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Pizzoferrato M, Puca P, Ennas S, Cammarota G, Guidi L. Glucagon-like peptide-2 analogues for Crohn’s disease patients with short bowel syndrome and intestinal failure. World J Gastroenterol 2022; 28:6258-6270. [PMID: 36504557 PMCID: PMC9730438 DOI: 10.3748/wjg.v28.i44.6258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 11/01/2022] [Accepted: 11/17/2022] [Indexed: 02/06/2023] Open
Abstract
Short bowel syndrome (SBS) with intestinal failure (IF) is a rare but severe complication of Crohn’s disease (CD), which is the most frequent benign condition that leads to SBS after repeated surgical resections, even in the era of biologics and small molecules. Glucagon-like peptide-2 analogues have been deeply studied recently for the treatment of SBS-IF. These drugs have a significant intestinotrophic effect and the potential to reduce the chronic dependence of SBS-IF patients on parenteral support or nutrition. Teduglutide has been approved for the treatment of SBS-IF, and apraglutide is currently in clinical development. The use of these drugs was examined with a focus on their use in CD patients.
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Affiliation(s)
- Marco Pizzoferrato
- UOC Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Pierluigi Puca
- UOC Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Sara Ennas
- UOC Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
| | - Giovanni Cammarota
- UOC Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome 00168, Italy
| | - Luisa Guidi
- UOC Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
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Maher D, Ting P, Edmundson A, Cuda TJ, Clark DA. Diminishing lengths of subsequent bowel resections in the surgical management of ileal Crohn's disease. ANZ J Surg 2022; 92:2921-2925. [PMID: 36129467 DOI: 10.1111/ans.18047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 09/04/2022] [Accepted: 09/05/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Crohn's disease is a chronic inflammatory bowel disease that most commonly affects the ileum. As a result, it is associated with a high lifetime risk of one or more surgical resections. The surgical paradigm is to preserve intestinal length. This study aims to assess the length of ileum resected at the index operation and at subsequent ileocolic resections for Crohn's disease. METHODS This is a retrospective study assessing the clinical and pathological data of patients undergoing ileocolic resection for the management of Crohn's disease over the period 01/01/2002 to 31/07/2020 in two metropolitan Australian hospitals. RESULTS One hundred and seventy-six patients were analysed: 130 underwent a single resection; 31 underwent two resections; and 15 underwent three resections. The median age at the first operation was 37.2 years (range 18-69) with 60% of patients female. The median length resected at the first surgery was 17.8 cm (IQR 12.0) for small bowel, and 5.0 cm (IQR 1.0) for large bowel. The length of ileum resected at the first surgery was significantly greater than that of the second (P = 0.0001), without significant differences between the second and third resections (P = 0.49). The time interval from diagnosis to the first surgery had no significant impact on the length of intestine resected at the index ileocolic resection. CONCLUSION In Crohn's disease, the length of ileum removed at first resection is the greatest, with subsequent resection lengths less than the first.
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Affiliation(s)
- Declan Maher
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Pascallina Ting
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Aleksandra Edmundson
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Tahleesa J Cuda
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Medical Imaging Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - David A Clark
- Department of Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Department of Surgery, St Vincent's Private Hospital Northside, Brisbane, Queensland, Australia
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Wong M, Neam VC, Horslen SP, Faino A, Javid PJ. Child self-reported quality of life in pediatric intestinal failure. J Pediatr Surg 2022; 57:143-148. [PMID: 34872727 DOI: 10.1016/j.jpedsurg.2021.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 10/23/2021] [Accepted: 11/05/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Recent studies have focused on parent-reported health-related quality of life (HRQOL) in children with intestinal failure (IF). However, there is a paucity of data on HRQOL from the perspective of the child with IF. METHODS A prospective study of child self-reported HRQOL was performed in a regional intestinal rehabilitation program from 2015 to 2019. The PedsQL 4.0 Generic Core Scales were administered annually to children with IF ages five years and older along with their parents. Survey data was stratified by age and compared with parent-proxy scores and reference populations of healthy and chronically ill children. Linear mixed-effect models were constructed to identify associations with child self-reported HRQOL. RESULTS A total of 140 surveys were administered to 69 children and their parents. Median child age at survey was 8 (IQR 6-10) years. Child self-reported HRQOL scores increased with each increasing age range. Children reported higher HRQOL scores compared to parent-proxy data in all age groups. Children with IF had lower HRQOL scores compared to healthy children in all survey dimensions (p < 0.001) and to children with chronic illness in the school and social functioning dimensions (p < 0.05). In adjusted analysis, longer remnant bowel length was independently associated with decreased HRQOL scores in children (p < 0.05). CONCLUSIONS Children with IF reported better HRQOL compared to parent-proxy data. While these HRQOL scores improved with age, they remain significantly lower than healthy and chronically ill peers. The association between bowel length and child-reported HRQOL deserves further investigation. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Melissa Wong
- University of Washington School of Medicine, Seattle, WA 98195, USA
| | | | - Simon P Horslen
- University of Washington School of Medicine, Seattle, WA 98195, USA; Seattle Children's Hospital, Seattle, WA 98105, USA
| | - Anna Faino
- Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Patrick J Javid
- University of Washington School of Medicine, Seattle, WA 98195, USA; Seattle Children's Hospital, Seattle, WA 98105, USA.
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Rafeeqi TA, Diyaolu M, Thomas AL, Salimi-Jazi F, Wood LSY, Dunn JCY. Generation of Porcine Ileum Through Spring-Mediated Mechanical Distraction. J Surg Res 2022; 280:371-378. [PMID: 36037614 DOI: 10.1016/j.jss.2022.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 07/12/2022] [Accepted: 07/28/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Short bowel syndrome is a devastating gastrointestinal disorder in which decreased bowel length results in inadequate absorption causing nutritional deficiencies. Current treatment options are accompanied by significant morbidity. We have proposed spring-mediated distraction enterogenesis as a method to lengthen bowel with success seen in porcine jejunum. We hypothesize that spring-mediated distraction enterogenesis can be demonstrated in porcine ileum with preservation of ileal structure and function. MATERIALS AND METHODS Laparotomy was performed on juvenile female mini-Yucatan pigs and a gelatin-encapsulated compressed nitinol spring was inserted into the ileal lumen and affixed proximally and distally. A control segment distal to the spring segment was marked with sutures. Postoperatively, pigs were placed on a liquid diet and euthanized on postoperative day 7. Spring and control segments were measured and processed for immunohistochemistry to evaluate for the presence of vitamin B12-intrinsic factor cotransporter, chromogranin A-producing cells, and 5-HT producing cells. RESULTS All seven pigs survived to postoperative day 7 with no adverse effects. On average, pigs gained 84.3 ± 66.4 g/d. Spring segments lengthened 1.5 ± 0.7 cm with a relative lengthening by 128% ± 56%, which was statistically significant when compared to control (P < 0.01). The average density of chromogranin-A cells in control compared to spring segments was not significantly changed (2.9 ± 1.1 cells/mm versus 3.2 ± 1.2 cells/mm, P = 0.17). Both vitamin B12-intrinsic factor cotransporter and 5-HT producing cells were present in both control and lengthened ileum. CONCLUSIONS Intraluminal nitinol springs significantly lengthened porcine ileum. The increase in density of enteroendocrine cells may indicate enhanced endocrine function of the lengthened ileum.
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Affiliation(s)
- Talha A Rafeeqi
- Division of Pediatric Surgery, Stanford University, Stanford, California
| | - Modupeola Diyaolu
- Division of Pediatric Surgery, Stanford University, Stanford, California
| | - Anne-Laure Thomas
- Division of Pediatric Surgery, Stanford University, Stanford, California
| | | | - Lauren S Y Wood
- Division of Pediatric Surgery, Stanford University, Stanford, California
| | - James C Y Dunn
- Division of Pediatric Surgery, Stanford University, Stanford, California; Department of Bioengineering, Stanford University, Stanford, California.
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Schmidt LH, Aa JS, Hartmann B, Madsen GI, Qvist N, Ellebæk MB. Segmental reversal of the distal small intestine in a short bowel syndrome model in piglets showed detrimental effect on weight gain. BMC Gastroenterol 2022; 22:349. [PMID: 35858830 PMCID: PMC9297615 DOI: 10.1186/s12876-022-02418-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 07/06/2022] [Indexed: 11/15/2022] Open
Abstract
Background To investigate the effects of a reversed segment of the distal small intestine to improve weight gain in an experimental short bowel syndrome (SBS) model in piglets. Methods Twenty-four piglets underwent resection of 70% of the distal small intestine. In half of the animals a conventional anastomosis was performed, and in the other half, the distal 25 cm of the remnant jejunum was reversed before the intestinal continuity was recreated. Weight was measured daily until day 28, where the animals were euthanized. Glucagon-Like Peptide-2 (GLP-2) and Glucose-dependent Insulinotropic Peptide (GIP) was measured pre- and postoperatively at day 28. Results The group with reversal of small intestine had a significant lower weight gain at 5.26 ± 3.39 kg (mean ± SD) compared to the control group with 11.14 ± 3.83 kg (p < 0.05). In the control group greater villus height and crypt depth was found distally, and greater muscular thickness was found proximally in the intervention group. GLP-2 and GIP levels increased significantly in the control group. Conclusions Treatment of short bowel syndrome with a reversed jejunal segment of 25 cm had a detrimental effect on the weight gain.
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Affiliation(s)
- Lasse Hartmann Schmidt
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, J. B. Winsløws Vej 4, 5000, Odense C, Denmark.
| | - Jesper Stensig Aa
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, J. B. Winsløws Vej 4, 5000, Odense C, Denmark
| | - Bolette Hartmann
- Department of Medical Sciences, NNF Center for Basic Metabolic Research, Faculty of Health Science, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen N, Denmark
| | - Gunvor Iben Madsen
- Research Unit for Pathology, Odense University Hospital, University of Southern Denmark, J. B. Winsløws Vej 4, 5000, Odense C, Denmark
| | - Niels Qvist
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, J. B. Winsløws Vej 4, 5000, Odense C, Denmark
| | - Mark Bremholm Ellebæk
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, J. B. Winsløws Vej 4, 5000, Odense C, Denmark
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Lauro A, Santoro A, Cirocchi R, Michelini M, Zorzetti N, Cianci MC, Bellini MI, Casadei C, Ripoli MC, Coletta R, Khouzam S, Marino IR, D'Andrea V, Morabito A. Serial transverse enteroplasty (STEP) in case of short bowel syndrome: did we achieve our goal? A systematic review. Updates Surg 2022; 74:1209-1223. [PMID: 35804224 DOI: 10.1007/s13304-022-01316-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 06/14/2022] [Indexed: 11/25/2022]
Abstract
Surveys on Serial Transverse Enteroplasty (STEP) published in international literature (1 January 2003- 31 May 2021) were searched. Articles were included from 17 countries: 1/23 comparative and 22/23 cohort studies. STEP was performed on 308 patients: pediatrics, adults, and mixed ages. Pediatric group included 16 studies and the adult 6. Pre-STEP residual small bowell (SB) length for pediatrics and adults ranged from 18 to 26 cm and from 30 to 70 cm, respectively. Post-STEP increased SB length for pediatrics and adults ranged between 42 and 100% and 50% and 176%, respectively. For pediatrics, enteral autonomy was reached in 32.22% of cases, parenteral nutrition (PN) dependence was 36.11%, a repeated STEP procedure (Re-STEP) was needed in 17.22%, and a bowel transplant was performed in 6.11%. In adults, enteral autonomy was achieved in 52.38%, while PN dependence was 37.1%, and no Re-STEP or transplantation were required. For the mixed group, post-STEP bowel length increased from 2 to 50 cm, enteral autonomy was obtained in 43%, PN dependence was 57%, without reported Re-STEP or transplantation. Mortality rates were between 5.55% (pediatric) and 7.14% (adults). Preoperative length with preservation of ileocecal valve represented the main predictive factors to achieve enteral autonomy.
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Affiliation(s)
- A Lauro
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy.
| | - A Santoro
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - R Cirocchi
- Department of Surgery and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - M Michelini
- Department of Surgery and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - N Zorzetti
- Ospedale Civile "A. Costa", Porretta Terme, Bologna, Italy
| | - M C Cianci
- Department of Paediatric Surgery, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - M I Bellini
- Azienda Ospedaliera "San Camillo-Forlanini", Rome, Italy
| | - C Casadei
- IRCCS Azienda Ospedaliero, Universitaria Di Bologna, Bologna, Italy
| | - M C Ripoli
- Ospedale "Ceccarini", Riccione, Rimini, Italy
| | - R Coletta
- Department of Paediatric Surgery, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - S Khouzam
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - I R Marino
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - V D'Andrea
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - A Morabito
- Department of Paediatric Surgery, Meyer Children's Hospital, University of Florence, Florence, Italy
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57
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Yano K, Sugita K, Muto M, Matsukubo M, Onishi S, Kedoin C, Matsui M, Murakami M, Harumatsu T, Yamada K, Yamada W, Kumagai K, Ido A, Kaji T, Ieiri S. The preventive effect of recombinant human hepatocyte growth factor for hepatic steatosis in a rat model of short bowel syndrome. J Pediatr Surg 2022; 57:1286-1292. [PMID: 35396090 DOI: 10.1016/j.jpedsurg.2022.02.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 02/23/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Short bowel syndrome (SBS) patients require total parenteral nutrition (TPN) following massive small bowel resection (SBR), which may cause intestinal failure-associated liver disease (IFALD), a life-threatening complication. Hepatocyte growth factor (HGF) acts as a potent hepatocyte mitogen with anti inflammatory and antioxidant actions. The present study evaluated the effect of recombinant human HGF (rh-HGF) on SBR and subsequent IFALD using a parentally fed rat model of SBS. METHODS Rats underwent jugular vein catheterization for continuous TPN and 90% SBR. They were divided into 2 groups: TPN alone (SBS/TPN group: n = 7) or TPN plus the intravenous administration of rh-HGF (0.3 mg/kg/day) (SBS/TPN+HGF group: n = 7). On day 7, their tissues and stool were harvested to evaluate the effects of HGF. RESULTS Regarding the histological findings, based on the nonalcoholic fatty liver disease (NAFLD) activity score, the SBS/TPN+HGF group showed significantly less hepatic steatosis and inflammatory cell infiltration than the SBS/TPN group (NAFLD activity score, 4.00 ± 1.83 vs. 1.00 ± 0.82; p < 0.01). The SBS/TPN+HGF group showed a higher expression of Farnesoid X receptor in the liver and lower expression of Toll-like receptor 4 in the ileum than the SBS/TPN group. Regarding the composition of the bacterial gut microbiota, Actinobacteria, Bacteroidetes and Proteobacteria were decreased in the SBS/TPN+HGF group compared with the SBS/TPN group. CONCLUSION In our SBS with TPN rat model, rh-HGF administration had a preventive effect against hepatic steatosis and dysbiosis. rh-HGF may therefore be a potentially effective therapeutic agent for SBS and subsequent IFALD. TYPE OF STUDY Experimental research.
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Affiliation(s)
- Keisuke Yano
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Koshiro Sugita
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Mitsuru Muto
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Makoto Matsukubo
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Shun Onishi
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Chihiro Kedoin
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Mayu Matsui
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Masakazu Murakami
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Toshio Harumatsu
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Koji Yamada
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Waka Yamada
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan; Clinical Training Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Kotaro Kumagai
- Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, School of Medical and Dental Sciences, Kagoshima University Graduate, Kagoshima, Japan
| | - Akio Ido
- Digestive and Lifestyle Diseases, Department of Human and Environmental Sciences, School of Medical and Dental Sciences, Kagoshima University Graduate, Kagoshima, Japan
| | - Tatsuru Kaji
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan; Clinical Training Center, Kagoshima University Hospital, Kagoshima, Japan
| | - Satoshi Ieiri
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.
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Pohju AK, Hakkarainen AI, Pakarinen MP, Sipponen TM. Longitudinal evolution of catheter-related bloodstream infections, kidney function and liver status in a nationwide adult intestinal failure cohort. Scand J Gastroenterol 2022; 57:763-767. [PMID: 35174757 DOI: 10.1080/00365521.2022.2039281] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The development of intestinal failure-related complications in Finnish adults is unknown. This study aimed to investigate the incidence of catheter-related bloodstream infections (CRBSI), and the longitudinal changes in biochemical liver and kidney tests in a nationwide cohort. MATERIALS AND METHODS The search for Finnish adults with intestinal failure (IF) utilized a survey to Finnish health-care providers (n = 111) with the potential to provide long-term parenteral support (PS) for adult IF. Our nationwide, cross-sectional cohort included all IF patients aged ≥ 18 years who had received PS for ≥ 120 d in 2017. Data regarding CRBSI and biochemical liver and kidney tests were collected from patient records at the start of PS up to the latest available measurement in 2017. RESULTS In the nationwide cohort of 52 patients, the CRBSI incidence was 1.35/1000 catheter days. Seventy-three percent of CRBSI in a long-term catheter led to catheter replacement. During a median PS duration of 27.5 (interquartile range [IQR] 11.3-57.3) months, a statistically significant median change occurred in estimated glomerular filtration rate (eGFR; -8.5 ml/min/1.73 m2, IQR -30-7, p = .005) and alkaline phosphatase (ALP; 26 U/l, IQR -11-95, p = .019). In a multiple regression model for eGFR at data collection, baseline eGFR and age were strong explanatory variables. CONCLUSIONS Incidence of CRBSI, but not treatment strategies, in this nationwide adult IF population correspond well to those reported from specialized centers. Decreased kidney function and abnormal liver test results are frequent findings, and even more so over time, emphasizing the importance of regular monitoring.
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Affiliation(s)
- Anne K Pohju
- Clinical Nutrition Unit, Internal Medicine and Rehabilitation, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti I Hakkarainen
- Medical Imaging Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Neuroscience and Biomedical Engineering, Aalto University School of Science, Espoo, Finland
| | - Mikko P Pakarinen
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group, Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Taina M Sipponen
- Gastroenterology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Kastl A, Zong W, Gershuni VM, Friedman ES, Tanes C, Boateng A, Mitchell WJ, O’Connor K, Bittinger K, Terry NA, Bales C, Albenberg L, Wu GD. Dietary fiber-based regulation of bile salt hydrolase activity in the gut microbiota and its relevance to human disease. Gut Microbes 2022; 14:2083417. [PMID: 35658830 PMCID: PMC9176262 DOI: 10.1080/19490976.2022.2083417] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Complications of short bowel syndrome (SBS) include malabsorption and bacterial overgrowth, requiring prolonged dependence on parenteral nutrition (PN). We hypothesized that the intolerance of whole food in some SBS patients might be due to the effect of dietary fiber on the gut microbiome. Shotgun metagenomic sequencing and targeted metabolomics were performed using biospecimens collected from 55 children with SBS and a murine dietary fiber model. Bioinformatic analyses were performed on these datasets as well as from a healthy human dietary intervention study. Compared to healthy controls, the gut microbiota in SBS had lower diversity and increased Proteobacteria, a pattern most pronounced in children on PN and inversely correlated with whole food consumption. Whole food intake correlated with increased glycoside hydrolases (GH) and bile salt hydrolases (BSH) with reduced fecal conjugated bile acids suggesting that dietary fiber regulates BSH activity via GHs. Mechanistic evidence supporting this notion was generated via fecal and plasma bile acid profiling in a healthy human fiber-free dietary intervention study as well as in a dietary fiber mouse experiment. Gaussian mixture modeling of fecal bile acids was used to identify three clinically relevant SBS phenotypes. Dietary fiber is associated with bile acid deconjugation likely via an interaction between gut microbiota BSHs and GHs in the small intestine, which may lead to whole food intolerance in patients with SBS. This mechanism not only has potential utility in clinical phenotyping and targeted therapeutics in SBS based on bile acid metabolism but may have relevance to other intestinal disease states.
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Affiliation(s)
- Arthur Kastl
- Division of Gastroenterology, Hepatology, and Nutrition, the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Wenjing Zong
- Division of Gastroenterology, Hepatology, and Nutrition, the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Victoria M. Gershuni
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elliot S. Friedman
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ceylan Tanes
- Division of Gastroenterology, Hepatology, and Nutrition, the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Adoma Boateng
- Division of Gastroenterology, Hepatology, and Nutrition, the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - William J. Mitchell
- Division of Gastroenterology, Hepatology, and Nutrition, the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kathleen O’Connor
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kyle Bittinger
- Division of Gastroenterology, Hepatology, and Nutrition, the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Natalie A. Terry
- Division of Gastroenterology, Hepatology, and Nutrition, the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christina Bales
- Division of Gastroenterology, Hepatology, and Nutrition, the Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lindsey Albenberg
- Division of Gastroenterology, Hepatology, and Nutrition, the Children’s Hospital of Philadelphia, Philadelphia, PA, USA,CONTACT Lindsey Albenberg Children’s Hospital of Philadelphia, 2716 South Street, 14-140, Philadelphia, PA, 19146, USA
| | - Gary D. Wu
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Gary D. Wu Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, 915 BRB II/III, 421 Curie Blvd., Philadelphia, PA, 19104, USA
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Abstract
Short bowel syndrome (SBS) of infancy is a cause of prolonged morbidity with intolerance to enteral feeding, specialized nutritional needs, and partial/total dependence on parenteral nutrition. These infants can benefit from individualized nutritional strategies to support and enhance the process of intestinal adaptation. Early introduction of enteral feeds during the period of intestinal adaptation is crucial, even though the enteral feedings may need to be supplemented with an effective, safe, and nutritionally adequate parenteral nutritional regimen. Newer generation intravenous lipid emulsions can be effective in preventing and treating intestinal failure-associated liver disease. Prevention of infection(s), pharmaceutical interventions to enhance bowel motility and prevent/mitigate bacteria overgrowth, and specialized multidisciplinary care to minimize the injury to other organs such as the liver, kidneys, and the brain can assist in nutritional rehabilitation and lower the morbidity in SBS.
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Affiliation(s)
- Muralidhar H Premkumar
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin, Suite 6104, Houston, TX 77030, USA.
| | - Amuchou Soraisham
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nitasha Bagga
- Department of Neonatology, Rainbow Children's Hospital, Hyderabad, India
| | - L Adriana Massieu
- Department of Clinical Nutrition Services, Texas Children's Hospital, Houston, TX, USA
| | - Akhil Maheshwari
- Global Newborn Society (https://www.globalnewbornsociety.org/), Clarksville, MD, USA
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61
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Abstract
Intestinal failure (IF) secondary to short bowel syndrome is a challenging and complex medical condition with significant risk for surgical and medical complications. Significant advancements in the care of this patient population have led to improved survival rates. Due to their intensive medical needs children with IF are at risk for long-term complications that require comprehensive management and close monitoring. The purpose of this paper is to review the available literature emphasizing the surgical aspects of care for children with IF secondary to short bowel syndrome. A key priority in the surgical care of this patient population includes strategies to preserve available bowel and maximize its function. Utilization of novel surgical techniques and autologous bowel reconstruction can have a significant impact on children with IF secondary to short bowel syndrome related to the function of their bowel and ability to achieve enteral autonomy. It is also important to understand the potential long-term complications to ensure strategies are put in place to mitigate risk with early detection to improve long-term outcomes.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, Cincinatti Children's Hospital Medical Center, University of Cincinnati, Cincinnatii, USA; Cincinnati Children's Intestinal Rehabilitation Program, Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 2023, Cincinnati, Ohio 45229, USA.
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62
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Culbreath K, Keefe G, Staffa SJ, Wynne N, Grimstad F, Jimenez L, Jaksic T, Modi BP. Puberty and growth in patients with pediatric intestinal failure. J Pediatr Surg 2022; 57:1045-9. [PMID: 35287963 DOI: 10.1016/j.jpedsurg.2022.01.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 01/31/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Pediatric intestinal failure (PIF) affects nutrition, metabolism, and endocrine development, but its downstream impact on puberty is unknown. METHODS A retrospective review was performed of patients age >8 years with PIF managed at an intestinal rehabilitation program. Outcomes of interest were peak height velocity (PHV), age at PHV, and age at pubertal onset (Tanner stage 2). Outcomes were stratified by sex and compared to established norms. RESULTS Of 110 patients with PIF, 54.5% were male. Compared to the CDC 50th percentile, PHV in PIF patients was similar for females (8.09±2.36 vs. 7.37 cm/yr;p = 0.23) but significantly higher for males (9.27±2.56 vs. 7.91 cm/yr;p = 0.038). Age at PHV in PIF patients was significantly younger for both males (12.31±2.14 vs. 13.38 years;p = 0.049) and females (10.70±1.06 vs. 11.71 years;p = 0.001). PIF patients reached pubertal onset earlier than published norms; this was significant for males (12.41±1.80 vs. 13.44 years;p = 0.014), but not for females (10.45±1.81 vs. -11.15 years;p = 0.13). The mean height-for-age Z-score was -1.2, with 20% of patients having a Z-score less than -2. CONCLUSIONS Pubertal onset and growth are neither delayed nor diminished in patients with PIF. The high incidence of short stature, however, highlights the importance of optimizing prepubertal linear growth to attain full height potential. TYPE OF STUDY Prognosis study (Retrospective cohort study).
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63
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Saito S, Nakayama I, Nishie R, Higa T, Oka S. Severe Coagulopathy in a Patient With Short Bowel Syndrome. J Emerg Med 2022; 62:e101-4. [PMID: 35109974 DOI: 10.1016/j.jemermed.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 12/23/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Short bowel syndrome (SBS) refers to a malabsorptive state caused by extensive resection of the intestinal tract that leads to chronic diarrhea, electrolyte disturbances, and malnutrition. Although relatively uncommon, patients with SBS can present to the emergency department with more serious complications that are potentially life-threatening. Among these complications, coagulopathy secondary to SBS is an underrecognized condition. CASE REPORT We present a case of severe coagulopathy secondary to vitamin K deficiency in SBS. The patient presented with unexplained coagulopathy and spontaneous bleeding in multiple organs. With a review of surgical history and detailed clinical evaluation, SBS complicated with vitamin K deficiency was diagnosed, and the patient was treated successfully. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: When a patient with a history of repeated intestinal surgery presents with diarrhea, malnutrition, or electrolyte abnormalities, emergency physicians should suspect SBS. Among complications of SBS, vitamin K deficiency is a rare but serious cause of unexplained coagulopathy presenting to the emergency department. Understanding the pathophysiology of SBS facilitates early identification of complications and improves patient outcomes.
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64
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Tsikis ST, Fligor SC, Secor JD, Yu LJ, Pan A, Mitchell PD, Loring G, First E, Nedder AP, Grammer RM, Pattison B, Gura KM, Puder M. An in-line digestive cartridge increases enteral fat and vitamin absorption in a porcine model of short bowel syndrome. Clin Nutr 2022; 41:1093-1101. [PMID: 35413571 PMCID: PMC9050916 DOI: 10.1016/j.clnu.2022.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND & AIMS Short bowel syndrome (SBS) occurs after intestinal loss resulting in parenteral nutrition dependence and micronutrient deficiencies, which may lead to life-limiting complications. ALC-078 is a cartridge containing immobilized lipase that connects in-line with enteral feeding sets and digests fats in enteral nutrition (EN). In this study, we evaluate the efficacy of ALC-078 to improve fat and nutrient absorption in a porcine SBS model. METHODS Fifteen male Yorkshire piglets were assessed. Animals were randomized to no intestinal resection (n = 5), 75% resection (n = 5), or 75% resection + ALC-078 (n = 5). After recovery, animals were treated for 14 days. Piglets received 60% of nutrition from continuous EN and 40% from chow. The degree of fat malabsorption was determined by the coefficient of fat absorption (CFA) following a 72-h stool collection. Body weight, fat-soluble vitamins, and nutritional markers were assessed. RESULTS Adverse events were similar across the three groups (P = 1.00). ALC-078-treated animals had similar weight gain compared to resected piglets. Resected animals had a lower CFA compared to unresected controls (79.3% vs. 95.2%, P = 0.01) while there was no significant difference in the ALC-078 animals (87.1% vs. 95.2%, P = 0.19). Between Study Days 1 and 15, ALC-078 animals had increased concentrations of vitamin D (12.2 vs. 8.7 ng/mL, P = 0.0006), and vitamin E (4.3 vs. 2.5 mg/L, P = 0.03). These markers did not significantly change in untreated resected animals. CONCLUSION ALC-078 increases the absorption of fat-soluble vitamins and may improve fat malabsorption. Future studies should determine whether ALC-078 can reduce PN dependence and if these findings translate to human patients with SBS.
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Affiliation(s)
- S T Tsikis
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA; Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, USA
| | - S C Fligor
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA; Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, USA
| | - J D Secor
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA; Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, USA
| | - L J Yu
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA; Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, USA
| | - A Pan
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA; Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, USA
| | - P D Mitchell
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - G Loring
- Alcresta Therapeutics, Newton, MA 02462, USA
| | - E First
- Alcresta Therapeutics, Newton, MA 02462, USA
| | - A P Nedder
- Animal Care Resources Children's Hospital, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - R M Grammer
- Animal Care Resources Children's Hospital, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - B Pattison
- Animal Care Resources Children's Hospital, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - K M Gura
- Department of Pharmacy and the Division of Gastroenterology and Nutrition, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - M Puder
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA; Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA 02115, USA.
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Pauline M, Fouhse J, Hinchliffe T, Wizzard P, Patrick Nation, Huynh H, Wales P, Willing B, Turner J. Probiotic Treatment Versus Empiric Oral Antibiotics for Managing Dysbiosis in Short Bowel Syndrome: Impact on the Mucosal and Stool Microbiota, Short Chain Fatty Acids and Adaptation. JPEN J Parenter Enteral Nutr 2022; 46:1828-1838. [PMID: 35383975 DOI: 10.1002/jpen.2377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/22/2022] [Accepted: 03/25/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Infants and children with short bowel syndrome (SBS) are presumed to be at risk of gut microbial dysbiosis with potential sequelae of bacterial overgrowth that include sepsis, D-lactic acidosis, mucosal inflammation and malabsorption. In neonatal piglets with SBS, we compared intestinal microbial composition, short chain fatty acids (SCFA) and adaptation given probiotic treatment (Lactobacillus and Bifidobacterium spp.) versus oral metronidazole. METHODS Following 75% distal small intestinal resection, piglets were allocated to: probiotic (PRO, 500mg BID n=7), metronidazole (MET, 15mg/kg BID n=8) and placebo (PLA, 500mg BID n=8). After 10 days of parenteral and enteral nutrition, 16S rRNA gene amplicon sequencing (colon tissue and stool) were undertaken and SCFA analysis (stool and colon effluent) performed using gas chromatography. RESULTS In colon, Shannon diversity was higher for PRO compared to MET and PLA (p=0.002). PRO and PLA increased abundance of Bacteroidetes species (e.g. Bacteroides fragilis), compared to MET (p<0.001). PRO compared to PLA increased abundance of Firmicutes species (e.g. Lactobacillus fermentum) (p<0.001). MET increased abundance of Proteobacteria members, predominately Enterobacteriaceae compared to PRO (p=0.004). In stool, microbial findings were similar and SCFA (butyrate) concentrations were highest for PRO (p=0.003) compared to MET. CONCLUSION In pediatric SBS, the empiric use of oral antibiotics, such as metronidazole, is common for presumed clinical consequences of microbial dysbiosis. In this study of SBS piglets, that approach was associated with decreased microbial diversity and increased abundance of potentially inflammatory Proteobacteria. In contrast, a probiotic treatment using Lactobacillus and Bifidobacterium spp. increased both diversity and SCFAs. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Mirielle Pauline
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Janelle Fouhse
- Faculty of Agriculture, Life and Environmental Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Tierah Hinchliffe
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Patrick Nation
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Hien Huynh
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Paul Wales
- Department of Surgery, Cincinnati Children's Hospital Medical Center and University of Cincinnati
| | - Benjamin Willing
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Justine Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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66
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Jones BC, O’Sullivan B, Amin SP, Hill S, Eaton S, De Coppi P. Patient-level costing analysis of paediatric short bowel syndrome care in a specialist tertiary centre. Pediatr Surg Int 2022; 38:533-539. [PMID: 35211770 PMCID: PMC8913464 DOI: 10.1007/s00383-022-05074-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/24/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To undertake a pilot study estimating patient-level costs of care for paediatric short bowel syndrome (SBS) from the healthcare provider perspective. METHODS A pilot group of patients with anatomical SBS was selected at a single specialist tertiary centre in the United Kingdom. The Patient Level Information and Costing System (PLICS) was used to extract costing data for all hospital-based activities related to SBS, from the implementation of PLICS in 2016 to April 2021. Patient-specific and pooled data were reported descriptively in per patient-year terms. RESULTS Five patients had full PLICS data available for the 5-year study period and 2 patients had 4 years of data. The median cost for hospital care of SBS was £52,834 per patient-year (range £1804-£331,489). The key cost drivers were inpatient beds, pharmacy, and staffing costs, which made up > 60% of annual costs. In the first 3 years following index admission (n = 2), there was a steady decline in the annual cost of care to a level comparable with patients with established SBS. CONCLUSION Patient-level cost of care analysis for SBS is feasible using PLICS. Hospital-related costs vary widely between and within individual patients over time. Key drivers of cost are related to complications of SBS.
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Affiliation(s)
- Brendan C. Jones
- Developmental Biology and Cancer Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, UK ,Specialist Neonatal and Paediatric Surgery Unit, Great Ormond Street Hospital, London, UK
| | - Benjamin O’Sullivan
- Department of Paediatric Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | | | - Susan Hill
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Simon Eaton
- Developmental Biology and Cancer Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Paolo De Coppi
- Developmental Biology and Cancer Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, UK ,Specialist Neonatal and Paediatric Surgery Unit, Great Ormond Street Hospital, London, UK
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67
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Zhu C, Li Y. An updated overview of glucagon-like peptide-2 analog trophic therapy for short bowel syndrome in adults. J Int Med Res 2022; 50:3000605221086145. [PMID: 35343263 PMCID: PMC8966062 DOI: 10.1177/03000605221086145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Short bowel syndrome (SBS) is a clinical condition characterized by a failure to achieve optimal intestinal adaptation, which is necessary to maintain oral/enteral autonomy. At present, the treatment options for SBS are primarily intestinal replacement and rehabilitation. Intestinal rehabilitation mainly includes non-transplantation surgery and intestinal rehabilitation measures. In recent years, intestinal rehabilitation in patients with SBS using nutritional intestinal hormones, especially glucagon-like peptide-2 analogs, has made great progress. Many high-quality studies have provided evidence-based medical findings to support the development of clinical guidelines. This article reviews the latest research advancements regarding the use of glucagon-like peptide-2 analogs (teduglutide, glepaglutide, and apraglutide) in the treatment of SBS.
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Affiliation(s)
- Changzhen Zhu
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
| | - Yuanxin Li
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing 102218, China
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68
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Gray M, Duggan CP. 3.10 Intestinal Failure and Malabsorption. World Rev Nutr Diet 2022; 124:285-290. [PMID: 35240625 DOI: 10.1159/000516725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 03/28/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Megan Gray
- Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA,
| | - Christopher P Duggan
- Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
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69
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Richards CA. Commentary on ethical dilemmas in the management of infants with necrotizing enterocolitis totalis. J Pediatr Surg 2022; 57:335-6. [PMID: 34742577 DOI: 10.1016/j.jpedsurg.2021.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 09/16/2021] [Indexed: 11/20/2022]
Abstract
This is a commentary on the manuscript titled "Ethical Dilemmas in the Management of Infants with Necrotizing Enterocolitis Totalis".
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70
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Pennington EC, Javid PJ, Sullins V, Mueller C, Hunter CJ. Ethical dilemmas in the management of infants with necrotizing enterocolitis totalis. J Pediatr Surg 2022; 57:329-334. [PMID: 34654549 DOI: 10.1016/j.jpedsurg.2021.08.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 08/15/2021] [Accepted: 08/27/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE Necrotizing enterocolitis (NEC) totalis is a devastating disease of the newborn intestine. A precise clinical definition of the extent of gastrointestinal involvement is lacking in the existing literature, and the clinical outcomes are typically viewed as grim. METHODS Herein, we present a series of clinical case examples of patients with varying degrees of NEC totalis and other co-morbid conditions, with possible anticipated outcomes based on current data. RESULTS We define the key ethical issues and provide a framework and discussion of the ethical issues involved in the care of patients with NEC totalis and recommendations of how to approach discussions with the family of these patients We discuss the ethical considerations for both the providers caring for these patients, and the patient's family members. CONCLUSION The management of patients with NEC totalis is complex and ethically challenging. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Elliot C Pennington
- Helen DeVos Children's Hospital and Michigan State University College of Human Medicine, 330 Barclay Ave NE, Suite 202, Grand Rapids, MI 49503
| | - Patrick J Javid
- Seattle Children's Hospital and University of Washington School of Medicine, Seattle, WA
| | - Veronica Sullins
- Division of Pediatric Surgery, UCLA Mattel Children's Hospital, 10833 Le Conte Ave, Box 709818, Los Angeles, CA 90095, United States
| | - Claudia Mueller
- Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA 94305
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71
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Berman L, Levy C, Miller JM. Commentary on ethical dilemmas in the management of infants with enterocolitis totalis. J Pediatr Surg 2022; 57:337-338. [PMID: 34686376 DOI: 10.1016/j.jpedsurg.2021.09.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 10/20/2022]
Abstract
This is a Commentary on the manuscript titled "Ethical Dilemmas in the Management of Infants with Necrotizing Enterocolitis Totalis" by Pennington E, Javid P, Mueller C, et al.
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Affiliation(s)
- Loren Berman
- Nemours Children's Health-Delaware Valley, Department of Surgery, Wilmington, DE, and Sidney Kimmel Medical College at Thomas Jefferson University, 1600 Rockland Road, Philadelphia, PA, Wilmington, DE 19803, United States.
| | - Carly Levy
- Nemours Children's Health-Delaware Valley, Department of Pediatrics, Division of Palliative Medicine, Wilmington, DE, and Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| | - Jonathan M Miller
- Nemours Children's Health-Delaware Valley, Department of Pediatrics, Division of Academic General Pediatrics, Wilmington, DE, and Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
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72
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Mizushima T, Udagawa E, Hasegawa M, Tazuke Y, Okuyama H, Fernandez J, Nakamura S. Etiologies and treatments of chronic intestinal failure- short bowel syndrome (SBS) in Japanese adults: a real-world observational study. Surg Today 2022. [PMID: 35195767 DOI: 10.1007/s00595-022-02469-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/26/2021] [Indexed: 12/03/2022]
Abstract
Purpose Short bowel syndrome (SBS) with intestinal failure (SBS-IF) requires long-term parenteral nutrition (PN). This study investigated the real-world etiologies of SBS, treatment patterns, and PN-related outcomes among adult patients with SBS-IF in Japan. Methods This retrospective, observational cohort study was based on data from April, 2008 to January, 2020 from one of the largest hospital-based claim databases in Japan. Analyzed patients were aged ≥ 16 years, had received continuous PN for ≥ 6 months, and had SBS or undergone SBS-related surgery with a diagnosis of a causative disease. The primary endpoint was PN weaning. Results We analyzed data for 393 patients. The most frequent causes of SBS-IF were ileus (31.8%), Crohn’s disease (20.1%), and mesenteric ischemia (16.0%). Of 144/393 (36.6%) patients who were weaned off their PN, 48 (33.3%) were subsequently restarted on PN. Of 276/393 (70.2%) patients whose PN was initiated in hospital, 156 (56.5%) transitioned to home management. The mean duration of initial PN was 450.4 and 675.5 days for patients who were able or unable to be weaned off PN, respectively. Sepsis (67.4%), catheter-related bloodstream infections (49.1%), and liver disorders (45.0%) were the most reported PN-related complications. Conclusions Most patients with SBS-IF in Japan could not be weaned off PN and suffered life-threatening complications. Supplementary Information The online version contains supplementary material available at 10.1007/s00595-022-02469-9.
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Tsikis ST, Fligor SC, Secor JD, Yu LJ, Pan A, Loring G, First E, Nedder AP, Grammer RM, Rudie C, Gura KM, Puder M. Outcomes and Perioperative Nutritional Management in a Porcine Model of Short Bowel Syndrome. J Surg Res 2022; 274:59-67. [PMID: 35123284 DOI: 10.1016/j.jss.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/06/2021] [Accepted: 01/04/2022] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Short bowel syndrome (SBS) results from significant intestinal loss and is characterized by insufficient absorption of nutrients and fluids. Preclinical large animal SBS models typically require parenteral nutrition (PN) support and may not be appropriate for studying interventions to improve intestinal absorption or adaptation. Here, we describe the development of a porcine SBS model that does not require PN support. METHODS Eight male Yorkshire piglets underwent either a 75% or 90% jejunoileal resection (n = 5) or no resection (n = 3). Continuous enteral nutrition (EN) was provided via a gastrostomy tube. The final SBS model consisted of a 75% resection and nutrition provided via combination EN (60%) and per oral pig chow (40%). Body weight and concentration of fat-soluble vitamins were assessed on postoperative days (POD) 7, 14, and 21. For assessing fat malabsorption, the coefficient of fat absorption (CFA) was calculated following a 72-h stool collection. RESULTS Resected animals had decreased weight gain compared to unresected controls (POD21 + 8.3% versus +28.8%, P = 0.048). Vitamin D concentration was significantly lower in resected animals compared to controls on POD 7, POD 14, and POD 21. Serum vitamin E concentration was also lower on POD 21. Resected animals developed fat malabsorption with lower CFA (76.5% versus 95.3%, P = 0.014). CONCLUSIONS We describe the development of a porcine SBS model that does not require PN support. Piglets in this model gain less weight, demonstrate fat malabsorption, and develop fat-soluble vitamin deficiencies. This model will benefit investigations of intestinal absorption or adaptation while potentially decreasing costs and confounding complications related to PN administration.
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Affiliation(s)
- Savas Theodore Tsikis
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Scott C Fligor
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jordan D Secor
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lumeng J Yu
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amy Pan
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Eric First
- Alcresta Therapeutics, Newton, Massachusetts
| | - Arthur P Nedder
- Animal Care Resources Children's Hospital, Boston Children's Hospital, Boston, Massachusetts
| | - Robin M Grammer
- Animal Care Resources Children's Hospital, Boston Children's Hospital, Boston, Massachusetts
| | - Coral Rudie
- Department of Gastroenterology, Boston Children's Hospital, Boston, Massachusetts
| | - Kathleen M Gura
- Department of Pharmacy and the Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - Mark Puder
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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Hinchliffe T, Pauline ML, Wizzard PR, Jovel J, Nation PN, Wales PW, Madsen KL, Turner JM. The effect of fecal microbial transplant on intestinal microbial composition in short bowel neonatal piglets. JPEN J Parenter Enteral Nutr 2022; 46:1393-1403. [PMID: 35043436 DOI: 10.1002/jpen.2333] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/29/2021] [Accepted: 01/03/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Short bowel syndrome (SBS) in neonates is associated with microbial dysbiosis due to intestinal surgery, prolonged hospitalization, enteral nutrition, and repeated antibiotic exposure. Sepsis and liver disease, leading causes of morbidity and mortality in SBS, may relate to such intestinal dysbiosis. We investigated the safety and feasibility of fecal microbial transplant (FMT) to alter intestinal microbial composition in SBS piglets. METHODS Following a 75% distal small intestinal resection, piglets were fed parenteral nutrition (PN) and elemental diet (ED), and randomized to saline (SAL, n=12) or FMT (n=12) treatments delivered by gastric tube on day 2 (d2). FMT donor was a healthy adult pig. Comparisons were also made to healthy sow-fed littermate controls (SOW, n=6). Stool samples were collected daily, and tissue samples were collected at baseline and termination. Microbial DNA was extracted from stool and analyzed using 16S rRNA sequencing. RESULTS All piglets survived to the endpoint. On d2-4, FMT piglets had some differences in microbiota composition, compared to SAL, SOW, and donor. Between base and term, there were transitory changes to alpha and beta diversity in FMT and SAL. CONCLUSION FMT treatment in post-surgical neonatal piglets with SBS appears safe, with no increase in sepsis and no mortality. In SBS piglets, FMT induced transient changes to the intestinal microbiota. However, these changes did not persist long-term. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Tierah Hinchliffe
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Mirielle L Pauline
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela R Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Juan Jovel
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Patrick N Nation
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Paul W Wales
- Department of Surgery, Cincinnati Children's Hospital Medical Center and University of Cincinnati
| | - Karen L Madsen
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Tecos ME, Steinberger AE, Guo J, Warner BW. Distal Small Bowel Resection Yields Enhanced Intestinal and Colonic Adaptation. J Surg Res 2022; 273:100-109. [PMID: 35033819 PMCID: PMC10364185 DOI: 10.1016/j.jss.2021.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 09/29/2021] [Accepted: 11/17/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Murine ileocecal resection (ICR) has been used to investigate intestinal adaptation. The established model often includes the sacrifice of significant length of the proximal colon. Here, we optimized a highly selective vascular approach to the ICR, with primary jejunal-colic anastomosis yielding maximal colonic preservation. MATERIALS AND METHODS Forty C57BL/6 mice underwent a highly vascularly selective ICR. The terminal branches of the ileocecal artery are isolated apart from the mesenteric branches supplying the small bowel to be resected. The distal 50% of small bowel and cecum are resected; a primary jejuno-colonic anastomosis is performed. Animals were sacrificed at postoperative weeks 2 (n = 10) and 10 (n = 29). Proximal 50% small bowel resection (SBR) with jejuno-ileal anastomosis was also performed for comparison. RESULTS The entire colon (with exception of the cecum) was preserved in 100% of animals. Ninety-seven percent of animals survived to postoperative week 10, and all exhibited structural adaptation in the remnant small intestine epithelium. Crypts deepened by 175%, and villi lengthened by 106%, versus 39% and 29% in the proximal SBR cohort, respectively. Colonic proliferation, structural adaptation, and functional adaptation (measured by p-histone 3, luminal-facing apical crypt border size, and sucrase isomaltase, respectively) were increased in ICR compared with proximal SBR. CONCLUSIONS Highly selective isolation of the cecal vasculature allows for greater colon preservation and yields enhanced remnant intestine epithelial adaptation. ICR is also associated with greater colonic adaptation and unique plasticity toward an intestinal phenotype. These findings underscore major differences between resection sites and offer insights into the critical adaptive mechanisms in response to massive intestinal loss.
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Affiliation(s)
- Maria E Tecos
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children's Hospital, Washington, University in St. Louis School of Medicine, St. Louis, Missouri; Division of General Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Allie E Steinberger
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children's Hospital, Washington, University in St. Louis School of Medicine, St. Louis, Missouri; Division of General Surgery, Department of Surgery, Barnes Jewish Hospital, Washington, University in St. Louis School of Medicine, St. Louis, Missouri
| | - Jun Guo
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children's Hospital, Washington, University in St. Louis School of Medicine, St. Louis, Missouri
| | - Brad W Warner
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children's Hospital, Washington, University in St. Louis School of Medicine, St. Louis, Missouri.
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Khosravi MB, Naderi-Boldaji V, Khalili F, Sahmeddini MA, Eghbal MH, Vatankhah P, Nikoupour H, Shamsaeefar A, Ghazanfar Tehran S. Anesthesia Aspects of Multivisceral Transplantation: A Case Series Study. Int J Organ Transplant Med 2022; 13:71-77. [PMID: 37641733 PMCID: PMC10460526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
Background Multi-visceral transplantation (MvTx) usually refers to the transplantation of more than three intra-abdominal organs. A successful MvTx requires strong multidisciplinary teamwork of transplant surgeons, anesthesiologists, and intensivists. Case presentation We present five cases of MvTx with a history of short bowel syndrome admitted to the Abu-Ali Sina Hospital, Shiraz, Iran from May 2019 to January 2020 and describe anesthetic considerations in MvTx. Subjects were identified (4F/1M) with a mean age of 43 years old (range 35-51). The most frequent cause of intestinal failure was portal vein thrombosis, followed by bowel gangrene and short bowel syndrome. The mean ±SD duration of the operation was 360±60 min. The bleeding volume was approximately 2600±1474 cc, and 4±1 bags of packed red blood cells were transfused. Sepsis was the main cause of death in our series. Conclusion Careful preoperative planning, vigilant intraoperative anesthetic management, and prevention of postoperative infection are imperative to achieve the best outcomes.
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Affiliation(s)
- M B Khosravi
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - V Naderi-Boldaji
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - F Khalili
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - M A Sahmeddini
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - M H Eghbal
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - P Vatankhah
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - H Nikoupour
- Abo-Ali Sina Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - A Shamsaeefar
- Abo-Ali Sina Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - S Ghazanfar Tehran
- Anesthesiology and Critical Care Research Center, Alzahra Hospital, Guilan University of Medical Sciences, Rasht, Iran
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Shafiekhani M, Azadeh N, Ashrafzadeh K, Esmaeili M, Nikoupour H. Serial transverse enteroplasty and nipple valve construction, two life saving techniques for patients with short bowel syndrome, a report of 5 cases. BMC Surg 2021; 21:446. [PMID: 34969388 PMCID: PMC8717644 DOI: 10.1186/s12893-021-01454-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/24/2021] [Indexed: 11/29/2022] Open
Abstract
Background Various abdominal pathologies end up with surgical resection of small intestine. When the small intestine remnant is too short for adequate fluid and micronutrients absorption, short bowel syndrome is diagnosed. The disabling condition needs a multidisciplinary approach to design parenteral nutrition, care for thrombotic, hepatic and infectious complications and gradually wean the patient from parenteral nutrition. Various surgical techniques have been introduced to increase absorptive mucosa and enhance the intestinal adaptation process. Serial transverse enteroplasty and nipple valve reconstruction are among the procedures, which will be discussed in the current article. Case presentation Herein, we presented 5 cases of short bowel syndrome as a consequence of abdominal laparotomies, patients were referred to our center to receive parenteral nutrition and to be prepared for the final autologous gastrointestinal reconstruction or intestinal transplantation, if indicated. Conclusion Patient’s age, performance status and bowel remnant length determines the appropriate technique for autologous gastrointestinal reconstruction. Serial transverse enteroplasty is designed to increase bowel’s length by creating zigzag patterns through dilated bowel loops. Presence of ileocecal valve is crucial to delay intestinal transit time and to prevent colonic bacterial transfer to ileum. Patient’s with ileocecal valve loss benefit from creating an artificial valve, namely, nipple valve.
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Affiliation(s)
- Mojtaba Shafiekhani
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nazanin Azadeh
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Kiarash Ashrafzadeh
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Esmaeili
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamed Nikoupour
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
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Haghshenas M, Rolle U, Hutter M, Theilen TM. Incidence of surgical procedures for gastrointestinal complications after abdominal wall closure in patients with gastroschisis and omphalocele. Pediatr Surg Int 2021; 37:1531-42. [PMID: 34435217 DOI: 10.1007/s00383-021-04977-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE This study aims to define the extent of additional surgical procedures after abdominal wall closure (AWC) in patients with gastroschisis (GS) and omphalocele (OC) with special focus on gastrointestinal related operations. METHODS A retrospective chart review was performed including all operations in GS and OC patients in the first year after AWC (2010-2019). The risk for surgery was calculated using the one-year cumulative incidence (CI). RESULTS 33 GS patients (18 simple GS, 15 complex) and 24 OC patients (12 without (= OCL), 12 OC patients with liver protrusion (= OCL +)) were eligible for analysis. 43 secondary operations (23 in GS, 20 in OC patients) occurred after a median time of 84 days (16-824) in GS and 114.5 days (12-4368) in OC. Patients with complex versus simple GS had a significantly higher risk of undergoing a secondary operation (one-year CI 64.3% vs. 24.4%; p = 0.05). 86.5% of surgical procedures in complex GS and 36.3% in OCL + were related to gastrointestinal complications. Complex GS had a significantly higher risk for GI-related surgery than simple GS. Bowel obstruction was a risk factor for surgery in complex GS (one-year CI 35.7%). CONCLUSION Complex GS and OCL + patients had the highest risk of undergoing secondary operations, especially those with gastrointestinal complications.
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Pironi L, Steiger E, Joly F, Jeppesen PB, Wanten G, Sasdelli AS, Chambrier C, Aimasso U, Mundi MS, Szczepanek K, Jukes A, Theilla M, Kunecki M, Daniels J, Serlie M, Poullenot F, Cooper SC, Rasmussen HH, Compher C, Seguy D, Crivelli A, Santarpia L, Guglielmi FW, Kozjek NR, Schneider SM, Ellegard L, Thibault R, Matras P, Matysiak K, Van Gossum A, Forbes A, Wyer N, Taus M, Virgili NM, O'Callaghan M, Chapman B, Osland E, Cuerda C, Udvarhelyi G, Jones L, Won Lee AD, Masconale L, Orlandoni P, Spaggiari C, Díez MB, Doitchinova-Simeonova M, Serralde-Zúñiga AE, Olveira G, Krznaric Z, Czako L, Kekstas G, Sanz-Paris A, Jáuregui MEP, Murillo AZ, Schafer E, Arends J, Suárez-Llanos JP, Youssef NN, Brillanti G, Nardi E, Lal S. Characteristics of adult patients with chronic intestinal failure due to short bowel syndrome: An international multicenter survey. Clin Nutr ESPEN 2021; 45:433-441. [PMID: 34620351 DOI: 10.1016/j.clnesp.2021.07.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/08/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND AIMS The case-mix of patients with intestinal failure due to short bowel syndrome (SBS-IF) can differ among centres and may also be affected by the timeframe of data collection. Therefore, the ESPEN international multicenter cross-sectional survey was analyzed to compare the characteristics of SBS-IF cohorts collected within the same timeframe in different countries. METHODS The study included 1880 adult SBS-IF patients collected in 2015 by 65 centres from 22 countries. The demographic, nutritional, SBS type (end jejunostomy, SBS-J; jejuno-colic anastomosis, SBS-JC; jejunoileal anastomosis with an intact colon and ileocecal valve, SBS-JIC), underlying disease and intravenous supplementation (IVS) characteristics were analyzed. IVS was classified as fluid and electrolyte alone (FE) or parenteral nutrition admixture (PN). The mean daily IVS volume, calculated on a weekly basis, was categorized as <1, 1-2, 2-3 and >3 L/day. RESULTS In the entire group: 60.7% were females and SBS-J comprised 60% of cases, while mesenteric ischaemia (MI) and Crohn' disease (CD) were the main underlying diseases. IVS dependency was longer than 3 years in around 50% of cases; IVS was infused ≥5 days/week in 75% and FE in 10% of cases. Within the SBS-IF cohort: CD was twice and thrice more frequent in SBS-J than SBS-JC and SBS-JIC, respectively, while MI was more frequent in SBS-JC and SBS-JIC. Within countries: SBS-J represented 75% or more of patients in UK and Denmark and 50-60% in the other countries, except Poland where SBS-JC prevailed. CD was the main underlying disease in UK, USA, Denmark and The Netherlands, while MI prevailed in France, Italy and Poland. CONCLUSIONS SBS-IF type is primarily determined by the underlying disease, with significant variation between countries. These novel data will be useful for planning and managing both clinical activity and research studies on SBS.
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Affiliation(s)
- Loris Pironi
- CHU Rennes, Nutrition Unit, Clinique Saint Yves, Home Parenteral Nutrition Centre, INRAE, INSERM, Univ Rennes, Nutrition Metabolisms and Cancer, NuMeCan, Rennes, France.
| | - Ezra Steiger
- Home Nutrition Support, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Francisca Joly
- Centre for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Palle B Jeppesen
- Rigshospitalet, Department of Gastroenterology, Copenhagen, Denmark
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Anna S Sasdelli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Centre for Chronic Intestinal Failure - Clinical Nutrition and Metabolism Unit, Bologna, Italy
| | - Cecile Chambrier
- Unité de Nutrition Clinique Intensive, Hospices Civils de Lyon, Hôpital Lyon Sud, Lyon, France
| | | | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo College of Medicine, Rochester, MN, USA
| | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - Amelia Jukes
- University Hospital of Wales, Cardiff, United Kingdom
| | - Miriam Theilla
- Rabin Medical Center, Petach Tikva, Sackler School of Medicine, Tel Aviv University, Israel
| | | | - Joanne Daniels
- Nottingham University Hospital NHS Trust, Nottingham, United Kingdom
| | - Mireille Serlie
- Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Florian Poullenot
- Service de Gastroentérologie, Hôpital Haut-Lévêque, CHU de Bordeaux, Pessac, France
| | - Sheldon C Cooper
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Henrik H Rasmussen
- Centre for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Charlene Compher
- Hospital of the University of Pennsylvania, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - David Seguy
- Service de Nutrition, CHRU de Lille, Lille, France
| | - Adriana Crivelli
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante de Intestino, Hospital Universitario Fundacion Favaloro, Buenos Aires, Argentina
| | | | | | | | - Stéphane M Schneider
- Gastroenterology and Clinical Nutrition, CHU of Nice, Université Côte D'Azur, Nice, France
| | - Lars Ellegard
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Ronan Thibault
- CHU Rennes, Nutrition Unit, Clinique Saint Yves, Home Parenteral Nutrition Centre, INRAE, INSERM, Univ Rennes, Nutrition Metabolisms and Cancer, NuMeCan, Rennes, France
| | - Przemysław Matras
- Department of General and Transplant Surgery and Clinical Nutrition, Medical University of Lublin, Lublin, Poland
| | - Konrad Matysiak
- Centre for Intestinal Failure, Department of General, Endocrinological and Gastroenterological Surgery, Poznań University of Medical Science, Poznań, Poland
| | - Andrè Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - Alastair Forbes
- Institute of Internal Medicine, University of Tartu, Tartu, Estonia, And Previously at Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Nicola Wyer
- University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom
| | - Marina Taus
- SOD Dietetica e Nutrizione Clinica, Centro Riferimento Regionale NAD, Ospedali Riuniti di Ancona, Italy
| | - Nuria M Virgili
- Facultatiu Especialista. Servei D'Endocrinologia I Nutrició, Hospital Universitari de Bellvitge, Barcelona, Spain
| | | | | | - Emma Osland
- Royal Brisbane and Women's Hospital, Herston, Australia
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | | | - Lynn Jones
- Royal Prince Alfred Hospital, Camperdown, Australia
| | - Andre D Won Lee
- Hospital Das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Paolo Orlandoni
- Nutrizione Clinica-Centro di Riferimento Regionale NAD, IRCCS-INRCA, Ancona, Italy
| | | | - Marta Bueno Díez
- Servei D'Endocrinologia I Nutrició, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | | | | | | | - Zeljko Krznaric
- Centre of Clinical Nutrition, Department of Medicine, University Hospital Centre, Zagreb, Croatia
| | - Laszlo Czako
- First Department of Internal Medicine, Szeged, Hungary
| | | | | | | | | | - Eszter Schafer
- Magyar Honvedseg Egészségügyi Központ (MHEK), Budapest, Hungary
| | - Jann Arends
- Department of Medicine, Oncology and Hematology, University of Freiburg, Germany
| | - José P Suárez-Llanos
- Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Nader N Youssef
- VectivBio AG Basel, Switzerland, Digestive Healthcare Center, NJ, USA
| | - Giorgia Brillanti
- Alma Mater Studiorum, University of Bologna, Department of Medical and Surgical Sciences, Bologna, Italy
| | - Elena Nardi
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
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Phyo LY, Singkhamanan K, Laochareonsuk W, Surachat K, Phutong N, Boonsanit K, Chiengkriwate P, Sangkhathat S. Fecal microbiome alterations in pediatric patients with short bowel syndrome receiving a rotating cycle of gastrointestinal prophylactic antibiotics. Pediatr Surg Int 2021; 37:1371-81. [PMID: 34156541 DOI: 10.1007/s00383-021-04948-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pediatric patients with short bowel syndrome (SBS) are at risk of developing small intestinal bacterial overgrowth (SIBO). Prevention of SIBO using cyclic enteric antibiotics has been implemented to control the balance in microbial ecosystems, although its effectiveness has not been well studied. PURPOSE This study aimed to explore the change in the gut microbial composition in SBS patients during cyclic antibiotic phases and antibiotic-free period, and to compare the microbiota composition between healthy controls and SBS patients. METHOD SBS patients taking oral metronidazole alternating with trimethoprim-sulfamethoxazole (TMP-SMT) and antibiotic-free conditions as a '10-day cyclic protocol' were involved in fecal microbiome study using Illumina 16S sequencing. RESULTS When healthy control possessed the majority of Bacteroidetes spp. (54%) and Firmicutes spp. (33%), the microbial composition in SBS patients especially Firmicutes spp. and Proteobacteria spp. was prominently changed in each phase of treatment. In antibiotic-free period, SBS patients displayed 49% Firmicutes and 36% Proteobacteria. However, higher Proteobacteria than Firmicutes were detected at the commencement of metronidazole (58% versus 33%). Similarly, 56% Proteobacteria and 27% Firmicutes were found during TMP-SMT. Escherichia coli increased prominently during the antibiotic periods. CONCLUSION Prophylactic antibiotics change the gut microbiota composition in an unfavorable direction, especially when repeatedly used for a long period. This practice should be reconsidered. LEVEL OF EVIDENCE III.
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Goulet O, Breton A, Coste ME, Dubern B, Ecochard-Dugelay E, Guimber D, Loras-Duclaux I, Abi Nader E, Marinier E, Peretti N, Lambe C. Pediatric Home Parenteral Nutrition in France: A six years national survey. Clin Nutr 2021; 40:5278-5287. [PMID: 34534896 DOI: 10.1016/j.clnu.2021.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/31/2021] [Accepted: 08/05/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS Home Parenteral Nutrition (HPN) is the cornerstone management for children suffering from chronic intestinal failure (CIF). In France, HPN is organized from a network of 7 certified centers located in University Hospitals spread across the national territory. This study aims to review the data involving children on HPN over a 6-years period in France to outline the global and continuous improvement in care. PATIENTS AND METHODS This cross-sectional study included all children enrolled in any of the 7 French HPN certified centers from January 1st, 2014 to December 31st, 2019. Data was recorded from annual databases provided by each center regarding: age at inclusion, indication and duration of HPN, type of intravenous lipid emulsion (ILE), outcome [PN weaning off, transfer to adult center, death, intestinal transplantation (ITx)], rate of catheter-related bloodstream infections (CRSBIs) for 1000 days of HPN, Taurolidine lock procedure (TLP) use and prevalence of cholestasis defined as conjugated bilirubin ≥20 μmol/l. RESULTS The number of patients increased by 43.6% from 268 in 2014 to 385 in 2019. According to the year of follow up, the indications for HPN were short bowel syndrome (SBS) (42.3-46.6%), congenital enteropathies (CE) (18.5-22.8%), chronic intestinal pseudo-obstruction syndrome (CIPOS) (13.0-16.3%), long segment Hirschsprung's disease (LSHD) (9.7-13.3%), Crohn's disease (CD) (1.6-2.6%) and other non-primary digestive diseases (NPDD) such as immune deficiency, cancer or metabolic disease (4.0-9.2%). The median age at discharge on HPN decreased from 11.7 months in 2014 to 8.3 months in 2019 (p < .001). By December 31st, 2019, 44.8% of children had left the HPN program after a median duration ranging between 39.9 and 66.4 months. Among these patients, 192 (74.2%) were weaned off PN (94.7% SBS), 41 (15.8%) were transferred to adult centers for CIPOS (42%), SBS (31%) or CE (27%), 21 died (8.1%) - mostly in relation to cancer or immune deficiency - and 5 were transplanted (1.9%): 4 underwent combined liver-intestine transplantation for LSHD (n = 2), SBS, CE and one multivisceral Tx for CIPOS. The use of a composite fish-oil based ILE increased from 67.4% in 2014 to 88.3% in 2019 (p < 0.001). CRBSIs dropped from 1.04 CRSBIs per 1000 days HPN in 2014 to 0.61 in 2019 (p < 0.001) while meantime, the percentage of children receiving TLP increased from 29.4% to 63.0% (p < 0.001). The prevalence of cholestasis (conjugated bilirubin ≥ 20 μmol/l) was low and stable between 4.1 and 5.9% of children during the study period. CONCLUSION In France, the number of children enrolled in a HPN program continuously increased over a 6 years period. SBS is the leading cause of CIF requiring HPN. The rate of CRBSIs dropped dramatically as the use of TLP increased. Mortality rate was low and mainly in relation to the underlying disease (cancer, immune deficiency). Cholestasis and intestinal Tx remained very rare.
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Affiliation(s)
- Olivier Goulet
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Necker-Enfants Malades University of Paris-UFR Paris Descartes, Certified Center for Home Parenteral Nutrition, Reference Center for Rare Digestive Diseases in Children, Paris, France
| | - Anne Breton
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Purpan University Hospital, Certified Center for Home Parenteral Nutrition, Toulouse, France
| | - Marie-Edith Coste
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, La Timone University Hospital, Certified Center for Home Parenteral Nutrition, Marseille, France
| | - Béatrice Dubern
- Division of Pediatric Nutrition and Gastroenterology, Armand Trousseau University Hospital, Certified Center for Home Parenteral Nutrition, Sorbonne University, Paris, France
| | - Emmanuelle Ecochard-Dugelay
- Division of Pediatric Gastroenterology and Nutrition, Robert Debré University Hospital, Certified Center for Home Parenteral Nutrition, Reference Center for Rare Digestive Diseases in Children Paris, France
| | - Dominique Guimber
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Jeanne de Flandre University Hospital, Certified Center for Home Parenteral Nutrition, Reference Center for Rare Digestive Diseases in Children, Lille, France
| | - Irène Loras-Duclaux
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Pediatric University Hospital, Certified Center for Home Parenteral Nutrition, Reference Center for Rare Digestive Diseases in Children, Lyon, France
| | - Elie Abi Nader
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Necker-Enfants Malades University of Paris-UFR Paris Descartes, Certified Center for Home Parenteral Nutrition, Reference Center for Rare Digestive Diseases in Children, Paris, France
| | - Evelyne Marinier
- Division of Pediatric Gastroenterology and Nutrition, Robert Debré University Hospital, Certified Center for Home Parenteral Nutrition, Reference Center for Rare Digestive Diseases in Children Paris, France
| | - Noel Peretti
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Pediatric University Hospital, Certified Center for Home Parenteral Nutrition, Reference Center for Rare Digestive Diseases in Children, Lyon, France
| | - Cecile Lambe
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Necker-Enfants Malades University of Paris-UFR Paris Descartes, Certified Center for Home Parenteral Nutrition, Reference Center for Rare Digestive Diseases in Children, Paris, France.
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Cuerda C, Pironi L, Arends J, Bozzetti F, Gillanders L, Jeppesen PB, Joly F, Kelly D, Lal S, Staun M, Szczepanek K, Van Gossum A, Wanten G, Schneider SM, Bischoff SC. ESPEN practical guideline: Clinical nutrition in chronic intestinal failure. Clin Nutr 2021; 40:5196-5220. [PMID: 34479179 DOI: 10.1016/j.clnu.2021.07.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 07/02/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND This practical guideline is based on the ESPEN Guidelines on Chronic Intestinal Failure in Adults. METHODOLOGY ESPEN guidelines have been shortened and transformed into flow charts for easier use in clinical practice. The practical guideline is dedicated to all professionals including physicians, dieticians, nutritionists, and nurses working with patients with chronic intestinal failure. RESULTS This practical guideline consists of 112 recommendations with short commentaries for the management and treatment of benign chronic intestinal failure, including home parenteral nutrition and its complications, intestinal rehabilitation, and intestinal transplantation. CONCLUSION This practical guideline gives guidance to health care providers involved in the management of patients with chronic intestinal failure.
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Affiliation(s)
- Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Loris Pironi
- Alma Mater Studiorum - University of Bologna, Department of Medical and Surgical Sciences, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna, Centre for Chronic Intestinal Failure - Clinical Nutrition and Metabolism Unit, Italy
| | - Jann Arends
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | | | - Lyn Gillanders
- Emeritus of Auckland City Hospital, Auckland, New Zealand
| | - Palle Bekker Jeppesen
- Rigshospitalet, Department of Intestinal Failure and Liver Diseases Gastroenterology, Copenhagen, Denmark
| | - Francisca Joly
- Centre for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Darlene Kelly
- Emeritus of Mayo Graduate School of Medicine, Rochester, Minnesota
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Michael Staun
- Rigshospitalet, Department of Intestinal Failure and Liver Diseases Gastroenterology, Copenhagen, Denmark
| | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - André Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Stéphane Michel Schneider
- Gastroenterology and Clinical Nutrition, CHU of Nice, University of Nice Sophia Antipolis, Nice, France
| | - Stephan C Bischoff
- Department of Nutritional Medicine and Prevention, University of Hohenheim, Stuttgart, Germany
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83
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Ladebo L, Vinter-Jensen L, Hestvang J, Mikkelsen MS, Rasmussen HH, Christrup LL, Drewes AM, Olesen AE. Oral absorption of oxycodone in patients with short bowel syndrome. Scand J Gastroenterol 2021; 56:1023-1029. [PMID: 34196257 DOI: 10.1080/00365521.2021.1944299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Short bowel syndrome is a disorder with several complications such as malnutrition and failure of drug therapy. Treatment with opioids is needed in many patients, and oral medication is preferred. However, optimal dosing is a difficult task as current guidelines are based on an intact gastrointestinal tract. Hence, the aim of this explorative case study was to assess the pharmacokinetics of orally administered oxycodone in patients with short bowel syndrome. METHODS Six patients with short bowel syndrome were administered 10 mg oral solution oxycodone after an overnight fast. Oxycodone plasma concentrations were determined over a 6-hour period. Pharmacokinetic profiles were visually inspected. Pharmacokinetic parameters: maximum plasma concentration, time of maximum concentration and area under the curve were calculated. Data were also compared to mean values obtained in healthy participants. RESULTS A clinically relevant concentration of oxycodone was found in all patients, although with large inter-individual variation. The absorption fraction tended to correlate positively with total intestinal length. Additionally, preservation of some or the entire colon seemed further to increase the absorption fraction. Time of maximum concentration varied from 30 min to approximately 90 min. CONCLUSIONS Oxycodone is absorbed in a clinically relevant extent in patients with short bowel syndrome, but bioavailability varies greatly between patients, which shall be taken into consideration. Absorption is related to functional small intestinal length, but preservation of colon is also beneficial. Still, optimal therapeutic dosing must be individualized, and other factors such as those related to malnutrition and motility shall also be taken into consideration.
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Affiliation(s)
- Louise Ladebo
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Lars Vinter-Jensen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Centre for Nutrition and Bowel Disease, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Johanne Hestvang
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Clinical Pharmacology, Aalborg University Hospital, Aalborg, Denmark
| | - Maja Schjønning Mikkelsen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Clinical Pharmacology, Aalborg University Hospital, Aalborg, Denmark
| | - Henrik Højgaard Rasmussen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Centre for Nutrition and Bowel Disease, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Lona Louring Christrup
- Faculty of Health and Medical Sciences, Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne Estrup Olesen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Clinical Pharmacology, Aalborg University Hospital, Aalborg, Denmark
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84
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Schlager L, Stift A, Gartner J, Hütterer E, Harpain F. Bridging intestinal failure with Teduglutide - A case report. Int J Surg Case Rep 2021; 86:106270. [PMID: 34418803 PMCID: PMC8384933 DOI: 10.1016/j.ijscr.2021.106270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/29/2021] [Accepted: 08/01/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction and importance Intestinal failure (IF) describes the state of a person's gastrointestinal absorption capabilities becoming unable to absorb fluids and nutrients needed to sustain normal physiology, leading to severe comorbidities and if left untreated, to death. IF is most commonly seen as a result of short bowel syndrome (SBS). Teduglutide is a glucagon-like peptide 2 (GLP-2) analogue used in the treatment of patients with SBS and intestinal failure (IF) as a way to reduce the need for parenteral support. Teduglutide leads to the growth of intestinal mucosa by stimulating intestinal crypt cell growth and inhibiting enterocyte apoptosis. It is usually prescribed as a final treatment step after the diagnosis of SBS-IF is made. Case presentation In this case report we present a novel strategy for using teduglutide as a bridging therapy to intestinal reconstruction. The patient achieved enteral autonomy preoperatively, underwent surgery, and remained in enteral autonomy after intestinal reconstruction. Clinical discussion Teduglutide has been previously exclusively used as continuous therapy in SBS-IF, this is the first reported case of using teduglutide as bridging to intestinal reconstruction. The hypothesis of this approach was to achieve an adequate nutritional status for reconstruction without the disadvantages of parenteral support. Conclusion The controlled application of teduglutide can provide the benefits of preoperative nutritional optimization without the disadvantages of parenteral support and at the same time facilitate an earlier and easier intestinal reconstruction. Teduglutide can be used to reduce parenteral support in SBS-IF patients awaiting intestinal reconstruction Teduglutide can be used preoperatively to optimize a patient's nutritional status Using teduglutide as bridging therapy to surgery prevents patients from experiencing parenteral nutrition-associated complications
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Affiliation(s)
- Lukas Schlager
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Austria
| | - Anton Stift
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Austria.
| | - Johanna Gartner
- Department of Gastroenterology and Hepatology, Hanusch Hospital, Vienna, Austria
| | - Elisabeth Hütterer
- Department of Medicine I, Division of Oncology, Medical University of Vienna, Austria
| | - Felix Harpain
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Austria
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85
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Aubert M, Mege D, Billiauws L, Joly F, Panis Y. State-of-the-art colorectal disease: conservative surgical management of intestinal failure in adults. Int J Colorectal Dis 2021; 36:1597-607. [PMID: 33629118 DOI: 10.1007/s00384-021-03863-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Intestinal failure (IF) is defined by the reduction of gut function under the minimum necessary for adequate absorption of macronutrients and/or electrolytes, requiring home parenteral nutrition (HPN) to maintain health and/or growth. Among the different causes of IF, short bowel syndrome (SBS) is one of the main causes of IF in adults. Management of IF and SBS is complex and requires a multidisciplinary approach. The aim of this study was to review the place and the modalities of conservative surgical procedures performed for IF in adults. RESULTS-CONCLUSION HPN has drastically modified the poor prognosis of these patients, leading to an overall survival around 70-75% at 5 years in patients without cancer. However, HPN is associated with life-threatening long-term complications, including liver failure and catheter-related complications, main causes of deaths for these patients. Surgery can be proposed, in order to try to reduce SBS consequences with either conservative or non-conservative procedures. Simple bowel continuity restoration should be performed as often as possible in order to wean or at least to reduce HPN. Lengthening procedures are proposed to increase the absorption surface of the remnant bowel. These procedures can be only performed on a dilated small bowel. The slowing transit time procedure is represented by segmental reversal of the small bowel. Intestinal transplantation is the last surgical option for patients with IF but is still today associated with high mortality and failure rates. Thus, conservative procedures have a major role in the surgical armentarium for patients with IF.
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86
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Proli F, Faragalli A, Talbotec C, Bucci A, Zemrani B, Chardot C, Abi Nader E, Goulet O, Lambe C. Variation of plasma citrulline as a predictive factor for weaning off long-term parenteral nutrition in children with neonatal short bowel syndrome. Clin Nutr 2021; 40:4941-4947. [PMID: 34358840 DOI: 10.1016/j.clnu.2021.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/11/2021] [Accepted: 07/13/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND & AIMS Long-term parenteral nutrition (PN) is the mainstay of the therapeutic strategy in intestinal failure (IF) due to neonatal short bowel syndrome (SBS). Our aim was to identify prognostic factors for PN weaning and to assess if measuring plasma citrulline concentrations over time could account for the intestinal adaptation in progress. METHODS This retrospective study included children with neonatal SBS with surgical measurement of the residual bowel length and repeated plasma citrulline assessments during a 4-year follow-up. The degree of IF was assessed by the PN dependency index (PN caloric intake/Resting energy expenditure). The analysis was carried out according to SBS anatomical groups: end-jejunostomy (type 1), jejuno-colic (type 2) and jejuno-ileal anastomosis (type 3). RESULTS Fifty-five patients (8 type 1, 27 type 2, 20 type 3) were included. None of the patients with SBS type 1, 11 (41%) with type 2 and 11 (55%) with type 3 were weaned off during the follow-up period. Plasma citrulline levels significantly increased with time in patients who were finally weaned off PN; conversely, the levels did not consistently increase in patients who were still on PN at the end of the study period. There was an inverse relationship between plasma citrulline levels and the PN dependency index. The increasing citrulline levels had a positive effect on the probability of weaning, 2.7 times higher for each point increase in citrulline. No significant effect of age and residual bowel length at baseline was found. CONCLUSION The increased plasma citrulline level over time in addition to the SBS anatomical type is a reliable marker for subsequent PN weaning. The prediction of PN weaning assessed solely by the residual bowel length or a single measurement of citrulline is insufficient and should also take into account the anatomical type of SBS and repeated measurements of plasma citrulline levels.
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Affiliation(s)
- Francesco Proli
- Division of Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Intestinal Diseases, Intestinal Rehabilitation Center, Certified Center for Home Parenteral Nutrition, Hôpital Necker Enfants Malades, Université de Paris, Faculté de Médecine Paris-Descartes, France; Department of Pediatrics, Department of Woman, Child Health and Public Health, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy.
| | - Andrea Faragalli
- Centre of Epidemiology, Biostatistics and Medical Information Technology, Università Pol. Delle Marche, Ancona, Italy
| | - Cécile Talbotec
- Division of Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Intestinal Diseases, Intestinal Rehabilitation Center, Certified Center for Home Parenteral Nutrition, Hôpital Necker Enfants Malades, Université de Paris, Faculté de Médecine Paris-Descartes, France
| | - Andrea Bucci
- Department of Economics, University G. D'Annunzio of Chieti-Pescara, Pescara, Italy
| | - Boutaina Zemrani
- Division of Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Intestinal Diseases, Intestinal Rehabilitation Center, Certified Center for Home Parenteral Nutrition, Hôpital Necker Enfants Malades, Université de Paris, Faculté de Médecine Paris-Descartes, France
| | - Christophe Chardot
- Pediatric Surgery, Hôpital Necker Enfants Malades, Université de Paris, Faculté de Médecine Paris-Descartes, France
| | - Elie Abi Nader
- Division of Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Intestinal Diseases, Intestinal Rehabilitation Center, Certified Center for Home Parenteral Nutrition, Hôpital Necker Enfants Malades, Université de Paris, Faculté de Médecine Paris-Descartes, France
| | - Olivier Goulet
- Division of Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Intestinal Diseases, Intestinal Rehabilitation Center, Certified Center for Home Parenteral Nutrition, Hôpital Necker Enfants Malades, Université de Paris, Faculté de Médecine Paris-Descartes, France
| | - Cécile Lambe
- Division of Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Intestinal Diseases, Intestinal Rehabilitation Center, Certified Center for Home Parenteral Nutrition, Hôpital Necker Enfants Malades, Université de Paris, Faculté de Médecine Paris-Descartes, France
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87
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Brockmann JG, Hüsing-Kabar A, Bohlen K, Höckelmann CL, Pascher A. [Chronic intestinal failure]. Chirurg 2021. [PMID: 34264370 DOI: 10.1007/s00104-021-01423-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 10/20/2022]
Abstract
The term intestinal failure (IF) is understood as the transient or irreversible loss of the resorptive capacity of the bowels. This includes a multitude of diseases, some of which have anatomical causes and others functional causes. The functional capacity (absorption and motility) of the remaining digestive tract and the bacterial overgrowth and false colonization of the small bowel are of prognostic importance. After exclusion of pathological intestinal findings, such as stenosis and dilatation, initially conservative treatment is employed with the aim of intestinal adaptation. Before failure or complications, initially conservative surgery and then organ replacement by transplantation should be considered. The IF is a temporary or permanent condition. For adults a length of 100cm small bowel without the colon, 60cm still with continuity to the colon and 35cm small bowel with complete preservation of the colon including the ileocecal valve are potentially sufficient for intestinal autonomy.
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88
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Wood LS, Hosseini HS, Diyaolu M, Thomas AL, Taylor JS, Dunn JC. Mechanical lengthening of porcine small intestine with decreased forces. J Pediatr Surg 2021; 56:1192-1198. [PMID: 33836847 DOI: 10.1016/j.jpedsurg.2021.03.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 03/12/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION short bowel syndrome is marked by inadequate intestinal surface area to absorb nutrients. Current treatments are focused on medical management and surgical reconfiguration of the dilated intestine. We propose the use of spring-mediated distraction enterogenesis as a novel intervention to increase intestinal length. Given our previous success lengthening intestinal segments using springs with spring constant ~7 N/m that exerts 0.46 N or higher, we sought to determine the minimal force needed to lengthen porcine small intestinal segments, and to explore effects on intestine over time. METHODS Juvenile Yucatan pigs underwent laparotomy with enterotomy to introduce nitinol springs intraluminally (n = 21 springs). Bowel segments (control, spring-distracted) were retrieved on post-operative day (POD) 7 and 14, and lengths measured. Thickness of cross-sectional intestinal layers were measured using H&E, and submucosal collagen fiber orientation measured using trichrome stained sections. RESULTS all pigs survived to POD7 and 14. Spring constants of at least 2 N/m exerting a minimum force of 0.10 N significantly lengthened intestinal segments (p <0.0001). The stronger the spring force, the greater the induced thickness of various intestinal layers at POD7 and 14. Collagen fiber orientation was also more disordered because of stronger springs. CONCLUSION a spring constant of approximately 2 N/m exerting 0.10 N and greater significantly lengthens intestinal segments and stimulates intestinal structural changes at POD7 and 14. This suggests a decreased force is capable of inducing spring-mediated distraction enterogenesis.
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Affiliation(s)
- Lauren Sy Wood
- Division of Pediatric Surgery, Stanford University School of Medicine, 453 Quarry Road, MC 5733, Stanford, CA 94304, United States
| | - Hadi S Hosseini
- Division of Pediatric Surgery, Stanford University School of Medicine, 453 Quarry Road, MC 5733, Stanford, CA 94304, United States
| | - Modupeola Diyaolu
- Division of Pediatric Surgery, Stanford University School of Medicine, 453 Quarry Road, MC 5733, Stanford, CA 94304, United States
| | - Anne-Laure Thomas
- Division of Pediatric Surgery, Stanford University School of Medicine, 453 Quarry Road, MC 5733, Stanford, CA 94304, United States
| | - Jordan S Taylor
- Division of Pediatric Surgery, Stanford University School of Medicine, 453 Quarry Road, MC 5733, Stanford, CA 94304, United States
| | - James Cy Dunn
- Division of Pediatric Surgery, Stanford University School of Medicine, 453 Quarry Road, MC 5733, Stanford, CA 94304, United States.
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89
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Abstract
Introduction: The goal for pediatric short bowel syndrome (SBS) patients is intestinal adaptation. Until recently, the medical management of pediatric SBS has centered on the prevention and treatment of complications in order to allow time for adaptation. Teduglutide, glucagon-like peptide 2 (GLP-2) analog, has recently been approved for use in pediatric SBS patients greater than 1 year of age as a novel agent to augment intestinal adaptation. Areas covered: This article reviews the pharmacology, safety, efficacy, and tolerability of GLP-2 analog teduglutide in pediatric patients greater than 1 year of age. We review all current studies and discuss teduglutide's place in pediatric SBS therapy. Expert opinion: Teduglutide marks the first successful pharmacological intervention that augments the natural process of adaptation safely and effectively in SBS pediatric patients. More studies and further development are needed to optimize its potential in other pediatric patients.
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Affiliation(s)
- Beatrice E Rosete
- Department of Pharmacy, Seattle Children's Hospital, Seattle, WA, USA.,School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Danielle Wendel
- Department of Gastroenterology, Hepatology and Nutrition, Seattle Children's Hospital, Seattle, WA, USA.,Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Simon P Horslen
- Department of Gastroenterology, Hepatology and Nutrition, Seattle Children's Hospital, Seattle, WA, USA.,Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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90
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Mazzuoli S, Regano N, Lamacchia S, Silvestri A, Guglielmi FW. Intestinal iatrogenic hyperadaptation in patients with short bowel syndrome and Crohn's disease: Is this an indication for mandatory lifelong injections of teduglutide? Nutrition 2021; 91-92:111396. [PMID: 34399400 DOI: 10.1016/j.nut.2021.111396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/20/2021] [Accepted: 06/16/2021] [Indexed: 11/18/2022]
Abstract
Short bowel syndrome with chronic intestinal failure (SBS-CIF) is a rare disease leading to a markedly decreased absorption of fluids and nutrients. Intestinal adaptation in patients with SBS-CIF who are treated with home parenteral nutrition is a natural repair process activated by increased secretions of glucagon-like peptide-2, inducing intestinal trophism, nutrient transport, and lowering gastrointestinal motility. Teduglutide (TED), a glucagon-like peptide-2 analog, offers a new, effective therapeutic alternative to boost intestinal adaptation. There is still no consensus regarding the question of whether intestinal adaptation is permanent or a transient, drug-dependent process requiring lifelong injections of TED. Here we report the clinical cases of two female patients with SBS-CIF secondary to Crohn's disease, who had received TED for 36 and 41 mo. In both patients, TED was discontinued for 5 d but needed to be resumed after an additional 5 d. In patient 1, the discontinuation of TED was accidental (the patient inadvertently injected frozen TED vials); whereas in patient 2, the suspension was at the patient's request. A rapid, significant (P < 0.0001) decline of intestinal function (diarrheal evacuations, fecal volume, food intake) was documented after the suspension of active TED in patient 1. After the resumption of active TED, the symptoms rapidly and significantly (P < 0.0001) improved. The same trend was observed in patient 2. Infective causes of diarrhea were ruled out in both patients. In conclusion, our experience shows that even after long-term treatment, the iatrogenic hyperadaptation process obtained with TED results is a temporary, drug-dependent process and vanishes with the suspension of therapy. These clinical cases suggest that in patients with SBS-CIF receiving TED, this treatment must be administered lifelong.
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Affiliation(s)
- Silvia Mazzuoli
- Gastroenterology Department, Monsignor Raffaele Dimiccoli Hospital, Barletta, Italy
| | - Nunzia Regano
- Gastroenterology Department, Monsignor Raffaele Dimiccoli Hospital, Barletta, Italy
| | - Stefania Lamacchia
- Gastroenterology Department, Monsignor Raffaele Dimiccoli Hospital, Barletta, Italy
| | - Angela Silvestri
- Gastroenterology Department, Monsignor Raffaele Dimiccoli Hospital, Barletta, Italy
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91
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Aksan A, Farrag K, Blumenstein I, Schröder O, Dignass AU, Stein J. Chronic intestinal failure and short bowel syndrome in Crohn’s disease. World J Gastroenterol 2021; 27:3440-3465. [PMID: 34239262 PMCID: PMC8240052 DOI: 10.3748/wjg.v27.i24.3440] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 01/24/2021] [Accepted: 03/08/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic intestinal failure (CIF) is a rare but feared complication of Crohn’s disease. Depending on the remaining length of the small intestine, the affected intestinal segment, and the residual bowel function, CIF can result in a wide spectrum of symptoms, from single micronutrient malabsorption to complete intestinal failure. Management of CIF has improved significantly in recent years. Advances in home-based parenteral nutrition, in particular, have translated into increased survival and improved quality of life. Nevertheless, 60% of patients are permanently reliant on parenteral nutrition. Encouraging results with new drugs such as teduglutide have added a new dimension to CIF therapy. The outcomes of patients with CIF could be greatly improved by more effective prevention, understanding, and treatment. In complex cases, the care of patients with CIF requires a multidisciplinary approach involving not only physicians but also dietitians and nurses to provide optimal intestinal rehabilitation, nutritional support, and an improved quality of life. Here, we summarize current literature on CIF and short bowel syndrome, encompassing epidemiology, pathophysiology, and advances in surgical and medical management, and elucidate advances in the understanding and therapy of CIF-related complications such as catheter-related bloodstream infections and intestinal failure-associated liver disease.
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Affiliation(s)
- Aysegül Aksan
- Institute of Nutritional Sciences, Justus-Liebig-Universität, Giessen 35392, Germany
- Department of Clinical Research, Interdisziplinäres Crohn Colitis Centrum Rhein-Main, Frankfurt am Main 60594, Germany
| | - Karima Farrag
- Department of Clinical Research, Interdisziplinäres Crohn Colitis Centrum Rhein-Main, Frankfurt am Main 60594, Germany
- Department of Gastroenterology and Clinical Nutrition, DGD Kliniken Sachsenhausen, Teaching Hospital of the JW Goethe University, Frankfurt am Main 60594, Germany
| | - Irina Blumenstein
- Department of Gastroenterology, Hepatology and Clinical Nutrition, First Medical Clinic, JW Goethe University Hospital, Frankfurt am Main 60529, Germany
| | - Oliver Schröder
- Department of Clinical Research, Interdisziplinäres Crohn Colitis Centrum Rhein-Main, Frankfurt am Main 60594, Germany
- Department of Gastroenterology and Clinical Nutrition, DGD Kliniken Sachsenhausen, Teaching Hospital of the JW Goethe University, Frankfurt am Main 60594, Germany
| | - Axel U Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Goethe-University, Frankfurt am Main 60431, Germany
| | - Jürgen Stein
- Department of Clinical Research, Interdisziplinäres Crohn Colitis Centrum Rhein-Main, Frankfurt am Main 60594, Germany
- Department of Gastroenterology and Clinical Nutrition, DGD Kliniken Sachsenhausen, Teaching Hospital of the JW Goethe University, Frankfurt am Main 60594, Germany
- Institute of Pharmaceutical Chemistry, JW Goethe University, 60438 Frankfurt am Main, Germany
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Sowerbutts AM, Burden S, Griffiths J, Abraham A, Farrer K, Leahy G, Teubner A, Cloutier A, Twist K, Kelly S, Lal S. Glucagon-like peptide 2 analogues in the treatment of intestinal failure: A qualitative exploration of the views of patients and their families in decision making. Clin Nutr ESPEN 2021; 44:263-9. [PMID: 34330477 DOI: 10.1016/j.clnesp.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/25/2021] [Accepted: 06/03/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIMS Patients with short bowel syndrome and type 3 intestinal failure (SBS-IF) are dependent on parenteral nutrition (PN), a lifesaving treatment but inconvenient and with risks. Glucagon-like peptide 2 analogue (teduglutide) can reduce patients' need for PN. However, it comes with the risk of a number of side effects. This qualitative study investigated patients' decision making process to start teduglutide and how family members contributed to the decision. METHODS In-depth semi-structured interviews were conducted with nine participants, six patients with SBS-IF and three family members about the decision to take teduglutide. Interviews were transcribed verbatim and analysed using framework analysis. RESULTS The prominent motivation for taking teduglutide (Revestive® Takeda Pharmaceuticals Limited) was reducing or stopping PN. Other motivations were to help others by assisting in developing the knowledge base around teduglutide, patients felt that they had nothing to lose by trying the drug and the support of relatives. The reasons patients considered not taking the drug were that they had accepted being on PN, the potential side effects of teduglutide and undergoing extra monitoring. However, the monitoring programme also acted as a motivator providing reassurance that patients would be observed and supported with side effects. Family members were happy to support patients' decision to try teduglutide, although they had more reservations, indicating a higher risk threshold. CONCLUSION Patients considered potential benefits of teduglutide outweighed any disadvantages. Relatives, although supportive, had more reservations.
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Abstract
INTRODUCTION Short bowel syndrome (SBS) is a rare, highly disabling, life-threatening condition due to extensive intestinal resections, characterized by diarrhea, malabsorption, and malnutrition. SBS is the main cause of intestinal failure (SBS-IF). The primary therapy for SBS-IF is intravenous supplementation (IVS) of nutrients. The pharmacological therapy aims to improve the remnant bowel function, leading to the decrease of IVS requirement. AREAS COVERED This review provides a safety perspective and discusses unmet clinical needs on pharmacotherapy for SBS, ranging from symptomatic agents traditionally used off-label to manage hypersecretion and diarrhea, to curative drugs with selective intestinotrophic properties. Real-world evidence on symptomatic drugs is lacking. Data on teduglutide - the first-in-class glucagon-like peptide-2 (GLP-2) receptor agonist approved in SBS - are mainly derived from clinical trials, with several unsettled safety issues, including the risk of malignancies. EXPERT OPINION Defining the long-term safety of drugs used for SBS is a priority; a unified list of commonly used drugs with consolidated proof of effectiveness is needed to harmonize the symptomatic pharmacological approach to SBS. GLP-2 receptor agonists are a promising curative pharmaco-therapeutic approach, although long-term safety and effectiveness deserve further real-world assessment. Pharmacovigilance and global data sharing are crucial to support safe prescribing in SBS.
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Hu X, Cheng W, Fan S, Huang Y, Chen X, Jiang Z, Wang J. Therapeutic potential of an intestinotrophic hormone, glucagon-like peptide 2, for treatment of type 2 short bowel syndrome rats with intestinal bacterial and fungal dysbiosis. BMC Infect Dis 2021; 21:583. [PMID: 34134659 DOI: 10.1186/s12879-021-06270-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/02/2021] [Indexed: 12/21/2022] Open
Abstract
Background Previous studies showed that type 2 short bowel syndrome (SBS) rats were accompanied by severe intestinal bacterial dysbiosis. Limited data are available for intestinal fungal dysbiosis. Moreover, no effective therapeutic drugs are available for these microbiota dysbiosis. The aims of our study were to investigate the therapeutic potential of glucagon-like peptide 2 (GLP-2) for these microbiota dysbiosis in type 2 SBS rats. Methods 8-week-old male SD rats which underwent 80% small bowel resection, ileocecum resection, partial colon resection and jejunocolostomy, were treated with saline (SBS group, n = 5) or GLP-2 (GLP2.SBS group, n = 5). The Sham group rats which underwent transection and re-anastomosis were given a saline placebo (Sham group, n = 5). 16S rRNA and ITS sequencing were applied to evaluate the colonic bacterial and fungal composition at 22 days after surgery, respectively. Results The relative abundance of Actinobacteria, Firmicutes and proinflammatory Proteobacteria increased significantly in SBS group rats, while the relative abundance of Bacteroidetes, Verrucomicrobia and Tenericutes decreased remarkably. GLP-2 treatment significantly decreased Proteus and increased Clostridium relative to the saline treated SBS rats. The diversity of intestinal fungi was significantly increased in SBS rats, accompanied with some fungi abnormally increased and some resident fungi (e.g., Penicillium) significantly decreased. GLP-2 treatment significantly decreased Debaryomyces and Meyerozyma, and increased Penicillium. Moreover, GLP-2 partially restored the bacteria-fungi interkingdom interaction network of SBS rats. Conclusion Our study confirms the bacterial and fungal dysbiosis in type 2 SBS rats, and GLP-2 partially ameliorated these microbiota dysbiosis. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06270-w.
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Sobocki J, Zaczek Z, Jurczak P, Lachowicz K, Kunecki M, Groszek P, Majewska K, Panczyk M, Forbes A. Restricted v. unrestricted oral intake in high output end-jejunostomy patients referred to reconstructive surgery. Br J Nutr 2021; 125:1125-31. [PMID: 32873362 DOI: 10.1017/S0007114520003360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The major complication of end jejunostomy is excessive fluid and electrolyte loss through the stoma, leading to hypovolaemia and dyselectrolytaemia within days and malnutrition within weeks. The aim was to compare the results of two nutritional approaches: unrestricted and restricted oral intake in patients with end jejunostomy commencing home parenteral nutrition (HPN) in terms of liver and renal biochemical markers and time to reconstructive bowel surgery with correlation to stoma output. Twenty patients with stabilised high output end-jejunostomy were divided into two groups. Group A consisted of ten patients with oral intake restricted to keep stomal output under 1000 ml. Group B consisted of ten patients with unrestricted oral intake. The following parameters were evaluated over 6 months: stomal output, self-estimation of general condition, body weight gain, plasma bilirubin and creatinine, number of hospitalisations prior to reconstructive surgery, the frequency of ostomy bag emptying, feelings of hunger and thirst in the daytime, and the time to reconstructive surgery. Stoma losses were compensated by parenteral supply. In group B, lower quality of life was observed, reflected by weakness, permanent feelings of hunger and thirst and the need for night-time emptying of the stoma bag. Patients in group B developed more complications and required more time to prepare for surgery. One death occurred in group B due to renal insufficiency followed by septic complications. Restricted oral intake seems to be more effective for prevention of HPN-related complications and shortening of time to surgery. Unrestricted oral intake appears to provoke uncontrolled losses of energy and protein, inhibiting weight gain.
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96
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Mercer DF, Burnett TR, Hobson BD, Logan SJ, Gerhardt BK, Iwansky SN, Quiros-Tejeira RE. Repeat serial transverse enteroplasty leads to reduction in parenteral nutrition in children with short bowel syndrome. J Pediatr Surg 2021; 56:733-737. [PMID: 32736789 DOI: 10.1016/j.jpedsurg.2020.06.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/19/2020] [Accepted: 06/30/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/PURPOSE Following a serial transverse enteroplasty (STEP) procedure some children develop redilation of the small intestine leading to impaired enteral tolerance and inability to wean parenteral nutrition (PN). The benefit of a second STEP procedure (2STEP) has been controversial. METHODS We performed a retrospective review of our experience (2008-2018) performing 2STEP, with comparative analysis of nutritional outcomes pre- and postsurgery. RESULTS During this period 2STEP was performed in 23 patients (13 F:10 M) at a median (25%-75%) age of 2.2 (1.2-3.6) years. Median intestinal length was 68 (40-105) cm before and 85 (40-128) cm after 2STEP. Leading up to 2STEP, PN provided almost 75% of estimated calorie needs. By 24 weeks following 2STEP drops in mean PN percent approached statistical significance (p = 0.07) and at most recent follow up the mean PN percentage was statistically better than at the time of operation or 4 weeks prior to 2STEP, and was nearly significant compared with 12 weeks (p = 0.07) and 24 weeks (p = 0.06) prior. Thirteen children were completely off parenteral support. CONCLUSION When small intestine redilation occurs following a STEP procedure and where PN cannot otherwise be weaned we believe these data support performing a 2STEP. We cannot predict preoperatively which children will ultimately benefit. LEVEL OF EVIDENCE 3 (retrospective comparative study).
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Affiliation(s)
- David F Mercer
- Department of Surgery, University of Nebraska Medical Center, 983285 Nebraska Medical Center, Omaha, NE, USA 68198-3285.
| | - Tyler R Burnett
- Department of Surgery, University of Nebraska Medical Center, 983285 Nebraska Medical Center, Omaha, NE, USA 68198-3285
| | - Brandy D Hobson
- Department of Clinical Nutrition, University of Nebraska Medical Center, 983285 Nebraska Medical Center, Omaha, NE, USA 68198-3285
| | - Samantha J Logan
- Department of Clinical Nutrition, University of Nebraska Medical Center, 983285 Nebraska Medical Center, Omaha, NE, USA 68198-3285
| | - Brandi K Gerhardt
- Department of Surgery, University of Nebraska Medical Center, 983285 Nebraska Medical Center, Omaha, NE, USA 68198-3285
| | - Sarah N Iwansky
- Department of Surgery, University of Nebraska Medical Center, 983285 Nebraska Medical Center, Omaha, NE, USA 68198-3285
| | - Ruben E Quiros-Tejeira
- Department of Pediatrics, University of Nebraska Medical Center, 983285 Nebraska Medical Center, Omaha, NE, USA 68198-3285
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Boscarelli A, Codrich D, Schleef J. Technical innovations for autologous intestinal reconstruction surgery in children with short bowel syndrome. Pediatr Surg Int 2021; 37:523-524. [PMID: 33403476 DOI: 10.1007/s00383-020-04844-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Alessandro Boscarelli
- Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", via dell'Istria, 65/1, 34137, Trieste, Italy.
| | - Daniela Codrich
- Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", via dell'Istria, 65/1, 34137, Trieste, Italy
| | - Jürgen Schleef
- Department of Pediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", via dell'Istria, 65/1, 34137, Trieste, Italy.,Chief of Surgical Department, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
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Zhang T, Feng H, Cao Y, Tao Y, Lu L, Yan W, Li F, Wang Y, Cai W. Long-term outcomes of various pediatric short bowel syndrome in China. Pediatr Surg Int 2021; 37:495-502. [PMID: 33394086 DOI: 10.1007/s00383-020-04797-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The goal of this study was to analyze long-term outcome of various pediatric short bowel syndrome (SBS) at an intestinal rehabilitation center in China. METHODS One hundred and fifty-seven children with SBS were enrolled in this study from October 1988 to July 2019. Their long-term follow-up outcome was analyzed according to the age of disease onset, parenteral nutrition (PN) duration, and anatomic types of short bowel, respectively. The clinical characteristics, which included demographics, the length of residual small bowel, PN duration, PN dependence, SBS-related complications such as IF-related liver disease (IFALD), catheter-related bloodstream infection (CRBI), and mortality were compared among the groups. RESULTS The main etiology for SBS were intestinal atresia, NEC, and volvulus. Five of 157 patients did not wean off PN. The incidence of IFALD and CRBI was 24.2 and 22.3%, respectively. Sixteen cases died because of infection and liver failure and eight patients lost to follow-up. The survival rate of the 157 patients was 84.7%. PN duration was longer in the infants and children group (284 ± 457 d vs. 110 ± 64 d, P = 0.021; R = 0.264, P = 0.001) and more patients did not wean off PN than in the neonates group (11.6% vs. 0, P = 0.001; R = 0.295, P < 0.001). Patients with PN with a duration of longer than 90 days had more CRBIs (30.6%, P = 0.025; R = 0.236, P = 0.003). Additionally, the rate of CRBI was higher in patients with stoma (30.0%, P = 0.032). There was no difference in mortality among the groups. In five PN dependence patients, none was SBS onset in neonates. CONCLUSION Pediatric patients with SBS could achieve favorable long-term survival and enteral autonomy. Different standards of SBS classification such as the age of disease onset, PN duration, and anatomic types of short bowel did not impact the overall mortality of pediatric SBS. Prolonged PN duration positively correlated with the age of disease onset and the incidence of CRBI. Patients with the complete continuity of intestinal tract suffered less from CRBI.
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Chen K, Joly F, Mu F, Kelkar SS, Olivier C, Xie J, Seidner DL. Predictors and timing of response to teduglutide in patients with short bowel syndrome dependent on parenteral support. Clin Nutr ESPEN 2021; 43:420-427. [PMID: 34024550 DOI: 10.1016/j.clnesp.2021.03.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND AIMS This study aimed to identify predictors and estimate time to teduglutide response among adult patients with short bowel syndrome with intestinal failure (SBS-IF) dependent on parenteral support (PS). METHODS Post-hoc analysis was performed on individual patient data from teduglutide-treated patients in the phase III teduglutide trial STEPS and the STEPS-2 extension. Response was defined as ≥20% PS volume reduction from baseline for two consecutive visits. Early responders experienced the reduction at 20 and 24 weeks during STEPS while late responders experienced the reduction during STEPS-2. Timing and predictors for response were assessed among the treated population using Cox proportional hazard model. Time to response was compared in aetiological subgroups using Kaplan-Meier analysis. Patient characteristics and time to response were compared between early vs. late responders. RESULTS A total of 34 patients were included in this analysis; overall median time to response was 4.3 months. The presence of stoma predicted a positive response to teduglutide (hazard ratio [HR]: 5.6; 95% confidence interval [CI]: 1.4-21.9; p = 0.013). Vascular disease (vs. inflammatory bowel disease [IBD]) as cause of major intestinal resection (HR: 0.2; 95% CI: 0.0-0.8; p = 0.015), presence of ileocecal valve (HR: 0.1; 95% CI: 0.0-0.8; p = 0.047), and female sex (HR: 0.3; 95% CI: 0.1-1.0; p = 0.026) are negatively associated with response. In subgroup analyses, patients with IBD (vs. vascular disease), with (vs. without) a stoma, and without (vs. with) colon-in-continuity had a shorter time to response (all p < 0.05). The mean times to response were 3.6 (standard deviation (SD): 1.1) months for early responders (n = 27) and 10.0 (SD: 6.1) months for late responders (n = 7). Fewer early responders had colon-in-continuity (51.9%) and ileocecal valve (0.0%) compared to late responders (100% and 28.6%, respectively; both p < 0.05). Early responders had a lower mean percentage of colon remaining compared to late responders (24.6% vs. 57.1%, respectively; p = 0.016). CONCLUSIONS Time to response to teduglutide depends on bowel anatomy and SBS-IF aetiology. IBD, presence of a stoma, and absence of ileocecal valve were associated with earlier response to teduglutide. These findings may enhance management of patients with SBS-IF; however, due to sample size limitations, additional studies are needed to confirm these findings.
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Affiliation(s)
- Kristina Chen
- Shire Human Genetic Therapies, Inc. (a Takeda company), Takeda Pharmaceutical Company Limited, 650 E Kendall Street, Cambridge, MA 02142, USA.
| | - Francisca Joly
- Beaujon Hospital, Clichy and Research Center for Inflammation, University of Paris, 100 Boulevard du Général Leclerc, 92110, Paris, France.
| | - Fan Mu
- Analysis Group, 111 Huntington Ave., Floor 14, Boston, MA 02199, USA.
| | - Sneha S Kelkar
- Analysis Group, 151 West 42nd St., Floor 23, New York, NY 10036, USA.
| | - Clement Olivier
- Shire International GmbH (a Takeda company), Zug, Switzerland.
| | - Jipan Xie
- Analysis Group, 333 South Hope St., 27th Floor, Los Angeles, CA 90071, USA.
| | - Douglas L Seidner
- Digestive Disease and Surgical Institute, Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, 9500 Euclid Ave./A51, Cleveland, OH 44195, USA.
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Nouri Gharajalar S, Kazemi-Darabadi S, Valinezhad Lajimi H, Shahbazfar AA. The Roles of Lactobacillus Acidophilus and Pectin in Preventing Postoperative Sepsis and Intestinal Adaptation in a Rat Model of Short Bowel Syndrome. Probiotics Antimicrob Proteins 2021; 13:1355-1362. [PMID: 33719025 DOI: 10.1007/s12602-021-09764-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 11/24/2022]
Abstract
One of the primary causes of morbidity and mortality in those with short bowel syndrome (SBS) is sepsis, caused by bacterial translocation (BT). Since synbiotics can cease gut-related bacterial overgrowth, they may serve as a supportive dietary supplement-based strategy after gastrointestinal surgery. This study was conducted to determine the effects of Lactobacillus acidophilus and pectin on BT and gut adaptation after extensive small bowel resection in the rat. Forty rats were distributed in four groups. Group A suffered laparotomy, group B suffered gut transection and reanastomosis, SBS rats (group C) suffered 75% small gut resection, and finally, Group D suffered gut resection and treated with a synbiotic cocktail from day 7 before the surgery to day 14 after it. Intestinal structural changes and BT to mesenteric lymph nodes, liver, portal blood, and peripheral blood were detected on day 15 post-surgery. Treatment with a synbiotic cocktail led to a considerable reduction in bacterial translocation to liver and portal vein (degree II) compared with SBS untreated rats. Also, synbiotic administration significantly increased jejunum and ileum villus height and crypt depth, ileum villus width, and percentage of goblet cells in jejunum and ileum compared with SBS rats. In the rat model of short bowel syndrome, L. acidophilus, and pectin, as a potential synbiotic compound, could decrease the BT from the gut and improve the bowel adaptation.
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Affiliation(s)
- Sahar Nouri Gharajalar
- Department of Pathobiology, Faculty of Veterinary Medicine, University of Tabriz, Tabriz, Iran.
| | - Siamak Kazemi-Darabadi
- Department of Clinical Science, Faculty of Veterinary Medicine, University of Tabriz, Tabriz, Iran
| | | | - Amir-Ali Shahbazfar
- Department of Pathobiology, Faculty of Veterinary Medicine, University of Tabriz, Tabriz, Iran
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