Intestinal Rehabilitation, Episode 2: Overwhelming intestinal damage, Part 1

The outlook for preterm infants with short bowel syndrome has changed over the last two decades as a result of advances in medical and surgical care.

A more aggressive approach to surgical resection has accompanied improved outcomes in short bowel syndrome.

Intestinal transplant is not experimental therapy; it is part of the continuum of therapy for a child with short bowel syndrome.

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.

There is an algorithm of children with overwhelming sepsis where surgery cannot salvage these patients and there is no life-saving option.

Many infants will rally without having their bowel removed, which allows them an opportunity for recovery.

In the acute phase with infarcted gut, the clinical picture is usually one of overwhelming sepsis, and even after resection leaving ultra-short bowel, patients are rocky and unstable due to sepsis, SIRS, or septic experience.

In the very acute time, the primary cause of death is sepsis and multi-organ failure.

In the intermediate and longer term, complications include intestinal failure-associated liver disease, recurrent sepsis, or line problems, which historically led to death or transplant.

Much of the success seen in the last two decades is because clinicians are way better at preventing sepsis and liver disease.

The first goal when seeing these infants is protecting the liver.

Decompressing the duodenum is needed to protect the liver, and when the liver is inflamed with high bilirubin, it is in a catabolic state.

When in the OR wanting to buy time, one of the first things to consider is how to keep the proximal bowel decompressed.

Babies born with duodenal atresia or very proximal jejunal atresia are born with elevated direct or conjugated bilirubins, supporting the concept that an undecompressed foregut affects liver function.

Liver function is affected by multiple factors: prematurity, sepsis, choice of TPN, and presence or absence of enteral nutrition.

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.

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.

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.

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.

The inflection point of bowel loss that requires prolonged TPN is about 50%.

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.

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.

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.

Once proximal bowel is controlled with a drain, stomas should be avoided because they lose abdominal domain and lose bowel down the road.

The percentage of infants that do well with proximal drain therapy when facing dead gut is more than 70 to 80%.

The approach to overwhelming bowel necrosis does not differ based on diagnosis (volvulus, infarct, mesenteric thrombosis), but the outcome does.

Kids with NEC have the best outcomes because it is a microvascular disease.

Controlling proximal bowel without allowing enteric content has been key to salvaging NEC patients with good outcomes.