# Intestinal Failure — GCMD Library living collection

Also covered as: short bowel syndrome · necrotizing enterocolitis · gastroschisis · cholestasis · bacterial overgrowth · intestinal atresia · Hirschsprung disease · liver failure

Experts: Dr. Paul Wales, Dr. Michael Helmrath, Dr. Ellen Encisco, Dr. Rod Gerardo

Updated: n/a · 28 episodes · 751 cited statements

## Episodes
### Fundamentals
- [Multidisciplinary Approach: Intestinal Failure Innovations](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036) — video · 97:52 · [machine version](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036.md)
- [Intestinal rehabilitation: What is intestinal rehab? - Episode 1](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741) — video · 14:33 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741.md)
- [Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742) — podcast · 14:33 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742.md)
- [Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 1](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141) — podcast · 16:18 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141.md)

### Acute Management
- [Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 1](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954) — podcast · 13:27 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954.md)

### Nutritional Management
- [Intestinal Failure - Feeding Access and Nutrition](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740) — video · 118:06 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740.md)
- [Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 2](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240) — podcast · 13:37 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240.md)
- [Intestinal Rehabilitation, Episode 7: Refeeding in a neonatal patient](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209) — podcast · 16:09 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209.md)
- [Intestinal Rehabilitation Episode 8: Refeeding of an Older Patient](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227) — podcast · 12:05 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227.md)

### Surgical Management
- [Practical Approach: Intestinal Failure Innovations](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035) — video · 116:52 · [machine version](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035.md)
- [Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 2](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993) — podcast · 17:21 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993.md)
- [Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909) — video · 19:07 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909.md)
- [Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913) — podcast · 19:07 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913.md)

### Complications
- [Intestinal Rehabilitation, Episode 4: Surgical Management, Part 2](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099) — podcast · 12:24 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099.md)
- [Intestinal Rehabilitation, Episode 6: Cholestasis](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734) — podcast · 15:25 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734.md)

### Evidence & Research
- [Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929) — podcast · 44:19 · [machine version](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929.md)
- [Biliary Atresia, Appendicitis, Intestinal Failure, and Anesthetic...](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308) — podcast · 44:19 · [machine version](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308.md)
- [CAPS - The use of urine sodium to creatinine ratio as a marker of total body sodium in infants with intestinal failure - Sara Choi](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432) — video · 8:40 · [machine version](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432.md)
- [Journal of Pediatric Surgery Article Review: June 2022, AAP Issue](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878) — video · 15:54 · [machine version](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878.md)
- [Journal of Pediatric Surgery Article Review: June 2022, AAP Issue](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881) — podcast · 15:54 · [machine version](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881.md)
- [Outcomes of Children With Short Bowel Syndrome: Experiences in a Multidisciplinary Intestinal Rehabilitation Unit Over Two Decades](https://qa.library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027) — video · 0:45 · [machine version](https://qa.library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027.md)
- [Impact of social determinants of health on outcomes in pediatric short bowel syndrome...](https://qa.library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896) — video · 0:43 · [machine version](https://qa.library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896.md)

### In-Depth Reviews
- [Intestinal Failure with Dr. Brad Warner](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927) — podcast · 52:46 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927.md)
- [Intestinal Failure with Dr. Brad Warner](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296) — podcast · 52:46 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296.md)
- [Intestinal Rehabilitation Webinar 2023 - Top 5 Key Takeaways](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768) — video · 12:14 · [machine version](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768.md)
- [Advancements in Pediatric Intestinal Failure: Innovative Therapies and Improved Outcomes](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892) — video · 17:45 · [machine version](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892.md)

### Patient & Family Education
- [Reliance on total parenteral nutrition (TPN) and travelling abroad](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804) — video · 1:42 · [machine version](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804.md)

### Long-Term Care
- [Care transition from a pediatric intestinal rehabilitation program to adult care and the risk of all-cause mortality: A retrospective cohort study](https://qa.library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901) — video · 1:01 · [machine version](https://qa.library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901.md)

## Chapters
- [0:00](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=0) Defining Team-Based Care Models (Ep 4)
- [10:00](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=600) Patient Identification and Early Intervention (Ep 4)
- [20:00](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1200) Central Line Management and Infection Prevention (Ep 4)
- [40:00](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2400) TPN Composition and Lipid Management (Ep 4)
- [60:00](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3600) Growth, Nutrition, and Functional Assessment (Ep 4)
- [80:00](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4800) Feeding Challenges and Surgical Decision-Making (Ep 4)
- [0:09](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=9) Defining Intestinal Failure and the Role of Intestinal Rehabilitation (Ep 27)
- [5:10](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=310) Intestinal Rehabilitation Programs and Outcomes (Ep 27)
- [7:54](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=474) Evolution of Lipid Emulsions in Parenteral Nutrition (Ep 27)
- [11:55](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=715) Central Line Complications and Lock Solutions (Ep 27)
- [13:45](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=825) GLP-2 Analogs for Intestinal Adaptation (Ep 27)
- [16:29](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=989) Summary and Future Directions (Ep 27)
- [0:00](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=0) Introduction and series overview (Ep 7)
- [0:55](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=55) Corticosteroids after Kasai for biliary atresia (Dr. von Almen) (Ep 7)
- [10:54](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=654) Skin antiseptic agents and surgical site infections (Dr. Holcomb, part 1) (Ep 7)
- [20:18](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1218) Non-operative antibiotic treatment for non-perforated appendicitis (Dr. Holcomb, part 2) (Ep 7)
- [30:41](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1841) Predictors of enteral autonomy in pediatric intestinal failure (Dr. Lipskar, part 1) (Ep 7)
- [36:44](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2204) Anesthetic neurotoxicity in the developing brain (Dr. Lipskar, part 2) (Ep 7)
- [0:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=0) Introduction and Feeding Access Strategies (Ep 1)
- [7:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=420) Surgical Techniques for Feeding Access (Ep 1)
- [17:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1020) Gastrostomy Timing and Indications (Ep 1)
- [28:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1680) STEP Procedure Indications and Timing (Ep 1)
- [40:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=2400) Referral Patterns and Remote Management (Ep 1)
- [54:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=3240) Formula Selection and Breast Milk Benefits (Ep 1)
- [72:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=4320) Microbiome Management: Antibiotics versus Prebiotics (Ep 1)
- [90:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=5400) Hypermotility Management (Ep 1)
- [104:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6240) Monitoring and Emerging Therapies (Ep 1)
- [0:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=0) Introduction and Definition of Intestinal Failure (Ep 2)
- [1:39](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=99) Prognostic Factors and Bowel Length Thresholds (Ep 2)
- [6:38](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=398) Causes of Mortality and Timing of Transplant Evaluation (Ep 2)
- [9:42](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=582) Medical Management and TPN Strategies (Ep 2)
- [16:15](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=975) Enteral Feeding Advancement Protocol (Ep 2)
- [20:09](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1209) Indications for Surgical Intervention (Ep 2)
- [26:01](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1561) Surgical Lengthening Procedures: Bianchi vs STEP (Ep 2)
- [35:59](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2159) Management of TPN-Related Cholestasis (Ep 2)
- [41:32](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2492) Bacterial Overgrowth and Growth Factor Therapy (Ep 2)
- [46:30](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2790) Intestinal Transplantation and Multidisciplinary Care (Ep 2)
- [52:03](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=3123) Closing Remarks (Ep 2)
- [0:00](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=0) Introduction and series overview (Ep 3)
- [0:55](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=55) Corticosteroids after Kasai for biliary atresia (Dr. von Almen) (Ep 3)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "Team approach to intestinal failure reduced 1-year mortality from 30-40% to approximately 5% per year at University of Michigan" — Sam (clinical) [Ep 4 · 2:23](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=143)
- "Cincinnati's intestinal failure program was started in 1984" — Sam (clinical) [Ep 4 · 2:51](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=171)
- "Intestinal failure is defined by inadequate bowel length OR bowel that doesn't absorb nutrition and fluid adequately to maintain growth" — Monique (clinical) [Ep 4 · 3:47](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=227)
- "Almost 30% of patients leaving NICU without rotavirus vaccination were readmitted with rotavirus infection" (epidemiological) [Ep 4 · 16:56](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1016)
- "Joint weekly rounds with surgeons, gastroenterologists, dietitians, and neonatologists help identify protocol deviations and build family rapport" — Sam (clinical) [Ep 4 · 18:11](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1091)
- "Breast milk provides not just immunostimulatory benefits but motility effects through oligosaccharides and healing properties" (clinical) [Ep 4 · 30:13](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=1813)
- "PIFCON study data showing 25% mortality or transplant referral are now archaic; outcomes have improved dramatically in past 5 years" — Sam (opinion) [Ep 4 · 33:36](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2016)
- "Cincinnati reduced catheter-related bloodstream infections from 12 per 1000 catheter-days to 2 per 1000, approaching <1 per 1000" (clinical) [Ep 4 · 37:31](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2251)
- "Standardized central line bundles and multi-hospital communication networks have reduced line infections across pediatric populations" (clinical) [Ep 4 · 38:54](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2334)
- "Intestinal failure patients have unique propensity for line infections and different infection types compared to general pediatric population" (clinical) [Ep 4 · 39:45](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2385)
- "Toronto experience paper in JPGN examined PICC lines for TPN administration" (clinical) [Ep 4 · 41:13](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2473)
- "Complication-free survival of PICC lines is approximately half that of broviacs according to IR literature" — Sam (clinical) [Ep 4 · 44:58](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2698)
- "Subclavian approach for central lines carries higher risk of stenosis compared to jugular approach" — Valerie (clinical) [Ep 4 · 46:26](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=2786)
- "Lack of vascular access is no longer a common indication for intestinal transplant in past 3 years at some centers" (clinical) [Ep 4 · 50:04](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3004)
- "Ethanol locks use 70% concentration with 2-6 hour dwell time, can be given 3 times weekly (Monday/Wednesday/Friday) with good results" — Sam (clinical) [Ep 4 · 60:20](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3620)
- "Ethanol locks work better with 6.6 French catheters than smaller catheters; smaller PICC lines tend to occlude" — Sam (clinical) [Ep 4 · 61:04](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3664)
- "Younger NPO infants often cannot tolerate TPN windows required for ethanol locks" — Sam (clinical) [Ep 4 · 61:28](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3688)
- "UK predominantly uses taurolidine locks rather than ethanol locks for line infection prevention" — Girish (clinical) [Ep 4 · 63:55](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3835)
- "Line care education is crucial; recurrent infections warrant revisiting line care practices before implementing locks" — Girish (clinical) [Ep 4 · 64:23](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3863)
- "Fungal line infections are pulled more promptly, but some centers now treat through even fungal infections in patients with limited vascular access" (clinical) [Ep 4 · 65:32](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=3932)
- "Phytosterols in soy-based lipids are cleared poorly, share cholesterol transporter (down-regulated by endotoxemia), and reduce FXR receptor expression causing hepatocyte damage" — Sam (clinical) [Ep 4 · 68:34](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4114)
- "Limiting lipid intake to 1 g/kg/day reduces cholestasis rate to less than 5% of patients" — Sam (clinical) [Ep 4 · 69:42](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4182)
- "Fish oil-based lipid (Omegaven) may have anti-inflammatory advantage and benefit patients who don't respond to lipid restriction" — Sam (clinical) [Ep 4 · 70:43](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4243)
- "Neonatologists often maintain higher lipid doses (2-3 g/kg/day) due to concern about depriving infants of linoleic acid and affecting brain development" — Sam (clinical) [Ep 4 · 71:50](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4310)
- "With lipid restriction protocols, cholestasis rarely emerges from Cincinnati NICU" (clinical) [Ep 4 · 72:39](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4359)
- "Standard metrics for essential fatty acid deficiency are based on malnourished children not on TPN, so altered triene:tetraene ratios may not apply the same way" (opinion) [Ep 4 · 74:14](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4454)
- "Symptomatic essential fatty acid deficiency is not seen in practice with lipid restriction protocols" (clinical) [Ep 4 · 74:41](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4481)
- "Higher glucose infusion rates become less efficient as caloric source and are pushed toward fatty acid and fat deposition" (clinical) [Ep 4 · 75:16](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4516)
- "Age-based glucose infusion rate limits: generally 15-16 in premature/infants, gradually decreasing with age" (guideline) [Ep 4 · 75:41](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4541)
- "Intestinal failure patients may not need to maintain 50th percentile growth; unclear what appropriate growth curve should be for this population" (opinion) [Ep 4 · 76:04](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4564)
- "Neurodevelopmental outcomes in intestinal failure are multifactorial (prolonged hospitalization, recurrent admissions, neonatal insults), not solely attributable to lipid strategies" — Girish (clinical) [Ep 4 · 79:31](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4771)
- "Babies with spontaneous intestinal perforation (no functional bowel removed) still require 2-3 months of parenteral nutrition" (clinical) [Ep 4 · 82:03](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=4923)
- "Feed absorption and ability to progress feeds are the best measures of bowel function, not absolute bowel length" — Girish (clinical) [Ep 4 · 85:29](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5129)
- "Ability to wean TPN while maintaining good growth is the most important functional measure" (opinion) [Ep 4 · 86:18](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5178)
- "Upper GI studies can identify problems but cannot rule them out; absence of findings does not exclude anastomotic issues" (clinical) [Ep 4 · 88:16](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5296)
- "Delayed contrast films may reveal that barium flows into anastomosis but doesn't flow out well, suggesting functional problem" (clinical) [Ep 4 · 88:43](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5323)
- "Some anastomoses are not strictured but kinked or twisted, creating functional rather than anatomic obstruction" (clinical) [Ep 4 · 88:43](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5323)
- "Endoscopy is valuable for visualizing anastomosis diameter; sometimes can get scope on both sides but cannot see anastomosis itself" — Sam (clinical) [Ep 4 · 90:45](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5445)
- "Motility abnormalities in short bowel syndrome are not well described; manometric assessment is less helpful in this population" — Sam (opinion) [Ep 4 · 94:28](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5668)
- "Post-gastric tube feeding with gastric decompression can demonstrate distal bowel function and avoid unnecessary surgeries" (clinical) [Ep 4 · 95:24](https://qa.library.globalcastmd.com/watch/multidisciplinary-approach-intestinal-failure-innovations-1036?t=5724)
- "Intestinal failure is defined as the reduction of functioning intestinal mass below that which can sustain life, resulting in dependence on supplemental parenteral support for a minimum of 60 days within a 74 consecutive day interval." — Stephanie Oliveira (clinical) [Ep 27 · 0:26](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=26)
- "More than 50% of intestinal failure cases are related to short bowel syndrome, with additional cases from mucosal enteropathies and dysmotility disorders." — Stephanie Oliveira (epidemiological) [Ep 27 · 0:43](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=43)
- "Most causes of short bowel syndrome in pediatrics occur during the neonatal period, including gastroschisis, necrotizing enterocolitis, bowel atresia, and intestinal volvulus." — Stephanie Oliveira (clinical) [Ep 27 · 0:55](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=55)
- "The field is now focusing on neurocognitive outcomes, quality of life, and caregiver burnout as more children survive intestinal failure." — Stephanie Oliveira (opinion) [Ep 27 · 1:18](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=78)
- "Chronic intestinal inflammation resembling Crohn's disease is now being observed in intestinal failure patients, requiring management with inflammatory bowel disease therapies like biologics." — Lizzie Lee (host_summary) [Ep 27 · 1:24](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=84)
- "The cause of chronic intestinal inflammation in intestinal failure survivors is not known." — Stephanie Oliveira (clinical) [Ep 27 · 1:37](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=97)
- "Intestinal rehabilitation treatment strategy lacks clear-cut guidelines because every patient is unique with different gestational age, bowel resection, anatomy, and comorbidities." — Stephanie Oliveira (clinical) [Ep 27 · 1:48](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=108)
- "The goal of intestinal rehabilitation is to optimize intestinal function and adaptation before the development of irreversible complications." — Stephanie Oliveira (clinical) [Ep 27 · 2:07](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=127)
- "Intestinal adaptation is an active compensatory process that starts immediately after bowel resection." — Stephanie Oliveira (clinical) [Ep 27 · 2:30](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=150)
- "Food, bacteria, and hormones in the gut are important factors that enhance intestinal adaptation." — Stephanie Oliveira (clinical) [Ep 27 · 2:42](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=162)
- "Enteral autonomy is defined as getting off TPN with all nutrition going to the gut, either by mouth or by feeding tube." — Stephanie Oliveira (clinical) [Ep 27 · 3:11](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=191)
- "A 2012 Pediatric Intestinal Failure Consortium study showed 50% of intestinal failure patients achieved enteral autonomy, while 25% either died or had intestinal transplant." — Lizzie Lee (host_summary) [Ep 27 · 3:19](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=199)
- "From 2010 to 2015, a repeat study with double the number of patients showed approximately 50% still reached enteral autonomy, but the number of transplants and deaths significantly decreased." — Stephanie Oliveira (epidemiological) [Ep 27 · 3:33](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=213)
- "The establishment of multidisciplinary teams is one factor that changed outcomes in intestinal failure." — Stephanie Oliveira (clinical) [Ep 27 · 3:46](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=226)
- "Studies from Canada, Michigan, and Spain show that multidisciplinary intestinal rehabilitation teams improve survival." — Lizzie Lee (host_summary) [Ep 27 · 3:51](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=231)
- "Predictors of reaching enteral autonomy include residual bowel length (more is better), follow-up at an institution with an intestinal rehabilitation program, and no STEP procedure." — Stephanie Oliveira (clinical) [Ep 27 · 4:03](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=243)
- "Patients should be referred to intestinal rehabilitation programs when not making progress, on prolonged TPN, or have significant comorbidities, preferably sooner rather than later." — Stephanie Oliveira (guideline) [Ep 27 · 4:19](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=259)
- "Patients should not be referred to intestinal rehabilitation when several irreversible complications have already occurred and transplant is the only remaining option." — Stephanie Oliveira (guideline) [Ep 27 · 4:39](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=279)
- "Intestinal transplantation is considered when there are irreversible complications, though the number of transplants has significantly decreased over the last several decades." — Stephanie Oliveira (clinical) [Ep 27 · 4:49](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=289)
- "Liver disease associated with intestinal failure ranges from mild cholestasis to profound steatosis (in older children/adolescents/adults), with progression through inflammation, fibrosis, and ultimately cirrhosis leading to death or transplantation." — Paul Wales (clinical) [Ep 27 · 5:23](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=323)
- "Risk factors for intestinal failure-associated liver disease include prematurity, lack of enteral feeding, inability to feed due to anatomy, recurrent infections/sepsis, and components of TPN." — Paul Wales (clinical) [Ep 27 · 5:41](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=341)
- "The term 'intestinal rehabilitation program' was coined in the year 2000." — Paul Wales (clinical) [Ep 27 · 6:08](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=368)
- "Intestinal rehabilitation teams improve outcomes through integration of care, improved communication, and better continuity." — Paul Wales (clinical) [Ep 27 · 6:12](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=372)
- "Intestinal rehabilitation programs rely heavily on speech, language, and occupational therapy specialists." — Paul Wales (clinical) [Ep 27 · 6:34](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=394)
- "While patients are on TPN, the goal is to mitigate progression of liver disease, sepsis, and vascular complications." — Paul Wales (clinical) [Ep 27 · 6:38](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=398)
- "Families of intestinal failure patients manage significant tasks at home including running TPN pumps, adding vitamins, programming pumps, recording ins and outs, managing G-tubes, and managing stomas." — Paul Wales (clinical) [Ep 27 · 6:54](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=414)
- "High-quality families demonstrate evidence of burnout over time despite education and empowerment efforts." — Paul Wales (clinical) [Ep 27 · 7:11](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=431)
- "Literature shows intestinal rehabilitation programs improve survival related to liver dysfunction, decrease septic episodes, reduce central line complications, reduce ICU admissions, and enable patients listed for transplant to come off the list due to improved status." — Paul Wales (epidemiological) [Ep 27 · 7:25](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=445)
- "Mortality in intestinal failure has decreased with intestinal rehabilitation programs." — Paul Wales (epidemiological) [Ep 27 · 7:43](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=463)
- "Lipids in parenteral nutrition are a source of essential fatty acids, a non-protein energy source important for growth, and fatty acids have a major role in cellular pathways." — Paul Wales (clinical) [Ep 27 · 8:02](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=482)
- "Historically, most lipid emulsions in North America are soybean-based with high phytosterol content, high omega-6 long-chain polyunsaturated fatty acid content, and low antioxidant content." — Paul Wales (clinical) [Ep 27 · 8:15](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=495)
- "Prolonged soybean-based lipid exposure is associated with deterioration of liver function, specifically cholestasis." — Paul Wales (clinical) [Ep 27 · 8:31](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=511)
- "For every day an infant is exposed to soybean lipid dosed at greater than 2.5 g/kg/day, there is a 3% increase in the odds ratio of developing advanced liver disease." — Paul Wales (epidemiological) [Ep 27 · 8:51](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=531)
- "First-generation lipid emulsions were soybean-based, rich in omega-6 PUFA (such as Intralipid), and have been in use for 40 years." — Paul Wales (clinical) [Ep 27 · 9:15](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=555)
- "Second-generation lipid emulsions attempt to reduce omega-6 exposure by diluting the soybean component." — Lizzie Lee (host_summary) [Ep 27 · 9:26](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=566)
- "Third-generation lipid emulsions reduce omega-6 component and change the omega-6 to omega-3 ratio by adding omega-3 lipids." — Paul Wales (clinical) [Ep 27 · 9:32](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=572)
- "Omega-6 fatty acids promote inflammation while omega-3 fatty acids lead to a more anti-inflammatory response." — Lizzie Lee (host_summary) [Ep 27 · 9:43](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=583)
- "Omega-6 lipids are metabolized to arachidonic acid, which produces leukotrienes and prostaglandins with a more pro-inflammatory profile." — Paul Wales (clinical) [Ep 27 · 9:51](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=591)
- "Omega-3 lipids are metabolized through EPA and DHA, leading to production of cytokines with a less inflammatory profile." — Paul Wales (clinical) [Ep 27 · 10:01](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=601)
- "Omega-3 lipids improve bile flow by decreasing lithogenicity of bile, decreasing steatosis, stimulating improved beta-oxidation and clearance, lowering oxidative stress, and supporting immune function." — Paul Wales (clinical) [Ep 27 · 10:15](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=615)
- "The two main strategies for improving lipids in parenteral nutrition are lipid minimization and change in composition." — Paul Wales (clinical) [Ep 27 · 10:32](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=632)
- "Literature dating back decades shows that restricting exposure to soybean lipid improves cholestasis, particularly when dosed at 1 g/kg/day or less." — Paul Wales (clinical) [Ep 27 · 10:42](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=642)
- "In preterm babies, fat is important for growth, especially for neurocognitive development, creating a risk of essential fatty acid deficiency if lipid dosing is restricted too much." — Paul Wales (clinical) [Ep 27 · 11:00](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=660)
- "In utero, babies receive significant amounts of DHA and arachidonic acid through the placenta, but standard lipid emulsions in TPN fall short of providing these." — Lizzie Lee (host_summary) [Ep 27 · 11:12](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=672)
- "DHA and arachidonic acid are important for retinal and brain development." — Paul Wales (clinical) [Ep 27 · 11:22](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=682)
- "None of the current lipid emulsions were designed for premature babies; they were all designed for adults in critical care settings." — Paul Wales (clinical) [Ep 27 · 11:26](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=686)
- "Work is currently underway with industry to create a lipid emulsion specifically tailored to preterm babies with higher arachidonic acid content." — Paul Wales (clinical) [Ep 27 · 11:38](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=698)
- "Central lines are the lifeline for intestinal failure patients, and without venous access, families cannot be supported." — Paul Wales (clinical) [Ep 27 · 12:03](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=723)
- "Central lines are at risk for complications including infections, blockages, thrombosis, and breakage." — Paul Wales (clinical) [Ep 27 · 12:10](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=730)
- "In the United States, there are approximately 240,000 central line-associated bloodstream infections (CLABSIs) annually, with each costing about $30,000, totaling approximately $2 billion per year nationwide." — Paul Wales (epidemiological) [Ep 27 · 12:24](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=744)
- "The team pivoted to 4% tetrasodium EDTA (Taurolock/Kitelock) when ethanol became too expensive and difficult to obtain." — Paul Wales (clinical) [Ep 27 · 12:48](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=768)
- "4% tetrasodium EDTA (Kitelock) is antithrombotic, anti-fibrinolytic, and antimicrobial, satisfying all three criteria important for a good lock solution." — Paul Wales (clinical) [Ep 27 · 12:48](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=768)
- "Kitelock addresses three issues of central line complications: organisms, clot/thrombosis, and biofilm." — Lizzie Lee (host_summary) [Ep 27 · 13:09](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=789)
- "Kitelock is licensed in Europe and Australia but not available in the United States." — Paul Wales (clinical) [Ep 27 · 13:23](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=803)
- "A multi-center randomized trial of Kitelock versus heparin went live 4 weeks ago and is actively recruiting patients, with results expected within the next year." — Paul Wales (clinical) [Ep 27 · 13:29](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=809)
- "In short bowel syndrome, there are three anatomical subtypes: Type 1 (high jejunostomy), Type 2 (loss of distal small bowel/ileum and part of colon with small bowel-colonic anastomosis), and Type 3 (loss of mid-small bowel with retained ileum and intact colon)." — Paul Wales (clinical) [Ep 27 · 13:58](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=838)
- "Patients with Type 3 short bowel syndrome have the best prognosis because they still have residual ileum." — Lizzie Lee (host_summary) [Ep 27 · 14:19](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=859)
- "The most common anatomical subtype of short bowel syndrome in pediatrics is Type 2." — Paul Wales (epidemiological) [Ep 27 · 14:26](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=866)
- "Type 1 and Type 2 short bowel syndrome patients struggle because they lack an ileum." — Paul Wales (clinical) [Ep 27 · 14:31](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=871)
- "The ileum is where GLP-2 is naturally produced." — Lizzie Lee (host_summary) [Ep 27 · 14:36](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=876)
- "Without an ileum, infants cannot generate the necessary GLP-2 hormone surge to drive their own intestinal adaptation." — Lizzie Lee (host_summary) [Ep 27 · 14:39](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=879)
- "Native GLP-2 hormone has a half-life of 7 minutes, making it impractical for clinical use." — Paul Wales (clinical) [Ep 27 · 14:53](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=893)
- "GLP-2 has been altered by one amino acid to create an analog called teduglutide, which has a half-life of 2 hours and is given once daily by subcutaneous injection." — Paul Wales (clinical) [Ep 27 · 14:58](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=898)
- "A multi-center phase 3 study published in 2020 at Cincinnati Children's showed patients receiving teduglutide had a 40% reduction in TPN fluid and calorie requirements over a six-month period." — Paul Wales (epidemiological) [Ep 27 · 15:23](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=923)
- "70% of patients who received teduglutide achieved the study endpoint of a 20% reduction in TPN requirements." — Paul Wales (epidemiological) [Ep 27 · 15:32](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=932)
- "Teduglutide is licensed for children greater than 1 year of age." — Paul Wales (guideline) [Ep 27 · 15:48](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=948)
- "Teduglutide has made a big difference in practice, with even children with very extreme anatomy able to get off TPN." — Paul Wales (clinical) [Ep 27 · 15:50](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=950)
- "Another GLP-2 analog, apraglutide, has a longer half-life and can be given once weekly." — Paul Wales (clinical) [Ep 27 · 16:02](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=962)
- "Apraglutide works even better than teduglutide, producing more bowel lengthening." — Paul Wales (clinical) [Ep 27 · 16:10](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=970)
- "These interventions (optimized lipids, central line infection prevention, GLP-2 analogs) have led to a decrease in transplantation since 2008." — Paul Wales (epidemiological) [Ep 27 · 16:36](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=996)
- "The decrease in transplantation is in large part because of the successes of intestinal rehabilitation." — Paul Wales (opinion) [Ep 27 · 16:41](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=1001)
- "Outcomes of intestinal transplant at 5 years are approximately 65%." — Paul Wales (epidemiological) [Ep 27 · 16:41](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=1001)
- "The goal is to avoid transplant and lifelong immunosuppression whenever possible." — Paul Wales (opinion) [Ep 27 · 16:49](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=1009)
- "Children have much greater adaptive potential than adults because of their inherent gut growth capacity." — Lizzie Lee (host_summary) [Ep 27 · 16:54](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=1014)
- "The proportion of children reaching enteral autonomy has improved over the past 20 years." — Lizzie Lee (host_summary) [Ep 27 · 17:00](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=1020)
- "Controlling liver disease buys time for intestinal adaptation." — Lizzie Lee (host_summary) [Ep 27 · 17:06](https://qa.library.globalcastmd.com/watch/advancements-in-pediatric-intestinal-failure-innovative-therapies-and-improved-outcomes-13892?t=1026)
- "The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy." — Daniel von Allmen (host_summary) [Ep 7 · 2:48](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=168)
- "The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference." — Daniel von Allmen (host_summary) [Ep 7 · 3:32](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=212)
- "High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo." — Daniel von Allmen (host_summary) [Ep 7 · 4:01](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=241)
- "Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo." — Daniel von Allmen (host_summary) [Ep 7 · 4:39](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=279)
- "Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events." — Daniel von Allmen (host_summary) [Ep 7 · 4:55](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=295)
- "Dr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results." — Daniel von Allmen (opinion) [Ep 7 · 5:31](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=331)
- "The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids." — Daniel von Allmen (host_summary) [Ep 7 · 7:11](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=431)
- "Two proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant)." — Daniel von Allmen (clinical) [Ep 7 · 9:09](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=549)
- "The START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen." — Daniel von Allmen (clinical) [Ep 7 · 10:09](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=609)
- "A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other." — Whit Holcomb (host_summary) [Ep 7 · 11:20](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=680)
- "Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol." — Whit Holcomb (host_summary) [Ep 7 · 13:49](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=829)
- "The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge." — Whit Holcomb (host_summary) [Ep 7 · 14:20](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=860)
- "Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days." — Whit Holcomb (host_summary) [Ep 7 · 14:48](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=888)
- "Dr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision)." — Whit Holcomb (clinical) [Ep 7 · 16:30](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=990)
- "Most pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice." — Whit Holcomb (opinion) [Ep 7 · 17:03](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1023)
- "Chloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day." — Whit Holcomb (clinical) [Ep 7 · 18:16](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1096)
- "A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year." — Whit Holcomb (host_summary) [Ep 7 · 20:35](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1235)
- "Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation." — Whit Holcomb (host_summary) [Ep 7 · 22:42](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1362)
- "In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate)." — Whit Holcomb (host_summary) [Ep 7 · 23:14](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1394)
- "Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization." — Whit Holcomb (host_summary) [Ep 7 · 24:35](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1475)
- "Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation." — Whit Holcomb (host_summary) [Ep 7 · 24:55](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1495)
- "The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned." — Whit Holcomb (host_summary) [Ep 7 · 25:20](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1520)
- "Dr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics." — Whit Holcomb (opinion) [Ep 7 · 26:33](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1593)
- "Immunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics." — Whit Holcomb (clinical) [Ep 7 · 27:00](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1620)
- "The challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation." — Whit Holcomb (opinion) [Ep 7 · 27:22](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1642)
- "Long-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis." — Whit Holcomb (opinion) [Ep 7 · 27:52](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1672)
- "Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment." — Whit Holcomb (host_summary) [Ep 7 · 29:19](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1759)
- "If appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk." — Whit Holcomb (opinion) [Ep 7 · 29:45](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1785)
- "A PIFCON multi-center cohort study of 272 children with intestinal failure (median follow-up 33 months) found enteral autonomy was achieved in 43%, 13% remained PN-dependent, and 43% died or underwent transplant." — Aaron Lipskar (host_summary) [Ep 7 · 31:31](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1891)
- "Necrotizing enterocolitis as the underlying diagnosis, care at an intestinal rehab facility without a transplant center, and presence of an ileocecal valve were all statistically significantly associated with higher rates of enteral autonomy." — Aaron Lipskar (host_summary) [Ep 7 · 32:58](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1978)
- "Residual small bowel length was also a statistically significant predictor of enteral autonomy, though less impressive than the other three variables." — Aaron Lipskar (host_summary) [Ep 7 · 33:19](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=1999)
- "The protective effect of necrotizing enterocolitis on enteral autonomy is surprising and goes against understanding of that inflammatory illness, showing how much remains to be learned." — Aaron Lipskar (opinion) [Ep 7 · 33:55](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2035)
- "A companion paper in the same journal (Journal of Pediatrics, July 2015) found necrotizing enterocolitis was a poor predictor of growth outcome in infants with short bowel syndrome." — Aaron Lipskar (host_summary) [Ep 7 · 34:46](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2086)
- "The PIFCON study underscores the importance of managing children with intestinal failure in multidisciplinary intestinal rehab programs, where catheter-associated bloodstream infection elimination and cholestasis prevention have changed outcomes." — Aaron Lipskar (opinion) [Ep 7 · 36:11](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2171)
- "Animal studies show that commonly used anesthetics and sedatives (propofol, etomidate, sevoflurane, isoflurane, ketamine) that increase GABA receptor activity or block glutamate receptors produce neurotoxic effects in laboratory animals from nematodes to nonhuman primates." — Aaron Lipskar (host_summary) [Ep 7 · 38:09](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2289)
- "Observational studies in children undergoing early anesthesia offer conflicting results and are confounded by multiple factors, but suggest some children may have deficits—association, not causation." — Aaron Lipskar (host_summary) [Ep 7 · 38:43](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2323)
- "SmartTots June 2014 statement concluded that animal data is sufficiently convincing to warrant large-scale clinical studies and recommended avoiding anesthesia in children under 3 unless urgent or potentially harmful if not attended to." — Aaron Lipskar (host_summary) [Ep 7 · 39:11](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2351)
- "Dr. Lipskar has not yet delayed an inguinal hernia repair for anesthetic concerns." — Aaron Lipskar (opinion) [Ep 7 · 40:53](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2453)
- "At Cohen Children's Medical Center, circumcisions outside the neonatal period are done with general plus regional anesthesia." — Aaron Lipskar (clinical) [Ep 7 · 41:09](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2469)
- "Regional anesthesia and agents like precedex may help decrease the amount of potentially neurotoxic general anesthesia; almost every laparoscopic, thoracoscopic, or open operation has a regional block option." — Aaron Lipskar (opinion) [Ep 7 · 41:31](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2491)
- "Dr. Ponsky's chief of anesthesiology instituted a 'rule of two': defer elective operations until after age 2 and avoid two anesthetics in one year." — Todd Ponsky (clinical) [Ep 7 · 42:16](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2536)
- "Dr. Ponsky now defers dermoid cyst excision in a 6-month-old until 18 months but does not delay inguinal hernia repair due to known incarceration risk in young infants." — Todd Ponsky (opinion) [Ep 7 · 42:31](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2551)
- "A survey of ~150 parents in a primary care pediatrics office found the vast majority did not know anesthetic neurotoxicity was a major issue (Dr. Lipskar's unpublished study, to be presented at AAP)." — Aaron Lipskar (clinical) [Ep 7 · 43:17](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-308?t=2597)
- "Breast milk provides significant benefit to time to wean off parenteral nutrition in gastroschisis and NEC patients compared to formula-only feeding." — Michael Helmrath (clinical) [Ep 1 · 59:57](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=3597)
- "Breast milk contains non-nutrient oligosaccharides (2-fucosyllactose, 3-fucosyllactose) that are immunomodulatory and affect microflora, not present in current formulas." — Michael Helmrath (clinical) [Ep 1 · 86:39](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=5199)
- "STEP procedures done in the first year of life, especially in infants not progressing with enteral feeds, are not beneficial unless specifically avoiding line infections and bacterial overgrowth." — Michael Helmrath (opinion) [Ep 1 · 29:35](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1775)
- "In the STEP registry paper on early neonatal STEP, only 3 patients came off parenteral nutrition, whereas natural data predict 80-90% of such patients would be off TPN at 12 months without surgery." — Michael Helmrath (clinical) [Ep 1 · 31:32](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1892)
- "Dilated bowel does not become motile because you did a STEP procedure on it; if bowel hasn't been able to advance feeds, STEP will not make non-functioning bowel work." — Michael Helmrath (opinion) [Ep 1 · 29:46](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1786)
- "The one thing that makes bowel adapt is feeding the bowel; procedures that cause problems in reinitiating feeds cause damage to the patient." — Michael Helmrath (clinical) [Ep 1 · 30:13](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1813)
- "In a classic French study by Jolie, adults with short bowel syndrome had 60% absorption with ad lib feeding, 85% with continuous drip feeds, and 75% with half calories by mouth plus overnight drip feeds." — Sam Kocoshis (host_summary) [Ep 1 · 17:15](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1035)
- "Donor breast milk is less advantageous than maternal breast milk because it is usually from mothers 10-14 months postpartum, has lower caloric density and protein, and freezing may inactivate trophic factors." — Sam Kocoshis (clinical) [Ep 1 · 62:40](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=3760)
- "About 60% of patients weaned off TPN have deficiencies in one micronutrient or another." — Sam Kocoshis (epidemiological) [Ep 1 · 71:51](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=4311)
- "Metronidazole is the wrong choice for bacterial overgrowth because it has limited spectrum, knocks off anaerobes, and facilitates aerobic overgrowth; 2/3 of bloodstream infections were seen in patients on prophylactic Flagyl." — Sam Kocoshis (clinical) [Ep 1 · 90:10](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=5410)
- "Prebiotics (oligosaccharides) induce a more healthful flora; probiotics are not routinely recommended due to case reports of central line infections, though these likely occurred through direct line contamination rather than translocation." — Sam Kocoshis (opinion) [Ep 1 · 83:28](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=5008)
- "If using antibiotics for bacterial overgrowth, selective decontamination with non-absorbable aminoglycosides (tobramycin) and colistin may be preferable to metronidazole." — Sam Kocoshis (opinion) [Ep 1 · 92:27](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=5547)
- "Citrulline is produced by the gut and may predict ability to wean off TPN when measured as a total number, but as a weekly or monthly lab it does not inform clinical care changes." — Michael Helmrath (clinical) [Ep 1 · 75:49](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=4549)
- "GLP-2 analog can reduce fecal output such that TPN can be reduced by about 20% in 60-70% of adult patients, and totally emancipate about 20% from TPN in extension studies." — Sam Kocoshis (host_summary) [Ep 1 · 114:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6840)
- "When creating a jejunal feeding access, dividing the bowel 2-3 cm distal to ligament of Treitz and bringing the distal bowel up as a chimney with side-to-end anastomosis allows placement of a Mickey button without luminal obstruction." — Michael Helmrath (clinical) [Ep 1 · 3:15](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=195)
- "Placing a 3-4 French feeding tube in distal bowel and bringing it out as a stent (not maturing as mucous fistula) allows easy distal feeding by syringe injection without catheter access issues." — Michael Helmrath (clinical) [Ep 1 · 1:12](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=72)
- "When operating on a 2-month-old with jejunal atresia unable to advance feeds beyond 20 mL/kg, if the anastomosis is patent but dilated bowel is present and the child has 50% estimated bowel length, tapering is preferable to STEP." — Michael Helmrath (opinion) [Ep 1 · 28:07](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=1687)
- "Acceptable stoma output is not defined by a hard number; patients with 40-50 cc/kg output can continue feeding if electrolyte profile is acceptable and CO2 is not dropping into the teens." — Michael Helmrath (clinical) [Ep 1 · 111:28](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6688)
- "Knee-jerk reactions to volume of output (unless patient is sick with acidosis and abnormal electrolytes) should be avoided; variable feeding amounts over longer periods are detrimental to weaning from TPN." — Michael Helmrath (opinion) [Ep 1 · 112:03](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6723)
- "In infants, only pancreatic proteases are present in adult quantities; amylases appear between 6-12 months and lipase reaches adult levels by end of first year." — Sam Kocoshis (clinical) [Ep 1 · 109:38](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6578)
- "Pancreatic enzymes in short gut patients go through before they've released, and there is concern they may cause strictures or stoma problems in areas of stenosis and dysmotility." — Michael Helmrath (opinion) [Ep 1 · 109:07](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6547)
- "Cholestyramine in effective doses will bind nutrients, fat-soluble vitamins, and fats, with risk of hyperchloremic acidosis and bezoars; homeopathic doses may improve stool appearance but not reduce volume." — Sam Kocoshis (clinical) [Ep 1 · 106:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6360)
- "Ursodiol (Actigall) in very short gut can contribute to diarrhea due to osmotic component and has no real benefit in preventing cholestasis." — Simon Horslen or Jeff Rudolph (clinical) [Ep 1 · 107:25](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6445)
- "Anti-inflammatory agents (5-ASA products, steroid-based enemas) can be helpful in managing hypermotility when there is documented inflammation, particularly in challenging Hirschsprung's patients with dysbiosis." — Michael Helmrath (clinical) [Ep 1 · 104:08](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=6248)
- "Since developing a mature multidisciplinary intestinal rehabilitation program, internal transplant candidates have declined by 75%, and intestinal transplants are almost non-existent." — Sam Kocoshis (epidemiological) [Ep 1 · 41:08](https://qa.library.globalcastmd.com/watch/intestinal-failure-feeding-access-and-nutrition-740?t=2468)
- "Intestinal failure is an umbrella term for when the small intestine is unable to absorb or digest enough nutrition to support the patient entirely by oral or enteral feeding." — Brad Warner (clinical) [Ep 2 · 1:42](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=102)
- "The intestine of a newborn or fetus doubles in length in the last trimester of gestation." — Brad Warner (clinical) [Ep 2 · 3:03](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=183)
- "For a neonate with an ileocecal valve and entire colon, 10 to 15 centimeters of small intestine is a ballpark figure for potential salvageability." — Brad Warner (clinical) [Ep 2 · 4:03](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=243)
- "Without the colon and ileocecal valve, at least 15 to 20 centimeters of small intestine would be needed for potential salvageability in neonates." — Brad Warner (clinical) [Ep 2 · 4:37](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=277)
- "In adult studies, adults with less than 50 centimeters of intestine have about 40% mortality after 5 to 10 years." — Brad Warner (epidemiological) [Ep 2 · 4:51](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=291)
- "According to Pediatric Intestinal Failure Research Consortium data, approximately 25% of children with short gut syndrome die, 25% need a transplant, and 50% can wean off TPN." — Brad Warner (epidemiological) [Ep 2 · 6:38](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=398)
- "The most common causes of death in intestinal failure include liver failure, septic episodes from central line or bacterial overgrowth, variceal bleeding from liver disease, and loss of IV access." — Brad Warner (clinical) [Ep 2 · 7:11](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=431)
- "Intestinal adaptation in humans probably takes place over about a year or two after small bowel resection." — Brad Warner (clinical) [Ep 2 · 7:49](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=469)
- "Stool outputs of up to 40 cc per kilo per day are acceptable when advancing enteral feeding; beyond that threshold, enteral feeding should be reduced." — Brad Warner (clinical) [Ep 2 · 8:30](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=510)
- "The most common causes of short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias, with trauma and inflammatory bowel disease further down the list." — Brad Warner (epidemiological) [Ep 2 · 9:22](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=562)
- "For TPN, the goal is about 100 to 120 calories per kilo per day for total calories, with about 50% from glucose and the remainder from fat and protein." — Brad Warner (clinical) [Ep 2 · 10:22](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=622)
- "TPN should provide about 2 to 3 grams of protein per kilo per day and about 2 to 3 grams of fat per kilo per day." — Brad Warner (clinical) [Ep 2 · 10:45](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=645)
- "Babies should gain about 20 to 30 grams a day, which approximates in utero weight gain for a newborn." — Brad Warner (clinical) [Ep 2 · 12:05](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=725)
- "Lipid reduction strategy involves reducing fat from 2-3 g/kg/day given daily down to about 1 g/kg/day delivered twice or three times a week, which has been effective in reducing TPN-associated cholestasis." — Brad Warner (clinical) [Ep 2 · 12:53](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=773)
- "Omegaven is a fish oil-based fat containing primarily omega-3 fatty acids that are anti-inflammatory, in contrast to soybean-based intralipid which contains pro-inflammatory omega-6 fatty acids." — Brad Warner (clinical) [Ep 2 · 13:46](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=826)
- "SMOF lipid contains soybean-based lipid (essential fatty acids), medium chain triglycerides (more easily digested), olive oil, and fish oil, and has recently been FDA approved in the United States." — Brad Warner (clinical) [Ep 2 · 15:08](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=908)
- "Breast milk is the best choice for neonates because it contains proper fat composition plus growth factors such as epidermal growth factor and insulin-like growth factors that promote adaptation." — Brad Warner (opinion) [Ep 2 · 18:11](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1091)
- "Complex formulas fed enterally may stimulate adaptation better than elemental formulas because they cause secretion of enterotrophic hormones to a greater extent." — Brad Warner (opinion) [Ep 2 · 19:26](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1166)
- "There is a threshold percentage of enteral calories that prevents the onset of TPN-related liver damage, though the exact number is unknown; 90% enteral feeding carries far less risk than 10% enteral feeding." — Brad Warner (clinical) [Ep 2 · 20:56](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1256)
- "Surgical intervention should be considered when patients regress in enteral tolerance (e.g., tolerating 50% enteral a month ago but now down to 20%), when there are multiple episodes of sepsis with abdominal distention and dilated bowel loops, or when the child develops jaundice." — Brad Warner (clinical) [Ep 2 · 22:33](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1353)
- "Dilated bowel loops greater than 4 to 5 centimeters in diameter, combined with failure to advance enteral feeds or regression, is an indication for surgical intervention." — Brad Warner (clinical) [Ep 2 · 25:43](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1543)
- "Less than 5 to 10% of patients with over 100 centimeters of intestine should require TPN, suggesting an underlying motility or mucosal problem if they remain TPN-dependent." — Brad Warner (clinical) [Ep 2 · 27:53](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1673)
- "The STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation because it is easier to perform with less risk of injuring the mesenteric blood supply." — Brad Warner (clinical) [Ep 2 · 29:31](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1771)
- "The Bianchi procedure takes advantage of the bifurcating blood supply to the bowel wall, allowing longitudinal division to create two tubes of bowel, effectively doubling the length." — Brad Warner (clinical) [Ep 2 · 30:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1800)
- "STEP procedures can redilate and require redo operations, and outcomes are not as good when a STEP needs to be redone compared to never needing a redo." — Brad Warner (clinical) [Ep 2 · 32:54](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=1974)
- "A Bianchi can be performed first, then a STEP can be done later if needed, but a Bianchi cannot be done after a STEP has been performed (unless the STEP was inadequate)." — Brad Warner (clinical) [Ep 2 · 33:26](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2006)
- "Tapering should be considered for children with dilated bowel who have at least 90 to 100 centimeters of intestinal length." — Brad Warner (clinical) [Ep 2 · 38:21](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2301)
- "Teduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1 to 2 liters per week." — Brad Warner (clinical) [Ep 2 · 43:45](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2625)
- "Growth hormone and glutamine combinations have been administered to patients, but results are primarily mixed and it hasn't been a huge advance in weaning TPN." — Brad Warner (clinical) [Ep 2 · 45:40](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2740)
- "Current survival for small bowel transplant is about 50 to 60% at 5 years, with one-year survivals now above 70 to 80%." — Brad Warner (epidemiological) [Ep 2 · 46:51](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2811)
- "The intestine is an immunogenic organ filled with white cells and macrophages that mount a huge graft-versus-host response, requiring industrial strength immunosuppression that increases risk for malignancies and infections." — Brad Warner (clinical) [Ep 2 · 47:11](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2831)
- "Ethanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters." — Brad Warner (clinical) [Ep 2 · 49:22](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=2962)
- "Multidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID specialists, and interventional radiologists improve survival in intestinal failure patients, as demonstrated in series from Boston, Michigan, and Texas." — Brad Warner (clinical) [Ep 2 · 51:16](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-927?t=3076)
- "The START trial randomized 140 infants with biliary atresia to high-dose steroids (IV for 2 weeks, oral for 2 weeks, taper over 9 weeks) versus placebo within 72 hours of Kasai portoenterostomy." — Daniel von Allmen (host_summary) [Ep 3 · 2:48](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=168)
- "The primary outcome was serum total bilirubin <1.5 mg/dL with native liver at 6 months post-Kasai; the study was powered to detect a 25% absolute treatment difference." — Daniel von Allmen (host_summary) [Ep 3 · 3:32](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=212)
- "High-dose steroid therapy after Kasai did not result in a statistically significant treatment difference in bile drainage at 6 months: 58.6% in the steroid group versus 48.6% in placebo." — Daniel von Allmen (host_summary) [Ep 3 · 4:01](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=241)
- "Survival without liver transplant at 24 months was not statistically different: 58.7% for steroids versus 49.4% for placebo." — Daniel von Allmen (host_summary) [Ep 3 · 4:39](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=279)
- "Adverse events were common in both groups (near 80%), largely reflecting severe underlying liver dysfunction; steroid treatment was associated with earlier onset of serious adverse events." — Daniel von Allmen (host_summary) [Ep 3 · 4:55](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=295)
- "Dr. von Almen personally used steroids after Kasai in the past but has stopped based on the START trial results." — Daniel von Allmen (opinion) [Ep 3 · 5:31](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=331)
- "The authors of the START trial believe anything less than a 25% difference in bile drainage is not worth the potential early complications of steroids." — Daniel von Allmen (host_summary) [Ep 3 · 7:11](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=431)
- "Two proposed mechanisms for steroid benefit in biliary atresia: reducing ongoing inflammation to preserve ductules, and acting as a choleretic to maintain bile flow (analogous to diuresis after kidney transplant)." — Daniel von Allmen (clinical) [Ep 3 · 9:09](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=549)
- "The START trial specifically tested a 13-week course of high-dose steroids; the lack of benefit applies to that regimen." — Daniel von Allmen (clinical) [Ep 3 · 10:09](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=609)
- "A Washington State registry study of clean-contaminated adult general surgery cases (60% colorectal, 34% bariatric) found no single skin antiseptic agent associated with lower SSI risk than any other." — Whit Holcomb (host_summary) [Ep 3 · 11:20](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=680)
- "Isopropyl alcohol as part of the antiseptic mixture conferred no benefit: unadjusted SSI rate 4.5% without alcohol versus 4.6% with alcohol." — Whit Holcomb (host_summary) [Ep 3 · 13:49](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=829)
- "The registry could not identify SSI diagnosed after discharge, likely underestimating the true SSI rate; a recent report showed 50% or more SSIs are diagnosed after discharge." — Whit Holcomb (host_summary) [Ep 3 · 14:20](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=860)
- "Most SSIs occur 3–10 days after operation; average length of stay in the study was 6–7 days." — Whit Holcomb (host_summary) [Ep 3 · 14:48](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=888)
- "Dr. Holcomb's institution switched to chlorhexidine with isopropyl alcohol (chloraprep) except for mucous membrane preps (e.g., circumcision)." — Whit Holcomb (clinical) [Ep 3 · 16:30](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=990)
- "Most pediatric surgery cases are clean (not clean-contaminated), so the Washington State study does not directly address pediatric practice." — Whit Holcomb (opinion) [Ep 3 · 17:03](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1023)
- "Chloraprep or similar agents dry faster than betadine/iodine preps, allowing cases to start sooner; this matters when doing 6–7 cases per day." — Whit Holcomb (clinical) [Ep 3 · 18:16](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1096)
- "A pilot randomized trial in children aged 5–15 with non-perforated appendicitis (based on imaging) compared non-operative antibiotic treatment versus laparoscopic appendectomy; follow-up was one year." — Whit Holcomb (host_summary) [Ep 3 · 20:35](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1235)
- "Of 225 children with appendicitis, 50 were randomized (26 to surgery, 24 to antibiotics); 77 families declined participation." — Whit Holcomb (host_summary) [Ep 3 · 22:42](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1362)
- "In the antibiotic group, 2 of 24 underwent appendectomy during primary treatment, 1 had recurrent appendicitis at 9 months, and 6 more had appendectomy for recurrent pain or parental desire (none with histologic appendicitis)—total 9 of 24 (38% failure rate)." — Whit Holcomb (host_summary) [Ep 3 · 23:14](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1394)
- "Median time to discharge was significantly shorter in the surgical group, but the antibiotic group had a stipulated 48-hour minimum hospitalization." — Whit Holcomb (host_summary) [Ep 3 · 24:35](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1475)
- "Cost for the initial inpatient stay was significantly lower in the antibiotic group despite longer hospitalization, highlighting the cost of undergoing an operation." — Whit Holcomb (host_summary) [Ep 3 · 24:55](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1495)
- "The pilot study demonstrates that a definitive randomized trial comparing antibiotics and laparoscopic appendectomy for non-perforated appendicitis is safe and feasible; a multi-center study is planned." — Whit Holcomb (host_summary) [Ep 3 · 25:20](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1520)
- "Dr. Holcomb has not treated acute appendicitis non-operatively at his institution but knows of poor operative candidates treated successfully with antibiotics." — Whit Holcomb (opinion) [Ep 3 · 26:33](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1593)
- "Immunosuppressed cancer patients with typhlitis (not appendicitis but similar) are sometimes treated non-operatively, and most resolve with antibiotics." — Whit Holcomb (clinical) [Ep 3 · 27:00](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1620)
- "The challenge will be identifying which population of appendicitis patients can be treated successfully non-operatively versus which should undergo early operation." — Whit Holcomb (opinion) [Ep 3 · 27:22](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1642)
- "Long-term follow-up is critical; even a 10-year follow-up leaves patients only 15–20 years old, with 40–50 years of life remaining at risk for recurrent appendicitis." — Whit Holcomb (opinion) [Ep 3 · 27:52](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1672)
- "Some parents in the pilot study wanted their child's appendix removed to avoid future worry, even after successful antibiotic treatment." — Whit Holcomb (host_summary) [Ep 3 · 29:19](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1759)
- "If appendectomy can be done as an outpatient same-day procedure, it may be difficult to argue for 1–2 days of antibiotics with uncertain long-term recurrence risk." — Whit Holcomb (opinion) [Ep 3 · 29:45](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1785)
- "A PIFCON multi-center cohort study of 272 children with intestinal failure (median follow-up 33 months) found enteral autonomy was achieved in 43%, 13% remained PN-dependent, and 43% died or underwent transplant." — Aaron Lipskar (host_summary) [Ep 3 · 31:31](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1891)
- "Necrotizing enterocolitis as the underlying diagnosis, care at an intestinal rehab facility without a transplant center, and presence of an ileocecal valve were all statistically significantly associated with higher rates of enteral autonomy." — Aaron Lipskar (host_summary) [Ep 3 · 32:58](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1978)
- "Residual small bowel length was also a statistically significant predictor of enteral autonomy, though less impressive than the other three variables." — Aaron Lipskar (host_summary) [Ep 3 · 33:19](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=1999)
- "The protective effect of necrotizing enterocolitis on enteral autonomy is surprising and goes against understanding of that inflammatory illness, showing how much remains to be learned." — Aaron Lipskar (opinion) [Ep 3 · 33:55](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2035)
- "A companion paper in the same journal (Journal of Pediatrics, July 2015) found necrotizing enterocolitis was a poor predictor of growth outcome in infants with short bowel syndrome." — Aaron Lipskar (host_summary) [Ep 3 · 34:46](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2086)
- "The PIFCON study underscores the importance of managing children with intestinal failure in multidisciplinary intestinal rehab programs, where catheter-associated bloodstream infection elimination and cholestasis prevention have changed outcomes." — Aaron Lipskar (opinion) [Ep 3 · 36:11](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2171)
- "Animal studies show that commonly used anesthetics and sedatives (propofol, etomidate, sevoflurane, isoflurane, ketamine) that increase GABA receptor activity or block glutamate receptors produce neurotoxic effects in laboratory animals from nematodes to nonhuman primates." — Aaron Lipskar (host_summary) [Ep 3 · 38:09](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2289)
- "Observational studies in children undergoing early anesthesia offer conflicting results and are confounded by multiple factors, but suggest some children may have deficits—association, not causation." — Aaron Lipskar (host_summary) [Ep 3 · 38:43](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2323)
- "SmartTots June 2014 statement concluded that animal data is sufficiently convincing to warrant large-scale clinical studies and recommended avoiding anesthesia in children under 3 unless urgent or potentially harmful if not attended to." — Aaron Lipskar (host_summary) [Ep 3 · 39:11](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2351)
- "Dr. Lipskar has not yet delayed an inguinal hernia repair for anesthetic concerns." — Aaron Lipskar (opinion) [Ep 3 · 40:53](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2453)
- "At Cohen Children's Medical Center, circumcisions outside the neonatal period are done with general plus regional anesthesia." — Aaron Lipskar (clinical) [Ep 3 · 41:09](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2469)
- "Regional anesthesia and agents like precedex may help decrease the amount of potentially neurotoxic general anesthesia; almost every laparoscopic, thoracoscopic, or open operation has a regional block option." — Aaron Lipskar (opinion) [Ep 3 · 41:31](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2491)
- "Dr. Ponsky's chief of anesthesiology instituted a 'rule of two': defer elective operations until after age 2 and avoid two anesthetics in one year." — Todd Ponsky (clinical) [Ep 3 · 42:16](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2536)
- "Dr. Ponsky now defers dermoid cyst excision in a 6-month-old until 18 months but does not delay inguinal hernia repair due to known incarceration risk in young infants." — Todd Ponsky (opinion) [Ep 3 · 42:31](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2551)
- "A survey of ~150 parents in a primary care pediatrics office found the vast majority did not know anesthetic neurotoxicity was a major issue (Dr. Lipskar's unpublished study, to be presented at AAP)." — Aaron Lipskar (clinical) [Ep 3 · 43:17](https://qa.library.globalcastmd.com/watch/biliary-atresia-appendicitis-intestinal-failure-and-anesthetic-929?t=2597)
- "Until recently, there was no standardized definition for intestinal failure." — Paul Wales (clinical) [Ep 8 · 1:56](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=116)
- "Intestinal failure is when gut function is insufficient to absorb enough nutrients, fluids, and calories to support survival and, in children, growth." — Paul Wales (clinical) [Ep 8 · 2:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=123)
- "New guidelines define intestinal failure as requiring parenteral support for at least 60 days due to inadequate intestinal function." — Rod Gerardo (host_summary) [Ep 8 · 2:24](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=144)
- "Earlier recognition and taking advantage of the gut's biology to adapt are time dependent." — Michael Helmrath (clinical) [Ep 8 · 2:40](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=160)
- "An intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm that brings coordinated care for children with intestinal failure through comprehensive management of their specialized nutrition and other associated needs, as defined in recent ASPEN guidelines." — Paul Wales (guideline) [Ep 8 · 3:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=183)
- "Intestinal rehabilitation requires managing comorbidities including sepsis and liver disease that challenge infant growth." — Rod Gerardo (host_summary) [Ep 8 · 3:33](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=213)
- "The intestinal rehabilitation approach streamlines care and improves communication with families and between care providers." — Paul Wales (clinical) [Ep 8 · 3:44](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=224)
- "Intestinal rehabilitation depends on nutrition in the gut, nutrition in the body, and healing." — Michael Helmrath (clinical) [Ep 8 · 4:07](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=247)
- "Pattern recognition from multiple experienced clinicians observing patients over time is essential in intestinal rehabilitation." — Michael Helmrath (clinical) [Ep 8 · 4:19](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=259)
- "Causes of intestinal failure divide into three categories: short bowel syndrome, motility disorders, and congenital enteropathies." — Paul Wales (clinical) [Ep 8 · 4:39](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=279)
- "Short bowel syndrome is by far the most common category of intestinal failure in pediatric patients." — Paul Wales (epidemiological) [Ep 8 · 4:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=290)
- "Causes of short bowel syndrome include congenital anomalies (intestinal atresia, malrotation, volvulus, gastroschisis, long segment Hirschsprung disease) and acquired neonatal diseases (necrotizing enterocolitis)." — Paul Wales (clinical) [Ep 8 · 5:06](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=306)
- "Motility disorders occur when abnormalities of intestinal muscle or the nerves controlling that muscle prevent coordinated propulsion of food and stool." — Paul Wales (clinical) [Ep 8 · 5:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=345)
- "Congenital enteropathies are conditions where patients have all their bowel but the mucosal lining does not digest or absorb properly." — Paul Wales (clinical) [Ep 8 · 6:17](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=377)
- "Mucosal defects in enteropathies lead to hypersecretion and profuse fluid losses, preventing nutrient absorption." — Ellen Encisco (host_summary) [Ep 8 · 6:30](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=390)
- "Some patients have elements of two or all three categories of intestinal failure in their presentation." — Paul Wales (clinical) [Ep 8 · 7:11](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=431)
- "Gastroschisis can involve all three categories: short bowel from nonviable tissue, inflammation affecting absorption, and motility issues." — Ellen Encisco (host_summary) [Ep 8 · 7:22](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=442)
- "Most intestinal failure patients are infants or babies, but some older pediatric patients develop intestinal failure from inflammatory bowel disease, Crohn disease complications, trauma, malignancy, or vascular thrombosis." — Paul Wales (epidemiological) [Ep 8 · 7:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=465)
- "Access and availability to intestinal rehabilitation programs is still very rare." — Rod Gerardo (host_summary) [Ep 8 · 8:41](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=521)
- "Three time points exist for diagnosis and referral to intestinal rehab: prenatal diagnosis (atresia with cystic fibrosis, gastroschisis), postnatal acquired problems (volvulus, NEC), and later presentations after discharge when patients fail to progress." — Michael Helmrath (clinical) [Ep 8 · 8:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=533)
- "Innovation in intestinal rehabilitation comes from multiple approaches to problems and different visions, with more expertise leading to better outcomes." — Michael Helmrath (opinion) [Ep 8 · 10:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=615)
- "Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being adequately addressed." — Michael Helmrath (clinical) [Ep 8 · 10:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=651)
- "The intestinal rehabilitation team includes dietitians (for nutritional needs), social workers, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology." — Michael Helmrath (clinical) [Ep 8 · 11:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=712)
- "Overall long-term survival in major intestinal rehabilitation programs is usually over 90%." — Rod Gerardo (host_summary) [Ep 8 · 12:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=754)
- "Long-term survivors now develop chronic comorbidities not previously seen to the same extent because patients did not live long enough, including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life problems." — Paul Wales (clinical) [Ep 8 · 12:46](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-what-is-intestinal-rehab-episode-1-4741?t=766)
- "Until recently, there was no standardized definition for intestinal failure." — Paul Wales (guideline) [Ep 9 · 1:56](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=116)
- "Intestinal failure is a functional problem where gut function is insufficient to absorb enough nutrients, fluids, and calories to support survival and, in children, growth." — Paul Wales (clinical) [Ep 9 · 2:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=123)
- "New guidelines define intestinal failure as inadequate intestinal function requiring parenteral support for at least 60 days." — Rod Gerardo (host_summary) [Ep 9 · 2:24](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=144)
- "Earlier recognition and taking advantage of the gut's adaptive biology are time dependent." — Michael Helmrath (clinical) [Ep 9 · 2:40](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=160)
- "An intestinal rehabilitation program is a multidisciplinary collaborative patient care paradigm that brings coordinated care for children with intestinal failure through comprehensive management of their specialized nutrition and other associated needs, as defined in recent ASPEN guidelines." — Paul Wales (guideline) [Ep 9 · 3:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=183)
- "Intestinal rehabilitation requires managing comorbidities including sepsis and liver disease that challenge infant growth." — Rod Gerardo (host_summary) [Ep 9 · 3:33](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=213)
- "Intestinal rehabilitation streamlines care and improves communication between family and care providers through an amalgamation of experts providing holistic, comprehensive, coordinated care." — Paul Wales (clinical) [Ep 9 · 3:44](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=224)
- "Intestinal rehabilitation depends on key factors: nutrition in the gut, nutrition in the body, and healing." — Michael Helmrath (clinical) [Ep 9 · 4:07](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=247)
- "Pattern recognition from multiple expert eyes observing a patient over time is essential in intestinal rehabilitation." — Michael Helmrath (clinical) [Ep 9 · 4:19](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=259)
- "Short bowel syndrome is by far the most common category of intestinal failure in pediatric patients." — Paul Wales (epidemiological) [Ep 9 · 4:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=290)
- "Causes of short bowel syndrome are usually related to neonatal disorders including congenital anomalies (intestinal atresia, malrotation, volvulus, gastroschisis, long segment Hirschsprung disease) or acquired diseases (necrotizing enterocolitis)." — Paul Wales (clinical) [Ep 9 · 4:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=290)
- "Motility disorders occur when abnormalities of the intestinal muscle itself or the nerves controlling that muscle prevent coordinated propulsion of food and stool, making patients dependent on intravenous support." — Paul Wales (clinical) [Ep 9 · 5:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=345)
- "Enteropathies or congenital diarrheas are conditions where the patient has all of their bowel but the mucosal lining that digests and absorbs does not work, leading to hypersecretion and profuse fluid losses." — Paul Wales (clinical) [Ep 9 · 6:17](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=377)
- "Some patients will have elements of two or all three categories of intestinal failure; for example, gastroschisis can involve short bowel, inflammation affecting absorption, and motility issues." — Paul Wales (clinical) [Ep 9 · 7:11](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=431)
- "Although most intestinal failure patients are infants or babies, older pediatric patients can develop intestinal failure from inflammatory bowel disease, Crohn's disease complications, trauma, malignancy, or vascular thrombosis leading to gut loss." — Paul Wales (clinical) [Ep 9 · 7:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=465)
- "Families reach intestinal rehabilitation programs at three time points: prenatal diagnosis (typically atresia with cystic fibrosis or gastroschisis), postnatal acquired problems (volvulus or NEC), and later diagnosis after discharge when patients fail to progress." — Michael Helmrath (clinical) [Ep 9 · 8:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=533)
- "Innovation comes from multiple approaches to a problem and different visions; bringing in more expertise leads to better outcomes." — Michael Helmrath (opinion) [Ep 9 · 10:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=615)
- "Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being met." — Michael Helmrath (clinical) [Ep 9 · 10:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=651)
- "The intestinal rehabilitation team includes dietitians (understanding nutritional needs), social work, nurse practitioners, pharmacy, interventional radiology, pathology, and subspecialties including endocrinology and nephrology." — Michael Helmrath (clinical) [Ep 9 · 11:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=712)
- "Overall survival in big intestinal rehabilitation programs is usually over 90% long-term." — Rod Gerardo (host_summary) [Ep 9 · 12:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=754)
- "Improved survival has revealed chronic comorbidities not previously seen to the same extent because patients did not live long enough, including renal dysfunction, metabolic bone disease, neurocognitive issues, and quality of life concerns." — Paul Wales (clinical) [Ep 9 · 12:46](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-1-what-is-intestinal-rehabilitation-4742?t=766)
- "The outlook for preterm infants with short bowel syndrome has changed over the last two decades as a result of advances in medical and surgical care." — Paul Wales (clinical) [Ep 10 · 0:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=51)
- "A more aggressive approach to surgical resection has accompanied improved outcomes in short bowel syndrome." — Paul Wales (clinical) [Ep 10 · 1:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=83)
- "Intestinal transplant is not experimental therapy; it is part of the continuum of therapy for a child with short bowel syndrome." — Paul Wales (clinical) [Ep 10 · 2:38](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=158)
- "Mistakes are commonly made because clinicians think they can predict the future with their eyes, predetermining care based on what they believe will happen rather than allowing the clinical scenario to drive the direction of care." — Michael Helmrath (opinion) [Ep 10 · 3:11](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=191)
- "There is an algorithm of children with overwhelming sepsis where surgery cannot salvage these patients and there is no life-saving option." — Michael Helmrath (clinical) [Ep 10 · 3:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=214)
- "Many infants will rally without having their bowel removed, which allows them an opportunity for recovery." — Michael Helmrath (clinical) [Ep 10 · 3:41](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=221)
- "In the acute phase with infarcted gut, the clinical picture is usually one of overwhelming sepsis, and even after resection leaving ultra-short bowel, patients are rocky and unstable due to sepsis, SIRS, or septic experience." — Paul Wales (clinical) [Ep 10 · 4:10](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=250)
- "In the very acute time, the primary cause of death is sepsis and multi-organ failure." — Paul Wales (clinical) [Ep 10 · 4:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=274)
- "In the intermediate and longer term, complications include intestinal failure-associated liver disease, recurrent sepsis, or line problems, which historically led to death or transplant." — Paul Wales (clinical) [Ep 10 · 4:44](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=284)
- "Much of the success seen in the last two decades is because clinicians are way better at preventing sepsis and liver disease." — Paul Wales (clinical) [Ep 10 · 5:02](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=302)
- "The first goal when seeing these infants is protecting the liver." — Michael Helmrath (clinical) [Ep 10 · 5:14](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=314)
- "Research at Dr. Helmrath's lab and elsewhere has shown that giving fish oils and trying to improve bilirubin is not enough; the liver must be taken care of to reach the point where bowel reconstruction is possible." — Ellen Gootee (host_summary) [Ep 10 · 5:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=331)
- "Decompressing the duodenum is needed to protect the liver, and when the liver is inflamed with high bilirubin, it is in a catabolic state." — Michael Helmrath (clinical) [Ep 10 · 5:49](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=349)
- "When in the OR wanting to buy time, one of the first things to consider is how to keep the proximal bowel decompressed." — Michael Helmrath (clinical) [Ep 10 · 6:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=363)
- "Babies born with duodenal atresia or very proximal jejunal atresia are born with elevated direct or conjugated bilirubins, supporting the concept that an undecompressed foregut affects liver function." — Paul Wales (clinical) [Ep 10 · 6:14](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=374)
- "Liver function is affected by multiple factors: prematurity, sepsis, choice of TPN, and presence or absence of enteral nutrition." — Paul Wales (clinical) [Ep 10 · 6:42](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=402)
- "Placing a retrograde tube in the duodenum or jejunum that goes up to the pylorus to decompress the bowel has given time to allow children to recover from the acute event." — Michael Helmrath (clinical) [Ep 10 · 7:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=435)
- "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) [Ep 10 · 7:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=454)
- "The distal bowel (ileum) is remarkably important and can be salvaged by ileocecal blood flow; leaving it alone has allowed salvage of a lot of tissue in Cincinnati." — Michael Helmrath (clinical) [Ep 10 · 8:04](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=484)
- "Proximal control allows tissue time to regenerate, which is often on the order of 6, 8, or 12 weeks based on the liver getting better." — Michael Helmrath (clinical) [Ep 10 · 8:17](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=497)
- "The inflection point of bowel loss that requires prolonged TPN is about 50%." — Michael Helmrath (clinical) [Ep 10 · 9:27](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=567)
- "If dealing with less than 50% bowel necrosis, the best option is to remove that bowel and the child's adaptive potential is really great, especially if ileum is preserved." — Michael Helmrath (clinical) [Ep 10 · 9:35](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=575)
- "If necrotic bowel is focal and less than 50%, it should be removed and the child managed accordingly; the approach is not to leave all dead bowel in place." — Michael Helmrath (clinical) [Ep 10 · 9:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=591)
- "When bowel necrosis is patchy with areas that look terrible, bad, and maybe a little good (mosaicism), proximally controlling the bowel with a drain and providing time to heal gives opportunity to return later; not all bowel will survive and islands of mucosa will need to be tubularized and reconnected." — Michael Helmrath (clinical) [Ep 10 · 10:00](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=600)
- "Once proximal bowel is controlled with a drain, stomas should be avoided because they lose abdominal domain and lose bowel down the road." — Michael Helmrath (clinical) [Ep 10 · 10:59](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=659)
- "The percentage of infants that do well with proximal drain therapy when facing dead gut is more than 70 to 80%." — Michael Helmrath (clinical) [Ep 10 · 11:11](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=671)
- "The approach to overwhelming bowel necrosis does not differ based on diagnosis (volvulus, infarct, mesenteric thrombosis), but the outcome does." — Michael Helmrath (clinical) [Ep 10 · 11:39](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=699)
- "Kids with NEC have the best outcomes because it is a microvascular disease." — Michael Helmrath (clinical) [Ep 10 · 11:48](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=708)
- "Controlling proximal bowel without allowing enteric content has been key to salvaging NEC patients with good outcomes." — Michael Helmrath (clinical) [Ep 10 · 11:54](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-1-4954?t=714)
- "Infants with intestinal failure have compromised intestinal function, putting them at increased risk of malabsorption and electrolyte and fluid deficits." — Sarah Choi (clinical) [Ep 14 · 0:36](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=36)
- "Sodium depletion can go unrecognized, resulting in poor growth refractory to increased caloric intake." — Sarah Choi (clinical) [Ep 14 · 0:45](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=45)
- "Sodium supplementation has been shown to be associated with weight gain and overall growth in infants with intestinal failure." — Sarah Choi (clinical) [Ep 14 · 1:00](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=60)
- "Serum sodium does not reflect total sodium stores." — Sarah Choi (clinical) [Ep 14 · 1:04](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=64)
- "Fractional excretion of sodium is the optimum measure of total body sodium but is inconvenient in the pediatric population as it requires a paired urine and blood sample." — Sarah Choi (clinical) [Ep 14 · 1:14](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=74)
- "At BC Women's Hospital, urine sodium is used as a non-invasive marker to estimate total body sodium in infants with intestinal failure, with a value above 30 suggesting sodium sufficiency." — Sarah Choi (clinical) [Ep 14 · 1:29](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=89)
- "Urine sodium doesn't account for volume status, therefore can result in oversupplementation or under supplementation with sodium." — Sarah Choi (clinical) [Ep 14 · 1:44](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=104)
- "The urine sodium to urine creatinine ratio offers a non-invasive measure which accounts for variable urine flow and has shown to be strongly correlated with fractional excretion of sodium." — Sarah Choi (clinical) [Ep 14 · 1:57](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=117)
- "The use of the urine sodium to creatinine ratio has not yet been validated in the intestinal failure population." — Sarah Choi (clinical) [Ep 14 · 2:13](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=133)
- "In the study cohort of 22 infants, median gestational age was 31 weeks, median birth weight was 1.9 kg, and median age of enrollment was 8 days." — Sarah Choi (epidemiological) [Ep 14 · 3:18](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=198)
- "Gastroschisis was the most common etiology of intestinal failure in the study cohort." — Sarah Choi (epidemiological) [Ep 14 · 3:30](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=210)
- "There was no significant correlation between either urine sodium or the ratio with daily weight gain when evaluating the entire data set." — Sarah Choi (clinical) [Ep 14 · 3:41](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=221)
- "The ratio was more strongly associated with sodium intake when compared to urine sodium alone." — Sarah Choi (clinical) [Ep 14 · 4:04](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=244)
- "Urine sodium values above 29 and ratio values above 35 best predicted adequate weight gain." — Sarah Choi (clinical) [Ep 14 · 4:18](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=258)
- "The urine sodium threshold of 29 is similar to previous studies, as it is generally accepted that urine sodium values above 30 is suggestive of sodium sufficiency." — Sarah Choi (clinical) [Ep 14 · 4:28](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=268)
- "In the majority of urine sodium and ratio values, both markers were concordant, meaning that if urine sodium value met the threshold, then the ratio also met the threshold." — Sarah Choi (clinical) [Ep 14 · 4:41](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=281)
- "In 19% of the time, the urine sodium and ratio values were discordant." — Sarah Choi (clinical) [Ep 14 · 4:54](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=294)
- "Patients with stomas, even those without intestinal failure, run the risk of sodium depletion, which has a significant impact on their growth." — Paul Wales (clinical) [Ep 14 · 6:08](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=368)
- "Stomas and high stool losses are a large source of sodium bicarbonate as well as magnesium loss." — Paul Wales (clinical) [Ep 14 · 6:19](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=379)
- "Sodium status needs to be thought of, especially in the setting of a baby experiencing poor weight gain in the exposure to what is believed to be adequate calories." — Paul Wales (clinical) [Ep 14 · 6:26](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=386)
- "When sodium is replaced, it helps restore growth, but it doesn't allow catch up growth." — Paul Wales (clinical) [Ep 14 · 6:38](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=398)
- "It's important to track these patients serially so that a trend can be detected and sodium depletion can be avoided in the first place." — Paul Wales (opinion) [Ep 14 · 6:45](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=405)
- "If it becomes part of practice to order urine electrolytes at the time that someone's doing their TPN blood work, it's easy to calculate the fractional excretion of sodium ratio." — Paul Wales (opinion) [Ep 14 · 7:12](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=432)
- "Having potassium, chloride, and osmolality added to the urine electrolytes in addition to just the sodium gives a better picture of whether someone is truly sodium depleted." — Paul Wales (opinion) [Ep 14 · 7:30](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=450)
- "If potassium level is higher than sodium level in urine, that often indicates the aldosterone pathway is turned on." — Paul Wales (clinical) [Ep 14 · 7:41](https://qa.library.globalcastmd.com/watch/caps-the-use-of-urine-sodium-to-creatinine-ratio-as-a-marker-of-total-body-sodium-in-infants-with-intestinal-failure-sara-choi-5432?t=461)
- "The Midwest Pediatric Surgery Research Consortium (MWPSC) was established by departments of Pediatric Surgery from 11 children's hospitals" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 15 · 2:15](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=135)
- "The NAT study used historical patterns captured by trauma registries to predict what the volume should have been during the initial COVID time period and compared that to observed rates" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 15 · 3:42](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=222)
- "NAT was higher after the lockdown, not during the lockdown" — Todd Ponsky and Biran Modi (clinical) [Ep 15 · 4:07](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=247)
- "Initially non-accidental trauma rates dropped a little bit, but after that the rate increased above what they had expected during the stay at home orders" — Nicole Chandler (host_summary) [Ep 15 · 4:16](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=256)
- "Patients disproportionately affected were older kids who were older than 5 years who would most commonly be in school, minority children, and lower socioeconomic groups as determined by the social vulnerability index" — Nicole Chandler (host_summary) [Ep 15 · 4:31](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=271)
- "CDC Social Vulnerability Index was uniquely created to see neighborhood's vulnerability during times of crises" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 15 · 5:12](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=312)
- "During times of public health crises, it's important to maintain systems of protection for children" — Nicole Chandler (opinion) [Ep 15 · 5:37](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=337)
- "One has to be careful not to make too strong of conclusions based on any data when it's related to simply ICD 10 codes, regardless of how many institutions and how long the evaluation period was" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 15 · 6:07](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=367)
- "There are very few cell lines available to study hepatoblastoma, and a number of cell lines touted to be hepatoblastoma are actually hepatocellular carcinoma" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 15 · 6:47](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=407)
- "Management of metastatic hepatoblastoma continues to pose significant treatment challenges" — Nicole Chandler (clinical) [Ep 15 · 7:13](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=433)
- "The new hepatoblastoma cell line was created by injecting labeled cells into mouse tail vein, harvesting lung metastases, culturing surviving cells, and repeating the process until establishing a reliably metastatic cell line" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 15 · 7:24](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=444)
- "Compared to the original human cell line, the new cell line exhibited increased tumorigenicity, invasiveness, and increased resistance to chemotherapy" — Nicole Chandler (host_summary) [Ep 15 · 8:14](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=494)
- "PSORC (Pediatric Surgical Oncology Research Collaborative) is a multi-institutional consortium of North American pediatric surgeons focused on advancing care of children with cancer" — Marcus Malik (clinical) [Ep 15 · 9:46](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=586)
- "PSORC was founded because there was a need to amalgamate data from multiple institutions to better study surgical questions in pediatric cancer" — Marcus Malik (clinical) [Ep 15 · 10:05](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=605)
- "The most common localization techniques for small pulmonary nodules were wire and methylene blue dye, followed by methylene blue dye only" — Nicole Chandler (host_summary) [Ep 15 · 10:49](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=649)
- "There was no difference in successful IR localization or successful resection of pulmonary nodules when comparing different localization techniques" — Nicole Chandler (host_summary) [Ep 15 · 10:56](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=656)
- "Image-guided localization techniques varied significantly among institutions but all were wildly successful, showing that experience is probably more important than the actual technique itself" — Nicole Chandler (opinion) [Ep 15 · 12:06](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=726)
- "Pediatric intestinal failure was defined as requirement of parenteral nutrition for 60 days or more at any time, with diagnosis before 8 years of age" — Todd Ponsky and Biran Modi (clinical) [Ep 15 · 12:57](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=777)
- "The hypothesis was that chronic pediatric intestinal failure would delay puberty and potentially dull the sharp spike of puberty in terms of peak height velocity" — Todd Ponsky and Biran Modi (clinical) [Ep 15 · 13:44](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=824)
- "Peak height velocity occurred at significantly younger ages for both males and females with intestinal failure" — Nicole Chandler (host_summary) [Ep 15 · 14:00](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=840)
- "Puberty onset occurred significantly earlier compared to established norms for males, meaning they reached pubertal onset earlier than the CDC 50th percentile" — Nicole Chandler (host_summary) [Ep 15 · 14:00](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=840)
- "There is a high incidence of short stature in chronic intestinal failure" — Todd Ponsky and Biran Modi (clinical) [Ep 15 · 14:37](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=877)
- "The finding that short stature is not because kids are missing out on pubertal timing and peak height velocity suggests we need to do a better job at setting them up to go into puberty with working on their height and linear growth" — Todd Ponsky and Biran Modi (opinion) [Ep 15 · 14:37](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5878?t=877)
- "The Midwest Pediatric Surgery Research Consortium (MWPSC) was established by departments of Pediatric Surgery from 11 children's hospitals" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 16 · 2:15](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=135)
- "The NAT study used historical patterns captured by trauma registries to predict what the volume should have been during the initial COVID time period and compared that to observed rates" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 16 · 3:42](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=222)
- "NAT was higher after the lockdown, not during the lockdown" — Todd Ponsky and Biran Modi (clinical) [Ep 16 · 4:07](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=247)
- "Initially non-accidental trauma rates dropped a little bit, but after that the rate increased above what they had expected during the stay at home orders" — Nicole Chandler (host_summary) [Ep 16 · 4:16](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=256)
- "Patients disproportionately affected were older kids who were older than 5 years who would most commonly be in school, minority children, and lower socioeconomic groups as determined by the social vulnerability index" — Nicole Chandler (host_summary) [Ep 16 · 4:31](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=271)
- "CDC's Social Vulnerability Index was uniquely created to see neighborhood's vulnerability during times of crises" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 16 · 5:12](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=312)
- "During times of public health crises, it's important to maintain systems of protection for children" — Nicole Chandler (opinion) [Ep 16 · 5:37](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=337)
- "One has to be careful not to make too strong of conclusions based on ICD 10 codes, no matter how many institutions and how long the evaluation period was" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 16 · 6:07](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=367)
- "There are very few cell lines available to study hepatoblastoma, and a number of cell lines touted to be hepatoblastoma are actually hepatocellular carcinoma" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 16 · 6:47](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=407)
- "Management of metastatic hepatoblastoma continues to pose significant treatment challenges" — Nicole Chandler (clinical) [Ep 16 · 7:13](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=433)
- "The researchers labeled hepatoblastoma cells with luciferase, injected them into mouse tail veins where they preferentially went to lungs, harvested and cultured surviving cells, and repeated this process until establishing a reliable metastatic cell line" — Ellen Incisco and M. Tom Bash (host_summary) [Ep 16 · 7:24](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=444)
- "The new metastatic hepatoblastoma cell line exhibited increased tumorigenicity, invasiveness, and increased resistance to chemotherapy compared to the original human cell line" — Nicole Chandler (host_summary) [Ep 16 · 8:14](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=494)
- "We never had a hepatoblastoma cell line mouse model before" — Todd Ponsky and Biran Modi (clinical) [Ep 16 · 8:29](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=509)
- "PSORC (Pediatric Surgical Oncology Research Collaborative) is a multi-institutional consortium of North American pediatric surgeons focused on advancing care of children with cancer" — Marcus Malik (clinical) [Ep 16 · 9:46](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=586)
- "There has not been consistency in localization techniques for small pulmonary nodules across North America, with surgeons doing their own thing" — Marcus Malik (clinical) [Ep 16 · 10:19](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=619)
- "The most common localization techniques were wire and methylene blue dye, followed by methylene blue dye only" — Nicole Chandler (host_summary) [Ep 16 · 10:49](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=649)
- "There was no difference in successful IR localization or successful resection of pulmonary nodules among the different localization techniques" — Nicole Chandler (host_summary) [Ep 16 · 10:56](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=656)
- "Time under anesthesia can be long and quite variable depending on whether institutions use hybrid ORs or have IR on different floors" — Marcus Malik (clinical) [Ep 16 · 11:10](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=670)
- "ICG will become much more popular and more effective for nodule localization in 5 years" — Todd Ponsky and Biran Modi (opinion) [Ep 16 · 11:54](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=714)
- "Image guided localization techniques varied significantly among institutions but all were wildly successful, showing that experience is probably more important than the actual technique itself" — Nicole Chandler (opinion) [Ep 16 · 12:06](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=726)
- "The study focused on patients with pediatric intestinal failure, defined as requirement of parenteral nutrition for 60 days or more at any time, who had the diagnosis before age 8 and were older than 8 at time of study" — Todd Ponsky and Biran Modi (clinical) [Ep 16 · 12:52](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=772)
- "Puberty is at least partially dependent on having good nutritional stores based on hormonal drivers of puberty" — Todd Ponsky and Biran Modi (clinical) [Ep 16 · 13:38](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=818)
- "The hypothesis was that chronic pediatric intestinal failure would delay puberty and potentially dull the sharp spike of peak height velocity" — Todd Ponsky and Biran Modi (clinical) [Ep 16 · 13:45](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=825)
- "Peak height velocity occurred at significantly younger ages for both males and females with intestinal failure" — Nicole Chandler (host_summary) [Ep 16 · 14:00](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=840)
- "Puberty onset occurred significantly earlier compared to established norms for males, meaning they reached pubertal onset earlier than the CDC 50th percentile" — Nicole Chandler (host_summary) [Ep 16 · 14:00](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=840)
- "Children with intestinal failure might be slightly short statured but are not severely undersized compared to the general population" — Todd Ponsky and Biran Modi (clinical) [Ep 16 · 14:20](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=860)
- "There is a high incidence of short stature in chronic intestinal failure" — Todd Ponsky and Biran Modi (clinical) [Ep 16 · 14:37](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=877)
- "The finding that kids with intestinal failure are not missing out on pubertal timing and peak height velocity suggests we need to do a better job at setting them up to go into puberty by working on their height and linear growth" — Todd Ponsky and Biran Modi (opinion) [Ep 16 · 14:37](https://qa.library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-june-2022-aap-issue-5881?t=877)
- "Adrian Bianchi first reported the longitudinal intestinal lengthening procedure (Bianchi procedure) that divides bowel along its two leaves and tubularizes it." — Michael Helmrath (clinical) [Ep 17 · 1:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=83)
- "In the 1980s and 1990s, babies with intestinal failure had poor outcomes primarily due to liver progression to inflammation and fibrosis associated with parenteral nutrition, lipids, and phytosterols." — Ellen Encisco (host_summary) [Ep 17 · 1:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=110)
- "Rising direct bilirubin was recognized as a sign that children with intestinal failure would not do well." — Michael Helmrath (clinical) [Ep 17 · 2:13](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=133)
- "The first 4 months of life is when care for intestinal failure patients is most uncoordinated, and surgical decisions made during this period have the most profound effect on long-term outcome." — Todd Ponsky (host_summary) [Ep 17 · 2:29](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=149)
- "The gut doubles in length during the last trimester and the first year of life, and this maturation process occurs when the baby is fed." — Michael Helmrath (clinical) [Ep 17 · 2:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=175)
- "Healthy growth of the intestine requires nutrition; anything that disrupts this affects maturation of both absorptive/digestive capacity and peristalsis." — Michael Helmrath (clinical) [Ep 17 · 3:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=183)
- "Absorptive surface area comes from the waves of peristalsis moving over the villi, not from the exposed length of bowel." — Todd Ponsky (host_summary) [Ep 17 · 3:32](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=212)
- "Lengthening bowel that doesn't have peristalsis does not increase absorption; very short bowel children can sometimes come off TPN because their motility is good." — Michael Helmrath (clinical) [Ep 17 · 3:46](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=226)
- "The majority of pediatric short bowel syndrome cases present at birth due to neonatal causes: congenital GI anomalies or acquired conditions like necrotizing enterocolitis." — Paul Wales (epidemiological) [Ep 17 · 4:18](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=258)
- "When reestablishing bowel continuity, size discrepancy between bowel ends must be addressed or a functional obstruction will result even if the anastomosis is patent." — Paul Wales (clinical) [Ep 17 · 5:42](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=342)
- "Size discrepancy can be managed by resection to a more appropriate caliber, tapering enteroplasty, or serial transverse enteroplasty (STEP) depending on available bowel length." — Paul Wales (clinical) [Ep 17 · 6:02](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=362)
- "Gastroschisis patients tend to not do as well with STEP procedures regardless of whether atresia is present; among STEP procedures performed over the years, gastroschisis cases consistently had worse outcomes." — Paul Wales (epidemiological) [Ep 17 · 7:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=428)
- "Gastroschisis patients have inherent dysmotility." — Todd Ponsky (host_summary) [Ep 17 · 7:21](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=441)
- "The enteric nervous system in gastroschisis is damaged from exposure to amniotic fluid and requires a healing and recovery phase; this regeneration is attenuated by dysmotility and stasis, not enhanced." — Michael Helmrath (clinical) [Ep 17 · 7:32](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=452)
- "In atresia without gastroschisis, the bowel may have good peristalsis from working against an obstruction, and when done correctly with proper orientation, a longitudinal lengthening procedure may benefit the child." — Michael Helmrath (opinion) [Ep 17 · 7:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=475)
- "Children who undergo STEP procedures in their first year of life sometimes never progress and are labeled as poor motility patients unable to tolerate enteral feeds." — Michael Helmrath (clinical) [Ep 17 · 8:19](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=499)
- "Among patients with limited gut, necrotizing enterocolitis patients do best because they have been fed before, have established GI motility, and the maturation phase has already been initiated." — Michael Helmrath (opinion) [Ep 17 · 8:40](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=520)
- "STEP procedure is not usually performed unless bowel is at least 5 centimeters dilated to make it worthwhile." — Paul Wales (clinical) [Ep 17 · 9:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=549)
- "At birth, neonatal bowel is usually not dilated enough to apply the STEP procedure." — Ellen Encisco (host_summary) [Ep 17 · 9:36](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=576)
- "In scenarios where bowel is not adequately dilated, options include resecting bulbs with tapering enteroplasty, establishing continuity if possible, or leaving bowel disconnected with distal feeding tube access to grow the distal bowel before reconnection." — Paul Wales (clinical) [Ep 17 · 9:41](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=581)
- "The STEP procedure was originally described by HP Kim and Tom Jackson." — Paul Wales (clinical) [Ep 17 · 10:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=645)
- "For STEP, a transverse supraumbilical abdominal incision is used, all adhesions are lysed, and the entire intestinal tract is laid out from top to bottom to understand anatomy and maximize mobility." — Paul Wales (clinical) [Ep 17 · 11:02](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=662)
- "The anti-mesenteric surface of the bowel is marked with surgical pen after drying with a lap sponge; maintaining this alignment prevents longitudinal twisting of the bowel during stapling." — Paul Wales (clinical) [Ep 17 · 11:29](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=689)
- "Bowel length is measured before the procedure using 30 silk dipped in mineral oil; caliber and length of the dilated segment to be stepped are also recorded." — Paul Wales (clinical) [Ep 17 · 11:58](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=718)
- "An endo-GIA stapler is preferred over an open GIA stapler because the smaller cartridge head is more amenable in smaller patients." — Paul Wales (opinion) [Ep 17 · 12:20](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=740)
- "Staple lines are applied perpendicular to the mesentery at 90° and 270° (3 o'clock and 9 o'clock positions if mesenteric vessels are at 0°)." — Paul Wales (clinical) [Ep 17 · 12:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=754)
- "A vascular (white) cartridge with 2.5 mm staples that crimp to 1 mm is used; this is more appropriate for younger patients' bowel thickness and prevents leaks that occurred with classic blue loads in early experience." — Paul Wales (clinical) [Ep 17 · 12:58](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=778)
- "Target caliber for STEP is 1.5 cm in babies and 2 to 2.5 cm in older infants or children; making it too narrow risks obstruction, especially in patients with borderline motility." — Paul Wales (clinical) [Ep 17 · 13:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=803)
- "Before firing the stapler, measurements are taken to both the end of the bowel and to the side to ensure proper caliber is maintained throughout the length." — Paul Wales (clinical) [Ep 17 · 14:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=849)
- "A U-stitch with 4-0 PDS is placed in the crotch of each staple line to prevent potential leaks at that point." — Paul Wales (clinical) [Ep 17 · 14:28](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=868)
- "The procedure is performed with a partner, alternating sides of the bowel, working down the length; 45 mm cartridges are most versatile, but 30 mm and 60 mm cartridges may be needed depending on bowel diameter." — Paul Wales (clinical) [Ep 17 · 14:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=890)
- "At the top and bottom of the STEP segment, an additional oblique staple line is fired to taper the transition and avoid a 'dog ear' blind loop that can dilate over time." — Paul Wales (clinical) [Ep 17 · 15:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=908)
- "If one part of the stepped bowel becomes dilated, the STEP segments can rotate away from each other separately, causing twisting and functional obstruction." — Ellen Encisco (host_summary) [Ep 17 · 15:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=957)
- "After completing the STEP, the length of stepped bowel, new total bowel length, and final caliber (2-2.5 cm) are recorded." — Todd Ponsky (host_summary) [Ep 17 · 16:13](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=973)
- "The STEP procedure is performed with staple lines perpendicular to the mesentery (90° and 270°), not in the anti-mesenteric to mesenteric orientation (180° and 0°)." — Paul Wales (clinical) [Ep 17 · 16:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=983)
- "The duodenum is not stepped; the STEP procedure starts where the bowel begins to dilate, usually distal to the duodenum." — Paul Wales (clinical) [Ep 17 · 16:56](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=1016)
- "Avoiding staple lines in the duodenum allows proximal access if emergency reoperation is needed for a leak." — Paul Wales (opinion) [Ep 17 · 17:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=1023)
- "If duodenal narrowing is needed, a stapler is used to partially narrow the lateral side away from the bile duct and ampulla; plication sutures are not used because they usually fail." — Paul Wales (clinical) [Ep 17 · 17:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=1035)
- "The duodenum has no mesentery, making it impossible to orient 90° and 270° positions; surgeons who STEP the duodenum end up entering the bowel at inconsistent orientations." — Michael Helmrath (clinical) [Ep 17 · 17:32](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5909?t=1052)
- "The biggest benefit of the STEP procedure is tapering the bowel and reestablishing a more normal caliber to improve motility." — Paul Wales (clinical) [Ep 19 · 1:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=112)
- "STEP does not create new bowel but redistributes it to reestablish more normal caliber bowel, which helps improve motility overall." — Ellen Encisco (host_summary) [Ep 19 · 2:04](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=124)
- "It can take up to 6 months before you actually start to see a significant improvement in absorptive capacity after STEP." — Paul Wales (clinical) [Ep 19 · 3:04](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=184)
- "Improvements in absorptive capacity are measured with fecal fat, alpha-1 antitrypsin clearance, xylose absorption, and citrulline levels as they rise over time." — Paul Wales (clinical) [Ep 19 · 3:16](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=196)
- "The reason absorptive improvement takes time is that inflamed, sick, leaky mucosa in the setting of bacterial overgrowth needs to heal." — Paul Wales (clinical) [Ep 19 · 3:24](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=204)
- "About 50% reduction in parental nutrition support can be expected after STEP." — Ellen Encisco (host_summary) [Ep 19 · 3:33](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=213)
- "Half of the people that have a STEP will have progression of improved enteral tolerance, and half will actually have a worsening." — Michael Helmrath (clinical) [Ep 19 · 3:40](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=220)
- "The six month postoperative period is very critical for analyzing how the patient is moving forward after STEP." — Michael Helmrath (clinical) [Ep 19 · 3:46](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=226)
- "Before operating for a STEP procedure, you need to first rule out other anatomical problems by laying out the bowel and getting the mesentery completely oriented." — Michael Helmrath (clinical) [Ep 19 · 4:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=248)
- "If you only focus on the STEP without examining the complete anatomy, you will miss some of the reasons why these kids aren't getting better." — Michael Helmrath (clinical) [Ep 19 · 4:14](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=254)
- "The management of these kids is not a one-stop shopping that you're going to fix with your operation; there is nothing wrong with staging." — Michael Helmrath (opinion) [Ep 19 · 4:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=293)
- "Ulcers at STEP staple lines are not uncommon, and many kids have been transfused every month for years because of that." — Anton Bash (host_summary) [Ep 19 · 5:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=353)
- "Recurrent bleeding from STEP staple lines is an absolute indication to operate." — Michael Helmrath (clinical) [Ep 19 · 6:01](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=361)
- "Bleeding at STEP staple lines is an underreported complication that is really difficult to manage in some cases." — Paul Wales (clinical) [Ep 19 · 6:24](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=384)
- "There is a whole spectrum of findings from ulcers at staple lines, from just having specks of blood in the stool to enough bleeding that kids might have to be transfused every week and a half." — Ellen Encisco (host_summary) [Ep 19 · 6:32](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=392)
- "Staple line ulcers can recur after treatment." — Ellen Encisco (host_summary) [Ep 19 · 6:47](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=407)
- "Staple line bleeding is hypothesized to be a microbiome problem occurring in a pro-inflammatory environment." — Paul Wales (opinion) [Ep 19 · 6:49](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=409)
- "Staple line bleeding tends to occur in type 2 anatomy, which is small bowel to colonic remnant in the absence of an intact colon ileocecal valve." — Paul Wales (clinical) [Ep 19 · 6:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=415)
- "Pathology of staple line ulcers shows non-specific inflammation with no vasculitis, no viral elements, and no obvious ischemia." — Paul Wales (clinical) [Ep 19 · 7:12](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=432)
- "Teams have tried enteral omega 3 lipid supplements, bacterial overgrowth management with cycled antibiotics or probiotics, 5ASA, budesonide, and immune modulators like Remicade for staple line bleeding, but none have been the perfect remedy." — Ellen Encisco (host_summary) [Ep 19 · 7:21](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=441)
- "The underlying issue in staple line bleeding is not in the bowel but actually in the mesentery." — Ellen Encisco (host_summary) [Ep 19 · 7:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=472)
- "Mesenteric inflammation and scarring creates an obstruction to venous outflow, resulting in venous hypertension along the staple lines." — Michael Helmrath (clinical) [Ep 19 · 8:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=483)
- "Mesenteric inflammation causes scarring and obstructs venous outflow, leading to enlarged veins and venous hypertension on the bowel, and even large lymph nodes from lymphatic obstruction." — Ellen Encisco (host_summary) [Ep 19 · 8:17](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=497)
- "During operation for staple line bleeding, you can see vessels the size of your thumb and really big adenopathy because the lymphatics are also obstructed." — Michael Helmrath (clinical) [Ep 19 · 8:33](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=513)
- "It is very important to free up the mesentery from scar, which is a dense scar." — Michael Helmrath (clinical) [Ep 19 · 8:42](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=522)
- "Once you free up the mesenteric scar, those big vessels come right back to normal." — Anton Bash (host_summary) [Ep 19 · 8:47](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=527)
- "Venous hypertension is what leads to the bleeding at staple lines." — Michael Helmrath (clinical) [Ep 19 · 8:56](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=536)
- "Dr. Helmrath typically revises the staple line with a hand sewn stitch when mesenteric scarring and venous hypertension are present." — Ellen Encisco (host_summary) [Ep 19 · 9:00](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=540)
- "The key in managing staple line bleeding is to look at the mesentery and free up the mesentery, not just look at the bowel." — Michael Helmrath (clinical) [Ep 19 · 9:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=549)
- "Mesenteric scarring causing venous hypertension is obvious if you're looking for it during operation." — Michael Helmrath (opinion) [Ep 19 · 9:27](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=567)
- "Most referrals for intestinal rehabilitation have had multiple operations before coming to the specialist center." — Paul Wales (clinical) [Ep 19 · 10:05](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=605)
- "Optimizing a child's anatomy may not be conducive to just one operation; you have to set yourself up sometimes planning for the next case." — Paul Wales (opinion) [Ep 19 · 10:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=609)
- "Doing things in a staged fashion is typical for the intestinal rehabilitation patient population." — Ellen Encisco (host_summary) [Ep 19 · 10:25](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=625)
- "Dr. Helmrath documents detailed operative notes for himself describing orientation, landmarks, and what was done to guide future operations." — Michael Helmrath (clinical) [Ep 19 · 10:33](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=633)
- "As intestinal rehabilitation patients grow and develop, more issues might arise requiring additional operations." — Ellen Encisco (host_summary) [Ep 19 · 10:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=645)
- "Surgeons should try not to be the hero and try not to do everything, especially in the first week of life; understand that biology, physiology, and growth are a spectrum." — Michael Helmrath (opinion) [Ep 19 · 10:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=652)
- "The surgeon plays a huge role in intestinal rehabilitation even when patients are doing well, because you have to see the progress." — Michael Helmrath (opinion) [Ep 19 · 11:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=668)
- "Intestinal rehabilitation is a lifelong issue, and surgeons typically follow these patients for a long time." — Ellen Encisco (host_summary) [Ep 19 · 11:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-2-6099?t=675)
- "Adrian Bianchi first reported the longitudinal intestinal lengthening procedure (Bianchi procedure) that divides bowel along its two leaves and tubularizes it." — Michael Helmrath (clinical) [Ep 18 · 1:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=83)
- "In the 1980s and 1990s, babies with intestinal failure had poor outcomes primarily due to liver progression to inflammation and fibrosis associated with parenteral nutrition, lipids, and phytosterols." — Ellen Encisco (host_summary) [Ep 18 · 1:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=110)
- "Rising direct bilirubin was recognized as a sign that children with intestinal failure would not do well." — Michael Helmrath (clinical) [Ep 18 · 2:13](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=133)
- "The first 4 months of life is when care for intestinal failure patients is most uncoordinated, and surgical decisions made during this period have the most profound effect on long-term outcome." — Todd Ponsky (host_summary) [Ep 18 · 2:29](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=149)
- "The gut doubles in length during the last trimester and the first year of life, and this maturation process occurs when the baby is fed." — Michael Helmrath (clinical) [Ep 18 · 2:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=175)
- "Healthy growth of the intestine requires nutrition; anything that disrupts this affects maturation of both absorptive/digestive capacity and peristalsis." — Michael Helmrath (clinical) [Ep 18 · 3:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=183)
- "Absorptive surface area comes from the waves of peristalsis moving over the villi, not from the exposed length of bowel." — Todd Ponsky (host_summary) [Ep 18 · 3:32](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=212)
- "Lengthening bowel that doesn't have peristalsis does not increase absorption; very short bowel children can sometimes come off TPN because their motility is good." — Michael Helmrath (clinical) [Ep 18 · 3:46](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=226)
- "The majority of pediatric short bowel syndrome cases present at birth due to neonatal causes: congenital GI anomalies or acquired conditions like necrotizing enterocolitis." — Paul Wales (epidemiological) [Ep 18 · 4:18](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=258)
- "When reestablishing bowel continuity, size discrepancy between bowel ends must be addressed or a functional obstruction will result even if the anastomosis is patent." — Paul Wales (clinical) [Ep 18 · 5:42](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=342)
- "Size discrepancy can be managed by resection to a more appropriate caliber, tapering enteroplasty, or serial transverse enteroplasty (STEP) depending on available bowel length." — Paul Wales (clinical) [Ep 18 · 6:02](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=362)
- "Gastroschisis patients tend to not do as well with STEP procedures regardless of whether atresia is present; among STEP procedures performed over the years, gastroschisis cases consistently had worse outcomes." — Paul Wales (epidemiological) [Ep 18 · 7:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=428)
- "Gastroschisis patients have inherent dysmotility." — Todd Ponsky (host_summary) [Ep 18 · 7:21](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=441)
- "The enteric nervous system in gastroschisis is damaged from exposure to amniotic fluid and requires a healing and recovery phase; this regeneration is attenuated by dysmotility and stasis, not enhanced." — Michael Helmrath (clinical) [Ep 18 · 7:32](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=452)
- "In atresia without gastroschisis, the bowel may have good peristalsis from working against an obstruction, and when done correctly with proper orientation, a longitudinal lengthening procedure may benefit the child." — Michael Helmrath (opinion) [Ep 18 · 7:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=475)
- "Children who undergo STEP procedures in their first year of life sometimes never progress and are labeled as poor motility patients unable to tolerate enteral feeds." — Michael Helmrath (clinical) [Ep 18 · 8:19](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=499)
- "Among patients with limited gut, necrotizing enterocolitis patients do best because they have been fed before, have established GI motility, and the maturation phase has already been initiated." — Michael Helmrath (opinion) [Ep 18 · 8:40](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=520)
- "STEP procedure is not usually performed unless bowel is at least 5 centimeters dilated to make it worthwhile." — Paul Wales (clinical) [Ep 18 · 9:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=549)
- "At birth, neonatal bowel is usually not dilated enough to apply the STEP procedure." — Ellen Encisco (host_summary) [Ep 18 · 9:36](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=576)
- "In scenarios where bowel is not adequately dilated, options include resecting bulbs with tapering enteroplasty, establishing continuity if possible, or leaving bowel disconnected with distal feeding tube access to grow the distal bowel before reconnection." — Paul Wales (clinical) [Ep 18 · 9:41](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=581)
- "The STEP procedure was originally described by HP Kim and Tom Jackson." — Paul Wales (clinical) [Ep 18 · 10:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=645)
- "For STEP, a transverse supraumbilical abdominal incision is used, all adhesions are lysed, and the entire intestinal tract is laid out from top to bottom to understand anatomy and maximize mobility." — Paul Wales (clinical) [Ep 18 · 11:02](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=662)
- "The anti-mesenteric surface of the bowel is marked with surgical pen after drying with a lap sponge; maintaining this alignment prevents longitudinal twisting of the bowel during stapling." — Paul Wales (clinical) [Ep 18 · 11:29](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=689)
- "Bowel length is measured before the procedure using 30 silk dipped in mineral oil; caliber and length of the dilated segment to be stepped are also recorded." — Paul Wales (clinical) [Ep 18 · 11:58](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=718)
- "An endo-GIA stapler is preferred over an open GIA stapler because the smaller cartridge head is more amenable in smaller patients." — Paul Wales (opinion) [Ep 18 · 12:20](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=740)
- "Staple lines are applied perpendicular to the mesentery at 90° and 270° (3 o'clock and 9 o'clock positions if mesenteric vessels are at 0°)." — Paul Wales (clinical) [Ep 18 · 12:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=754)
- "A vascular (white) cartridge with 2.5 mm staples that crimp to 1 mm is used; this is more appropriate for younger patients' bowel thickness and prevents leaks that occurred with classic blue loads in early experience." — Paul Wales (clinical) [Ep 18 · 12:58](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=778)
- "Target caliber for STEP is 1.5 cm in babies and 2 to 2.5 cm in older infants or children; making it too narrow risks obstruction, especially in patients with borderline motility." — Paul Wales (clinical) [Ep 18 · 13:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=803)
- "Before firing the stapler, measurements are taken to both the end of the bowel and to the side to ensure proper caliber is maintained throughout the length." — Paul Wales (clinical) [Ep 18 · 14:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=849)
- "A U-stitch with 4-0 PDS is placed in the crotch of each staple line to prevent potential leaks at that point." — Paul Wales (clinical) [Ep 18 · 14:28](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=868)
- "The procedure is performed with a partner, alternating sides of the bowel, working down the length; 45 mm cartridges are most versatile, but 30 mm and 60 mm cartridges may be needed depending on bowel diameter." — Paul Wales (clinical) [Ep 18 · 14:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=890)
- "At the top and bottom of the STEP segment, an additional oblique staple line is fired to taper the transition and avoid a 'dog ear' blind loop that can dilate over time." — Paul Wales (clinical) [Ep 18 · 15:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=908)
- "If one part of the stepped bowel becomes dilated, the STEP segments can rotate away from each other separately, causing twisting and functional obstruction." — Ellen Encisco (host_summary) [Ep 18 · 15:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=957)
- "After completing the STEP, the length of stepped bowel, new total bowel length, and final caliber (2-2.5 cm) are recorded." — Todd Ponsky (host_summary) [Ep 18 · 16:13](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=973)
- "The STEP procedure is performed with staple lines perpendicular to the mesentery (90° and 270°), not in the anti-mesenteric to mesenteric orientation (180° and 0°)." — Paul Wales (clinical) [Ep 18 · 16:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=983)
- "The duodenum is not stepped; the STEP procedure starts where the bowel begins to dilate, usually distal to the duodenum." — Paul Wales (clinical) [Ep 18 · 16:56](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=1016)
- "Avoiding staple lines in the duodenum allows proximal access if emergency reoperation is needed for a leak." — Paul Wales (opinion) [Ep 18 · 17:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=1023)
- "If duodenal narrowing is needed, a stapler is used to partially narrow the lateral side away from the bile duct and ampulla; plication sutures are not used because they usually fail." — Paul Wales (clinical) [Ep 18 · 17:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=1035)
- "The duodenum has no mesentery, making it impossible to orient 90° and 270° positions; surgeons who STEP the duodenum end up entering the bowel at inconsistent orientations." — Michael Helmrath (clinical) [Ep 18 · 17:32](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-4-surgical-management-part-1-5913?t=1052)
- "Cincinnati Children's Hospital institutionally defined cholestasis as conjugated bilirubin greater than 3 mg/dL or 50 micromoles/L sustained for 2 weeks and not associated with a septic event." — Paul Wales (guideline) [Ep 20 · 1:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=69)
- "A 2021 JPN publication defined cholestasis as conjugated bilirubin around 2 mg/dL or 34 micromoles/L for 2 weeks, not associated with a septic event." — Paul Wales (guideline) [Ep 20 · 1:20](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=80)
- "Advanced liver disease is defined as conjugated bilirubin above 5 or 6 mg/dL." — Cecilia Gigena (host_summary) [Ep 20 · 1:48](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=108)
- "As treatment has improved with different lipid emulsions and nutrition approaches, cholestasis has become more an indicator of underlying diseases to address rather than a primary morbidity/mortality factor." — Michael Helmrath (opinion) [Ep 20 · 1:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=117)
- "Historically, 25-50% of intestinal failure patients died because of associated liver disease; now it is less than 2%." — Cecilia Gigena (host_summary) [Ep 20 · 2:36](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=156)
- "In young children, intestinal failure-associated liver disease presents as cholestatic liver disease, whereas in adolescents and adults it tends to be steatosis (fatty deposition)." — Paul Wales (clinical) [Ep 20 · 2:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=177)
- "Risk factors for intestinal failure-associated liver disease include prematurity, lack of enteral feeding, sepsis, and TPN components." — Cecilia Gigena (host_summary) [Ep 20 · 3:19](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=199)
- "Prematurity is not modifiable by the clinical team, but lack of enteral feeding, sepsis, and TPN components are modifiable risk factors." — Paul Wales (clinical) [Ep 20 · 3:30](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=210)
- "Prevention of cholestasis requires aggressive introduction of enteral feeding to establish enterohepatic circulation and surgical procedures to optimize anatomy for feed delivery." — Paul Wales (clinical) [Ep 20 · 4:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=249)
- "Limiting intravenous fat to 1 g/kg/day can help prevent cholestasis." — Michael Helmrath (clinical) [Ep 20 · 5:12](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=312)
- "New lipid emulsions including Omegaven (used first in the US) and SMOF (used in Europe and Canada, now prevalent in the US for 3-4 years) can reverse or prevent cholestasis." — Michael Helmrath (clinical) [Ep 20 · 5:20](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=320)
- "SMOF lipid emulsion is composed of soybean oil, medium chain triglycerides, olive oil, and fish oil." — Ellen [last name unclear] (host_summary) [Ep 20 · 6:04](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=364)
- "A major advantage of SMOF is the ability to provide more calories from fat (as much as 2-2.5 g/kg) while supporting healthy growth." — Michael Helmrath (clinical) [Ep 20 · 6:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=375)
- "Patients on SMOF lipid emulsions can still develop cholestasis due to other factors beyond lipid composition." — Ellen [last name unclear] (host_summary) [Ep 20 · 6:41](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=401)
- "Two strategies for reversing cholestasis are dose restriction and change of lipid composition." — Paul Wales (clinical) [Ep 20 · 7:00](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=420)
- "Conventional intralipid (soybean-based) produces prostaglandins and eicosanoids that are pro-inflammatory when metabolized." — Paul Wales (clinical) [Ep 20 · 7:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=428)
- "SMOF lipid promotes bile flow, is hepatoprotective, and can be delivered at conventional dose to achieve somatic growth and provide neurologic nutrients while protecting the liver." — Paul Wales (clinical) [Ep 20 · 7:19](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=439)
- "SMOF lipid does not contain enough arachidonic acid, so dose restriction of SMOF can lead to essential fatty acid deficiency." — Paul Wales (clinical) [Ep 20 · 7:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=465)
- "When SMOF is delivered at conventional dosing, no patients develop essential fatty acid deficiency." — Paul Wales (clinical) [Ep 20 · 7:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=477)
- "Conventional dosing for lipids is settling around 2.5 g/kg/day, but nutrition guidelines for preterm infants and babies state 3-4 g/kg/day." — Paul Wales (guideline) [Ep 20 · 8:06](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=486)
- "A bilirubin of 2 mg/dL is not advanced liver disease, is not dangerous, and is usually transient; Dr. Wales would not change lipid emulsion at this threshold." — Paul Wales (opinion) [Ep 20 · 8:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=532)
- "When refeeding a cholestatic liver after proximal jejunostomy takedown, direct bilirubin typically rises in the first week as bile acid pool is reintroduced and the liver becomes more active in bile salt production." — Michael Helmrath (clinical) [Ep 20 · 9:38](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=578)
- "GGT, AST, and ALT will go up in the first week or two after anastomosis takedown surgery, then slowly come down over several weeks." — Michael Helmrath (clinical) [Ep 20 · 10:04](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=604)
- "When direct bilirubin rises after refeeding, the main differential to rule out is urinary tract infection or gram-negative infection; extensive imaging such as ultrasounds is not needed." — Michael Helmrath (clinical) [Ep 20 · 10:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=623)
- "It is important to provide proximal drainage of the duodenum in high-risk intestinal failure patients; Dr. Helmrath places a lake drain for this purpose." — Michael Helmrath (clinical) [Ep 20 · 10:46](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=646)
- "Ongoing cholestasis with proximal blockage puts pressure in the biliary system at a much higher level and speeds up the cholestatic process." — Michael Helmrath (clinical) [Ep 20 · 11:18](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=678)
- "G-tubes do not decompress the duodenum." — Michael Helmrath (clinical) [Ep 20 · 11:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=691)
- "A lake drain helps identify proximal bowel and leaves the bowel at appropriate size to make future anastomosis easier without large size mismatch." — Ellen [last name unclear] (host_summary) [Ep 20 · 11:36](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=696)
- "During secondary surgical or autologous reconstruction procedures, a liver biopsy is commonly taken to provide an up-to-date microscopic snapshot." — Paul Wales (clinical) [Ep 20 · 12:11](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=731)
- "Prophylactic cholecystectomy is not recommended because the gallbladder helps with enterohepatic circulation and many patients will not need it." — Cecilia Gigena (host_summary) [Ep 20 · 12:24](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=744)
- "Liver function and biochemistry are followed routinely as inpatient and at outpatient clinic visits." — Paul Wales (clinical) [Ep 20 · 12:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=773)
- "Elastography (FibroScan) is available for monitoring but is good for mild/no fibrosis or very advanced fibrosis; it is not as sensitive for patients with intermediate fibrosis." — Paul Wales (clinical) [Ep 20 · 13:00](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=780)
- "Follow-up visit frequency for children on TPN at home ranges from every 1-4 months depending on patient stability; actively adapting patients may be seen more frequently due to rapid changes being made." — Paul Wales (clinical) [Ep 20 · 13:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-6-cholestasis-6734?t=811)
- "Children reliant on TPN and their families may face challenges when traveling abroad" (host_summary) [Ep 23 · 0:21](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=21)
- "Medication and appropriate medical supplies must accompany TPN-dependent children on their travels" (host_summary) [Ep 23 · 0:30](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=30)
- "Parents and families may have concerns about not having access to specialist emergency care for their child whilst abroad" (host_summary) [Ep 23 · 0:37](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=37)
- "ERNICA has developed an online map tool to identify specialist centers across Europe that are able to administer TPN and meet particular criteria" (host_summary) [Ep 23 · 0:46](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=46)
- "The ERNICA map tool is accessible from the publicly available ERNICA website" (host_summary) [Ep 23 · 0:58](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=58)
- "Users can search for specialist centers per country and access detailed information on each center through the tool" (host_summary) [Ep 23 · 1:04](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=64)
- "A holiday checklist document is available for download on the ERNICA website" (host_summary) [Ep 23 · 1:11](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=71)
- "Templates are available for local healthcare providers to provide a written record of the child's medical history and clinical precautions" (host_summary) [Ep 23 · 1:18](https://qa.library.globalcastmd.com/watch/reliance-on-total-parenteral-nutrition-and-travelling-abroad-7804?t=78)
- "Older patients (ages 8-16) who experience volvulus can lose 90+% of their bowel." — Michael Helmrath (clinical) [Ep 22 · 1:11](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=71)
- "The benefit and curse in older patients with bowel loss is that they already know how to eat and have established that behavior." — Paul Wales (clinical) [Ep 22 · 1:24](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=84)
- "In older children, normal feeding behavior is important in many social aspects of life, not just nutrition." — Cecilia Gigena (host_summary) [Ep 22 · 1:30](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=90)
- "Even if you cannot cure the patient and get them off TPN, it is important to make compromises to optimize quality of life." — Paul Wales (opinion) [Ep 22 · 1:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=110)
- "The general strategy is to push the macronutrient modules of protein and fat, which are well tolerated." — Paul Wales (clinical) [Ep 22 · 2:14](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=134)
- "Most patients with short bowel do not tolerate simple sugars very well." — Paul Wales (clinical) [Ep 22 · 2:21](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=141)
- "The general concept of pushing solids and minimizing fluid intake helps prevent dumping." — Paul Wales (clinical) [Ep 22 · 2:25](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=145)
- "Smaller meals more frequently of solids separated from liquids, with minimization of simple sugars, reduces dumping tendency." — Paul Wales (clinical) [Ep 22 · 2:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=151)
- "Patients who have transitioned off TPN often come back with problems when diet history reveals they have gotten loose with diet choices, particularly increased sugars." — Paul Wales (clinical) [Ep 22 · 2:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=172)
- "Minimizing sugars reduces symptoms related to bacterial overgrowth, making patients less bloated and gassy." — Paul Wales (clinical) [Ep 22 · 3:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=211)
- "In older children with fluid losses (by stoma or other source), if they are on parenteral support, some fluid can be replaced IV." — Paul Wales (clinical) [Ep 22 · 3:48](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=228)
- "As you try to get patients off IV support, keeping them hydrated by replenishing losses through enteral replacements is important." — Paul Wales (clinical) [Ep 22 · 4:01](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=241)
- "Transport requires sodium and glucose, so the rehydration solution must contain some glucose and some salt." — Paul Wales (clinical) [Ep 22 · 4:11](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=251)
- "There are homemade recipes for oral rehydration solutions and over-the-counter preparations available." — Paul Wales (clinical) [Ep 22 · 4:39](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=279)
- "Gatorade does not always work well for rehydration because it has too much sugar in it." — Paul Wales (clinical) [Ep 22 · 4:48](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=288)
- "Some patients can come off TPN but still need a central line for IV fluids; without IV fluids they end up sleeping most of the day and lack energy." — Michael Helmrath (clinical) [Ep 22 · 4:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=295)
- "Being in a hydrated state is extremely important to making the bowel work well." — Michael Helmrath (clinical) [Ep 22 · 5:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=308)
- "Sometimes patients cannot drink rehydration solution, but the GI tract can use it (via G-tube)." — Michael Helmrath (clinical) [Ep 22 · 5:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=331)
- "Energy use goes up dramatically during puberty." — Michael Helmrath (clinical) [Ep 22 · 5:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=351)
- "Children who are doing well often hit the wall when they start puberty because their energy needs overcome their nutrient input." — Michael Helmrath (clinical) [Ep 22 · 6:10](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=370)
- "The goal is always healthy growth, and it is important to be proactive, add supplements, and hope they will take extra nutritional support." — Michael Helmrath (opinion) [Ep 22 · 6:10](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=370)
- "It is all about normal growth parameters and getting patients through puberty." — Paul Wales (opinion) [Ep 22 · 6:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=383)
- "Some kids end up back on parenteral support to get through puberty." — Paul Wales (clinical) [Ep 22 · 6:28](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=388)
- "When patients are not growing anymore as adults, borderline or marginal gut function is often enough to sustain them." — Paul Wales (clinical) [Ep 22 · 6:33](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=393)
- "Clinicians should look at the growth chart for both weight and height, and not accept a 3rd percentile." — Michael Helmrath (opinion) [Ep 22 · 6:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=417)
- "There are very few conditions with intestinal failure that have restricted growth." — Michael Helmrath (clinical) [Ep 22 · 7:06](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=426)
- "Patients need to be monitored for micronutrient deficiencies after getting off TPN, as this is when they often get into trouble." — Paul Wales (clinical) [Ep 22 · 7:22](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=442)
- "Long-term growth and outcome need to be followed, highlighting the importance of multidisciplinary teams." — Paul Wales (opinion) [Ep 22 · 7:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=451)
- "Weight is tracked as a major metric for growth, but it has to be balanced with height." — Paul Wales (clinical) [Ep 22 · 8:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=531)
- "What is commonly seen in this population is round babies where their weight for height is elevated." — Paul Wales (clinical) [Ep 22 · 8:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=537)
- "There is increasing data looking at quality of weight: how much is fat weight versus lean body mass." — Paul Wales (clinical) [Ep 22 · 9:01](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=541)
- "For any child not meeting growth potential, numerous other diagnoses can be responsible, ranging from endocrine issues to pancreatic insufficiency to micronutrient issues." — Michael Helmrath (clinical) [Ep 22 · 9:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=574)
- "The concept is that patients are capable of having normal growth, and as you address issues and improve something, you need reasonable follow-up time on the order of weeks, not months." — Michael Helmrath (opinion) [Ep 22 · 9:48](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=588)
- "Much of the growth monitoring can be done remotely; patients do not need to travel for assessment, but you cannot wait until the next appointment." — Michael Helmrath (opinion) [Ep 22 · 10:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-8-refeeding-of-an-older-patient-7227?t=615)
- "One goal in intestinal failure management is to establish normal feeding habits that promote gut function and optimize quality of life including social aspects of eating." — Paul Wales (clinical) [Ep 21 · 0:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=57)
- "Factors to consider when refeeding include poor gastric emptying, poor gastric function, high stoma outputs versus high stooling output, and the age of the child at the time of intestinal damage." — Michael Helmrath (clinical) [Ep 21 · 1:27](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=87)
- "When initiating feeds in patients with high stoma output, losses increase initially, but this must be pushed through in a hospital setting where volume replacement is available." — Paul Wales (clinical) [Ep 21 · 2:22](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=142)
- "Damaged bowel is in a secretory phase even when not fed, but feeding stimulates the bowel into an absorptive state through luminal nutrition, eventually reducing stoma volume output." — Michael Helmrath (clinical) [Ep 21 · 2:37](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=157)
- "Mother's breast milk is the ideal feeding choice due to nutritional value and immunomodulatory and growth-healing effects not present in typical formulas." — Michael Helmrath (clinical) [Ep 21 · 3:40](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=220)
- "Donor breast milk is the second choice when mother's breast milk is unavailable." — Michael Helmrath (clinical) [Ep 21 · 4:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=248)
- "Breast milk has lower protein levels than desired and likely requires supplementation." — Cecilia Gigena (host_summary) [Ep 21 · 4:21](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=261)
- "In short bowel syndrome, protein absorption is fairly well preserved, so the benefit of completely broken-down protein formulas (free amino acids or hydrolysates) is primarily from an allergy perspective." — Paul Wales (clinical) [Ep 21 · 4:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=274)
- "Many formulas have moved from predominant long-chain fat to increasing MCT components, but long-chain fat is a stronger driver for adaptation." — Paul Wales (clinical) [Ep 21 · 5:04](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=304)
- "Long-chain fatty acids have developmental and immune properties." — Michael Helmrath (clinical) [Ep 21 · 5:21](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=321)
- "It is a common mistake to increase enteral feeds by the same volume that TPN is decreased, assuming the child will absorb all those calories, which results in stunted growth." — Michael Helmrath (clinical) [Ep 21 · 5:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=351)
- "One milliliter of parenteral nutrition is not isocaloric with one milliliter of formula, and advancing beyond 100-120 per kilo creates problems with not only calories and protein but also sodium and calcium due to compositional differences." — Paul Wales (clinical) [Ep 21 · 6:06](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=366)
- "At some point during feeding advancement, fortification is necessary." — Paul Wales (clinical) [Ep 21 · 6:28](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=388)
- "If the child tolerates it and does not have lung issues, the total daily volume can be expanded from 140 to 160, 170, or occasionally even 180 per kilogram." — Michael Helmrath (clinical) [Ep 21 · 6:44](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=404)
- "Feeding options include bolus (oral or gastric via tube), continuous (post-pyloric tube or surgical J-tube), or a hybrid model with gastric bolus component plus continuous component (gastric or post-pyloric)." — Paul Wales (clinical) [Ep 21 · 7:21](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=441)
- "Bolus feeds are preferred as the default approach; patients should fail bolus feeds before being placed on continuous feeds as the sole delivery method." — Paul Wales (opinion) [Ep 21 · 8:05](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=485)
- "Continuous feeds can be used as a supplemental approach, with bolus feeds during the day and continuous supplementation overnight." — Paul Wales (clinical) [Ep 21 · 8:17](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=497)
- "Even when oral feeding is non-nutritive, it is important for skill development; children who never learn to suck, swallow, and process food by mouth will not eat solids later and will remain dependent on tube feeding." — Paul Wales (clinical) [Ep 21 · 8:40](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=520)
- "The stomach is the most complicated part of the GI tract because it must coordinate both back-and-forth sloshing and coordinated squeezing with pyloric relaxation several times per minute to induce gastric emptying." — Michael Helmrath (clinical) [Ep 21 · 9:28](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=568)
- "When children have not been fed and have had an injury, gastric coordination is commonly completely disrupted." — Michael Helmrath (clinical) [Ep 21 · 9:43](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=583)
- "Most gastric dysmotility requires time and stimulation; the way to provide time when the rest of the GI tract works is to place a tube beyond the stomach for feeding." — Michael Helmrath (clinical) [Ep 21 · 10:02](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=602)
- "In a baby, the best way to achieve distal feeding is through an NJ tube with a G-tube decompressing the stomach, allowing feeding outside the stomach while simultaneously decompressing it." — Michael Helmrath (clinical) [Ep 21 · 10:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=615)
- "Distal feeding stimulates the distal small bowel and colon to produce hormones that signal the stomach to start functioning, breaking the dysmotility cycle." — Michael Helmrath (clinical) [Ep 21 · 10:33](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=633)
- "Post-pyloric refeeding can be done as a bolus or over a pump; bolus is preferred, but at Cincinnati a protocol of running feeds over a pump for one hour works well, typically starting at 5 then 10 cc per kilogram and advancing based on tolerance." — Michael Helmrath (clinical) [Ep 21 · 11:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=663)
- "Feeding the colon causes stoma output to decrease quickly, reflecting hormonal effects of the distal bowel, and often the stomach will start to work." — Michael Helmrath (clinical) [Ep 21 · 11:25](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=685)
- "The largest benefit of distal bowel refeeding is that when the two bowel ends are reconnected, the distal bowel has been functionally used, making postoperative feeding easier to initiate." — Michael Helmrath (clinical) [Ep 21 · 11:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=710)
- "The technical benefit of distal feeding is that size discrepancy at anastomosis is significantly improved because the bowel has been used." — Paul Wales (clinical) [Ep 21 · 12:12](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=732)
- "Undigested formula in the colon is a trigger that can cause stress to the bowel and may not be the healthiest approach." — Michael Helmrath (opinion) [Ep 21 · 12:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=754)
- "Placing a feeding tube into the stomach and tacking the stomach up does not commit the child to a lifelong G-tube or even one for the first year; it is no different than another tube and can be directed out of the pylorus into the proximal small bowel." — Michael Helmrath (clinical) [Ep 21 · 12:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=773)
- "When children with G-tubes do well, the tube can be removed and the hole heals like any other in these patients." — Michael Helmrath (clinical) [Ep 21 · 13:24](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=804)
- "The hole from a removed G-tube closes very quickly." — Paul Wales (clinical) [Ep 21 · 13:43](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=823)
- "A G-tube provides versatility for nutrition supplementation, medication delivery, and venting for gassy or bloated children to improve enteral tolerance." — Paul Wales (clinical) [Ep 21 · 13:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=831)
- "The morbidity from a G-tube is extremely low and the benefit can be very high." — Michael Helmrath (clinical) [Ep 21 · 14:05](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=845)
- "Young infants, babies, and young children have tremendous gut growth potential, with the gut growing for the first several years of life." — Paul Well (clinical) [Ep 24 · 0:49](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=49)
- "A term baby will have 160 centimeters of small bowel, and by age 5 years it almost triples to about 425 to 450 centimeters." — Paul Well (clinical) [Ep 24 · 1:17](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=77)
- "Residual bowel should be discussed as a percentage of what is normal for a child of that age, not in absolute centimeters." — Paul Well (clinical) [Ep 24 · 1:02](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=62)
- "You can have as low as 10% expected gut length and still achieve enteral autonomy if you have the majority of your colon in continuity." — Paul Well (clinical) [Ep 24 · 1:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=111)
- "The more important factor than the ileocecal valve is the presence or absence of the distal small bowel (ileum) and right colon that can act as a site for bile reclamation and enterohepatic circulation." — Michael Helmrath (clinical) [Ep 24 · 2:30](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=150)
- "The distal ileum produces hormones and incretins including GLP-2, GLP-1, and PYY." — Michael Helmrath (clinical) [Ep 24 · 2:43](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=163)
- "The importance is not the ileocecal valve itself but the distal ileum and proximal colon where bilioenteric circulation occurs and where hormones and peptides that help intestinal growth and absorption are produced." (host_summary) [Ep 24 · 3:01](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=181)
- "The surgical strategy at the first operation should provide a pathway forward that allows early interval feeding." — Michael Helmrath (clinical) [Ep 24 · 3:29](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=209)
- "It is sometimes better to stage reconstruction with the plan to restore bowel continuity under more controlled conditions." — Michael Helmrath (opinion) [Ep 24 · 3:38](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=218)
- "In situations of overwhelming intestinal loss, the strategy is to provide proximal control that allows feeding to occur without the enteral stream going through, and to leave questionable bowel segments that have potential to heal and can make a huge difference in the child's lifetime." — Michael Helmrath (clinical) [Ep 24 · 3:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=233)
- "As long as you can divert proximally and the baby is stable, you can leave questionable bowel for potential use at later secondary reconstructive procedures." (clinical) [Ep 24 · 4:26](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=266)
- "The overarching principle is to deliver adequate nutrition to have normal growth within normal parameters, ideally enterally." — Paul Well (clinical) [Ep 24 · 5:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=308)
- "As much as possible, the goal is to establish normal feeding behavior, recognizing that enteral nutrition is more than just nutrition." — Paul Well (clinical) [Ep 24 · 5:28](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=328)
- "If a patient needs tube support from the beginning, bolus feeding should be tried rather than defaulting to continuous feeding." — Paul Well (clinical) [Ep 24 · 5:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=352)
- "If the child fails a gastric approach (both bolus and continuous), the strategy is to feed beyond the stomach and decompress the stomach through an NG tube." — Paul Well (clinical) [Ep 24 · 6:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=375)
- "Breast milk is the formula of choice, not only for its nutritional benefits but for all the other beneficial components within breast milk." — Paul Well (clinical) [Ep 24 · 6:42](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=402)
- "Starting at the single amino acid level for protein is the generalized preference, ensuring patients are not having high stool output, high fluid losses, wound breakdown, rashes, or emesis." — Michael Helmrath (clinical) [Ep 24 · 7:28](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=448)
- "Long-chain fat is the preferred fat module rather than MCT fat, especially in the setting of short bowel syndrome." — Paul Well (clinical) [Ep 24 · 7:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=477)
- "Long-chain fat is a much stronger stimulus for GLP-2 release compared to MCT, which is important when trying to drive intestinal adaptation." — Paul Well (clinical) [Ep 24 · 8:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=495)
- "Not every child needs to be on SMOF lipids." — Paul Well (opinion) [Ep 24 · 9:00](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=540)
- "For preterm babies, SMOF is not the ideal lipid emulsion but is the best currently available." — Paul Well (clinical) [Ep 24 · 9:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=543)
- "SMOF lipids do not have enough arachidonic acid, which is important for brain development." — Paul Well (clinical) [Ep 24 · 9:16](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=556)
- "Two strategies exist to treat cholestasis: reduce the total amount of fat, or change the composition to introduce SMOF lipids or Omegaven." (clinical) [Ep 24 · 9:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=574)
- "Lipid restrictions that reduce lipid dose to 1 g per kg per day can reverse cholestasis but result in reduced calorie delivery that can impair growth and potentially impact neurocognitive development." (clinical) [Ep 24 · 9:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=590)
- "Omegaven is essentially pure fish oil with omega-3 and is dosed at 1 g/kg, so babies take a calorie hit." (clinical) [Ep 24 · 10:07](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=607)
- "SMOF lipids are a better choice as they are a more well-balanced emulsion with an omega-3 and omega-6 ratio of 2.5 to 1, are less inflammatory than Intralipid, and promote bile flow." (clinical) [Ep 24 · 10:28](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=628)
- "SMOF lipids should not be restricted and can be given at no less than 2 or 2.5 g per kg per day." (clinical) [Ep 24 · 10:28](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-webinar-2023-top-5-key-takeaways-8768?t=628)
- "This retrospective study examined 64 pediatric patients with short bowel syndrome managed by a multidisciplinary intestinal rehab program between 2001 and 2022." — Lizzie Lee (host_summary) [Ep 25 · 0:10](https://qa.library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=10)
- "89% of patients with short bowel syndrome in the study survived." — Lizzie Lee (host_summary) [Ep 25 · 0:22](https://qa.library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=22)
- "78% of patients with short bowel syndrome were able to wean off parenteral nutrition." — Lizzie Lee (host_summary) [Ep 25 · 0:22](https://qa.library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=22)
- "Survival rates of children with short bowel syndrome improved over time in the study period." — Lizzie Lee (host_summary) [Ep 25 · 0:22](https://qa.library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=22)
- "Introduction of fish oil-based parenteral nutrition in 2007 improved survival in pediatric short bowel syndrome patients." — Lizzie Lee (host_summary) [Ep 25 · 0:31](https://qa.library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=31)
- "Presence of intestinal failure associated liver disease affected survival in pediatric short bowel syndrome patients." — Lizzie Lee (host_summary) [Ep 25 · 0:31](https://qa.library.globalcastmd.com/watch/outcomes-of-children-with-short-bowel-syndrome-experiences-in-a-multidisciplinary-intestinal-rehabilitation-unit-over-two-decades-10027?t=31)
- "Advances in medicine have dramatically improved survival rates for children with intestinal failure" — Julian Goddard (host_summary) [Ep 26 · 0:00](https://qa.library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=0)
- "Cincinnati Children's intestinal rehabilitation team tracked 46 patients who turned 20 to examine outcomes when they transitioned to adult healthcare centers or continued pediatric care" — Julian Goddard (epidemiological) [Ep 26 · 0:13](https://qa.library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=13)
- "59% of patients transitioned to adult focused programs while the rest continued receiving care at Cincinnati Children's" — Julian Goddard (epidemiological) [Ep 26 · 0:23](https://qa.library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=23)
- "Patients who transitioned to adult care had a significantly higher mortality rate of 33% compared to 5% among those who stayed in pediatric care" — Julian Goddard (epidemiological) [Ep 26 · 0:29](https://qa.library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=29)
- "Patients who transitioned to adult care showed no obvious differences in medical complexity or disease burden compared to those who remained in pediatric care" — Julian Goddard (epidemiological) [Ep 26 · 0:29](https://qa.library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=29)
- "The median time from transition to death was approximately 12 months" — Julian Goddard (epidemiological) [Ep 26 · 0:42](https://qa.library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=42)
- "Young adults with a history of intestinal failure aging out of pediatric care remain a critically vulnerable population in need of greater attention and support until structured transition programs are developed and widely implemented" — Julian Goddard (opinion) [Ep 26 · 0:46](https://qa.library.globalcastmd.com/watch/care-transition-from-a-pediatric-intestinal-rehabilitation-program-to-adult-care-and-the-risk-of-all-cause-mortality-a-retrospective-cohort-study-11901?t=46)
- "This was a retrospective cohort study of children with short bowel syndrome in an intestinal rehabilitation program, followed from 2006 to 2019." — Lizzie Lee (host_summary) [Ep 28 · 0:07](https://qa.library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896?t=7)
- "The study asked whether social determinants of health predict outcomes like bloodstream infections, liver disease, and achieving enteral autonomy." — Lizzie Lee (host_summary) [Ep 28 · 0:16](https://qa.library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896?t=16)
- "Social determinants of health do predict outcomes in pediatric short bowel syndrome in real ways." — Lizzie Lee (host_summary) [Ep 28 · 0:24](https://qa.library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896?t=24)
- "Distance from the hospital was associated with higher risks of serious complications in children with short bowel syndrome." — Lizzie Lee (host_summary) [Ep 28 · 0:27](https://qa.library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896?t=27)
- "Parental education was linked with fewer central line infections in children with short bowel syndrome." — Lizzie Lee (host_summary) [Ep 28 · 0:33](https://qa.library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896?t=33)
- "Social determinants need to be considered to support families of children with short bowel syndrome better." — Lizzie Lee (host_summary) [Ep 28 · 0:37](https://qa.library.globalcastmd.com/watch/impact-of-social-determinants-of-health-on-outcomes-in-pediatric-short-bowel-syndrome-13896?t=37)
- "Intestinal failure is an umbrella term for when the small intestine is unable to absorb or digest enough nutrition to support the patient entirely by oral or enteral feeding" — Brad Warner (clinical) [Ep 6 · 1:42](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=102)
- "The intestine of a newborn or fetus doubles in length in the last trimester of gestation" — Brad Warner (clinical) [Ep 6 · 3:03](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=183)
- "A 24-25 week premature infant with 20-25 cm of bowel will likely increase to at least 50 cm just on the basis of growth alone" — Brad Warner (clinical) [Ep 6 · 3:13](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=193)
- "For a neonate with ileocecal valve and entire colon, 10-15 cm of small intestine is a ballpark figure for potential viability" — Brad Warner (clinical) [Ep 6 · 4:03](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=243)
- "Without the colon and ileocecal valve, at least 15-20 cm of small intestine would be needed for potential viability in a neonate" — Brad Warner (clinical) [Ep 6 · 4:37](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=277)
- "In adult studies, patients with less than 50 cm of intestine have about 40% mortality after 5-10 years" — Brad Warner (epidemiological) [Ep 6 · 4:51](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=291)
- "According to Pediatric Intestinal Failure Research Consortium data, of children on TPN for more than several months due to short gut syndrome: 25% die, 25% need transplant, and 50% can wean off TPN" — Brad Warner (epidemiological) [Ep 6 · 6:38](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=398)
- "Common causes of death in intestinal failure include liver failure, septic episodes from central line or bacterial overgrowth, variceal bleeding from liver disease, and loss of IV access" — Brad Warner (clinical) [Ep 6 · 7:11](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=431)
- "Intestinal adaptation in humans probably takes place over about a year or two after small bowel resection" — Brad Warner (clinical) [Ep 6 · 7:49](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=469)
- "The goal of management is to wean TPN and push enteral feeding, accepting stool outputs of up to 40 cc per kilo per day as the limit" — Brad Warner (clinical) [Ep 6 · 8:19](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=499)
- "The most common reasons children develop short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias" — Brad Warner (epidemiological) [Ep 6 · 9:22](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=562)
- "For TPN, target about 100-120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein" — Brad Warner (clinical) [Ep 6 · 10:22](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=622)
- "Shoot for about 2-3 g of protein per kilo per day and about 2-3 g of fat per kilo per day in TPN" — Brad Warner (clinical) [Ep 6 · 10:45](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=645)
- "Begin enteral feeding as soon as feasible after resection and reanastomosis when they start stooling, generally starting with slow continuous drip" — Brad Warner (clinical) [Ep 6 · 11:06](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=666)
- "With continuous drip feeding, nutrient transporters are upregulated and ability to get more nutrition in may be advantageous" — Brad Warner (opinion) [Ep 6 · 11:23](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=683)
- "Want a baby to gain about 20-30 g a day, which approximates in utero progression for a newborn" — Brad Warner (clinical) [Ep 6 · 12:05](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=725)
- "Lipid reduction strategy takes fat from 2-3 g per kilo per day given daily down to about 1 g per kilo per day delivered twice or 3 times a week, which has been effective in reducing TPN-associated cholestasis" — Brad Warner (clinical) [Ep 6 · 12:53](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=773)
- "Omegaven is a fish oil-based fat containing primarily omega-3 fatty acids that are anti-inflammatory, compared to soybean-based intralipid with omega-6 fatty acids that are pro-inflammatory" — Brad Warner (clinical) [Ep 6 · 14:03](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=843)
- "When fish oil (omegaven) is introduced to children getting jaundiced, there has been demonstrated significant fall in their jaundice levels" — Brad Warner (clinical) [Ep 6 · 14:38](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=878)
- "SMOF lipid contains soybean-based lipid (essential fatty acids), medium chain triglycerides (more easily digested), olive oil, and fish oil, and has recently been FDA approved in the United States" — Brad Warner (clinical) [Ep 6 · 15:08](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=908)
- "Breast milk is the best choice for neonates because it contains proper fat, growth factors like EGF and IGF, and milk oligosaccharides that enhance adaptation" — Brad Warner (opinion) [Ep 6 · 18:11](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1091)
- "Complex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent" — Brad Warner (opinion) [Ep 6 · 19:26](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1166)
- "There is a threshold percentage of enteral calories that prevents onset of liver damage from TPN, with 90% enteral feeding having far less risk of TPN-related cholestasis than 10% enteral" — Brad Warner (clinical) [Ep 6 · 21:19](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1279)
- "Time to consider surgical intervention is when enteral tolerance plateaus and then declines (going backward rather than forward), or with multiple sepsis episodes plus abdominal distention and dilated bowel loops, or when child starts getting jaundiced" — Brad Warner (clinical) [Ep 6 · 22:33](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1353)
- "Dilated bowel loops can cause subclinical portal bacteremia contributing to jaundice, and bacterial overgrowth causes secretory diarrhea that impairs enzyme function" — Brad Warner (clinical) [Ep 6 · 23:28](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1408)
- "More than 4-5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention" — Brad Warner (clinical) [Ep 6 · 25:43](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1543)
- "If a child has over 100 centimeters of intestine, less than 5-10% should require TPN, suggesting there may be an underlying motility or mucosal problem" — Brad Warner (clinical) [Ep 6 · 27:53](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1673)
- "For bowel lengthening, need less than 100 cm (ideally less than 50 cm) of intestine and bowel that is at least 4-5 cm dilated" — Brad Warner (clinical) [Ep 6 · 28:37](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1717)
- "The STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation" — Brad Warner (epidemiological) [Ep 6 · 29:31](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1771)
- "The Bianchi procedure takes advantage of the V-shaped blood supply bifurcation before reaching the bowel wall, allowing creation of two tubes each supplied by one arm of the V" — Brad Warner (clinical) [Ep 6 · 30:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1800)
- "STEP procedure is easier to perform with less risk of injuring mesenteric blood supply because you only cut partially across the bowel at right angles" — Brad Warner (clinical) [Ep 6 · 32:30](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1950)
- "STEP can redilate requiring redo procedures, and outcomes are not as good if you have to redo a STEP compared to never needing a redo" — Brad Warner (clinical) [Ep 6 · 32:54](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=1974)
- "You can do a Bianchi and then later do a STEP on top of it, but you cannot do a Bianchi once a STEP has been done" — Brad Warner (clinical) [Ep 6 · 33:26](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2006)
- "In a case where a STEP was acting as a brake causing dysmotility, removing the distal stepped bowel allowed the patient to completely wean off TPN" — Brad Warner (clinical) [Ep 6 · 35:04](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2104)
- "Would taper a child with dilated bowel who had at least 90-100 centimeters of intestinal length" — Brad Warner (clinical) [Ep 6 · 38:23](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2303)
- "Strategies for TPN cholestasis include bile salts (chenodeoxycholic acid), changing lipid composition, and increasing enteral feeds" — Brad Warner (clinical) [Ep 6 · 39:00](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2340)
- "Dan Teitelbaum's trial of cholecystokinin to promote bile flow and mitigate TPN cholestasis did not work" — Brad Warner (clinical) [Ep 6 · 39:23](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2363)
- "Dilated bowel is a nidus for infection encouraging translocation of bacteria and endotoxin into portal circulation, damaging the liver" — Brad Warner (clinical) [Ep 6 · 39:51](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2391)
- "Medical management of bacterial overgrowth includes oral antibiotics (Cipro, Flagyl), probiotics (lactobacilli), prebiotics, and potentially fecal transplantation" — Brad Warner (clinical) [Ep 6 · 40:26](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2426)
- "The gut bacteria in short gut syndrome become more efficient, creating an obesogenic-like microbiome that helps adapt by encouraging greater absorption and digestion" — Brad Warner (clinical) [Ep 6 · 41:54](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2514)
- "In mouse studies, oral vancomycin to knock out gram-positive organisms completely prevented hepatic steatosis after bowel resection" — Brad Warner (clinical) [Ep 6 · 42:19](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2539)
- "Teduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1-2 liters per week" — Brad Warner (clinical) [Ep 6 · 43:57](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2637)
- "Teduglutide is not yet approved for children in the United States, with concerns about malignancy risk due to promoting proliferation" — Brad Warner (clinical) [Ep 6 · 44:34](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2674)
- "Growth factors shown to promote adaptation in animal studies include EGF, HB-EGF (demonstrated by Gail Bessner), interleukins, and growth hormone with glutamine" — Brad Warner (clinical) [Ep 6 · 45:13](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2713)
- "Growth hormone and glutamine combinations in patients have shown primarily mixed results and are expensive" — Brad Warner (clinical) [Ep 6 · 45:46](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2746)
- "Survival for small bowel transplant is about 50-60% at 5 years, with one-year survivals now above 70-80%" — Brad Warner (epidemiological) [Ep 6 · 46:51](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2811)
- "The intestine is highly immunogenic, filled with white cells and macrophages that mount a huge graft-versus-host response, requiring industrial strength immunosuppression" — Brad Warner (clinical) [Ep 6 · 47:11](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2831)
- "Ethanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters" — Brad Warner (clinical) [Ep 6 · 49:22](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=2962)
- "Multidisciplinary teams including pharmacists, nutritionists, surgeons, GI doctors, ID specialists, and interventional radiologists improve survival in intestinal failure patients, as demonstrated in series from Boston, Michigan, and Texas" — Brad Warner (clinical) [Ep 6 · 51:20](https://qa.library.globalcastmd.com/watch/intestinal-failure-with-dr-brad-warner-296?t=3080)
- "Jejunostomy chimney technique involves dividing bowel 2-3 cm distal to ligament of Treitz, bringing distal limb up as chimney over splenic flexure with side-to-end anastomosis, allowing Mickey button placement without luminal obstruction" (clinical) [Ep 5 · 3:00](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=180)
- "Placing balloon catheter directly in jejunal lumen creates obstruction; chimney technique avoids this by creating separate access limb" (clinical) [Ep 5 · 4:21](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=261)
- "Distal feeding can be provided through 3-4 French feeding tube placed in distal bowel and brought out as stent rather than matured mucous fistula, allowing easy refeeding without catheter access issues" (clinical) [Ep 5 · 0:57](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=57)
- "Refeeding distal bowel provides significant benefit for fluid/electrolyte absorption and allows bowel to dilate and mature, potentially decreasing technical problems at takedown" (clinical) [Ep 5 · 1:45](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=105)
- "When proximal and distal stomas are placed close together, takedown is less stressful on patient and surgeon than complete laparotomy to find and reconnect distant bowel segments" (opinion) [Ep 5 · 8:02](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=482)
- "Gastrostomy tubes in very small premature infants (700 grams) can be deferred by placing 3 French feeding tube coiled in stomach, then later dilating tract with wire and interventional radiology to place primary tube without second surgery" (clinical) [Ep 5 · 14:46](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=886)
- "Gastrostomy tube placement has costs including leakage issues if placed against costal margin in small infants; timing and location require careful consideration" (clinical) [Ep 5 · 20:41](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1241)
- "Prolapsed gastrostomy tubes can cause significant formula loss during feeds; removing dysfunctional gastrostomy allows some children to thrive better" (clinical) [Ep 5 · 22:46](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1366)
- "In 2-month-old with jejunal atresia unable to advance feeds beyond 20 mL/kg, if anastomosis appears patent at reoperation, would still revise it rather than leave it alone" (clinical) [Ep 5 · 24:16](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1456)
- "At end of intestinal failure operation, must ensure no kinking, restriction, or potential problems remain - cannot tolerate leaving anything that 'could be a problem but is probably all right'" (clinical) [Ep 5 · 25:29](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1529)
- "STEP procedure in first year of life, especially in infant who has not progressed with enteral feeds, is not beneficial unless specifically avoiding line infections and bacterial overgrowth" (clinical) [Ep 5 · 29:20](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1760)
- "Dysmotile bowel does not become motile because you did a STEP procedure on it; if bowel hasn't been fed and isn't functioning, STEP won't make it work" (clinical) [Ep 5 · 29:32](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1772)
- "The one thing that makes bowel adapt is feeding the bowel; procedures causing problems reinitiating feeds cause damage to patient" (clinical) [Ep 5 · 30:06](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1806)
- "In patient with 50% estimated bowel length, expectation is they will come off parenteral nutrition; should not overtry to salvage bad bowel when good bowel exists" (clinical) [Ep 5 · 28:07](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1687)
- "STEP registry paper showing procedures can be done safely in early neonatal period found only 3 patients came off parenteral nutrition, whereas natural data shows 80-90% of such patients off TPN at 12 months just by being fed" (epidemiological) [Ep 5 · 31:18](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1878)
- "Kids who had early STEP procedures have often redilated, undergone second STEPs, and had mechanical obstructions very detrimental to feeding ability" (clinical) [Ep 5 · 31:43](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1903)
- "Indication for lengthening procedure is complications from bacterial overgrowth (d-lactic acidosis) or ultra-short bowel with very dilated segment where tapering doesn't make sense - generally not decisions made at 2-3 months old but after first birthday" (clinical) [Ep 5 · 33:21](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2001)
- "Expectation of going from 10 mL/kg enteral feeds to off TPN in 3 months after STEP is a fairy tale that doesn't exist" (opinion) [Ep 5 · 34:06](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2046)
- "Surgical techniques for intestinal failure are not out of realm of any pediatric surgeon, but outcomes differ when done in isolation without multidisciplinary team consideration" (opinion) [Ep 5 · 34:46](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2086)
- "Since maturing multidisciplinary program, transplant candidates declined by 75% and internal transplants almost non-existent" (epidemiological) [Ep 5 · 40:47](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2447)
- "Patients should be referred to intestinal rehabilitation programs as soon as identified as needing comprehensive approach, not when complications exhausted local knowledge" (opinion) [Ep 5 · 44:23](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2663)
- "Programs do far better with children who do not already have complications of their disease than patients who come already suffering from current management" (clinical) [Ep 5 · 44:34](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=2674)
- "In gastroschisis and surgical necrotizing enterocolitis, significant benefit to time to wean off parenteral nutrition based solely on breast milk (fortified or not) versus formula only" (clinical) [Ep 5 · 59:42](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3582)
- "Breast milk is not just formula but really a therapy with components that are anti-inflammatory and promotile" (clinical) [Ep 5 · 60:19](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3619)
- "Benefit to kids with spontaneous intestinal perforation is not seen with breast milk, suggesting specific anti-inflammatory and promotile components important for other conditions" (clinical) [Ep 5 · 60:20](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3620)
- "Donor breast milk is less advantageous than maternal breast milk; usually taken from mothers 10-14 months postpartum before weaning, has lower caloric density and protein, and freezing may inactivate trophic factors" (clinical) [Ep 5 · 62:25](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3745)
- "Express maternal breast milk is favorite approach; when patient predicted to do badly, go to elemental formulas as second line" (clinical) [Ep 5 · 63:19](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3799)
- "Free amino acid formulas are relatively hyperosmolar at 20 kcal/oz (osmolarity around 350-360); going higher increases osmolarity, so tend to avoid high caloric density formulas in very young infants" (clinical) [Ep 5 · 64:20](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3860)
- "In study by Joly et al in French adult cohort, hyperphagic adults with short bowel had 60% absorption coefficient with ad lib eating, 85% with continuous drip feeds, and 75% with half calories by mouth during day plus overnight drip feeds" (host_summary) [Ep 5 · 17:01](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1021)
- "Continuous drip feeding improves absorptive index, but combining daytime oral intake with nighttime drip feeds may offer best of both approaches" (host_summary) [Ep 5 · 17:40](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=1060)
- "Prefer isotonic formulas (15-17 cal/oz) because digestion changes osmolarity in jejunum, and most bad kids don't have ileum so jejunum has no ability to absorb against concentration gradient" (clinical) [Ep 5 · 65:20](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3920)
- "Kids without upper GI dysmotility handle volume much better than concentration, so keep concentration low and advance volume" (clinical) [Ep 5 · 65:55](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3955)
- "Introduction of baby foods, meats, and vegetables remarkably helpful in adaptation process once kids get older" (clinical) [Ep 5 · 66:03](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=3963)
- "TPN panel includes renal panel, liver panel, calcium/phosphorus/magnesium; no longer follow prealbumin or RBP as money-saving strategy, follow albumin instead for chronic changes" (clinical) [Ep 5 · 70:04](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4204)
- "Follow essential fatty acids monthly or every other month if on low lipid TPN; iron, ferritin, TIBC every 2-3 months; zinc, copper, ceruloplasmin every 3-6 months; selenium every 6 months" (clinical) [Ep 5 · 70:43](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4243)
- "About 60% of patients weaned off TPN have deficiencies in one micronutrient or another" (epidemiological) [Ep 5 · 71:36](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4296)
- "Follow B12 annually plus methylmalonic acid and homocysteine as more sensitive surrogate markers, since B12 can be synthesized by bacteria or falsely elevated with liver disease" (clinical) [Ep 5 · 72:03](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4323)
- "Breast milk has non-nutrient oligosaccharides (2FL, 3FL) that are not nutrient source to humans but affect microflora and dysbiosis; 80% of secretor mothers make 2FL which is immunomodulatory" (clinical) [Ep 5 · 85:56](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5156)
- "Dysbiosis in intestinal failure patients is profound and furthered by H2 blockers and antibiotics; how this affects adaptive process not well understood" (clinical) [Ep 5 · 86:24](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5184)
- "Older patient recommends prebiotics more and antibiotics less; almost all patients with substantial resection and lost ileocecal valve have element of small bowel contamination with colonic flora" (opinion) [Ep 5 · 83:13](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=4993)
- "Want to encourage right flora (anaerobes) and discourage wrong flora (putrefactive bacteria like E. coli, Klebsiella); too many antibiotics kill bacteria you want present to break down starches into butyric acid" (clinical) [Ep 5 · 83:59](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5039)
- "Use antibiotics selectively: for d-lactic acidosis, hyperammonemia, or older child no longer thriving on previously adequate caloric intake; if used, finite period 2-3 weeks, and abandon if no improved growth velocity" (clinical) [Ep 5 · 85:06](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5106)
- "In recent data, probably 2/3 of bloodstream infections seen in patients on prophylactic Flagyl, because knocking out anaerobes facilitates aerobic overgrowth and presumably translocation" (clinical) [Ep 5 · 90:33](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5433)
- "Metronidazole has limited spectrum, knocks off anaerobes, facilitates growth of aerobes - absolutely the wrong choice for bacterial overgrowth" (opinion) [Ep 5 · 91:56](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5516)
- "If desperate for antibiotics, might use selective decontamination with non-absorbable aminoglycoside (Tobramycin) and Colistin" (clinical) [Ep 5 · 92:16](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5536)
- "Rifaximin may have role but not well studied in bacterial overgrowth, appropriate dose unknown, and no stable suspension available" (clinical) [Ep 5 · 92:37](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5557)
- "Use metronidazole to promote motility by decreasing overgrowth, improving mucosal quality, decreasing inflammation, and increasing tolerance and absorption - not to prevent bacterial infection" (clinical) [Ep 5 · 93:26](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5606)
- "When culture most bacteria causing overgrowth, get anaerobes qualitatively, which is reason for metronidazole use" (clinical) [Ep 5 · 94:29](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5669)
- "Lack of knowledge about microbiome in children with intestinal failure; tend to use antibiotics based on clinical findings - gram negatives or cholestasis suggests non-absorbable aminoglycoside; sudden distension with frothy diarrhea or lactic acidosis suggests Flagyl" (clinical) [Ep 5 · 95:24](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5724)
- "Patients seem to advance well once on solid food, likely due to more physiological exposure to complex proteins and oligosaccharides, but can't identify single causative factor yet" (clinical) [Ep 5 · 96:45](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5805)
- "Use antibiotics and not probiotics, only when forced to (d-lactic acidosis, stalling feeds with distension); metronidazole used because anaerobes are gas producers and cause lactic acidosis" (clinical) [Ep 5 · 97:56](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5876)
- "Metronidazole doesn't work for everyone; with lactic acidosis, very specific antibiotics seem to work and must find best one; try not to cycle, use once and see how long before recurrence" (clinical) [Ep 5 · 98:47](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5927)
- "Worry about probiotics getting in central lines through external contamination more than translocation; lactobacillus species extremely hard to clear, may require line removal" (clinical) [Ep 5 · 99:41](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=5981)
- "One case established blood infection with same genotype as lactobacillus given as probiotic, which turned program away from probiotics in all kids with central lines" (clinical) [Ep 5 · 100:06](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6006)
- "First consideration with increased output is whether overfeeding and overtaxing gut, providing elements for osmotic diarrhea" (clinical) [Ep 5 · 101:17](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6077)
- "Reanastomosing colon helps with output; when colon involved, anti-motility drugs like loperamide become helpful" (clinical) [Ep 5 · 101:51](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6111)
- "Use soluble fibers to decrease high output; have tried octreotide but not found very useful and worry about chronic use with growth hormone suppression" (clinical) [Ep 5 · 102:20](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6140)
- "For patients with lot of gastric output, might use proton pump inhibitor to decrease gastric secretions, but must balance with potential medication risks" (clinical) [Ep 5 · 103:12](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6192)
- "Documented inflammation found on endoscopy in some kids; using anti-inflammatory agents (5-ASA products) seems to have impact, sometimes steroid-based enemas helpful depending on location" (clinical) [Ep 5 · 103:50](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6230)
- "Anti-inflammatories really helpful in challenging Hirschsprung's patients with dysbiosis and high stool frequency not well managed with other interventions" (clinical) [Ep 5 · 104:29](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6269)
- "Successfully managed some Hirschsprung's patients (8-9 years old, stooling 12 times daily, not responding to antibiotic cycling or prebiotics/formulas) with long-term anti-inflammatories and 5-ASA with remarkable success" (clinical) [Ep 5 · 104:49](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6289)
- "Avoid cholestyramine as much as possible; doses effective in firming stool usually bind nutrients, fat-soluble vitamins, and fats; slight risk for hyperchloremic acidosis and cholestyramine bezos" (clinical) [Ep 5 · 105:42](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6342)
- "Encountered patients on almost homeopathic cholestyramine doses whose parents/physicians believed stools looked better, but not sure stool volume actually declined" (clinical) [Ep 5 · 106:30](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6390)
- "Ursodiol in child with very short gut can contribute to diarrhea due to osmotic component with no real benefit preventing cholestasis" (clinical) [Ep 5 · 107:10](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6430)
- "Pancreatic enzymes not physiologic in humans until 5-7 months of age; worry about enzymes in dysmotile bowel areas especially with stomas - have seen strictures/stoma problems related to enzymes sitting in stenotic areas" (clinical) [Ep 5 · 108:12](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6492)
- "Only pancreatic enzyme present in adult quantities in young infants are proteases; amylases don't appear until 6-12 months, lipase doesn't reach adult levels until end of first year" (clinical) [Ep 5 · 109:23](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6563)
- "Short gut patients have high trypsinogen levels because they don't have enough enterokinase, but formal pancreatic stimulation shows proteases do appear" (clinical) [Ep 5 · 109:52](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6592)
- "Problem with pancreatic enzymes in short gut is they go through before releasing" (clinical) [Ep 5 · 110:47](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6647)
- "No upper number for acceptable stoma output that is hard and fast; have many patients with 40-50 cc/kg stoma output who continue feeding based on electrolyte profile" (clinical) [Ep 5 · 111:14](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6674)
- "Don't want patients acidotic (CO2 dropping to teens despite maximizing acetate) - that's the limit, not volume; electrolytes and acidosis drive decision, not volume" (clinical) [Ep 5 · 111:29](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6689)
- "Knee-jerk reactions to volume of output (unless otherwise sick with acidosis/abnormal electrolytes) should not be made; using nurse-callable number for output leads to variable feeding over longer time, very detrimental to weaning program" (opinion) [Ep 5 · 111:45](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6705)
- "Stoma output or stool output more relevant in guiding fluid and electrolyte replacement than making decisions about stopping or decreasing feeds" (clinical) [Ep 5 · 112:36](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6756)
- "Patients receiving GLP-2 analog therapies have dramatically decreased stomal output with benefit in fluid and electrolytes, though whether this gives sustainable benefit and whether use in kids is indicated not yet determined" (clinical) [Ep 5 · 113:12](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6792)
- "Adult GLP-2 analog studies suggest it is beneficial: can reduce fecal output in 60-70% of patients allowing 20% TPN reduction, and in extension study 20% of patients totally emancipated from TPN" (host_summary) [Ep 5 · 113:45](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6825)
- "Some patients do fine on GLP-2 analog while on it but regress when they come off, so jury still out" (clinical) [Ep 5 · 114:35](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6875)
- "Studies waiting until children have late intestinal failure not likely to give needed insight; multi-institutional trials following patients in areas where they can be monitored will provide better outcomes and insight for next 5-10 years" (opinion) [Ep 5 · 114:53](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6893)
- "Major advancements made in intestinal failure field in last 5-6 years not fully recognized; trajectory suggests remarkably different treatment paradigm in very short time" (opinion) [Ep 5 · 115:31](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6931)
- "When patients on long-term TPN, must monitor not just growth (weight and length) but micronutrient status - impacts neurodevelopmental/cognitive outcome and bone health" (clinical) [Ep 5 · 116:10](https://qa.library.globalcastmd.com/watch/practical-approach-intestinal-failure-innovations-1035?t=6970)
- "In Toronto, ultra-short gut is classified as less than 20% of expected bowel length for age; in a term baby that corresponds to 20–30 centimeters." — Paul Wales (clinical) [Ep 11 · 1:37](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=97)
- "Overall survival in the ultra-short gut population in the current era of management is over 90%, actually 90–95%." — Paul Wales (epidemiological) [Ep 11 · 1:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=112)
- "Ultra-short gut patients in the current era do not die of liver failure anymore and are rarely transplanted." (host_summary) [Ep 11 · 2:03](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=123)
- "Ultra-short gut patients who reached enteral autonomy required multiple nutritional supplements but were able to grow within normal parameters." — Paul Wales (clinical) [Ep 11 · 2:07](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=127)
- "Long-term risks of death from liver disease or sepsis in ultra-short gut patients have been transformed in the current era of management." — Paul Wales (clinical) [Ep 11 · 2:13](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=133)
- "Ultra-short gut patients who did better tended to have some remnant ileum and longer colonic remnants." — Paul Wales (clinical) [Ep 11 · 2:26](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=146)
- "The ileum reclaims bile, tells the liver what to do, and produces hormones like GLP-2, PYY, and others that slow motility and signal the jejunum to reabsorb fluid." — Michael Helmrath (clinical) [Ep 11 · 2:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=175)
- "The colon can account for one-third to one-half of the caloric needs of these babies when exposed to undigested nutrients." — Michael Helmrath (clinical) [Ep 11 · 3:15](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=195)
- "These children with overwhelming intestinal catastrophe are largely neurologically fine—they are running and playing—and their life expectancy is not associated with lifelong care needs that most parents would not want." — Michael Helmrath (clinical) [Ep 11 · 3:24](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=204)
- "The child should be the one driving the care, not the surgeon's expectations or lack thereof; without changing that early paradigm, nothing else can improve in this population." — Michael Helmrath (opinion) [Ep 11 · 3:48](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=228)
- "Bowel removed is bowel never to be used; the fear that delayed surgery drives neurocognitive harm needs to be supported with data." — Michael Helmrath (opinion) [Ep 11 · 4:26](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=266)
- "NEC totalis in NEC patients is fairly rare; most NEC patients do not have overwhelming totalis." — Michael Helmrath (epidemiological) [Ep 11 · 4:48](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=288)
- "A dozen or more children with NEC totalis at Cincinnati have survived, are off TPN, and have done remarkably well; the comparative group is dead children who have no neurological function." — Michael Helmrath (clinical) [Ep 11 · 4:54](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=294)
- "Once these patients survive the acute phase, the opportunities to rehabilitate the bowel and the new tools that will be developed in the next decade are going to be profound." — Michael Helmrath (opinion) [Ep 11 · 5:25](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=325)
- "The opportunity given to the child is made at the time the surgeon opens the belly and sees catastrophe; removing all bowel eliminates all future potential based on clinical acumen that the outcome will be bad." — Michael Helmrath (opinion) [Ep 11 · 5:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=334)
- "The first team that must be convinced of this approach is the neonatology team, because historically they are the ones who removed breathing tubes and allowed these babies to pass." — Michael Helmrath (clinical) [Ep 11 · 5:49](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=349)
- "Neonatologists see some of the survivors—ex-premature infants with intestinal failure—return to their follow-up clinics, which informs their perspective." — Paul Wales (clinical) [Ep 11 · 5:59](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=359)
- "Not every child needs to die with a laparotomy decision; the data will tell whether the unoperated septic/inflammatory response leads to negative outcomes." — Paul Wales (opinion) [Ep 11 · 6:10](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=370)
- "Long-term neurocognitive tracking of this population is part of the program's responsibility and is beneficial to patients." — Paul Wales (opinion) [Ep 11 · 6:29](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=389)
- "If you see protein growth, linear growth, and head growth in the baby, that is brain growth; a baby will not grow well with an unhealthy liver or poor management." — Michael Helmrath (clinical) [Ep 11 · 6:47](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=407)
- "An unhealthy liver does not provide the protein necessary for neurocognitive development; liver health is the number one priority early in management." — Michael Helmrath (clinical) [Ep 11 · 6:59](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=419)
- "Lipid restriction as a way of controlling liver disease was never a practice subscribed to by the speakers." — Paul Wales (opinion) [Ep 11 · 7:20](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=440)
- "Babies, especially 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 they are no longer growing and their livers are catabolic, so feeding 150 kcal/kg will not result in growth." — Michael Helmrath (clinical) [Ep 11 · 7:43](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=463)
- "For a 30-week baby with extensive NEC and a long segment of dead bowel, the surgeon knows the baby will need multiple operations, so a transverse incision is used because it causes the least problems over time." — Michael Helmrath (clinical) [Ep 11 · 8:21](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=501)
- "The surgeon finds a segment of bowel just beyond what is expected to heal (1–2 cm margin) and brings in an 8 or 10 French Blake drain, often from the left lower quadrant if normally rotated, placing it through bowel that is not expected to do well and advancing it retrograde to the pylorus." — Michael Helmrath (clinical) [Ep 11 · 8:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=511)
- "A loose tie is placed around the most healthy part of the bowel around the drain to control secretions, and a purse-string is placed at the insertion site and secured to the skin, essentially stemming the bowel to the abdominal wall; this takes minutes." — Michael Helmrath (clinical) [Ep 11 · 8:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=533)
- "If the stomach is visible, a purse-string is placed in the stomach and a 5–7 French feeding tube is inserted into the proximal bowel and tied, taking one to two minutes; this avoids having to access the left upper quadrant later for a G-tube." — Michael Helmrath (clinical) [Ep 11 · 9:29](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=569)
- "The surgeon tries to close the abdomen primarily, but if there is concern about dead bowel, Alloderm is placed; if very worried, a drain is placed in the abdomen to allow drainage." — Michael Helmrath (clinical) [Ep 11 · 9:54](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=594)
- "The surgeon tries to avoid significant dissection of the distal ileum to preserve blood supply and allow collateralization to recover as much proximal bowel as possible." — Michael Helmrath (clinical) [Ep 11 · 10:08](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=608)
- "If the distal diverted bowel is baggy and filled with bloody enteric fluid, and there are distal perforations with patchy necrosis, the surgeon may place stitches distal to proximal to bring the bowel together to preserve muscle, planning to manage it later." — Michael Helmrath (clinical) [Ep 11 · 10:30](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=630)
- "A refeeding tube is placed in the distal bowel to allow refeeding and let the intermediate bowel hang out and heal; this depends on the amount of proximal bowel and whether feeding is feasible." — Michael Helmrath (clinical) [Ep 11 · 10:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=653)
- "In one current case with 40 cm of proximal bowel, refeeding is allowing the surgeon to wait longer for intervening bowel to heal, and the baby's liver is fine, buying time because the fluid output from injured bowel is very high." — Michael Helmrath (clinical) [Ep 11 · 11:06](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=666)
- "When damaged bowel weeps and secretes fluids, the volume of output is high; as it heals and regenerates the ability to reabsorb fluid, the drain output will decrease, signaling that the bowel is healing." (host_summary) [Ep 11 · 11:25](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=685)
- "The surgeon's intraoperative decisions—what is done and what is not done—have a lifelong impact and are critically important; these decisions can determine whether the child stays on or gets off TPN or whether they survive." — Paul Wales (opinion) [Ep 11 · 11:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=713)
- "These conversations about approach need to be had with neonatologists and dietitians in the room, not just surgical colleagues, because they must be on board." — Michael Helmrath (opinion) [Ep 11 · 12:33](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=753)
- "Families are not able to make decisions in these situations; once the family is told that the baby is the one driving decisions moving forward, it makes things easier for them when outcomes are bad." — Michael Helmrath (opinion) [Ep 11 · 12:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=765)
- "Many babies taken to the OR are not as critically sick as believed; once proximal bowel is controlled and everything is decompressed, many will slowly improve." — Michael Helmrath (clinical) [Ep 11 · 13:22](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=802)
- "Traditional teaching is to remove obviously dead and infarcted bowel, leave suspicious or questionable bowel, and return in 24–48 hours to let it demarcate; the approach described is a departure from that teaching." — Paul Wales (clinical) [Ep 11 · 13:52](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=832)
- "Some of these children look worse over the next 24–36 hours, then start to stabilize—they may not get better, but they stop getting worse." — Paul Wales (clinical) [Ep 11 · 14:20](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=860)
- "Long-term, if all bowel is removed, many patients will heal but there is no opportunity for rehabilitation; that experiment has been done." — Michael Helmrath (opinion) [Ep 11 · 14:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=871)
- "Blake tubes have linear cuts on the outside so they do not get obstructed when secretions accumulate; they are soft and do not put pressure on damaged bowel; they can be connected to a bulb syringe and cut to size." — Michael Helmrath (clinical) [Ep 11 · 14:47](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=887)
- "The downside of Blake tubes is that they cannot be changed over a wire like JP drains with side holes; the ideal tube would be a Blake with a central hole for wire passage." — Michael Helmrath (opinion) [Ep 11 · 14:59](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-2-overwhelming-intestinal-damage-part-2-4993?t=899)
- "Adaptation is defined as developing and strengthening gut function, occurring naturally in infants during in utero development and the first few years of life, or as a regenerative response to damage in older children." — Michael Helmrath (clinical) [Ep 12 · 0:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=55)
- "Adaptation generally takes months and years, not weeks and days, and requires enteral nutrition in all situations." — Michael Helmrath (clinical) [Ep 12 · 1:25](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=85)
- "In short gut syndrome, residual intestine undergoes adaptation to compensate and reestablish function to absorb enough nutrients and fluids to maintain survival." — Paul Wales (clinical) [Ep 12 · 2:02](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=122)
- "The adaptive process is driven by the presence of intraluminal nutrients and their interaction with gut secretions (pancreatic, biliary) and trophic gut peptides." — Paul Wales (clinical) [Ep 12 · 2:16](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=136)
- "Structural changes during adaptation include mucosal hypertrophy (increased villous length), increased blood supply through angiogenesis, bowel dilation, and in younger children, gut lengthening—all increasing surface area for nutrient absorption." — Paul Wales (clinical) [Ep 12 · 2:42](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=162)
- "Functional changes during adaptation include slowed motility to allow more contact time and up-regulation of enterocyte transporters to move nutrients across cells more efficiently." — Paul Wales (clinical) [Ep 12 · 3:04](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=184)
- "The duodenum senses caloric intake, monitors sugars, receives hepatobiliary secretions, takes up iron, and functions as an endocrine engine recognizing meal initiation." — Michael Helmrath (clinical) [Ep 12 · 3:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=214)
- "The jejunum is largely a source of fluid secretion needed for digestion, with random back-and-forth sloshing motion like a washing machine." — Michael Helmrath (clinical) [Ep 12 · 3:54](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=234)
- "The ileum secretes different hormones including the incretins GLP-2, GLP-1, and PYY, which stop gastric emptying and slow motility when excess liquid is detected in the distal bowel and proximal colon." — Michael Helmrath (clinical) [Ep 12 · 4:06](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=246)
- "The distal ileum's ability to take up bile sends a signal to the liver, the metabolic engine that helps regulate the whole metabolism of the patient." — Michael Helmrath (clinical) [Ep 12 · 4:31](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=271)
- "In short gut patients, the colon becomes a source of energy uptake when exposed to free fatty acids, which requires the presence of bacteria." — Michael Helmrath (clinical) [Ep 12 · 4:50](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=290)
- "Colonic adaptation does not occur in most normal patients because energy is already reclaimed before reaching the colon." — Michael Helmrath (clinical) [Ep 12 · 5:01](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=301)
- "Adaptation is highly influenced by modifiable factors including formula type, H2 blockers, antibiotics, illness episodes, and motility changes." — Michael Helmrath (clinical) [Ep 12 · 5:13](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=313)
- "Until very recently, there was no standardized definition for enteral autonomy, and most intestinal failure outcomes have poor definitions." — Paul Wales (clinical) [Ep 12 · 5:35](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=335)
- "The current ASPEN guidelines define enteral autonomy as independence from parenteral support for 12 weeks with maintenance of adequate growth and hydration during that time period." — Paul Wales (guideline) [Ep 12 · 6:39](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=399)
- "A patient is not truly off TPN unless they can actually grow off TPN; stopping TPN without achieving growth is a mistake." — Paul Wales (clinical) [Ep 12 · 6:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=413)
- "Healthy growth is the underlying driver of successful TPN weaning, not time off TPN." — Michael Helmrath (clinical) [Ep 12 · 7:06](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=426)
- "The last thing a patient needs to come off TPN is fluid; without adequate hydration, the baby will not grow and will not efficiently absorb nutrition, losing energy and decreasing their growth trajectory." — Michael Helmrath (clinical) [Ep 12 · 7:13](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=433)
- "In the 2012 Squires/PIFCO paper, 50% of patients achieved enteral autonomy over 5-6 years, 25% died, and 25% received transplants." — Paul Wales (epidemiological) [Ep 12 · 7:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=477)
- "Recent papers from the last 5-6 years show that 60-80% of patients now achieve enteral autonomy, representing improved outcomes compared to historical data." — Paul Wales (epidemiological) [Ep 12 · 8:25](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=505)
- "Higher proportions of patients are now surviving to have the ability to reach enteral autonomy due to better management of TPN complications such as line infections, liver disease, and vascular thrombosis." — Paul Wales (clinical) [Ep 12 · 6:10](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=370)
- "In the past, patients were lost to complications such as liver disease before they could reach their adaptive potential; current management is much better at preventing these complications." — Paul Wales (clinical) [Ep 12 · 6:20](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=380)
- "Small bowel length is an independently significant variable predicting adaptive capacity, which is intuitive since the majority of nutrient digestion and fluid absorption occurs in the small bowel." — Paul Wales (clinical) [Ep 12 · 9:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=595)
- "The ileum has a much greater capacity to adapt than the jejunum; patients with predominant ileal anatomy do better than those with predominant jejunal anatomy." — Paul Wales (clinical) [Ep 12 · 10:18](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=618)
- "A full-term baby is born with approximately 160 centimeters of small bowel, which grows to about 425 centimeters by age 5 years, with the steepest growth rate between 35 weeks gestation and 6 months postnatal." — Paul Wales (clinical) [Ep 12 · 10:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=634)
- "The presence or absence of the ileocecal valve is a predictor of adaptation, though the valve itself may not be the important factor; rather, loss of the valve typically accompanies loss of the terminal ileum, which is the bigger factor affecting adaptive potential." — Paul Wales (opinion) [Ep 12 · 11:13](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=673)
- "When a patient has the majority of their small bowel, it almost does not matter how much colon they have—probability of enteral autonomy is 85-100%." — Paul Wales (clinical) [Ep 12 · 11:53](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=713)
- "When small bowel remnant is less than 50% of expected length, the colon becomes vitally important, assuming an increasing role in energy absorption from short-chain fatty acids and fluid/salt absorption." — Paul Wales (clinical) [Ep 12 · 12:06](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=726)
- "Lab data from Cincinnati shows a shift in microbiota to more acid-producing bacteria in an acidotic state, with increased bile due to lack of reclamation." — Michael Helmrath (clinical) [Ep 12 · 12:40](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=760)
- "Bacterial colonization differences from normal are part of the adaptive response and should not automatically be considered pathological; they need to be studied and taken into context." — Michael Helmrath (opinion) [Ep 12 · 13:06](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=786)
- "NEC is an acquired condition; infants are born, start eating (often reaching near-full feeds), then have an incident usually at 2-3 weeks of life, meaning they have not been using their gut during the critical 35-week-to-6-months adaptive window." — Michael Helmrath (clinical) [Ep 12 · 13:26](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=806)
- "Whether a child has been fed before makes them different from one who has never been fed, affecting their adaptive potential." — Michael Helmrath (clinical) [Ep 12 · 13:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=825)
- "Surgical planning for short gut patients is like a game of chess requiring consideration of the second, third, and fourth steps ahead." — Michael Helmrath (opinion) [Ep 12 · 13:58](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=838)
- "The sooner a child can be fed safely and bowel access achieved without exposing them to surgical risk, the more the adaptive process can be leveraged." — Michael Helmrath (clinical) [Ep 12 · 14:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=849)
- "Cincinnati strategies were developed to take advantage of the easiest, safest way to use the bowel early without needing to return immediately to surgery." — Michael Helmrath (clinical) [Ep 12 · 14:23](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=863)
- "Surgery puts children in harm's way regardless of surgeon talent, so balancing surgical intervention with optimization of adaptation has led to improved outcomes." — Michael Helmrath (opinion) [Ep 12 · 14:48](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-1-5141?t=888)
- "Nutritional choices including elemental versus semi-elemental versus intact macronutrient diet selection are guided by residual anatomy and functional status" — Wales (clinical) [Ep 13 · 1:09](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=69)
- "Inadequate caloric support results in poor growth, impaired healing, and diminished adaptive response" — Wales (clinical) [Ep 13 · 1:38](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=98)
- "Implementation of a feeding protocol is associated with achieving full enteral autonomy in a shorter time period, based on literature from Chris Duggan's group at Boston" — Rod (host_summary) [Ep 13 · 1:55](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=115)
- "Bowel heals with adhesions which bring blood supply to the bowel and help it heal" — Helmuth (clinical) [Ep 13 · 2:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=165)
- "Placing a tube beyond the pylorus at time of surgery while allowing NG decompression of the stomach, later changed to gastrostomy tube, has been beneficial at Cincinnati Children's" — Helmuth (clinical) [Ep 13 · 3:05](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=185)
- "Refeeding through a tube is done best and allows standardized nursing feeding practices" — Helmuth (opinion) [Ep 13 · 3:21](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=201)
- "High ostomy outputs without feeding are an indication to feed, as long as the child can be hydrated, though this presents a clinical challenge" — Helmuth (clinical) [Ep 13 · 3:56](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=236)
- "After massive bowel resection, patients can be hypergastrinemic with elevated acid secretion for 6 to 12 months due to loss of distal bowel and hormonal feedback" — Wales (clinical) [Ep 13 · 4:35](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=275)
- "Acid blockade (H2 blocker or PPI) can decrease gastric volume in the short term" — Wales (clinical) [Ep 13 · 4:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=297)
- "Acid blockade carries risk of bacterial overgrowth by losing the acid barrier" — Wales (clinical) [Ep 13 · 5:11](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=311)
- "Prokinetic therapy options include intravenous agents (metoclopramide, erythromycin) or enteral agents (domperidone, cisapride) to improve gastric emptying and motility" — Wales (clinical) [Ep 13 · 5:20](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=320)
- "Increased secretions result from thick, leaky mucosa which requires delivery of luminal nutrients to heal" — Wales (clinical) [Ep 13 · 5:59](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=359)
- "Serum bicarbonate above 20 indicates feeding is generally safe even with high ostomy outputs (40-60 cc/kg), and acetate can be added to TPN for hydration support" — Helmuth (clinical) [Ep 13 · 6:17](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=377)
- "Enteral antibiotics are often cycled for bacterial overgrowth treatment in an empiric and ad hoc manner" — Wales (clinical) [Ep 13 · 6:49](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=409)
- "Anti-secretory or anti-diarrheal medications to decrease losses include octreotide, clonidine, and loperamide" — Wales (clinical) [Ep 13 · 6:57](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=417)
- "Antibiotic treatment should have defined endpoints and duration rather than empiric two-week courses when the child is not showing clinical signs of illness" — Helmuth (opinion) [Ep 13 · 7:38](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=458)
- "Surgical procedures to promote adaptation fall into three categories: restoring continuity, affecting motility, and lengthening the bowel" — Wales (clinical) [Ep 13 · 7:58](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=478)
- "Closing a stoma immediately recruits more bowel" — Wales (clinical) [Ep 13 · 7:58](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=478)
- "As bowel becomes increasingly dilated, its motility becomes impaired" — Wales (clinical) [Ep 13 · 8:36](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=516)
- "Dilated bowel with impaired motility leads to stool stasis, mucosal inflammation, barrier damage allowing bacterial translocation, potential sepsis, and malabsorption" — Rod (host_summary) [Ep 13 · 8:41](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=521)
- "Restoring bowel caliber to normal improves motility, clearance, decreases bacterial overgrowth, allows mucosal healing, and improves absorption" — Wales (clinical) [Ep 13 · 9:01](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=541)
- "Bowel tapering can be performed on the anti-mesenteric side or the dilated segment can be resected if the patient has adequate length" — Wales (clinical) [Ep 13 · 9:14](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=554)
- "Bowel lengthening procedures include the Bianchi procedure (longitudinal intestinal lengthening, available since 1980) and the serial transverse enteroplasty (STEP)" — Wales (clinical) [Ep 13 · 9:33](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=573)
- "The most important factor for efficacy of both Bianchi and STEP procedures is that they taper the bowel" — Wales (clinical) [Ep 13 · 9:45](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=585)
- "STEP differs from anti-mesenteric tapering or resection by preserving all available mucosa without removing any" — Wales (clinical) [Ep 13 · 9:51](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=591)
- "In patients who are shorter with dilated bowel segments where resection is undesirable, STEP or Bianchi become options to preserve all mucosa while addressing dilatation" — Wales (clinical) [Ep 13 · 10:01](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=601)
- "Bowel lengthening procedures redistribute rather than increase surface area; ongoing dilatation and bowel growth in infants and young children eventually result in more surface area through downstream adaptive responses" — Wales (clinical) [Ep 13 · 10:38](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=638)
- "It takes approximately 6 months to see changes in absorption after bowel lengthening procedures, as demonstrated in published absorption studies measuring fecal fat, alpha-1 antitrypsin clearance, xylose, and citrulline" — Wales (clinical) [Ep 13 · 11:05](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=665)
- "An upper GI study can rule in a problem but does not rule out a problem; a normal upper GI does not exclude an anatomical problem" — Helmuth (clinical) [Ep 13 · 11:34](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=694)
- "The new ASPEN guidelines define enteral autonomy as independence from parenteral support for 12 weeks" — Ellen (host_summary) [Ep 13 · 12:05](https://qa.library.globalcastmd.com/watch/intestinal-rehabilitation-episode-3-enteral-autonomy-part-2-5240?t=725)

## Common questions
### What did Paul Wales say about Intestinal Failure?
Dr. Wales defined intestinal failure as a functional problem where gut function is insufficient to absorb enough nutrients, fluids, and calories to support survival and, in children, growth. He noted that until recently there was no standardized definition for the condition. Dr. Wales identified that causes of intestinal failure can be divided into three categories, though some patients present with elements of two or all three categories. He also described intermediate and longer-term complications including intestinal failure-associated liver disease, recurrent sepsis, and line problems.

## Changelog
- Sep 9: Summaries and takeaways published for 4 audiences
- Sep 7: Audit reverted — short clips unhidden
- Sep 7: 1 item hidden — never mention Intestinal Failure; unhide from the owner view
- Aug 31: 29 doctors auto-found from episode dossiers
- Aug 30: 29 doctors auto-found from episode dossiers
- Aug 30: 29 doctors auto-found from episode dossiers
- Aug 30: Members-only episodes removed from this collection
- Aug 29: 32 doctors auto-found from episode dossiers
- Aug 29: 32 doctors auto-found from episode dossiers
- Aug 29: Collection generated from campaign corpus: 35 items, 34 dossiers, summaries for 2 audience(s)
- Aug 29: Collection reviewed and published
- Aug 29: Collection generated from campaign corpus: 21 items, 21 dossiers, summaries for 2 audience(s)
- Aug 29: Collection generated from campaign corpus: 21 items, 21 dossiers, summaries for 2 audience(s)

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