Intestinal Rehabilitation, Episode 4: Surgical Management, Part 2
With Dr. Paul Wales & Dr. Michael Helmrath · hosted by Dr. Ellen Encisco & Dr. Anton Bash · StayCurrentMD
Cued at 3:40 · stops at 4:25 · press play
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
The biggest benefit of the STEP procedure is tapering the bowel and reestablishing a more normal caliber to improve motility.
It can take up to 6 months before you actually start to see a significant improvement in absorptive capacity after STEP.
Improvements in absorptive capacity are measured with fecal fat, alpha-1 antitrypsin clearance, xylose absorption, and citrulline levels as they rise over time.
The reason absorptive improvement takes time is that inflamed, sick, leaky mucosa in the setting of bacterial overgrowth needs to heal.
Half of the people that have a STEP will have progression of improved enteral tolerance, and half will actually have a worsening.
The six month postoperative period is very critical for analyzing how the patient is moving forward after STEP.
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.
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.
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.
Recurrent bleeding from STEP staple lines is an absolute indication to operate.
Bleeding at STEP staple lines is an underreported complication that is really difficult to manage in some cases.
Staple line bleeding is hypothesized to be a microbiome problem occurring in a pro-inflammatory environment.
Staple line bleeding tends to occur in type 2 anatomy, which is small bowel to colonic remnant in the absence of an intact colon ileocecal valve.
Pathology of staple line ulcers shows non-specific inflammation with no vasculitis, no viral elements, and no obvious ischemia.
Mesenteric inflammation and scarring creates an obstruction to venous outflow, resulting in venous hypertension along the staple lines.
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.
It is very important to free up the mesentery from scar, which is a dense scar.
Venous hypertension is what leads to the bleeding at staple lines.
The key in managing staple line bleeding is to look at the mesentery and free up the mesentery, not just look at the bowel.
Mesenteric scarring causing venous hypertension is obvious if you're looking for it during operation.
Most referrals for intestinal rehabilitation have had multiple operations before coming to the specialist center.
Optimizing a child's anatomy may not be conducive to just one operation; you have to set yourself up sometimes planning for the next case.
Dr. Helmrath documents detailed operative notes for himself describing orientation, landmarks, and what was done to guide future operations.
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.
The surgeon plays a huge role in intestinal rehabilitation even when patients are doing well, because you have to see the progress.
STEP does not create new bowel but redistributes it to reestablish more normal caliber bowel, which helps improve motility overall.
About 50% reduction in parental nutrition support can be expected after STEP.
Ulcers at STEP staple lines are not uncommon, and many kids have been transfused every month for years because of that.
There is a whole spectrum of findings from ulcers at staple lines, from just having specks of blood in the stool to enough bleeding that kids might have to be transfused every week and a half.
Staple line ulcers can recur after treatment.
Teams have tried enteral omega 3 lipid supplements, bacterial overgrowth management with cycled antibiotics or probiotics, 5ASA, budesonide, and immune modulators like Remicade for staple line bleeding, but none have been the perfect remedy.
The underlying issue in staple line bleeding is not in the bowel but actually in the mesentery.
Mesenteric inflammation causes scarring and obstructs venous outflow, leading to enlarged veins and venous hypertension on the bowel, and even large lymph nodes from lymphatic obstruction.
Once you free up the mesenteric scar, those big vessels come right back to normal.
Dr. Helmrath typically revises the staple line with a hand sewn stitch when mesenteric scarring and venous hypertension are present.
Doing things in a staged fashion is typical for the intestinal rehabilitation patient population.
As intestinal rehabilitation patients grow and develop, more issues might arise requiring additional operations.
Intestinal rehabilitation is a lifelong issue, and surgeons typically follow these patients for a long time.