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Cullis PS, Fouad D, Goldstein AM, Wong KKY, Boonthai A, Lobos P, Pakarinen MP, Losty PD. Major surgical conditions of childhood and their lifelong implications: comprehensive review. BJS Open 2024; 8:zrae028. [PMID: 38776252 PMCID: PMC11110943 DOI: 10.1093/bjsopen/zrae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/18/2023] [Accepted: 01/30/2024] [Indexed: 05/24/2024] Open
Abstract
BACKGROUND In recent decades, the survival of children with congenital anomalies and paediatric cancer has improved dramatically such that there has been a steady shift towards understanding their lifelong health outcomes. Paediatric surgeons will actively manage such conditions in childhood and adolescence, however, adult surgeons must later care for these 'grown-ups' in adulthood. This article aims to highlight some of those rare disorders encountered by paediatric surgeons requiring long-term follow-up, their management in childhood and their survivorship impact, in order that the adult specialist may be better equipped with skills and knowledge to manage these patients into adulthood. METHODS A comprehensive literature review was performed to identify relevant publications. Research studies, review articles and guidelines were sought, focusing on the paediatric management and long-term outcomes of surgical conditions of childhood. The article has been written for adult surgeon readership. RESULTS This article describes the aforementioned conditions, their management in childhood and their lifelong implications, including: oesophageal atresia, tracheo-oesophageal fistula, malrotation, short bowel syndrome, duodenal atresia, gastroschisis, exomphalos, choledochal malformations, biliary atresia, Hirschsprung disease, anorectal malformations, congenital diaphragmatic hernia, congenital lung lesions and paediatric cancer. CONCLUSION The increasing survivorship of children affected by surgical conditions will translate into a growing population of adults with lifelong conditions and specialist healthcare needs. The importance of transition from childhood to adulthood is becoming realized. It is hoped that this timely review will enthuse the readership to offer care for such vulnerable patients, and to collaborate with paediatric surgeons in providing successful and seamless transitional care.
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Affiliation(s)
- Paul S Cullis
- Department of Paediatric Surgery, Royal Hospital for Children Edinburgh, Edinburgh, UK
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Dina Fouad
- Department of Paediatric Surgery, Leicester Children’s Hospital, Leicester, UK
| | - Allan M Goldstein
- Department of Paediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth K Y Wong
- Department of Paediatric Surgery, Queen Mary’s Hospital, University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Ampaipan Boonthai
- Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pablo Lobos
- Department of Paediatric Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mikko P Pakarinen
- The New Children’s Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Women’s and Children’s Health, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, University of Southern Denmark, Odense, Denmark
| | - Paul D Losty
- Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
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2
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Alves VA, Giesta JM, Bosa VL, Goldani HAS. Bioelectrical impedance phase angle and nutritional status in children with intestinal failure on prolonged parenteral nutrition. J Pediatr (Rio J) 2024:S0021-7557(24)00039-1. [PMID: 38614136 DOI: 10.1016/j.jped.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 12/12/2023] [Accepted: 12/16/2023] [Indexed: 04/15/2024] Open
Abstract
OBJECTIVE To compare the phase angle (PhA) through bioelectrical impedance (BIA) of children with intestinal failure (IF) using prolonged parenteral nutrition (PN) followed by an Intestinal Rehabilitation Program, with a control group. METHODS Children under 10 years of age with IF using prolonged PN for >60 days (study group) were included. The control group consisted of healthy children without chronic pathologies, matched by sex and age. Anthropometric parameters evaluated were: weight, height, weight/age z-score (W/A), height/age z-score (H/A), BMI, BMI/A z-score, arm circumference, triceps skinfold, subscapular skinfold, mid-arm muscle circumference. BIA parameters were resistance (R), reactance (Xc), and phase angle (PhA). RESULTS Twenty-eight children were included in the study group, median (IQR) age was 11 (8-27) months, 53.6 % were male. In the control group, 28 children were included, median (IQR) age was 12.5 (8-24.7) months, 50 % were male. Children from the study group had W/A z-scores and H/A z-scores significantly lower than controls. There was no significant difference between PhA in the study group and controls, [median (IQR) 4.3° (3.8;4.6) vs 4.0° (3.8;5.4) respectively, p = 0.980]. Prematurity was significantly higher in the study group than in the controls, but there was no significant correlation between gestational age at birth and PhA of the children from the study group. CONCLUSION Children with IF using prolonged PN showed lower W/A and H/A compared to the control group, but without significant difference between the PhA of children with IF compared to controls.
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Affiliation(s)
- Victória A Alves
- Post-Graduate Program of Child and Adolescent Health, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
| | - Juliana M Giesta
- Post-Graduate Program of Child and Adolescent Health, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Vera L Bosa
- Department of Nutrition, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Helena A S Goldani
- Post-Graduate Program of Child and Adolescent Health, Faculdade de Medicina, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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3
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Mutanen A, Pakarinen MP. Featuring molecular regulation of bile acid homeostasis in pediatric short bowel syndrome. Clin Res Hepatol Gastroenterol 2023; 47:102220. [PMID: 37769812 DOI: 10.1016/j.clinre.2023.102220] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/29/2023] [Accepted: 09/19/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Disturbed bile acid homeostasis may foster development of short bowel syndrome (SBS) associated liver disease during and after weaning off parenteral nutrition (PN). Our aim was to study hepatic molecular regulation of bile acid homeostasis in relation to serum and fecal bile acid profiles in pediatric SBS. METHODS Liver histopathology and mRNA expression of genes regulating synthesis, uptake and export of bile acids, and cellular receptors involved in bile acid signaling were measured in SBS patients (n = 33, median age 3.2 years). Simultaneously, serum (n = 24) and fecal (n = 10) bile acid profiles were assessed. Sixteen patients were currently on PN. Results of patients were compared to healthy control subjects. RESULTS Nine of ten (90 %) patients with histological cholestasis received current PN, while portal inflammation was present in 60 % (6/10) of patients with cholestasis compared to 13 % (3/23) without cholestasis (P = 0.01). In all SBS patients, hepatic synthesis and uptake of bile acids was increased. Patients on current PN showed widespread repression of hepatic FXR target genes, including downregulated canalicular (BSEP, MDR3) and basolateral (MRP3) bile acid exporters. Serum and fecal primary bile acids were increased both during and after weaning off PN. CONCLUSIONS Bile acid homeostasis in SBS is characterized by interrupted enterohepatic circulation promoting increased hepatic synthesis and conservation of bile acids. In PN dependent SBS patients with hepatic cholestasis and inflammation, the molecular fingerprint of downregulated hepatocyte canalicular and basolateral bile acid export with simultaneously increased synthesis and uptake of bile acids could favor their accumulation in hepatocytes and predispose to liver disease.
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Affiliation(s)
- Annika Mutanen
- Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, The New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko P Pakarinen
- Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, The New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.
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4
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Ghidini F, Tognon C, Verlato G, Duci M, Andreetta M, Leon FF, Gamba P. A survival analysis of cuffed tunneled silicon central venous catheters in children affected by short bowel syndrome: A lesson from the past. J Vasc Access 2023; 24:1158-1166. [PMID: 35081815 DOI: 10.1177/11297298211069458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Tunneled central venous catheters (CVC) are crucial in the management of children affected by short bowel syndrome (SBS). This work aims to investigate the outcomes of tunneled CVC and to identify factors influencing their survival. METHODS All the children diagnosed with SBS and undergone a procedure of insertion of a tunneled CVC from 2010 to 2019 were included. Demographic data and surgical information about the procedures were collected. Regression models and Kaplan-Meier analysis were performed to estimate the survival. RESULTS Eighteen patients, eight males (44%), with a median length of residual bowel measuring 72 cm (IQR 50-102 cm), were enrolled. Thirty-nine Broviac CVCs were inserted with a mean number of 2.2 CVCs per patient and 13365 line-days. The overall incidence of complications was 3.2/1000 line-days, and the incidence of central line associated bloodstream infections (CLABSI) was 1.1/1000 line-days. No episode of catheter thrombosis was reported. The median survival was 269 days (IQR 82-1814 days). The survival was negatively influenced by a younger age at insertion (R2 = 0.29; p < 0.001), 2.7 Fr diameter (median survival 76 days; p < 0.001) and the occurrence of complications (median survival 169 days; p = 0.002). The length of residual bowel was a mild risk factor for anticipated removal (OR 1.1; CI95 1.0-1.1; p = 0.05). CONCLUSION CVC-related complications negatively influenced the survival of the line. An elder age at insertion together with a larger CVC diameter increased the survival of the line, while a shorter residual bowel was associated with an anticipated removal due to complications.
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Affiliation(s)
- Filippo Ghidini
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Costanza Tognon
- Pediatric Anesthesiology, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Giovanna Verlato
- Neonatal Intensive Care and Pediatric Nutrition Service, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Miriam Duci
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Marina Andreetta
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Francesco Fascetti Leon
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Piergiorgio Gamba
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
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Mutanen A, Engstrand Lilja H, Wester T, Norrby H, Borg H, Persson S, Bjornland K, Brun AC, Telborn L, Stenström P, Pakarinen MP. A nordic multicenter study on contemporary outcomes of pediatric short bowel syndrome in 208 patients. Clin Nutr 2023; 42:1095-1103. [PMID: 37270343 DOI: 10.1016/j.clnu.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/05/2023] [Accepted: 05/21/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND & AIMS Despite advances in the management of short bowel syndrome related intestinal failure (SBS-IF), large-scale contemporary pediatric studies are scarce. The aim of this multicenter study was to assess key outcomes and clinical prognostic factors in a recent Nordic pediatric SBS-IF population. METHODS Patients with SBS-IF treated during 2010-2019, whose parenteral support (PS) started at age <1 year and continued >60 consecutive days were included and retrospectively reviewed. All six participating centers followed multidisciplinary SBS-IF management. Risk factors for PS dependency, intestinal failure associated liver disease (IFALD) and mortality were assessed with Cox regression and Kaplan Meier analyses. IFALD was defined with serum liver biochemistry levels. RESULTS Among 208 patients, SBS-IF resulted from NEC in 49%, gastroschisis w/wo atresia in 14%, small bowel atresia in 12%, volvulus in 11%, and other diagnoses in 14%. Median age-adjusted small bowel length was 43% (IQR 21-80%). After median follow up of 4.4 years (IQR 2.5-6.9), enteral autonomy was reached by 76%, none had undergone intestinal transplantation, and overall survival was 96%. Half of deaths (4/8) were caused by septic complications. Although biochemical cholestasis occurred only in 3% at latest follow-up and none of deaths were directly caused by IFALD, elevated liver biochemistry (HR 0.136; P = 0.017) and shorter remaining small bowel (HR 0.941; P = 0.040) predicted mortality. Shorter remaining small bowel and colon, and presence of end-ostomy were the main predictors of PS dependency, but not IFALD. Patients with NEC reached enteral autonomy more efficiently and had decreased incidence of IFALD compared to other etiologies. CONCLUSIONS Although with current multidisciplinary management, prognosis of pediatric SBS is encouraging, septic complications and IFALD still associated with the remaining low mortality rate.
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Affiliation(s)
- Annika Mutanen
- Department of Pediatric Surgery, The New Children's Hospital, University of Helsinki, Stenbäckinkatu 9, 00029 HUS, Helsinki, Finland.
| | - Helene Engstrand Lilja
- Department of Pediatric Surgery, University Children's Hospital, Uppsala University, Uppsala, Sweden
| | - Tomas Wester
- Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karoliska Institutet, Stockholm, Sweden
| | - Heimir Norrby
- Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Helena Borg
- Department of Pediatric Surgery, The Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Sara Persson
- Department of Pediatric Surgery, The Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Kristin Bjornland
- Department of Pediatric Surgery, Oslo University Hospital and University of Oslo, Oslo, Norway
| | | | - Lovisa Telborn
- Department of Pediatric Surgery, Skane University Hospital, Lund University, Lund, Sweden
| | - Pernilla Stenström
- Department of Pediatric Surgery, Skane University Hospital, Lund University, Lund, Sweden
| | - Mikko P Pakarinen
- Department of Pediatric Surgery, The New Children's Hospital, University of Helsinki, Stenbäckinkatu 9, 00029 HUS, Helsinki, Finland; Department of Women's and Children's Health, Karoliska Institutet, Stockholm, Sweden
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Zorzetti N, Marino IR, Sorrenti S, Navarra GG, D'Andrea V, Lauro A. Small bowel transplant - novel indications and recent progress. Expert Rev Gastroenterol Hepatol 2023; 17:677-690. [PMID: 37264646 DOI: 10.1080/17474124.2023.2221433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/24/2023] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Advances in the management of intestinal failure have led to a reduction in the number of intestinal transplants. The number of bowel transplants has been mainly stable even though a slight increase has been observed in the last 5 years. AREAS COVERED Standard indication includes patients with a reasonable life expectancy. Recent progress can be deduced by the increased number of intestine transplants in adults: this is due to the continuous improvement of 1-year graft survival worldwide (without differences in 3- and 5-year) associated with better abdominal wall closure techniques. This review aims to provide an update on new indications and changes in trends of pediatric and adult intestine transplantation. This analysis, which stretches through the past 5 years, is based on a collection of related manuscripts from PubMed. EXPERT COMMENTARY Intestinal transplants should be solely intended for a group of individuals for whom indications for transplantation are clear and both medical and surgical rehabilitations have failed. Nevertheless, many protocols developed over the years have not yet solved the key question represented by the over-immunosuppression. Novel indications and recent progress in the bowel transplant field, minimal yet consistent, represent a pathway to be followed.
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Affiliation(s)
- Noemi Zorzetti
- General Surgery, Ospedale Civile "A. Costa", Alto Reno Terme, Bologna, Italy
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Salvatore Sorrenti
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Vito D'Andrea
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Augusto Lauro
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
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Demirok A, Nagelkerke SCJ, Benninga MA, Köglmeier J, Mutanen A, Arnell H, Felcht J, Guimber D, Wahlstedt C, Avitzur Y, Lambe C, Tabbers MM. Development of a core outcome set for pediatric chronic intestinal failure. JPEN J Parenter Enteral Nutr 2023; 47:364-371. [PMID: 36546585 DOI: 10.1002/jpen.2468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND In research on pediatric chronic intestinal failure, heterogeneity in reported definitions and outcomes exists. This leads to a risk of reporting bias and impossibility of evidence synthesis. Also, reported outcomes should be relevant to both healthcare providers and patients and their parents. Therefore, the aim of this study is to create a core outcome set (COS) to be used in studies on pediatric chronic intestinal failure. METHODS Candidate outcomes were selected from a recent systematic review. A three-round Delphi study among key stakeholders and a consensus meeting with an expert panel were undertaken to achieve consensus on the COS. RESULTS Seventy-two stakeholders (79%) completed all three rounds of the Delphi process. Ninety-eight outcomes were assessed, and five new outcomes were added after the first round. Ten outcomes were included in the final COS: weaning from parenteral nutrition, growth, mortality, central line-related infection, central line longevity, sepsis not related to central line infection, central line-related thrombosis, intestinal failure-associated liver disease, (serious) adverse events, and health-related quality of life. CONCLUSION This pediatric chronic intestinal failure COS consists of 10 outcomes important for all key stakeholders. Usage of this set in future research should minimize outcome heterogeneity and enhance the value of evidence synthesis. This will lead to better management in this field of rare gastrointestinal conditions.
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Affiliation(s)
- Aysenur Demirok
- Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam University Medical Center University of Amsterdam, Amsterdam, the Netherlands
| | - Sjoerd C J Nagelkerke
- Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam University Medical Center University of Amsterdam, Amsterdam, the Netherlands
| | - Marc A Benninga
- Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam University Medical Center University of Amsterdam, Amsterdam, the Netherlands
| | - Jutta Köglmeier
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Annika Mutanen
- Department of Pediatric Surgery, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Henrik Arnell
- Pediatric Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Hospital, Karolinska University Hospital and Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Judith Felcht
- Pediatric Surgery, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Dominique Guimber
- Pediatric Gastroenterology, Hepatology and Nutrition, Jeanne de Flandre Hospital, Lille University Hospital, Lille, France
| | - Christina Wahlstedt
- Pediatric Gastroenterology, Hepatology and Nutrition, Astrid Lindgren Children's Hospital, Karolinska University Hospital and Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Cécile Lambe
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, Hôpital Necker-Enfants Malades, Université Paris Cité, Paris, France
| | - Merit M Tabbers
- Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam University Medical Center University of Amsterdam, Amsterdam, the Netherlands
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8
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Gunnar R, Mutanen A, Merras-Salmio L, Pakarinen MP. Histopathological liver steatosis linked with high parenteral glucose and amino acid supply in infants with short bowel syndrome. JPEN J Parenter Enteral Nutr 2023; 47:41-50. [PMID: 35633305 PMCID: PMC10084272 DOI: 10.1002/jpen.2416] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/29/2022] [Accepted: 05/26/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Steatosis is a common feature of intestinal failure-associated liver disease (IFALD) in adult and older pediatric patients receiving long-term parenteral nutrition (PN). There are limited clinical data concerning steatosis in infants with short bowel syndrome (SBS). We investigated early histopathological steatosis and its association to PN. METHODS In this retrospective study, 31 patients with SBS had a diagnostic liver biopsy taken at the median age of 5 (IQR 3-8) months. Follow-up biopsy was available for 24 patients at the median age of 29 (IQR 14-52) months. We evaluated the biopsies for steatosis and other histopathological signs of IFALD and compared results with patient characteristics, PN composition, and liver biochemistry. RESULTS Diagnostic biopsies revealed steatosis in 8 (26%) patients. At the age of 3 months, patients with steatosis had received higher amounts of parenteral glucose: median 15.1 (IQR 12.4-17.2) vs 12.3 (8.7-14.4) g/kg/d (P = 0.04), amino acids: 2.9 (2.5-3.4) vs 2.2 (1.6-2.7) g/kg/d (P = 0.03), and energy: 87 (80-98) vs 73 (54-79) kcal/kg/d (P = 0.01) than those without steatosis. We detected no significant differences in parenteral lipid intake between the groups. Steatosis also associated with increased serum bile acid (P = 0.02), alanine aminotransferase (P = 0.0002), and aspartate aminotransferase (P = 0.001) levels. CONCLUSIONS In this cohort, high parenteral glucose, amino acid, and energy provision associated with liver steatosis in infants with SBS. We recommend monitoring of bile acid and transaminase levels while aiming for PN with balanced macronutrient supply according to current recommendations to protect the liver from steatosis.
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Affiliation(s)
- Riikka Gunnar
- Department of Gastroenterology, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Pediatric Liver and Gut Research Group, New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Annika Mutanen
- Pediatric Liver and Gut Research Group, New Children's Hospital, Helsinki University Hospital, Helsinki, Finland.,Department of Pediatric Surgery, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Laura Merras-Salmio
- Department of Gastroenterology, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Pediatric Liver and Gut Research Group, New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Mikko P Pakarinen
- Pediatric Liver and Gut Research Group, New Children's Hospital, Helsinki University Hospital, Helsinki, Finland.,Department of Pediatric Surgery, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Cerdó T, García-Santos JA, Rodríguez-Pöhnlein A, García-Ricobaraza M, Nieto-Ruíz A, G. Bermúdez M, Campoy C. Impact of Total Parenteral Nutrition on Gut Microbiota in Pediatric Population Suffering Intestinal Disorders. Nutrients 2022; 14:4691. [PMID: 36364953 PMCID: PMC9658482 DOI: 10.3390/nu14214691] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 08/10/2023] Open
Abstract
Parenteral nutrition (PN) is a life-saving therapy providing nutritional support in patients with digestive tract complications, particularly in preterm neonates due to their gut immaturity during the first postnatal weeks. Despite this, PN can also result in several gastrointestinal complications that are the cause or consequence of gut mucosal atrophy and gut microbiota dysbiosis, which may further aggravate gastrointestinal disorders. Consequently, the use of PN presents many unique challenges, notably in terms of the potential role of the gut microbiota on the functional and clinical outcomes associated with the long-term use of PN. In this review, we synthesize the current evidence on the effects of PN on gut microbiome in infants and children suffering from diverse gastrointestinal diseases, including necrotizing enterocolitis (NEC), short bowel syndrome (SBS) and subsequent intestinal failure, liver disease and inflammatory bowel disease (IBD). Moreover, we discuss the potential use of pre-, pro- and/or synbiotics as promising therapeutic strategies to reduce the risk of severe gastrointestinal disorders and mortality. The findings discussed here highlight the need for more well-designed studies, and harmonize the methods and its interpretation, which are critical to better understand the role of the gut microbiota in PN-related diseases and the development of efficient and personalized approaches based on pro- and/or prebiotics.
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Affiliation(s)
- Tomás Cerdó
- Maimonides Institute for Research in Biomedicine of Córdoba (IMIBIC), Reina Sofia University Hospital, University of Córdoba, 14004 Córdoba, Spain
| | - José Antonio García-Santos
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - Anna Rodríguez-Pöhnlein
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - María García-Ricobaraza
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - Ana Nieto-Ruíz
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - Mercedes G. Bermúdez
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - Cristina Campoy
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
- Spanish Network of Biomedical Research in Epidemiology and Public Health (CIBERESP), Granada’s Node, Carlos III Health Institute, Avda. Monforte de Lemos 5, 28028 Madrid, Spain
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10
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Mutanen A, Pöntinen V, Gunnar R, Merras-Salmio L, Pakarinen MP. Efficient achievement of enteral autonomy facilitates resolution of liver injury in necrotizing enterocolitis induced short bowel syndrome. Sci Rep 2022; 12:17516. [PMID: 36266329 PMCID: PMC9584958 DOI: 10.1038/s41598-022-22414-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/14/2022] [Indexed: 01/12/2023] Open
Abstract
Children with short bowel syndrome (SBS) are at high risk for intestinal failure associated liver disease (IFALD). The aim of this retrospective follow-up study was to compare weaning off parenteral nutrition (PN) and IFALD between necrotizing enterocolitis (NEC) and non-NEC induced SBS. Altogether, 77 patients with neonatal SBS treated by our multidisciplinary intestinal failure unit (NEC n = 38, non-NEC SBS n = 39) were included and followed-up at least for 2 years until median age of 10 years (interquartile range, 6.0-16). Occurrence and characteristics of IFALD was assessed with liver biopsies obtained at median age of 3.2 (1.0-6.7) years (n = 62) and serum liver biochemistry. Overall, NEC patients had less end-jejunostomies and autologous intestinal reconstruction surgeries performed compared to non-NEC patients (< 0.05), while remaining small bowel anatomy was comparable between groups. Cumulative weaning off PN was more frequent and duration of PN shorter among NEC patients (P < 0.05). Overall cumulative probability of histological IFALD was lower among NEC patients during whole follow-up period (P = 0.052) and at 10 years (P = 0.024). NEC patients had lower ALT and GGT levels at last follow-up (P < 0.05 for all). In univariate Cox regression analysis, absence of end-jejunostomy, NEC diagnosis, longer remaining small bowel length, multidisciplinary treatment and prematurity were predictive for weaning off PN, while NEC diagnosis and lower birth weight in addition to multidisciplinary care protected from histological IFALD. Neonates with NEC induced SBS reached enteral autonomy earlier than those with non-NEC SBS, which associated with more efficient resolution of histological IFALD among long-term survivors.
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Affiliation(s)
- Annika Mutanen
- grid.7737.40000 0004 0410 2071Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, P.O Box 347, 00029 HUS Helsinki, Finland
| | - Ville Pöntinen
- grid.7737.40000 0004 0410 2071Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, P.O Box 347, 00029 HUS Helsinki, Finland
| | - Riikka Gunnar
- grid.7737.40000 0004 0410 2071Department of Pediatric Gastroenterology, Pediatric Liver and Gut Research Group, Pediatric Research Center, New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Laura Merras-Salmio
- grid.7737.40000 0004 0410 2071Department of Pediatric Gastroenterology, Pediatric Liver and Gut Research Group, Pediatric Research Center, New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko P. Pakarinen
- grid.7737.40000 0004 0410 2071Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, P.O Box 347, 00029 HUS Helsinki, Finland
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11
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Goldani HA, Ceza MR, Godoy LL, Giesta JM, Beier S, Oliveira JG, Nunes DL, Feldens L, Lucena IR, Taniguchi AN, Hallberg SC, Durant D, Boettcher S, Schneider MA, Mello PP, Riberg MG, Signorini AV, Miller C, Santos BL, Silveira CO, Morais MC, Laggazio TV, Costa CC, Kieling CO. Outcomes of the First 54 Pediatric Patients on Long-Term Home Parenteral Nutrition from a Single Brazilian Center. J Pediatr Gastroenterol Nutr 2022; 75:104-109. [PMID: 35578384 PMCID: PMC9236303 DOI: 10.1097/mpg.0000000000003473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 03/28/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Data on multidisciplinary programs dedicated to home parenteral nutrition (HPN) in Latin America are limited. This study describes the results of the first multidisciplinary pediatric intestinal rehabilitation program for HPN at a public tertiary hospital in Brazil. METHODS We retrospectively reviewed patients aged 0-18 years with intestinal failure (IF) who required parenteral nutrition (PN) for >60 days between January/2014 and December/2020. RESULTS Fifty-four patients were discharged on HPN (15 achieved enteral autonomy, 34 continued on HPN at the end of the study, 1 underwent intestinal transplantation, and 4 died). The median (IQR) age at the study endpoint of patients who achieved enteral autonomy was 14.1 (9.7-19) versus 34.7 (20.4-53.9) months in those who did not achieve enteral autonomy. Overall prevalence of catheter-related thrombosis was 66.7% and catheter-related bloodstream infection rate was 0.39/1000 catheter-days. Intestinal failure-associated liver disease (IFALD) was present in 24% of all patients; none of the patients who achieved enteral autonomy had IFALD. All patients showed significant improvement in anthropometric parameters during the HPN period. The sociodemographic characteristics of the patients' family members were mothers less than 20 years old (7.5%), schooling time more than 10 years (55.5%), and household income between 1 and 3 times the minimum wage (64.8%). The 5-year survival rate for HPN is 90%, and 27.7% of patients achieve enteral autonomy. CONCLUSION The treatment of pediatric patients with IF followed by a multidisciplinary pediatric intestinal rehabilitation program with HPN is feasible and safe in the Brazilian public health system.
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Affiliation(s)
- Helena A.S. Goldani
- From the Pediatric Gastroenterology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Child and Adolescent Health, Universidade Federal do Rio Grande do Sul
| | - Marilia R. Ceza
- From the Pediatric Gastroenterology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Liege L. Godoy
- Pediatric Nursing Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Juliana M. Giesta
- Nutrition Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Simone Beier
- Social Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Juliana G. Oliveira
- From the Pediatric Gastroenterology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Daltro L. Nunes
- From the Pediatric Gastroenterology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Leticia Feldens
- Pediatric Surgery Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Iara R.S. Lucena
- Radiology Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | | | - Silvia C. Hallberg
- Psychology Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Daiane Durant
- Pediatric Nursing Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Simone Boettcher
- Pediatric Nursing Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Marcia A. Schneider
- Nutrology Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Patricia P. Mello
- Nutrology Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Mariana G.L. Riberg
- Pharmacy Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Alana V. Signorini
- Speech and Language Therapy Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Cristina Miller
- Physiotherapy Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Berenice L. Santos
- Graduate Program in Child and Adolescent Health, Universidade Federal do Rio Grande do Sul
| | - Claudete O. Silveira
- Administrative Department, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Maira C.M. Morais
- Administrative Department, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Terezinha V. Laggazio
- Administrative Department, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Carla C. Costa
- Social Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Carlos O. Kieling
- From the Pediatric Gastroenterology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
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12
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Catheter-related bloodstream infections in children with intestinal failure: a 6-year review from an intestinal rehabilitation center in China. World J Pediatr 2022; 18:271-277. [PMID: 35211921 DOI: 10.1007/s12519-022-00519-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 01/17/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Children with intestinal failure (IF) have frequent catheter-related bloodstream infections (CRBSIs). This study aimed to analyze the clinical presentation and laboratory parameters of CRBSIs in children with IF. METHODS This 6-year retrospective study was conducted among IF children with CRBSIs at an intestinal rehabilitation center in China. Clinical data were collected, including data of temperature and gastrointestinal symptoms. Blood/catheter culture, fecal tests, and calculation of inflammatory index were performed, which were obtained within 1 week since CRBSI onset. RESULTS Fifty children with 87 CRBSIs were identified, of which there were 17 suspected and 70 confirmed cases. Seventy-two pathogens were cultured from 70 positive blood cultures: 63% were Gram-positive organisms, 23% were Gram-negative organisms, and 11% were fungal organisms. Overall, 48.6% were enteric organisms; 47.2% of bacterial pathogens were consistent between fecal and blood cultures. Moreover, 46.3% fecal routines showed abnormalities including increased white blood cells, occult blood positive and the presence of fat droplets. The consistent symptom at onset of CRBSIs was fever and gastrointestinal symptoms including increased stool output, abdominal distension, or both. C-reactive protein (CRP) and procalcitonin (PCT) were elevated, i.e., 16.5 mg/L [interquartile range (IQR) 8.7-44.7] and 0.48 ng/mL (IQR 0.2-1.76), respectively. CONCLUSIONS IF children had a high rate of CRBSIs, of which larger proportions were due to Gram-positive and enteric organisms. Fever and/or gastrointestinal symptoms, combined with elevated CRP and PCT, is conducive to the early diagnosis of CRBSIs in IF patients.
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13
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Vernon-Roberts A, Lopez RN, Frampton CM, Day AS. Meta-analysis of the efficacy of taurolidine in reducing catheter-related bloodstream infections for patients receiving parenteral nutrition. JPEN J Parenter Enteral Nutr 2022; 46:1535-1552. [PMID: 35233792 PMCID: PMC9541343 DOI: 10.1002/jpen.2363] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/07/2022] [Accepted: 02/28/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Parenteral nutrition administered via central venous catheter is an established treatment option for people with intestinal failure. A serious complication of central venous catheters is the high risk of catheter-related blood stream infections (CRBSI). Catheter locking solutions are one strategy for CRBSI prevention, with the solution taurolidine showing beneficial effects. The aim of this meta-analysis was to identify and synthesize evidence to assess taurolidine efficacy against comparators for the prevention of CRBSI for people with intestinal failure on parenteral nutrition. METHODS Six health literature databases were searched for efficacy data of rate of CRBSI for taurolidine versus control among our study population, no study design limits were applied. Individual study data were presented for the number of CRBSI and catheter days, and rate ratio. Overall data were synthesized as a pooled risk ratio, with sub-group analysis by study design, control type, and taurolidine solution. RESULTS Thirty-four studies were included in the final analysis. At the individual level all studies showed superior efficacy of taurolidine versus control for prevention of CRBSI. When the data were synthesized, the pooled risk ratio was 0.49 (95% CI 0.46 to 0.53, p=<0.0001), indicating a 51% decreased risk of CRBSI through the use of taurolidine. Sub-group analysis showed no difference depending on study design (p=0.23), or control type (p=0.37), and a significant difference for taurolidine type (p=0.0005). CONCLUSION Taurolidine showed superior efficacy over controls regardless of study design or comparator group. The results show that taurolidine provides effective CRBSI reduction for people with intestinal failure on parenteral nutrition. This article is protected by copyright. All rights reserved.
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14
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Merras-Salmio L, Pakarinen MP. Infection Prevention and Management in Pediatric Short Bowel Syndrome. Front Pediatr 2022; 10:864397. [PMID: 35844766 PMCID: PMC9279907 DOI: 10.3389/fped.2022.864397] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 06/10/2022] [Indexed: 12/12/2022] Open
Abstract
Short bowel syndrome (SBS) is a rare disease with potentially life-threatening consequences. In addition to intestinal failure-associated liver disease, infections and other complications related to central venous catheters (CVCs) cause a significant burden to patients with SBS and may even necessitate an intestinal transplant eventually. The need for long-term central venous access and the intestinal dysfunction associated with SBS drive the need for intestinal failure-specific approach to prevent and treat infections in patients with SBS. In bacterial infections, the line can often be salvaged with proficient antibiotic therapy. Repeated catheter replacements are predisposed to recurrent infections and thrombotic complications, which may limit the long-term survival of patients with SBS. Protocol-based CVC access procedures and daily care including taurolidine and ethanol catheter locks have been shown to reduce infection rates substantially. Compromised intestinal function in SBS predisposes to small bowel bacterial overgrowth, mucosal injury, and increased permeability. These pathophysiological changes are concentrated in a subset of patients with excessive bowel dilatation and frequent bowel-derived infections. In such patients, reconstructive intestinal surgery may be indicated. Probiotics have not been effective in infection prevention in SBS and carry a significant risk of complications. While more studies focusing on the prevention of infections and their complications are needed, protocol-based approach and multidisciplinary teams in the care of patients with SBS have been shown to reduce complications and improve outcomes.
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Affiliation(s)
- Laura Merras-Salmio
- Pediatric Gastroenterology Unit, Children's Hospital, Helsinki University Hospital, Helsinki, Finland.,Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Mikko P Pakarinen
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Department of Pediatric Surgery, Children's Hospital, Helsinki University Hospital, Helsinki, Finland
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15
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Jiang W, Chen G, Wang Y, Zhong W, Zhou C, Zhang J, Lv X, Du C, Zhu Z, Geng Q, Tang W. Multi-Center Analysis of Predictive Factors of Enteral Autonomy and Risk Factors of Complications of Pediatric Intestinal Failure in China. Front Pediatr 2022; 10:813865. [PMID: 35186808 PMCID: PMC8848277 DOI: 10.3389/fped.2022.813865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/10/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The aim of this study was to identify predictors for enteral autonomy and intestinal failure (IF)-related complications and evaluate the outcomes of a multi-center pediatric cohort in China. METHODS The medical records of pediatric patients with IF treated at four medical centers in China from January 1, 2012 to November 31, 2020 were retrospectively reviewed. Enteral autonomy was defined as sustained growth and cessation of parenteral nutrition for >90 days. Multivariate logistic regression analysis was used to identify factors predictive of enteral autonomy and the risk factors of complications, such as IF-associated liver disease (IFALD) and catheter-related bloodstream infection (CRBSI). RESULTS The study cohort of 92 pediatric patients with IF included 71 (77%) who underwent surgery and 21 (23%) who received non-surgical treatment. Eventually, 63 (68.5%) patients achieved enteral autonomy by the end of the follow-up period. Multivariate logistic regression analysis indicated that longer duration of parenteral nutrition (PN), sepsis, and non-breastfeeding were risk factors for enteral autonomy. When considering the detailed intraoperative data, the presence of an ileocecal valve (ICV) and greater residual small bowel (RSB) length were reaffirmed as predictors of achieving enteral autonomy. Medium/long-chain (MCT/LCT) lipids or sepsis were identified as negative predictors for IFALD. Univariate analysis revealed that the use of MCT/LCT lipids was associated with a greater likelihood of CRBSI. CONCLUSION In this cohort, enteral autonomy was achieved at a percentage of 68.5%, and the risk factors for not achieving enteral autonomy were a longer duration of PN, sepsis, and non-breastfeeding. The presence of an ICV and a greater RSB length were important predictors of achieving enteral autonomy.
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Affiliation(s)
- Weiwei Jiang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Guanglin Chen
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ying Wang
- Division of Pediatric Gastroenterology and Nutrition, Shanghai Jiaotong University School of Medicine Xinhua Hospital, Shanghai, China
| | - Wei Zhong
- Department of Neonatal Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Chonggao Zhou
- Department of Neonatal Surgery, Hunan Children's Hospital, Changsha, China
| | - Jie Zhang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaofeng Lv
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Chunxia Du
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Zhongxian Zhu
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Qiming Geng
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Weibing Tang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
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16
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Modi BP, Galloway DP, Gura K, Nucci A, Plogsted S, Tucker A, Wales PW. ASPEN definitions in pediatric intestinal failure. JPEN J Parenter Enteral Nutr 2021; 46:42-59. [PMID: 34287974 DOI: 10.1002/jpen.2232] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 11/09/2022]
Abstract
Pediatric intestinal failure (PIF) is a relatively rare disease entity which requires focused interdisciplinary care and specialized nutrition management. There has long been a lack of consensus in the definition of key terms related to PIF due to its rarity and plethora of small studies rather than large trials. As such, the American Society for Parenteral and Enteral Nutrition (ASPEN) Pediatric Intestinal Failure Section, composed of clinicians from a variety of disciplines caring for children with intestinal failure, is uniquely poised to provide insight into this definition void. This document is the product of an effort by the Section to create evidence-based consensus definitions, with the goal of allowing for appropriate comparisons between clinical studies and measurement of longterm patient outcomes. This manuscript was approved by the ASPEN Board of Directors. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Biren P Modi
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David P Galloway
- Division of Gastroenterology, Hepatology and Nutrition, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kathleen Gura
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Anita Nucci
- Department of Nutrition, Georgia State University, Atlanta, Georgia, USA
| | | | - Alyssa Tucker
- Department of Clinical Nutrition, Children's National Medical Center, Washington, District of Columbia, USA
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment, Department of Surgery, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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17
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Sanaksenaho G, Mutanen A, Godbole N, Hukkinen M, Merras-Salmio L, Kivisaari R, Kyrönlahti A, Pihlajoki M, Lohi J, Heikinheimo M, Pakarinen MP. Compromised duodenal mucosal integrity in children with short bowel syndrome after adaptation to enteral autonomy. J Pediatr Surg 2021; 56:966-974. [PMID: 33131778 DOI: 10.1016/j.jpedsurg.2020.09.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/23/2020] [Accepted: 09/21/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Intestinal adaptation has been extensively studied experimentally, but very limited data is available on human subjects. In this study we assessed intestinal adaption in humans with short bowel syndrome (SBS). METHODS We comparatively evaluated mucosal hyperplasia, inflammation, barrier function and nutrient transport using histology, immunohistochemistry and qPCR for selected 52 key genes in duodenal biopsies obtained from children with SBS after weaning off parenteral nutrition (n = 33), and matched controls without intestinal pathology (n = 12). Small bowel dilatation was assessed from contrast small bowel series. RESULTS Duodenal mucosa of SBS children showed increased histologic inflammation of lamina propria (p = 0.033) and mucosal mRNA expression of tumor necrosis factor (p = 0.027), transforming growth factor (TGF)-β2 (p = 0.006) and caveolin-1 (CAV1; p = 0.001). Villus height, crypt depth, enterocyte proliferation, apoptosis and expression of proliferation and nutrient transport genes remained unchanged. Pathologic small bowel dilatation reduced crypt depth (p = 0.045) and downregulated mRNA expression of interleukin (IL)-6 by three-fold (p = 0.008), while correlating negatively with IL6 (r = -0.609, p = 0.004). Loss of ileocecal valve (ICV) upregulated mRNA expression of toll-like receptor 4 (TLR4), TGF-β1, CAV1, several apoptosis regulating genes, and mRNA expression of zonulin (p < 0.05 for all). CONCLUSIONS Despite successful adaptation to enteral autonomy, duodenal mucosa of SBS children displayed histologic and molecular signs of abnormal inflammation and regulation of epithelial permeability, whereas no structural or molecular signs of adaptive hyperplasia or enhanced nutrient transport were observed. Excessive dilatation of the remaining small bowel paralleled impaired duodenal crypt homeostasis, while absence of ICV modified regulation of mucosal inflammation, regeneration and permeability. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Galina Sanaksenaho
- Division of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Annika Mutanen
- Division of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Nimish Godbole
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maria Hukkinen
- Division of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Laura Merras-Salmio
- Department of Pediatric Gastroenterology, Pediatric Liver and Gut Research Group, Children's Hospital, Pediatric Research Centre, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Reetta Kivisaari
- HUS Medical Imaging Center, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Antti Kyrönlahti
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marjut Pihlajoki
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jouko Lohi
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markku Heikinheimo
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko P Pakarinen
- Division of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
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18
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Fatemizadeh R, Gollins L, Hagan J, Debuyserie A, King K, Vogel AM, Van Buren KL, Hair AB, Premkumar MH. In neonatal-onset surgical short bowel syndrome survival is high, and enteral autonomy is related to residual bowel length. JPEN J Parenter Enteral Nutr 2021; 46:339-347. [PMID: 33881791 DOI: 10.1002/jpen.2124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND In an era of improved management and treatment options, this study aims to describe the long-term outcomes and factors predictive of outcomes of neonatal-onset intestinal failure (IF) due to surgical short bowel syndrome (SBS). METHODS Retrospective, single-center cohort study of infants born between January 2011 and December 2018 with inclusion criteria: <44 weeks postmenstrual age at SBS diagnosis, <28 days on admission, parenteral nutrition dependence >60 days, and documented intestinal resection. Primary outcomes included survival and achievement of enteral autonomy (EA). Data analysis utilized Fisher.s exact test, Kruskal-Wallis test, survival analysis methods, Cox proportional hazards regression, linear regression and logistic regression. RESULTS Ninety-five patients (males 56%) were studied with median follow-up of 38 months (IQR 19, 59). Survival at last follow-up was 96%, and EA was achieved in 85%. Forty-eight patients had documented residual bowel length (RBL) with median length of 49 cm (IQR 36, 80). Survival in patients with RBL of <30cm (n = 8), 30-59cm (n = 19), and >60cm (n = 21) was 100%, 95%, and 95% respectively. Shorter RBL was associated with longer time to achieve EA (p = 0.007), but not with survival (p = 0.81). Delay in achieving EA was associated with absence of ileocecal valve (p = 0.002) and bloodstream infections (p < 0.001). Peak conjugated bilirubin correlated with increased mortality (p = 0.002). CONCLUSION Overall high rate of survival and achievement of EA was found in neonatal onset IF due to SBS. EA but not survival was correlated with RBL. Ileocecal valve, bloodstream infections, and conjugated bilirubin levels were the other predictive factors of outcomes.
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Affiliation(s)
- Roxana Fatemizadeh
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Laura Gollins
- Clinical Nutrition Services, Texas Children's Hospital, Houston, Texas, USA
| | - Joseph Hagan
- Section of Neonatal-Perinatal Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Anne Debuyserie
- Section of Neonatal-Perinatal Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Kristi King
- Clinical Nutrition Services, Texas Children's Hospital, Houston, Texas, USA
| | - Adam M Vogel
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Kristin L Van Buren
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Amy B Hair
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Muralidhar H Premkumar
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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19
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Prediction, identification and progression of histopathological liver disease activity in children with intestinal failure. J Hepatol 2021; 74:593-602. [PMID: 33002568 DOI: 10.1016/j.jhep.2020.09.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/22/2020] [Accepted: 09/18/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Diagnostic criteria, progression risk and optimal monitoring for intestinal failure (IF)-associated liver disease (IFALD) remain undefined. We assessed predictors, non-invasive markers and progression of histopathological liver disease in patients with IF. METHODS In total, 77 children with IF and median age of 1.7 years underwent diagnostic liver biopsy, which was repeated in 48 patients after 2.9 years with simultaneous evaluation of liver biochemistry, liver stiffness, serum citrulline (a surrogate for viable enterocyte mass), spleen size, esophageal varices and clinical data. Patients were staged according to histopathological liver disease activity: active IFALD (cholestasis and/or inflammation), chronic IFALD (significant fibrosis and/or steatosis), or no IFALD (none of these features). RESULTS Diagnostic liver biopsy revealed active, chronic or no IFALD in 48%, 21% and 31% of patients. Active IFALD was segregated by low serum citrulline, parenteral nutrition (PN) dependency and young age, while weaning off PN and older age predicted chronic IFALD. Although the liver histopathology in most patients either normalized (52%) or transformed to a less reactive (chronic) disease stage (23%), 19% of patients retained and 6.3% progressed to an active cholestatic/inflammatory IFALD phenotype. Decreased serum citrulline and PN-dependency also predicted active IFALD in follow-up biopsies. Increased median liver biochemistry values and liver stiffness only associated with active IFALD, which was accurately identified by gamma-glutamyltransferase (GGT), citrulline and liver stiffness, their combinations reaching diagnostic and follow-up AUROC values above 0.90. CONCLUSIONS Active IFALD, essentially predicted by intestinal disruption and PN-dependency, was accurately detected by GGT, liver stiffness and citrulline, which together with recent advances in clinical management options, provides new avenues for monitoring and targeted liver protection in patients with IF. LAY SUMMARY Liver disease is a common and critical complication in patients with intestinal failure, who require intravenous nutrition for survival due to severe intestinal dysfunction. We showed that both intravenous nutrition dependency and intestinal disruption essentially predicted development of active histopathological liver disease, which persisted in 25% of patients during long-term follow-up and could be accurately detected without the need for liver biopsy. Identification of the active and potentially progressive histopathology offers new possibilities for monitoring and targeted liver protection in patients with intestinal failure.
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Diamanti A, Calvitti G, Martinelli D, Santariga E, Capriati T, Bolasco G, Iughetti L, Pujia A, Knafelz D, Maggiore G. Etiology and Management of Pediatric Intestinal Failure: Focus on the Non-Digestive Causes. Nutrients 2021; 13:nu13030786. [PMID: 33673586 PMCID: PMC7997222 DOI: 10.3390/nu13030786] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/24/2021] [Indexed: 12/20/2022] Open
Abstract
Background: Intestinal failure (IF) is defined as reduction in functioning gut mass below the minimal amount necessary for adequate digestion and absorption. In most cases, IF results from intrinsic diseases of the gastrointestinal tract (digestive IF) (DIF); few cases arise from digestive vascular components, gut annexed (liver and pancreas) and extra-digestive organs or from systemic diseases (non-digestive IF) (NDIF). The present review revised etiology and treatments of DIF and NDIF, with special focus on the pathophysiological mechanisms, whereby NDIF develops. Methods: We performed a comprehensive search of published literature from January 2010 to the present by selecting the following search strings: “intestinal failure” OR “home parenteral nutrition” OR “short bowel syndrome” OR “chronic pseudo-obstruction” OR “chronic intestinal pseudo-obstruction” OR “autoimmune enteropathy” OR “long-term parenteral nutrition”. Results: We collected overall 1656 patients with well-documented etiology of IF: 1419 with DIF (86%) and 237 with NDIF (14%), 55% males and 45% females. Among DIF cases, 66% had SBS and among NDIF cases 90% had malabsorption/maldigestion. Conclusions: The improved availability of diagnostic and therapeutic tools has increased prevalence and life expectancy of rare and severe diseases responsible for IF. The present review greatly expands the spectrum of knowledge on the pathophysiological mechanisms through which the diseases not strictly affecting the intestine can cause IF. In view of the rarity of the majority of pediatric IF diseases, the development of IF Registries is strongly required; in fact, through information flow within the network, the Registries could improve IF knowledge and management.
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Affiliation(s)
- Antonella Diamanti
- Hepatology Gastroenterology and Nutrition Unit, “Bambino Gesù” Children Hospital, 00165 Rome, Italy; (T.C.); (G.B.); (D.K.); (G.M.)
- Correspondence: ; Tel.: +39-0668592189
| | - Giacomo Calvitti
- Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, 41121 Modena, Italy; (G.C.); (L.I.)
| | - Diego Martinelli
- Metabolic Diseases Unit, “Bambino Gesù” Children Hospital, 00165 Rome, Italy;
| | - Emma Santariga
- Clinical Nutrition Unit, Department of Medical and Surgical Sciences, University Magna Graecia, 88100 Catanzaro, Italy; (E.S.); (A.P.)
| | - Teresa Capriati
- Hepatology Gastroenterology and Nutrition Unit, “Bambino Gesù” Children Hospital, 00165 Rome, Italy; (T.C.); (G.B.); (D.K.); (G.M.)
| | - Giulia Bolasco
- Hepatology Gastroenterology and Nutrition Unit, “Bambino Gesù” Children Hospital, 00165 Rome, Italy; (T.C.); (G.B.); (D.K.); (G.M.)
| | - Lorenzo Iughetti
- Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, 41121 Modena, Italy; (G.C.); (L.I.)
| | - Arturo Pujia
- Clinical Nutrition Unit, Department of Medical and Surgical Sciences, University Magna Graecia, 88100 Catanzaro, Italy; (E.S.); (A.P.)
| | - Daniela Knafelz
- Hepatology Gastroenterology and Nutrition Unit, “Bambino Gesù” Children Hospital, 00165 Rome, Italy; (T.C.); (G.B.); (D.K.); (G.M.)
| | - Giuseppe Maggiore
- Hepatology Gastroenterology and Nutrition Unit, “Bambino Gesù” Children Hospital, 00165 Rome, Italy; (T.C.); (G.B.); (D.K.); (G.M.)
- Medical Sciences Department Ferrara University, 44121 Ferrara, Italy
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Schmidt ML, Wendel D, Horslen SP, Lane ER, Brandão LR, Gottschalk E, Belza C, Courtney-Martin G, Wales PW, Avitzur Y. Secondary Anticoagulation Prophylaxis for Catheter-Related Thrombosis in Pediatric Intestinal Failure: Comparison of Short- Vs Long-Term Treatment Protocols. JPEN J Parenter Enteral Nutr 2020; 45:1432-1440. [PMID: 33616995 DOI: 10.1002/jpen.2055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/11/2020] [Accepted: 11/25/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Catheter-related thrombosis (CRT) is a devastating complication of central venous catheters in children with intestinal failure (IF), but the optimal preventive therapy of CRT is unknown. This study assessed the efficacy and safety of 2 protocols of secondary anticoagulation prophylaxis with low-molecular-weight heparin (LMWH). METHODS This is a comparative cohort study of children from 2 IF programs who received secondary anticoagulation prophylaxis with LMWH for CRT. The short-term protocol group (N = 13) received therapeutic dosing until thrombus resolution or ≤3 months. In the long-term protocol group (N = 26), prophylactic dosing continued until line removal. Patients underwent routine annual vascular ultrasound and were followed for ≥1 year. The primary outcome was development of secondary thrombosis; post hoc analysis assessed rates of secondary thrombosis at 12 months. RESULTS Patient demographics were similar between groups. Secondary thrombosis occurred in 8 of 13 (62%) patients in the short-term group and in 9 of 26 (35%) in the long-term protocol group (P = .019) in a median time of 144.5 and 689 days, respectively (P = .01). Secondary thrombosis within 12 months occurred in 7 of 13 (54%, short term) and 2 of 26 (8%, long term) patients (P = .001). Secondary thrombosis was associated with catheter replacements (23.5 vs 5.5 catheters per 1000 catheter days; P = .016) and longer daily parenteral nutrition (PN) infusion (24 vs 15.25 hours; P = .044). Compliance was good (>80% of doses) in 92% of patients. CONCLUSIONS Long-term secondary anticoagulation prophylaxis with LMWH reduces the incidence of secondary thrombosis and should be considered in children with CRT that require PN for prolonged periods of time.
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Affiliation(s)
- Melanie Lissa Schmidt
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), SickKids Hospital, Toronto, Ontario, Canada.,Lawson Research - Pediatrics, London Health Sciences Centre, London, Ontario, Canada
| | - Danielle Wendel
- Division of Gastroenterology and Hepatology, Seattle Children's, Seattle, Washington, USA
| | - Simon Peter Horslen
- Division of Gastroenterology and Hepatology, Seattle Children's, Seattle, Washington, USA
| | - Erin Richardson Lane
- Division of Gastroenterology and Hepatology, Seattle Children's, Seattle, Washington, USA
| | - Leonardo Rodrigues Brandão
- Division of Hematology and Oncology, Department of Paediatrics, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Emily Gottschalk
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), SickKids Hospital, Toronto, Ontario, Canada
| | - Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), SickKids Hospital, Toronto, Ontario, Canada
| | - Glenda Courtney-Martin
- Group for Improvement of Intestinal Function and Treatment (GIFT), SickKids Hospital, Toronto, Ontario, Canada
| | - Paul William Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), SickKids Hospital, Toronto, Ontario, Canada.,Division of General and Thoracic Surgery, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, SickKids Hospital, University of Toronto, Toronto, Ontario, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), SickKids Hospital, Toronto, Ontario, Canada
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Abstract
OBJECTIVE The aim of the study was to evaluate the outcome and to identify predictors for survival and enteral autonomy in neonatal intestinal failure (IF). METHODS A retrospective observational study in a Swedish tertiary centre of children born between 1995 and 2016 with neonatal IF, defined as dependency on parenteral nutrition (PN) ≥60 days, starting with PN before the age of 44 gestational weeks. Data were extracted from medical records and predictors for survival and enteral autonomy were identified by the Cox regression model. Time to death and weaning off PN analysis were performed with Kaplan-Meier curves including log rank test. RESULTS In total, 105 children were included. Median gestational age was 28 weeks (22-42), 50% were born extremely preterm (<28 gestational weeks). PN started at a median age of 2 days (0-147) with a median duration of 196 days (60-3091). Necrotizing enterocolitis was the dominating cause of IF (61%). Overall survival was 88%, 5 children died of sepsis and 4 of intestinal failure-associated liver disease. Survival increased from 75% during 1995 to 2008 to 96% during 2009 to 2016 (P = 0.0040). Age-adjusted small bowel length of >50% and birth 2009 to 2016 were predictors for survival. Enteral autonomy was achieved in 87%, with positive prediction by small bowel length of >25% of expected for gestational age and remaining ileocecal valve. CONCLUSIONS Preterm neonates with IF, at high risk of IF-associated morbidity, showed a high overall survival rate. Small-bowel length and being born 2009 to 2016 were predictors for survival and remaining ICV and small-bowel length were predictors for enteral autonomy.
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Yang J, Sun H, Wan S, Mamtawla G, Gao X, Zhang L, Wang X. Prolonged Parenteral Nutrition Is One of the Most Significant Risk Factors for Nosocomial Infections in Adult Patients With Intestinal Failure. Nutr Clin Pract 2020; 35:903-910. [PMID: 32166772 DOI: 10.1002/ncp.10483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Intestinal failure (IF) and its management are associated with an increased likelihood of infectious complications. This study aimed to evaluate the prevalence and potential risk factors for nosocomial infections (NIs) in hospitalized adult patients with IF. METHODS In total, 259 eligible patients with IF admitted to a single clinical nutrition center in a tertiary referral hospital from January 1, 2012, to January 1, 2019, were retrospectively identified. NIs were defined according to the 2008 Centers for Disease Control and Prevention criteria. Univariate and multivariate analyses were performed to identify independent risk factors for NIs. RESULTS The mean age of the study population was 47.0 ± 17.7 years, and 158 (61.0%) were men. The mean body mass index was 16.2 ± 2.9 kg/m2 , and 219 (84.6%) were diagnosed with malnutrition. The prevalence of NIs was 25.5% (113 NIs in 66 patients). The most common NIs were pneumonia (14.3%), bacteremia of unknown origin (13.5%), catheter-related bloodstream infection (5.0%), lower respiratory tract infection (5.0%), surgical site infection (3.9%), and urinary tract infection (1.9%). Multivariate analysis revealed that decreased serum albumin level (odds ratio [OR], 0.884; 95% CI, 0.883-0.978, P < .05), presence of gallbladder stones or cholestasis (OR, 3.144; 95% CI, 1.044-9.464; P < .05), and prolonged parenteral nutrition (PN) use (OR, 1.072; 95% CI, 1.039-1.105; P < .001) were independent predictors for NIs. CONCLUSIONS NIs remain prevalent in hospitalized adult patients with IF. Prolonged PN use was one of the most significant predictors for NIs.
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Affiliation(s)
- Jianbo Yang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P. R. China
| | - Haifeng Sun
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P. R. China
| | - Songlin Wan
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P. R. China
| | - Gulsudum Mamtawla
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P. R. China
| | - Xuejin Gao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P. R. China
| | - Li Zhang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P. R. China
| | - Xinying Wang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P. R. China
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Management of Five Hundred Patients With Gut Failure at a Single Center: Surgical Innovation Versus Transplantation With a Novel Predictive Model. Ann Surg 2020; 270:656-674. [PMID: 31436550 DOI: 10.1097/sla.0000000000003523] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE(S) To define the evolving role of integrative surgical management including transplantation for patients gut failure (GF). METHODS A total of 500 patients with total parenteral nutrition-dependent catastrophic and chronic GF were referred for surgical intervention particularly transplantation and comprised the study population. With a mean age of 45 ± 17 years, 477 (95%) were adults and 23 (5%) were children. Management strategy was guided by clinical status, splanchnic organ functions, anatomy of residual gut, and cause of GF. Surgery was performed in 462 (92%) patients and 38 (8%) continued medical treatment. Definitive autologous gut reconstruction (AGR) was achievable in 378 (82%), primary transplant in 42 (9%), and AGR followed by transplant in 42 (9%). The 84 transplant recipients received 94 allografts; 67 (71%) liver-free and 27 (29%) liver-contained. The 420 AGR patients received a total of 790 reconstructive and remodeling procedures including primary reconstruction, interposition alimentary-conduits, intestinal/colonic lengthening, and reductive/decompressive surgery. Glucagon-like peptide-2 was used in 17 patients. RESULTS Overall patient survival was 86% at 1-year and 68% at 5-years with restored nutritional autonomy (RNA) in 63% and 78%, respectively. Surgery achieved a 5-year survival of 70% with 82% RNA. AGR achieved better long-term survival and transplantation better (P = 0.03) re-established nutritional autonomy. Both AGR and transplant were cost effective and quality of life better improved after AGR. A model to predict RNA after AGR was developed computing anatomy of reconstructed gut, total parenteral nutrition requirements, cause of GF, and serum bilirubin. CONCLUSIONS Surgical integration is an effective management strategy for GF. Further progress is foreseen with the herein-described novel techniques and established RNA predictive model.
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25
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Sanaksenaho G, Mutanen A, Godbole N, Kyrönlahti A, Koivusalo A, Lohi J, Pihlajoki M, Heikinheimo M, Pakarinen MP. Parenteral Nutrition-Dependent Children With Short-Bowel Syndrome Lack Duodenal-Adaptive Hyperplasia but Show Molecular Signs of Altered Mucosal Function. JPEN J Parenter Enteral Nutr 2020; 44:1291-1300. [PMID: 31985858 DOI: 10.1002/jpen.1763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 10/30/2019] [Accepted: 12/04/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although adaptive mucosal growth of the remaining small intestine is an essential compensatory mechanism to bowel resection in experimental short-bowel syndrome (SBS), only scarce clinical data are available. We studied structural and molecular mechanisms of intestinal adaptation in children with SBS. METHODS Fourteen patients, who had been dependent on parenteral nutrition (PN) since neonatal period for a median (interquartile range)1.4 (0.7-6.5) years, were studied at the age of 1.5 (1.0-6.5) years. Median length of remaining small bowel was 33 (12-60) cm, and 6 patients had their ileocecal valve preserved. Six children without gastrointestinal disorders served as age-matched and gender-matched controls. All patients underwent duodenal biopsies. Mucosal microarchitecture, proliferation, apoptosis, inflammation, and epithelial-barrier function were addressed using histology, immunohistochemistry, and quantitative real-time polymerase chain reaction. RESULTS Villus height, crypt depth, enterocyte proliferation, and apoptosis were similar in patients and matched controls. Messenger RNA (mRNA) expression of numerous genes regulating gut epithelial-barrier function (TGFB2, CAV1, CLDN1, MUC2, and NLRC4) was significantly altered. Of various nutrient transporters studied, only expression of SLC2A1 encoding facilitative glucose transporter GLUT1 was increased among patients, whereas RNA expression of genes encoding sodium-dependent glucose, sterol, fatty-acid, and peptide transport remained unchanged. CONCLUSION Duodenal mucosal hyperplasia has a limited role in mediating physiological adaptation following intestinal resection among PN-dependent children with SBS. Further clinical studies addressing functional significance of the observed alterations in mucosal RNA expression are warranted.
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Affiliation(s)
- Galina Sanaksenaho
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Annika Mutanen
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Nimish Godbole
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti Kyrönlahti
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti Koivusalo
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jouko Lohi
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marjut Pihlajoki
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markku Heikinheimo
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko P Pakarinen
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Neonatal Intestinal Failure Is Independently Associated With Impaired Cognitive Development Later in Childhood. J Pediatr Gastroenterol Nutr 2020; 70:64-71. [PMID: 31651669 DOI: 10.1097/mpg.0000000000002529] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The impact of pediatric intestinal failure (IF) on neurodevelopment beyond infancy has not been systematically studied. Our aim was to evaluate cognitive and motor impairment and to identify risk factors for adverse outcomes among children with IF. METHODS We conducted a cross-sectional single-center study at the Helsinki University Children's Hospital. Patients with IF with >60 days of parental nutrition (PN) dependency aged between 3 and 16 years (n = 40) were invited to participate. The cognitive and motor skills were evaluated using validated tests: Wechsler Preschool and Primary Scale of Intelligence, 3rd edition, Wechsler Intelligence Scale for Children, 4th edition, and Movement Assessment Battery for Children, 2nd edition. RESULTS All the patients attending the study tests (n = 30, males = 24) were included. Their median age, gestational age, and birth weight was 7.5 (range 3-16) years, 35 (interquartile range [IQR] 28-38) weeks and 2238 (IQR 1040-3288) grams, respectively. Median duration of PN was 13 (IQR 5-37) months and 9 patients were currently on PN. Median intelligence quotient was 78 (IQR 65-91) and 10 (35%) patients had an intelligence quotient under 70 (-2 standard deviation). Significant motor impairment was detected in 10 patients (36%) and milder difficulties in 8 (28%). Adverse cognitive outcome was associated with neonatal short bowel syndrome, number of interventions under general anesthesia, and length of inpatient status, whereas adverse motor outcome was associated with prematurity. CONCLUSION Clinically significant cognitive and motor impairments are alarmingly common among neonatal patients with IF. We recommend early neurodevelopmental follow-up for all children with IF.
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Abstract
Insufficient absorptive mucosal surface is the fundamental problem in the short bowel state. Intestinal adaptation has been well studied, and it is well recognized that it may lead to dilatation of the bowel with increased thickness of the bowel wall, resulting from both mucosal hypertrophy and hyperplasia. Autologous reconstructive surgery exploits bowel dilatation in short bowel syndrome and maximizes the absorptive potential of the available mucosal surface. Indeed, autologous gastrointestinal reconstructive procedures may be better viewed as optimizing bowel diameter rather than focusing on length, thus allowing better prograde peristalsis and improved contact between luminal nutrients and mucosa, ultimately enhancing absorption.
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Affiliation(s)
- Riccardo Coletta
- Department of Paediatric Surgery, Center for Intestinal Reconstruction and Rehabilitation, Meyer Children's Hospital, Viale Gaetanao Pieraccini. 24, Florence 50139, Italy; School of Environment and Life Science, University of Salford, Salford, UK
| | - Antonino Morabito
- Department of Paediatric Surgery, Center for Intestinal Reconstruction and Rehabilitation, Meyer Children's Hospital, Viale Gaetanao Pieraccini. 24, Florence 50139, Italy; School of Environment and Life Science, University of Salford, Salford, UK; Department of NeuroFarBa, University of Florence, Florence, Italy
| | - Kishore Iyer
- Intestinal Rehabilitation & Transplant Program, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, One Gustave Levy Place, Box 1104, New York, NY 10029, USA.
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Lauro A, Coletta R, Morabito A. Restoring gut physiology in short bowel patients: from bench to clinical application of autologous intestinal reconstructive procedures. Expert Rev Gastroenterol Hepatol 2019; 13:785-796. [PMID: 31282770 DOI: 10.1080/17474124.2019.1640600] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: Short bowel syndrome represents the leading etiology that causes intestinal failure both in children and adults. Total parenteral nutrition support has dramatically improved the prognosis for these patients but, if related irreversible complications occur, the alternative is represented by surgery and/or transplantation. Areas covered: Autologous gastrointestinal reconstructive procedures are a feasible, alternative approach with good long-term outcome data inexperienced surgical centers. Expert opinion: Ongoing innovative efforts have driven the surgical options for successful autologous reconstructive surgery: bowel elongation/tapering techniques (LILT, STEP, and the new SILT) together with the 'reversed bowel segment' procedure are now recognized procedures and all must be tailored to the individual patient needs to obtain the optimal result in terms of enteral autonomy. Background laboratory experimentation with new procedures e.g. options for bowel dilation techniques and distraction-induced enterogenesis, may provide additional management and treatment modalities.
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Affiliation(s)
- Augusto Lauro
- a Emergency General Surgery, St. Orsola University Hospital-Alma Mater Studiorum , Bologna , Italy
| | - R Coletta
- b Department of Pediatric Surgery, Pediatric Autologous Bowel Reconstruction, Rehabilitation & Regenerative Medicine Unit, Meyer Children's Hospital , Florence , Italy.,c Department of NEUROFABRA, University of Florence , Florence , Italy
| | - A Morabito
- b Department of Pediatric Surgery, Pediatric Autologous Bowel Reconstruction, Rehabilitation & Regenerative Medicine Unit, Meyer Children's Hospital , Florence , Italy.,c Department of NEUROFABRA, University of Florence , Florence , Italy
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Pohju A, Pakarinen MP, Sipponen T. Fragmented management of long-term parenteral support for adult intestinal failure in Finland. Scand J Gastroenterol 2019; 54:414-418. [PMID: 30915863 DOI: 10.1080/00365521.2019.1588370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objectives: Parenteral support (PS) is the first-line therapy for intestinal failure (IF). Optimal patient outcomes require experienced multidisciplinary teams adhering to structured protocols. As practices to provide long-term PS for adult IF patients in Finland are unknown, this cross-sectional nationwide study aimed to evaluate current management of PS for adult IF across the country. Materials and methods: An internet-based survey was emailed to all Finnish hospitals and hospital-at-home services with the potential to provide PS for adult IF. The survey included 20 items addressing the provision of long-term PS for adult IF patients (aged ≥18 years). Data were analysed using descriptive statistics. Results: Overall, 52 (47%) of the 111 identified units responded. Of responding units, 38 (73%) had at some point provided long-term (≥120 days) PS for adult IF, and 23 (44%) had done so during the preceding year. Only three units currently managed ≥3 adult patients. Most (65%) of the respondents worked in a hospital and were either physicians (38%) or dietitians (39%). Only 65% of respondents reported that their unit had an assigned physician responsible for PS provision, and 28% reported that a team was responsible for long-term PS. Only 26% of respondents reported having a written protocol to guide PS management. Conclusions: Health care providers with very limited experience and a fragmented approach manage most Finnish adult IF patients. Evidence-based protocols and multidisciplinary teams are scarce. The care for adult IF patients on long-term PS needs to be improved in Finland.
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Affiliation(s)
- Anne Pohju
- a Clinical Nutrition Unit, Internal Medicine and Rehabilitation , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Mikko P Pakarinen
- b Section of Pediatric Surgery, Pediatric Liver and Gut Research Group , Children's Hospital, Pediatric Research Center, University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Taina Sipponen
- c Department of Gastroenterology , Abdominal Center, University of Helsinki and Helsinki University Hospital , Helsinki , Finland
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Hukkinen M, Merras-Salmio L, Pakarinen MP. Health-related quality of life and neurodevelopmental outcomes among children with intestinal failure. Semin Pediatr Surg 2018; 27:273-279. [PMID: 30342603 DOI: 10.1053/j.sempedsurg.2018.07.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Treatment results of pediatric intestinal failure have improved markedly during the last decades. With improved survival the attention is turning to other essential outcomes including quality of life and neurodevelopment. So far, relatively few studies with limited number of patients and variable methodology have addressed these issues. Based on these studies using generic health related quality of life tools, children with intestinal failure demonstrate decreased physical health, while PN-dependence is also associated with compromised emotional functioning. Impairments of social functioning are frequently observed among older children and parents. Few recent studies on neurodevelopment imply significant impairments in motor and mental skills among children with intestinal failure despite small sample sizes and limited follow-up times. Development of a disease-specific survey designed for the pediatric intestinal failure population could better reveal the health issues with greatest impact on quality of life. Robust studies with appropriate methodology on neurodevelopment in pediatric intestinal failure with extended follow-up times are urgently needed. Quality of life and neurodevelopment requires greater attention from medical professionals managing children with intestinal failure.
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Affiliation(s)
- Maria Hukkinen
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, P.O. Box 281, 00029 HUS Helsinki, Finland; Section of Pediatric Surgery, Children's Hospital, Helsinki University Hospital, Finland
| | - Laura Merras-Salmio
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, P.O. Box 281, 00029 HUS Helsinki, Finland; Section of Pediatric Gastroenterology, Children's Hospital, Helsinki University Hospital, Finland
| | - Mikko P Pakarinen
- Pediatric Liver and Gut Research Group, Children's Hospital, Helsinki University Hospital, P.O. Box 281, 00029 HUS Helsinki, Finland; Section of Pediatric Surgery, Children's Hospital, Helsinki University Hospital, Finland.
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Abstract
Pediatric intestinal failure is a complex and devastating condition defined as the inability of the intestine to absorb an adequate amount of fluid and nutrients to sustain life. The primary goal of intestinal failure treatment is to achieve enteral autonomy with a customized treatment plan. Although recent improvements in intestinal failure patient care have led to significant improvements in the morbidity and mortality rate, children with intestinal failure are at risk for multiple complications such as intestinal failure associated liver disease, recurrent septic episodes, central line complications, metabolic bone disease, impaired kidney function, and failure to thrive. In this article, we review the current literature on the etiology and factors affecting prognosis of pediatric IF.
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Affiliation(s)
- Annika Mutanen
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
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