Michael Helmrath
1052 statements · 12 topics
Abdominal Wall Defects
· guest expert
Colorectal / ARM & Hirschsprung
· guest expert
Etiologies (Gastroschisis/NEC/Atresia/Volvulus)
· guest expert
Intestinal Failure
· guest expert
Intestinal Rehab
· guest expert
Motility / Pseudo-obstruction
· guest expert
Short Bowel Syndrome
· guest expert
Featured statements
The strategy that I've used that I think works very well, is that you, you're not committing the child to a lifelong G tube or even for the first year. If you just place a feeding tube into the. Stomach and stand the stomach up. It's no different than another tube in a kit and especially as I said before, I often direct it out of the pylorus into the proximal small bowel and so it's a source of feeding that allows you to overcome some obstacles that you can never always predict. And, and when these children do well, you just take it out and it's like any other hole that just heals in these kids.
quote ·
Intestinal Failure
In a baby, uh, the, the best way to get distal feeding is either through an NJ tube, um, with the G tube just decompressing the stomach, so that the baby is allowed to be fed outside the stomach while decompressing the stomach at the same time. And that what ends up happening is that the seeing that you do stimulates the distal small bowel and the colon to produce hormones that largely will tell the stomach to start functioning, and you'll actually break the the cycle.
quote ·
Intestinal Failure
Yeah, remember that especially if there's been damaged bowel, it's gonna be in a secretory phase, even if it's not fed, and people are scared then to feed. And feeling like it's gonna be totally uncontrollable, whereas what happens is the exact opposite, as you start to feed the bowel, then gets in an absorptive state, because the nutrition that's present in the luminal stimulate it to do so, and you'll actually start to see less volume out the stoma in time.
quote ·
Intestinal Rehab
By far the most complicated part of our GI tract is the stomach, because it does both the back and forth, uh, sloshing around that the small bowel does, but in addition, it has to coordinate a squeeze with the relaxation of the pylorus several. Times a minute to induce small amounts of gastric emptying, and so it's not uncommon that when children haven't been fed and they've had an injury, the coordination of the stomach is completely off.
quote ·
Intestinal Rehab
There is definitely an algorithm of children that have overwhelming sepsis, and surgery cannot salvage these patients. We don't have a life saving option for those patients, but many will actually rally without having their bowel removed, which allows them to have an opportunity which many don't understand yet today.
I think some patients actually can come off a TPN but still need a central line for IV fluids, and that in the absence of IV fluids, really, they end up sleeping most of the days, they don't have a lot of energy.
quote ·
Midgut Volvulus
Nothing matches these filters — clear the search or widen the filters.
Michael's statements about Abdominal Wall Defects 22 statements
Open the Abdominal Wall Defects collection →
Intestinal rehabilitation: What is intestinal rehab? - Episode 1
Statement
Earlier recognition and taking advantage of the gut's biology to adapt are time dependent.
Open
Statement
Intestinal rehabilitation depends on nutrition in the gut, nutrition in the body, and healing.
Open
Quotation
What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing.
Open
Statement
Pattern recognition from multiple experienced clinicians observing patients over time is essential in intestinal rehabilitation.
Open
Quotation
So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time.
Open
Statement
Three time points exist for diagnosis and referral to intestinal rehab: prenatal diagnosis (atresia with cystic fibrosis, gastroschisis), postnatal acquired problems (volvulus, NEC), and later presentations after discharge when patients fail to progress.
Open
Statement
Innovation in intestinal rehabilitation comes from multiple approaches to problems and different visions, with more expertise leading to better outcomes.
Open
Statement
Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being adequately addressed.
Open
Statement
The intestinal rehabilitation team includes dietitians (for nutritional needs), social workers, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology.
Open
Quotation
I think the big key to a person watching the podcast is that they get hope. These are wonderful children. They're, they're opportunities to grow up and to live the lives that their families want is really in front of them.
Open
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?
Statement
Earlier recognition and taking advantage of the gut's adaptive biology are time dependent.
Open
Quotation
And so earlier recognition and and taking advantage of the biology of the gut that wants to accommodate, we call it adapt um and meet the needs of the child um are time dependent.
Open
Quotation
What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing.
Open
Statement
Intestinal rehabilitation depends on key factors: nutrition in the gut, nutrition in the body, and healing.
Open
Quotation
So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time.
Open
Statement
Pattern recognition from multiple expert eyes observing a patient over time is essential in intestinal rehabilitation.
Open
Statement
Families reach intestinal rehabilitation programs at three time points: prenatal diagnosis (typically atresia with cystic fibrosis or gastroschisis), postnatal acquired problems (volvulus or NEC), and later diagnosis after discharge when patients fail to progress.
Open
Statement
Innovation comes from multiple approaches to a problem and different visions; bringing in more expertise leads to better outcomes.
Open
Statement
Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being met.
Open
Statement
The intestinal rehabilitation team includes dietitians (understanding nutritional needs), social work, nurse practitioners, pharmacy, interventional radiology, pathology, and subspecialties including endocrinology and nephrology.
Open
Michael's statements about Cholestasis 23 statements
Open the Cholestasis collection →
Intestinal Rehabilitation, Episode 6: Cholestasis
Statement
As treatment has improved with different lipid emulsions and nutrition approaches, cholestasis has become more an indicator of underlying diseases to address rather than a primary morbidity/mortality factor.
Open
Quotation
I believe though that as we've gotten better and we've learned how to use lipid emulgens differently and nutrition differently and our approaches. That the definition of cholestasis is not as much as a morbidity mortality as much as it is an indicator of underlying diseases that we need to address.
Open
Statement
New lipid emulsions including Omegaven (used first in the US) and SMOF (used in Europe and Canada, now prevalent in the US for 3-4 years) can reverse or prevent cholestasis.
Open
Quotation
One of the major advantages I think of the addition of SMP is the ability to provide more calories from fat, as much as 2 2.5 g per kilo. I think that people need to recognize that the management of These kids is healthy growth.
Open
Statement
A major advantage of SMOF is the ability to provide more calories from fat (as much as 2-2.5 g/kg) while supporting healthy growth.
Open
Statement
When refeeding a cholestatic liver after proximal jejunostomy takedown, direct bilirubin typically rises in the first week as bile acid pool is reintroduced and the liver becomes more active in bile salt production.
Open
Quotation
One of the first things that you'll get your neonatologist telling you about when you start feeding is they'll get worried because the direct bilirubin goes up. That's normal.
Open
Statement
GGT, AST, and ALT will go up in the first week or two after anastomosis takedown surgery, then slowly come down over several weeks.
Open
Statement
When direct bilirubin rises after refeeding, the main differential to rule out is urinary tract infection or gram-negative infection; extensive imaging such as ultrasounds is not needed.
Open
Statement
It is important to provide proximal drainage of the duodenum in high-risk intestinal failure patients; Dr. Helmrath places a lake drain for this purpose.
Open
Statement
Ongoing cholestasis with proximal blockage puts pressure in the biliary system at a much higher level and speeds up the cholestatic process.
Open
Intestinal Rehabilitation Webinar 2023 - Top 5 Key Takeaways
Statement
The more important factor than the ileocecal valve is the presence or absence of the distal small bowel (ileum) and right colon that can act as a site for bile reclamation and enterohepatic circulation.
Open
Quotation
So, to me, I believe the more important fact is the presence or absence of the distal small bowel or the ileum and even right colon that can act as a reclamation of bile and get the inneroppatic circulation.
Open
Statement
The surgical strategy at the first operation should provide a pathway forward that allows early interval feeding.
Open
Quotation
I think sometimes strategy at the first operation is to be able to provide a pathway forward that allows early interval feeding.
Open
Statement
It is sometimes better to stage reconstruction with the plan to restore bowel continuity under more controlled conditions.
Open
Statement
In situations of overwhelming intestinal loss, the strategy is to provide proximal control that allows feeding to occur without the enteral stream going through, and to leave questionable bowel segments that have potential to heal and can make a huge difference in the child's lifetime.
Open
Statement
Starting at the single amino acid level for protein is the generalized preference, ensuring patients are not having high stool output, high fluid losses, wound breakdown, rashes, or emesis.
Open
Michael's statements about Colorectal / ARM & Hirschsprung 22 statements
Open the Colorectal / ARM & Hirschsprung collection →
Intestinal rehabilitation: What is intestinal rehab? - Episode 1
Statement
Earlier recognition and taking advantage of the gut's biology to adapt are time dependent.
Open
Quotation
What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing.
Open
Statement
Intestinal rehabilitation depends on nutrition in the gut, nutrition in the body, and healing.
Open
Statement
Pattern recognition from multiple experienced clinicians observing patients over time is essential in intestinal rehabilitation.
Open
Quotation
So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time.
Open
Statement
Three time points exist for diagnosis and referral to intestinal rehab: prenatal diagnosis (atresia with cystic fibrosis, gastroschisis), postnatal acquired problems (volvulus, NEC), and later presentations after discharge when patients fail to progress.
Open
Statement
Innovation in intestinal rehabilitation comes from multiple approaches to problems and different visions, with more expertise leading to better outcomes.
Open
Statement
Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being adequately addressed.
Open
Statement
The intestinal rehabilitation team includes dietitians (for nutritional needs), social workers, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology.
Open
Quotation
I think the big key to a person watching the podcast is that they get hope. These are wonderful children. They're, they're opportunities to grow up and to live the lives that their families want is really in front of them.
Open
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?
Statement
Earlier recognition and taking advantage of the gut's adaptive biology are time dependent.
Open
Quotation
And so earlier recognition and and taking advantage of the biology of the gut that wants to accommodate, we call it adapt um and meet the needs of the child um are time dependent.
Open
Quotation
What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing.
Open
Statement
Intestinal rehabilitation depends on key factors: nutrition in the gut, nutrition in the body, and healing.
Open
Statement
Pattern recognition from multiple expert eyes observing a patient over time is essential in intestinal rehabilitation.
Open
Quotation
So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time.
Open
Statement
Families reach intestinal rehabilitation programs at three time points: prenatal diagnosis (typically atresia with cystic fibrosis or gastroschisis), postnatal acquired problems (volvulus or NEC), and later diagnosis after discharge when patients fail to progress.
Open
Statement
Innovation comes from multiple approaches to a problem and different visions; bringing in more expertise leads to better outcomes.
Open
Statement
Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being met.
Open
Statement
The intestinal rehabilitation team includes dietitians (understanding nutritional needs), social work, nurse practitioners, pharmacy, interventional radiology, pathology, and subspecialties including endocrinology and nephrology.
Open
Michael's statements about Crohn's Disease 22 statements
Open the Crohn's Disease collection →
Intestinal rehabilitation: What is intestinal rehab? - Episode 1
Statement
Earlier recognition and taking advantage of the gut's biology to adapt are time dependent.
Open
Quotation
What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing.
Open
Statement
Intestinal rehabilitation depends on nutrition in the gut, nutrition in the body, and healing.
Open
Statement
Pattern recognition from multiple experienced clinicians observing patients over time is essential in intestinal rehabilitation.
Open
Quotation
So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time.
Open
Statement
Three time points exist for diagnosis and referral to intestinal rehab: prenatal diagnosis (atresia with cystic fibrosis, gastroschisis), postnatal acquired problems (volvulus, NEC), and later presentations after discharge when patients fail to progress.
Open
Statement
Innovation in intestinal rehabilitation comes from multiple approaches to problems and different visions, with more expertise leading to better outcomes.
Open
Statement
Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being adequately addressed.
Open
Statement
The intestinal rehabilitation team includes dietitians (for nutritional needs), social workers, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology.
Open
Quotation
I think the big key to a person watching the podcast is that they get hope. These are wonderful children. They're, they're opportunities to grow up and to live the lives that their families want is really in front of them.
Open
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?
Statement
Earlier recognition and taking advantage of the gut's adaptive biology are time dependent.
Open
Quotation
And so earlier recognition and and taking advantage of the biology of the gut that wants to accommodate, we call it adapt um and meet the needs of the child um are time dependent.
Open
Quotation
What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing.
Open
Statement
Intestinal rehabilitation depends on key factors: nutrition in the gut, nutrition in the body, and healing.
Open
Statement
Pattern recognition from multiple expert eyes observing a patient over time is essential in intestinal rehabilitation.
Open
Quotation
So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time.
Open
Statement
Families reach intestinal rehabilitation programs at three time points: prenatal diagnosis (typically atresia with cystic fibrosis or gastroschisis), postnatal acquired problems (volvulus or NEC), and later diagnosis after discharge when patients fail to progress.
Open
Statement
Innovation comes from multiple approaches to a problem and different visions; bringing in more expertise leads to better outcomes.
Open
Statement
Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being met.
Open
Statement
The intestinal rehabilitation team includes dietitians (understanding nutritional needs), social work, nurse practitioners, pharmacy, interventional radiology, pathology, and subspecialties including endocrinology and nephrology.
Open
Michael's statements about Etiologies (Gastroschisis/NEC/Atresia/Volvulus) 48 statements
Open the Etiologies (Gastroschisis/NEC/Atresia/Volvulus) collection →
Intestinal rehabilitation: What is intestinal rehab? - Episode 1
Statement
Earlier recognition and taking advantage of the gut's biology to adapt are time dependent.
Open
Statement
Intestinal rehabilitation depends on nutrition in the gut, nutrition in the body, and healing.
Open
Quotation
What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing.
Open
Statement
Pattern recognition from multiple experienced clinicians observing patients over time is essential in intestinal rehabilitation.
Open
Quotation
So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time.
Open
Statement
Three time points exist for diagnosis and referral to intestinal rehab: prenatal diagnosis (atresia with cystic fibrosis, gastroschisis), postnatal acquired problems (volvulus, NEC), and later presentations after discharge when patients fail to progress.
Open
Statement
Innovation in intestinal rehabilitation comes from multiple approaches to problems and different visions, with more expertise leading to better outcomes.
Open
Statement
Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being adequately addressed.
Open
Statement
The intestinal rehabilitation team includes dietitians (for nutritional needs), social workers, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology.
Open
Quotation
I think the big key to a person watching the podcast is that they get hope. These are wonderful children. They're, they're opportunities to grow up and to live the lives that their families want is really in front of them.
Open
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?
Quotation
And so earlier recognition and and taking advantage of the biology of the gut that wants to accommodate, we call it adapt um and meet the needs of the child um are time dependent.
Open
Statement
Earlier recognition and taking advantage of the gut's adaptive biology are time dependent.
Open
Quotation
What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing.
Open
Statement
Intestinal rehabilitation depends on key factors: nutrition in the gut, nutrition in the body, and healing.
Open
Quotation
So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time.
Open
Statement
Pattern recognition from multiple expert eyes observing a patient over time is essential in intestinal rehabilitation.
Open
Statement
Families reach intestinal rehabilitation programs at three time points: prenatal diagnosis (typically atresia with cystic fibrosis or gastroschisis), postnatal acquired problems (volvulus or NEC), and later diagnosis after discharge when patients fail to progress.
Open
Statement
Innovation comes from multiple approaches to a problem and different visions; bringing in more expertise leads to better outcomes.
Open
Statement
Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being met.
Open
Statement
The intestinal rehabilitation team includes dietitians (understanding nutritional needs), social work, nurse practitioners, pharmacy, interventional radiology, pathology, and subspecialties including endocrinology and nephrology.
Open
Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 1
Statement
Mistakes are commonly made because clinicians think they can predict the future with their eyes, predetermining care based on what they believe will happen rather than allowing the clinical scenario to drive the direction of care.
Open
Quotation
Mistakes I believe are commonly made because we think we can predict the future with our eyes, and that the first line of treating a baby with overwhelming catastrophe is to allow the clinical scenario to drive the direction of care and not us predicting. Predetermining the care based on what we believe will happen.
Open
Statement
There is an algorithm of children with overwhelming sepsis where surgery cannot salvage these patients and there is no life-saving option.
Open
Quotation
There is definitely an algorithm of children that have overwhelming sepsis, and surgery cannot salvage these patients. We don't have a life saving option for those patients, but many will actually rally without having their bowel removed, which allows them to have an opportunity which many don't understand yet today.
Open
Statement
Many infants will rally without having their bowel removed, which allows them an opportunity for recovery.
Open
Statement
Decompressing the duodenum is needed to protect the liver, and when the liver is inflamed with high bilirubin, it is in a catabolic state.
Open
Quotation
Decompressing the duodenum is the is the needed thing that has to occur to buy you that. to protect the liver and that when the liver is inflamed and has high bilirubin, it's in a catabolic state.
Open
Statement
When in the OR wanting to buy time, one of the first things to consider is how to keep the proximal bowel decompressed.
Open
Statement
Placing a retrograde tube in the duodenum or jejunum that goes up to the pylorus to decompress the bowel has given time to allow children to recover from the acute event.
Open
Quotation
A 30-week-old baby's gut is in a very highly developmental phase and its ability to regenerate is much More profound than a full term baby and certainly a one year old baby.
Open
Statement
A 30-week-old baby's gut is in a highly developmental phase and its ability to regenerate is much more profound than a full-term baby and certainly a one-year-old baby.
Open
Quotation
The distal bowel, the ileum, is remarkably important and can be salvaged by ileocecal blood flow, and leaving it alone and allowing that to occur has allowed us to salvage a lot of tissue in Cincinnati.
Open
Statement
The distal bowel (ileum) is remarkably important and can be salvaged by ileocecal blood flow; leaving it alone has allowed salvage of a lot of tissue in Cincinnati.
Open
Statement
Proximal control allows tissue time to regenerate, which is often on the order of 6, 8, or 12 weeks based on the liver getting better.
Open
Statement
If dealing with less than 50% bowel necrosis, the best option is to remove that bowel and the child's adaptive potential is really great, especially if ileum is preserved.
Open
Statement
If necrotic bowel is focal and less than 50%, it should be removed and the child managed accordingly; the approach is not to leave all dead bowel in place.
Open
Statement
When bowel necrosis is patchy with areas that look terrible, bad, and maybe a little good (mosaicism), proximally controlling the bowel with a drain and providing time to heal gives opportunity to return later; not all bowel will survive and islands of mucosa will need to be tubularized and reconnected.
Open
Statement
Once proximal bowel is controlled with a drain, stomas should be avoided because they lose abdominal domain and lose bowel down the road.
Open
Statement
The percentage of infants that do well with proximal drain therapy when facing dead gut is more than 70 to 80%.
Open
Statement
The approach to overwhelming bowel necrosis does not differ based on diagnosis (volvulus, infarct, mesenteric thrombosis), but the outcome does.
Open
Statement
Controlling proximal bowel without allowing enteric content has been key to salvaging NEC patients with good outcomes.
Open
Michael's statements about Gastroschisis 39 statements
Open the Gastroschisis collection →
Intestinal Failure - Feeding Access and Nutrition
Statement
Placing a 3-4 French feeding tube in distal bowel and bringing it out as a stent (not maturing as mucous fistula) allows easy distal feeding by syringe injection without catheter access issues.
Open
Statement
When creating a jejunal feeding access, dividing the bowel 2-3 cm distal to ligament of Treitz and bringing the distal bowel up as a chimney with side-to-end anastomosis allows placement of a Mickey button without luminal obstruction.
Open
Statement
When operating on a 2-month-old with jejunal atresia unable to advance feeds beyond 20 mL/kg, if the anastomosis is patent but dilated bowel is present and the child has 50% estimated bowel length, tapering is preferable to STEP.
Open
Statement
STEP procedures done in the first year of life, especially in infants not progressing with enteral feeds, are not beneficial unless specifically avoiding line infections and bacterial overgrowth.
Open
Statement
Dilated bowel does not become motile because you did a STEP procedure on it; if bowel hasn't been able to advance feeds, STEP will not make non-functioning bowel work.
Open
Statement
The one thing that makes bowel adapt is feeding the bowel; procedures that cause problems in reinitiating feeds cause damage to the patient.
Open
Quotation
The one thing that makes the bowel adapt is feeding the bowel and procedures in which you have problems in reinitiating feeds have really caused damage to that patient.
Open
Statement
In the STEP registry paper on early neonatal STEP, only 3 patients came off parenteral nutrition, whereas natural data predict 80-90% of such patients would be off TPN at 12 months without surgery.
Open
Quotation
I think the idea that steps can be done safely is not the question. I think the question is that is a step procedure giving you a benefit over the adaptive response that occurs typically in a patient based on data compared to other patients not managed with the step.
Open
Quotation
I think it's important to recognize that what you look at is can an operation be done safely or without complication doesn't necessarily make it the right operation for that patient.
Open
Quotation
The expectation of going from 10 per kilo of enteral feeds, you're doing a step and that kid's gonna be off a TPN in 3 months is a fairy tale that belongs in Disney World.
Open
Statement
Breast milk provides significant benefit to time to wean off parenteral nutrition in gastroschisis and NEC patients compared to formula-only feeding.
Open
Statement
Citrulline is produced by the gut and may predict ability to wean off TPN when measured as a total number, but as a weekly or monthly lab it does not inform clinical care changes.
Open
Statement
Breast milk contains non-nutrient oligosaccharides (2-fucosyllactose, 3-fucosyllactose) that are immunomodulatory and affect microflora, not present in current formulas.
Open
Statement
Anti-inflammatory agents (5-ASA products, steroid-based enemas) can be helpful in managing hypermotility when there is documented inflammation, particularly in challenging Hirschsprung's patients with dysbiosis.
Open
Statement
Pancreatic enzymes in short gut patients go through before they've released, and there is concern they may cause strictures or stoma problems in areas of stenosis and dysmotility.
Open
Statement
Acceptable stoma output is not defined by a hard number; patients with 40-50 cc/kg output can continue feeding if electrolyte profile is acceptable and CO2 is not dropping into the teens.
Open
Statement
Knee-jerk reactions to volume of output (unless patient is sick with acidosis and abnormal electrolytes) should be avoided; variable feeding amounts over longer periods are detrimental to weaning from TPN.
Open
Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 1
Statement
Adaptation is a natural process occurring in all infants during uterine development and the first few years of life, or as a regenerative response to damage in older children
Open
Statement
Adaptation takes time measured in months and years, not weeks and days, and requires enteral nutrition in all situations
Open
Statement
The duodenum is where caloric intake and sugars are sensed, hepatobiliary secretions occur, iron is absorbed, and it functions as an endocrine engine recognizing meal initiation
Open
Statement
The jejunum is largely a source of secretion of large amounts of fluid needed for digestion, with random back-and-forth sloshing motion
Open
Statement
The ileum secretes incretins GLP-2, GLP-1, and PYY that stop gastric emptying and slow motility when there is too much liquid in the distal bowel
Open
Statement
Distal ileum bile uptake sends a signal to the liver, which regulates the whole metabolism of the patient
Open
Statement
The colon, specifically the right colon, is a source of energy uptake from free fatty acids in short gut patients, which requires the presence of bacteria
Open
Statement
Colonic adaptation does not occur in most patients because energy is reclaimed before reaching the colon
Open
Quotation
The last thing you need to come off a TPN is fluid. And so without hydration, the baby won't grow.
Open
Statement
The last thing needed to come off TPN is fluid, and without hydration the baby will not grow or efficiently absorb nutrition
Open
Statement
Lab data shows a shift in microbiota to one that is more acid-producing in an acidotic state, likely more full of bile because it is not being reclaimed
Open
Statement
NEC is an acquired condition; infants are born, start eating, often get up to full feeds, then have an incident usually at 2-3 weeks of life
Open
Statement
NEC patients have not been using their gut in utero during the critical period of 35 weeks to 6 months, making them different from children who have been fed before
Open
Quotation
It's really important that when you do a procedure on this child that you understand the 2nd and the 3rd and the 4th step. You, this is a game of chess. You really have to plan ahead.
Open
Statement
The sooner a child can be fed safely and bowel access obtained without exposing them to surgical risk, the more advantage can be taken of the adaptive process
Open
Quotation
You put kids in harm's way when you go to the operating room, no matter how talented you are.
Open
Statement
Surgery puts kids in harm's way no matter how talented the surgeon, so balancing operative risk with the ability to optimize feeding has led to improved outcomes
Open
Michael's statements about Intestinal Failure 304 statements
Open the Intestinal Failure collection →
Intestinal Failure - Feeding Access and Nutrition
Statement
Placing a 3-4 French feeding tube in distal bowel and bringing it out as a stent (not maturing as mucous fistula) allows easy distal feeding by syringe injection without catheter access issues.
Open
Statement
When creating a jejunal feeding access, dividing the bowel 2-3 cm distal to ligament of Treitz and bringing the distal bowel up as a chimney with side-to-end anastomosis allows placement of a Mickey button without luminal obstruction.
Open
Statement
When operating on a 2-month-old with jejunal atresia unable to advance feeds beyond 20 mL/kg, if the anastomosis is patent but dilated bowel is present and the child has 50% estimated bowel length, tapering is preferable to STEP.
Open
Statement
STEP procedures done in the first year of life, especially in infants not progressing with enteral feeds, are not beneficial unless specifically avoiding line infections and bacterial overgrowth.
Open
Statement
Dilated bowel does not become motile because you did a STEP procedure on it; if bowel hasn't been able to advance feeds, STEP will not make non-functioning bowel work.
Open
Quotation
The one thing that makes the bowel adapt is feeding the bowel and procedures in which you have problems in reinitiating feeds have really caused damage to that patient.
Open
Statement
The one thing that makes bowel adapt is feeding the bowel; procedures that cause problems in reinitiating feeds cause damage to the patient.
Open
Statement
In the STEP registry paper on early neonatal STEP, only 3 patients came off parenteral nutrition, whereas natural data predict 80-90% of such patients would be off TPN at 12 months without surgery.
Open
Quotation
I think the idea that steps can be done safely is not the question. I think the question is that is a step procedure giving you a benefit over the adaptive response that occurs typically in a patient based on data compared to other patients not managed with the step.
Open
Quotation
I think it's important to recognize that what you look at is can an operation be done safely or without complication doesn't necessarily make it the right operation for that patient.
Open
Quotation
The expectation of going from 10 per kilo of enteral feeds, you're doing a step and that kid's gonna be off a TPN in 3 months is a fairy tale that belongs in Disney World.
Open
Statement
Breast milk provides significant benefit to time to wean off parenteral nutrition in gastroschisis and NEC patients compared to formula-only feeding.
Open
Statement
Citrulline is produced by the gut and may predict ability to wean off TPN when measured as a total number, but as a weekly or monthly lab it does not inform clinical care changes.
Open
Statement
Breast milk contains non-nutrient oligosaccharides (2-fucosyllactose, 3-fucosyllactose) that are immunomodulatory and affect microflora, not present in current formulas.
Open
Statement
Anti-inflammatory agents (5-ASA products, steroid-based enemas) can be helpful in managing hypermotility when there is documented inflammation, particularly in challenging Hirschsprung's patients with dysbiosis.
Open
Statement
Pancreatic enzymes in short gut patients go through before they've released, and there is concern they may cause strictures or stoma problems in areas of stenosis and dysmotility.
Open
Statement
Acceptable stoma output is not defined by a hard number; patients with 40-50 cc/kg output can continue feeding if electrolyte profile is acceptable and CO2 is not dropping into the teens.
Open
Statement
Knee-jerk reactions to volume of output (unless patient is sick with acidosis and abnormal electrolytes) should be avoided; variable feeding amounts over longer periods are detrimental to weaning from TPN.
Open
Intestinal rehabilitation: What is intestinal rehab? - Episode 1
Statement
Earlier recognition and taking advantage of the gut's biology to adapt are time dependent.
Open
Quotation
What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing.
Open
Statement
Intestinal rehabilitation depends on nutrition in the gut, nutrition in the body, and healing.
Open
Statement
Pattern recognition from multiple experienced clinicians observing patients over time is essential in intestinal rehabilitation.
Open
Quotation
So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time.
Open
Statement
Three time points exist for diagnosis and referral to intestinal rehab: prenatal diagnosis (atresia with cystic fibrosis, gastroschisis), postnatal acquired problems (volvulus, NEC), and later presentations after discharge when patients fail to progress.
Open
Statement
Innovation in intestinal rehabilitation comes from multiple approaches to problems and different visions, with more expertise leading to better outcomes.
Open
Statement
Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being adequately addressed.
Open
Statement
The intestinal rehabilitation team includes dietitians (for nutritional needs), social workers, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology.
Open
Quotation
I think the big key to a person watching the podcast is that they get hope. These are wonderful children. They're, they're opportunities to grow up and to live the lives that their families want is really in front of them.
Open
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?
Quotation
And so earlier recognition and and taking advantage of the biology of the gut that wants to accommodate, we call it adapt um and meet the needs of the child um are time dependent.
Open
Statement
Earlier recognition and taking advantage of the gut's adaptive biology are time dependent.
Open
Statement
Intestinal rehabilitation depends on key factors: nutrition in the gut, nutrition in the body, and healing.
Open
Quotation
What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing.
Open
Quotation
So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time.
Open
Statement
Pattern recognition from multiple expert eyes observing a patient over time is essential in intestinal rehabilitation.
Open
Statement
Families reach intestinal rehabilitation programs at three time points: prenatal diagnosis (typically atresia with cystic fibrosis or gastroschisis), postnatal acquired problems (volvulus or NEC), and later diagnosis after discharge when patients fail to progress.
Open
Statement
Innovation comes from multiple approaches to a problem and different visions; bringing in more expertise leads to better outcomes.
Open
Statement
Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being met.
Open
Statement
The intestinal rehabilitation team includes dietitians (understanding nutritional needs), social work, nurse practitioners, pharmacy, interventional radiology, pathology, and subspecialties including endocrinology and nephrology.
Open
Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 1
Statement
Mistakes are commonly made because clinicians think they can predict the future with their eyes, predetermining care based on what they believe will happen rather than allowing the clinical scenario to drive the direction of care.
Open
Quotation
Mistakes I believe are commonly made because we think we can predict the future with our eyes, and that the first line of treating a baby with overwhelming catastrophe is to allow the clinical scenario to drive the direction of care and not us predicting. Predetermining the care based on what we believe will happen.
Open
Quotation
There is definitely an algorithm of children that have overwhelming sepsis, and surgery cannot salvage these patients. We don't have a life saving option for those patients, but many will actually rally without having their bowel removed, which allows them to have an opportunity which many don't understand yet today.
Open
Statement
There is an algorithm of children with overwhelming sepsis where surgery cannot salvage these patients and there is no life-saving option.
Open
Statement
Many infants will rally without having their bowel removed, which allows them an opportunity for recovery.
Open
Statement
Decompressing the duodenum is needed to protect the liver, and when the liver is inflamed with high bilirubin, it is in a catabolic state.
Open
Quotation
Decompressing the duodenum is the is the needed thing that has to occur to buy you that. to protect the liver and that when the liver is inflamed and has high bilirubin, it's in a catabolic state.
Open
Statement
When in the OR wanting to buy time, one of the first things to consider is how to keep the proximal bowel decompressed.
Open
Statement
Placing a retrograde tube in the duodenum or jejunum that goes up to the pylorus to decompress the bowel has given time to allow children to recover from the acute event.
Open
Quotation
A 30-week-old baby's gut is in a very highly developmental phase and its ability to regenerate is much More profound than a full term baby and certainly a one year old baby.
Open
Statement
A 30-week-old baby's gut is in a highly developmental phase and its ability to regenerate is much more profound than a full-term baby and certainly a one-year-old baby.
Open
Statement
The distal bowel (ileum) is remarkably important and can be salvaged by ileocecal blood flow; leaving it alone has allowed salvage of a lot of tissue in Cincinnati.
Open
Quotation
The distal bowel, the ileum, is remarkably important and can be salvaged by ileocecal blood flow, and leaving it alone and allowing that to occur has allowed us to salvage a lot of tissue in Cincinnati.
Open
Statement
Proximal control allows tissue time to regenerate, which is often on the order of 6, 8, or 12 weeks based on the liver getting better.
Open
Statement
If dealing with less than 50% bowel necrosis, the best option is to remove that bowel and the child's adaptive potential is really great, especially if ileum is preserved.
Open
Statement
If necrotic bowel is focal and less than 50%, it should be removed and the child managed accordingly; the approach is not to leave all dead bowel in place.
Open
Statement
When bowel necrosis is patchy with areas that look terrible, bad, and maybe a little good (mosaicism), proximally controlling the bowel with a drain and providing time to heal gives opportunity to return later; not all bowel will survive and islands of mucosa will need to be tubularized and reconnected.
Open
Statement
Once proximal bowel is controlled with a drain, stomas should be avoided because they lose abdominal domain and lose bowel down the road.
Open
Statement
The percentage of infants that do well with proximal drain therapy when facing dead gut is more than 70 to 80%.
Open
Statement
The approach to overwhelming bowel necrosis does not differ based on diagnosis (volvulus, infarct, mesenteric thrombosis), but the outcome does.
Open
Statement
Controlling proximal bowel without allowing enteric content has been key to salvaging NEC patients with good outcomes.
Open
Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 2
Statement
The ileum reclaims bile, tells the liver what to do, and produces hormones like GLP-2, PYY, and others that slow motility and signal the jejunum to reabsorb fluid.
Open
Quotation
The colon can actually maybe account for a third. Half of the caloric needs of some of these babies when exposed to undigested nutrients.
Open
Statement
The colon can account for one-third to one-half of the caloric needs of these babies when exposed to undigested nutrients.
Open
Statement
These children with overwhelming intestinal catastrophe are largely neurologically fine—they are running and playing—and their life expectancy is not associated with lifelong care needs that most parents would not want.
Open
Quotation
These kids largely are neurologically fine. They're running and playing, and the, the thought that you would be salvaging a baby to have a lifelong care need and their, their life expectancy would not be associated with things that most parents would want for their children is not what we see in the clinic.
Open
Statement
The child should be the one driving the care, not the surgeon's expectations or lack thereof; without changing that early paradigm, nothing else can improve in this population.
Open
Quotation
And again, I think the take home message of this is the child should be the one driving the care, not your expectations or the lack thereof.
Open
Quotation
Well, I mean, obviously bowel removed is bowel never to be used. The, the fear that it's driving a neurocognitive thing, I think needs to be supported with data.
Open
Statement
Bowel removed is bowel never to be used; the fear that delayed surgery drives neurocognitive harm needs to be supported with data.
Open
Statement
NEC totalis in NEC patients is fairly rare; most NEC patients do not have overwhelming totalis.
Open
Quotation
The neck kids do remarkably well, and I would argue most neck kids don't have overwhelming totalis.
Open
Quotation
Certainly, the, the comparative group to that patient is in a cemetery. As, as rude as that sounds, um, a dead child has no neurological function.
Open
Statement
A dozen or more children with NEC totalis at Cincinnati have survived, are off TPN, and have done remarkably well; the comparative group is dead children who have no neurological function.
Open
Statement
Once these patients survive the acute phase, the opportunities to rehabilitate the bowel and the new tools that will be developed in the next decade are going to be profound.
Open
Quotation
Once they live, the opportunities for us to move forward in this field and rehabilitate the bowel, the new tools that we will make in the next decade are going to be profound.
Open
Statement
The opportunity given to the child is made at the time the surgeon opens the belly and sees catastrophe; removing all bowel eliminates all future potential based on clinical acumen that the outcome will be bad.
Open
Quotation
But the opportunity given to that child is made at the time that you open the belly and you see catastrophe.
Open
Quotation
So you remove all the potential that we have in the future. Based on your clinical acumen that this is gonna have a bad outcome, and that it's time to withdraw.
Open
Quotation
And the first team that has to be convinced is your neonatologist because they're the ones at the bedside who historically removed the breathing tubes on these kids and allowed them to pass.
Open
Statement
The first team that must be convinced of this approach is the neonatology team, because historically they are the ones who removed breathing tubes and allowed these babies to pass.
Open
Statement
If you see protein growth, linear growth, and head growth in the baby, that is brain growth; a baby will not grow well with an unhealthy liver or poor management.
Open
Quotation
If you see protein growth and linear growth of your baby and head growth, that's brain growth, and a baby will not grow well with a, with an unhealthy liver and is not managed well.
Open
Quotation
Unhealthy liver is, is not providing the protein for the neurocognitive development, period. And that's why it's the number one priority early, uh, that you should have.
Open
Statement
An unhealthy liver does not provide the protein necessary for neurocognitive development; liver health is the number one priority early in management.
Open
Statement
Babies, especially premature babies in the first year of life, have caloric needs of 80–120 kcal/kg because they are growing and developing; when critically ill they are no longer growing and their livers are catabolic, so feeding 150 kcal/kg will not result in growth.
Open
Quotation
When you're critically ill, you no longer are growing and developing. You can feed these babies 150 k cals per kilo, but they will not grow because their livers are catabolic.
Open
Statement
For a 30-week baby with extensive NEC and a long segment of dead bowel, the surgeon knows the baby will need multiple operations, so a transverse incision is used because it causes the least problems over time.
Open
Quotation
So I know this baby is going to need multiple operations. So the incision is a transverse incision because I know over time that's the one that's going to give me the least problems.
Open
Statement
The surgeon finds a segment of bowel just beyond what is expected to heal (1–2 cm margin) and brings in an 8 or 10 French Blake drain, often from the left lower quadrant if normally rotated, placing it through bowel that is not expected to do well and advancing it retrograde to the pylorus.
Open
Statement
A loose tie is placed around the most healthy part of the bowel around the drain to control secretions, and a purse-string is placed at the insertion site and secured to the skin, essentially stemming the bowel to the abdominal wall; this takes minutes.
Open
Statement
If the stomach is visible, a purse-string is placed in the stomach and a 5–7 French feeding tube is inserted into the proximal bowel and tied, taking one to two minutes; this avoids having to access the left upper quadrant later for a G-tube.
Open
Statement
The surgeon tries to close the abdomen primarily, but if there is concern about dead bowel, Alloderm is placed; if very worried, a drain is placed in the abdomen to allow drainage.
Open
Quotation
I try to avoid doing significant dissection of the distal ileum one because I wanna preserve the blood. So I wanna let the collateralization happen to recover as much of that proximal bowel as possible.
Open
Statement
The surgeon tries to avoid significant dissection of the distal ileum to preserve blood supply and allow collateralization to recover as much proximal bowel as possible.
Open
Statement
If the distal diverted bowel is baggy and filled with bloody enteric fluid, and there are distal perforations with patchy necrosis, the surgeon may place stitches distal to proximal to bring the bowel together to preserve muscle, planning to manage it later.
Open
Quotation
I will put a refeeding tube in the distal bowel so I can refeed and let that intermediate bowel. To sort of hang out.
Open
Statement
A refeeding tube is placed in the distal bowel to allow refeeding and let the intermediate bowel hang out and heal; this depends on the amount of proximal bowel and whether feeding is feasible.
Open
Statement
In one current case with 40 cm of proximal bowel, refeeding is allowing the surgeon to wait longer for intervening bowel to heal, and the baby's liver is fine, buying time because the fluid output from injured bowel is very high.
Open
Quotation
And so it's just buying me time and the time is because the amount of fluid that comes out of injured bowel is very high.
Open
Statement
These conversations about approach need to be had with neonatologists and dietitians in the room, not just surgical colleagues, because they must be on board.
Open
Quotation
I think these conversations need to be had with other providers. in the room, not just your surgical colleagues, because the, the neonatologists and dietitians have to be on board.
Open
Quotation
Families are, are not able to make decisions. Once you explain to the family that the individual making the decisions moving forward is a baby, and you explain that to them, when things go bad, it actually makes it easier for them.
Open
Statement
Families are not able to make decisions in these situations; once the family is told that the baby is the one driving decisions moving forward, it makes things easier for them when outcomes are bad.
Open
Statement
Many babies taken to the OR are not as critically sick as believed; once proximal bowel is controlled and everything is decompressed, many will slowly improve.
Open
Quotation
I think you'd be surprised at the number of kids who are sick, taken to the OR, but they're not as critically sick as we believe they're going to be.
Open
Quotation
Many of those kids, once you control the proximal bowel and you get everything decompressed, will actually slowly get better.
Open
Quotation
Long term, if you take everything out, there are many of them that will heal, and then we have no opportunity. That Experiment's been done.
Open
Statement
Long-term, if all bowel is removed, many patients will heal but there is no opportunity for rehabilitation; that experiment has been done.
Open
Statement
Blake tubes have linear cuts on the outside so they do not get obstructed when secretions accumulate; they are soft and do not put pressure on damaged bowel; they can be connected to a bulb syringe and cut to size.
Open
Quotation
The Blake tube has linear cuts on the outside, so they, they won't get obstructed in many situations when secretions and stuff get around them. And that's why I like them a lot.
Open
Statement
The downside of Blake tubes is that they cannot be changed over a wire like JP drains with side holes; the ideal tube would be a Blake with a central hole for wire passage.
Open
Quotation
What's the downside of them is you can't change them over a wire, like you can a JP and other ones that just have side holes.
Open
Quotation
If I had the best scenario, it would be a blake tube that has a central hole that I could pass a wire.
Open
Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 1
Statement
Adaptation is defined as developing and strengthening gut function, occurring naturally in infants during in utero development and the first few years of life, or as a regenerative response to damage in older children.
Open
Statement
Adaptation is defined as developing and strengthening gut function, occurring naturally in infants during in utero development and the first few years of life, or as a regenerative response to damage in older children.
Open
Quotation
And it generally takes time, and that time is measured in. Months and years and not weeks and days, but the one thing that it requires in all situations is enteral nutrition.
Open
Statement
Adaptation generally takes months and years, not weeks and days, and requires enteral nutrition in all situations.
Open
Quotation
And it generally takes time, and that time is measured in. Months and years and not weeks and days, but the one thing that it requires in all situations is enteral nutrition.
Open
Statement
Adaptation generally takes months and years, not weeks and days, and requires enteral nutrition in all situations.
Open
Statement
The duodenum senses caloric intake, monitors sugars, receives hepatobiliary secretions, takes up iron, and functions as an endocrine engine recognizing meal initiation.
Open
Statement
The duodenum senses caloric intake, monitors sugars, receives hepatobiliary secretions, takes up iron, and functions as an endocrine engine recognizing meal initiation.
Open
Statement
The jejunum is largely a source of fluid secretion needed for digestion, with random back-and-forth sloshing motion like a washing machine.
Open
Statement
The jejunum is largely a source of fluid secretion needed for digestion, with random back-and-forth sloshing motion like a washing machine.
Open
Statement
The ileum secretes different hormones including the incretins GLP-2, GLP-1, and PYY, which stop gastric emptying and slow motility when excess liquid is detected in the distal bowel and proximal colon.
Open
Statement
The ileum secretes different hormones including the incretins GLP-2, GLP-1, and PYY, which stop gastric emptying and slow motility when excess liquid is detected in the distal bowel and proximal colon.
Open
Statement
The distal ileum's ability to take up bile sends a signal to the liver, the metabolic engine that helps regulate the whole metabolism of the patient.
Open
Statement
The distal ileum's ability to take up bile sends a signal to the liver, the metabolic engine that helps regulate the whole metabolism of the patient.
Open
Statement
In short gut patients, the colon becomes a source of energy uptake when exposed to free fatty acids, which requires the presence of bacteria.
Open
Statement
In short gut patients, the colon becomes a source of energy uptake when exposed to free fatty acids, which requires the presence of bacteria.
Open
Quotation
It, in fact, in, in our patients is a source of energy uptake when allowed to see things like free fatty acids, and that requires the presence of bacteria.
Open
Quotation
It, in fact, in, in our patients is a source of energy uptake when allowed to see things like free fatty acids, and that requires the presence of bacteria.
Open
Statement
Colonic adaptation does not occur in most normal patients because energy is already reclaimed before reaching the colon.
Open
Statement
Colonic adaptation does not occur in most normal patients because energy is already reclaimed before reaching the colon.
Open
Statement
Adaptation is highly influenced by modifiable factors including formula type, H2 blockers, antibiotics, illness episodes, and motility changes.
Open
Statement
Adaptation is highly influenced by modifiable factors including formula type, H2 blockers, antibiotics, illness episodes, and motility changes.
Open
Statement
The last thing a patient needs to come off TPN is fluid; without adequate hydration, the baby will not grow and will not efficiently absorb nutrition, losing energy and decreasing their growth trajectory.
Open
Statement
The last thing a patient needs to come off TPN is fluid; without adequate hydration, the baby will not grow and will not efficiently absorb nutrition, losing energy and decreasing their growth trajectory.
Open
Quotation
But what people don't recognize is the last thing you need to come off a TPN is fluid.
Open
Quotation
But what people don't recognize is the last thing you need to come off a TPN is fluid.
Open
Statement
Lab data from Cincinnati shows a shift in microbiota to more acid-producing bacteria in an acidotic state, with increased bile due to lack of reclamation.
Open
Statement
Lab data from Cincinnati shows a shift in microbiota to more acid-producing bacteria in an acidotic state, with increased bile due to lack of reclamation.
Open
Quotation
And just seeing something that's different than normal doesn't make it bad, needs to be studied and needs to be taken into context.
Open
Statement
Bacterial colonization differences from normal are part of the adaptive response and should not automatically be considered pathological; they need to be studied and taken into context.
Open
Statement
Bacterial colonization differences from normal are part of the adaptive response and should not automatically be considered pathological; they need to be studied and taken into context.
Open
Quotation
And just seeing something that's different than normal doesn't make it bad, needs to be studied and needs to be taken into context.
Open
Statement
NEC is an acquired condition; infants are born, start eating (often reaching near-full feeds), then have an incident usually at 2-3 weeks of life, meaning they have not been using their gut during the critical 35-week-to-6-months adaptive window.
Open
Statement
NEC is an acquired condition; infants are born, start eating (often reaching near-full feeds), then have an incident usually at 2-3 weeks of life, meaning they have not been using their gut during the critical 35-week-to-6-months adaptive window.
Open
Statement
Whether a child has been fed before makes them different from one who has never been fed, affecting their adaptive potential.
Open
Statement
Whether a child has been fed before makes them different from one who has never been fed, affecting their adaptive potential.
Open
Quotation
Ask yourself, has this child been fed before, because that child's different than the one that's never been fed.
Open
Quotation
Ask yourself, has this child been fed before, because that child's different than the one that's never been fed.
Open
Statement
Surgical planning for short gut patients is like a game of chess requiring consideration of the second, third, and fourth steps ahead.
Open
Statement
Surgical planning for short gut patients is like a game of chess requiring consideration of the second, third, and fourth steps ahead.
Open
Statement
The sooner a child can be fed safely and bowel access achieved without exposing them to surgical risk, the more the adaptive process can be leveraged.
Open
Statement
The sooner a child can be fed safely and bowel access achieved without exposing them to surgical risk, the more the adaptive process can be leveraged.
Open
Statement
Cincinnati strategies were developed to take advantage of the easiest, safest way to use the bowel early without needing to return immediately to surgery.
Open
Statement
Cincinnati strategies were developed to take advantage of the easiest, safest way to use the bowel early without needing to return immediately to surgery.
Open
Statement
Surgery puts children in harm's way regardless of surgeon talent, so balancing surgical intervention with optimization of adaptation has led to improved outcomes.
Open
Quotation
You put kids in harm's way when you go to the operating room, no matter how talented you are.
Open
Quotation
You put kids in harm's way when you go to the operating room, no matter how talented you are.
Open
Statement
Surgery puts children in harm's way regardless of surgeon talent, so balancing surgical intervention with optimization of adaptation has led to improved outcomes.
Open
Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1
Statement
Adrian Bianchi first reported the longitudinal intestinal lengthening procedure (Bianchi procedure) that divides bowel along its two leaves and tubularizes it.
Open
Statement
Rising direct bilirubin was recognized as a sign that children with intestinal failure would not do well.
Open
Statement
The gut doubles in length during the last trimester and the first year of life, and this maturation process occurs when the baby is fed.
Open
Statement
Healthy growth of the intestine requires nutrition; anything that disrupts this affects maturation of both absorptive/digestive capacity and peristalsis.
Open
Quotation
The outcome is one that should benefit the child for 80, 90 years, not just the next 2 months.
Open
Statement
Lengthening bowel that doesn't have peristalsis does not increase absorption; very short bowel children can sometimes come off TPN because their motility is good.
Open
Quotation
The better the waves going over the villa, The more exposure of nutrients and removal of waste that you have is not increased by lengthening the bowel that doesn't peristals. That's just more static water.
Open
Quotation
So we see very short bowel kids sometimes come off a TPM because their motility is so good.
Open
Statement
The enteric nervous system in gastroschisis is damaged from exposure to amniotic fluid and requires a healing and recovery phase; this regeneration is attenuated by dysmotility and stasis, not enhanced.
Open
Statement
In atresia without gastroschisis, the bowel may have good peristalsis from working against an obstruction, and when done correctly with proper orientation, a longitudinal lengthening procedure may benefit the child.
Open
Statement
Children who undergo STEP procedures in their first year of life sometimes never progress and are labeled as poor motility patients unable to tolerate enteral feeds.
Open
Statement
Among patients with limited gut, necrotizing enterocolitis patients do best because they have been fed before, have established GI motility, and the maturation phase has already been initiated.
Open
Quotation
Anything that creates a potential worsening of motility and gastroschisis, especially in the first year of life should be something you should strongly think about before doing.
Open
Statement
The duodenum has no mesentery, making it impossible to orient 90° and 270° positions; surgeons who STEP the duodenum end up entering the bowel at inconsistent orientations.
Open
Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1
Statement
Adrian Bianchi first reported the longitudinal intestinal lengthening procedure (Bianchi procedure) that divides bowel along its two leaves and tubularizes it.
Open
Statement
Rising direct bilirubin was recognized as a sign that children with intestinal failure would not do well.
Open
Statement
The gut doubles in length during the last trimester and the first year of life, and this maturation process occurs when the baby is fed.
Open
Statement
Healthy growth of the intestine requires nutrition; anything that disrupts this affects maturation of both absorptive/digestive capacity and peristalsis.
Open
Quotation
The outcome is one that should benefit the child for 80, 90 years, not just the next 2 months.
Open
Statement
Lengthening bowel that doesn't have peristalsis does not increase absorption; very short bowel children can sometimes come off TPN because their motility is good.
Open
Quotation
The better the waves going over the villa, The more exposure of nutrients and removal of waste that you have is not increased by lengthening the bowel that doesn't peristals. That's just more static water.
Open
Quotation
So we see very short bowel kids sometimes come off a TPM because their motility is so good.
Open
Statement
The enteric nervous system in gastroschisis is damaged from exposure to amniotic fluid and requires a healing and recovery phase; this regeneration is attenuated by dysmotility and stasis, not enhanced.
Open
Statement
In atresia without gastroschisis, the bowel may have good peristalsis from working against an obstruction, and when done correctly with proper orientation, a longitudinal lengthening procedure may benefit the child.
Open
Statement
Children who undergo STEP procedures in their first year of life sometimes never progress and are labeled as poor motility patients unable to tolerate enteral feeds.
Open
Statement
Among patients with limited gut, necrotizing enterocolitis patients do best because they have been fed before, have established GI motility, and the maturation phase has already been initiated.
Open
Quotation
Anything that creates a potential worsening of motility and gastroschisis, especially in the first year of life should be something you should strongly think about before doing.
Open
Statement
The duodenum has no mesentery, making it impossible to orient 90° and 270° positions; surgeons who STEP the duodenum end up entering the bowel at inconsistent orientations.
Open
Intestinal Rehabilitation, Episode 4: Surgical Management, Part 2
Quotation
Half of the people that have a step will have progression of improved animal tolerance. Half will have actually a worsening.
Open
Statement
Half of the people that have a STEP will have progression of improved enteral tolerance, and half will actually have a worsening.
Open
Statement
The six month postoperative period is very critical for analyzing how the patient is moving forward after STEP.
Open
Quotation
If you're going to operate on a kid for a step procedure, you need to first rule out other anatomical problems.
Open
Statement
Before operating for a STEP procedure, you need to first rule out other anatomical problems by laying out the bowel and getting the mesentery completely oriented.
Open
Statement
If you only focus on the STEP without examining the complete anatomy, you will miss some of the reasons why these kids aren't getting better.
Open
Statement
The management of these kids is not a one-stop shopping that you're going to fix with your operation; there is nothing wrong with staging.
Open
Quotation
The management of these kids is not a one-stop shopping that you're going to fix that kid with your operation. There is nothing wrong with staging.
Open
Quotation
One of the things that we've seen as a complication here is that the kids have done really well with step procedures, but they have continued loss from either they lose protein in the stool or we see recurrent bleeding.
Open
Statement
Mesenteric inflammation and scarring creates an obstruction to venous outflow, resulting in venous hypertension along the staple lines.
Open
Quotation
And so that mesenteric fire that Causes inflammation and scarring, creates an obstruction to venous outflow.
Open
Quotation
And when you operate. You can see vessels the size of your thumb, and you'll see really big adenopathy because the lymphatics are also obstructed.
Open
Statement
During operation for staple line bleeding, you can see vessels the size of your thumb and really big adenopathy because the lymphatics are also obstructed.
Open
Statement
The key in managing staple line bleeding is to look at the mesentery and free up the mesentery, not just look at the bowel.
Open
Quotation
So the key to me in that situation of bleeding is look at the mesentery. Make sure you free up the mesentery. Don't just look at the bowel.
Open
Statement
Mesenteric scarring causing venous hypertension is obvious if you're looking for it during operation.
Open
Statement
Dr. Helmrath documents detailed operative notes for himself describing orientation, landmarks, and what was done to guide future operations.
Open
Quotation
Try not to be the hero. Try not to do everything, especially the first week in life. Understand biology and physiology and growth is a spectrum, and. Optimize it.
Open
Statement
Surgeons should try not to be the hero and try not to do everything, especially in the first week of life; understand that biology, physiology, and growth are a spectrum.
Open
Statement
The surgeon plays a huge role in intestinal rehabilitation even when patients are doing well, because you have to see the progress.
Open
Quotation
This population is one that the surgeon plays a huge role in, even when they're doing well, because you have to see the progress.
Open
Intestinal Rehabilitation, Episode 6: Cholestasis
Quotation
I believe though that as we've gotten better and we've learned how to use lipid emulgens differently and nutrition differently and our approaches. That the definition of cholestasis is not as much as a morbidity mortality as much as it is an indicator of underlying diseases that we need to address.
Open
Statement
As treatment has improved with different lipid emulsions and nutrition approaches, cholestasis has become more an indicator of underlying diseases to address rather than a primary morbidity/mortality factor.
Open
Statement
New lipid emulsions including Omegaven (used first in the US) and SMOF (used in Europe and Canada, now prevalent in the US for 3-4 years) can reverse or prevent cholestasis.
Open
Statement
A major advantage of SMOF is the ability to provide more calories from fat (as much as 2-2.5 g/kg) while supporting healthy growth.
Open
Quotation
One of the major advantages I think of the addition of SMP is the ability to provide more calories from fat, as much as 2 2.5 g per kilo. I think that people need to recognize that the management of These kids is healthy growth.
Open
Statement
When refeeding a cholestatic liver after proximal jejunostomy takedown, direct bilirubin typically rises in the first week as bile acid pool is reintroduced and the liver becomes more active in bile salt production.
Open
Quotation
One of the first things that you'll get your neonatologist telling you about when you start feeding is they'll get worried because the direct bilirubin goes up. That's normal.
Open
Statement
GGT, AST, and ALT will go up in the first week or two after anastomosis takedown surgery, then slowly come down over several weeks.
Open
Statement
When direct bilirubin rises after refeeding, the main differential to rule out is urinary tract infection or gram-negative infection; extensive imaging such as ultrasounds is not needed.
Open
Statement
It is important to provide proximal drainage of the duodenum in high-risk intestinal failure patients; Dr. Helmrath places a lake drain for this purpose.
Open
Statement
Ongoing cholestasis with proximal blockage puts pressure in the biliary system at a much higher level and speeds up the cholestatic process.
Open
Intestinal Rehabilitation, Episode 7: Refeeding in a neonatal patient
Statement
Factors to consider when refeeding include poor gastric emptying, poor gastric function, high stoma outputs versus high stooling output, and the age of the child at the time of intestinal damage.
Open
Quotation
Yeah, remember that especially if there's been damaged bowel, it's gonna be in a secretory phase, even if it's not fed, and people are scared then to feed. And feeling like it's gonna be totally uncontrollable, whereas what happens is the exact opposite, as you start to feed the bowel, then gets in an absorptive state, because the nutrition that's present in the luminal stimulate it to do so, and you'll actually start to see less volume out the stoma in time.
Open
Statement
Damaged bowel is in a secretory phase even when not fed, but feeding stimulates the bowel into an absorptive state through luminal nutrition, eventually reducing stoma volume output.
Open
Statement
Mother's breast milk is the ideal feeding choice due to nutritional value and immunomodulatory and growth-healing effects not present in typical formulas.
Open
Quotation
Mom's breast milk is ideal, not just because of the nutritional value, but certainly because it has all the immunomodulatory beneficial effects, growth healing effects. That are not present in typical formulas.
Open
Statement
It is a common mistake to increase enteral feeds by the same volume that TPN is decreased, assuming the child will absorb all those calories, which results in stunted growth.
Open
Quotation
It's a common mistake to increase enteral feeds by X volume that you decrease TPN by, and what you end up doing is you're assuming that the child. And absorb all those calories, and you end up stunting the growth.
Open
Statement
If the child tolerates it and does not have lung issues, the total daily volume can be expanded from 140 to 160, 170, or occasionally even 180 per kilogram.
Open
Statement
The stomach is the most complicated part of the GI tract because it must coordinate both back-and-forth sloshing and coordinated squeezing with pyloric relaxation several times per minute to induce gastric emptying.
Open
Quotation
By far the most complicated part of our GI tract is the stomach, because it does both the back and forth, uh, sloshing around that the small bowel does, but in addition, it has to coordinate a squeeze with the relaxation of the pylorus several. Times a minute to induce small amounts of gastric emptying, and so it's not uncommon that when children haven't been fed and they've had an injury, the coordination of the stomach is completely off.
Open
Statement
When children have not been fed and have had an injury, gastric coordination is commonly completely disrupted.
Open
Statement
Most gastric dysmotility requires time and stimulation; the way to provide time when the rest of the GI tract works is to place a tube beyond the stomach for feeding.
Open
Quotation
Most of this requires just time. And stimulation, so the way to to buy that time when the rest of the GI tract works is to place a tube beyond the stomach that you can feed from.
Open
Quotation
In a baby, uh, the, the best way to get distal feeding is either through an NJ tube, um, with the G tube just decompressing the stomach, so that the baby is allowed to be fed outside the stomach while decompressing the stomach at the same time. And that what ends up happening is that the seeing that you do stimulates the distal small bowel and the colon to produce hormones that largely will tell the stomach to start functioning, and you'll actually break the the cycle.
Open
Statement
In a baby, the best way to achieve distal feeding is through an NJ tube with a G-tube decompressing the stomach, allowing feeding outside the stomach while simultaneously decompressing it.
Open
Statement
Distal feeding stimulates the distal small bowel and colon to produce hormones that signal the stomach to start functioning, breaking the dysmotility cycle.
Open
Statement
Post-pyloric refeeding can be done as a bolus or over a pump; bolus is preferred, but at Cincinnati a protocol of running feeds over a pump for one hour works well, typically starting at 5 then 10 cc per kilogram and advancing based on tolerance.
Open
Statement
Feeding the colon causes stoma output to decrease quickly, reflecting hormonal effects of the distal bowel, and often the stomach will start to work.
Open
Quotation
Interestingly, by feeding the colon, one of the things you'll notice quickly is that the output from the stoma actually goes down, speaking to all the hormonal effects of the distal bowel, and often the stomach will start to work.
Open
Statement
The largest benefit of distal bowel refeeding is that when the two bowel ends are reconnected, the distal bowel has been functionally used, making postoperative feeding easier to initiate.
Open
Statement
Undigested formula in the colon is a trigger that can cause stress to the bowel and may not be the healthiest approach.
Open
Quotation
I think undigested formula in the colon is a trigger. It definitely can cause stress to the bowel, and so I'm not sure it's the healthiest thing to do.
Open
Quotation
The strategy that I've used that I think works very well, is that you, you're not committing the child to a lifelong G tube or even for the first year. If you just place a feeding tube into the. Stomach and stand the stomach up. It's no different than another tube in a kit and especially as I said before, I often direct it out of the pylorus into the proximal small bowel and so it's a source of feeding that allows you to overcome some obstacles that you can never always predict. And, and when these children do well, you just take it out and it's like any other hole that just heals in these kids.
Open
Statement
Placing a feeding tube into the stomach and tacking the stomach up does not commit the child to a lifelong G-tube or even one for the first year; it is no different than another tube and can be directed out of the pylorus into the proximal small bowel.
Open
Statement
When children with G-tubes do well, the tube can be removed and the hole heals like any other in these patients.
Open
Quotation
So it's, it's an ace in the hole, cause the morbidity from that tube is extremely low, and the benefit could be very, very.
Open
Intestinal Rehabilitation Episode 8: Refeeding of an Older Patient
Quotation
Like the recent slew of kids we have that are between 8 and 16 that were eating just fine, and one day boom, they had a volvulus and they've lost 90+% of the bowel.
Open
Statement
Some patients can come off TPN but still need a central line for IV fluids; without IV fluids they end up sleeping most of the day and lack energy.
Open
Quotation
I think some patients actually can come off a TPN but still need a central line for IV fluids, and that in the absence of IV fluids, really, they end up sleeping most of the days, they don't have a lot of energy.
Open
Statement
Sometimes patients cannot drink rehydration solution, but the GI tract can use it (via G-tube).
Open
Quotation
The other key point to remember is that the energy use goes up dramatically during puberty, and so you often will find a child who is actually doing well, and they hit the wall when they start puberty because their energy needs are overcoming their nutrient input.
Open
Statement
Children who are doing well often hit the wall when they start puberty because their energy needs overcome their nutrient input.
Open
Statement
The goal is always healthy growth, and it is important to be proactive, add supplements, and hope they will take extra nutritional support.
Open
Quotation
I can't emphasize enough to look at the growth chart, both the weight, but also the height, and don't accept a 3rd percentile.
Open
Statement
Clinicians should look at the growth chart for both weight and height, and not accept a 3rd percentile.
Open
Statement
For any child not meeting growth potential, numerous other diagnoses can be responsible, ranging from endocrine issues to pancreatic insufficiency to micronutrient issues.
Open
Statement
The concept is that patients are capable of having normal growth, and as you address issues and improve something, you need reasonable follow-up time on the order of weeks, not months.
Open
Statement
Much of the growth monitoring can be done remotely; patients do not need to travel for assessment, but you cannot wait until the next appointment.
Open
Intestinal Rehabilitation Webinar 2023 - Top 5 Key Takeaways
Quotation
So, to me, I believe the more important fact is the presence or absence of the distal small bowel or the ileum and even right colon that can act as a reclamation of bile and get the inneroppatic circulation.
Open
Statement
The more important factor than the ileocecal valve is the presence or absence of the distal small bowel (ileum) and right colon that can act as a site for bile reclamation and enterohepatic circulation.
Open
Statement
The surgical strategy at the first operation should provide a pathway forward that allows early interval feeding.
Open
Quotation
I think sometimes strategy at the first operation is to be able to provide a pathway forward that allows early interval feeding.
Open
Statement
It is sometimes better to stage reconstruction with the plan to restore bowel continuity under more controlled conditions.
Open
Statement
In situations of overwhelming intestinal loss, the strategy is to provide proximal control that allows feeding to occur without the enteral stream going through, and to leave questionable bowel segments that have potential to heal and can make a huge difference in the child's lifetime.
Open
Statement
Starting at the single amino acid level for protein is the generalized preference, ensuring patients are not having high stool output, high fluid losses, wound breakdown, rashes, or emesis.
Open
Michael's statements about Intestinal Rehab 358 statements
Open the Intestinal Rehab collection →
Intestinal Failure - Feeding Access and Nutrition
Statement
Placing a 3-4 French feeding tube in distal bowel and bringing it out as a stent (not maturing as mucous fistula) allows easy distal feeding by syringe injection without catheter access issues.
Open
Statement
When creating a jejunal feeding access, dividing the bowel 2-3 cm distal to ligament of Treitz and bringing the distal bowel up as a chimney with side-to-end anastomosis allows placement of a Mickey button without luminal obstruction.
Open
Statement
When operating on a 2-month-old with jejunal atresia unable to advance feeds beyond 20 mL/kg, if the anastomosis is patent but dilated bowel is present and the child has 50% estimated bowel length, tapering is preferable to STEP.
Open
Statement
STEP procedures done in the first year of life, especially in infants not progressing with enteral feeds, are not beneficial unless specifically avoiding line infections and bacterial overgrowth.
Open
Statement
Dilated bowel does not become motile because you did a STEP procedure on it; if bowel hasn't been able to advance feeds, STEP will not make non-functioning bowel work.
Open
Quotation
The one thing that makes the bowel adapt is feeding the bowel and procedures in which you have problems in reinitiating feeds have really caused damage to that patient.
Open
Statement
The one thing that makes bowel adapt is feeding the bowel; procedures that cause problems in reinitiating feeds cause damage to the patient.
Open
Statement
In the STEP registry paper on early neonatal STEP, only 3 patients came off parenteral nutrition, whereas natural data predict 80-90% of such patients would be off TPN at 12 months without surgery.
Open
Quotation
I think the idea that steps can be done safely is not the question. I think the question is that is a step procedure giving you a benefit over the adaptive response that occurs typically in a patient based on data compared to other patients not managed with the step.
Open
Quotation
I think it's important to recognize that what you look at is can an operation be done safely or without complication doesn't necessarily make it the right operation for that patient.
Open
Quotation
The expectation of going from 10 per kilo of enteral feeds, you're doing a step and that kid's gonna be off a TPN in 3 months is a fairy tale that belongs in Disney World.
Open
Statement
Breast milk provides significant benefit to time to wean off parenteral nutrition in gastroschisis and NEC patients compared to formula-only feeding.
Open
Statement
Citrulline is produced by the gut and may predict ability to wean off TPN when measured as a total number, but as a weekly or monthly lab it does not inform clinical care changes.
Open
Statement
Breast milk contains non-nutrient oligosaccharides (2-fucosyllactose, 3-fucosyllactose) that are immunomodulatory and affect microflora, not present in current formulas.
Open
Statement
Anti-inflammatory agents (5-ASA products, steroid-based enemas) can be helpful in managing hypermotility when there is documented inflammation, particularly in challenging Hirschsprung's patients with dysbiosis.
Open
Statement
Pancreatic enzymes in short gut patients go through before they've released, and there is concern they may cause strictures or stoma problems in areas of stenosis and dysmotility.
Open
Statement
Acceptable stoma output is not defined by a hard number; patients with 40-50 cc/kg output can continue feeding if electrolyte profile is acceptable and CO2 is not dropping into the teens.
Open
Statement
Knee-jerk reactions to volume of output (unless patient is sick with acidosis and abnormal electrolytes) should be avoided; variable feeding amounts over longer periods are detrimental to weaning from TPN.
Open
Intestinal rehabilitation: What is intestinal rehab? - Episode 1
Statement
Earlier recognition and taking advantage of the gut's biology to adapt are time dependent.
Open
Quotation
What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing.
Open
Statement
Intestinal rehabilitation depends on nutrition in the gut, nutrition in the body, and healing.
Open
Statement
Pattern recognition from multiple experienced clinicians observing patients over time is essential in intestinal rehabilitation.
Open
Quotation
So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time.
Open
Statement
Three time points exist for diagnosis and referral to intestinal rehab: prenatal diagnosis (atresia with cystic fibrosis, gastroschisis), postnatal acquired problems (volvulus, NEC), and later presentations after discharge when patients fail to progress.
Open
Statement
Innovation in intestinal rehabilitation comes from multiple approaches to problems and different visions, with more expertise leading to better outcomes.
Open
Statement
Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being adequately addressed.
Open
Statement
The intestinal rehabilitation team includes dietitians (for nutritional needs), social workers, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology.
Open
Quotation
I think the big key to a person watching the podcast is that they get hope. These are wonderful children. They're, they're opportunities to grow up and to live the lives that their families want is really in front of them.
Open
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?
Quotation
And so earlier recognition and and taking advantage of the biology of the gut that wants to accommodate, we call it adapt um and meet the needs of the child um are time dependent.
Open
Statement
Earlier recognition and taking advantage of the gut's adaptive biology are time dependent.
Open
Quotation
What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing.
Open
Statement
Intestinal rehabilitation depends on key factors: nutrition in the gut, nutrition in the body, and healing.
Open
Quotation
So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time.
Open
Statement
Pattern recognition from multiple expert eyes observing a patient over time is essential in intestinal rehabilitation.
Open
Statement
Families reach intestinal rehabilitation programs at three time points: prenatal diagnosis (typically atresia with cystic fibrosis or gastroschisis), postnatal acquired problems (volvulus or NEC), and later diagnosis after discharge when patients fail to progress.
Open
Statement
Innovation comes from multiple approaches to a problem and different visions; bringing in more expertise leads to better outcomes.
Open
Statement
Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being met.
Open
Statement
The intestinal rehabilitation team includes dietitians (understanding nutritional needs), social work, nurse practitioners, pharmacy, interventional radiology, pathology, and subspecialties including endocrinology and nephrology.
Open
Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 1
Statement
Mistakes are commonly made because clinicians think they can predict the future with their eyes, predetermining care based on what they believe will happen rather than allowing the clinical scenario to drive the direction of care.
Open
Quotation
Mistakes I believe are commonly made because we think we can predict the future with our eyes, and that the first line of treating a baby with overwhelming catastrophe is to allow the clinical scenario to drive the direction of care and not us predicting. Predetermining the care based on what we believe will happen.
Open
Statement
There is an algorithm of children with overwhelming sepsis where surgery cannot salvage these patients and there is no life-saving option.
Open
Quotation
There is definitely an algorithm of children that have overwhelming sepsis, and surgery cannot salvage these patients. We don't have a life saving option for those patients, but many will actually rally without having their bowel removed, which allows them to have an opportunity which many don't understand yet today.
Open
Statement
Many infants will rally without having their bowel removed, which allows them an opportunity for recovery.
Open
Quotation
Decompressing the duodenum is the is the needed thing that has to occur to buy you that. to protect the liver and that when the liver is inflamed and has high bilirubin, it's in a catabolic state.
Open
Statement
Decompressing the duodenum is needed to protect the liver, and when the liver is inflamed with high bilirubin, it is in a catabolic state.
Open
Statement
When in the OR wanting to buy time, one of the first things to consider is how to keep the proximal bowel decompressed.
Open
Statement
Placing a retrograde tube in the duodenum or jejunum that goes up to the pylorus to decompress the bowel has given time to allow children to recover from the acute event.
Open
Quotation
A 30-week-old baby's gut is in a very highly developmental phase and its ability to regenerate is much More profound than a full term baby and certainly a one year old baby.
Open
Statement
A 30-week-old baby's gut is in a highly developmental phase and its ability to regenerate is much more profound than a full-term baby and certainly a one-year-old baby.
Open
Quotation
The distal bowel, the ileum, is remarkably important and can be salvaged by ileocecal blood flow, and leaving it alone and allowing that to occur has allowed us to salvage a lot of tissue in Cincinnati.
Open
Statement
The distal bowel (ileum) is remarkably important and can be salvaged by ileocecal blood flow; leaving it alone has allowed salvage of a lot of tissue in Cincinnati.
Open
Statement
Proximal control allows tissue time to regenerate, which is often on the order of 6, 8, or 12 weeks based on the liver getting better.
Open
Statement
If dealing with less than 50% bowel necrosis, the best option is to remove that bowel and the child's adaptive potential is really great, especially if ileum is preserved.
Open
Statement
If necrotic bowel is focal and less than 50%, it should be removed and the child managed accordingly; the approach is not to leave all dead bowel in place.
Open
Statement
When bowel necrosis is patchy with areas that look terrible, bad, and maybe a little good (mosaicism), proximally controlling the bowel with a drain and providing time to heal gives opportunity to return later; not all bowel will survive and islands of mucosa will need to be tubularized and reconnected.
Open
Statement
Once proximal bowel is controlled with a drain, stomas should be avoided because they lose abdominal domain and lose bowel down the road.
Open
Statement
The percentage of infants that do well with proximal drain therapy when facing dead gut is more than 70 to 80%.
Open
Statement
The approach to overwhelming bowel necrosis does not differ based on diagnosis (volvulus, infarct, mesenteric thrombosis), but the outcome does.
Open
Statement
Controlling proximal bowel without allowing enteric content has been key to salvaging NEC patients with good outcomes.
Open
Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 2
Statement
The ileum reclaims bile, tells the liver what to do, and produces hormones like GLP-2, PYY, and others that slow motility and signal the jejunum to reabsorb fluid.
Open
Statement
The ileum reclaims bile, tells the liver what to do, and produces hormones like GLP-2, PYY, and others that slow motility and signal the jejunum to reabsorb fluid.
Open
Statement
The colon can account for one-third to one-half of the caloric needs of these babies when exposed to undigested nutrients.
Open
Quotation
The colon can actually maybe account for a third. Half of the caloric needs of some of these babies when exposed to undigested nutrients.
Open
Statement
The colon can account for one-third to one-half of the caloric needs of these babies when exposed to undigested nutrients.
Open
Quotation
The colon can actually maybe account for a third. Half of the caloric needs of some of these babies when exposed to undigested nutrients.
Open
Statement
These children with overwhelming intestinal catastrophe are largely neurologically fine—they are running and playing—and their life expectancy is not associated with lifelong care needs that most parents would not want.
Open
Statement
These children with overwhelming intestinal catastrophe are largely neurologically fine—they are running and playing—and their life expectancy is not associated with lifelong care needs that most parents would not want.
Open
Quotation
These kids largely are neurologically fine. They're running and playing, and the, the thought that you would be salvaging a baby to have a lifelong care need and their, their life expectancy would not be associated with things that most parents would want for their children is not what we see in the clinic.
Open
Quotation
These kids largely are neurologically fine. They're running and playing, and the, the thought that you would be salvaging a baby to have a lifelong care need and their, their life expectancy would not be associated with things that most parents would want for their children is not what we see in the clinic.
Open
Statement
The child should be the one driving the care, not the surgeon's expectations or lack thereof; without changing that early paradigm, nothing else can improve in this population.
Open
Statement
The child should be the one driving the care, not the surgeon's expectations or lack thereof; without changing that early paradigm, nothing else can improve in this population.
Open
Quotation
And again, I think the take home message of this is the child should be the one driving the care, not your expectations or the lack thereof.
Open
Quotation
And again, I think the take home message of this is the child should be the one driving the care, not your expectations or the lack thereof.
Open
Quotation
Well, I mean, obviously bowel removed is bowel never to be used. The, the fear that it's driving a neurocognitive thing, I think needs to be supported with data.
Open
Quotation
Well, I mean, obviously bowel removed is bowel never to be used. The, the fear that it's driving a neurocognitive thing, I think needs to be supported with data.
Open
Statement
Bowel removed is bowel never to be used; the fear that delayed surgery drives neurocognitive harm needs to be supported with data.
Open
Statement
Bowel removed is bowel never to be used; the fear that delayed surgery drives neurocognitive harm needs to be supported with data.
Open
Quotation
The neck kids do remarkably well, and I would argue most neck kids don't have overwhelming totalis.
Open
Statement
NEC totalis in NEC patients is fairly rare; most NEC patients do not have overwhelming totalis.
Open
Statement
NEC totalis in NEC patients is fairly rare; most NEC patients do not have overwhelming totalis.
Open
Quotation
The neck kids do remarkably well, and I would argue most neck kids don't have overwhelming totalis.
Open
Statement
A dozen or more children with NEC totalis at Cincinnati have survived, are off TPN, and have done remarkably well; the comparative group is dead children who have no neurological function.
Open
Quotation
Certainly, the, the comparative group to that patient is in a cemetery. As, as rude as that sounds, um, a dead child has no neurological function.
Open
Statement
A dozen or more children with NEC totalis at Cincinnati have survived, are off TPN, and have done remarkably well; the comparative group is dead children who have no neurological function.
Open
Quotation
Certainly, the, the comparative group to that patient is in a cemetery. As, as rude as that sounds, um, a dead child has no neurological function.
Open
Quotation
Once they live, the opportunities for us to move forward in this field and rehabilitate the bowel, the new tools that we will make in the next decade are going to be profound.
Open
Statement
Once these patients survive the acute phase, the opportunities to rehabilitate the bowel and the new tools that will be developed in the next decade are going to be profound.
Open
Statement
Once these patients survive the acute phase, the opportunities to rehabilitate the bowel and the new tools that will be developed in the next decade are going to be profound.
Open
Quotation
Once they live, the opportunities for us to move forward in this field and rehabilitate the bowel, the new tools that we will make in the next decade are going to be profound.
Open
Quotation
But the opportunity given to that child is made at the time that you open the belly and you see catastrophe.
Open
Quotation
But the opportunity given to that child is made at the time that you open the belly and you see catastrophe.
Open
Statement
The opportunity given to the child is made at the time the surgeon opens the belly and sees catastrophe; removing all bowel eliminates all future potential based on clinical acumen that the outcome will be bad.
Open
Statement
The opportunity given to the child is made at the time the surgeon opens the belly and sees catastrophe; removing all bowel eliminates all future potential based on clinical acumen that the outcome will be bad.
Open
Quotation
So you remove all the potential that we have in the future. Based on your clinical acumen that this is gonna have a bad outcome, and that it's time to withdraw.
Open
Quotation
So you remove all the potential that we have in the future. Based on your clinical acumen that this is gonna have a bad outcome, and that it's time to withdraw.
Open
Statement
The first team that must be convinced of this approach is the neonatology team, because historically they are the ones who removed breathing tubes and allowed these babies to pass.
Open
Statement
The first team that must be convinced of this approach is the neonatology team, because historically they are the ones who removed breathing tubes and allowed these babies to pass.
Open
Quotation
And the first team that has to be convinced is your neonatologist because they're the ones at the bedside who historically removed the breathing tubes on these kids and allowed them to pass.
Open
Quotation
And the first team that has to be convinced is your neonatologist because they're the ones at the bedside who historically removed the breathing tubes on these kids and allowed them to pass.
Open
Statement
If you see protein growth, linear growth, and head growth in the baby, that is brain growth; a baby will not grow well with an unhealthy liver or poor management.
Open
Statement
If you see protein growth, linear growth, and head growth in the baby, that is brain growth; a baby will not grow well with an unhealthy liver or poor management.
Open
Quotation
If you see protein growth and linear growth of your baby and head growth, that's brain growth, and a baby will not grow well with a, with an unhealthy liver and is not managed well.
Open
Quotation
If you see protein growth and linear growth of your baby and head growth, that's brain growth, and a baby will not grow well with a, with an unhealthy liver and is not managed well.
Open
Quotation
Unhealthy liver is, is not providing the protein for the neurocognitive development, period. And that's why it's the number one priority early, uh, that you should have.
Open
Quotation
Unhealthy liver is, is not providing the protein for the neurocognitive development, period. And that's why it's the number one priority early, uh, that you should have.
Open
Statement
An unhealthy liver does not provide the protein necessary for neurocognitive development; liver health is the number one priority early in management.
Open
Statement
An unhealthy liver does not provide the protein necessary for neurocognitive development; liver health is the number one priority early in management.
Open
Statement
Babies, especially premature babies in the first year of life, have caloric needs of 80–120 kcal/kg because they are growing and developing; when critically ill they are no longer growing and their livers are catabolic, so feeding 150 kcal/kg will not result in growth.
Open
Statement
Babies, especially premature babies in the first year of life, have caloric needs of 80–120 kcal/kg because they are growing and developing; when critically ill they are no longer growing and their livers are catabolic, so feeding 150 kcal/kg will not result in growth.
Open
Quotation
When you're critically ill, you no longer are growing and developing. You can feed these babies 150 k cals per kilo, but they will not grow because their livers are catabolic.
Open
Quotation
When you're critically ill, you no longer are growing and developing. You can feed these babies 150 k cals per kilo, but they will not grow because their livers are catabolic.
Open
Quotation
So I know this baby is going to need multiple operations. So the incision is a transverse incision because I know over time that's the one that's going to give me the least problems.
Open
Statement
For a 30-week baby with extensive NEC and a long segment of dead bowel, the surgeon knows the baby will need multiple operations, so a transverse incision is used because it causes the least problems over time.
Open
Quotation
So I know this baby is going to need multiple operations. So the incision is a transverse incision because I know over time that's the one that's going to give me the least problems.
Open
Statement
For a 30-week baby with extensive NEC and a long segment of dead bowel, the surgeon knows the baby will need multiple operations, so a transverse incision is used because it causes the least problems over time.
Open
Statement
The surgeon finds a segment of bowel just beyond what is expected to heal (1–2 cm margin) and brings in an 8 or 10 French Blake drain, often from the left lower quadrant if normally rotated, placing it through bowel that is not expected to do well and advancing it retrograde to the pylorus.
Open
Statement
The surgeon finds a segment of bowel just beyond what is expected to heal (1–2 cm margin) and brings in an 8 or 10 French Blake drain, often from the left lower quadrant if normally rotated, placing it through bowel that is not expected to do well and advancing it retrograde to the pylorus.
Open
Statement
A loose tie is placed around the most healthy part of the bowel around the drain to control secretions, and a purse-string is placed at the insertion site and secured to the skin, essentially stemming the bowel to the abdominal wall; this takes minutes.
Open
Statement
A loose tie is placed around the most healthy part of the bowel around the drain to control secretions, and a purse-string is placed at the insertion site and secured to the skin, essentially stemming the bowel to the abdominal wall; this takes minutes.
Open
Statement
If the stomach is visible, a purse-string is placed in the stomach and a 5–7 French feeding tube is inserted into the proximal bowel and tied, taking one to two minutes; this avoids having to access the left upper quadrant later for a G-tube.
Open
Statement
If the stomach is visible, a purse-string is placed in the stomach and a 5–7 French feeding tube is inserted into the proximal bowel and tied, taking one to two minutes; this avoids having to access the left upper quadrant later for a G-tube.
Open
Statement
The surgeon tries to close the abdomen primarily, but if there is concern about dead bowel, Alloderm is placed; if very worried, a drain is placed in the abdomen to allow drainage.
Open
Statement
The surgeon tries to close the abdomen primarily, but if there is concern about dead bowel, Alloderm is placed; if very worried, a drain is placed in the abdomen to allow drainage.
Open
Quotation
I try to avoid doing significant dissection of the distal ileum one because I wanna preserve the blood. So I wanna let the collateralization happen to recover as much of that proximal bowel as possible.
Open
Statement
The surgeon tries to avoid significant dissection of the distal ileum to preserve blood supply and allow collateralization to recover as much proximal bowel as possible.
Open
Statement
The surgeon tries to avoid significant dissection of the distal ileum to preserve blood supply and allow collateralization to recover as much proximal bowel as possible.
Open
Quotation
I try to avoid doing significant dissection of the distal ileum one because I wanna preserve the blood. So I wanna let the collateralization happen to recover as much of that proximal bowel as possible.
Open
Statement
If the distal diverted bowel is baggy and filled with bloody enteric fluid, and there are distal perforations with patchy necrosis, the surgeon may place stitches distal to proximal to bring the bowel together to preserve muscle, planning to manage it later.
Open
Statement
If the distal diverted bowel is baggy and filled with bloody enteric fluid, and there are distal perforations with patchy necrosis, the surgeon may place stitches distal to proximal to bring the bowel together to preserve muscle, planning to manage it later.
Open
Quotation
I will put a refeeding tube in the distal bowel so I can refeed and let that intermediate bowel. To sort of hang out.
Open
Quotation
I will put a refeeding tube in the distal bowel so I can refeed and let that intermediate bowel. To sort of hang out.
Open
Statement
A refeeding tube is placed in the distal bowel to allow refeeding and let the intermediate bowel hang out and heal; this depends on the amount of proximal bowel and whether feeding is feasible.
Open
Statement
A refeeding tube is placed in the distal bowel to allow refeeding and let the intermediate bowel hang out and heal; this depends on the amount of proximal bowel and whether feeding is feasible.
Open
Statement
In one current case with 40 cm of proximal bowel, refeeding is allowing the surgeon to wait longer for intervening bowel to heal, and the baby's liver is fine, buying time because the fluid output from injured bowel is very high.
Open
Statement
In one current case with 40 cm of proximal bowel, refeeding is allowing the surgeon to wait longer for intervening bowel to heal, and the baby's liver is fine, buying time because the fluid output from injured bowel is very high.
Open
Quotation
And so it's just buying me time and the time is because the amount of fluid that comes out of injured bowel is very high.
Open
Quotation
And so it's just buying me time and the time is because the amount of fluid that comes out of injured bowel is very high.
Open
Quotation
I think these conversations need to be had with other providers. in the room, not just your surgical colleagues, because the, the neonatologists and dietitians have to be on board.
Open
Statement
These conversations about approach need to be had with neonatologists and dietitians in the room, not just surgical colleagues, because they must be on board.
Open
Statement
These conversations about approach need to be had with neonatologists and dietitians in the room, not just surgical colleagues, because they must be on board.
Open
Quotation
I think these conversations need to be had with other providers. in the room, not just your surgical colleagues, because the, the neonatologists and dietitians have to be on board.
Open
Quotation
Families are, are not able to make decisions. Once you explain to the family that the individual making the decisions moving forward is a baby, and you explain that to them, when things go bad, it actually makes it easier for them.
Open
Statement
Families are not able to make decisions in these situations; once the family is told that the baby is the one driving decisions moving forward, it makes things easier for them when outcomes are bad.
Open
Quotation
Families are, are not able to make decisions. Once you explain to the family that the individual making the decisions moving forward is a baby, and you explain that to them, when things go bad, it actually makes it easier for them.
Open
Statement
Families are not able to make decisions in these situations; once the family is told that the baby is the one driving decisions moving forward, it makes things easier for them when outcomes are bad.
Open
Statement
Many babies taken to the OR are not as critically sick as believed; once proximal bowel is controlled and everything is decompressed, many will slowly improve.
Open
Quotation
I think you'd be surprised at the number of kids who are sick, taken to the OR, but they're not as critically sick as we believe they're going to be.
Open
Quotation
I think you'd be surprised at the number of kids who are sick, taken to the OR, but they're not as critically sick as we believe they're going to be.
Open
Statement
Many babies taken to the OR are not as critically sick as believed; once proximal bowel is controlled and everything is decompressed, many will slowly improve.
Open
Quotation
Many of those kids, once you control the proximal bowel and you get everything decompressed, will actually slowly get better.
Open
Quotation
Many of those kids, once you control the proximal bowel and you get everything decompressed, will actually slowly get better.
Open
Statement
Long-term, if all bowel is removed, many patients will heal but there is no opportunity for rehabilitation; that experiment has been done.
Open
Statement
Long-term, if all bowel is removed, many patients will heal but there is no opportunity for rehabilitation; that experiment has been done.
Open
Quotation
Long term, if you take everything out, there are many of them that will heal, and then we have no opportunity. That Experiment's been done.
Open
Quotation
Long term, if you take everything out, there are many of them that will heal, and then we have no opportunity. That Experiment's been done.
Open
Statement
Blake tubes have linear cuts on the outside so they do not get obstructed when secretions accumulate; they are soft and do not put pressure on damaged bowel; they can be connected to a bulb syringe and cut to size.
Open
Statement
Blake tubes have linear cuts on the outside so they do not get obstructed when secretions accumulate; they are soft and do not put pressure on damaged bowel; they can be connected to a bulb syringe and cut to size.
Open
Quotation
The Blake tube has linear cuts on the outside, so they, they won't get obstructed in many situations when secretions and stuff get around them. And that's why I like them a lot.
Open
Quotation
The Blake tube has linear cuts on the outside, so they, they won't get obstructed in many situations when secretions and stuff get around them. And that's why I like them a lot.
Open
Quotation
What's the downside of them is you can't change them over a wire, like you can a JP and other ones that just have side holes.
Open
Statement
The downside of Blake tubes is that they cannot be changed over a wire like JP drains with side holes; the ideal tube would be a Blake with a central hole for wire passage.
Open
Statement
The downside of Blake tubes is that they cannot be changed over a wire like JP drains with side holes; the ideal tube would be a Blake with a central hole for wire passage.
Open
Quotation
What's the downside of them is you can't change them over a wire, like you can a JP and other ones that just have side holes.
Open
Quotation
If I had the best scenario, it would be a blake tube that has a central hole that I could pass a wire.
Open
Quotation
If I had the best scenario, it would be a blake tube that has a central hole that I could pass a wire.
Open
Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 1
Statement
Adaptation is defined as developing and strengthening gut function, occurring naturally in infants during in utero development and the first few years of life, or as a regenerative response to damage in older children.
Open
Statement
Adaptation is defined as developing and strengthening gut function, occurring naturally in infants during in utero development and the first few years of life, or as a regenerative response to damage in older children.
Open
Quotation
And it generally takes time, and that time is measured in. Months and years and not weeks and days, but the one thing that it requires in all situations is enteral nutrition.
Open
Statement
Adaptation generally takes months and years, not weeks and days, and requires enteral nutrition in all situations.
Open
Quotation
And it generally takes time, and that time is measured in. Months and years and not weeks and days, but the one thing that it requires in all situations is enteral nutrition.
Open
Statement
Adaptation generally takes months and years, not weeks and days, and requires enteral nutrition in all situations.
Open
Statement
The duodenum senses caloric intake, monitors sugars, receives hepatobiliary secretions, takes up iron, and functions as an endocrine engine recognizing meal initiation.
Open
Statement
The duodenum senses caloric intake, monitors sugars, receives hepatobiliary secretions, takes up iron, and functions as an endocrine engine recognizing meal initiation.
Open
Statement
The jejunum is largely a source of fluid secretion needed for digestion, with random back-and-forth sloshing motion like a washing machine.
Open
Statement
The jejunum is largely a source of fluid secretion needed for digestion, with random back-and-forth sloshing motion like a washing machine.
Open
Statement
The ileum secretes different hormones including the incretins GLP-2, GLP-1, and PYY, which stop gastric emptying and slow motility when excess liquid is detected in the distal bowel and proximal colon.
Open
Statement
The ileum secretes different hormones including the incretins GLP-2, GLP-1, and PYY, which stop gastric emptying and slow motility when excess liquid is detected in the distal bowel and proximal colon.
Open
Statement
The distal ileum's ability to take up bile sends a signal to the liver, the metabolic engine that helps regulate the whole metabolism of the patient.
Open
Statement
The distal ileum's ability to take up bile sends a signal to the liver, the metabolic engine that helps regulate the whole metabolism of the patient.
Open
Statement
In short gut patients, the colon becomes a source of energy uptake when exposed to free fatty acids, which requires the presence of bacteria.
Open
Quotation
It, in fact, in, in our patients is a source of energy uptake when allowed to see things like free fatty acids, and that requires the presence of bacteria.
Open
Statement
In short gut patients, the colon becomes a source of energy uptake when exposed to free fatty acids, which requires the presence of bacteria.
Open
Quotation
It, in fact, in, in our patients is a source of energy uptake when allowed to see things like free fatty acids, and that requires the presence of bacteria.
Open
Statement
Colonic adaptation does not occur in most normal patients because energy is already reclaimed before reaching the colon.
Open
Statement
Colonic adaptation does not occur in most normal patients because energy is already reclaimed before reaching the colon.
Open
Statement
Adaptation is highly influenced by modifiable factors including formula type, H2 blockers, antibiotics, illness episodes, and motility changes.
Open
Statement
Adaptation is highly influenced by modifiable factors including formula type, H2 blockers, antibiotics, illness episodes, and motility changes.
Open
Quotation
But what people don't recognize is the last thing you need to come off a TPN is fluid.
Open
Quotation
But what people don't recognize is the last thing you need to come off a TPN is fluid.
Open
Statement
The last thing a patient needs to come off TPN is fluid; without adequate hydration, the baby will not grow and will not efficiently absorb nutrition, losing energy and decreasing their growth trajectory.
Open
Statement
The last thing a patient needs to come off TPN is fluid; without adequate hydration, the baby will not grow and will not efficiently absorb nutrition, losing energy and decreasing their growth trajectory.
Open
Statement
Lab data from Cincinnati shows a shift in microbiota to more acid-producing bacteria in an acidotic state, with increased bile due to lack of reclamation.
Open
Statement
Lab data from Cincinnati shows a shift in microbiota to more acid-producing bacteria in an acidotic state, with increased bile due to lack of reclamation.
Open
Statement
Bacterial colonization differences from normal are part of the adaptive response and should not automatically be considered pathological; they need to be studied and taken into context.
Open
Quotation
And just seeing something that's different than normal doesn't make it bad, needs to be studied and needs to be taken into context.
Open
Statement
Bacterial colonization differences from normal are part of the adaptive response and should not automatically be considered pathological; they need to be studied and taken into context.
Open
Quotation
And just seeing something that's different than normal doesn't make it bad, needs to be studied and needs to be taken into context.
Open
Statement
NEC is an acquired condition; infants are born, start eating (often reaching near-full feeds), then have an incident usually at 2-3 weeks of life, meaning they have not been using their gut during the critical 35-week-to-6-months adaptive window.
Open
Statement
NEC is an acquired condition; infants are born, start eating (often reaching near-full feeds), then have an incident usually at 2-3 weeks of life, meaning they have not been using their gut during the critical 35-week-to-6-months adaptive window.
Open
Statement
Whether a child has been fed before makes them different from one who has never been fed, affecting their adaptive potential.
Open
Quotation
Ask yourself, has this child been fed before, because that child's different than the one that's never been fed.
Open
Quotation
Ask yourself, has this child been fed before, because that child's different than the one that's never been fed.
Open
Statement
Whether a child has been fed before makes them different from one who has never been fed, affecting their adaptive potential.
Open
Statement
Surgical planning for short gut patients is like a game of chess requiring consideration of the second, third, and fourth steps ahead.
Open
Statement
Surgical planning for short gut patients is like a game of chess requiring consideration of the second, third, and fourth steps ahead.
Open
Statement
The sooner a child can be fed safely and bowel access achieved without exposing them to surgical risk, the more the adaptive process can be leveraged.
Open
Statement
The sooner a child can be fed safely and bowel access achieved without exposing them to surgical risk, the more the adaptive process can be leveraged.
Open
Statement
Cincinnati strategies were developed to take advantage of the easiest, safest way to use the bowel early without needing to return immediately to surgery.
Open
Statement
Cincinnati strategies were developed to take advantage of the easiest, safest way to use the bowel early without needing to return immediately to surgery.
Open
Quotation
You put kids in harm's way when you go to the operating room, no matter how talented you are.
Open
Statement
Surgery puts children in harm's way regardless of surgeon talent, so balancing surgical intervention with optimization of adaptation has led to improved outcomes.
Open
Statement
Surgery puts children in harm's way regardless of surgeon talent, so balancing surgical intervention with optimization of adaptation has led to improved outcomes.
Open
Quotation
You put kids in harm's way when you go to the operating room, no matter how talented you are.
Open
Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1
Statement
Adrian Bianchi first reported the longitudinal intestinal lengthening procedure (Bianchi procedure) that divides bowel along its two leaves and tubularizes it.
Open
Statement
Rising direct bilirubin was recognized as a sign that children with intestinal failure would not do well.
Open
Statement
The gut doubles in length during the last trimester and the first year of life, and this maturation process occurs when the baby is fed.
Open
Statement
Healthy growth of the intestine requires nutrition; anything that disrupts this affects maturation of both absorptive/digestive capacity and peristalsis.
Open
Quotation
The outcome is one that should benefit the child for 80, 90 years, not just the next 2 months.
Open
Statement
Lengthening bowel that doesn't have peristalsis does not increase absorption; very short bowel children can sometimes come off TPN because their motility is good.
Open
Quotation
The better the waves going over the villa, The more exposure of nutrients and removal of waste that you have is not increased by lengthening the bowel that doesn't peristals. That's just more static water.
Open
Quotation
So we see very short bowel kids sometimes come off a TPM because their motility is so good.
Open
Statement
The enteric nervous system in gastroschisis is damaged from exposure to amniotic fluid and requires a healing and recovery phase; this regeneration is attenuated by dysmotility and stasis, not enhanced.
Open
Statement
In atresia without gastroschisis, the bowel may have good peristalsis from working against an obstruction, and when done correctly with proper orientation, a longitudinal lengthening procedure may benefit the child.
Open
Statement
Children who undergo STEP procedures in their first year of life sometimes never progress and are labeled as poor motility patients unable to tolerate enteral feeds.
Open
Statement
Among patients with limited gut, necrotizing enterocolitis patients do best because they have been fed before, have established GI motility, and the maturation phase has already been initiated.
Open
Quotation
Anything that creates a potential worsening of motility and gastroschisis, especially in the first year of life should be something you should strongly think about before doing.
Open
Statement
The duodenum has no mesentery, making it impossible to orient 90° and 270° positions; surgeons who STEP the duodenum end up entering the bowel at inconsistent orientations.
Open
Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1
Statement
Adrian Bianchi first reported the longitudinal intestinal lengthening procedure (Bianchi procedure) that divides bowel along its two leaves and tubularizes it.
Open
Statement
Rising direct bilirubin was recognized as a sign that children with intestinal failure would not do well.
Open
Statement
The gut doubles in length during the last trimester and the first year of life, and this maturation process occurs when the baby is fed.
Open
Statement
Healthy growth of the intestine requires nutrition; anything that disrupts this affects maturation of both absorptive/digestive capacity and peristalsis.
Open
Quotation
The outcome is one that should benefit the child for 80, 90 years, not just the next 2 months.
Open
Quotation
The better the waves going over the villa, The more exposure of nutrients and removal of waste that you have is not increased by lengthening the bowel that doesn't peristals. That's just more static water.
Open
Statement
Lengthening bowel that doesn't have peristalsis does not increase absorption; very short bowel children can sometimes come off TPN because their motility is good.
Open
Quotation
So we see very short bowel kids sometimes come off a TPM because their motility is so good.
Open
Statement
The enteric nervous system in gastroschisis is damaged from exposure to amniotic fluid and requires a healing and recovery phase; this regeneration is attenuated by dysmotility and stasis, not enhanced.
Open
Statement
In atresia without gastroschisis, the bowel may have good peristalsis from working against an obstruction, and when done correctly with proper orientation, a longitudinal lengthening procedure may benefit the child.
Open
Statement
Children who undergo STEP procedures in their first year of life sometimes never progress and are labeled as poor motility patients unable to tolerate enteral feeds.
Open
Statement
Among patients with limited gut, necrotizing enterocolitis patients do best because they have been fed before, have established GI motility, and the maturation phase has already been initiated.
Open
Quotation
Anything that creates a potential worsening of motility and gastroschisis, especially in the first year of life should be something you should strongly think about before doing.
Open
Statement
The duodenum has no mesentery, making it impossible to orient 90° and 270° positions; surgeons who STEP the duodenum end up entering the bowel at inconsistent orientations.
Open
Intestinal Rehabilitation, Episode 4: Surgical Management, Part 2
Statement
Half of the people that have a STEP will have progression of improved enteral tolerance, and half will actually have a worsening.
Open
Quotation
Half of the people that have a step will have progression of improved animal tolerance. Half will have actually a worsening.
Open
Statement
The six month postoperative period is very critical for analyzing how the patient is moving forward after STEP.
Open
Quotation
If you're going to operate on a kid for a step procedure, you need to first rule out other anatomical problems.
Open
Statement
Before operating for a STEP procedure, you need to first rule out other anatomical problems by laying out the bowel and getting the mesentery completely oriented.
Open
Statement
If you only focus on the STEP without examining the complete anatomy, you will miss some of the reasons why these kids aren't getting better.
Open
Quotation
The management of these kids is not a one-stop shopping that you're going to fix that kid with your operation. There is nothing wrong with staging.
Open
Statement
The management of these kids is not a one-stop shopping that you're going to fix with your operation; there is nothing wrong with staging.
Open
Quotation
One of the things that we've seen as a complication here is that the kids have done really well with step procedures, but they have continued loss from either they lose protein in the stool or we see recurrent bleeding.
Open
Quotation
And so that mesenteric fire that Causes inflammation and scarring, creates an obstruction to venous outflow.
Open
Statement
Mesenteric inflammation and scarring creates an obstruction to venous outflow, resulting in venous hypertension along the staple lines.
Open
Statement
During operation for staple line bleeding, you can see vessels the size of your thumb and really big adenopathy because the lymphatics are also obstructed.
Open
Quotation
And when you operate. You can see vessels the size of your thumb, and you'll see really big adenopathy because the lymphatics are also obstructed.
Open
Statement
The key in managing staple line bleeding is to look at the mesentery and free up the mesentery, not just look at the bowel.
Open
Quotation
So the key to me in that situation of bleeding is look at the mesentery. Make sure you free up the mesentery. Don't just look at the bowel.
Open
Statement
Mesenteric scarring causing venous hypertension is obvious if you're looking for it during operation.
Open
Statement
Dr. Helmrath documents detailed operative notes for himself describing orientation, landmarks, and what was done to guide future operations.
Open
Statement
Surgeons should try not to be the hero and try not to do everything, especially in the first week of life; understand that biology, physiology, and growth are a spectrum.
Open
Quotation
Try not to be the hero. Try not to do everything, especially the first week in life. Understand biology and physiology and growth is a spectrum, and. Optimize it.
Open
Quotation
This population is one that the surgeon plays a huge role in, even when they're doing well, because you have to see the progress.
Open
Statement
The surgeon plays a huge role in intestinal rehabilitation even when patients are doing well, because you have to see the progress.
Open
Intestinal Rehabilitation, Episode 6: Cholestasis
Quotation
I believe though that as we've gotten better and we've learned how to use lipid emulgens differently and nutrition differently and our approaches. That the definition of cholestasis is not as much as a morbidity mortality as much as it is an indicator of underlying diseases that we need to address.
Open
Statement
As treatment has improved with different lipid emulsions and nutrition approaches, cholestasis has become more an indicator of underlying diseases to address rather than a primary morbidity/mortality factor.
Open
Statement
New lipid emulsions including Omegaven (used first in the US) and SMOF (used in Europe and Canada, now prevalent in the US for 3-4 years) can reverse or prevent cholestasis.
Open
Quotation
One of the major advantages I think of the addition of SMP is the ability to provide more calories from fat, as much as 2 2.5 g per kilo. I think that people need to recognize that the management of These kids is healthy growth.
Open
Statement
A major advantage of SMOF is the ability to provide more calories from fat (as much as 2-2.5 g/kg) while supporting healthy growth.
Open
Statement
When refeeding a cholestatic liver after proximal jejunostomy takedown, direct bilirubin typically rises in the first week as bile acid pool is reintroduced and the liver becomes more active in bile salt production.
Open
Quotation
One of the first things that you'll get your neonatologist telling you about when you start feeding is they'll get worried because the direct bilirubin goes up. That's normal.
Open
Statement
GGT, AST, and ALT will go up in the first week or two after anastomosis takedown surgery, then slowly come down over several weeks.
Open
Statement
When direct bilirubin rises after refeeding, the main differential to rule out is urinary tract infection or gram-negative infection; extensive imaging such as ultrasounds is not needed.
Open
Statement
It is important to provide proximal drainage of the duodenum in high-risk intestinal failure patients; Dr. Helmrath places a lake drain for this purpose.
Open
Statement
Ongoing cholestasis with proximal blockage puts pressure in the biliary system at a much higher level and speeds up the cholestatic process.
Open
Intestinal Rehabilitation, Episode 7: Refeeding in a neonatal patient
Statement
Factors to consider when refeeding include poor gastric emptying, poor gastric function, high stoma outputs versus high stooling output, and the age of the child at the time of intestinal damage.
Open
Statement
Damaged bowel is in a secretory phase even when not fed, but feeding stimulates the bowel into an absorptive state through luminal nutrition, eventually reducing stoma volume output.
Open
Quotation
Yeah, remember that especially if there's been damaged bowel, it's gonna be in a secretory phase, even if it's not fed, and people are scared then to feed. And feeling like it's gonna be totally uncontrollable, whereas what happens is the exact opposite, as you start to feed the bowel, then gets in an absorptive state, because the nutrition that's present in the luminal stimulate it to do so, and you'll actually start to see less volume out the stoma in time.
Open
Statement
Mother's breast milk is the ideal feeding choice due to nutritional value and immunomodulatory and growth-healing effects not present in typical formulas.
Open
Quotation
Mom's breast milk is ideal, not just because of the nutritional value, but certainly because it has all the immunomodulatory beneficial effects, growth healing effects. That are not present in typical formulas.
Open
Statement
It is a common mistake to increase enteral feeds by the same volume that TPN is decreased, assuming the child will absorb all those calories, which results in stunted growth.
Open
Quotation
It's a common mistake to increase enteral feeds by X volume that you decrease TPN by, and what you end up doing is you're assuming that the child. And absorb all those calories, and you end up stunting the growth.
Open
Statement
If the child tolerates it and does not have lung issues, the total daily volume can be expanded from 140 to 160, 170, or occasionally even 180 per kilogram.
Open
Quotation
By far the most complicated part of our GI tract is the stomach, because it does both the back and forth, uh, sloshing around that the small bowel does, but in addition, it has to coordinate a squeeze with the relaxation of the pylorus several. Times a minute to induce small amounts of gastric emptying, and so it's not uncommon that when children haven't been fed and they've had an injury, the coordination of the stomach is completely off.
Open
Statement
The stomach is the most complicated part of the GI tract because it must coordinate both back-and-forth sloshing and coordinated squeezing with pyloric relaxation several times per minute to induce gastric emptying.
Open
Statement
When children have not been fed and have had an injury, gastric coordination is commonly completely disrupted.
Open
Quotation
Most of this requires just time. And stimulation, so the way to to buy that time when the rest of the GI tract works is to place a tube beyond the stomach that you can feed from.
Open
Statement
Most gastric dysmotility requires time and stimulation; the way to provide time when the rest of the GI tract works is to place a tube beyond the stomach for feeding.
Open
Statement
In a baby, the best way to achieve distal feeding is through an NJ tube with a G-tube decompressing the stomach, allowing feeding outside the stomach while simultaneously decompressing it.
Open
Quotation
In a baby, uh, the, the best way to get distal feeding is either through an NJ tube, um, with the G tube just decompressing the stomach, so that the baby is allowed to be fed outside the stomach while decompressing the stomach at the same time. And that what ends up happening is that the seeing that you do stimulates the distal small bowel and the colon to produce hormones that largely will tell the stomach to start functioning, and you'll actually break the the cycle.
Open
Statement
Distal feeding stimulates the distal small bowel and colon to produce hormones that signal the stomach to start functioning, breaking the dysmotility cycle.
Open
Statement
Post-pyloric refeeding can be done as a bolus or over a pump; bolus is preferred, but at Cincinnati a protocol of running feeds over a pump for one hour works well, typically starting at 5 then 10 cc per kilogram and advancing based on tolerance.
Open
Quotation
Interestingly, by feeding the colon, one of the things you'll notice quickly is that the output from the stoma actually goes down, speaking to all the hormonal effects of the distal bowel, and often the stomach will start to work.
Open
Statement
Feeding the colon causes stoma output to decrease quickly, reflecting hormonal effects of the distal bowel, and often the stomach will start to work.
Open
Statement
The largest benefit of distal bowel refeeding is that when the two bowel ends are reconnected, the distal bowel has been functionally used, making postoperative feeding easier to initiate.
Open
Quotation
I think undigested formula in the colon is a trigger. It definitely can cause stress to the bowel, and so I'm not sure it's the healthiest thing to do.
Open
Statement
Undigested formula in the colon is a trigger that can cause stress to the bowel and may not be the healthiest approach.
Open
Quotation
The strategy that I've used that I think works very well, is that you, you're not committing the child to a lifelong G tube or even for the first year. If you just place a feeding tube into the. Stomach and stand the stomach up. It's no different than another tube in a kit and especially as I said before, I often direct it out of the pylorus into the proximal small bowel and so it's a source of feeding that allows you to overcome some obstacles that you can never always predict. And, and when these children do well, you just take it out and it's like any other hole that just heals in these kids.
Open
Statement
Placing a feeding tube into the stomach and tacking the stomach up does not commit the child to a lifelong G-tube or even one for the first year; it is no different than another tube and can be directed out of the pylorus into the proximal small bowel.
Open
Statement
When children with G-tubes do well, the tube can be removed and the hole heals like any other in these patients.
Open
Quotation
So it's, it's an ace in the hole, cause the morbidity from that tube is extremely low, and the benefit could be very, very.
Open
Intestinal Rehabilitation Episode 8: Refeeding of an Older Patient
Quotation
Like the recent slew of kids we have that are between 8 and 16 that were eating just fine, and one day boom, they had a volvulus and they've lost 90+% of the bowel.
Open
Quotation
I think some patients actually can come off a TPN but still need a central line for IV fluids, and that in the absence of IV fluids, really, they end up sleeping most of the days, they don't have a lot of energy.
Open
Statement
Some patients can come off TPN but still need a central line for IV fluids; without IV fluids they end up sleeping most of the day and lack energy.
Open
Statement
Sometimes patients cannot drink rehydration solution, but the GI tract can use it (via G-tube).
Open
Quotation
The other key point to remember is that the energy use goes up dramatically during puberty, and so you often will find a child who is actually doing well, and they hit the wall when they start puberty because their energy needs are overcoming their nutrient input.
Open
Statement
Children who are doing well often hit the wall when they start puberty because their energy needs overcome their nutrient input.
Open
Statement
The goal is always healthy growth, and it is important to be proactive, add supplements, and hope they will take extra nutritional support.
Open
Statement
Clinicians should look at the growth chart for both weight and height, and not accept a 3rd percentile.
Open
Quotation
I can't emphasize enough to look at the growth chart, both the weight, but also the height, and don't accept a 3rd percentile.
Open
Statement
For any child not meeting growth potential, numerous other diagnoses can be responsible, ranging from endocrine issues to pancreatic insufficiency to micronutrient issues.
Open
Statement
The concept is that patients are capable of having normal growth, and as you address issues and improve something, you need reasonable follow-up time on the order of weeks, not months.
Open
Statement
Much of the growth monitoring can be done remotely; patients do not need to travel for assessment, but you cannot wait until the next appointment.
Open
Intestinal Rehabilitation Webinar 2023 - Top 5 Key Takeaways
Quotation
So, to me, I believe the more important fact is the presence or absence of the distal small bowel or the ileum and even right colon that can act as a reclamation of bile and get the inneroppatic circulation.
Open
Statement
The more important factor than the ileocecal valve is the presence or absence of the distal small bowel (ileum) and right colon that can act as a site for bile reclamation and enterohepatic circulation.
Open
Quotation
I think sometimes strategy at the first operation is to be able to provide a pathway forward that allows early interval feeding.
Open
Statement
The surgical strategy at the first operation should provide a pathway forward that allows early interval feeding.
Open
Statement
It is sometimes better to stage reconstruction with the plan to restore bowel continuity under more controlled conditions.
Open
Statement
In situations of overwhelming intestinal loss, the strategy is to provide proximal control that allows feeding to occur without the enteral stream going through, and to leave questionable bowel segments that have potential to heal and can make a huge difference in the child's lifetime.
Open
Statement
Starting at the single amino acid level for protein is the generalized preference, ensuring patients are not having high stool output, high fluid losses, wound breakdown, rashes, or emesis.
Open
Michael's statements about Midgut Volvulus 72 statements
Open the Midgut Volvulus collection →
Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 2
Statement
The ileum reclaims bile, tells the liver what to do, and produces hormones like GLP-2, PYY, and others that slow motility and signal the jejunum to reabsorb fluid.
Open
Quotation
The colon can actually maybe account for a third. Half of the caloric needs of some of these babies when exposed to undigested nutrients.
Open
Statement
The colon can account for one-third to one-half of the caloric needs of these babies when exposed to undigested nutrients.
Open
Quotation
These kids largely are neurologically fine. They're running and playing, and the, the thought that you would be salvaging a baby to have a lifelong care need and their, their life expectancy would not be associated with things that most parents would want for their children is not what we see in the clinic.
Open
Statement
These children with overwhelming intestinal catastrophe are largely neurologically fine—they are running and playing—and their life expectancy is not associated with lifelong care needs that most parents would not want.
Open
Statement
The child should be the one driving the care, not the surgeon's expectations or lack thereof; without changing that early paradigm, nothing else can improve in this population.
Open
Quotation
And again, I think the take home message of this is the child should be the one driving the care, not your expectations or the lack thereof.
Open
Statement
Bowel removed is bowel never to be used; the fear that delayed surgery drives neurocognitive harm needs to be supported with data.
Open
Quotation
Well, I mean, obviously bowel removed is bowel never to be used. The, the fear that it's driving a neurocognitive thing, I think needs to be supported with data.
Open
Statement
NEC totalis in NEC patients is fairly rare; most NEC patients do not have overwhelming totalis.
Open
Quotation
The neck kids do remarkably well, and I would argue most neck kids don't have overwhelming totalis.
Open
Statement
A dozen or more children with NEC totalis at Cincinnati have survived, are off TPN, and have done remarkably well; the comparative group is dead children who have no neurological function.
Open
Quotation
Certainly, the, the comparative group to that patient is in a cemetery. As, as rude as that sounds, um, a dead child has no neurological function.
Open
Quotation
Once they live, the opportunities for us to move forward in this field and rehabilitate the bowel, the new tools that we will make in the next decade are going to be profound.
Open
Statement
Once these patients survive the acute phase, the opportunities to rehabilitate the bowel and the new tools that will be developed in the next decade are going to be profound.
Open
Statement
The opportunity given to the child is made at the time the surgeon opens the belly and sees catastrophe; removing all bowel eliminates all future potential based on clinical acumen that the outcome will be bad.
Open
Quotation
But the opportunity given to that child is made at the time that you open the belly and you see catastrophe.
Open
Quotation
So you remove all the potential that we have in the future. Based on your clinical acumen that this is gonna have a bad outcome, and that it's time to withdraw.
Open
Quotation
And the first team that has to be convinced is your neonatologist because they're the ones at the bedside who historically removed the breathing tubes on these kids and allowed them to pass.
Open
Statement
The first team that must be convinced of this approach is the neonatology team, because historically they are the ones who removed breathing tubes and allowed these babies to pass.
Open
Statement
If you see protein growth, linear growth, and head growth in the baby, that is brain growth; a baby will not grow well with an unhealthy liver or poor management.
Open
Quotation
If you see protein growth and linear growth of your baby and head growth, that's brain growth, and a baby will not grow well with a, with an unhealthy liver and is not managed well.
Open
Statement
An unhealthy liver does not provide the protein necessary for neurocognitive development; liver health is the number one priority early in management.
Open
Quotation
Unhealthy liver is, is not providing the protein for the neurocognitive development, period. And that's why it's the number one priority early, uh, that you should have.
Open
Statement
Babies, especially premature babies in the first year of life, have caloric needs of 80–120 kcal/kg because they are growing and developing; when critically ill they are no longer growing and their livers are catabolic, so feeding 150 kcal/kg will not result in growth.
Open
Quotation
When you're critically ill, you no longer are growing and developing. You can feed these babies 150 k cals per kilo, but they will not grow because their livers are catabolic.
Open
Statement
For a 30-week baby with extensive NEC and a long segment of dead bowel, the surgeon knows the baby will need multiple operations, so a transverse incision is used because it causes the least problems over time.
Open
Quotation
So I know this baby is going to need multiple operations. So the incision is a transverse incision because I know over time that's the one that's going to give me the least problems.
Open
Statement
The surgeon finds a segment of bowel just beyond what is expected to heal (1–2 cm margin) and brings in an 8 or 10 French Blake drain, often from the left lower quadrant if normally rotated, placing it through bowel that is not expected to do well and advancing it retrograde to the pylorus.
Open
Statement
A loose tie is placed around the most healthy part of the bowel around the drain to control secretions, and a purse-string is placed at the insertion site and secured to the skin, essentially stemming the bowel to the abdominal wall; this takes minutes.
Open
Statement
If the stomach is visible, a purse-string is placed in the stomach and a 5–7 French feeding tube is inserted into the proximal bowel and tied, taking one to two minutes; this avoids having to access the left upper quadrant later for a G-tube.
Open
Statement
The surgeon tries to close the abdomen primarily, but if there is concern about dead bowel, Alloderm is placed; if very worried, a drain is placed in the abdomen to allow drainage.
Open
Quotation
I try to avoid doing significant dissection of the distal ileum one because I wanna preserve the blood. So I wanna let the collateralization happen to recover as much of that proximal bowel as possible.
Open
Statement
The surgeon tries to avoid significant dissection of the distal ileum to preserve blood supply and allow collateralization to recover as much proximal bowel as possible.
Open
Statement
If the distal diverted bowel is baggy and filled with bloody enteric fluid, and there are distal perforations with patchy necrosis, the surgeon may place stitches distal to proximal to bring the bowel together to preserve muscle, planning to manage it later.
Open
Quotation
I will put a refeeding tube in the distal bowel so I can refeed and let that intermediate bowel. To sort of hang out.
Open
Statement
A refeeding tube is placed in the distal bowel to allow refeeding and let the intermediate bowel hang out and heal; this depends on the amount of proximal bowel and whether feeding is feasible.
Open
Statement
In one current case with 40 cm of proximal bowel, refeeding is allowing the surgeon to wait longer for intervening bowel to heal, and the baby's liver is fine, buying time because the fluid output from injured bowel is very high.
Open
Quotation
And so it's just buying me time and the time is because the amount of fluid that comes out of injured bowel is very high.
Open
Statement
These conversations about approach need to be had with neonatologists and dietitians in the room, not just surgical colleagues, because they must be on board.
Open
Quotation
I think these conversations need to be had with other providers. in the room, not just your surgical colleagues, because the, the neonatologists and dietitians have to be on board.
Open
Quotation
Families are, are not able to make decisions. Once you explain to the family that the individual making the decisions moving forward is a baby, and you explain that to them, when things go bad, it actually makes it easier for them.
Open
Statement
Families are not able to make decisions in these situations; once the family is told that the baby is the one driving decisions moving forward, it makes things easier for them when outcomes are bad.
Open
Statement
Many babies taken to the OR are not as critically sick as believed; once proximal bowel is controlled and everything is decompressed, many will slowly improve.
Open
Quotation
I think you'd be surprised at the number of kids who are sick, taken to the OR, but they're not as critically sick as we believe they're going to be.
Open
Quotation
Many of those kids, once you control the proximal bowel and you get everything decompressed, will actually slowly get better.
Open
Statement
Long-term, if all bowel is removed, many patients will heal but there is no opportunity for rehabilitation; that experiment has been done.
Open
Quotation
Long term, if you take everything out, there are many of them that will heal, and then we have no opportunity. That Experiment's been done.
Open
Statement
Blake tubes have linear cuts on the outside so they do not get obstructed when secretions accumulate; they are soft and do not put pressure on damaged bowel; they can be connected to a bulb syringe and cut to size.
Open
Quotation
The Blake tube has linear cuts on the outside, so they, they won't get obstructed in many situations when secretions and stuff get around them. And that's why I like them a lot.
Open
Statement
The downside of Blake tubes is that they cannot be changed over a wire like JP drains with side holes; the ideal tube would be a Blake with a central hole for wire passage.
Open
Quotation
What's the downside of them is you can't change them over a wire, like you can a JP and other ones that just have side holes.
Open
Quotation
If I had the best scenario, it would be a blake tube that has a central hole that I could pass a wire.
Open
Intestinal Rehabilitation Episode 8: Refeeding of an Older Patient
Quotation
Like the recent slew of kids we have that are between 8 and 16 that were eating just fine, and one day boom, they had a volvulus and they've lost 90+% of the bowel.
Open
Statement
Some patients can come off TPN but still need a central line for IV fluids; without IV fluids they end up sleeping most of the day and lack energy.
Open
Quotation
I think some patients actually can come off a TPN but still need a central line for IV fluids, and that in the absence of IV fluids, really, they end up sleeping most of the days, they don't have a lot of energy.
Open
Statement
Sometimes patients cannot drink rehydration solution, but the GI tract can use it (via G-tube).
Open
Quotation
The other key point to remember is that the energy use goes up dramatically during puberty, and so you often will find a child who is actually doing well, and they hit the wall when they start puberty because their energy needs are overcoming their nutrient input.
Open
Statement
The goal is always healthy growth, and it is important to be proactive, add supplements, and hope they will take extra nutritional support.
Open
Statement
Children who are doing well often hit the wall when they start puberty because their energy needs overcome their nutrient input.
Open
Statement
Clinicians should look at the growth chart for both weight and height, and not accept a 3rd percentile.
Open
Quotation
I can't emphasize enough to look at the growth chart, both the weight, but also the height, and don't accept a 3rd percentile.
Open
Statement
For any child not meeting growth potential, numerous other diagnoses can be responsible, ranging from endocrine issues to pancreatic insufficiency to micronutrient issues.
Open
Statement
The concept is that patients are capable of having normal growth, and as you address issues and improve something, you need reasonable follow-up time on the order of weeks, not months.
Open
Statement
Much of the growth monitoring can be done remotely; patients do not need to travel for assessment, but you cannot wait until the next appointment.
Open
Michael's statements about Motility / Pseudo-obstruction 22 statements
Open the Motility / Pseudo-obstruction collection →
Intestinal rehabilitation: What is intestinal rehab? - Episode 1
Statement
Earlier recognition and taking advantage of the gut's biology to adapt are time dependent.
Open
Statement
Intestinal rehabilitation depends on nutrition in the gut, nutrition in the body, and healing.
Open
Quotation
What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing.
Open
Statement
Pattern recognition from multiple experienced clinicians observing patients over time is essential in intestinal rehabilitation.
Open
Quotation
So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time.
Open
Statement
Three time points exist for diagnosis and referral to intestinal rehab: prenatal diagnosis (atresia with cystic fibrosis, gastroschisis), postnatal acquired problems (volvulus, NEC), and later presentations after discharge when patients fail to progress.
Open
Statement
Innovation in intestinal rehabilitation comes from multiple approaches to problems and different visions, with more expertise leading to better outcomes.
Open
Statement
Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being adequately addressed.
Open
Statement
The intestinal rehabilitation team includes dietitians (for nutritional needs), social workers, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology.
Open
Quotation
I think the big key to a person watching the podcast is that they get hope. These are wonderful children. They're, they're opportunities to grow up and to live the lives that their families want is really in front of them.
Open
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?
Quotation
And so earlier recognition and and taking advantage of the biology of the gut that wants to accommodate, we call it adapt um and meet the needs of the child um are time dependent.
Open
Statement
Earlier recognition and taking advantage of the gut's adaptive biology are time dependent.
Open
Quotation
What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing.
Open
Statement
Intestinal rehabilitation depends on key factors: nutrition in the gut, nutrition in the body, and healing.
Open
Quotation
So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time.
Open
Statement
Pattern recognition from multiple expert eyes observing a patient over time is essential in intestinal rehabilitation.
Open
Statement
Families reach intestinal rehabilitation programs at three time points: prenatal diagnosis (typically atresia with cystic fibrosis or gastroschisis), postnatal acquired problems (volvulus or NEC), and later diagnosis after discharge when patients fail to progress.
Open
Statement
Innovation comes from multiple approaches to a problem and different visions; bringing in more expertise leads to better outcomes.
Open
Statement
Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being met.
Open
Statement
The intestinal rehabilitation team includes dietitians (understanding nutritional needs), social work, nurse practitioners, pharmacy, interventional radiology, pathology, and subspecialties including endocrinology and nephrology.
Open
Michael's statements about Necrotizing Enterocolitis 83 statements
Open the Necrotizing Enterocolitis collection →
Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 2
Statement
The ileum reclaims bile, tells the liver what to do, and produces hormones like GLP-2, PYY, and others that slow motility and signal the jejunum to reabsorb fluid.
Open
Statement
The colon can account for one-third to one-half of the caloric needs of these babies when exposed to undigested nutrients.
Open
Quotation
The colon can actually maybe account for a third. Half of the caloric needs of some of these babies when exposed to undigested nutrients.
Open
Statement
These children with overwhelming intestinal catastrophe are largely neurologically fine—they are running and playing—and their life expectancy is not associated with lifelong care needs that most parents would not want.
Open
Quotation
These kids largely are neurologically fine. They're running and playing, and the, the thought that you would be salvaging a baby to have a lifelong care need and their, their life expectancy would not be associated with things that most parents would want for their children is not what we see in the clinic.
Open
Statement
The child should be the one driving the care, not the surgeon's expectations or lack thereof; without changing that early paradigm, nothing else can improve in this population.
Open
Quotation
And again, I think the take home message of this is the child should be the one driving the care, not your expectations or the lack thereof.
Open
Quotation
Well, I mean, obviously bowel removed is bowel never to be used. The, the fear that it's driving a neurocognitive thing, I think needs to be supported with data.
Open
Statement
Bowel removed is bowel never to be used; the fear that delayed surgery drives neurocognitive harm needs to be supported with data.
Open
Statement
NEC totalis in NEC patients is fairly rare; most NEC patients do not have overwhelming totalis.
Open
Quotation
The neck kids do remarkably well, and I would argue most neck kids don't have overwhelming totalis.
Open
Statement
A dozen or more children with NEC totalis at Cincinnati have survived, are off TPN, and have done remarkably well; the comparative group is dead children who have no neurological function.
Open
Quotation
Certainly, the, the comparative group to that patient is in a cemetery. As, as rude as that sounds, um, a dead child has no neurological function.
Open
Statement
Once these patients survive the acute phase, the opportunities to rehabilitate the bowel and the new tools that will be developed in the next decade are going to be profound.
Open
Quotation
Once they live, the opportunities for us to move forward in this field and rehabilitate the bowel, the new tools that we will make in the next decade are going to be profound.
Open
Quotation
But the opportunity given to that child is made at the time that you open the belly and you see catastrophe.
Open
Statement
The opportunity given to the child is made at the time the surgeon opens the belly and sees catastrophe; removing all bowel eliminates all future potential based on clinical acumen that the outcome will be bad.
Open
Quotation
So you remove all the potential that we have in the future. Based on your clinical acumen that this is gonna have a bad outcome, and that it's time to withdraw.
Open
Quotation
And the first team that has to be convinced is your neonatologist because they're the ones at the bedside who historically removed the breathing tubes on these kids and allowed them to pass.
Open
Statement
The first team that must be convinced of this approach is the neonatology team, because historically they are the ones who removed breathing tubes and allowed these babies to pass.
Open
Statement
If you see protein growth, linear growth, and head growth in the baby, that is brain growth; a baby will not grow well with an unhealthy liver or poor management.
Open
Quotation
If you see protein growth and linear growth of your baby and head growth, that's brain growth, and a baby will not grow well with a, with an unhealthy liver and is not managed well.
Open
Quotation
Unhealthy liver is, is not providing the protein for the neurocognitive development, period. And that's why it's the number one priority early, uh, that you should have.
Open
Statement
An unhealthy liver does not provide the protein necessary for neurocognitive development; liver health is the number one priority early in management.
Open
Statement
Babies, especially premature babies in the first year of life, have caloric needs of 80–120 kcal/kg because they are growing and developing; when critically ill they are no longer growing and their livers are catabolic, so feeding 150 kcal/kg will not result in growth.
Open
Quotation
When you're critically ill, you no longer are growing and developing. You can feed these babies 150 k cals per kilo, but they will not grow because their livers are catabolic.
Open
Statement
For a 30-week baby with extensive NEC and a long segment of dead bowel, the surgeon knows the baby will need multiple operations, so a transverse incision is used because it causes the least problems over time.
Open
Quotation
So I know this baby is going to need multiple operations. So the incision is a transverse incision because I know over time that's the one that's going to give me the least problems.
Open
Statement
The surgeon finds a segment of bowel just beyond what is expected to heal (1–2 cm margin) and brings in an 8 or 10 French Blake drain, often from the left lower quadrant if normally rotated, placing it through bowel that is not expected to do well and advancing it retrograde to the pylorus.
Open
Statement
A loose tie is placed around the most healthy part of the bowel around the drain to control secretions, and a purse-string is placed at the insertion site and secured to the skin, essentially stemming the bowel to the abdominal wall; this takes minutes.
Open
Statement
If the stomach is visible, a purse-string is placed in the stomach and a 5–7 French feeding tube is inserted into the proximal bowel and tied, taking one to two minutes; this avoids having to access the left upper quadrant later for a G-tube.
Open
Statement
The surgeon tries to close the abdomen primarily, but if there is concern about dead bowel, Alloderm is placed; if very worried, a drain is placed in the abdomen to allow drainage.
Open
Statement
The surgeon tries to avoid significant dissection of the distal ileum to preserve blood supply and allow collateralization to recover as much proximal bowel as possible.
Open
Quotation
I try to avoid doing significant dissection of the distal ileum one because I wanna preserve the blood. So I wanna let the collateralization happen to recover as much of that proximal bowel as possible.
Open
Statement
If the distal diverted bowel is baggy and filled with bloody enteric fluid, and there are distal perforations with patchy necrosis, the surgeon may place stitches distal to proximal to bring the bowel together to preserve muscle, planning to manage it later.
Open
Quotation
I will put a refeeding tube in the distal bowel so I can refeed and let that intermediate bowel. To sort of hang out.
Open
Statement
A refeeding tube is placed in the distal bowel to allow refeeding and let the intermediate bowel hang out and heal; this depends on the amount of proximal bowel and whether feeding is feasible.
Open
Statement
In one current case with 40 cm of proximal bowel, refeeding is allowing the surgeon to wait longer for intervening bowel to heal, and the baby's liver is fine, buying time because the fluid output from injured bowel is very high.
Open
Quotation
And so it's just buying me time and the time is because the amount of fluid that comes out of injured bowel is very high.
Open
Statement
These conversations about approach need to be had with neonatologists and dietitians in the room, not just surgical colleagues, because they must be on board.
Open
Quotation
I think these conversations need to be had with other providers. in the room, not just your surgical colleagues, because the, the neonatologists and dietitians have to be on board.
Open
Statement
Families are not able to make decisions in these situations; once the family is told that the baby is the one driving decisions moving forward, it makes things easier for them when outcomes are bad.
Open
Quotation
Families are, are not able to make decisions. Once you explain to the family that the individual making the decisions moving forward is a baby, and you explain that to them, when things go bad, it actually makes it easier for them.
Open
Quotation
I think you'd be surprised at the number of kids who are sick, taken to the OR, but they're not as critically sick as we believe they're going to be.
Open
Statement
Many babies taken to the OR are not as critically sick as believed; once proximal bowel is controlled and everything is decompressed, many will slowly improve.
Open
Quotation
Many of those kids, once you control the proximal bowel and you get everything decompressed, will actually slowly get better.
Open
Statement
Long-term, if all bowel is removed, many patients will heal but there is no opportunity for rehabilitation; that experiment has been done.
Open
Quotation
Long term, if you take everything out, there are many of them that will heal, and then we have no opportunity. That Experiment's been done.
Open
Statement
Blake tubes have linear cuts on the outside so they do not get obstructed when secretions accumulate; they are soft and do not put pressure on damaged bowel; they can be connected to a bulb syringe and cut to size.
Open
Quotation
The Blake tube has linear cuts on the outside, so they, they won't get obstructed in many situations when secretions and stuff get around them. And that's why I like them a lot.
Open
Statement
The downside of Blake tubes is that they cannot be changed over a wire like JP drains with side holes; the ideal tube would be a Blake with a central hole for wire passage.
Open
Quotation
What's the downside of them is you can't change them over a wire, like you can a JP and other ones that just have side holes.
Open
Quotation
If I had the best scenario, it would be a blake tube that has a central hole that I could pass a wire.
Open
Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 1
Statement
Adaptation is defined as developing and strengthening gut function, occurring naturally in infants during in utero development and the first few years of life, or as a regenerative response to damage in older children.
Open
Quotation
And it generally takes time, and that time is measured in. Months and years and not weeks and days, but the one thing that it requires in all situations is enteral nutrition.
Open
Statement
Adaptation generally takes months and years, not weeks and days, and requires enteral nutrition in all situations.
Open
Statement
The duodenum senses caloric intake, monitors sugars, receives hepatobiliary secretions, takes up iron, and functions as an endocrine engine recognizing meal initiation.
Open
Statement
The jejunum is largely a source of fluid secretion needed for digestion, with random back-and-forth sloshing motion like a washing machine.
Open
Statement
The ileum secretes different hormones including the incretins GLP-2, GLP-1, and PYY, which stop gastric emptying and slow motility when excess liquid is detected in the distal bowel and proximal colon.
Open
Statement
The distal ileum's ability to take up bile sends a signal to the liver, the metabolic engine that helps regulate the whole metabolism of the patient.
Open
Statement
In short gut patients, the colon becomes a source of energy uptake when exposed to free fatty acids, which requires the presence of bacteria.
Open
Quotation
It, in fact, in, in our patients is a source of energy uptake when allowed to see things like free fatty acids, and that requires the presence of bacteria.
Open
Statement
Colonic adaptation does not occur in most normal patients because energy is already reclaimed before reaching the colon.
Open
Statement
Adaptation is highly influenced by modifiable factors including formula type, H2 blockers, antibiotics, illness episodes, and motility changes.
Open
Quotation
But what people don't recognize is the last thing you need to come off a TPN is fluid.
Open
Statement
The last thing a patient needs to come off TPN is fluid; without adequate hydration, the baby will not grow and will not efficiently absorb nutrition, losing energy and decreasing their growth trajectory.
Open
Statement
Lab data from Cincinnati shows a shift in microbiota to more acid-producing bacteria in an acidotic state, with increased bile due to lack of reclamation.
Open
Quotation
And just seeing something that's different than normal doesn't make it bad, needs to be studied and needs to be taken into context.
Open
Statement
Bacterial colonization differences from normal are part of the adaptive response and should not automatically be considered pathological; they need to be studied and taken into context.
Open
Statement
NEC is an acquired condition; infants are born, start eating (often reaching near-full feeds), then have an incident usually at 2-3 weeks of life, meaning they have not been using their gut during the critical 35-week-to-6-months adaptive window.
Open
Quotation
Ask yourself, has this child been fed before, because that child's different than the one that's never been fed.
Open
Statement
Whether a child has been fed before makes them different from one who has never been fed, affecting their adaptive potential.
Open
Statement
Surgical planning for short gut patients is like a game of chess requiring consideration of the second, third, and fourth steps ahead.
Open
Statement
The sooner a child can be fed safely and bowel access achieved without exposing them to surgical risk, the more the adaptive process can be leveraged.
Open
Statement
Cincinnati strategies were developed to take advantage of the easiest, safest way to use the bowel early without needing to return immediately to surgery.
Open
Statement
Surgery puts children in harm's way regardless of surgeon talent, so balancing surgical intervention with optimization of adaptation has led to improved outcomes.
Open
Quotation
You put kids in harm's way when you go to the operating room, no matter how talented you are.
Open
Michael's statements about Short Bowel Syndrome 37 statements
Open the Short Bowel Syndrome collection →
Intestinal rehabilitation: What is intestinal rehab? - Episode 1
Statement
Earlier recognition and taking advantage of the gut's biology to adapt are time dependent.
Open
Statement
Intestinal rehabilitation depends on nutrition in the gut, nutrition in the body, and healing.
Open
Quotation
What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing.
Open
Statement
Pattern recognition from multiple experienced clinicians observing patients over time is essential in intestinal rehabilitation.
Open
Quotation
So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time.
Open
Statement
Three time points exist for diagnosis and referral to intestinal rehab: prenatal diagnosis (atresia with cystic fibrosis, gastroschisis), postnatal acquired problems (volvulus, NEC), and later presentations after discharge when patients fail to progress.
Open
Statement
Innovation in intestinal rehabilitation comes from multiple approaches to problems and different visions, with more expertise leading to better outcomes.
Open
Statement
Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being adequately addressed.
Open
Statement
The intestinal rehabilitation team includes dietitians (for nutritional needs), social workers, nurse practitioners, pharmacy, interventional radiology, pathology, endocrinology, and nephrology.
Open
Quotation
I think the big key to a person watching the podcast is that they get hope. These are wonderful children. They're, they're opportunities to grow up and to live the lives that their families want is really in front of them.
Open
Intestinal Rehabilitation, Episode 1: What is intestinal rehabilitation?
Statement
Earlier recognition and taking advantage of the gut's adaptive biology are time dependent.
Open
Quotation
And so earlier recognition and and taking advantage of the biology of the gut that wants to accommodate, we call it adapt um and meet the needs of the child um are time dependent.
Open
Quotation
What is intestinal rehabilitation really comes down to the key factors that drive that process, and that's nutrition in the gut. But it's also nutrition in the body, and it's healing.
Open
Statement
Intestinal rehabilitation depends on key factors: nutrition in the gut, nutrition in the body, and healing.
Open
Quotation
So it's pattern recognition, and that's Multiple eyes on a baby does, who've seen them over time.
Open
Statement
Pattern recognition from multiple expert eyes observing a patient over time is essential in intestinal rehabilitation.
Open
Statement
Families reach intestinal rehabilitation programs at three time points: prenatal diagnosis (typically atresia with cystic fibrosis or gastroschisis), postnatal acquired problems (volvulus or NEC), and later diagnosis after discharge when patients fail to progress.
Open
Statement
Innovation comes from multiple approaches to a problem and different visions; bringing in more expertise leads to better outcomes.
Open
Statement
Transitioning older children with intestinal failure into their late teen years and beyond is a major obstacle currently not being met.
Open
Statement
The intestinal rehabilitation team includes dietitians (understanding nutritional needs), social work, nurse practitioners, pharmacy, interventional radiology, pathology, and subspecialties including endocrinology and nephrology.
Open
Intestinal Rehabilitation, Episode 4: Surgical Management, Part 1
Statement
Adrian Bianchi first reported the longitudinal intestinal lengthening procedure (Bianchi procedure) that divides bowel along its two leaves and tubularizes it.
Open
Statement
Rising direct bilirubin was recognized as a sign that children with intestinal failure would not do well.
Open
Statement
The gut doubles in length during the last trimester and the first year of life, and this maturation process occurs when the baby is fed.
Open
Statement
Healthy growth of the intestine requires nutrition; anything that disrupts this affects maturation of both absorptive/digestive capacity and peristalsis.
Open
Quotation
The outcome is one that should benefit the child for 80, 90 years, not just the next 2 months.
Open
Statement
Lengthening bowel that doesn't have peristalsis does not increase absorption; very short bowel children can sometimes come off TPN because their motility is good.
Open
Quotation
The better the waves going over the villa, The more exposure of nutrients and removal of waste that you have is not increased by lengthening the bowel that doesn't peristals. That's just more static water.
Open
Quotation
So we see very short bowel kids sometimes come off a TPM because their motility is so good.
Open
Statement
The enteric nervous system in gastroschisis is damaged from exposure to amniotic fluid and requires a healing and recovery phase; this regeneration is attenuated by dysmotility and stasis, not enhanced.
Open
Statement
In atresia without gastroschisis, the bowel may have good peristalsis from working against an obstruction, and when done correctly with proper orientation, a longitudinal lengthening procedure may benefit the child.
Open
Statement
Children who undergo STEP procedures in their first year of life sometimes never progress and are labeled as poor motility patients unable to tolerate enteral feeds.
Open
Statement
Among patients with limited gut, necrotizing enterocolitis patients do best because they have been fed before, have established GI motility, and the maturation phase has already been initiated.
Open
Quotation
Anything that creates a potential worsening of motility and gastroschisis, especially in the first year of life should be something you should strongly think about before doing.
Open
Statement
The duodenum has no mesentery, making it impossible to orient 90° and 270° positions; surgeons who STEP the duodenum end up entering the bowel at inconsistent orientations.
Open