Intestinal rehabilitation: What is intestinal rehab? - Episode 1

We’re starting a new series about intestinal rehabilitation and all of its intricacies. We’re joined by Drs. Michael Helmrath and Paul Wales, leaders of the Intestinal Rehabilitation Program at Cincinnati Children’s.

Hosted by: Todd Ponsky, Rod Gerardo, Ellen Encisco

100:00:04,080 --> 00:00:06,560Hey, there, listeners, this is Rod Gerardo.
200:00:07,040 --> 00:00:08,400This is Ellen Encisco. 
300:00:08,400 --> 00:00:12,800We are research residents at Cincinnati Children's Hospital Medical Center
400:00:13,040 --> 00:00:16,920and we're super excited because the intestinal
500:00:16,920 --> 00:00:20,280rehabilitation team at Children's is growing.
600:00:20,760 --> 00:00:22,960We've gained a new attending surgeon.
700:00:23,120 --> 00:00:25,280And to celebrate this, we're going to start a new series.
800:00:25,280 --> 00:00:28,480We're kicking this series off today about intestinal rehab.
900:00:28,520 --> 00:00:30,560What is it? What is the diagnosis?
1000:00:30,840 --> 00:00:32,960I know next to nothing about this.
1100:00:32,960 --> 00:00:35,120I don't know about you, Ellen. Not enough.
1200:00:35,840 --> 00:00:38,000This is the Stay Current Pediatric Surgery podcast.
1300:00:43,400 --> 00:00:44,240Hello. 
1400:00:44,320 --> 00:00:46,240I'm Michael Helmrath That's Dr. 
1500:00:46,240 --> 00:00:47,120Michael Helmrath. 
1600:00:47,120 --> 00:00:49,000He's a pediatric surgeon at Cincinnati Children's 
1700:00:49,000 --> 00:00:51,520Hospital Medical Center and the former director
1800:00:51,720 --> 00:00:54,320of the intestinal rehab program at Cincinnati Children's.
1900:00:54,520 --> 00:00:56,440He's excited to bring in his friend. 
2000:00:56,440 --> 00:01:00,160I'm Paul Wales, I'm a pediatric surgeon,
2100:01:00,400 --> 00:01:04,160and he lead the intestinal rehab program at the Hospital for Sick Children
2200:01:04,520 --> 00:01:06,080and is now joining Cincinnati 
2300:01:06,080 --> 00:01:09,760Children's as the new and current director of the intestinal rehab program.
2400:01:10,200 --> 00:01:11,160You know, Dr. 
2500:01:11,160 --> 00:01:15,560Helmrath and I, we didn't work directly together for for many years.
2600:01:15,560 --> 00:01:19,520I've obviously been aware of a lot of his groundbreaking work
2700:01:19,520 --> 00:01:21,760that he's performed in tissue regeneration.
2800:01:22,400 --> 00:01:26,080A key part that Paul's team had come up with novel strategies
2900:01:26,080 --> 00:01:30,000how you introduce new pharma to these patients.
3000:01:31,320 --> 00:01:31,960Many of the 
3100:01:31,960 --> 00:01:35,240patients require a very patient specific approach,
3200:01:35,240 --> 00:01:38,960which emphasizes understanding the natural history of disease.
3300:01:39,400 --> 00:01:43,240I guess, Ellen, the big question here is why do we even need intestinal rehab?
3400:01:43,240 --> 00:01:44,880But to answer that question? 
3500:01:44,880 --> 00:01:46,880Dr. Wales brought up an initial question. 
3600:01:46,880 --> 00:01:50,280Let's go back one step before that and sort of define
3700:01:50,280 --> 00:01:52,720what is intestinal failure, because that sort of leads
3800:01:52,720 --> 00:01:55,680into who's going to benefit from an intestinal rehab program.
3900:01:56,280 --> 00:01:59,600And up until recently, there really was no
4000:01:59,960 --> 00:02:02,600standardized definition for intestinal failure.
4100:02:03,040 --> 00:02:05,400It's it's really a functional problem. 
4200:02:05,400 --> 00:02:09,120Essentially, when someone's gut for whatever the diagnosis,
4300:02:09,120 --> 00:02:13,000whatever the reason, their gut function is in insufficient
4400:02:13,000 --> 00:02:17,920to absorb enough nutrients, fluids, calories to support survival.
4500:02:17,920 --> 00:02:20,560And in the case of children growth,
4600:02:20,640 --> 00:02:23,760which is a big distinction between adults and children.
4700:02:24,320 --> 00:02:27,400Now these new guidelines, they say that for a patient
4800:02:27,400 --> 00:02:30,040to be defined as having intestinal failure,
4900:02:30,600 --> 00:02:35,640then they have to have inadequate intestinal function to the point
5000:02:36,120 --> 00:02:40,520where they necessitate parenteral support for at least 60 days.
5100:02:40,760 --> 00:02:45,440And so earlier recognition and taking advantage of the biology
5200:02:45,640 --> 00:02:49,360of the gut that wants to accommodate, we call it, adapt
5300:02:50,160 --> 00:02:53,960and meet the needs of the child, are time dependent.
5400:02:54,280 --> 00:02:56,040So with the intestinal rehabilitation 
5500:02:56,040 --> 00:02:59,880programs, we are taking care of patients with intestinal failure.
5600:02:59,960 --> 00:03:04,360And so what is intestinal rehabilitation? So
5700:03:05,320 --> 00:03:07,600an intestinal rehabilitation program,
5800:03:08,320 --> 00:03:11,640as we defined also in these Aspen guidelines
5900:03:11,640 --> 00:03:16,600that just came out, is a multidisciplinary or interdisciplinary
6000:03:16,600 --> 00:03:19,440collaborative patient care paradigm
6100:03:20,000 --> 00:03:23,160that that brings coordinated care
6200:03:23,680 --> 00:03:28,320for children with intestinal failure through comprehensive management
6300:03:28,440 --> 00:03:33,480of their specialized nutrition and other associated needs that they have.
6400:03:33,640 --> 00:03:35,800It's like a dream team, but for pediatric guts.
6500:03:35,920 --> 00:03:38,000So on top of the nutrition, then you also have to think
6600:03:38,000 --> 00:03:41,080about the comorbidities, sepsis, liver disease,
6700:03:41,280 --> 00:03:43,920anything that would challenge the growth of this baby.
6800:03:44,400 --> 00:03:48,520It's an amalgamation of experts that come from different aspects of care,
6900:03:49,440 --> 00:03:53,760providing a holistic, comprehensive, coordinated approach
7000:03:53,760 --> 00:03:55,960to patient management. 
7100:03:55,960 --> 00:03:59,080Hopefully, by doing that, you streamline care.
7200:03:59,400 --> 00:04:03,520You improve communication not only with with the family,
7300:04:03,520 --> 00:04:06,400but also between care providers and team members.
7400:04:07,160 --> 00:04:11,480What is intestinal rehabilitation really comes down to the key
7500:04:11,480 --> 00:04:15,160factors that drive that process, and that's nutrition in the gut,
7600:04:15,640 --> 00:04:18,640but it's also nutrition in the body and it's healing.
7700:04:19,000 --> 00:04:20,880People like Dr. Wales, Dr. 
7800:04:20,880 --> 00:04:24,160Helmrath have taken care of patients with these issues before,
7900:04:24,240 --> 00:04:28,320so it's pattern recognition and that's what multiple eyes on a baby does.
8000:04:28,600 --> 00:04:29,920You see them over time. 
8100:04:29,920 --> 00:04:31,200It's pattern recognition. 
8200:04:31,200 --> 00:04:34,240But then on top of that, it's understanding all of these
8300:04:34,240 --> 00:04:37,600different causes of intestinal failure.
8400:04:37,840 --> 00:04:39,600They were able to break that down for us. 
8500:04:39,600 --> 00:04:39,920Patients 
8600:04:39,920 --> 00:04:43,200that are going to come to intestinal rehab program have intestinal failure,
8700:04:43,720 --> 00:04:45,760and we can divide
8800:04:46,520 --> 00:04:50,200the causes into of intestinal failure into three categories
8900:04:50,800 --> 00:04:55,600their short bowel syndrome, which by far is the most common category
9000:04:55,880 --> 00:05:00,760in pediatric patients with intestinal failure and causes of short bowel syndrome
9100:05:00,760 --> 00:05:05,440are usually related to diagnoses of or disorders of the neonate.
9200:05:05,840 --> 00:05:10,840So congenital anomalies such as intestinal atresia, malrotation, volvulus,
9300:05:12,360 --> 00:05:14,560gastroschisis, 
9400:05:14,720 --> 00:05:18,040the long segment Hirschsprungs disease, things like that
9500:05:19,120 --> 00:05:22,760or acquired diseases of the newborn, such as necrotizing enterocolitis.
9600:05:23,200 --> 00:05:23,920Okay, so that makes sense. 
9700:05:23,920 --> 00:05:28,520So basically, our first category for causes is any condition
9800:05:28,520 --> 00:05:32,520that may lead to loss of intestines or impair the intestinal formation
9900:05:33,040 --> 00:05:36,800and therefore leave the bowel shortened will therefore cause a child
10000:05:36,800 --> 00:05:37,600to not be able to absorb 
10100:05:37,600 --> 00:05:41,120nutrients as well, which we mentioned at the beginning is key.
10200:05:41,600 --> 00:05:44,960Oh. Category number two, that is motility disorders.
10300:05:45,520 --> 00:05:47,520So if we think of the intestine like a pipe
10400:05:47,760 --> 00:05:51,160and that pipe is made of muscle that contracts in the coordinated way
10500:05:51,160 --> 00:05:55,000to push food and stool from one end to the other, you can have abnormalities
10600:05:55,000 --> 00:05:59,320of the muscle itself or of the nerves that control that muscle,
10700:06:00,040 --> 00:06:03,720and the bowel is unable to push things through in a coordinated way.
10800:06:03,720 --> 00:06:07,280So, so these children basically have difficulty
10900:06:07,560 --> 00:06:10,840passing the nutrients through their intestines as a result,
11000:06:10,840 --> 00:06:13,240and they're therefore dependent on intravenous support.
11100:06:13,520 --> 00:06:15,640And then and then there's a third category,
11200:06:16,120 --> 00:06:19,000and that's kind of like the opposite of slow transit
11300:06:19,120 --> 00:06:23,400what we call the mucosal enteropathies or the congenital diarrheas.
11400:06:23,920 --> 00:06:27,360And these are conditions where the patient has all of their bowel.
11500:06:27,360 --> 00:06:31,320But the mucosa, the inside lining that that absorbs,
11600:06:31,960 --> 00:06:33,880digests and absorbs doesn't work. 
11700:06:33,880 --> 00:06:35,440Contents move too fast. 
11800:06:35,440 --> 00:06:38,920In order for the bowel to have time to absorb any any of the nutrients.
11900:06:39,280 --> 00:06:40,600So three different flavors. 
12000:06:40,600 --> 00:06:43,880first, you don't have enough bowel to absorb nutrients.
12100:06:44,520 --> 00:06:48,240second, the food moves too slow and you can't absorb it.
12200:06:48,440 --> 00:06:51,120And then the third category of intestinal failure.
12300:06:51,480 --> 00:06:55,120So not only are the contents moving too fast,
12400:06:55,320 --> 00:07:00,560but this occurs due to the bowels inability to digest in combination
12500:07:00,760 --> 00:07:05,200with increased secretions, and that's oftentimes congenital ideologies.
12600:07:05,440 --> 00:07:09,040The reason it's important to at least identify these three categories
12700:07:09,040 --> 00:07:12,520is that some patients will have elements of one, two
12800:07:12,520 --> 00:07:15,960or three of the cattery categories the way they present.
12900:07:16,440 --> 00:07:18,640For example, think about gastroschisis. 
13000:07:18,640 --> 00:07:21,160The bowel could be short because it was not available.
13100:07:21,280 --> 00:07:23,280It could be inflamed so it doesn't absorb well.
13200:07:23,560 --> 00:07:26,560And all of these issues might affect motility, too.
13300:07:27,320 --> 00:07:31,360So a kid with gastroschisis could essentially have all three categories.
13400:07:31,880 --> 00:07:32,240Right. 
13500:07:32,240 --> 00:07:36,400So any patient that that that fits one of those
13600:07:36,400 --> 00:07:39,640three categories is going to be referred to intestinal rehab program.
13700:07:40,120 --> 00:07:42,720And although most of them are infants or babies,
13800:07:42,720 --> 00:07:45,560there are some older kids that develop.
13900:07:45,760 --> 00:07:46,800Wait a minute. 
14000:07:46,800 --> 00:07:51,280You see intestinal failure in older pediatric patients to things like
14100:07:51,400 --> 00:07:55,280inflammatory bowel disease or Crohn's disease, where they've had, you know, lost
14200:07:55,840 --> 00:08:00,960gut as a result of complications of that trauma, malignancy,
14300:08:01,960 --> 00:08:04,720vascular thrombosis that has led to gut loss.
14400:08:05,040 --> 00:08:09,960These are these are diagnoses that we tend to see more in older patients or
14500:08:09,960 --> 00:08:14,880in adult series and less so in pediatrics, like we're going to discuss,
14600:08:14,920 --> 00:08:18,840we're going to get into the details, of all of these things in later podcasts.
14700:08:19,360 --> 00:08:21,640Yeah, those will be subcategories of this whole.
14800:08:21,640 --> 00:08:22,760That's why we're going to a series. 
14900:08:22,760 --> 00:08:24,800We're going to dove deep into each of these. 
15000:08:24,800 --> 00:08:30,280Certainly families that live within the region can get given the opportunities
15100:08:30,360 --> 00:08:32,680to understand deliberate from the beginning,
15200:08:32,680 --> 00:08:35,920this is probably going to be beneficial for a lot of the patients.
15300:08:36,000 --> 00:08:40,720The main reason I think we're doing this podcast is because access
15400:08:40,720 --> 00:08:45,280and availability to an intestinal rehab program is still very, very rare.
15500:08:45,480 --> 00:08:46,480There's really three
15600:08:47,760 --> 00:08:50,400time points where families reach to us.
15700:08:50,840 --> 00:08:54,600OK, so there's three different categories of intestinal failure.
15800:08:54,880 --> 00:08:58,000There are also three general time points
15900:08:58,320 --> 00:09:00,680that these diagnoses can be picked up.
16000:09:01,000 --> 00:09:05,840And by picked up we mean also like and then referred to intestinal rehab centers.
16100:09:06,520 --> 00:09:09,320The first one is a prenatal diagnosis.
16200:09:09,640 --> 00:09:11,280Prenataly 
16300:09:11,600 --> 00:09:13,880when there's a prenatal diagnosis.
16400:09:14,080 --> 00:09:18,880It typically ends up being an atresia that could be with cystic
16500:09:18,880 --> 00:09:22,960fibrosis gastroschisis very commonly.
16600:09:23,360 --> 00:09:26,680The second time point would be postnataly,
16700:09:26,920 --> 00:09:30,440with acquired problems such as vovulus or neck.
16800:09:30,720 --> 00:09:34,440The third one, which is patients who are discharged,
16900:09:34,680 --> 00:09:38,560they don't really progress outside of the hospital and then they come back
17000:09:38,560 --> 00:09:43,640and then they have a later diagnosis that maybe leads to short gut or the
17100:09:44,320 --> 00:09:47,200something other diagnosis that leads them to necessitating
17200:09:47,200 --> 00:09:48,720intestinal rehabilitation. 
17300:09:48,720 --> 00:09:50,480So those are the three time points. 
17400:09:50,480 --> 00:09:52,280The fact that we have these different 
17500:09:52,280 --> 00:09:55,440times and people present have to have infrastructure to be able to
17600:09:56,400 --> 00:09:58,960have the families get the support they need when they need it.
17700:09:59,200 --> 00:10:00,960Now you just brought in. 
17800:10:00,960 --> 00:10:04,840That's Todd Ponsky he's a pediatric surgeon at Cincinnati Children's Hospital.
17900:10:05,080 --> 00:10:08,480The two of you being the two world's experts, all under one roof.
18000:10:08,720 --> 00:10:09,920Why did you do that? 
18100:10:09,920 --> 00:10:14,560So I long believed that your ideas at first come to your head
18200:10:14,560 --> 00:10:19,760always have ways to improve in that that you only see things through one way.
18300:10:19,760 --> 00:10:20,760Innovation comes 
18400:10:20,760 --> 00:10:24,800from multiple approaches to the problem and different visions of the problem.
18500:10:25,160 --> 00:10:29,680The more expertize you bring in, the better the outcome.
18600:10:30,040 --> 00:10:32,120So that combined knowledge of Dr.
18700:10:32,120 --> 00:10:33,000Helmrath and Dr. 
18800:10:33,000 --> 00:10:37,160Wales along with the experience that we have at Cincinnati Children's
18900:10:37,160 --> 00:10:41,760Hospital, is great because there are a lot of next
19000:10:41,760 --> 00:10:45,400level questions that honestly need some better answers.
19100:10:45,600 --> 00:10:48,960How do you take the older child who has had intestinal failure
19200:10:49,120 --> 00:10:52,280and entering their late teen years and later destined to be
19300:10:52,280 --> 00:10:56,520a major obstacle that we need to address that is currently not being met?
19400:10:56,560 --> 00:11:00,320How do you integrate new strategies of therapy?
19500:11:00,400 --> 00:11:05,240How do you look at new therapies like drug therapies and say now who can get it?
19600:11:05,560 --> 00:11:09,320Previously, we didn't really have good robust data to answer these questions.
19700:11:09,320 --> 00:11:14,000So, so since children's is really uniquely situated in this endeavor,
19800:11:14,240 --> 00:11:17,880now that these two surgeons are under the same roof. But
19900:11:18,400 --> 00:11:22,520to have the team approach an integrated approach to the complex patients,
20000:11:24,040 --> 00:11:26,480it just is a rare thing to find and
20100:11:26,640 --> 00:11:30,960and we are going to expand it to a point that it's never been done.
20200:11:30,960 --> 00:11:33,040Pheonominal. All right, Rod.
20300:11:33,640 --> 00:11:37,960So having the whole team of everyone necessary is key.
20400:11:38,000 --> 00:11:40,680Obviously, we have the surgeons, we have the GI doctors
20500:11:41,280 --> 00:11:44,080now, but we also have a neonatologist and probably more importantly,
20600:11:44,080 --> 00:11:46,560the part of the team that is not physicians.
20700:11:47,040 --> 00:11:51,600But you can't say enough about the dieticians
20800:11:51,600 --> 00:11:55,280in understanding the nutritional needs of a child as they are met.
20900:11:55,360 --> 00:11:57,840Social work is really key.
21000:11:57,880 --> 00:12:02,080I think the the other aspect is that our extended providers,
21100:12:03,040 --> 00:12:07,160the people that are at the bedside our nurse practitioners are fantastic.
21200:12:07,440 --> 00:12:09,640And the list just keeps going.
21300:12:10,080 --> 00:12:13,320Some people would say pharmacy as well and as well as social work,
21400:12:13,400 --> 00:12:16,160really good interventional radiology, for instance.
21500:12:17,080 --> 00:12:18,400Pathology and all the other 
21600:12:18,400 --> 00:12:22,000sort of ologies you know, like endocrinology nephrology.
21700:12:22,280 --> 00:12:25,760With improvements like transplant and multidisciplinary organizations,
21800:12:25,920 --> 00:12:28,680we can see some really big strides forward in this field.
21900:12:28,920 --> 00:12:33,960The survival overall in big programs is usually over 90% long term survival.
22000:12:34,240 --> 00:12:37,040And while this is a cause for celebration on its own,
22100:12:37,800 --> 00:12:40,000keep in mind that is also raised a lot of new issues.
22200:12:40,800 --> 00:12:43,440But now what we're seeing is we have kids that have developed
22300:12:43,440 --> 00:12:46,560chronic co-morbidities that co-morbidities that never
22400:12:46,560 --> 00:12:49,560we didn't really see to the same extent because they didn't live long enough.
22500:12:49,720 --> 00:12:50,320Now Dr. 
22600:12:50,320 --> 00:12:51,280Helmrath and Dr. 
22700:12:51,280 --> 00:12:56,000Wales are seeing diseases like renal dysfunction and metabolic bone disease, and
22800:12:57,520 --> 00:12:57,960then the 
22900:12:57,960 --> 00:13:02,080neurocognitive issues and, you know, the quality of life issues.
23000:13:02,080 --> 00:13:04,200And that's why having a coordinated team
23100:13:05,200 --> 00:13:08,640that can track these problems long term is vital.
23200:13:08,920 --> 00:13:12,480OK, so if you're listening to this podcast and you're thinking to yourself,
23300:13:12,680 --> 00:13:14,280What am I going to get out of this series? 
23400:13:14,280 --> 00:13:15,520How is it going to help me? 
23500:13:15,520 --> 00:13:19,720I think the big key to a person watching a podcast is that they get hope.
23600:13:19,720 --> 00:13:23,440These are wonderful children, their opportunities to grow up,
23700:13:23,440 --> 00:13:25,520and they live the lives that their families want.
23800:13:25,520 --> 00:13:27,120Is really in front of them. 
23900:13:27,120 --> 00:13:30,040You're going to hear some experts talk about their process
24000:13:30,040 --> 00:13:32,720for taking care of these patients, how they think about them,
24100:13:33,080 --> 00:13:36,640what important things to know when you encounter one of these patients
24200:13:36,760 --> 00:13:40,120and may or may not need to refer them to a dedicated center?
24300:13:40,240 --> 00:13:44,280And people can't believe the culture that happens in the NICU.
24400:13:44,320 --> 00:13:49,200My goodness, I saw no way forward and look this little child full of light.
24500:13:49,440 --> 00:13:50,520And there's nothing 
24600:13:50,520 --> 00:13:54,760that puts more energy back into you wanting to do better than that home.
24700:13:55,920 --> 00:13:58,600Like I said, we work for her. 
24800:14:00,440 --> 00:14:01,120There you have it. 
24900:14:01,120 --> 00:14:04,760Episode one of our series on intestinal rehab.
25000:14:05,280 --> 00:14:08,400If you like this or learn something.
25100:14:08,440 --> 00:14:09,920Make sure to follow us on social media. 
25200:14:09,920 --> 00:14:11,040Subscribe to our YouTube channel. 
25300:14:11,040 --> 00:14:12,760Download the Stay Current in Pediatric Surgery app, 
25400:14:12,760 --> 00:14:15,040which is in the Apple App Store and the Google Play Store. 
25500:14:15,040 --> 00:14:19,120But until then, I'm Rod and I'm Ellen, and remember
25600:14:19,920 --> 00:14:23,400knowledge should be free, It was a little lagging.
25700:14:24,160 --> 00:14:25,160Should we do it again? 
25800:14:25,160 --> 00:14:26,840No that's, That's OK. 
25900:14:26,840 --> 00:14:27,960I think it's better this way.