From
Dr. Michael Helmrath
Managing overwhelming intestinal catastrophe in neonates: when to operate
With Dr. Paul Wales & Dr. Michael Helmrath · hosted by Dr. Rod Gerardo
Chapter 1 of 7
Paradigm shift
Introduction and paradigm shift overview
Expert statements on this page
No expert statements were drawn from this page.
Host summaries · secondary, not cited in answers
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Ultra-short gut is defined as less than 20% of expected bowel length for age, which in a term baby is 20-30 centimeters or less
In babies with ultra-short gut managed with current era approaches, overall survival is over 90%
Ultra-short gut patients who did better tended to have remnant ileum as part of residual bowel and longer colonic remnants
The ileum produces hormones like GLP-2, PYY and others that slow motility and signal the jejunum to reabsorb fluid
The colon can account for a third to half of caloric needs in these babies when exposed to undigested nutrients
These children with intestinal failure are largely neurologically fine, running and playing, with normal life expectancy
Bowel removed is bowel never to be used
The fear that inflammatory response from delayed surgery affects neurocognitive outcomes needs to be supported with data
NEC totalis in NEC kids is fairly rare
A dozen or more kids with NEC totalis have survived, gotten off TPN, and done remarkably well
If a baby grows well with protein growth, linear growth, and head growth, that represents brain growth
A baby will not grow well with an unhealthy liver that is not managed well
An unhealthy liver does not provide the protein needed for neurocognitive development
Lipid restriction was never a practice subscribed to by the Cincinnati program for managing these patients
Premature babies in the first year of life have caloric needs of 80-120 kcal/kg because they are growing and developing
When critically ill, babies no longer grow and develop; they can be fed 150 kcal/kg but will not grow because their livers are catabolic
A transverse incision is preferred because it will cause the least problems over time with multiple operations
An 8 or 10 French Blake drain is placed through bowel that is not expected to heal well, advanced retrograde to the pylorus, with a tie around healthy bowel to control secretions
A 5-7 French feeding tube can be placed in the stomach through a purse string to enable early feeding access
Significant dissection of the distal ileum should be avoided to preserve blood supply and allow collateralization to recover proximal bowel
A refeeding tube can be placed in distal bowel to allow intermediate bowel to heal while maintaining liver health
Intraoperative decisions by the surgeon have a lifelong impact on whether a child with short bowel syndrome stays on or gets off TPN or whether they survive
Many kids who appear critically sick preoperatively are not as critically sick as believed once proximal bowel is controlled and decompressed
Often these kids look worse over the next 24-36 hours after surgery, then stop getting worse before they start improving
Blake tubes have linear cuts on the outside so they do not get obstructed when secretions accumulate around them
The downside of Blake tubes is they cannot be changed over a wire like JP drains with side holes
Blake tubes are soft and do not put much pressure on damaged bowel, and can be connected to a bulb syringe
Ultra-short gut patients with survival rates of 90-95% rarely die of liver failure anymore and rarely get transplanted
When damaged bowel weeps and secretes fluids, the volume of output is initially high; as it heals and regenerates reabsorptive capacity, drain output decreases as a sign of healing
50% bowel length is the cutoff used to determine salvageability in overwhelming intestinal catastrophe