical Atresia patients may have good peristalsis from bowel working against obstruction, and longitudinal stapling procedures may benefit them ↗
▶ Ep 5 · 8:19
clinical Children who undergo STEP procedures in the first year of life sometimes never progress and are labeled as poor motility patients unable to tolerate enteral feeds ↗
▶ Ep 5 · 8:19
quote I have seen many a child with a first operation at that time that included steps that have just never gone forward and then have been labeled a poor motility child and accepted to not be able to tolerate enteral feeds, which I have challenges with. ↗
▶ Ep 5 · 8:40
opinion Necrotizing enterocolitis patients do better than other intestinal failure etiologies because they have been fed before disease onset, initiating GI motility and maturation ↗
▶ Ep 5 · 8:43
quote They just do better when they heal. Most of them because they've been fed before. They already have geo immertility starting. That maturation phase has already been turned on because they didn't get neck the day they were born. ↗
▶ Ep 5 · 8:54
quote Tresia's 2, and I run from gastroschisis. ↗
▶ Ep 5 · 10:22
opinion Stepping the duodenum in non-rotated children is fraught with problems and causes significant issues later in life ↗
▶ Ep 5 · 17:32
clinical The duodenum has no mesentery, making it impossible to orient staple lines at 3 and 9 o'clock positions as in the jejunum ↗