Two takeaways here, one of which is the ileocecal region. May not be important to preserve and may actually be injurious. And the second point is that administration of a specific bile acid that is more um uh lipophilic and, uh, and more hepatic, uh, I guess, uh, protective could be potential therapy for patients that have cholestatic liver disease after a massive intestinal resection.
Two takeaways here, one of which is the ileocecal region. May not be important to preserve and may actually be injurious. And the second point is that administration of a specific bile acid that is more um uh lipophilic and, uh, and more hepatic, uh, I guess, uh, protective could be potential therapy for patients that have cholestatic liver disease after a massive intestinal resection.
Two takeaways here, one of which is the ileocecal region. May not be important to preserve and may actually be injurious. And the second point is that administration of a specific bile acid that is more um uh lipophilic and, uh, and more hepatic, uh, I guess, uh, protective could be potential therapy for patients that have cholestatic liver disease after a massive intestinal resection.
I think breast milk is, uh, uh, if you know, if you're in a newborn situation, is probably the very best because it not only contains what the baby needs in terms of the proper fat and all of that, but it's, it has other things in there that are really, um, I think from an investigative standpoint, very rich to explore.
I think breast milk is, uh, uh, if you know, if you're in a newborn situation, is probably the very best because it not only contains what the baby needs in terms of the proper fat and all of that, but it's, it has other things in there that are really, um, I think from an investigative standpoint, very rich to explore.
I think breast milk is, uh, uh, if you know, if you're in a newborn situation, is probably the very best because it not only contains what the baby needs in terms of the proper fat and all of that, but it's, it has other things in there that are really, um, I think from an investigative standpoint, very rich to explore.
clinicalIntestinal 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↗
▶Ep 18 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 18 · 3:13
clinicalA 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↗
▶Ep 18 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10-15 cm of small intestine is a ballpark figure for potential viability↗
▶Ep 18 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15-20 cm of small intestine would be needed for potential viability in a neonate↗
▶Ep 18 · 4:51
epidemiologicalIn adult studies, patients with less than 50 cm of intestine have about 40% mortality after 5-10 years↗
▶Ep 18 · 6:38
epidemiologicalAccording 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↗
▶Ep 18 · 7:11
clinicalCommon 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↗
▶Ep 18 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection↗
▶Ep 18 · 8:19
clinicalThe 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↗
▶Ep 18 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should, you know, back off on your enteral feeding.↗
▶Ep 18 · 9:22
epidemiologicalThe most common reasons children develop short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias↗
▶Ep 18 · 10:22
clinicalFor TPN, target about 100-120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein↗
▶Ep 18 · 10:45
clinicalShoot for about 2-3 g of protein per kilo per day and about 2-3 g of fat per kilo per day in TPN↗
▶Ep 18 · 11:06
clinicalBegin enteral feeding as soon as feasible after resection and reanastomosis when they start stooling, generally starting with slow continuous drip↗
▶Ep 18 · 11:23
opinionWith continuous drip feeding, nutrient transporters are upregulated and ability to get more nutrition in may be advantageous↗
▶Ep 18 · 12:05
clinicalWant a baby to gain about 20-30 g a day, which approximates in utero progression for a newborn↗
▶Ep 18 · 12:53
clinicalLipid 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↗
▶Ep 18 · 14:03
clinicalOmegaven 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↗
▶Ep 18 · 14:38
clinicalWhen fish oil (omegaven) is introduced to children getting jaundiced, there has been demonstrated significant fall in their jaundice levels↗
▶Ep 18 · 15:08
clinicalSMOF 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↗
▶Ep 18 · 18:11
opinionBreast milk is the best choice for neonates because it contains proper fat, growth factors like EGF and IGF, and milk oligosaccharides that enhance adaptation↗
▶Ep 18 · 19:26
opinionComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 18 · 21:19
clinicalThere 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↗
quoteMy time that I would be starting to think about doing lengthening procedures or intervening surgically would be is if you hit a point rally and now you start backing away.↗
▶Ep 18 · 22:33
clinicalTime 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↗
▶Ep 18 · 23:28
clinicalDilated bowel loops can cause subclinical portal bacteremia contributing to jaundice, and bacterial overgrowth causes secretory diarrhea that impairs enzyme function↗
▶Ep 18 · 25:43
clinicalMore than 4-5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention↗
▶Ep 18 · 27:53
clinicalIf 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↗
▶Ep 18 · 28:37
clinicalFor bowel lengthening, need less than 100 cm (ideally less than 50 cm) of intestine and bowel that is at least 4-5 cm dilated↗
▶Ep 18 · 29:31
epidemiologicalThe STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation↗
▶Ep 18 · 30:00
clinicalThe 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↗
▶Ep 18 · 32:30
clinicalSTEP procedure is easier to perform with less risk of injuring mesenteric blood supply because you only cut partially across the bowel at right angles↗
▶Ep 18 · 32:54
clinicalSTEP can redilate requiring redo procedures, and outcomes are not as good if you have to redo a STEP compared to never needing a redo↗
▶Ep 18 · 33:26
clinicalYou 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↗
▶Ep 18 · 33:26
quoteYou can do a Bianchi and then go back in and do another step on top of a Bianchi. You can't do a Bianchi once a step has been done.↗
▶Ep 18 · 35:04
clinicalIn 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↗
▶Ep 18 · 35:21
quoteI really made it a point to say that I think it's the step that is acting as a brake, you know, and they ended up letting me take out the distal bowel.↗
▶Ep 18 · 35:40
quoteSo that makes me feel like steps are not as innocuous as as we think they are, and because of that, I, I don't know, I tend to lean a little bit more as a primary to do a Bianchi, and if I have to redo something, I might, I might do it as a step then↗
▶Ep 18 · 38:23
clinicalWould taper a child with dilated bowel who had at least 90-100 centimeters of intestinal length↗
▶Ep 18 · 39:00
clinicalStrategies for TPN cholestasis include bile salts (chenodeoxycholic acid), changing lipid composition, and increasing enteral feeds↗
▶Ep 18 · 39:23
clinicalDan Teitelbaum's trial of cholecystokinin to promote bile flow and mitigate TPN cholestasis did not work↗
▶Ep 18 · 39:51
clinicalDilated bowel is a nidus for infection encouraging translocation of bacteria and endotoxin into portal circulation, damaging the liver↗
▶Ep 18 · 40:26
clinicalMedical management of bacterial overgrowth includes oral antibiotics (Cipro, Flagyl), probiotics (lactobacilli), prebiotics, and potentially fecal transplantation↗
▶Ep 18 · 41:54
clinicalThe gut bacteria in short gut syndrome become more efficient, creating an obesogenic-like microbiome that helps adapt by encouraging greater absorption and digestion↗
▶Ep 18 · 42:19
clinicalIn mouse studies, oral vancomycin to knock out gram-positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 18 · 43:57
clinicalTeduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1-2 liters per week↗
▶Ep 18 · 44:34
clinicalTeduglutide is not yet approved for children in the United States, with concerns about malignancy risk due to promoting proliferation↗
▶Ep 18 · 45:13
clinicalGrowth factors shown to promote adaptation in animal studies include EGF, HB-EGF (demonstrated by Gail Bessner), interleukins, and growth hormone with glutamine↗
▶Ep 18 · 45:46
clinicalGrowth hormone and glutamine combinations in patients have shown primarily mixed results and are expensive↗
▶Ep 18 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50-60% at 5 years, with one-year survivals now above 70-80%↗
▶Ep 18 · 46:51
quoteRight now, the survival for small bowel transplant is about 50 to 60% at 5 years.↗
▶Ep 18 · 47:11
clinicalThe intestine is highly immunogenic, filled with white cells and macrophages that mount a huge graft-versus-host response, requiring industrial strength immunosuppression↗
▶Ep 18 · 49:22
clinicalEthanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters↗
▶Ep 18 · 50:33
quoteI think if they're doing well. Um, and they're not jaundiced, um, doing it for the sake of getting them off of TPN may be a bit premature if they're, if they're otherwise doing well↗
▶Ep 18 · 51:20
clinicalMultidisciplinary 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↗
▶Ep 18 · 51:20
quoteThis is a team sport in taking care of these patients.↗
clinicalIntestinal 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↗
▶Ep 75 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 75 · 3:13
clinicalA 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↗
▶Ep 75 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10-15 cm of small intestine is a ballpark figure for potential viability↗
▶Ep 75 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15-20 cm of small intestine would be needed for potential viability in a neonate↗
▶Ep 75 · 4:51
epidemiologicalIn adult studies, patients with less than 50 cm of intestine have about 40% mortality after 5-10 years↗
▶Ep 75 · 6:38
epidemiologicalAccording 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↗
▶Ep 75 · 7:11
clinicalCommon 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↗
▶Ep 75 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection↗
▶Ep 75 · 8:19
clinicalThe 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↗
▶Ep 75 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should, you know, back off on your enteral feeding.↗
▶Ep 75 · 9:22
epidemiologicalThe most common reasons children develop short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias↗
▶Ep 75 · 10:22
clinicalFor TPN, target about 100-120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein↗
▶Ep 75 · 10:45
clinicalShoot for about 2-3 g of protein per kilo per day and about 2-3 g of fat per kilo per day in TPN↗
▶Ep 75 · 11:06
clinicalBegin enteral feeding as soon as feasible after resection and reanastomosis when they start stooling, generally starting with slow continuous drip↗
▶Ep 75 · 11:23
opinionWith continuous drip feeding, nutrient transporters are upregulated and ability to get more nutrition in may be advantageous↗
▶Ep 75 · 12:05
clinicalWant a baby to gain about 20-30 g a day, which approximates in utero progression for a newborn↗
▶Ep 75 · 12:53
clinicalLipid 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↗
▶Ep 75 · 14:03
clinicalOmegaven 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↗
▶Ep 75 · 14:38
clinicalWhen fish oil (omegaven) is introduced to children getting jaundiced, there has been demonstrated significant fall in their jaundice levels↗
▶Ep 75 · 15:08
clinicalSMOF 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↗
▶Ep 75 · 18:11
opinionBreast milk is the best choice for neonates because it contains proper fat, growth factors like EGF and IGF, and milk oligosaccharides that enhance adaptation↗
▶Ep 75 · 19:26
opinionComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 75 · 21:19
clinicalThere 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↗
quoteMy time that I would be starting to think about doing lengthening procedures or intervening surgically would be is if you hit a point rally and now you start backing away.↗
▶Ep 75 · 22:33
clinicalTime 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↗
▶Ep 75 · 23:28
clinicalDilated bowel loops can cause subclinical portal bacteremia contributing to jaundice, and bacterial overgrowth causes secretory diarrhea that impairs enzyme function↗
▶Ep 75 · 25:43
clinicalMore than 4-5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention↗
▶Ep 75 · 27:53
clinicalIf 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↗
▶Ep 75 · 28:37
clinicalFor bowel lengthening, need less than 100 cm (ideally less than 50 cm) of intestine and bowel that is at least 4-5 cm dilated↗
▶Ep 75 · 29:31
epidemiologicalThe STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation↗
▶Ep 75 · 30:00
clinicalThe 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↗
▶Ep 75 · 32:30
clinicalSTEP procedure is easier to perform with less risk of injuring mesenteric blood supply because you only cut partially across the bowel at right angles↗
▶Ep 75 · 32:54
clinicalSTEP can redilate requiring redo procedures, and outcomes are not as good if you have to redo a STEP compared to never needing a redo↗
▶Ep 75 · 33:26
clinicalYou 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↗
▶Ep 75 · 33:26
quoteYou can do a Bianchi and then go back in and do another step on top of a Bianchi. You can't do a Bianchi once a step has been done.↗
▶Ep 75 · 35:04
clinicalIn 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↗
▶Ep 75 · 35:21
quoteI really made it a point to say that I think it's the step that is acting as a brake, you know, and they ended up letting me take out the distal bowel.↗
▶Ep 75 · 35:40
quoteSo that makes me feel like steps are not as innocuous as as we think they are, and because of that, I, I don't know, I tend to lean a little bit more as a primary to do a Bianchi, and if I have to redo something, I might, I might do it as a step then↗
▶Ep 75 · 38:23
clinicalWould taper a child with dilated bowel who had at least 90-100 centimeters of intestinal length↗
▶Ep 75 · 39:00
clinicalStrategies for TPN cholestasis include bile salts (chenodeoxycholic acid), changing lipid composition, and increasing enteral feeds↗
▶Ep 75 · 39:23
clinicalDan Teitelbaum's trial of cholecystokinin to promote bile flow and mitigate TPN cholestasis did not work↗
▶Ep 75 · 39:51
clinicalDilated bowel is a nidus for infection encouraging translocation of bacteria and endotoxin into portal circulation, damaging the liver↗
▶Ep 75 · 40:26
clinicalMedical management of bacterial overgrowth includes oral antibiotics (Cipro, Flagyl), probiotics (lactobacilli), prebiotics, and potentially fecal transplantation↗
▶Ep 75 · 41:54
clinicalThe gut bacteria in short gut syndrome become more efficient, creating an obesogenic-like microbiome that helps adapt by encouraging greater absorption and digestion↗
▶Ep 75 · 42:19
clinicalIn mouse studies, oral vancomycin to knock out gram-positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 75 · 43:57
clinicalTeduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1-2 liters per week↗
▶Ep 75 · 44:34
clinicalTeduglutide is not yet approved for children in the United States, with concerns about malignancy risk due to promoting proliferation↗
▶Ep 75 · 45:13
clinicalGrowth factors shown to promote adaptation in animal studies include EGF, HB-EGF (demonstrated by Gail Bessner), interleukins, and growth hormone with glutamine↗
▶Ep 75 · 45:46
clinicalGrowth hormone and glutamine combinations in patients have shown primarily mixed results and are expensive↗
▶Ep 75 · 46:51
quoteRight now, the survival for small bowel transplant is about 50 to 60% at 5 years.↗
▶Ep 75 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50-60% at 5 years, with one-year survivals now above 70-80%↗
▶Ep 75 · 47:11
clinicalThe intestine is highly immunogenic, filled with white cells and macrophages that mount a huge graft-versus-host response, requiring industrial strength immunosuppression↗
▶Ep 75 · 49:22
clinicalEthanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters↗
▶Ep 75 · 50:33
quoteI think if they're doing well. Um, and they're not jaundiced, um, doing it for the sake of getting them off of TPN may be a bit premature if they're, if they're otherwise doing well↗
▶Ep 75 · 51:20
clinicalMultidisciplinary 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↗
▶Ep 75 · 51:20
quoteThis is a team sport in taking care of these patients.↗
clinicalIntestinal 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↗
▶Ep 25 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 25 · 3:13
clinicalA 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↗
▶Ep 25 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10-15 cm of small intestine is a ballpark figure for potential viability↗
▶Ep 25 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15-20 cm of small intestine would be needed for potential viability in a neonate↗
▶Ep 25 · 4:51
epidemiologicalIn adult studies, patients with less than 50 cm of intestine have about 40% mortality after 5-10 years↗
▶Ep 25 · 6:38
epidemiologicalAccording 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↗
▶Ep 25 · 7:11
clinicalCommon 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↗
▶Ep 25 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection↗
▶Ep 25 · 8:19
clinicalThe 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↗
▶Ep 25 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should, you know, back off on your enteral feeding.↗
▶Ep 25 · 9:22
epidemiologicalThe most common reasons children develop short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias↗
▶Ep 25 · 10:22
clinicalFor TPN, target about 100-120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein↗
▶Ep 25 · 10:45
clinicalShoot for about 2-3 g of protein per kilo per day and about 2-3 g of fat per kilo per day in TPN↗
▶Ep 25 · 11:06
clinicalBegin enteral feeding as soon as feasible after resection and reanastomosis when they start stooling, generally starting with slow continuous drip↗
▶Ep 25 · 11:23
opinionWith continuous drip feeding, nutrient transporters are upregulated and ability to get more nutrition in may be advantageous↗
▶Ep 25 · 12:05
clinicalWant a baby to gain about 20-30 g a day, which approximates in utero progression for a newborn↗
▶Ep 25 · 12:53
clinicalLipid 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↗
▶Ep 25 · 14:03
clinicalOmegaven 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↗
▶Ep 25 · 14:38
clinicalWhen fish oil (omegaven) is introduced to children getting jaundiced, there has been demonstrated significant fall in their jaundice levels↗
▶Ep 25 · 15:08
clinicalSMOF 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↗
▶Ep 25 · 18:11
opinionBreast milk is the best choice for neonates because it contains proper fat, growth factors like EGF and IGF, and milk oligosaccharides that enhance adaptation↗
▶Ep 25 · 19:26
opinionComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 25 · 21:19
clinicalThere 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↗
quoteMy time that I would be starting to think about doing lengthening procedures or intervening surgically would be is if you hit a point rally and now you start backing away.↗
▶Ep 25 · 22:33
clinicalTime 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↗
▶Ep 25 · 23:28
clinicalDilated bowel loops can cause subclinical portal bacteremia contributing to jaundice, and bacterial overgrowth causes secretory diarrhea that impairs enzyme function↗
▶Ep 25 · 25:43
clinicalMore than 4-5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention↗
▶Ep 25 · 27:53
clinicalIf 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↗
▶Ep 25 · 28:37
clinicalFor bowel lengthening, need less than 100 cm (ideally less than 50 cm) of intestine and bowel that is at least 4-5 cm dilated↗
▶Ep 25 · 29:31
epidemiologicalThe STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation↗
▶Ep 25 · 30:00
clinicalThe 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↗
▶Ep 25 · 32:30
clinicalSTEP procedure is easier to perform with less risk of injuring mesenteric blood supply because you only cut partially across the bowel at right angles↗
▶Ep 25 · 32:54
clinicalSTEP can redilate requiring redo procedures, and outcomes are not as good if you have to redo a STEP compared to never needing a redo↗
▶Ep 25 · 33:26
quoteYou can do a Bianchi and then go back in and do another step on top of a Bianchi. You can't do a Bianchi once a step has been done.↗
▶Ep 25 · 33:26
clinicalYou 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↗
▶Ep 25 · 35:04
clinicalIn 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↗
▶Ep 25 · 35:21
quoteI really made it a point to say that I think it's the step that is acting as a brake, you know, and they ended up letting me take out the distal bowel.↗
▶Ep 25 · 35:40
quoteSo that makes me feel like steps are not as innocuous as as we think they are, and because of that, I, I don't know, I tend to lean a little bit more as a primary to do a Bianchi, and if I have to redo something, I might, I might do it as a step then↗
▶Ep 25 · 38:23
clinicalWould taper a child with dilated bowel who had at least 90-100 centimeters of intestinal length↗
▶Ep 25 · 39:00
clinicalStrategies for TPN cholestasis include bile salts (chenodeoxycholic acid), changing lipid composition, and increasing enteral feeds↗
▶Ep 25 · 39:23
clinicalDan Teitelbaum's trial of cholecystokinin to promote bile flow and mitigate TPN cholestasis did not work↗
▶Ep 25 · 39:51
clinicalDilated bowel is a nidus for infection encouraging translocation of bacteria and endotoxin into portal circulation, damaging the liver↗
▶Ep 25 · 40:26
clinicalMedical management of bacterial overgrowth includes oral antibiotics (Cipro, Flagyl), probiotics (lactobacilli), prebiotics, and potentially fecal transplantation↗
▶Ep 25 · 41:54
clinicalThe gut bacteria in short gut syndrome become more efficient, creating an obesogenic-like microbiome that helps adapt by encouraging greater absorption and digestion↗
▶Ep 25 · 42:19
clinicalIn mouse studies, oral vancomycin to knock out gram-positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 25 · 43:57
clinicalTeduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1-2 liters per week↗
▶Ep 25 · 44:34
clinicalTeduglutide is not yet approved for children in the United States, with concerns about malignancy risk due to promoting proliferation↗
▶Ep 25 · 45:13
clinicalGrowth factors shown to promote adaptation in animal studies include EGF, HB-EGF (demonstrated by Gail Bessner), interleukins, and growth hormone with glutamine↗
▶Ep 25 · 45:46
clinicalGrowth hormone and glutamine combinations in patients have shown primarily mixed results and are expensive↗
▶Ep 25 · 46:51
quoteRight now, the survival for small bowel transplant is about 50 to 60% at 5 years.↗
▶Ep 25 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50-60% at 5 years, with one-year survivals now above 70-80%↗
▶Ep 25 · 47:11
clinicalThe intestine is highly immunogenic, filled with white cells and macrophages that mount a huge graft-versus-host response, requiring industrial strength immunosuppression↗
▶Ep 25 · 49:22
clinicalEthanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters↗
▶Ep 25 · 50:33
quoteI think if they're doing well. Um, and they're not jaundiced, um, doing it for the sake of getting them off of TPN may be a bit premature if they're, if they're otherwise doing well↗
▶Ep 25 · 51:20
quoteThis is a team sport in taking care of these patients.↗
▶Ep 25 · 51:20
clinicalMultidisciplinary 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↗
Journal of Pediatric Article Review: June 2023, AAP Issue
▶Ep 8 · 2:22
quoteIn looking for mechanisms as to how this occurs, we sought to determine whether bile acids or the site of intestinal resection would really make a difference in terms of the liver injury.↗
▶Ep 8 · 3:28
quoteTwo takeaways here, one of which is the ileocecal region. May not be important to preserve and may actually be injurious. And the second point is that administration of a specific bile acid that is more um uh lipophilic and, uh, and more hepatic, uh, I guess, uh, protective could be potential therapy for patients that have cholestatic liver disease after a massive intestinal resection.↗
▶Ep 8 · 3:28
clinicalThe ileocecal region may not be important to preserve in short bowel syndrome and may actually be injurious↗
▶Ep 8 · 3:37
clinicalAdministration of a specific bile acid that is more lipophilic and hepatoprotective could be potential therapy for patients with cholestatic liver disease after massive intestinal resection↗
▶Ep 8 · 4:13
clinicalIn clinical practice, surgeons cannot choose which intestinal segment to remove - they must remove what is dead and preserve as much viable bowel as possible↗
▶Ep 8 · 4:16
quoteYou can't choose that. You have to remove what's dead, and you intentionally would never remove anything that wasn't. You want to preserve as much↗
clinicalIntestinal 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.↗
▶Ep 14 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation.↗
▶Ep 14 · 4:03
clinicalFor a neonate with an ileocecal valve and entire colon, 10 to 15 centimeters of small intestine is a ballpark figure for potential salvageability.↗
▶Ep 14 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15 to 20 centimeters of small intestine would be needed for potential salvageability in neonates.↗
▶Ep 14 · 4:51
epidemiologicalIn adult studies, adults with less than 50 centimeters of intestine have about 40% mortality after 5 to 10 years.↗
▶Ep 14 · 6:38
epidemiologicalAccording 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.↗
▶Ep 14 · 7:11
clinicalThe 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.↗
▶Ep 14 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection.↗
▶Ep 14 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should, you know, back off on your enteral feeding.↗
▶Ep 14 · 8:30
clinicalStool outputs of up to 40 cc per kilo per day are acceptable when advancing enteral feeding; beyond that threshold, enteral feeding should be reduced.↗
▶Ep 14 · 9:22
epidemiologicalThe 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.↗
▶Ep 14 · 10:22
clinicalFor 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.↗
▶Ep 14 · 10:45
clinicalTPN 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.↗
▶Ep 14 · 12:05
clinicalBabies should gain about 20 to 30 grams a day, which approximates in utero weight gain for a newborn.↗
▶Ep 14 · 12:53
clinicalLipid 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.↗
▶Ep 14 · 13:46
clinicalOmegaven 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.↗
▶Ep 14 · 15:08
clinicalSMOF 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.↗
▶Ep 14 · 18:11
opinionBreast 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.↗
▶Ep 14 · 18:11
quoteI think breast milk is, uh, uh, if you know, if you're in a newborn situation, is probably the very best because it not only contains what the baby needs in terms of the proper fat and all of that, but it's, it has other things in there that are really, um, I think from an investigative standpoint, very rich to explore.↗
▶Ep 14 · 19:26
opinionComplex formulas fed enterally may stimulate adaptation better than elemental formulas because they cause secretion of enterotrophic hormones to a greater extent.↗
▶Ep 14 · 20:56
clinicalThere 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.↗
clinicalSurgical 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.↗
▶Ep 14 · 23:47
quoteI think probably dilated bowel loops are one central theme here. That can be responsible not just for the sepsis episodes but for inability to tolerate enteral feeding.↗
▶Ep 14 · 25:43
clinicalDilated 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.↗
▶Ep 14 · 27:53
clinicalLess 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.↗
▶Ep 14 · 29:31
clinicalThe 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.↗
▶Ep 14 · 30:00
clinicalThe 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.↗
▶Ep 14 · 32:54
clinicalSTEP 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.↗
▶Ep 14 · 33:26
clinicalA 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).↗
▶Ep 14 · 33:26
quoteYou can do a Bianchi and then go back in and do another step on top of a Bianchi. You can't do a Bianchi once a step has been done.↗
▶Ep 14 · 38:21
clinicalTapering should be considered for children with dilated bowel who have at least 90 to 100 centimeters of intestinal length.↗
▶Ep 14 · 43:45
clinicalTeduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1 to 2 liters per week.↗
▶Ep 14 · 45:40
clinicalGrowth 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.↗
▶Ep 14 · 46:51
epidemiologicalCurrent survival for small bowel transplant is about 50 to 60% at 5 years, with one-year survivals now above 70 to 80%.↗
▶Ep 14 · 47:11
clinicalThe 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.↗
▶Ep 14 · 49:16
quoteI think you want to try to do everything you can to avoid transplantation.↗
▶Ep 14 · 49:22
clinicalEthanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters.↗
▶Ep 14 · 51:16
clinicalMultidisciplinary 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.↗
▶Ep 14 · 51:20
quoteThis is a team sport in taking care of these patients.↗
Intestinal Failure with Dr. Brad Warner
▶Ep 30 · 1:42
clinicalIntestinal 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↗
▶Ep 30 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 30 · 3:13
clinicalA 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↗
▶Ep 30 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10-15 cm of small intestine is a ballpark figure for potential viability↗
▶Ep 30 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15-20 cm of small intestine would be needed for potential viability in a neonate↗
▶Ep 30 · 4:51
epidemiologicalIn adult studies, patients with less than 50 cm of intestine have about 40% mortality after 5-10 years↗
▶Ep 30 · 6:38
epidemiologicalAccording 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↗
▶Ep 30 · 7:11
clinicalCommon 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↗
▶Ep 30 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection↗
▶Ep 30 · 8:19
clinicalThe 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↗
▶Ep 30 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should, you know, back off on your enteral feeding.↗
▶Ep 30 · 9:22
epidemiologicalThe most common reasons children develop short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias↗
▶Ep 30 · 10:22
clinicalFor TPN, target about 100-120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein↗
▶Ep 30 · 10:45
clinicalShoot for about 2-3 g of protein per kilo per day and about 2-3 g of fat per kilo per day in TPN↗
▶Ep 30 · 11:06
clinicalBegin enteral feeding as soon as feasible after resection and reanastomosis when they start stooling, generally starting with slow continuous drip↗
▶Ep 30 · 11:23
opinionWith continuous drip feeding, nutrient transporters are upregulated and ability to get more nutrition in may be advantageous↗
▶Ep 30 · 12:05
clinicalWant a baby to gain about 20-30 g a day, which approximates in utero progression for a newborn↗
▶Ep 30 · 12:53
clinicalLipid 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↗
▶Ep 30 · 14:03
clinicalOmegaven 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↗
▶Ep 30 · 14:38
clinicalWhen fish oil (omegaven) is introduced to children getting jaundiced, there has been demonstrated significant fall in their jaundice levels↗
▶Ep 30 · 15:08
clinicalSMOF 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↗
▶Ep 30 · 18:11
opinionBreast milk is the best choice for neonates because it contains proper fat, growth factors like EGF and IGF, and milk oligosaccharides that enhance adaptation↗
▶Ep 30 · 19:26
opinionComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 30 · 21:19
clinicalThere 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↗
clinicalTime 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↗
▶Ep 30 · 22:33
quoteMy time that I would be starting to think about doing lengthening procedures or intervening surgically would be is if you hit a point rally and now you start backing away.↗
▶Ep 30 · 23:28
clinicalDilated bowel loops can cause subclinical portal bacteremia contributing to jaundice, and bacterial overgrowth causes secretory diarrhea that impairs enzyme function↗
▶Ep 30 · 25:43
clinicalMore than 4-5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention↗
▶Ep 30 · 27:53
clinicalIf 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↗
▶Ep 30 · 28:37
clinicalFor bowel lengthening, need less than 100 cm (ideally less than 50 cm) of intestine and bowel that is at least 4-5 cm dilated↗
▶Ep 30 · 29:31
epidemiologicalThe STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation↗
▶Ep 30 · 30:00
clinicalThe 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↗
▶Ep 30 · 32:30
clinicalSTEP procedure is easier to perform with less risk of injuring mesenteric blood supply because you only cut partially across the bowel at right angles↗
▶Ep 30 · 32:54
clinicalSTEP can redilate requiring redo procedures, and outcomes are not as good if you have to redo a STEP compared to never needing a redo↗
▶Ep 30 · 33:26
clinicalYou 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↗
▶Ep 30 · 33:26
quoteYou can do a Bianchi and then go back in and do another step on top of a Bianchi. You can't do a Bianchi once a step has been done.↗
▶Ep 30 · 35:04
clinicalIn 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↗
▶Ep 30 · 35:21
quoteI really made it a point to say that I think it's the step that is acting as a brake, you know, and they ended up letting me take out the distal bowel.↗
▶Ep 30 · 35:40
quoteSo that makes me feel like steps are not as innocuous as as we think they are, and because of that, I, I don't know, I tend to lean a little bit more as a primary to do a Bianchi, and if I have to redo something, I might, I might do it as a step then↗
▶Ep 30 · 38:23
clinicalWould taper a child with dilated bowel who had at least 90-100 centimeters of intestinal length↗
▶Ep 30 · 39:00
clinicalStrategies for TPN cholestasis include bile salts (chenodeoxycholic acid), changing lipid composition, and increasing enteral feeds↗
▶Ep 30 · 39:23
clinicalDan Teitelbaum's trial of cholecystokinin to promote bile flow and mitigate TPN cholestasis did not work↗
▶Ep 30 · 39:51
clinicalDilated bowel is a nidus for infection encouraging translocation of bacteria and endotoxin into portal circulation, damaging the liver↗
▶Ep 30 · 40:26
clinicalMedical management of bacterial overgrowth includes oral antibiotics (Cipro, Flagyl), probiotics (lactobacilli), prebiotics, and potentially fecal transplantation↗
▶Ep 30 · 41:54
clinicalThe gut bacteria in short gut syndrome become more efficient, creating an obesogenic-like microbiome that helps adapt by encouraging greater absorption and digestion↗
▶Ep 30 · 42:19
clinicalIn mouse studies, oral vancomycin to knock out gram-positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 30 · 43:57
clinicalTeduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1-2 liters per week↗
▶Ep 30 · 44:34
clinicalTeduglutide is not yet approved for children in the United States, with concerns about malignancy risk due to promoting proliferation↗
▶Ep 30 · 45:13
clinicalGrowth factors shown to promote adaptation in animal studies include EGF, HB-EGF (demonstrated by Gail Bessner), interleukins, and growth hormone with glutamine↗
▶Ep 30 · 45:46
clinicalGrowth hormone and glutamine combinations in patients have shown primarily mixed results and are expensive↗
▶Ep 30 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50-60% at 5 years, with one-year survivals now above 70-80%↗
▶Ep 30 · 46:51
quoteRight now, the survival for small bowel transplant is about 50 to 60% at 5 years.↗
▶Ep 30 · 47:11
clinicalThe intestine is highly immunogenic, filled with white cells and macrophages that mount a huge graft-versus-host response, requiring industrial strength immunosuppression↗
▶Ep 30 · 49:22
clinicalEthanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters↗
▶Ep 30 · 50:33
quoteI think if they're doing well. Um, and they're not jaundiced, um, doing it for the sake of getting them off of TPN may be a bit premature if they're, if they're otherwise doing well↗
▶Ep 30 · 51:20
quoteThis is a team sport in taking care of these patients.↗
▶Ep 30 · 51:20
clinicalMultidisciplinary 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↗
clinicalIntestinal 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.↗
▶Ep 2 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation.↗
▶Ep 2 · 4:03
clinicalFor a neonate with an ileocecal valve and entire colon, 10 to 15 centimeters of small intestine is a ballpark figure for potential salvageability.↗
▶Ep 2 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15 to 20 centimeters of small intestine would be needed for potential salvageability in neonates.↗
▶Ep 2 · 4:51
epidemiologicalIn adult studies, adults with less than 50 centimeters of intestine have about 40% mortality after 5 to 10 years.↗
▶Ep 2 · 6:38
epidemiologicalAccording 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.↗
▶Ep 2 · 7:11
clinicalThe 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.↗
▶Ep 2 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection.↗
▶Ep 2 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should, you know, back off on your enteral feeding.↗
▶Ep 2 · 8:30
clinicalStool outputs of up to 40 cc per kilo per day are acceptable when advancing enteral feeding; beyond that threshold, enteral feeding should be reduced.↗
▶Ep 2 · 9:22
epidemiologicalThe 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.↗
▶Ep 2 · 10:22
clinicalFor 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.↗
▶Ep 2 · 10:45
clinicalTPN 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.↗
▶Ep 2 · 12:05
clinicalBabies should gain about 20 to 30 grams a day, which approximates in utero weight gain for a newborn.↗
▶Ep 2 · 12:53
clinicalLipid 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.↗
▶Ep 2 · 13:46
clinicalOmegaven 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.↗
▶Ep 2 · 15:08
clinicalSMOF 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.↗
▶Ep 2 · 18:11
quoteI think breast milk is, uh, uh, if you know, if you're in a newborn situation, is probably the very best because it not only contains what the baby needs in terms of the proper fat and all of that, but it's, it has other things in there that are really, um, I think from an investigative standpoint, very rich to explore.↗
▶Ep 2 · 18:11
opinionBreast 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.↗
▶Ep 2 · 19:26
opinionComplex formulas fed enterally may stimulate adaptation better than elemental formulas because they cause secretion of enterotrophic hormones to a greater extent.↗
▶Ep 2 · 20:56
clinicalThere 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.↗
clinicalSurgical 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.↗
▶Ep 2 · 23:47
quoteI think probably dilated bowel loops are one central theme here. That can be responsible not just for the sepsis episodes but for inability to tolerate enteral feeding.↗
▶Ep 2 · 25:43
clinicalDilated 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.↗
▶Ep 2 · 27:53
clinicalLess 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.↗
▶Ep 2 · 29:31
clinicalThe 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.↗
▶Ep 2 · 30:00
clinicalThe 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.↗
▶Ep 2 · 32:54
clinicalSTEP 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.↗
▶Ep 2 · 33:26
clinicalA 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).↗
▶Ep 2 · 33:26
quoteYou can do a Bianchi and then go back in and do another step on top of a Bianchi. You can't do a Bianchi once a step has been done.↗
▶Ep 2 · 38:21
clinicalTapering should be considered for children with dilated bowel who have at least 90 to 100 centimeters of intestinal length.↗
▶Ep 2 · 43:45
clinicalTeduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1 to 2 liters per week.↗
▶Ep 2 · 45:40
clinicalGrowth 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.↗
▶Ep 2 · 46:51
epidemiologicalCurrent survival for small bowel transplant is about 50 to 60% at 5 years, with one-year survivals now above 70 to 80%.↗
▶Ep 2 · 47:11
clinicalThe 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.↗
▶Ep 2 · 49:16
quoteI think you want to try to do everything you can to avoid transplantation.↗
▶Ep 2 · 49:22
clinicalEthanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters.↗
▶Ep 2 · 51:16
clinicalMultidisciplinary 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.↗
▶Ep 2 · 51:20
quoteThis is a team sport in taking care of these patients.↗
Intestinal Failure with Dr. Brad Warner
▶Ep 6 · 1:42
clinicalIntestinal 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↗
▶Ep 6 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 6 · 3:13
clinicalA 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↗
▶Ep 6 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10-15 cm of small intestine is a ballpark figure for potential viability↗
▶Ep 6 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15-20 cm of small intestine would be needed for potential viability in a neonate↗
▶Ep 6 · 4:51
epidemiologicalIn adult studies, patients with less than 50 cm of intestine have about 40% mortality after 5-10 years↗
▶Ep 6 · 6:38
epidemiologicalAccording 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↗
▶Ep 6 · 7:11
clinicalCommon 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↗
▶Ep 6 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection↗
▶Ep 6 · 8:19
clinicalThe 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↗
▶Ep 6 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should, you know, back off on your enteral feeding.↗
▶Ep 6 · 9:22
epidemiologicalThe most common reasons children develop short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias↗
▶Ep 6 · 10:22
clinicalFor TPN, target about 100-120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein↗
▶Ep 6 · 10:45
clinicalShoot for about 2-3 g of protein per kilo per day and about 2-3 g of fat per kilo per day in TPN↗
▶Ep 6 · 11:06
clinicalBegin enteral feeding as soon as feasible after resection and reanastomosis when they start stooling, generally starting with slow continuous drip↗
▶Ep 6 · 11:23
opinionWith continuous drip feeding, nutrient transporters are upregulated and ability to get more nutrition in may be advantageous↗
▶Ep 6 · 12:05
clinicalWant a baby to gain about 20-30 g a day, which approximates in utero progression for a newborn↗
▶Ep 6 · 12:53
clinicalLipid 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↗
▶Ep 6 · 14:03
clinicalOmegaven 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↗
▶Ep 6 · 14:38
clinicalWhen fish oil (omegaven) is introduced to children getting jaundiced, there has been demonstrated significant fall in their jaundice levels↗
▶Ep 6 · 15:08
clinicalSMOF 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↗
▶Ep 6 · 18:11
opinionBreast milk is the best choice for neonates because it contains proper fat, growth factors like EGF and IGF, and milk oligosaccharides that enhance adaptation↗
▶Ep 6 · 19:26
opinionComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 6 · 21:19
clinicalThere 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↗
clinicalTime 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↗
▶Ep 6 · 22:33
quoteMy time that I would be starting to think about doing lengthening procedures or intervening surgically would be is if you hit a point rally and now you start backing away.↗
▶Ep 6 · 23:28
clinicalDilated bowel loops can cause subclinical portal bacteremia contributing to jaundice, and bacterial overgrowth causes secretory diarrhea that impairs enzyme function↗
▶Ep 6 · 25:43
clinicalMore than 4-5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention↗
▶Ep 6 · 27:53
clinicalIf 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↗
▶Ep 6 · 28:37
clinicalFor bowel lengthening, need less than 100 cm (ideally less than 50 cm) of intestine and bowel that is at least 4-5 cm dilated↗
▶Ep 6 · 29:31
epidemiologicalThe STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation↗
▶Ep 6 · 30:00
clinicalThe 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↗
▶Ep 6 · 32:30
clinicalSTEP procedure is easier to perform with less risk of injuring mesenteric blood supply because you only cut partially across the bowel at right angles↗
▶Ep 6 · 32:54
clinicalSTEP can redilate requiring redo procedures, and outcomes are not as good if you have to redo a STEP compared to never needing a redo↗
▶Ep 6 · 33:26
clinicalYou 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↗
▶Ep 6 · 33:26
quoteYou can do a Bianchi and then go back in and do another step on top of a Bianchi. You can't do a Bianchi once a step has been done.↗
▶Ep 6 · 35:04
clinicalIn 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↗
▶Ep 6 · 35:21
quoteI really made it a point to say that I think it's the step that is acting as a brake, you know, and they ended up letting me take out the distal bowel.↗
▶Ep 6 · 35:40
quoteSo that makes me feel like steps are not as innocuous as as we think they are, and because of that, I, I don't know, I tend to lean a little bit more as a primary to do a Bianchi, and if I have to redo something, I might, I might do it as a step then↗
▶Ep 6 · 38:23
clinicalWould taper a child with dilated bowel who had at least 90-100 centimeters of intestinal length↗
▶Ep 6 · 39:00
clinicalStrategies for TPN cholestasis include bile salts (chenodeoxycholic acid), changing lipid composition, and increasing enteral feeds↗
▶Ep 6 · 39:23
clinicalDan Teitelbaum's trial of cholecystokinin to promote bile flow and mitigate TPN cholestasis did not work↗
▶Ep 6 · 39:51
clinicalDilated bowel is a nidus for infection encouraging translocation of bacteria and endotoxin into portal circulation, damaging the liver↗
▶Ep 6 · 40:26
clinicalMedical management of bacterial overgrowth includes oral antibiotics (Cipro, Flagyl), probiotics (lactobacilli), prebiotics, and potentially fecal transplantation↗
▶Ep 6 · 41:54
clinicalThe gut bacteria in short gut syndrome become more efficient, creating an obesogenic-like microbiome that helps adapt by encouraging greater absorption and digestion↗
▶Ep 6 · 42:19
clinicalIn mouse studies, oral vancomycin to knock out gram-positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 6 · 43:57
clinicalTeduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1-2 liters per week↗
▶Ep 6 · 44:34
clinicalTeduglutide is not yet approved for children in the United States, with concerns about malignancy risk due to promoting proliferation↗
▶Ep 6 · 45:13
clinicalGrowth factors shown to promote adaptation in animal studies include EGF, HB-EGF (demonstrated by Gail Bessner), interleukins, and growth hormone with glutamine↗
▶Ep 6 · 45:46
clinicalGrowth hormone and glutamine combinations in patients have shown primarily mixed results and are expensive↗
▶Ep 6 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50-60% at 5 years, with one-year survivals now above 70-80%↗
▶Ep 6 · 46:51
quoteRight now, the survival for small bowel transplant is about 50 to 60% at 5 years.↗
▶Ep 6 · 47:11
clinicalThe intestine is highly immunogenic, filled with white cells and macrophages that mount a huge graft-versus-host response, requiring industrial strength immunosuppression↗
▶Ep 6 · 49:22
clinicalEthanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters↗
▶Ep 6 · 50:33
quoteI think if they're doing well. Um, and they're not jaundiced, um, doing it for the sake of getting them off of TPN may be a bit premature if they're, if they're otherwise doing well↗
▶Ep 6 · 51:20
quoteThis is a team sport in taking care of these patients.↗
▶Ep 6 · 51:20
clinicalMultidisciplinary 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↗
clinicalIntestinal 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.↗
▶Ep 15 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation.↗
▶Ep 15 · 4:03
clinicalFor a neonate with an ileocecal valve and entire colon, 10 to 15 centimeters of small intestine is a ballpark figure for potential salvageability.↗
▶Ep 15 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15 to 20 centimeters of small intestine would be needed for potential salvageability in neonates.↗
▶Ep 15 · 4:51
epidemiologicalIn adult studies, adults with less than 50 centimeters of intestine have about 40% mortality after 5 to 10 years.↗
▶Ep 15 · 6:38
epidemiologicalAccording 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.↗
▶Ep 15 · 7:11
clinicalThe 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.↗
▶Ep 15 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection.↗
▶Ep 15 · 8:30
clinicalStool outputs of up to 40 cc per kilo per day are acceptable when advancing enteral feeding; beyond that threshold, enteral feeding should be reduced.↗
▶Ep 15 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should, you know, back off on your enteral feeding.↗
▶Ep 15 · 9:22
epidemiologicalThe 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.↗
▶Ep 15 · 10:22
clinicalFor 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.↗
▶Ep 15 · 10:45
clinicalTPN 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.↗
▶Ep 15 · 12:05
clinicalBabies should gain about 20 to 30 grams a day, which approximates in utero weight gain for a newborn.↗
▶Ep 15 · 12:53
clinicalLipid 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.↗
▶Ep 15 · 13:46
clinicalOmegaven 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.↗
▶Ep 15 · 15:08
clinicalSMOF 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.↗
▶Ep 15 · 18:11
quoteI think breast milk is, uh, uh, if you know, if you're in a newborn situation, is probably the very best because it not only contains what the baby needs in terms of the proper fat and all of that, but it's, it has other things in there that are really, um, I think from an investigative standpoint, very rich to explore.↗
▶Ep 15 · 18:11
opinionBreast 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.↗
▶Ep 15 · 19:26
opinionComplex formulas fed enterally may stimulate adaptation better than elemental formulas because they cause secretion of enterotrophic hormones to a greater extent.↗
▶Ep 15 · 20:56
clinicalThere 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.↗
clinicalSurgical 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.↗
▶Ep 15 · 23:47
quoteI think probably dilated bowel loops are one central theme here. That can be responsible not just for the sepsis episodes but for inability to tolerate enteral feeding.↗
▶Ep 15 · 25:43
clinicalDilated 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.↗
▶Ep 15 · 27:53
clinicalLess 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.↗
▶Ep 15 · 29:31
clinicalThe 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.↗
▶Ep 15 · 30:00
clinicalThe 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.↗
▶Ep 15 · 32:54
clinicalSTEP 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.↗
▶Ep 15 · 33:26
clinicalA 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).↗
▶Ep 15 · 33:26
quoteYou can do a Bianchi and then go back in and do another step on top of a Bianchi. You can't do a Bianchi once a step has been done.↗
▶Ep 15 · 38:21
clinicalTapering should be considered for children with dilated bowel who have at least 90 to 100 centimeters of intestinal length.↗
▶Ep 15 · 43:45
clinicalTeduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1 to 2 liters per week.↗
▶Ep 15 · 45:40
clinicalGrowth 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.↗
▶Ep 15 · 46:51
epidemiologicalCurrent survival for small bowel transplant is about 50 to 60% at 5 years, with one-year survivals now above 70 to 80%.↗
▶Ep 15 · 47:11
clinicalThe 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.↗
▶Ep 15 · 49:16
quoteI think you want to try to do everything you can to avoid transplantation.↗
▶Ep 15 · 49:22
clinicalEthanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters.↗
▶Ep 15 · 51:16
clinicalMultidisciplinary 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.↗
▶Ep 15 · 51:20
quoteThis is a team sport in taking care of these patients.↗
Intestinal Failure with Dr. Brad Warner
▶Ep 34 · 1:42
clinicalIntestinal 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↗
▶Ep 34 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 34 · 3:13
clinicalA 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↗
▶Ep 34 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10-15 cm of small intestine is a ballpark figure for potential viability↗
▶Ep 34 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15-20 cm of small intestine would be needed for potential viability in a neonate↗
▶Ep 34 · 4:51
epidemiologicalIn adult studies, patients with less than 50 cm of intestine have about 40% mortality after 5-10 years↗
▶Ep 34 · 6:38
epidemiologicalAccording 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↗
▶Ep 34 · 7:11
clinicalCommon 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↗
▶Ep 34 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection↗
▶Ep 34 · 8:19
clinicalThe 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↗
▶Ep 34 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should, you know, back off on your enteral feeding.↗
▶Ep 34 · 9:22
epidemiologicalThe most common reasons children develop short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias↗
▶Ep 34 · 10:22
clinicalFor TPN, target about 100-120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein↗
▶Ep 34 · 10:45
clinicalShoot for about 2-3 g of protein per kilo per day and about 2-3 g of fat per kilo per day in TPN↗
▶Ep 34 · 11:06
clinicalBegin enteral feeding as soon as feasible after resection and reanastomosis when they start stooling, generally starting with slow continuous drip↗
▶Ep 34 · 11:23
opinionWith continuous drip feeding, nutrient transporters are upregulated and ability to get more nutrition in may be advantageous↗
▶Ep 34 · 12:05
clinicalWant a baby to gain about 20-30 g a day, which approximates in utero progression for a newborn↗
▶Ep 34 · 12:53
clinicalLipid 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↗
▶Ep 34 · 14:03
clinicalOmegaven 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↗
▶Ep 34 · 14:38
clinicalWhen fish oil (omegaven) is introduced to children getting jaundiced, there has been demonstrated significant fall in their jaundice levels↗
▶Ep 34 · 15:08
clinicalSMOF 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↗
▶Ep 34 · 18:11
opinionBreast milk is the best choice for neonates because it contains proper fat, growth factors like EGF and IGF, and milk oligosaccharides that enhance adaptation↗
▶Ep 34 · 19:26
opinionComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 34 · 21:19
clinicalThere 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↗
quoteMy time that I would be starting to think about doing lengthening procedures or intervening surgically would be is if you hit a point rally and now you start backing away.↗
▶Ep 34 · 22:33
clinicalTime 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↗
▶Ep 34 · 23:28
clinicalDilated bowel loops can cause subclinical portal bacteremia contributing to jaundice, and bacterial overgrowth causes secretory diarrhea that impairs enzyme function↗
▶Ep 34 · 25:43
clinicalMore than 4-5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention↗
▶Ep 34 · 27:53
clinicalIf 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↗
▶Ep 34 · 28:37
clinicalFor bowel lengthening, need less than 100 cm (ideally less than 50 cm) of intestine and bowel that is at least 4-5 cm dilated↗
▶Ep 34 · 29:31
epidemiologicalThe STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation↗
▶Ep 34 · 30:00
clinicalThe 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↗
▶Ep 34 · 32:30
clinicalSTEP procedure is easier to perform with less risk of injuring mesenteric blood supply because you only cut partially across the bowel at right angles↗
▶Ep 34 · 32:54
clinicalSTEP can redilate requiring redo procedures, and outcomes are not as good if you have to redo a STEP compared to never needing a redo↗
▶Ep 34 · 33:26
clinicalYou 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↗
▶Ep 34 · 33:26
quoteYou can do a Bianchi and then go back in and do another step on top of a Bianchi. You can't do a Bianchi once a step has been done.↗
▶Ep 34 · 35:04
clinicalIn 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↗
▶Ep 34 · 35:21
quoteI really made it a point to say that I think it's the step that is acting as a brake, you know, and they ended up letting me take out the distal bowel.↗
▶Ep 34 · 35:40
quoteSo that makes me feel like steps are not as innocuous as as we think they are, and because of that, I, I don't know, I tend to lean a little bit more as a primary to do a Bianchi, and if I have to redo something, I might, I might do it as a step then↗
▶Ep 34 · 38:23
clinicalWould taper a child with dilated bowel who had at least 90-100 centimeters of intestinal length↗
▶Ep 34 · 39:00
clinicalStrategies for TPN cholestasis include bile salts (chenodeoxycholic acid), changing lipid composition, and increasing enteral feeds↗
▶Ep 34 · 39:23
clinicalDan Teitelbaum's trial of cholecystokinin to promote bile flow and mitigate TPN cholestasis did not work↗
▶Ep 34 · 39:51
clinicalDilated bowel is a nidus for infection encouraging translocation of bacteria and endotoxin into portal circulation, damaging the liver↗
▶Ep 34 · 40:26
clinicalMedical management of bacterial overgrowth includes oral antibiotics (Cipro, Flagyl), probiotics (lactobacilli), prebiotics, and potentially fecal transplantation↗
▶Ep 34 · 41:54
clinicalThe gut bacteria in short gut syndrome become more efficient, creating an obesogenic-like microbiome that helps adapt by encouraging greater absorption and digestion↗
▶Ep 34 · 42:19
clinicalIn mouse studies, oral vancomycin to knock out gram-positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 34 · 43:57
clinicalTeduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1-2 liters per week↗
▶Ep 34 · 44:34
clinicalTeduglutide is not yet approved for children in the United States, with concerns about malignancy risk due to promoting proliferation↗
▶Ep 34 · 45:13
clinicalGrowth factors shown to promote adaptation in animal studies include EGF, HB-EGF (demonstrated by Gail Bessner), interleukins, and growth hormone with glutamine↗
▶Ep 34 · 45:46
clinicalGrowth hormone and glutamine combinations in patients have shown primarily mixed results and are expensive↗
▶Ep 34 · 46:51
quoteRight now, the survival for small bowel transplant is about 50 to 60% at 5 years.↗
▶Ep 34 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50-60% at 5 years, with one-year survivals now above 70-80%↗
▶Ep 34 · 47:11
clinicalThe intestine is highly immunogenic, filled with white cells and macrophages that mount a huge graft-versus-host response, requiring industrial strength immunosuppression↗
▶Ep 34 · 49:22
clinicalEthanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters↗
▶Ep 34 · 50:33
quoteI think if they're doing well. Um, and they're not jaundiced, um, doing it for the sake of getting them off of TPN may be a bit premature if they're, if they're otherwise doing well↗
▶Ep 34 · 51:20
quoteThis is a team sport in taking care of these patients.↗
▶Ep 34 · 51:20
clinicalMultidisciplinary 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↗
clinicalIntestinal 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↗
▶Ep 3 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 3 · 3:13
clinicalA 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↗
▶Ep 3 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10-15 cm of small intestine is a ballpark figure for potential viability↗
▶Ep 3 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15-20 cm of small intestine would be needed for potential viability in a neonate↗
▶Ep 3 · 4:51
epidemiologicalIn adult studies, patients with less than 50 cm of intestine have about 40% mortality after 5-10 years↗
▶Ep 3 · 6:38
epidemiologicalAccording 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↗
▶Ep 3 · 7:11
clinicalCommon 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↗
▶Ep 3 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection↗
▶Ep 3 · 8:19
clinicalThe 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↗
▶Ep 3 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should, you know, back off on your enteral feeding.↗
▶Ep 3 · 9:22
epidemiologicalThe most common reasons children develop short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias↗
▶Ep 3 · 10:22
clinicalFor TPN, target about 100-120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein↗
▶Ep 3 · 10:45
clinicalShoot for about 2-3 g of protein per kilo per day and about 2-3 g of fat per kilo per day in TPN↗
▶Ep 3 · 11:06
clinicalBegin enteral feeding as soon as feasible after resection and reanastomosis when they start stooling, generally starting with slow continuous drip↗
▶Ep 3 · 11:23
opinionWith continuous drip feeding, nutrient transporters are upregulated and ability to get more nutrition in may be advantageous↗
▶Ep 3 · 12:05
clinicalWant a baby to gain about 20-30 g a day, which approximates in utero progression for a newborn↗
▶Ep 3 · 12:53
clinicalLipid 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↗
▶Ep 3 · 14:03
clinicalOmegaven 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↗
▶Ep 3 · 14:38
clinicalWhen fish oil (omegaven) is introduced to children getting jaundiced, there has been demonstrated significant fall in their jaundice levels↗
▶Ep 3 · 15:08
clinicalSMOF 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↗
▶Ep 3 · 18:11
opinionBreast milk is the best choice for neonates because it contains proper fat, growth factors like EGF and IGF, and milk oligosaccharides that enhance adaptation↗
▶Ep 3 · 19:26
opinionComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 3 · 21:19
clinicalThere 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↗
quoteMy time that I would be starting to think about doing lengthening procedures or intervening surgically would be is if you hit a point rally and now you start backing away.↗
▶Ep 3 · 22:33
clinicalTime 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↗
▶Ep 3 · 23:28
clinicalDilated bowel loops can cause subclinical portal bacteremia contributing to jaundice, and bacterial overgrowth causes secretory diarrhea that impairs enzyme function↗
▶Ep 3 · 25:43
clinicalMore than 4-5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention↗
▶Ep 3 · 27:53
clinicalIf 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↗
▶Ep 3 · 28:37
clinicalFor bowel lengthening, need less than 100 cm (ideally less than 50 cm) of intestine and bowel that is at least 4-5 cm dilated↗
▶Ep 3 · 29:31
epidemiologicalThe STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation↗
▶Ep 3 · 30:00
clinicalThe 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↗
▶Ep 3 · 32:30
clinicalSTEP procedure is easier to perform with less risk of injuring mesenteric blood supply because you only cut partially across the bowel at right angles↗
▶Ep 3 · 32:54
clinicalSTEP can redilate requiring redo procedures, and outcomes are not as good if you have to redo a STEP compared to never needing a redo↗
▶Ep 3 · 33:26
clinicalYou 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↗
▶Ep 3 · 33:26
quoteYou can do a Bianchi and then go back in and do another step on top of a Bianchi. You can't do a Bianchi once a step has been done.↗
▶Ep 3 · 35:04
clinicalIn 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↗
▶Ep 3 · 35:21
quoteI really made it a point to say that I think it's the step that is acting as a brake, you know, and they ended up letting me take out the distal bowel.↗
▶Ep 3 · 35:40
quoteSo that makes me feel like steps are not as innocuous as as we think they are, and because of that, I, I don't know, I tend to lean a little bit more as a primary to do a Bianchi, and if I have to redo something, I might, I might do it as a step then↗
▶Ep 3 · 38:23
clinicalWould taper a child with dilated bowel who had at least 90-100 centimeters of intestinal length↗
▶Ep 3 · 39:00
clinicalStrategies for TPN cholestasis include bile salts (chenodeoxycholic acid), changing lipid composition, and increasing enteral feeds↗
▶Ep 3 · 39:23
clinicalDan Teitelbaum's trial of cholecystokinin to promote bile flow and mitigate TPN cholestasis did not work↗
▶Ep 3 · 39:51
clinicalDilated bowel is a nidus for infection encouraging translocation of bacteria and endotoxin into portal circulation, damaging the liver↗
▶Ep 3 · 40:26
clinicalMedical management of bacterial overgrowth includes oral antibiotics (Cipro, Flagyl), probiotics (lactobacilli), prebiotics, and potentially fecal transplantation↗
▶Ep 3 · 41:54
clinicalThe gut bacteria in short gut syndrome become more efficient, creating an obesogenic-like microbiome that helps adapt by encouraging greater absorption and digestion↗
▶Ep 3 · 42:19
clinicalIn mouse studies, oral vancomycin to knock out gram-positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 3 · 43:57
clinicalTeduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1-2 liters per week↗
▶Ep 3 · 44:34
clinicalTeduglutide is not yet approved for children in the United States, with concerns about malignancy risk due to promoting proliferation↗
▶Ep 3 · 45:13
clinicalGrowth factors shown to promote adaptation in animal studies include EGF, HB-EGF (demonstrated by Gail Bessner), interleukins, and growth hormone with glutamine↗
▶Ep 3 · 45:46
clinicalGrowth hormone and glutamine combinations in patients have shown primarily mixed results and are expensive↗
▶Ep 3 · 46:51
quoteRight now, the survival for small bowel transplant is about 50 to 60% at 5 years.↗
▶Ep 3 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50-60% at 5 years, with one-year survivals now above 70-80%↗
▶Ep 3 · 47:11
clinicalThe intestine is highly immunogenic, filled with white cells and macrophages that mount a huge graft-versus-host response, requiring industrial strength immunosuppression↗
▶Ep 3 · 49:22
clinicalEthanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters↗
▶Ep 3 · 50:33
quoteI think if they're doing well. Um, and they're not jaundiced, um, doing it for the sake of getting them off of TPN may be a bit premature if they're, if they're otherwise doing well↗
▶Ep 3 · 51:20
clinicalMultidisciplinary 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↗
▶Ep 3 · 51:20
quoteThis is a team sport in taking care of these patients.↗
Journal of Pediatric Article Review: June 2023, AAP Issue
▶Ep 10 · 2:22
quoteIn looking for mechanisms as to how this occurs, we sought to determine whether bile acids or the site of intestinal resection would really make a difference in terms of the liver injury.↗
▶Ep 10 · 2:22
quoteIn looking for mechanisms as to how this occurs, we sought to determine whether bile acids or the site of intestinal resection would really make a difference in terms of the liver injury.↗
▶Ep 10 · 3:28
clinicalThe ileocecal region may not be important to preserve in short bowel syndrome and may actually be injurious↗
▶Ep 10 · 3:28
quoteTwo takeaways here, one of which is the ileocecal region. May not be important to preserve and may actually be injurious. And the second point is that administration of a specific bile acid that is more um uh lipophilic and, uh, and more hepatic, uh, I guess, uh, protective could be potential therapy for patients that have cholestatic liver disease after a massive intestinal resection.↗
▶Ep 10 · 3:28
quoteTwo takeaways here, one of which is the ileocecal region. May not be important to preserve and may actually be injurious. And the second point is that administration of a specific bile acid that is more um uh lipophilic and, uh, and more hepatic, uh, I guess, uh, protective could be potential therapy for patients that have cholestatic liver disease after a massive intestinal resection.↗
▶Ep 10 · 3:28
clinicalThe ileocecal region may not be important to preserve in short bowel syndrome and may actually be injurious↗
▶Ep 10 · 3:37
clinicalAdministration of a specific bile acid that is more lipophilic and hepatoprotective could be potential therapy for patients with cholestatic liver disease after massive intestinal resection↗
▶Ep 10 · 3:37
clinicalAdministration of a specific bile acid that is more lipophilic and hepatoprotective could be potential therapy for patients with cholestatic liver disease after massive intestinal resection↗
▶Ep 10 · 4:13
clinicalIn clinical practice, surgeons cannot choose which intestinal segment to remove - they must remove what is dead and preserve as much viable bowel as possible↗
▶Ep 10 · 4:13
clinicalIn clinical practice, surgeons cannot choose which intestinal segment to remove - they must remove what is dead and preserve as much viable bowel as possible↗
▶Ep 10 · 4:16
quoteYou can't choose that. You have to remove what's dead, and you intentionally would never remove anything that wasn't. You want to preserve as much↗
▶Ep 10 · 4:16
quoteYou can't choose that. You have to remove what's dead, and you intentionally would never remove anything that wasn't. You want to preserve as much↗
clinicalIntestinal 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↗
▶Ep 1 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 1 · 3:13
clinicalA 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↗
▶Ep 1 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10-15 cm of small intestine is a ballpark figure for potential viability↗
▶Ep 1 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15-20 cm of small intestine would be needed for potential viability in a neonate↗
▶Ep 1 · 4:51
epidemiologicalIn adult studies, patients with less than 50 cm of intestine have about 40% mortality after 5-10 years↗
▶Ep 1 · 6:38
epidemiologicalAccording 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↗
▶Ep 1 · 7:11
clinicalCommon 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↗
▶Ep 1 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection↗
▶Ep 1 · 8:19
clinicalThe 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↗
▶Ep 1 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should, you know, back off on your enteral feeding.↗
▶Ep 1 · 9:22
epidemiologicalThe most common reasons children develop short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias↗
▶Ep 1 · 10:22
clinicalFor TPN, target about 100-120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein↗
▶Ep 1 · 10:45
clinicalShoot for about 2-3 g of protein per kilo per day and about 2-3 g of fat per kilo per day in TPN↗
▶Ep 1 · 11:06
clinicalBegin enteral feeding as soon as feasible after resection and reanastomosis when they start stooling, generally starting with slow continuous drip↗
▶Ep 1 · 11:23
opinionWith continuous drip feeding, nutrient transporters are upregulated and ability to get more nutrition in may be advantageous↗
▶Ep 1 · 12:05
clinicalWant a baby to gain about 20-30 g a day, which approximates in utero progression for a newborn↗
▶Ep 1 · 12:53
clinicalLipid 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↗
▶Ep 1 · 14:03
clinicalOmegaven 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↗
▶Ep 1 · 14:38
clinicalWhen fish oil (omegaven) is introduced to children getting jaundiced, there has been demonstrated significant fall in their jaundice levels↗
▶Ep 1 · 15:08
clinicalSMOF 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↗
▶Ep 1 · 18:11
opinionBreast milk is the best choice for neonates because it contains proper fat, growth factors like EGF and IGF, and milk oligosaccharides that enhance adaptation↗
▶Ep 1 · 19:26
opinionComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 1 · 21:19
clinicalThere 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↗
clinicalTime 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↗
▶Ep 1 · 22:33
quoteMy time that I would be starting to think about doing lengthening procedures or intervening surgically would be is if you hit a point rally and now you start backing away.↗
▶Ep 1 · 23:28
clinicalDilated bowel loops can cause subclinical portal bacteremia contributing to jaundice, and bacterial overgrowth causes secretory diarrhea that impairs enzyme function↗
▶Ep 1 · 25:43
clinicalMore than 4-5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention↗
▶Ep 1 · 27:53
clinicalIf 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↗
▶Ep 1 · 28:37
clinicalFor bowel lengthening, need less than 100 cm (ideally less than 50 cm) of intestine and bowel that is at least 4-5 cm dilated↗
▶Ep 1 · 29:31
epidemiologicalThe STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation↗
▶Ep 1 · 30:00
clinicalThe 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↗
▶Ep 1 · 32:30
clinicalSTEP procedure is easier to perform with less risk of injuring mesenteric blood supply because you only cut partially across the bowel at right angles↗
▶Ep 1 · 32:54
clinicalSTEP can redilate requiring redo procedures, and outcomes are not as good if you have to redo a STEP compared to never needing a redo↗
▶Ep 1 · 33:26
quoteYou can do a Bianchi and then go back in and do another step on top of a Bianchi. You can't do a Bianchi once a step has been done.↗
▶Ep 1 · 33:26
clinicalYou 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↗
▶Ep 1 · 35:04
clinicalIn 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↗
▶Ep 1 · 35:21
quoteI really made it a point to say that I think it's the step that is acting as a brake, you know, and they ended up letting me take out the distal bowel.↗
▶Ep 1 · 35:40
quoteSo that makes me feel like steps are not as innocuous as as we think they are, and because of that, I, I don't know, I tend to lean a little bit more as a primary to do a Bianchi, and if I have to redo something, I might, I might do it as a step then↗
▶Ep 1 · 38:23
clinicalWould taper a child with dilated bowel who had at least 90-100 centimeters of intestinal length↗
▶Ep 1 · 39:00
clinicalStrategies for TPN cholestasis include bile salts (chenodeoxycholic acid), changing lipid composition, and increasing enteral feeds↗
▶Ep 1 · 39:23
clinicalDan Teitelbaum's trial of cholecystokinin to promote bile flow and mitigate TPN cholestasis did not work↗
▶Ep 1 · 39:51
clinicalDilated bowel is a nidus for infection encouraging translocation of bacteria and endotoxin into portal circulation, damaging the liver↗
▶Ep 1 · 40:26
clinicalMedical management of bacterial overgrowth includes oral antibiotics (Cipro, Flagyl), probiotics (lactobacilli), prebiotics, and potentially fecal transplantation↗
▶Ep 1 · 41:54
clinicalThe gut bacteria in short gut syndrome become more efficient, creating an obesogenic-like microbiome that helps adapt by encouraging greater absorption and digestion↗
▶Ep 1 · 42:19
clinicalIn mouse studies, oral vancomycin to knock out gram-positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 1 · 43:57
clinicalTeduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1-2 liters per week↗
▶Ep 1 · 44:34
clinicalTeduglutide is not yet approved for children in the United States, with concerns about malignancy risk due to promoting proliferation↗
▶Ep 1 · 45:13
clinicalGrowth factors shown to promote adaptation in animal studies include EGF, HB-EGF (demonstrated by Gail Bessner), interleukins, and growth hormone with glutamine↗
▶Ep 1 · 45:46
clinicalGrowth hormone and glutamine combinations in patients have shown primarily mixed results and are expensive↗
▶Ep 1 · 46:51
quoteRight now, the survival for small bowel transplant is about 50 to 60% at 5 years.↗
▶Ep 1 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50-60% at 5 years, with one-year survivals now above 70-80%↗
▶Ep 1 · 47:11
clinicalThe intestine is highly immunogenic, filled with white cells and macrophages that mount a huge graft-versus-host response, requiring industrial strength immunosuppression↗
▶Ep 1 · 49:22
clinicalEthanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters↗
▶Ep 1 · 50:33
quoteI think if they're doing well. Um, and they're not jaundiced, um, doing it for the sake of getting them off of TPN may be a bit premature if they're, if they're otherwise doing well↗
▶Ep 1 · 51:20
clinicalMultidisciplinary 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↗
▶Ep 1 · 51:20
quoteThis is a team sport in taking care of these patients.↗
clinicalIntestinal 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↗
▶Ep 1 · 3:03
clinicalThe intestine of a newborn or fetus doubles in length in the last trimester of gestation↗
▶Ep 1 · 3:13
clinicalA 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↗
▶Ep 1 · 4:03
clinicalFor a neonate with ileocecal valve and entire colon, 10-15 cm of small intestine is a ballpark figure for potential viability↗
▶Ep 1 · 4:37
clinicalWithout the colon and ileocecal valve, at least 15-20 cm of small intestine would be needed for potential viability in a neonate↗
▶Ep 1 · 4:51
epidemiologicalIn adult studies, patients with less than 50 cm of intestine have about 40% mortality after 5-10 years↗
▶Ep 1 · 6:38
epidemiologicalAccording 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↗
▶Ep 1 · 7:11
clinicalCommon 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↗
▶Ep 1 · 7:49
clinicalIntestinal adaptation in humans probably takes place over about a year or two after small bowel resection↗
▶Ep 1 · 8:19
clinicalThe 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↗
▶Ep 1 · 8:30
quoteI would accept stool outputs of up to 40 ccs per kilo per day. That's when I would say you're hitting the limits by which you should, you know, back off on your enteral feeding.↗
▶Ep 1 · 9:22
epidemiologicalThe most common reasons children develop short gut syndrome are necrotizing enterocolitis, gastroschisis, midgut volvulus, and atresias↗
▶Ep 1 · 10:22
clinicalFor TPN, target about 100-120 calories per kilo per day for total calories, with about 50% from glucose and remainder from fat and protein↗
▶Ep 1 · 10:45
clinicalShoot for about 2-3 g of protein per kilo per day and about 2-3 g of fat per kilo per day in TPN↗
▶Ep 1 · 11:06
clinicalBegin enteral feeding as soon as feasible after resection and reanastomosis when they start stooling, generally starting with slow continuous drip↗
▶Ep 1 · 11:23
opinionWith continuous drip feeding, nutrient transporters are upregulated and ability to get more nutrition in may be advantageous↗
▶Ep 1 · 12:05
clinicalWant a baby to gain about 20-30 g a day, which approximates in utero progression for a newborn↗
▶Ep 1 · 12:53
clinicalLipid 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↗
▶Ep 1 · 14:03
clinicalOmegaven 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↗
▶Ep 1 · 14:38
clinicalWhen fish oil (omegaven) is introduced to children getting jaundiced, there has been demonstrated significant fall in their jaundice levels↗
▶Ep 1 · 15:08
clinicalSMOF 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↗
▶Ep 1 · 18:11
opinionBreast milk is the best choice for neonates because it contains proper fat, growth factors like EGF and IGF, and milk oligosaccharides that enhance adaptation↗
▶Ep 1 · 19:26
opinionComplex formulas fed enterally may stimulate adaptation better than elemental formulas by causing secretion of enterotrophic hormones to a greater extent↗
▶Ep 1 · 21:19
clinicalThere 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↗
quoteMy time that I would be starting to think about doing lengthening procedures or intervening surgically would be is if you hit a point rally and now you start backing away.↗
▶Ep 1 · 22:33
clinicalTime 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↗
▶Ep 1 · 23:28
clinicalDilated bowel loops can cause subclinical portal bacteremia contributing to jaundice, and bacterial overgrowth causes secretory diarrhea that impairs enzyme function↗
▶Ep 1 · 25:43
clinicalMore than 4-5 centimeters of bowel dilation with failure to advance enteral feeds or going backward is an indication for surgical intervention↗
▶Ep 1 · 27:53
clinicalIf 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↗
▶Ep 1 · 28:37
clinicalFor bowel lengthening, need less than 100 cm (ideally less than 50 cm) of intestine and bowel that is at least 4-5 cm dilated↗
▶Ep 1 · 29:31
epidemiologicalThe STEP (serial transverse enteroplasty) procedure has emerged as the most commonly performed lengthening operation↗
▶Ep 1 · 30:00
clinicalThe 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↗
▶Ep 1 · 32:30
clinicalSTEP procedure is easier to perform with less risk of injuring mesenteric blood supply because you only cut partially across the bowel at right angles↗
▶Ep 1 · 32:54
clinicalSTEP can redilate requiring redo procedures, and outcomes are not as good if you have to redo a STEP compared to never needing a redo↗
▶Ep 1 · 33:26
clinicalYou 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↗
▶Ep 1 · 33:26
quoteYou can do a Bianchi and then go back in and do another step on top of a Bianchi. You can't do a Bianchi once a step has been done.↗
▶Ep 1 · 35:04
clinicalIn 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↗
▶Ep 1 · 35:21
quoteI really made it a point to say that I think it's the step that is acting as a brake, you know, and they ended up letting me take out the distal bowel.↗
▶Ep 1 · 35:40
quoteSo that makes me feel like steps are not as innocuous as as we think they are, and because of that, I, I don't know, I tend to lean a little bit more as a primary to do a Bianchi, and if I have to redo something, I might, I might do it as a step then↗
▶Ep 1 · 38:23
clinicalWould taper a child with dilated bowel who had at least 90-100 centimeters of intestinal length↗
▶Ep 1 · 39:00
clinicalStrategies for TPN cholestasis include bile salts (chenodeoxycholic acid), changing lipid composition, and increasing enteral feeds↗
▶Ep 1 · 39:23
clinicalDan Teitelbaum's trial of cholecystokinin to promote bile flow and mitigate TPN cholestasis did not work↗
▶Ep 1 · 39:51
clinicalDilated bowel is a nidus for infection encouraging translocation of bacteria and endotoxin into portal circulation, damaging the liver↗
▶Ep 1 · 40:26
clinicalMedical management of bacterial overgrowth includes oral antibiotics (Cipro, Flagyl), probiotics (lactobacilli), prebiotics, and potentially fecal transplantation↗
▶Ep 1 · 41:54
clinicalThe gut bacteria in short gut syndrome become more efficient, creating an obesogenic-like microbiome that helps adapt by encouraging greater absorption and digestion↗
▶Ep 1 · 42:19
clinicalIn mouse studies, oral vancomycin to knock out gram-positive organisms completely prevented hepatic steatosis after bowel resection↗
▶Ep 1 · 43:57
clinicalTeduglutide (GLP-2 analog) has been shown in randomized prospective trials in adults to reduce TPN requirements by about 1-2 liters per week↗
▶Ep 1 · 44:34
clinicalTeduglutide is not yet approved for children in the United States, with concerns about malignancy risk due to promoting proliferation↗
▶Ep 1 · 45:13
clinicalGrowth factors shown to promote adaptation in animal studies include EGF, HB-EGF (demonstrated by Gail Bessner), interleukins, and growth hormone with glutamine↗
▶Ep 1 · 45:46
clinicalGrowth hormone and glutamine combinations in patients have shown primarily mixed results and are expensive↗
▶Ep 1 · 46:51
epidemiologicalSurvival for small bowel transplant is about 50-60% at 5 years, with one-year survivals now above 70-80%↗
▶Ep 1 · 46:51
quoteRight now, the survival for small bowel transplant is about 50 to 60% at 5 years.↗
▶Ep 1 · 47:11
clinicalThe intestine is highly immunogenic, filled with white cells and macrophages that mount a huge graft-versus-host response, requiring industrial strength immunosuppression↗
▶Ep 1 · 49:22
clinicalEthanol locks for central lines have significantly reduced the number of sepsis episodes in patients with short gut syndrome who have Broviac catheters↗
▶Ep 1 · 50:33
quoteI think if they're doing well. Um, and they're not jaundiced, um, doing it for the sake of getting them off of TPN may be a bit premature if they're, if they're otherwise doing well↗
▶Ep 1 · 51:20
quoteThis is a team sport in taking care of these patients.↗
▶Ep 1 · 51:20
clinicalMultidisciplinary 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↗
