Introduction to intestinal rehabilitation and intestinal failure in pediatric surgery

Until recently, there was no standardized definition for intestinal failure.

Intestinal failure is when someone's gut function is insufficient to absorb enough nutrients, fluids, and calories to support survival and, in children, growth.

Earlier recognition and taking advantage of the biology of the gut that wants to adapt and meet the needs of the child are time dependent.

An intestinal rehabilitation program is a multidisciplinary or interdisciplinary collaborative patient care paradigm that brings coordinated care for children with intestinal failure through comprehensive management of their specialized nutrition and other associated needs.

Intestinal rehabilitation comes down to key factors that drive the process: nutrition in the gut, nutrition in the body, and healing.

The causes of intestinal failure can be divided into three categories: short bowel syndrome, motility disorders, and mucosal enteropathies or congenital diarrheas.

Short bowel syndrome is by far the most common category in pediatric patients with intestinal failure.

Causes of short bowel syndrome are usually related to congenital anomalies such as intestinal atresia, malrotation, volvulus, gastroschisis, or long segment Hirschsprung's disease, or acquired diseases of the newborn such as necrotizing enterocolitis.

In motility disorders, the bowel is unable to push things through in a coordinated way due to abnormalities of the muscle itself or of the nerves that control that muscle.

In mucosal enteropathies or congenital diarrheas, the patient has all of their bowel, but the mucosa (the inside lining that digests and absorbs) doesn't work.

Some patients will have elements of one, two, or all three categories of intestinal failure.

Although most patients referred to intestinal rehab programs are infants or babies, there are some older kids that develop intestinal failure.

Older pediatric patients can develop intestinal failure from inflammatory bowel disease or Crohn's disease (where they've lost gut as a result of complications), trauma, malignancy, or vascular thrombosis leading to gut loss.

Diagnoses like inflammatory bowel disease, trauma, malignancy, and vascular thrombosis are seen more in older patients or in adult series, and less so in pediatrics.

Prenatal diagnoses that lead to intestinal rehab referral typically include atresia (which could be with cystic fibrosis) and gastroschisis.

Innovation comes from multiple approaches to the problem and different visions of the problem; the more expertise you bring in, the better the outcome is.

How to take the older child who's had intestinal failure into their late teen years and later is a major obstacle that needs to be addressed and is currently not being met.

Dietitians and understanding the nutritional needs of a child are critical components of the intestinal rehabilitation team.

Social work is a really key part of the intestinal rehabilitation team.

Extended providers including nurse practitioners are fantastic and essential to the intestinal rehabilitation team.

Pharmacy, social work, interventional radiology, pathology, endocrinology, and nephrology are all important components of the intestinal rehabilitation team.

Kids with intestinal failure who survive long-term have developed chronic comorbidities that weren't seen to the same extent before because they didn't live long enough.

Long-term survivors of intestinal failure are now seeing diseases like renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life issues.

Having a coordinated team that can track chronic comorbidity problems long-term is vital for intestinal failure patients.