# Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 1 — GCMD Library

We're back with a new episode from the Intestinal Rehabilitation Center at Cincinnati Children's Hospital. This time we're talking about the management of overwhelming intestinal damage in conditions such as necrotizing enterocolitis and volvulus. This is the first of two parts on this topic, stay tuned for part 2!

Article for further reading: Predicting Intestinal Adaptation in Pediatric Intestinal Failure - A Retrospective Cohort Study
https://journals.lww.com/annalsofsurgery/Abstract/2019/05000/Predicting_Intestinal_Adaptation_in_Ped...

Hosts: Ellen Encisco & Rod Gerardo

Type: podcast · 13 min · posted 2022-02-01 Canonical: https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954 ## Chapters - [0:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=0) Introduction and Clinical Scenario - [3:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=180) Clinical Observation Over Prediction - [5:20](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=320) Liver Protection Strategy - [7:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=454) Bowel Regeneration and the 50% Rule - [10:29](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=629) Outcomes and Diagnosis-Specific Considerations ## Statements - "The inflection point of bowel loss requiring prolonged TPN is about 50%" — Michael Helmrath (clinical) [9:27](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=567) - "Intestinal transplant is not experimental therapy but part of the continuum of therapy for a child with short bowel syndrome" — Paul Wales (guideline) [2:38](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=158) - "Babies born with duodenal atresia or very proximal jejunal atresia are born with elevated direct or conjugated bilirubins" — Paul Wales (clinical) [6:14](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=374) - "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" — Michael Helmrath (clinical) [7:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=454) - "The distal bowel, the ileum, can be salvaged by ileocecal blood flow" — Michael Helmrath (clinical) [8:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=484) - "Bowel regeneration with proximal control occurs over 6, 8, 12 weeks based on the liver getting better" — Michael Helmrath (clinical) [8:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=497) - "When the liver is inflamed and has high bilirubin, it's in a catabolic state" — Michael Helmrath (clinical) [5:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=357) - "Decompressing the duodenum is needed to protect the liver" — Michael Helmrath (clinical) [5:49](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=349) - "Giving fish oils and just trying to improve the bilirubin is not enough to protect the liver" — Ellen (clinical) [5:32](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=332) - "In the very acute time after bowel infarction, the risk is dying of sepsis and multi-organ failure" — Paul Wales (clinical) [4:31](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=271) - "Intermediate and longer term complications include intestinal failure associated liver disease, recurrent sepsis, or line problems" — Paul Wales (clinical) [4:44](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=284) - "Success in the last two decades is because we're way better at preventing sepsis and liver disease" — Paul Wales (epidemiological) [5:02](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=302) - "Factors affecting liver function include prematurity, sepsis, choice of TPN, and presence or absence of enteral nutrition" — Paul Wales (clinical) [6:42](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=402) - "If bowel necrosis is focal and less than 50%, the best option is to remove that bowel" — Michael Helmrath (clinical) [9:35](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=575) - "The adaptive potential for a child with less than 50% bowel loss is really great, especially if they have preserved ileum" — Michael Helmrath (clinical) [9:44](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=584) - "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" — Michael Helmrath (clinical) [10:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=600) - "Not all bowel will survive and it will become islands of mucosa that need to be tubularized and put back together again" — Michael Helmrath (clinical) [10:14](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=614) - "Stomas lose abdominal domain and lose bowel down the road" — Michael Helmrath (clinical) [10:59](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=659) - "The percentage of kids that do well with proximal drain therapy when looking at dead gut is more than 70 to 80%" — Michael Helmrath (clinical) [11:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=671) - "Kids with necrotizing enterocolitis have the best outcomes because it's a microvascular disease" — Michael Helmrath (clinical) [11:45](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=705) - "There is an algorithm of children that have overwhelming sepsis where surgery cannot salvage these patients and there is no life saving option" — Michael Helmrath (clinical) [3:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=214) - "Many babies will rally without having their bowel removed, which allows them an opportunity" — Michael Helmrath (clinical) [3:41](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=221) - "Mistakes are commonly made because surgeons think they can predict the future with their eyes" — Michael Helmrath (opinion) [3:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=191) - "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" — Michael Helmrath (opinion) [3:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=191) - "The outlook has changed and what's gone hand in hand with that is a bit more of an aggressive approach to surgical resection" — Paul Wales (opinion) [1:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=77) - "Comorbidities such as neurologic status, pulmonary function, cardiac function, or significant genetic or chromosomal anomaly factor into decision making about how to proceed" — Paul Wales (clinical) [1:39](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=99) - "The conversation with the family and understanding of the family's wishes is important to figure out if the baby is salvageable or not salvageable" — Rod Gerardo (clinical) [2:20](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=140) ## Transcript Hello. This week we're back with the 2nd episode, our newest series on intestinal rehabilitation, and we're talking to the two experts at Cincinnati Children's, Dr. Michael Helmrath and Dr. Paul Wales. This is Ellen and Cisco. This is Rod Gerardo, a research residence at Cincinnati Children's. A common problem we both face, and we get called about a lot is a preterm infants. That's Doctor Michael Helmrath. He is the former director of the intestinal rehab program. Basically, what you're facing is what looks to be overwhelming loss of the small bowel. Um, to your eye, it looks dead. The kids clinically may be sick, sometimes not as much as others, uh, and you're in the operating room. In this case, When we see this issue in the operating room, everyone asks themselves, what should we do? What should we, what's the next step? Well, it's interesting how things have evolved over time, um, because I, I think back to when I was a fellow, Part of that is related to just sort of, you know, what we've learned over time as well as just change in outcome in this general population of babies that have short bowel syndrome over the last two decades as a result of advances that have been. Made with medical and surgical care and things like that. That's Dr. Paul Wales. He is the new director of the intestinal rehabilitation program at Cincinnati Children's. So I think sort of the outlook in general has changed and what's gone hand in hand with that is a bit more of an aggressive approach to surgical resection. So this can seem like a very daunting, a very difficult case, and there are also some other considerations. What else is going on with the Factor into your decision making about how you might pursue, proceed with this patient in front of you might be related to other comorbid the existence of other comorbidities that the child is facing. One question you can ask is, what is the status of the baby neurologically? Do they have a lot of comorbidities, you know, with their pulmonary function or their cardiac function, or is there a significant genetic or chromosomal anomaly that the baby also has? Depending on how many comorbidities this child is facing, that might factor in to, you know, whether one might be more or less aggressive surgically from a, you know, from that regard. So then the other thing is you have to consider is the conversation that you have with the family and what is your understanding of the family's wishes, because ultimately, you want to figure out is this baby salvageable or not salvageable. And that can change your direction. Do you go to comfort care? That line has shifted significantly over time, especially with the availability of transplant, as you know, intestinal transplant is not, it's not experimental therapy. It's part of the continuum of therapy for a child with short bowel syndrome. So is it ethically appropriate to open and close a baby when you know that you could remove all of their intestines? So the idea to me. As a clinician is to allow the, uh, the baby to provide you with the clinical information to make the next step forward. 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. Predetermining the care based on what we believe will happen. There is definitely an algorithm of children that have overwhelming sepsis, and surgery cannot salvage these patients. We don't have a life saving option for those patients, but many will actually rally without having their bowel removed, which allows them to have an opportunity which many don't understand yet today. But my first question to you, Paul, is what do you think the limiting factor is for these children to have the time. To heal. What is the number one thing we have to prevent in the short term that in the past has led to the demise of many of these children? Well, acutely, if they've got, you know, infarcted gut, it's usually the clinical picture there is one of overwhelming sepsis. And even if you resected them and left them sort of ultra short, a lot of them, you know, are pretty rocky and unstable for a period of time just because of the fact that the. Sepsis, the SERS and or septic experience. So I would say in that in that very acute time, it's dying of sepsis and multi-organ failure. If we get through that acute sepsis, what's the first challenge that we have that acute phase? You know, you're trying to get them to tolerate whatever they'll tolerate depending on their residual anatomy, and then you start getting into the intermediate and longer term complications related to intestinal failure associated liver disease or recurrent sepsis or Lyme problems. And they would die or they would get transplanted. And to your point about giving them the time to heal, a lot of the success that we've seen in the last two decades is because we're way better at preventing sepsis. We're way better at preventing liver disease. The first goal that drives me when I see these kids is protecting the liver. I mean, sepsis and everything is in medical management, and they have to clear that hurdle. And obviously you need to control the ongoing. Enteric losses that can drive ongoing sepsis. What they found in Dr. Helmras's lab and other research is that giving fish oils and just trying to improve the bilirubin is not enough. We need to take care of the liver in order to get to that point where we can reconstruct the bowel, because if we reconstruct the bowel without a healthy liver, that's not helpful. That suggested very strongly to me that decompressing the duodenum is the is the needed thing that has to occur to buy you that. to protect the liver and that when the liver is inflamed and has high bilirubin, it's in a catabolic state. So I believe that when we're in the OR and we want to buy time, one of the first things that has to be considered is how to keep the proximal bowel decompressed. Do you agree with that? Well, to your point, I've seen babies born with duodenal atresia or very proximal jejunal atresia that are born with elevated direct or conjugated bilirubins. Kind of to your point, like that fore gut is not decompressed. Um, and so that would be an analogy to that. Having high pressure in the foregut and not allowing the liver to decompress is one of these risk factors for the patient not doing well, but it's multifactorial. You know, there's the prematurity aspect related to liver function, that there is sepsis, there is the choice of TPN, and there is the presence or absence of enteral nutrition. All of these things have an. on liver function and our job as a rehab program is to try to mitigate those risk factors the best we can to preserve that liver function as long as we can to give this baby the potential to reach their potential. So I guess the next part here that is worth reviewing is how they decompress the bowel. With that time, the first goal being to protect the liver. For me, putting in this retrograde tube in the The duodenum or the jejunum that goes up to the pylorus, I use a blade that decompresses it, has remarkably given me time to allow these children to recover from the acute event. The way I put the drain in, as you know, is that I, I control the proximal secretions through that, and that allows me to leave distal bowel, first understanding that a 30-week-old baby's gut is in a very highly developmental phase and its ability to regenerate is much More profound than a full term baby and certainly a one year old baby. Tissue in the gut can, I don't know, it's like, it's almost like it can surprise you if you give it the right environment that it can regenerate. The distal bowel, the ileum, is remarkably important and can be salvaged by ileocecal blood flow, and leaving it alone and allowing that to occur has allowed us to salvage a lot of tissue in Cincinnati. And so the proximal control also. Comes with the ability to give this tissue a time to regenerate, which is often on the order of 68, 12 weeks based on the liver getting better. If we have the liver in as good of a condition as it can be, that also helps the bowel recovery. You know, if we go back to sort of conventional teaching, right, like you go to the OR and you see what looks like dead gut, it's, it's green, it's gray, it's thin walled, it looks infarcted. The classical. or what we get hammered in our head in general surgery residency is when you see dead gut, you have to cut it out, right? And some people, you know, they cut it out, leave in discontinuity, come back for another second look laparotomy in a day or two, you know, trying to preserve as much of the bowel as you can. I think that's one of the main tenets that we're taught in general surgery residency. You know, Dr. Helmrath and Dr. Wales have learned with experience that the bowel may recover and you don't. To take it out right away. So then it begs the question, I mean, how do you make that decision of what to cut and what not to cut out when you're looking at a bunch of dead gut? It's a great point. And so you and I both know that the inflection point of bowel loss that really requires prolonged TPN is about 50%. If you're dealing with less than 50% of the bowel necrosis, the options for the kid moving forward are best to remove that bowel and to have a progress going forward. And the Adaptive potential for that child is really great. If they have preserved ileum, they're in a much preserved situation. And so there's not this idea that if it's dead, you leave it in. If it's dead and it's focal and it's less than 50%, take it out and manage the kid. And it's not like when you look at it, it's all dead. We all know it's patchy. And so if there's bes that look terrible and parts that look bad and parts of and maybe a little bit that looks good, and it's just, it's a mosaicism in that situation. Proximately controlling the bowel with a drain and providing time to heal gives you opportunity to come back later, and not all that bowel is going to survive, and it's going to become these islands of mucosa that need to be tubularized and put back together again. Going against the grain like that is kind of what makes Cincinnati special because oftentimes if you have a baby who has had multiple surgeries, multiple resections, then their bowel hasn't been given a chance. Chance to regenerate. Experts at places like Cincinnati Children's intestinal rehab programs understand more about the physiology, and maybe you don't have to take out all that bowel, and there are things you can do to help it regenerate and recover. I would challenge you though that once you control the proximal bowel with a drain, avoid stomas, which loses abdominal domain and loses bowel down the road, but you'll be surprised. That the percentage of kids that actually do well with that therapy, which I would argue is on the order of more than 70 to 80%, when you're looking at dead gut, you want to figure out is it more or less than 50%. That will help you determine what you can or cannot keep. And then I guess another consideration is, does the diagnosis play any role in what you're going to cut out, like if you're looking at volvulus or if you're looking at an infarct or if you're looking at, you know, a mesenteric thrombosis. those are the same things. Does the approach change based on the diagnosis that the child has? Well, I don't know that the approach differs, but the outcome does. So as you and I both know, kids with neck have the best outcomes because it's a microvascular disease. In recent patients, that controlling that proximal bowel without allowing the enteric content has been key to me salvaging these kids with really good outcomes, but the vasculature involvement. Definitely involved in the process and limits the age. That's the management becomes comfort care. What you're describing is ongoing active care. Let the baby decide, you know, some may continue to spiral because of just overwhelming sepsis and may not make it, but many, many will. And what helps facilitate that is the placement of a drain to help sort of decompress that proximal bowel, and I would encourage people to call us and we can walk. You through it, but part of your process is to um just change the culture at the immediate clinical time when the baby gets sick and remind yourself that the baby will tell you the right things to do if you watch the clinical. If you try to choose what you're going to do based on what you see, you're going to, I think, avoid some opportunities that uh we would currently provide that patient in Cincinnati. We're gonna pause it there and come back for part two. Yeah, we're out of time. We've got to cover this in a 2nd podcast. So come back. We'll finish the discussion with Dr. Wills and Dr. Helm Ross. If you like this episode and you want to hear more like this, let us know in the comments. Follow us on social media, subscribe to our YouTube channel. Download the Stay Current pediatric surgery app. But until then, I'm Rod and I'm Ellen. And remember, knowledge should be free, free. --- Not medical advice · citation policy: https://library.globalcastmd.com/ai