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Contreras-Ramírez MM, Giraldo-Villa A, Henao-Roldan C, Martínez-Volkmar MI, Valencia-Quintero AF, Montoya-Delgado DC, Ruiz-Navas P, García-Loboguerrero F. Progression in children with intestinal failure at a referral hospital in Medellín, Colombia. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2016; 81:21-7. [PMID: 26832759 DOI: 10.1016/j.rgmx.2015.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 12/03/2015] [Accepted: 12/10/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients with intestinal failure are unable to maintain adequate nutrition and hydration due to a reduction in the functional area of the intestine. Different strategies have the potential to benefit these patients by promoting intestinal autonomy, enhancing quality of life, and increasing survival. AIMS To describe the clinical characteristics of children with intestinal failure and disease progression in terms of intestinal autonomy and survival. MATERIALS AND METHODS A retrospective study was conducted, evaluating 33 pediatric patients with intestinal failure that were hospitalized within the time frame of December 2005 and December 2013 at a tertiary care referral center. Patient characteristics were described upon hospital admission, estimating the probability of achieving intestinal autonomy and calculating the survival rate. RESULTS Patient median age upon hospital admission was 2 months (interquartile range [IQR]: 1-4 months) and 54.5% of the patients were boys. Intestinal autonomy was achieved in 69.7% of the cases with a median time of 148 days (IQR: 63 - 431 days), which decreased to 63 days in patients with a spared ileocecal valve. Survival was 91% during a median follow-up of 281 days (IQR: 161 - 772 days). CONCLUSIONS Medical management of patients with intestinal failure is complex. Nutritional support and continuous monitoring are of the utmost importance and long-term morbidity and mortality depends on the early recognition and management of the associated complications.
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Affiliation(s)
- M M Contreras-Ramírez
- Grupo de Soporte Nutricional Pediátrico, Hospital Pablo Tobón Uribe, Medellín, Colombia.
| | - A Giraldo-Villa
- Epidemiología, Grupo de Soporte Nutricional Pediátrico, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - C Henao-Roldan
- Nutrición infantil, Grupo de Soporte Nutricional Pediátrico, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - M I Martínez-Volkmar
- Cuidado al niño en estado crítico de salud, Grupo de Soporte Nutricional Pediátrico, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - A F Valencia-Quintero
- Grupo de Soporte Nutricional Pediátrico, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - D C Montoya-Delgado
- Grupo de Soporte Nutricional Pediátrico, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - P Ruiz-Navas
- Grupo de Soporte Nutricional Pediátrico, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - F García-Loboguerrero
- Cuidado intensivo, Grupo de Soporte Nutricional Pediátrico, Hospital Pablo Tobón Uribe, Medellín, Colombia
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152
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Kong W, Wang J, Ying R, Li Y, Jin H, Mao Q, Yao D, Guo M. A potential anatomic subtype of short bowel syndrome: a matched case-control study. BMC Gastroenterol 2016; 16:12. [PMID: 26822147 PMCID: PMC4731974 DOI: 10.1186/s12876-016-0425-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 01/25/2016] [Indexed: 12/13/2022] Open
Abstract
Background Fundamental researches suggest that ileum presents greater adaptive potential than the jejunum. However, few studies estimate the association between ileum and adaptive potential in human. To discover the association, we conducted this matched case-control study. Methods A 1:2 pair-matched, case-control study was conducted from January 1, 2001 to January 1, 2015 in Intestinal Rehabilition and Transplant Center. The case group was ileum predominated (IP) group and the control group was jejunum predominated (JP) group. Demographic data, medical history and progression of each patient were collected. Results There were 24 IP cases and 48 JP controls in this study. The cumulative probabilities of parenteral nutrition (PN) weaning in IP group were higher than that in JP group. The Bristol stool scale scores of IP group were lower than that of JP group at third month. The Cox proportional hazards regression model confirmed that IP had a higher odds of PN weaning (OR = 2.69; 95 % CI: 1.27, 5.70, p = 0.01) as compared with JP group. The conditional logistic regression with 1:2 matching also confirmed IP group had a higher odds (OR = 4.84; 95 % CI: 2.02, 11.56, p <0.01). Conclusions Our results indicated that ileum presents greater adaptive potential than the jejunum in nutrition and fluid absorption. And a potential anatomic subtype of short bowel syndrome was proposed. Further research need to be conducted to more fully understand the adaptive potential of ileum besides nutrition and fluid absorption.
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Affiliation(s)
- Wencheng Kong
- Department of Gastroenterological Surgery, Hangzhou First People's Hospital, School of Clinical Medicine, Nanjing Medical University, Hangzhou, 310006, China
| | - Jian Wang
- Intestinal Rehabilition and Transplant Center, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, 210002, China
| | - Rongchao Ying
- Department of Gastroenterological Surgery, Hangzhou First People's Hospital, School of Clinical Medicine, Nanjing Medical University, Hangzhou, 310006, China
| | - Yousheng Li
- Intestinal Rehabilition and Transplant Center, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, 210002, China. .,Department of Surgery, Jinling Hospital, School of Medicine, Nanjing University, 305 East Zhongshan Road, Nanjing, 210002, China.
| | - Huicheng Jin
- Department of Gastroenterological Surgery, Hangzhou First People's Hospital, School of Clinical Medicine, Nanjing Medical University, Hangzhou, 310006, China
| | - Qi Mao
- Intestinal Rehabilition and Transplant Center, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, 210002, China
| | - Danhua Yao
- Intestinal Rehabilition and Transplant Center, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, 210002, China
| | - Mingxiao Guo
- Department of Gastroenterological Surgery, Linyi People's Hospital, Shandong, 276000, China
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153
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Recent Advances in the Management of Pediatric Short Bowel Syndrome: An Integrative Review of the Literature. CURRENT SURGERY REPORTS 2016. [DOI: 10.1007/s40137-015-0126-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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154
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Contreras-Ramírez M, Giraldo-Villa A, Henao-Roldan C, Martínez-Volkmar M, Valencia-Quintero A, Montoya-Delgado D, Ruiz-Navas P, García-Loboguerrero F. Progression in children with intestinal failure at a referral hospital in Medellín, Colombia. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2016. [DOI: 10.1016/j.rgmxen.2016.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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155
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Magkos F, Bradley D, Eagon JC, Patterson BW, Klein S. Effect of Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding on gastrointestinal metabolism of ingested glucose. Am J Clin Nutr 2016; 103:61-5. [PMID: 26607940 PMCID: PMC4691669 DOI: 10.3945/ajcn.115.116111] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 10/09/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Data from studies conducted in animal models suggest that intestinal glucose uptake and metabolism are upregulated after Roux-en-Y gastric bypass (RYGB) surgery, which contributes to a weight-loss-independent improvement in glycemic control. OBJECTIVE We conducted a cohort study to evaluate whether an increase in gastrointestinal metabolism of ingested glucose occurs in obese people who underwent RYGB compared with those who underwent laparoscopic adjustable gastric banding (LAGB). DESIGN A mixed meal containing stable isotope-labeled glucose was used to determine the gastrointestinal (small intestine and liver) retention, and presumably metabolism, of ingested glucose in obese subjects before and after matched weight loss (∼21%) induced by RYGB (n = 16) or LAGB (n = 9). RESULTS The total percentage of ingested glucose that appeared in the systemic circulation was slightly lower after than before RYGB (85% ± 9% and 90% ± 8%, respectively) but was slightly higher after than before LAGB (89% ± 3% and 85% ± 4%, respectively) (P-interaction < 0.05). Accordingly, gastrointestinal clearance of ingested glucose (cumulative percentage cleared over 6 h postprandially) increased after RYGB (from 10% ± 8% before to 15% ± 9% after surgery) but decreased after LAGB (from 15% ± 4% before to 11% ± 3% after surgery) (P < 0.05). Surgery-induced weight loss caused a similar decrease in the 6-h postprandial plasma glucose area under the curve in both RYGB and LAGB groups (-4% ± 9% and -6% ± 5%, respectively; P = 0.475). CONCLUSIONS These data support the notion that intestinal glucose disposal increases after RYGB surgery. However, the magnitude of the effect was small and did not result in weight-loss-independent therapeutic effects on postprandial glycemic control. This trial was registered at clinicaltrials.gov as NCT00981500.
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Affiliation(s)
- Faidon Magkos
- Center for Human Nutrition and Atkins Center of Excellence in Obesity Medicine, Washington University School of Medicine, St. Louis, MO; Singapore Institute for Clinical Sciences, Agency for Science, Technology, and Research (A*STAR), and Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - David Bradley
- Center for Human Nutrition and Atkins Center of Excellence in Obesity Medicine, Washington University School of Medicine, St. Louis, MO
| | - J Christopher Eagon
- Center for Human Nutrition and Atkins Center of Excellence in Obesity Medicine, Washington University School of Medicine, St. Louis, MO
| | - Bruce W Patterson
- Center for Human Nutrition and Atkins Center of Excellence in Obesity Medicine, Washington University School of Medicine, St. Louis, MO
| | - Samuel Klein
- Center for Human Nutrition and Atkins Center of Excellence in Obesity Medicine, Washington University School of Medicine, St. Louis, MO;
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156
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Autologous Reconstruction and Visceral Transplantation for Management of Patients With Gut Failure After Bariatric Surgery. Ann Surg 2015; 262:586-601. [DOI: 10.1097/sla.0000000000001440] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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157
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Naberhuis JK, Deutsch AS, Tappenden KA. Teduglutide-Stimulated Intestinal Adaptation Is Complemented and Synergistically Enhanced by Partial Enteral Nutrition in a Neonatal Piglet Model of Short Bowel Syndrome. JPEN J Parenter Enteral Nutr 2015; 41:853-865. [PMID: 26304601 DOI: 10.1177/0148607115602891] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Teduglutide, a glucagon-like peptide-2 (GLP-2) analogue, is available for long-term use by parenteral nutrition (PN)-dependent adults to promote intestinal adaptation but is not approved for use in pediatric patients. The objective of this study was to assess teduglutide-stimulated induced intestinal adaptation, potential synergies with partial enteral nutrition (PEN), and distinct temporal markers of adaptation in a neonatal piglet model of short bowel syndrome (SBS). MATERIALS AND METHODS Neonatal piglets (48 hours old; n = 72) underwent an 80% jejunoileal resection and were randomized to 1 of 4 treatment groups, in a 2 × 2 factorial design, with PN or PEN (80% standard PN/20% standard enteral nutrition) and teduglutide (0.1 mg/kg/d) or control. Piglets received nutrient infusions for 4 hours, 48 hours, or 7 days. RESULTS Teduglutide improved ( P < .05) mucosal surface area (villus height: duodenum, jejunum, ileum; crypt depth: ileum, colon; proliferation: duodenum, jejunum, ileum; colon; apoptosis: jejunum, ileum, colon) and acute nutrient processing capacity (glucose: duodenum, jejunum, ileum; glutamine: duodenum, jejunum). These effects were complemented and synergistically enhanced by PEN in both site and timing of action. Structural adaptations preceded functional adaptations, but crypt depth remained a strong indicator of adaptation, regardless of time. CONCLUSIONS The combination of teduglutide and PEN enhances intestinal adaptation beyond that of either therapy alone.
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Affiliation(s)
- Jane K Naberhuis
- 1 Division of Nutritional Sciences, University of Illinois, Urbana, Illinois, USA
| | - Andrew S Deutsch
- 1 Division of Nutritional Sciences, University of Illinois, Urbana, Illinois, USA
| | - Kelly A Tappenden
- 1 Division of Nutritional Sciences, University of Illinois, Urbana, Illinois, USA.,2 Department of Food Science and Human Nutrition, University of Illinois, Urbana, Illinois, USA
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158
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Seidner DL, Joly F, Youssef NN. Effect of Teduglutide, a Glucagon-like Peptide 2 Analog, on Citrulline Levels in Patients With Short Bowel Syndrome in Two Phase III Randomized Trials. Clin Transl Gastroenterol 2015; 6:e93. [PMID: 26111125 PMCID: PMC4816243 DOI: 10.1038/ctg.2015.15] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2015] [Indexed: 12/15/2022] Open
Abstract
Objectives: In clinical trials, treatment with the glucagon-like peptide 2 analog teduglutide was associated with improved fluid and nutrient absorption and increased intestinal villus height and crypt depth in patients with short bowel syndrome (SBS). Plasma citrulline, an amino acid produced by enterocytes, is considered a measure of enterocyte mass. This analysis assessed changes in plasma citrulline levels in patients with SBS in 2 phase III clinical studies of teduglutide. Methods: Both teduglutide studies (0.05 or 0.10 mg/kg/day in CL0600-004 and 0.05 mg/kg/day in CL0600-020) were phase III, 24-week, double-blind, and placebo controlled. Plasma citrulline levels were analyzed and validated by liquid chromatography coupled to tandem mass spectrometry. Results: In both the CL0600-004 and CL0600-020 studies, change in mean plasma citrulline concentrations at Week 24 vs. baseline was significantly greater with teduglutide compared with placebo (10.9 (0.05-mg/kg/day dose) and 15.7 (0.10-mg/kg/day dose) vs. 2.0 μmol/L and 20.6 vs. 0.7 μmol/L, respectively, for each study (P≤0.0001 for each comparison with placebo)). Teduglutide treatment was associated with reductions from baseline in PS (parenteral support) volume requirements; however, a significant correlation between PS reduction and increase in plasma citrulline at Week 24 was observed in only one out of the three teduglutide treatment groups. Conclusions: In 2 phase III studies, patients receiving teduglutide had significant increases in plasma citrulline at Week 24 compared with patients receiving placebo. Increases in plasma citrulline concentrations likely reflect enterocyte mass expansion, but no clear correlation was detected between change in plasma citrulline and change in weekly PS volume.
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Affiliation(s)
- Douglas L Seidner
- 1] Vanderbilt Center for Human Nutrition, Nashville, TN, USA [2] Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Francisca Joly
- Gastrointestinal and Metabolic Dysfunctions in Nutritional Pathologies, Inserm UMR 1149, Centre de Recherche sur l'Inflammation Paris Montmartre UFR de Médecine Paris Diderot, Paris, France
| | - Nader N Youssef
- Clinical Research and Development, NPS Pharmaceuticals, Bedminster, NJ, USA
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159
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Pakarinen MP. Autologous intestinal reconstruction surgery as part of comprehensive management of intestinal failure. Pediatr Surg Int 2015; 31:453-64. [PMID: 25820764 DOI: 10.1007/s00383-015-3696-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2015] [Indexed: 12/21/2022]
Abstract
Pediatric intestinal failure (IF) remains to be associated with significant morbidity and mortality, the most frequent underlying etiologies being short bowel syndrome (SBS), and primary motility disorders. Management aims to assure growth and development, while preventing complications and facilitating weaning off parenteral support (PS) by fully utilizing adaptation potential of the remaining gut. Probability of survival and weaning off PS is improved by coordinated multidisciplinary intestinal rehabilitation combining individualized physiological enteral and parenteral nutrition (PN), meticulous central line care and medical management with carefully planned surgical care. Increasing evidence suggests that autologous intestinal reconstruction (AIR) surgery is effective treatment for selected short bowel patients. Bowel lengthening procedures normalize pathological adaptation-associated short bowel dilatation with potential to support intestinal absorption and liver function by various mechanisms. Although reversed small intestinal segment, designed to prolong accelerated intestinal transit, improves absorption in adult SBS, its feasibility in children remains unclear. Controlled bowel obstruction to induce dilatation followed by bowel lengthening aims to gain extra length in patients with the shortest duodenojejunal remnant. Reduced PS requirement limits the extent of complications, improving prognosis and quality of life. The great majority of children with SBS can be weaned from PS while prognosis of intractable primary motility disorders remains poor without intestinal transplantation, which serves as a salvage therapy for life-threatening complications such as liver failure, central vein thrombosis or recurrent bloodstream infections.
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Affiliation(s)
- Mikko P Pakarinen
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group Helsinki, Children's Hospital, University of Helsinki and Helsinki University Hospital, Stenbackinkatu 11, Po Box 281, 00029 HUS, Helsinki, Finland,
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160
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Abu-Elmagd K. The concept of gut rehabilitation and the future of visceral transplantation. Nat Rev Gastroenterol Hepatol 2015; 12:108-20. [PMID: 25601664 DOI: 10.1038/nrgastro.2014.216] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In the 1990s, the introduction of visceral transplantation fuelled interest in other innovative therapeutic modalities for gut rehabilitation. Ethanol lock and omega-3 lipid formulations were introduced to reduce the risks associated with total parenteral nutrition (TPN). Autologous surgical reconstruction and bowel lengthening have been increasingly utilized for patients with complex abdominal pathology and short-bowel syndrome. Glucagon-like peptide 2 analogue, along with growth hormone, are available to enhance gut adaptation and achieve nutritional autonomy. Intestinal transplantation continues to be limited to a rescue therapy for patients with TPN failure. Nonetheless, survival outcomes have substantially improved with advances in surgical techniques, immunosuppressive strategies and postoperative management. Furthermore, both nutritional autonomy and quality of life can be restored for more than two decades in most survivors, with social support and inclusion of the liver being favourable predictors of long-term outcome. One of the current challenges is the discovery of biomarkers to diagnose early rejection and further improve liver-free allograft survival. Currently, chronic rejection with persistence of preformed and development of de novo donor-specific antibodies is a major barrier to long-term graft function; this issue might be overcome with innovative immunological and tolerogenic strategies. This Review discusses advances in the field of gut rehabilitation, including intestinal transplantation, and highlights future challenges. With the growing interest in individualized medicine and the value of health care, a novel management algorithm is proposed to optimize patient care through an integrated multidisciplinary team approach.
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Affiliation(s)
- Kareem Abu-Elmagd
- Transplant Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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161
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Vipperla K, O'Keefe SJ. Targeted therapy of short-bowel syndrome with teduglutide: the new kid on the block. Clin Exp Gastroenterol 2014; 7:489-95. [PMID: 25525380 PMCID: PMC4266252 DOI: 10.2147/ceg.s42665] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Extensive intestinal resection impairs the absorptive capacity and results in short-bowel syndrome-associated intestinal failure (SBS-IF), when fluid, electrolyte, acid-base, micro-, and macronutrient homeostasis cannot be maintained on a conventional oral diet. Several factors, including the length and site of the resected intestine, anatomical conformation of the remnant bowel, and the degree of postresection intestinal adaptation determine the disease severity. While mild SBS patients achieve nutritional autonomy with dietary modification (eg, hyperphagia, small frequent meals, and oral rehydration fluids), those with moderate-to-severe disease may develop SBS-IF and become dependent on parenteral support (PS) in the form of intravenous fluids and/or nutrition for sustenance of life. SBS-IF is a chronic debilitating disease associated with a poor quality of life, and carries significant morbidity and health care costs. Medical management of SBS-IF is primarily focused on individually tailored symptomatic treatment strategies, such as antisecretory and antidiarrheal agents to mitigate fluid losses, and PS. However, PS administration is associated with potentially life-threatening complications, such as central venous thromboses, bloodstream infections, and liver disease. In pursuit of a targeted therapy to augment intestinal adaptation, research over the past 2 decades has identified glucagon-like peptide, an intestinotrophic gut peptide that has been shown to enhance intestinal absorptive capacity by causing an increase in the villus length, crypt depth, and mesenteric blood flow and by decreasing gastrointestinal motility and secretions. Teduglutide, a recombinant analog of glucagon-like peptide-2, is the first targeted therapeutic agent to gain approval for use in adult SBS-IF. Teduglutide was shown to result in significant (20%–100%) reduction in PS-volume requirement and have a satisfactory safety profile in three randomized control trials. Further research is warranted to see if reduction in PS dependency translates to improved quality of life and reduced PS-associated complications.
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Affiliation(s)
- Kishore Vipperla
- Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Stephen J O'Keefe
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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162
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Lim DW, Turner JM, Wales PW. Emerging Piglet Models of Neonatal Short Bowel Syndrome. JPEN J Parenter Enteral Nutr 2014; 39:636-43. [PMID: 25293943 DOI: 10.1177/0148607114554621] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 09/15/2014] [Indexed: 12/19/2022]
Abstract
Short bowel syndrome (SBS) is a growing problem in the human neonatal population. In infants, SBS is the leading cause of intestinal failure, the state of being unable to absorb sufficient nutrients for growth and development. Neonates with SBS are dependent on long-term parenteral nutrition therapy, but many succumb to the complications of sepsis and liver disease. Research in neonatal SBS is challenged by the ethical limits of studying sick human neonates and the heterogeneous nature of the disease process. Outcomes in SBS vary depending on residual intestinal anatomy, intestinal length, patient age, and exposure to nutrition therapies. The neonatal piglet serves as an appropriate translational model of the human neonate because of similarities in gastrointestinal ontogeny, physiological maturity, and adaptive processes. Re-creating the disease process in a piglet model presents a unique opportunity for researchers to discover novel insights and therapies in SBS. Emerging piglet models of neonatal SBS now represent the entire spectrum of disease seen in human infants. This review aims to contextualize these emerging piglet models within the context of SBS as a heterogeneous disease. We first explore the factors that account for SBS heterogeneity and then explore the suitability of the neonatal piglet as an appropriate translational animal model. We then examine differences between the emerging piglet models of neonatal SBS and how these differences affect their translational potential to human neonates with SBS.
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Affiliation(s)
- David W Lim
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada Department of Agricultural, Food & Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - Paul W Wales
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada Department of Surgery, Hospital for Sick Children, and University of Toronto, Toronto, Ontario, Canada
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163
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Jeppesen PB. Pharmacologic options for intestinal rehabilitation in patients with short bowel syndrome. JPEN J Parenter Enteral Nutr 2014; 38:45S-52S. [PMID: 24615689 DOI: 10.1177/0148607114526241] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A primary goal of intestinal rehabilitation programs is to facilitate intestinal adaptation. Adult patients with short bowel syndrome (SBS) who are dependent on parenteral nutrition and/or intravenous fluid (PN/IV) support have 2 hormonal pharmacologic treatment options available that may promote intestinal growth: a glucagon-like peptide 2 analog (teduglutide) and recombinant human growth hormone (somatropin). In two phase III clinical trials (N=169), 24 weeks of teduglutide administered to outpatients with SBS resulted in significant decreases in PN/IV volume requirements of 2.5-4.4 L/wk. In an extension study of one of these trials, patients with SBS who completed 30 months of teduglutide experienced a mean PN/IV reduction of 7.6 L/wk from baseline. Furthermore, some patients achieved independence from PN/IV support. The most common adverse events associated with teduglutide treatment in clinical trials were gastrointestinal symptoms, including abdominal distension, abdominal pain, and nausea. This safety profile is consistent with the associated underlying diseases leading to SBS or the known mechanism of action of teduglutide. A single phase III study (N=41) evaluated the safety and efficacy of a 4-week inpatient course of somatropin in combination with a glutamine-supplemented diet for adults with SBS. Somatropin treatment significantly reduced parenteral support requirements by 1.1 L/d in these patients. The most common adverse events were peripheral edema and musculoskeletal events. Large-scale, long-term follow-up studies of somatropin for SBS have not been conducted. Although treatment for patients with SBS must be individualized, teduglutide and somatropin are positive extensions to existing fluid and nutrient management strategies.
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Affiliation(s)
- Palle B Jeppesen
- Department of Medical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
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164
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Affiliation(s)
- Kenneth J. Storch
- Atlantic Health System’s Metabolic, Weight & Wellness Center at Overlook Medical Center, Summit, New Jersey
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165
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Tappenden KA. Pathophysiology of short bowel syndrome: considerations of resected and residual anatomy. JPEN J Parenter Enteral Nutr 2014; 38:14S-22S. [PMID: 24500909 DOI: 10.1177/0148607113520005] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The human small intestine is organized with a proximal-to-distal gradient of mucosal structure and nutrient processing capacity. However, certain nutrients undergo site-specific digestion and absorption, such as iron and folate in the duodenum/jejunum vs vitamin B12 and bile salts in the ileum. Intestinal resection can result in short bowel syndrome (SBS) due to reduction of total and/or site-specific nutrient processing areas. Depending on the segment(s) of intestine resected, malabsorption can be nutrient specific (eg, vitamin B12 or fat) or sweeping, with deficiencies in energy, protein, and various micronutrients. Jejunal resections are generally better tolerated than ileal resections because of greater postresection adaptive capacity than that of the jejunum. Following intestinal resection, energy scavenging and fluid absorption become particularly important in the colon owing to loss of digestive and absorptive surface area in the resection portion. Resection-induced alterations in enteroendocrine cell abundance can further disrupt intestinal function. For example, patients with end jejunostomy have depressed circulating peptide YY and glucagon-like peptide 2 concentrations, which likely contribute to the rapid intestinal transit and blunted intestinal adaptation observed in this population. SBS-associated pathophysiology often extends beyond the gastrointestinal tract, with hepatobiliary disease, metabolic bone disease, D-lactic acidosis, and kidney stone formation being chronic complications. Clinical management of SBS must be individualized to account for the specific nutrient processing deficit within the remnant bowel and to mitigate potential complications, both inside and outside the gastrointestinal tract.
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Affiliation(s)
- Kelly A Tappenden
- Department of Food Science and Human Nutrition, University of Illinois at Urbana-Champaign, Urbana, Illinois
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166
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Matarese LE, Jeppesen PB, O’Keefe SJD. Short Bowel Syndrome in Adults. JPEN J Parenter Enteral Nutr 2014; 38:60S-64S. [DOI: 10.1177/0148607113518946] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Laura E. Matarese
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, East Carolina University, Greenville, North Carolina, USA
| | - Palle B. Jeppesen
- Department of Medical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
| | - Stephen J. D. O’Keefe
- Department of Medicine, Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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