Ileal Atresia Rapid Fire: Update Course 2015

Dressing adequately. It was actually in detail. We're already 10 minutes over, so let's go to Iolares. So apple peel deformity, this will be very quick. We'll run through this child with the apple peel ileal atresia, how do you manage this? This is a child, as you may see here, has a clear atresia between two ends of the bowel, and then this ischemic or necrotic looking apple apple peel. How would the group handle this one? Well, that's a, that's a tough one because of the schemic looking. Ilium, in general, if the ileum looks fine, you'd, you'd put it together and very gingerly and carefully put things back into the, into the um abdominal cavity. If, if you're concerned about that one though, I'm not sure I wouldn't put anything together. You might just drop it back in, um, and, um, and see because you've got to make sure that that bowel is. Appropriately vascularized in order to do anastomosis. So, I mean, this is not gastroschisis, you've just taken it out, OK. And so, you know, this is an atresia. I, I'm not sure you'll learn much from leaving it back in. OK. I guess somehow in my mind I was thinking it was a gastroschisis type valve, but, but anyway, I don't think you can put that together if, if there's, if you're concerned about the vascularization of the distal ileum. That's exactly right. So it was ischemic and it's easier to tell obviously on the table than on a, on a picture, um, and we did 4 anastomosis and put it all together. Uh, but, uh, you know, the point is these children have relatively short gut. The, um, apple peeled bowel is not, not always that healthy, and some, and this is also another clear case that needed one anastomosis. And then, uh, we have these cases where you do have a good distal small bowel. Um, that needs to have an anastomosis. I usually, what was the reason for the vascular insufficiency in that first bowel? Was it just twisted and you untwisted and it was fine? The 1st and 2nd 1, it just wasn't adequate, even though it wasn't twisted, just was inadequate. So you resected that resected because it was 4 resected, right? Yeah, resected. This, this one over here we resected as well. You can see it's non-viable bowel. And then this one, of course, nice and healthy. We do the anastomosis. I'm not sure what the group's experience is, but these are difficult cases. The only thing I would argue is, is if it was ischemic, not necrotic, you could wait till tomorrow and see if it pinked up at all. But you said, but then again, you did say it wasn't twisted or anything. It wasn't twisted. It didn't pink up on the table. It was what we found this kid. No, but that's a good point on this kid over here. I did do a placation. I find that, that a placation of this, uh, bowel is often helpful. Who does placation? So no, I was gonna say if you have that same patient but less small. bowel and you're worried about short bowel. I have done the steps to that proximal intestine in this scenario where you didn't have all the distal small bowel. Yes, and that's a good point. I mean, my, my preference is actually Bianchi procedure. I find it smoother. I find you get 22 equal chambers. You don't get these blind ending out pouchings, although the step is a very ingenious operation and a very good one when there's no good blood supply. But I, I wouldn't do that in the neonatal period. I would hook it up together, usually do a placation, then come back because these placations usually unravel with time. Come back and use that bowel for whatever your preference for bowel lengthening. The Last update from the step registry was to discourage doing um uh steps in the perinatal period, that those outcomes were. That those outcomes were difficult at best, and then also that steps in patients with gastroschisis and independent of these atresias, the patients have such motility disorders that they really aren't all that beneficial. What we're doing is we prefer a Bianchi as a choice because you can Bianchi and then step, um, whereas once you step you can re-step, but your, your ability to lengthen has been altered. So at least for the way we kind of think about it, and I'm we're working with Mike Humrath and Jamie Nathan and my other partners who focus on this disease process. We don't try to step early because it doesn't, it's not particularly favorable. I don't, I think location is certainly a choice, um, but it's not something that we, we generally will try to decompress that and salvage as much bowel length as possible. Yeah, I would, I would agree with you, Greg. Um, I, I, I also like to hear that you prefer the Bianchi because that's my philosophy as well. Um, we have a very big series in Washington DC, um, and the neonatal step is kind of, uh, unusual. I don't think I would, uh, I would, I wouldn't, uh, suggest that that's the right way to go. Uh, you do sometimes have to do something for that very dilated bowel that's dysfunctional, that becomes a cesspool of bacterial stasis. Yeah, I think that's, that's correct, but I think the point is we don't want to send out a message that the idea of a newborn step is something that is something that's being favorably looked upon in terms of at least my understanding from the last step registry report, which I think was just a couple of years ago. What about application versus tab? So that's, that's another great question. Um, in general, in these newborns, and especially one with a questionable shortcut, I would not, uh, taper because you want to save that bowel for, for potential lengthening later. Uh, certainly if a kid's got an extensive amount of, of, uh, bowel and you've got a segment, uh, that, that's dilated, then a plaque, then a, a tapering is very reasonable. OK, I think.