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Garnett GM, Kang KH, Jaksic T, Woo RK, Puapong DP, Kim HB, Johnson SM. First STEPs: serial transverse enteroplasty as a primary procedure in neonates with congenital short bowel. J Pediatr Surg 2014; 49:104-7; discussion 108. [PMID: 24439591 DOI: 10.1016/j.jpedsurg.2013.09.037] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 09/30/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Since its introduction as an alternative intestinal lengthening technique, serial transverse enteroplasty (STEP) has been increasingly used as the surgical treatment of choice for patients with refractory short bowel syndrome (SBS). While primary STEP for the treatment of congenital conditions was proposed in the original description of the procedure, emphasis was placed on a delayed or staged approach to these patients. To date, a comprehensive review of the outcomes from this sub-population has not been reported by the International STEP Data Registry. METHODS A retrospective review of the International STEP Data Registry was performed to identify all patients who underwent STEP as a primary operative procedure for the treatment of congenital SBS. Changes in pre- and post-STEP values were assessed using paired t-tests with significance set at p<0.05. Data are presented as mean ± standard deviation. RESULTS Fifteen patients underwent primary STEP for congenital SBS between September 1, 2004, and April 10, 2012. Thirteen patients had follow-up information available. Causes of congenital SBS included closing gastroschisis, small bowel atresia, and midgut volvulus. Twelve patients had pre- and post-STEP bowel measurements taken. Average pre- and post-STEP bowel lengths were 32 ± 16 cm and 47 ± 22 cm, respectively. Intestinal length was increased by a mean of 15 ± 12 cm for a relative small bowel length increase of 50.4 ± 27.3% (p<0.001). Only one patient required an ostomy at the time of primary STEP. A second patient required a temporary ostomy at 3months of age that was later closed. There was one death from intestinal failure associated liver disease (IFALD). Another patient experienced IFALD progression and required liver and intestinal transplantation. The most commonly reported complication following primary STEP was obstruction or bowel re-dilatation requiring additional operative interventions. Nine patients underwent second STEP procedures under these circumstances. Eight patients remain dependent on parenteral nutrition, while three patients achieved enteral autonomy. CONCLUSIONS Primary STEP is a feasible and safe surgical option for the treatment of congenital conditions resulting in SBS. Primary STEP establishes early bowel continuity, creates intestinal length from congenitally dilated bowel, and appears to obviate the need for interval stomas and their associated loss of bowel length in neonates with congenital SBS. However, with recent changes in SBS management emphasizing intestinal rehabilitation, additional studies are needed to assess the long-term impact on intestinal adaptation of STEP performed in the neonatal period prior to adoption of this technique.
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Miller J, Dalton MK, Duggan C, Lam S, Iglesias J, Jaksic T, Gura KM. Going with the flow or swimming against the tide: should children with central venous catheters swim? Nutr Clin Pract 2013; 29:97-109. [PMID: 24347530 DOI: 10.1177/0884533613515931] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Children who require long-term parenteral nutrition (PN) have central venous catheters (CVCs) in place to allow the safe and effective infusion of life-sustaining fluids and nutrition. Many consider recreational swimming to be a common part of childhood, but for some, the risk may outweigh the benefit. Children with CVCs may be at increased risk of exit site, tunnel, and catheter-related bloodstream infections (CRBSIs) if these catheters are immersed in water. The purpose of this review is to evaluate the current literature regarding the risk of infection for patients with CVCs who swim and determine if there is consensus among home PN (HPN) programs on this controversial issue. A total 45 articles were reviewed and 16 pediatric HPN programs were surveyed regarding swimming and CVCs. Due to the limited data available, a firm recommendation cannot be made. Recreational water associated outbreaks are well documented in the general public, as is the presence of human pathogens even in chlorinated swimming pools. As a medical team, practitioners can provide information and education regarding the potential risk, but ultimately the decision lies with the parents. If the parents decide swimming is worth the risk, they are encouraged to use products designed for this use and to change their child's dressing immediately after swimming. Due to our experience with a fatal event immediately after swimming, we continue to strongly discourage patients with CVCs from swimming. Further large and well-designed studies regarding the risk of swimming with a CVC are needed to make a strong, evidence-based recommendation.
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Ayers P, Adams S, Boullata J, Gervasio J, Holcombe B, Kraft MD, Marshall N, Neal A, Sacks G, Seres DS, Worthington P, Malone A, Teitelbaum D, Andris DA, Ayers P, Baroccas A, Compher C, Ireton-Jones C, Jaksic T, Robinson LA, Van Way CW, Ayers P, Adams S, Boullata J, Gervasio J, Holcombe B, Kraft M, Neal T, Sacks G, Seres DS, Taylor B, Worthington PA. A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations. JPEN J Parenter Enteral Nutr 2013; 38:296-333. [DOI: 10.1177/0148607113511992] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Jones BA, Hull MA, Potanos KM, Zurakowski D, Fitzgibbons SC, Ching YA, Duggan C, Jaksic T, Kim HB. Report of 111 consecutive patients enrolled in the International Serial Transverse Enteroplasty (STEP) Data Registry: a retrospective observational study. J Am Coll Surg 2013; 216:438-46. [PMID: 23357726 DOI: 10.1016/j.jamcollsurg.2012.12.018] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 12/03/2012] [Accepted: 12/04/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND The International Serial Transverse Enteroplasty (STEP) Data Registry is a voluntary online database created in 2004 to collect information on patients undergoing the STEP procedure. The aim of this study was to identify preoperative factors that are significantly associated with transplantation or death or attainment of enteral autonomy after STEP. STUDY DESIGN Data were collected from September 2004 to January 2010. Univariate and multivariate logistic regression analyses were applied to determine the predictors of transplantation or death or enteral autonomy post-STEP. Time to reach full enteral nutrition was estimated using a Kaplan-Meier curve. RESULTS Fourteen of the 111 patients in the Registry were excluded due to inadequate follow-up. Of the remaining 97 patients, 11 patients died and 5 progressed to intestinal transplantation. On multivariate analysis, higher direct bilirubin and shorter pre-STEP bowel length were independently predictive of progression to transplantation or death (p = 0.05 and p < 0.001, respectively). Of the 78 patients who were 7 days of age or older and required parenteral nutrition at the time of STEP, 37 (47%) achieved enteral autonomy after the first STEP. Longer pre-STEP bowel length was also independently associated with enteral autonomy (p = 0.002). Median time to reach enteral autonomy based on Kaplan-Meier analysis was 21 months (95% CI, 12-30). CONCLUSIONS Overall mortality post-STEP was 11%. Pre-STEP risk factors for progressing to transplantation or death were higher direct bilirubin and shorter bowel length. Among patients who underwent STEP for short bowel syndrome, 47% attained full enteral nutrition post-STEP. Patients with longer pre-STEP bowel length were significantly more likely to achieve enteral autonomy.
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Kang KHJ, Gutierrez IM, Zurakowski D, Diperna S, Buonomo C, Kim HB, Jaksic T. Bowel re-dilation following serial transverse enteroplasty (STEP). Pediatr Surg Int 2012; 28:1189-93. [PMID: 23160903 DOI: 10.1007/s00383-012-3212-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2012] [Indexed: 11/24/2022]
Abstract
PURPOSE The serial transverse enteroplasty (STEP) operation tapers and lengthens dilated small bowel. Some patients demonstrate bowel re-dilation following STEP. Factors associated with bowel re-dilation and its effect upon clinical outcome were evaluated. METHODS Twenty STEP operations were reviewed. Sixteen cases were operated for failure to advance enteral feeding and were further analyzed. Available pre- and post-STEP radiographs were independently assessed for bowel re-dilation by two experienced pediatric radiologists. Potential factors of re-dilation were evaluated. Full enteral autonomy was defined as no longer requiring parenteral nutrition (PN) and remaining off PN for at least 12 months after STEP. RESULTS There was complete concordance between the radiologists. 9 of 16 patients demonstrated radiographic bowel re-dilation following STEP. Age, follow-up duration, time interval between STEP and last imaging reviewed, gender, diagnoses, pre- and post-STEP bowel length and width were not significantly associated with re-dilation. However, median post-STEP duration of PN was significantly longer in the re-dilated group than in the non-dilated group (41 vs. 3 months, p = 0.006). In addition, only 1 of 9 re-dilated patients achieved enteral autonomy as compared with 6 of 7 non-dilated patients (p = 0.009). CONCLUSION Longer PN duration after STEP increases probability of bowel re-dilation. Patients who re-dilated following STEP are significantly less likely to achieve enteral autonomy. Larger prospective data collections are warranted to further explore these relationships.
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Gutierrez IM, Kang KH, Calvert CE, Johnson VM, Zurakowski D, Kamin D, Jaksic T, Duggan C. Risk factors for small bowel bacterial overgrowth and diagnostic yield of duodenal aspirates in children with intestinal failure: a retrospective review. J Pediatr Surg 2012; 47:1150-4. [PMID: 22703785 PMCID: PMC3377944 DOI: 10.1016/j.jpedsurg.2012.03.019] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 03/06/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Children with intestinal failure (IF) are at risk for small bowel bacterial overgrowth (SBBO) because of anatomical and other factors. We sought to identify risk factors for SBBO confirmed by quantitative duodenal culture. METHODS A single-center retrospective record review of children who had undergone endoscopic evaluation for SBBO (defined as bacterial growth in duodenal fluid of >10(5) colony-forming unit per mL) was performed. RESULTS We reviewed 57 children with median (25th-75th percentile) age 5.0 (2.0-9.2) years. Diagnoses included motility disorders (28%), necrotizing enterocolitis (16%), atresias (16%), gastroschisis (14%), and Hirschsprung disease (10.5%). Forty patients (70%) had confirmed SBBO. Univariate analysis showed no significant differences between patients with and without SBBO for the following variables: age, sex, diagnosis, presence of ileocecal valve, and antacid use. Patients receiving parenteral nutrition (PN) were more likely to have SBBO (70% vs 35%, P = .02). Multiple logistic regression analysis confirmed that PN administration was independently associated with SBBO (adjusted odds ratio, 5.1; adjusted 95% confidence interval, 1.4-18.3; P = .01). SBBO was not related to subsequent risk of catheter-related bloodstream infection (CRBSI). CONCLUSION SBBO is strongly and independently associated with PN use. Larger prospective cohorts and more systematic sampling techniques are needed to better determine the relationship between SBBO and gastrointestinal function.
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Hull MA, Jones BA, Zurakowski D, Raphael B, Lo C, Jaksic T, Duggan C. Low serum citrulline concentration correlates with catheter-related bloodstream infections in children with intestinal failure. JPEN J Parenter Enteral Nutr 2011; 35:181-7. [PMID: 21378247 DOI: 10.1177/0148607110381406] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Serum citrulline concentration is used as a biomarker of enterocyte mass and enteral tolerance, and low serum concentrations are correlated with bacteremia in immunosuppressed adults undergoing hematopoietic stem cell transplant. The authors sought to determine if citrulline was associated with the development of catheter-related bloodstream infections (CRBSIs) in children with intestinal failure. METHODS Data were reviewed from 66 children treated in a multidisciplinary intestinal rehabilitation program, who had serum concentration citrulline measured between January 2007 and August 2009. All patients had a diagnosis of intestinal failure requiring parenteral nutrition (PN) support. Exclusion criteria included central venous catheter in situ <30 days, creatinine clearance <20 mL/minute, or a history of organ transplant/immunosuppression. RESULTS A total of 15 patients were excluded because of the above criteria. In this cohort of 51 patients, 26 (51%) developed CRBSIs. Both groups were similar in terms of gestational age, diagnosis, nutrition status, and biochemical liver function tests. The mean (± standard deviation [SD]) minimum serum citrulline concentration was significantly lower in patients who developed CRBSIs (6.7 ± 4.6 µmol/L) than in those who did not (11.3 ± 6.4 µmol/L, P = .004). Multivariate logistic regression analysis identified lower minimum serum citrulline concentration and longer central venous catheter duration as independently associated with CRBSI (P = .003 and P = .038, respectively). CONCLUSIONS Low serum citrulline concentration and longer central venous catheter time are independently associated with CRBSI in children with intestinal failure. Serum citrulline concentration may be a useful biomarker to identify patients with intestinal failure who are at high risk of developing a CRBSI.
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Yang CFJ, Duro D, Zurakowski D, Lee M, Jaksic T, Duggan C. High prevalence of multiple micronutrient deficiencies in children with intestinal failure: a longitudinal study. J Pediatr 2011; 159:39-44.e1. [PMID: 21324480 PMCID: PMC3112274 DOI: 10.1016/j.jpeds.2010.12.049] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Revised: 12/08/2010] [Accepted: 12/30/2010] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine the prevalence of micronutrient deficiencies in children with intestinal failure as they transitioned from parenteral nutrition (PN) to enteral nutrition (EN). STUDY DESIGN We reviewed medical records of all patients with severe intestinal failure treated from 1999 to 2008 at a multidisciplinary intestinal rehabilitation program who had undergone micronutrient biochemical monitoring. RESULTS The cohort of 30 children (mean age, 5 years; range, 2 to 9 years; 18 boys) had median PN duration of 23 weeks (IQR, 13 to 34 weeks). Median transition from PN to full EN lasted 12 weeks (IQR, 8 to 20 weeks); during this transition, 33% of patients had at least one vitamin deficiency and 77% at least one mineral deficiency. After transition to 100% EN, 70% had at least one vitamin deficiency and 77% had at least one mineral deficiency, with the most common deficiencies being vitamin D (68%), zinc (67%), and iron deficiency (37%). After transition to 100% EN, multivariate analysis identified regular use of a multivitamin supplement (P=.004) and intact ileocecal valve (P=.02) as protective against the development of vitamin deficiencies, independent of bowel length, gestational age, and days on PN. CONCLUSIONS Children with intestinal failure exhibit a high prevalence of micronutrient deficiencies during intestinal rehabilitation. Regular monitoring and aggressive supplementation in children with intestinal failure is warranted.
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Abstract
Neonatal short bowel syndrome is a disease with a high morbidity and mortality. The management of these patients is complex and requires a multidisciplinary approach. Recent advances in medical and surgical treatment options have improved outcomes. The following review highlights salient points in the management of this challenging patient population.
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Raphael BP, Nurko S, Jiang H, Hart K, Kamin DS, Jaksic T, Duggan C. Cisapride improves enteral tolerance in pediatric short-bowel syndrome with dysmotility. J Pediatr Gastroenterol Nutr 2011; 52:590-4. [PMID: 21502831 PMCID: PMC3079853 DOI: 10.1097/mpg.0b013e3181fe2d7a] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Gastrointestinal dysmotility is common in pediatric short-bowel syndrome, leading to prolonged parenteral nutrition dependence. There is limited literature regarding the safety and efficacy of cisapride for this indication. The aim of the study was to describe the safety and efficacy of cisapride for enteral intolerance in pediatric short-bowel syndrome. METHODS Open-labeled pilot study in a limited access program for cisapride. Indications were short-bowel syndrome with underlying dysmotility and difficulty advancing enteral feeds despite standard therapies and without evidence of anatomic obstruction. Patients received cisapride 0.1 to 0.2 mg/kg per dose for 3 to 4 doses per day. We collected electrocardiogram, nutrition, and anthropometric data prospectively at study visits. RESULTS Ten patients with mean (SD) age of 30.3 (30.5) months were enrolled in our multidisciplinary pediatric intestinal rehabilitation program. Median (interquartile range [IQR]) duration of follow-up was 8.7 (3.1-14.3) months. Median (IQR) residual bowel length was 102 (85-130) cm. Median (IQR) citrulline level was 14.5 (10.5-31.3) μmol/L. Diagnoses included isolated gastroschisis (n = 3), gastroschisis with intestinal atresia (n = 4), necrotizing enterocolitis (n = 2), and long-segment Hirschsprung disease (n = 1). Six subjects had at least 1 prior bowel-lengthening procedure. Median (IQR) change in percentage enteral energy intake was 19.9% (15.4%-29.8%) during follow-up (P = 0.01). Seven patients improved in enteral tolerance during treatment and 2 were weaned completely from parenteral nutrition. Complications during therapy were prolonged corrected QT interval (n = 2), gastrointestinal bleeding (n = 2), D-lactic acidosis (n = 1), and death due to presumed sepsis (n = 1). Longitudinal analysis (general estimating equation model) showed a strong positive association between cisapride duration and improved enteral tolerance. Mean percentage of enteral intake increased by 2.9% for every month of cisapride treatment (P < 0.0001). CONCLUSIONS Cisapride is a potentially useful therapy in patients with pediatric short-bowel syndrome with gastrointestinal dysmotility. We observed modest improvement in feeding tolerance where prior treatments failed; however, patients treated with cisapride require careful cardiac monitoring because corrected QT prolongation occurred in 20% of our cohort.
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Steil GM, Alexander J, Papas A, Monica L, Modi BP, Piper H, Jaksic T, Gottlieb R, Agus MSD. Use of a continuous glucose sensor in an extracorporeal life support circuit. J Diabetes Sci Technol 2011; 5:93-8. [PMID: 21303630 PMCID: PMC3045226 DOI: 10.1177/193229681100500113] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Standard care for infants on extracorporeal life support (ECLS) relies on intermittent measurement of blood glucose (BG); however, this can lead to significant changes in BG that go unrecognized for several hours. The present study was designed to assess performance and clinical applicability of a subcutaneous glucose sensor technology modified for use as a blood-contacting sensor within the ECLS circuit. METHODS Twelve children, aged 3 years or less, requiring ECLS support were studied. Three continuous glucose sensors (Medtronic MiniMed) were inserted into hubs placed in line with the ECLS circuit. Blood glucose was assessed with a laboratory analyzer (BG(LAB); Bayer Rapidlab 860) approximately every 5 h (mean 4.9 ± 3.3 h) with more frequent samples obtained with a bedside monitor (HemoCue) as needed. Sensor current (I(SIG)) was transmitted to a laptop computer and retrospectively calibrated using BGLAB. Sensor performance was assessed by mean absolute relative difference (MARD), linear regression slope and intercept, and correlation, all with BGLAB as reference. RESULTS The BGLAB averaged 107.6 ± 36.4 mg/dl (mean ± standard deviation) ranging from 58 to 366 mg/dl. The MARD was 11.4%, with linear regression slope (0.86 ± 0.030) and intercept (9.0 ± 3.2 mg/dl) different from 1 and 0, respectively (p < .05), and correlation (r² = 0.76; p < .001). The system was not associated with any adverse events, and placement and removal into the hubs was easily accomplished. Instances in which more frequent BG values were obtained using a bedside HemoCue (BGHEMO) monitor showed the sensor to respond rapidly to changes. CONCLUSIONS We conclude that continuous sensors can be adapted for use in an ECLS circuit with accuracy similar to or better than that achieved with the subcutaneous site. Continuous glucose monitoring in this population can rapidly detect changes in BG that would not otherwise be observed. Further studies will be needed to assess the benefit of continuous glucose monitoring in this population.
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MESH Headings
- Biosensing Techniques/instrumentation
- Biosensing Techniques/methods
- Biosensing Techniques/standards
- Biosensing Techniques/statistics & numerical data
- Blood Glucose/analysis
- Blood Glucose Self-Monitoring
- Calibration
- Child, Preschool
- Extracorporeal Circulation/instrumentation
- Extracorporeal Circulation/methods
- Extracorporeal Circulation/standards
- Female
- Heart Defects, Congenital/blood
- Heart Defects, Congenital/therapy
- Hernia, Diaphragmatic/blood
- Hernia, Diaphragmatic/therapy
- Hernias, Diaphragmatic, Congenital
- Humans
- Infant
- Infant, Newborn
- Infant, Newborn, Diseases/blood
- Infant, Newborn, Diseases/therapy
- Male
- Monitoring, Physiologic/instrumentation
- Monitoring, Physiologic/methods
- Monitoring, Physiologic/standards
- Respiratory Insufficiency/blood
- Respiratory Insufficiency/congenital
- Respiratory Insufficiency/therapy
- Retrospective Studies
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Jaksic T, McMahon MM, Ziegler T, Mechanick JI. Defining the roles and responsibilities of medical, surgical, and nutrition societies for conducting research and providing medical education in nutrition. JPEN J Parenter Enteral Nutr 2010; 34:63S-9S. [PMID: 21149837 DOI: 10.1177/0148607110375696] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Nutrition research and education are the domains of many societies with somewhat divergent but often largely overlapping interests. Given the lack of consensus regarding appropriate nutrition therapy and the cacophony of educational efforts, cooperative endeavors seem prudent. The development of research consortia, data registries, tissue repositories, and a statistical core are all potentially beneficial. Such resources would result in clinical trials and quality improvement initiatives. Coordinated professional and public education, matched policy initiatives, and a unified process for the development of clinical guidelines are also desirable. The creation of durable alliances between nutrition societies and clinical organizations will require considerable effort and innovation.
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McClave SA, Mechanick JI, Kushner RF, DeLegge MH, Apovian CM, Brill JV, Friedman G, Heimburger DC, Jaksic T, Martindale RG, Moore FA, Shikora SA. Compilation of Recommendations From Summit on Increasing Physician Nutrition Experts. JPEN J Parenter Enteral Nutr 2010; 34:123S-32S. [DOI: 10.1177/0148607110373485] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Duro D, Fitzgibbons S, Valim C, Yang CFJ, Zurakowski D, Dolan M, Bechard L, Yu YM, Duggan C, Jaksic T. [13C]Methionine breath test to assess intestinal failure-associated liver disease. Pediatr Res 2010; 68:349-54. [PMID: 20581744 PMCID: PMC3721749 DOI: 10.1203/pdr.0b013e3181ed15e5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Oxidation of L[1-C]methionine ([C]-Met) in liver mitochondria can be quantified by measuring exhaled CO2. We hypothesized that CO2 recovery after i.v. administered [C]-Met would provide a noninvasive measure of liver function in pediatric intestinal failure-associated liver disease (IFALD). After Institutional Review Board (IRB) approval, 27 patients underwent L[1-C]-Met breath tests ([C]-MBTs), five of whom underwent repeat testing after clinical changes in liver function. Sterile, pyrogen-free [C]-Met was given i.v. Six breath samples collected during 120 min were analyzed for CO2 enrichment using isotope ratio mass spectrometry. Pediatric end-stage liver disease (PELD) scores were recorded, and total carbon dioxide (CO2) production was measured by indirect calorimetry. Twenty-seven patients (median age = 5.3 mo) underwent a total of 34 [C]-MBTs without adverse events. Fourteen patients had documented liver biopsies (five with cirrhosis and nine with cholestasis or fibrosis). The [C]-MBT differentiated patients with and without cirrhosis (medians 210 and 350, respectively, p = 0.04). Serial [C]-MBTs in five patients reflected changing PELD scores. i.v. administering the stable isotope [C]-Met with serial breath sampling provides a useful, safe, and potentially clinically relevant evaluation of hepatic function in pediatric IFALD. The [C]-MBT may also help quantify progression or improvement of IFALD.
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Duro D, Kalish LA, Johnston P, Jaksic T, McCarthy M, Martin C, Dunn JCY, Brandt M, Nobuhara KK, Sylvester KG, Moss RL, Duggan C. Risk factors for intestinal failure in infants with necrotizing enterocolitis: a Glaser Pediatric Research Network study. J Pediatr 2010; 157:203-208.e1. [PMID: 20447649 PMCID: PMC3217834 DOI: 10.1016/j.jpeds.2010.02.023] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Revised: 12/02/2009] [Accepted: 02/16/2010] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine risk factors for intestinal failure (IF) in infants undergoing surgery for necrotizing enterocolitis (NEC). STUDY DESIGN Infants were enrolled in a multicenter prospective cohort study. IF was defined as the requirement for parenteral nutrition for >or= 90 days. Logistic regression was used to identify predictors of IF. RESULTS Among 473 patients enrolled, 129 had surgery and had adequate follow-up data, and of these patients, 54 (42%) developed IF. Of the 265 patients who did not require surgery, 6 (2%) developed IF (OR 31.1, 95% CI, 12.9 - 75.1, P < .001). Multivariate analysis identified the following risk factors for IF: use of parenteral antibiotics on the day of NEC diagnosis (OR = 16.61, P = .022); birth weight < 750 grams, (OR = 9.09, P < .001); requirement for mechanical ventilation on the day of NEC diagnosis (OR = 6.16, P = .009); exposure to enteral feeding before NEC diagnosis (OR=4.05, P = .048); and percentage of small bowel resected (OR = 1.85 per 10 percentage point greater resection, P = .031). CONCLUSION The incidence of IF among infants undergoing surgical treatment for NEC is high. Variables characteristic of severe NEC (low birth weight, antibiotic use, ventilator use, and greater extent of bowel resection) were associated with the development of IF.
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Jones BA, Hull MA, Richardson DS, Zurakowski D, Gura K, Fitzgibbons SC, Duro D, Lo CW, Duggan C, Jaksic T. Efficacy of ethanol locks in reducing central venous catheter infections in pediatric patients with intestinal failure. J Pediatr Surg 2010; 45:1287-93. [PMID: 20620333 PMCID: PMC4547776 DOI: 10.1016/j.jpedsurg.2010.02.099] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Accepted: 02/23/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE We sought to determine whether a regimen of 70% ethanol locks could reduce the rate of central venous catheter (CVC) infections in parenteral nutrition-dependent children with intestinal failure. METHODS We performed a retrospective review of 23 parenteral nutrition-dependent children in our multidisciplinary intestinal rehabilitation clinic who started ethanol lock therapy between September 2007 and June 2009. The treatment regimen consisted of a 70% ethanol lock instilled 3 times per week in each catheter lumen. The rate of CVC infections before and after initiation of ethanol lock therapy was compared using the Wilcoxon signed ranks test with significance set at P < .05. RESULTS The most common diagnoses leading to intestinal failure were necrotizing enterocolitis (26.1%), gastroschisis (21.7%), and intestinal atresia (14.3%). Ethanol locks were well tolerated with no reported adverse side effects. The infection rate decreased from 9.9 per 1000 catheter days prior to initiation of ethanol locks to 2.1 per 1000 catheter days during therapy (P = .03). CONCLUSIONS A regimen of ethanol lock therapy administered three days per week appears to be a safe and effective means of reducing the rate of CVC infections in parenteral nutrition-dependent children with intestinal failure.
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Jaksic T, Hull MA, Modi BP, Ching YA, George D, Compher C. A.S.P.E.N. Clinical Guidelines. JPEN J Parenter Enteral Nutr 2010; 34:247-53. [DOI: 10.1177/0148607110369225] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Jaksic T. Intestinal failure. Preface. Semin Pediatr Surg 2010; 19:1-2. [PMID: 20123267 DOI: 10.1053/j.sempedsurg.2009.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Fitzgibbons SC, Jones BA, Hull MA, Zurakowski D, Duro D, Duggan C, Boctor D, Sigalet DL, Jaksic T. Relationship between biopsy-proven parenteralnutrition-associated liver fibrosis and biochemical cholestasis in children with short bowel syndrome. J Pediatr Surg 2010; 45:95-9; discussion 99. [PMID: 20105587 PMCID: PMC4548285 DOI: 10.1016/j.jpedsurg.2009.10.020] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Accepted: 10/06/2009] [Indexed: 12/29/2022]
Abstract
PURPOSE The aim of the study was to determine the frequency of biochemical cholestasis (direct bilirubin [DB] > or =2 mg/dL) in children with short bowel syndrome and biopsy-proven parenteral nutrition (PN)-associated liver disease and to define predictive factors for the occurrence and degree of hepatic fibrosis. METHODS After institutional review board approval, a retrospective review was conducted of patients followed by 2 multidisciplinary intestinal rehabilitation programs between January 1, 2000, and September 30, 2008. Inclusion criteria were exposure to PN (>30 days) and having undergone a liver biopsy. Liver biopsy specimens were graded from 0 to 3 based upon degree of fibrosis in the pathology report. The most recent DB within 10 days before biopsy was recorded. RESULTS A total of 66 children underwent 83 liver biopsy procedures. The most common diagnoses included necrotizing enterocolitis (NEC) (36.4%), gastroschisis (22.7%), and intestinal atresia (15.1%). Median age at biopsy was 6.1 months with a median duration of PN of 4.7 months. Of the patients, 70.3% had a history of exposure to parenteral omega-3 lipid emulsion. Of the liver biopsy specimens, 89% (74/83) demonstrated some degree of fibrosis (fibrosis scale 1-3), including 9.6% (8/83) with evidence of cirrhosis. 83% of biopsies without fibrosis and 55% of biopsies with fibrosis were obtained in patients without evidence of biochemical cholestasis (P = .20). Three (37%) of the 8 patients with cirrhosis on liver biopsy had no evidence of biochemical cholestasis. Univariate analysis identified only gestational age (GA) at birth as significantly associated with the degree of liver fibrosis (P = .03). A multivariate logistic regression model accounting for multiple biopsy procedures in patients revealed that GA was a predictor of fibrosis only in patients with a diagnosis other than NEC (P < .01). CONCLUSIONS In children with short bowel syndrome, biochemical cholestasis does not reflect the presence or degree of histologically confirmed PN-associated liver fibrosis. Careful follow-up, combined with further refinement of diagnostic and hepatoprotective strategies, may be warranted in this patient population.
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Wang H, Yu YM, Jaksic T, Traber D, Enkhaatar P, Tompkins RG, Fischman AJ. WITHDRAWN: Determination of underivatized 3-methylhistidine in human urine by liquid chromatography–mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2009. [DOI: 10.1016/j.jchromb.2009.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Fitzgibbons SC, Ching Y, Yu D, Carpenter J, Kenny M, Weldon C, Lillehei C, Valim C, Horbar JD, Jaksic T. Mortality of necrotizing enterocolitis expressed by birth weight categories. J Pediatr Surg 2009; 44:1072-5; discussion 1075-6. [PMID: 19524719 DOI: 10.1016/j.jpedsurg.2009.02.013] [Citation(s) in RCA: 383] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 02/17/2009] [Indexed: 11/30/2022]
Abstract
PURPOSE Low birth weight is the most important risk factor for developing necrotizing enterocolitis (NEC). We aimed to establish birth weight-based benchmarks for in-hospital mortality in neonates with NEC. METHODS Five hundred eleven centers belonging to the Vermont Oxford Network prospectively evaluated 71,808 neonates with birth weight of 501 to 1500 g between January 2005 and December 2006. The primary outcome variable was in-hospital mortality. RESULTS Birth weight was divided into 4 categories by 250-g increments. The NEC risk (P < .001) and mortality (P < .001) decreased with higher birth weight category. Necrotizing enterocolitis was associated with a significant odds ratio for death for each category (P < .001). Across groups, the odds ratio for NEC mortality increased with higher birth weight category (category 1 = 1.6 vs category 4 = 9.9; P < .001). CONCLUSION The in-hospital mortality rate of neonates with NEC remains high and is significantly related to birth weight category. Although the risk and absolute mortality of NEC decrease with higher birth weight, the odds ratios indicate that NEC has a relatively greater impact upon mortality at higher birth weight. These data afford birth weight-based mortality benchmarks that may be useful in assessing single center NEC outcomes and facilitating comparisons between centers.
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Yang CFJ, Lee M, Valim C, Hull M, Zhou J, Jones B, Gura K, Collier S, Lo C, Duggan C, Jaksic T. Persistent alanine aminotransferase elevations in children with parenteral nutrition-associated liver disease. J Pediatr Surg 2009; 44:1084-7; discussion 1087-8. [PMID: 19524721 PMCID: PMC4547788 DOI: 10.1016/j.jpedsurg.2009.02.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Accepted: 02/17/2009] [Indexed: 01/08/2023]
Abstract
BACKGROUND Parenteral nutrition-associated liver disease (PNALD) is a serious condition affecting many children with short bowel syndrome. The aim of this study was to longitudinally assess serum alanine aminotransferase (ALT), a marker for hepatocyte injury, in enterally fed children with PNALD. METHODS Retrospective chart review of 31 patients treated from 1999 to 2006 by the Center for Advanced Intestinal Rehabilitation at Children's Hospital Boston (Mass). Inclusion criteria included PN duration of greater than 3 months with subsequent tolerance of full enteral nutrition and evidence of PN-associated liver injury. Time to normalize ALT and direct bilirubin were estimated using Kaplan-Meier and Cox proportional hazards methods. RESULTS Mean age PN cessation was 6 months (range, 2-14 months). Median PN duration was 18 weeks (interquartile range [IQR], 13-33 weeks), and median follow-up was 24 weeks (IQR, 14-48 weeks). After transition to full enteral nutrition, 74% of children normalized direct bilirubin, whereas only 50% normalized ALT. Kaplan-Meier median time to direct bilirubin and ALT normalization were 13 weeks and 35 weeks, respectively (P = .001). CONCLUSION Children with PNALD who have achieved PN independence have persistent ALT elevation despite normal direct bilirubin levels. This implies that hepatic injury may be ongoing beyond the time of bilirubin normalization in this cohort of patients.
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Yu DC, Thiagarajan RR, Laussen PC, Laussen JP, Jaksic T, Weldon CB. Outcomes after the Ladd procedure in patients with heterotaxy syndrome, congenital heart disease, and intestinal malrotation. J Pediatr Surg 2009; 44:1089-95; discussion 1095. [PMID: 19524722 DOI: 10.1016/j.jpedsurg.2009.02.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Accepted: 02/17/2009] [Indexed: 12/21/2022]
Abstract
PURPOSE Heterotaxy syndrome (HS) patients often present with congenital heart disease and intestinal malrotation. Controversy exists regarding the management of these patients. Risk of midgut volvulus, morbidity from elective operations, and overall prognosis must be weighed when considering a Ladd procedure on asymptomatic HS/intestinal malrotation patients. METHODS This is a retrospective review comparing HS and non-heterotaxy syndrome (NHS) patients undergoing a Ladd procedure at Children's Hospital Boston (Mass) from January 1997 to September 2007. RESULTS Thirty-one HS and 51 NHS patients were identified. After a Ladd procedure, HS patients remained in the hospital 12.9 days, had a 9.7% risk of small bowel obstruction, and a 9.7% in-hospital mortality. If allowed to develop abdominal symptoms, 27% of HS patients with intestinal malrotation had a midgut volvulus at surgery. Intra-HS group comparison demonstrated longer hospital stays in symptomatic patients (P = .01). Mortality was greater in the HS than NHS patients, but deaths were related to cardiac disease and not to the Ladd procedure. CONCLUSIONS Elective Ladd procedures are well tolerated by HS patients. Given the risk of midgut volvulus and in light of improved survival beyond infanthood, once identified, HS patients with asymptomatic malrotation should be offered a prophylactic Ladd procedure.
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Fitzgibbons S, Ching YA, Valim C, Zhou J, Iglesias J, Duggan C, Jaksic T. Relationship between serum citrulline levels and progression to parenteral nutrition independence in children with short bowel syndrome. J Pediatr Surg 2009; 44:928-32. [PMID: 19433172 PMCID: PMC3217826 DOI: 10.1016/j.jpedsurg.2009.01.034] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 01/15/2009] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Although bowel length is an important prognostic variable used in the management of children with short bowel syndrome (SBS), reliable measurements can be difficult to obtain. Plasma citrulline (CIT) levels have been proposed as surrogate markers for bowel length and function. We sought to evaluate the relationship between CIT and parenteral nutrition (PN) independence in children with SBS. STUDY DESIGN A retrospective chart review performed for all patients seen in a multidisciplinary pediatric intestinal rehabilitation clinic with a recorded CIT between January 2005 and December 2007 (n = 27). RESULTS Median age at time of CIT determination was 2.4 years. Diagnoses included necrotizing enterocolitis (26%), intestinal atresias (19%), and gastroschisis (22%). Citrulline levels correlated well with bowel length (R = 0.73; P < .0001) and was a strong predictor of PN independence (P Wilcoxon = 0.002; area under the receiver operating characteristic curve = 0.88; 95% confidence interval, 0.75-1.00). The optimal CIT cutoff point distinguishing patients who reached PN independence was 15 micromol/L (sensitivity = 89%; specificity = 78%). CONCLUSION Plasma CIT levels are strong predictors of PN independence in children with SBS and correlate well with a patient's recorded bowel length. A cutoff CIT level of 15 micromol/L may serve as a prognostic measure in counseling patients regarding the likelihood of future PN independence.
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