101
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MESH Headings
- Diagnosis, Differential
- Drainage
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/etiology
- Enterocolitis, Necrotizing/therapy
- Humans
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/etiology
- Infant, Premature, Diseases/therapy
- Inflammation/complications
- Intestines/growth & development
- Intestines/microbiology
- Prebiotics
- Probiotics/therapeutic use
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Affiliation(s)
- Josef Neu
- Department of Pediatrics, University of Florida, Gainesville, USA
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102
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Abstract
OBJECTIVES Short bowel syndrome occurring after surgery for acquired or congenital intestinal abnormalities causes considerable neonatal morbidity and mortality. Animal models are a valuable research tool for this problem; however, few successful neonatal models have been developed and most do not include distal intestinal resection as seen commonly in human babies. We report novel piglet models addressing these gaps. SUBJECTS AND METHODS Neonatal piglets (1-6 days) underwent venous and gastric catheter insertion and 75% intestinal resection. Group 1 (n = 6) had midintestinal resection with jejunoileal anastomosis; group 2 (n = 5) had distal intestinal resection with jejunocolic anastomosis; group 3 (n = 5) were sham controls; and group 4 (n = 5) were sow reared. Postoperatively, groups 1 to 3 piglets commenced parenteral nutrition (PN), and enteral nutrition was introduced and advanced using a standard regimen. Data collection included days on PN, weight gain, fat absorption, small intestine lengthening, and bowel/liver histology. RESULTS Group 2 piglets had more days on PN (P = 0.008), less weight gain (P = 0.027), and greater malabsorption (P = 0.012). They did not show small intestine lengthening and had more cholestatic liver disease. Group 1 piglets had histological evident intestinal adaptation and 1.5-fold intestinal lengthening (P = 0.001). CONCLUSIONS These novel piglet models of short bowel syndrome are the first to represent the full clinical spectrum of intestinal failure as observed in human neonates. By considering the impact of different short bowel anatomy on potential for adaptation and growth, these animal models are a significant advance. They permit evaluation of new therapies to promote intestinal adaptation and reduce complications, such as cholestasis.
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103
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Sigalet D, Boctor D, Brindle M, Lam V, Robertson M. Elements of successful intestinal rehabilitation. J Pediatr Surg 2011; 46:150-6. [PMID: 21238657 DOI: 10.1016/j.jpedsurg.2010.09.083] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Accepted: 09/30/2010] [Indexed: 12/28/2022]
Abstract
PURPOSE The optimal therapy for intestinal failure (IF) is unknown. The results of a systematic, protocol-driven management strategy by a multidisciplinary team are described. METHODS Intestinal failure was defined as bowel length of less than 40 cm or parenteral nutrition (PN) for more than 42 days. A multidisciplinary team and protocol to prevent PN-associated liver disease (PNALD) were instituted in 2006. Data were gathered prospectively with consent and ethics board approval. RESULTS From 1998 to 2006, 33 patients were treated (historical cohort) with an overall survival of 72%. Rotating prophylactic antibiotics for bacterial overgrowth were given to 27% of patients; 6% had lipid-sparing PN, and none received fish oil-based lipids. Median time to intestinal rehabilitation was 7 ± 3.1 months, and 27% of patients who developed PNALD died. From 2006 to 2009, 31 patients were treated. Seventy-seven percent received PAB; 60%, lipid-sparing PN; and 47%, parenteral fish oil emulsion. Eighty-seven percent weaned from PN at 3.9 ± 3.8 months, and no patients developed PNALD with 100% survival. Novel lipid therapies were associated with changes in essential fatty acid profile and one case of clinical essential fatty acid deficiency. CONCLUSION The institution of a multidisciplinary team and a protocol-driven strategy to prevent PNALD improves survival in IF. Further studies are recommended.
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Affiliation(s)
- David Sigalet
- Division of Pediatric General Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Canada.
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104
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Saxena AK. Congenital Anomalies of Soft Tissues: Birth Defects Depending on Tissue Engineering Solutions and Present Advances in Regenerative Medicine. TISSUE ENGINEERING PART B-REVIEWS 2010; 16:455-66. [DOI: 10.1089/ten.teb.2009.0700] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Amulya K. Saxena
- Department of Pediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria
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105
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Shekherdimian S, Panduranga MK, Carman GP, Dunn JCY. The feasibility of using an endoluminal device for intestinal lengthening. J Pediatr Surg 2010; 45:1575-80. [PMID: 20713203 DOI: 10.1016/j.jpedsurg.2010.03.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2009] [Revised: 03/13/2010] [Accepted: 03/15/2010] [Indexed: 11/16/2022]
Abstract
PURPOSE Prior studies demonstrating the ability to lengthen intestinal segments with mechanical force required devices with extracorporeal components. The feasibility of using a completely implantable device for in vivo intestinal lengthening was evaluated in this study. METHODS Biocompatible Nitinol springs capable of 5-fold expansions were compressed using absorbable sutures and were implanted into isolated segments of proximal jejunum in rats. Springs compressed with nonabsorbable sutures served as controls. The animals were observed with serial abdominal x-rays until the springs became fully expanded. Intestinal segments were then retrieved for histologic analysis. Two-tailed and paired Student's t tests were used for statistical analysis. RESULTS Intestinal segments were successfully lengthened in the experimental group from 1.3 +/- 0.3 cm to 4.4 +/- 0.5 cm (P < .001). Maximum spring length was achieved on postoperative day 36 (range, 16-50 days). In the control group, there was also an increase in intestinal lengths, from 1.6 +/- 0.04 cm to 2.9 +/- 0.4 cm (P < .001) (Fig. 4). In percentages, a 250% increase in length was observed in the experimental group vs an 85% increase in the control group (P < .001). Microscopic evaluation of both control and experimental segments revealed gross preservation of intestinal architecture; however, muscular layer hypertrophy and villous atrophy were noted. CONCLUSIONS Continuous mechanical force with an implantable spring successfully lengthened isolated segments of small bowel in an animal model. Although similar results have been demonstrated using other devices, the current device is totally implantable and may be deployed endoscopically.
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Affiliation(s)
- Shant Shekherdimian
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA 90095-7098, USA
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106
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Current concepts in the medical management of pediatric intestinal failure. Curr Opin Organ Transplant 2010; 15:324-9. [DOI: 10.1097/mot.0b013e32833948be] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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107
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The rate of bloodstream infection is high in infants with short bowel syndrome: relationship with small bowel bacterial overgrowth, enteral feeding, and inflammatory and immune responses. J Pediatr 2010; 156:941-947.e1. [PMID: 20171649 PMCID: PMC2875373 DOI: 10.1016/j.jpeds.2009.12.008] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Revised: 11/10/2009] [Accepted: 12/04/2009] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This pilot study in parenteral nutrition-dependent infants with short bowel syndrome (SBS) evaluated the impact of feeding route and intestinal permeability on bloodstream infection (BSI), small bowel bacterial overgrowth (SBBO), and systemic immune responses, as well as fecal calprotectin as a biomarker for SBBO. STUDY DESIGN Ten infants (ages 4.2-15.4 months) with SBS caused by necrotizing enterocolitis were evaluated. Nutritional assessment, breath hydrogen testing, intestinal permeability, fecal calprotectin, serum flagellin- and lipopolysaccharide-specific antibody titers, and proinflammatory cytokine concentrations (tumor necrosis factor-alpha [TNF-alpha], interleukin-1 beta, -6, and -8) were performed at baseline and at 60 and 120 days. Healthy, age-matched control subjects (n = 5) were recruited. RESULTS BSI incidence was high (80%), and SBBO was common (50%). SBBO increased the odds for BSI (>7-fold; P = .009). Calprotectin levels were higher in children with SBS and SBBO versus those without SBBO and healthy control subjects (P < .05). Serum TNF-alpha, was elevated at baseline versus controls. Serum TNF-alpha and interleukin-1 beta, -6, and -8 levels diminished with increased enteral nutrition. Anti-flagellin and anti-lipopolysaccharide immunoglobulin G levels in children with SBS were lower versus control subjects and rose over time. CONCLUSION In children with SBS, SBBO increases the risk for BSI, and systemic proinflammatory response decreases with increasing enteral feeding and weaning parenteral nutrition.
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108
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Taqi E, Wallace LE, de Heuvel E, Chelikani PK, Zheng H, Berthoud HR, Holst JJ, Sigalet DL. The influence of nutrients, biliary-pancreatic secretions, and systemic trophic hormones on intestinal adaptation in a Roux-en-Y bypass model. J Pediatr Surg 2010; 45:987-95. [PMID: 20438940 DOI: 10.1016/j.jpedsurg.2010.02.036] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2010] [Accepted: 02/03/2010] [Indexed: 01/04/2023]
Abstract
PURPOSE The signals that govern the upregulation of nutrient absorption (adaptation) after intestinal resection are not well understood. A Gastric Roux-en-Y bypass (GRYB) model was used to isolate the relative contributions of direct mucosal stimulation by nutrients, biliary-pancreatic secretions, and systemic enteric hormones on intestinal adaptation in short bowel syndrome. METHODS Male rats (350-400 g; n = 8/group) underwent sham or GRYB with pair feeding and were observed for 14 days. Weight and serum hormonal levels (glucagon-like peptide-2 [GLP-2], PYY) were quantified. Adaptation was assessed by intestinal morphology and crypt cell kinetics in each intestinal limb of the bypass and the equivalent points in the sham intestine. Mucosal growth factors and expression of transporter proteins were measured in each limb of the model. RESULTS The GRYB animals lost weight compared to controls and exhibited significant adaptive changes with increased bowel width, villus height, crypt depth, and proliferation indices in the alimentary and common intestinal limbs. Although the biliary limb did not adapt at the mucosa, it did show an increased bowel width and crypt cell proliferation rate. The bypass animals had elevated levels of systemic PYY and GLP-2. At the mucosal level, insulin-like growth factor-1 (IGF-1) and basic fibroblast growth factor (bFGF) increased in all limbs of the bypass animals, whereas keratinocyte growth factor (KGF) and epidermal growth factor (EGF) had variable responses. The expression of the passive transporter of glucose, GLUT-2, expression was increased, whereas GLUT-5 was unchanged in all limbs of the bypass groups. Expression of the active mucosal transporter of glucose, SGLT-1 was decreased in the alimentary limb. CONCLUSIONS Adaptation occurred maximally in intestinal segments stimulated by nutrients. Partial adaptation in the biliary limb may reflect the effects of systemic hormones. Mucosal content of IGF-1, bFGF, and EGF appear to be stimulated by systemic hormones, potentially GLP-2, whereas KGF may be locally regulated. Further studies to examine the relationships between the factors controlling nutrient-induced adaptation are suggested. Direct contact with nutrients appears to be the most potent factor in inducing mucosal adaptation.
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Affiliation(s)
- Esmaeel Taqi
- Faculty of Medicine, Division of Pediatric General Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada AB T3B 6A8
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109
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Olieman JF, Poley MJ, Gischler SJ, Penning C, Escher JC, van den Hoonaard TL, van Goudoever JB, Bax NMA, Tibboel D, IJsselstijn H. Interdisciplinary management of infantile short bowel syndrome: resource consumption, growth, and nutrition. J Pediatr Surg 2010; 45:490-8. [PMID: 20223310 DOI: 10.1016/j.jpedsurg.2009.08.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Revised: 07/30/2009] [Accepted: 08/02/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND/PURPOSE To date, there are hardly any data on the treatment costs of infantile short bowel syndrome (SBS), despite growing interest in evidence-based and cost-effective medicine. Therefore, the aim of the study was to evaluate resource consumption and costs, next to studying nutritional and growth outcomes, in children with SBS who were treated by an interdisciplinary short bowel team. METHODS Data were collected for 10 children with infantile SBS (<or=1 year of age) born between 2002 and 2007. Data included demographic and medical data of the first admission and data on resource consumption, growth, and type of nutrition for the total follow-up period. Real economic costs were calculated in Euro (euro) and US dollar ($). RESULTS Seven of the 10 patients were discharged with home parenteral nutrition. Total follow-up varied between 9 months and 5.5 years (median, 1.5 years). Six patients could be weaned off parenteral nutrition and 5 patients off enteral tube feeding, resulting in full oral intake. Seven patients had normal growth. Median duration of initial hospital admission was 174 days, and average costs of initial admission amounted to euro166,045 ($218,681). Average total costs were euro269,700 ($355,195), reaching to a maximum of euro455,400 ($599,762). These costs mainly comprised hospital admissions (82%), followed by nutrition (12%), surgical interventions (5%), and outpatient visits (1%). CONCLUSIONS This study is among the first to describe resource consumption and costs in infants with SBS, examining real economic costs and extending beyond the initial hospitalization. Treatment of SBS requires considerable resource consumption, especially when patients depend on parenteral nutrition. Because the costs mainly comprise those of hospital admissions, early home parenteral nutrition could contribute to costs reduction. Interdisciplinary teams have the potential to facilitate early home parenteral nutrition and thus may reduce health care costs.
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Affiliation(s)
- Joanne F Olieman
- Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Erasmus MC, Rotterdam, The Netherlands.
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110
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Abstract
Pediatric short bowel syndrome (SBS) is most commonly caused by congenital or acquired conditions of the newborn. SBS is associated with an inability of the bowel to adequately absorb water and nutrients in sufficient quantities to meet caloric, fluid, and electrolyte demands, thus necessitating dependence on parenteral nutrition (PN). It is this dependence on PN, that is responsible for the majority of morbidity and mortality associated with SBS, including central venous catheter infections and PN-induced cholestatic liver dysfunction. There are very few estimates of SBS incidence and mortality in the literature. The epidemiology of SBS is reviewed and the limitations of the published literature are discussed.
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Affiliation(s)
- Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), Hospital for Sick Children, Toronto, Ontario, Canada.
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111
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Sigalet DL, Lam V, Boctor D. The assessment, and glucagon-like peptide-2 modulation, of intestinal absorption and function. Semin Pediatr Surg 2010; 19:44-9. [PMID: 20123273 DOI: 10.1053/j.sempedsurg.2009.11.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The treatment of patients with short bowel syndrome is hampered by a lack of treatment and measurement methods. This article reviews our evolving understanding of the role of glucagon-like peptide 2 (GLP-2) in controlling the adaptive process. The ability of the remnant intestine to produce GLP-2 appears to be predictive of the adaptive process; exogenous GLP-2 may be a therapy to augment adaptation. Strategies for monitoring patients, including conventional means, such as anthropomorphic measurements, plasma levels of specific nutrients, and vitamins and radiological contrast studies are reviewed. Investigational methods, such as nutrient balance studies, plasma citrulline levels, and the absorption of inert sugars (3-0 methyl glucose, mannitol, and lactulose) are discussed with the evidence to support their use.
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Affiliation(s)
- David L Sigalet
- Alberta Children's Hospital Intestinal Rehabilitation Program, Alberta Children's Hospital and University of Calgary, Calgary, Alberta, Canada.
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112
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McMellen ME, Wakeman D, Longshore SW, McDuffie LA, Warner BW. Growth factors: possible roles for clinical management of the short bowel syndrome. Semin Pediatr Surg 2010; 19:35-43. [PMID: 20123272 PMCID: PMC2891767 DOI: 10.1053/j.sempedsurg.2009.11.010] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The structural and functional changes during intestinal adaptation are necessary to compensate for the sudden loss of digestive and absorptive capacity after massive intestinal resection. When the adaptive response is inadequate, short bowel syndrome (SBS) ensues and patients are left with the requirement for parenteral nutrition and its associated morbidities. Several hormones have been studied as potential enhancers of the adaptation process. The effects of growth hormone, insulin-like growth factor-1, epidermal growth factor, and glucagon-like peptide 2 on adaptation have been studied extensively in animal models. In addition, growth hormone and glucagon-like peptide 2 have shown promise for the treatment of SBS in clinical trials in human beings. Several lesser studied hormones, including leptin, corticosteroids, thyroxine, testosterone, and estradiol, are also discussed.
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Affiliation(s)
- Mark E. McMellen
- Division of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - Derek Wakeman
- Division of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - Shannon W. Longshore
- Department of Surgery, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Lucas A. McDuffie
- School of Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Brad W. Warner
- Division of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO, USA,Correspondence: Brad W. Warner, MD Division of Pediatric Surgery St. Louis Children's Hospital, One Children's Place Suite 5S40, St. Louis, MO 63110 Tel.: 1 314 454 6022 Fax: 1 314 454 2442
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113
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Abstract
The management of the child with intestinal failure is complex, and it is developing into a multispecialty field of its own led by expert teams of both transplant and nontransplant surgeons, gastroenterologists, and dieticians. Patients are at risk for medical, surgical, and nutritional complications that should be anticipated so that they can be prevented or managed appropriately. Catheter associated infections and intestinal failure associated liver diseases are important complications that impact the likelihood of bowel adaptation and long-term survival. The clinical assessment of a pediatric intestinal failure patient should include evaluation of the child within the context of recognized prognostic factors.
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Affiliation(s)
- Jason S Soden
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Colorado Denver School of Medicine and The Children's Hospital, Aurora, Colorado 80045, USA.
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114
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Abstract
Only 50 years ago intestinal failure was considered incompatible with life. Since then, developments in parenteral nutrition, and, more recently, small intestinal transplantation, have provided new therapeutic options with the potential to offer long-term survival with a good quality of life. Current medical and surgical strategies are aimed at enhancing intestinal adaptation, improving absorption to achieve nutritional independence, and minimizing the complications of parenteral nutrition therapy. An integrated, multidisciplinary approach to the management of patients with intestinal failure, closely linked to a transplantation program to facilitate early referral, is recognized as a key factor in optimizing patient outcomes.
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Affiliation(s)
- Julie E Bines
- Department of Pediatrics, University of Melbourne, Flemington Road, Parkville, Vic. 3052, Australia.
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115
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Abstract
Intestinal failure (IF) is the ultimate malabsorption state, with multiple causes, requiring long-term therapy with enteral or intravenous fluids and nutrient supplements. The primary goal during management of children with potentially reversible IF is to promote intestinal autonomy while supporting normal growth, nutrient status, and preventing complications from parenteral nutrition therapy. This article presents how an improved understanding of digestive pathophysiology is essential for diagnosis, successful management, and prevention of nutrient deficiencies in children with IF.
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116
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Advances in the nontransplant medical and surgical management of intestinal failure. Curr Opin Organ Transplant 2009; 14:274-9. [DOI: 10.1097/mot.0b013e32832b1033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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