We're back with the second part of episode 2, management of overwhelming intestinal damage along with Drs. Michael Helmrath and Paul Wales from Intestinal Rehabilitation Center at Cincinnati Children's Hospital.
Article for further reading:
Predicting Intestinal Adaptation in Pediatric Intestinal Failure - A Retrospective Cohort Study
Hosts: Ellen Encisco & Rod Gerardo
Type: podcast · 17 min · posted 2022-02-08 Canonical: https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993 ## Chapters - [0:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=1) Introduction and Series Context - [1:23](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=83) Outcomes in Ultra-Short Gut Syndrome - [4:02](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=242) Timing of Intervention and Neurocognitive Concerns - [7:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=431) Nutritional Management and Lipid Restriction - [8:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=501) Operative Technique for Bowel Preservation - [11:42](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=702) Postoperative Course and Blake Tube Characteristics - [15:28](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=928) Summary and Closing ## Statements - "In Toronto, ultra-short gut is classified as less than 20% of expected bowel length for age" — Paul Wales (clinical) [1:37](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=97) - "In a term baby, ultra-short gut corresponds to 20 to 30 centimeters of bowel" — Paul Wales (clinical) [1:42](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=102) - "Overall survival in ultra-short gut patients in the current era is over 90%" — Paul Wales (clinical) [1:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=112) - "Survival in ultra-short gut is actually 90 to 95%" — Ellen (clinical) [2:01](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=121) - "Ultra-short gut patients don't die of liver failure anymore and rarely get transplanted" — Ellen (clinical) [2:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=123) - "Ultra-short gut patients who reached autonomy required multiple nutritional supplements" — Paul Wales (clinical) [2:10](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=130) - "Ultra-short gut patients with remnant ileum as part of residual bowel tended to do better" — Paul Wales (clinical) [2:26](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=146) - "Ultra-short gut patients with longer colonic remnants tended to adapt and get off TPN" — Paul Wales (clinical) [2:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=170) - "The ileum reclaims bile and tells the liver what to do" — Michael Helmrath (clinical) [2:55](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=175) - "The ileum produces hormones like GLP-2, PYY and others that slow motility and tell the jejunum to reabsorb fluid" — Michael Helmrath (clinical) [2:58](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=178) - "The colon can account for a third to half of the caloric needs of babies when exposed to undigested nutrients" — Michael Helmrath (clinical) [3:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=195) - "Short bowel syndrome kids are largely neurologically fine, running and playing" — Michael Helmrath (clinical) [3:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=204) - "Bowel removed is bowel never to be used" — Michael Helmrath (clinical) [4:26](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=266) - "Most necrotizing enterocolitis kids don't have overwhelming totalis; NEC totalis is fairly rare" — Michael Helmrath (epidemiological) [4:48](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=288) - "Cincinnati has a dozen or more NEC totalis kids that are off TPN and have done remarkably" — Michael Helmrath (clinical) [4:54](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=294) - "If a baby grows well with protein growth, linear growth and head growth, that's brain growth" — Michael Helmrath (clinical) [6:49](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=409) - "A baby will not grow well with an unhealthy liver" — Michael Helmrath (clinical) [6:59](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=419) - "An unhealthy liver is not providing the protein for neurocognitive development" — Michael Helmrath (clinical) [6:59](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=419) - "Lipid restriction was never a practice subscribed to by the Toronto program" — Paul Wales (opinion) [7:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=460) - "Premature babies in the first year of life have caloric needs of 80, 100, 120 per kilo because they're growing and developing" — Michael Helmrath (clinical) [7:43](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=463) - "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" — Michael Helmrath (clinical) [7:52](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=472) - "A transverse incision gives the least problems over time for patients requiring multiple operations" — Michael Helmrath (clinical) [8:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=505) - "An 8 or 10 French Blake drain is placed through bowel just beyond what is expected to heal, advanced retrograde to the pylorus" — Michael Helmrath (clinical) [8:37](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=517) - "A purse string is placed at the drain insertion site and secured to the skin, essentially creating a stoma to the abdominal wall" — Michael Helmrath (clinical) [9:10](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=550) - "A 5 to 7 French feeding tube can be placed into the proximal bowel via the stomach using a purse string technique" — Michael Helmrath (clinical) [9:29](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=569) - "Significant dissection of the distal ileum should be avoided to preserve blood supply and allow collateralization to recover proximal bowel" — Michael Helmrath (clinical) [10:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=608) - "A refeeding tube can be placed in the distal bowel to allow intermediate bowel to heal" — Michael Helmrath (clinical) [10:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=653) - "The volume of fluid output from injured bowel is very high initially; as bowel heals and regenerates reabsorptive capacity, output decreases" — Michael Helmrath (clinical) [11:19](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=679) - "Intraoperative decisions in short bowel syndrome have a lifelong impact" — Paul Wales (opinion) [12:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=720) - "Decisions made at the time of intraabdominal catastrophe can make the difference between staying on or getting off TPN or whether the child survives" — Paul Wales (opinion) [12:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=728) - "Many kids who appear critically sick preoperatively are not as sick as believed once proximal bowel is controlled and decompressed" — Michael Helmrath (clinical) [13:22](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=802) - "Kids may look worse over the first 24-36 hours postoperatively, then stop getting worse before they start improving" — Paul Wales (clinical) [14:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=861) - "Blake tubes have linear cuts on the outside so they won't get obstructed when secretions accumulate" — Michael Helmrath (clinical) [14:49](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=889) - "Blake tubes cannot be changed over a wire like JP drains with side holes" — Michael Helmrath (clinical) [14:58](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=898) - "Blake tubes are soft and don't tend to put pressure on damaged bowel" — Michael Helmrath (clinical) [15:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=906) - "Blake tubes can be connected to a bulb syringe and cut to size" — Michael Helmrath (clinical) [15:09](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=909) ## Transcript And we're back with episode 2, part 2 of our intestinal rehabilitation series. We ran out of time with the first part, so we're gonna give you the rest of this amazing conversation on overwhelming abdominal, intestinal catastrophe. With Doctor Paul Wales and Doctor Michael Helmrath from the Cincinnati Children's Intestinal Rehabilitation Program. I'm Rod Gerardo. This is Ellen and Cisco. We're research residents at Cincinnati Children's Hospital. Stick around. This is the sacred Pediatric Surgery podcast. So we left off last episode talking about the general concept that Doctor Helmrath and Doctor Wales want to impart on you, the listener, is that sometimes maybe we just need to let the baby tell us when it's time to operate. Instead of going by our own metrics or whatever experience we have had when it comes. to treating a patient with overwhelming intestinal catastrophe, and they define that as really severe necrotizing enterocolitis or, or volvulus or really anything that leads to an incredibly significant amount of intestinal loss. The goalposts have moved over the last two decades. I mean, so if you take babies with the More conventional approach, let's say, you know, babies that have what we, you know, would call ultra-short gut. What is the definition of an ultra-short gut? Like in Toronto, we, we classified that as less than 20% of expected for age. So, in a term baby, you're looking at, you know, 2020 to 30 centimeters. Anything less than that, 2025 centimeters would be what we would, you know, would be an ultra-shortcut kid. But even if, so if we look at that population and sort of the current era of management, the overall survival in that group was over 90%. It's actually 90 to 95%. They don't die of liver failure anymore. They rarely get transplanted. They were able to continue to grow within normal parameters. The ones that reached autonomy required multiple nutritional supplements. There should be more optimism in general with this population just because our ability to mitigate those long term, you know, risks. Of death from liver disease or sepsis have been transformed in the current era of management. Any maneuver that we can do that can preserve as much bowel as possible to shift this baby into a different risk category above or less than 50% expected gut length, for instance, would be helpful because the ones that did better with ultra short gut, in our experience, they had some remnant ileum as part of their residual bowel, and they tended to also be the ones that had a longer. Colonic remnants. So those are the ones that tended to adapt and get off of TPN. And that's because the ileum has a lot of functions that the rest of the bowel doesn't. Not only does it reclaim bile and tell the liver what to do, but it produces, um, hormones like GLP-2 that we know about, but PYY and others that slow motility and tell the jejunum to reabsorb some of that fluid that is, is the major problem of fluid losses that we see in these kids. The colon can actually maybe account for a third. Half of the caloric needs of some of these babies when exposed to undigested nutrients. 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. So we really do have an opportunity to affect lives and offer hope to families and these children that have overwhelming catastroph. Atrophes early on in life. 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. And without changing that early paradigm, nothing else can get better in this population. May be a provocative question for those who are more in the know with intestinal rehabilitation, but, you know, in the past with necrotizing enterocolitis, the feeling was, you know, you have to intervene as quickly as possible. Surgery. because there's an inflammatory response and that can potentially affect neurocognitive outcomes. Here's what Doctor Helmrath thought about that. Well, I mean, obviously bowel removed is bowel never to be used. The, the fear that it's driving a neurocognitive thing, I think needs to be supported with data. I do think that, you know, we do have new tools and kits, but it's not accessible until these kids get a little bit older, and that's one of the things that has to be accompanied by these programs is we have to. Continue to ask questions like that. The neck kids do remarkably well, and I would argue most neck kids don't have overwhelming totalis. Neck totalis in neck kids is, is fairly rare, but we have a dozen or more of these kids that had neck totalis that are off TPN, not only survived, but have done remarkably, and certainly, the, the comparative group to that patient is in a cemetery. As, as rude as that sounds, um, a dead child has no neurological function. You know, the question is how do you get to those kinds of outcomes where the patient is post-op running up to you in the hallway and giving you a hug, and it's, it's a really big team approach, not an algorithm. 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. But the opportunity given to that child is made at the time that you open the belly and you see catastrophe. 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. And the first team that has to be convinced is your neonatologist because they're the ones at the bedside who historically removed the breathing tubes on these kids and allowed them to pass. And I think to be fair to them, I mean, they, they do see some of these, the ones that survived, you know, historically, they, they would see these ex-prems, and some of them had intestinal failure that would come back to their follow-up clinic. I don't subscribe to the notion that Every kid needs to die with a laparotomy indecision. Like, I don't necessarily believe that. Um, and I think you're right. I mean, it's the data that will tell us if, if that, if that idea about the, uh, unoperated kid septic response, inflammatory response is gonna have a negative outcome. In Doctor Well's experience at other institutions, he has found that long-term neurocognitive tracking can be beneficial to the patients. You know, part of our responsibility as a program is to put these Kinds of things in place that this population has followed long term so that we get this data to be able to answer it. Yeah, that's exactly right. 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. Unhealthy liver is, is not providing the protein for the neurocognitive development, period. And that's why it's the number one priority early, uh, that you should have. In managing this. Make sure that you have a dietitian on your team. Make sure that your neonatologists are attentive to these nutritional demands as well. You know, when we talk about providing adequate nutrition, especially at this stage, so that this baby is anabolic and has the best neurocognitive outcome possible, you know, that feeds into the whole management strategy, you know, which is commonly done in many places, that of, you know, lipid restriction as a way of controlling that. And that, you know, that was never really a practice that we subscribe to. Babies, especially premature babies, the first year of life, they have the caloric needs 80, 100, 120 per kilo because they're growing and developing. 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. So let's say we have a 30-week baby with necrotizing enterocolitis, fairly extensive necrosis involving. The vast majority of the bowel. There's a long segment that looks dead. There's some patonecrotic areas farther down into the ileum or cecum, 10 centimeters from the jejunum, from the ligament of trites. It looks viable, and everything else is dead or sick. And so what would we do here? 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. And when I get into the abdomen and I see this situation, what I'll do is I'll, I'll find a segment. The bowel just beyond what I think is gonna heal, maybe, you know, 1 centimeter or two. And I'll bring in an 8 or 10 French blake drain. Um, often, if it's normally rotated, be from the left lower quadrant. Um, and I will put that through bowel, which I would generally feel is not gonna do well. And then I would place that, uh, retrograde up to the point of the pylorus, and then I would make a tie around, uh, with a viral loosely around the most healthy part of the bowel. And that kind of controls around the drain any of the secretions. And then at the site that I put it in, which will be a few centimeters around, I'll kind of put a purse string, and I'll tie that. And then I'll take that stitch out from the hole and I'll secure that to the skin. And so essentially, that's sort of stemming it up to the abdominal wall. And then I'll secure that on the outside. That generally takes on the order of minutes. Many of the times, at that point, I will be able to see the stomach, and I'll put a little purse string in the stomach. And I will put a 567 French uh feeding tube into the proximal bowel and tie that. Again, that takes me a minute or two. I use the same technique of that first string and taking that PDSL. But oftentimes, what it means is that you don't have to get back up in that left upper quadrant when uh you need to get a G tube later. And then I try to close the kids primarily, but if I worry that there's a lot of dead bowel and, and whatnot, I will put a little Alloderm in. If I'm really worried, Sometimes I'll put a drain in the abdomen just to allow stuff to drain out. 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. So for the distal bowel that's being diverted, if it's, you know, cause sometimes it's kind of baggy looking, it might be filled with, uh, bloody enteric fluid. Do you suck that out, uh, or leave it? In situ or what, what's your approach? If there's distal perforations and the baby's fine, I, I will, if you feel like it's patchy necrosis and there's areas that you worry about, I have no problem taking, uh, you know, a stitch distal to proximal and bringing the bowel together to help the muscle just so that it's preserved, and you'll go back later and, and manage that. I mean, it really depends on the extent of necrosis, and I will put a refeeding tube in the distal bowel so I can refeed and let that intermediate bowel. To sort of hang out. It depends on how much proximal bowel and whether I feel like I could feed. So we have a baby now that um has 40 centimeters of proximal bowel that we did that to, and that the refeeding is allowing me to wait longer for that intervening bowel to heal, and that baby's liver is fine. And so it's just buying me time and the time is because the amount of fluid that comes out of injured bowel is very high. So Doctor Helmrath also told us that when the bowel gets damaged, it weeps and secretes fluids. The The volume of output is going to be high. As it heals, it'll start to regenerate the ability to reabsorb that fluid. And so the output from the drain will go down and that'll be a sign that the bowel is healing. And so your volumes will come down. Yeah, because I think that initially an increase in volume would startle and concern most surgeons, but he's saying that this is kind of a normal process of the healing. The surgeon's role in the patient with short bowel syndrome is, is obviously significant. Partly for what we do and partly for what we don't do, right? Those intraoperative decisions have a lifelong impact. Um, and, and that's critically, that's so important. So, those, those decisions that you make at the time that you see an intraabdominal catastrophe can make the difference between whether this kid will get, stay on or get off TPN or whether they survive or don't. And again, it's a team approach. We have to talk to the neonatologists and the other providers about this approach. I mean, I've spent my life maybe doing that to a point. It's, it's really hard, and I think these conversations need to be had with other providers. in the room, not just your surgical colleagues, because the, the neonatologists and dietitians have to be on board. Families are, are not able to make decisions. 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. Or maybe the neonatologists who haven't worked closely with people like Dr. Helenrath or Dr. Wales, and you know, you're taking care of a sick baby and you're feeling pessimistic about its outcome. We asked Dr. Hillenweth and Dr. Wales, what is the time course after surgery and following these patients and how long it might take to recover and when you might start to say that they're not recovering. Yeah, what to expect. 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. And the, the point is, is to sit down and look at the big picture. I mean, yeah, platelet count of 6, and on Pressors is a bad thing, and then if it persists, then the baby is declaring them. What I'm stating is that many of those kids, once you control the proximal bowel and you get everything decompressed, will actually slowly get better. There's what's obviously dead and infarcted, which would traditionally be removed. Then there's what's suspicious or questionable, and you, and then you leave that and come back in 24 to 48 hours. Cause you're trying to give the person the benefit of the doubt, right? And let it demarcate. That's sort of the rationale, right? And what you're describing is departure from that sort of traditional teaching, right? And, and so, which I think is really interesting. But I agree with you. Often, some of these kids do get, they kind of look worse over the next 24, 36 hours, and then they start to, you know, they may not even be getting better, they just stop getting worse. 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. So we're talking about premature kid with overwhelming bowel loss in this conversation. So previously, Doctor Helmreth talked about the Blake tube. What does he mean by that? So I've used many different tubes. The Blake tube has linear cuts on the outside, so they, they won't get obstructed in many situations when secretions and stuff get around them. And that's why I like them a lot. What's the downside of them is you can't change them over a wire, like you can a JP and other ones that just have side holes. They're soft and so they don't tend to put a lot of pressure on damaged valve. They can be connected to a, uh, you know, a bulb syringe, which works great. So they don't, they're not perfect because I can't change them over a wire. You can cut them to size. It's what I use. It's not ideal. If I had the best scenario, it would be a blake tube that has a central hole that I could pass a wire. Someday in my life, maybe I'll remember. All right, so there you have it. That is our 2nd episode of the intestinal rehabilitation podcast with Doctor Helmrath and Dr. Wells, where we talked about. Overwhelming intestinal catastrophe, whether it's necrotizing enterocolitis or volvulus, whatever it is, and how to even approach these patients. We start off with talking to the family about goals of care preoperatively. You want to make sure that the liver is optimized intraoperatively, the number that you want to look for is 50%. That's kind of the cutoff for them to say, yes, this is salvageable, no, this is not salvageable. Even shorter than that, you could have a kid with ultra short guts. Syndrome, which they define less than 20% of your intestine, but the surprising thing is that sometimes even if you're looking at dead gut, you don't necessarily have to cut it out because these neonates have really impressive regenerative properties to their intestines. Postoperatively, we still have to think about the liver and how it's doing. We have to think about the diet, talk to the nutritionist or the dietitian. We talked a little bit about some of these thoughts around neurocognitive effects of necrotizing. E colitis. Overall, I would say Dr. Hillmroth and Dr. Wales have a lot of experience, and, you know, we're continuing to learn a lot from them. The main thing I got from this podcast is that like you could have a patient with seemingly a really significant concerning abdominal catastrophe, and with the proper perioperative considerations and intraoperative decision making, you know, they can come out of it and then grow up to be the kid that's running down the hall and giving me a hug on follow-up. If you like this episode and you wanna 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, be free. --- Not medical advice · citation policy: https://library.globalcastmd.com/ai