1
|
Santos MD, Magalhães V, Loureiro L, Pina P, Castro A, Aguiar P, Rocha A. Management of Short Bowel Syndrome With Chronic Intestinal Failure: A Single-Center Experience in Portugal. Cureus 2024; 16:e63443. [PMID: 39077232 PMCID: PMC11284821 DOI: 10.7759/cureus.63443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2024] [Indexed: 07/31/2024] Open
Abstract
INTRODUCTION Short bowel syndrome with chronic intestinal failure (SBS/CIF) is the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance due to a short bowel. Although SBS/CIF is rare, its clinical management is complex, challenging, expensive, and time-consuming. AIM This study aimed to analyze a single center's experience with SBS/CIF in adult patients treated with home parenteral nutrition (HPN). MATERIALS AND METHODS A retrospective single-center analysis of all 13 consecutive adult patients with SBS/CIF was included in an HPN program between January 1994 and August 2023. RESULTS Between 1992 and 2023, 13 patients were included in an HPN program. The primary underlying pathology was acute mesenteric ischemia. The median age of starting HPN was 44 years. Most were subjected to several surgeries of extensive intestinal resection with posterior intestinal reconstruction. Five of the 13 patients died while on HPN with a median duration of 42 months. The causes of death related to HPN were catheter sepsis, endocarditis with cardiac failure, or hepatic failure. One patient died due to underlying pathology: pelvic abscesses and bleeding related to radiotherapy. Eight patients remain alive, with a median time of HPN of 173 months. During the HPN support, the most frequent complications were venous catheter infection and venous territory thrombosis. None of the eight patients alive have hepatic failure. Two patients recently started teduglutide with good tolerance and need a reduction in HPN support. All eight patients have a satisfactory quality of life (parenteral support needs range between five and two nutrition bags per week). Conclusion: Home parenteral nutrition remains the gold standard of SBS/CIF treatment, although teduglutide may reduce HPN needs and complications and provide a better quality of life. Despite the small number of patients, the results shown in this study are not inferior to those in large-volume centers. The existence of the commitment and interest of professionals involved in SBS/CIF at Centro Hospitalar Universitário de Santo António, Portugal, was a fundamental key to achieving those results. A multidisciplinary healthcare group for HPN support can be essential to ensuring these patients' survival and quality of life.
Collapse
Affiliation(s)
- Marisa D Santos
- Colorectal Surgery, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), University of Porto, Porto, PRT
- Colorectal Surgery, Unidade Local de Saúde de Santo António (ULSSA), Porto, PRT
| | - Vania Magalhães
- Nutrition, Unidade Local de Saúde de Santo António (ULSSA), Porto, PRT
| | - Luis Loureiro
- Vascular Surgery, Unidade Local de Saúde de Santo António (ULSSA), Porto, PRT
| | - Pedro Pina
- Anesthesiology, Unidade Local de Saúde de Santo António (ULSSA), Porto, PRT
| | - Ana Castro
- Nephrology, Unidade Local de Saúde de Santo António (ULSSA), Porto, PRT
| | - Paulina Aguiar
- Pharmacy, Unidade Local de Saúde de Santo António (ULSSA), Porto, PRT
| | - Anabela Rocha
- Colorectal Surgery, Unidade Local de Saúde de Santo António (ULSSA), Porto, PRT
| |
Collapse
|
2
|
Ukkola-Vuoti L, Tuominen S, Pohju A, Kovac B, Lassenius MI, Merras-Salmio L, Pakarinen MP, Sallinen V, Pikkarainen S. Expenditure and survival of adult patients with intestinal failure due to short bowel syndrome: real-world evidence from Southern Finland. Scand J Gastroenterol 2024; 59:401-410. [PMID: 38217349 DOI: 10.1080/00365521.2024.2303063] [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: 10/03/2023] [Accepted: 01/03/2024] [Indexed: 01/15/2024]
Abstract
OBJECTIVES Comprehensive follow-up data from the largest hospital district in Finland was used to assess hospital-based healthcare resource utilization (HCRU) and expenses, incidence and prevalence, survival, and effect of comorbidities/complications on survival of adult patients with intestinal failure due to short bowel syndrome (SBS-IF). METHODS This study utilized electronic healthcare data covering all ≥18-year-old patients with SBS-IF at the Hospital District of Helsinki and Uusimaa in Finland between 2010 and 2019. Patients were followed from SBS-IF onset until the end of 2020 or death and compared to birth year and sex-matched control patients without SBS-IF. RESULTS The study included 77 patients with SBS-IF (cases) and 363 controls. Cases had high HCRU; the cumulative expenses were about tenfold compared to the controls, at the end of the study (€123,000 vs. €14,000 per patient). The expenses were highest during the first year after SBS-IF onset (€53,000 per patient). Of the cases with a median age 62.5 years, 51.9% died during study time. The median survival was 4.4 years from SBS-IF onset and cases died 13.5 times more likely during the follow-up compared to controls. Mortality risk was lower in female cases (hazard ratio (HR) 0.46; 95% confidence intervals (CI) 0.24, 0.9) and higher with presence of comorbidities (Charlson comorbidity index HR 1.55; 95% CI 1.2, 2.0) and mesenteric infarction (HR 4.5; 95% CI 1.95, 10.36). The incidence of adult SBS-IF was 0.6 per 100,000 adults. CONCLUSION Our study demonstrates a high demand for healthcare support and elevated mortality in adult SBS-IF-patients. Our results suggest that the presence of comorbidities is a key driver for mortality.
Collapse
Affiliation(s)
| | | | - Anne Pohju
- Clinical Nutrition Unit, Internal Medicine and Rehabilitation, Helsinki University Hospital, Helsinki, Finland
| | - Bianca Kovac
- Gastroenterolgy Department, Takeda Oy, Helsinki, Finland
| | | | - Laura Merras-Salmio
- Helsinki University Hospital, Pediatric Gastroenterology Unit, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko P Pakarinen
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Women's Health, Karolinska Institute, Solna, Sweden
| | - Ville Sallinen
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sampsa Pikkarainen
- Abdomen Center, Gastroenterology Unit, Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
3
|
Suzon B, Louis-Sidney F, Abel A, Moinet F, Bagoée C, Henry K, Coco-Viloin I, Cougnaud R, Wolff S, Guilpain P, Rivière S, Flori N, Deligny C, Maria A. [Severe small bowel involvement and chronic intestinal pseudo-obstruction in systemic sclerosis (scleroderma): Pathophysiological, diagnostic and therapeutic basis, including parenteral nutrition]. Rev Med Interne 2024; 45:147-155. [PMID: 38388303 DOI: 10.1016/j.revmed.2024.02.001] [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: 03/04/2023] [Revised: 01/15/2024] [Accepted: 02/03/2024] [Indexed: 02/24/2024]
Abstract
Gastrointestinal involvement in systemic sclerosis can be severe, reaching the critical point of chronic intestinal pseudo-obstruction, secondary to major disorders of small bowel motility. It is associated with some clinical and biological characteristics, in particular the positivity of anti-fibrillarin/U3RNP antibodies. Chronic intestinal pseudo-obstruction (CIPO) is complicated by a small intestinal bacterial overgrowth that requires cyclic antibiotic therapy. CIPO leads to a reduction of the food intake, due to painful symptoms, nausea and vomiting caused by meals, and ultimately to severe malnutrition. Meal splitting is often transiently effective and patients require exogenous nutritional support, mostly parenteral. Systemic sclerosis is not an obstacle to initiation and long-term continuation of parenteral nutrition and central venous catheter implantation is not associated with an increased risk of cutaneous or infectious complications. However, continuation of long-term parenteral nutrition requires monitoring in an expert nutrition center in order to adapt nutritional volumes and intakes and to limit potentially fatal cardiac and hepatobiliary complications. In addition to nutrition, prokinetic treatments, whose side effects must be known, can be associated. Invasive procedures, whose risk-benefit ratio must be carefully assessed, can also be used to treat symptoms exclusively.
Collapse
Affiliation(s)
- B Suzon
- Médecine Interne, CHU de Martinique, Fort-de-France, Martinique; Unité EpiCliV, Université des Antilles, Fort-de-France, Martinique.
| | - F Louis-Sidney
- Unité EpiCliV, Université des Antilles, Fort-de-France, Martinique; Rhumatologie, CHU de Martinique, Fort-de-France, Martinique
| | - A Abel
- Médecine Interne, CHU de Martinique, Fort-de-France, Martinique
| | - F Moinet
- Médecine Interne, CHU de Martinique, Fort-de-France, Martinique
| | - C Bagoée
- Médecine interne et polyvalente, Centre hospitalier territorial Gaston-Bourret, Nouméa, Nouvelle-Calédonie
| | - K Henry
- Maladies infectieuses et tropicales, Centre hospitalier de Cayenne, Cayenne, Guyane
| | - I Coco-Viloin
- Médecine Interne, CHU de Martinique, Fort-de-France, Martinique
| | - R Cougnaud
- Médecine Interne, CHU de Martinique, Fort-de-France, Martinique
| | - S Wolff
- Médecine Interne, CHU de Martinique, Fort-de-France, Martinique
| | - P Guilpain
- Médecine interne et maladies multi-organiques, Hôpital Saint Eloi, CHU de Montpellier, Montpellier, France; Institut de médecine régénérative et biothérapies, Inserm U1183, Montpellier, France; Faculté de médecine, Université de Montpellier, Montpellier, France
| | - S Rivière
- Médecine interne et maladies multi-organiques, Hôpital Saint Eloi, CHU de Montpellier, Montpellier, France
| | - N Flori
- Centre expert régional de nutrition, ICM, Montpellier, France
| | - C Deligny
- Médecine Interne, CHU de Martinique, Fort-de-France, Martinique; Unité EpiCliV, Université des Antilles, Fort-de-France, Martinique
| | - A Maria
- Institut de médecine régénérative et biothérapies, Inserm U1183, Montpellier, France; Faculté de médecine, Université de Montpellier, Montpellier, France; Médecine interne et immuno-oncologie (MedI2O), Hôpital Saint-Eloi, CHU de Montpellier, Montpellier, France
| |
Collapse
|
4
|
Winkler M, Tappenden K. Epidemiology, survival, costs, and quality of life in adults with short bowel syndrome. Nutr Clin Pract 2023; 38 Suppl 1:S17-S26. [PMID: 37115027 DOI: 10.1002/ncp.10964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/19/2023] [Accepted: 01/21/2023] [Indexed: 04/29/2023] Open
Abstract
Short bowel syndrome (SBS) is a rare disorder with known physical, psychosocial, and economic burdens and significant morbidity and mortality. Many individuals with SBS require long-term home parenteral nutrition (HPN). The incidence and prevalence of SBS is difficult to determine because it is often based on HPN usage and may not account for those who receive intravenous fluids or achieve enteral autonomy. The most common etiologies associated with SBS are Crohn's disease and mesenteric ischemia. Intestinal anatomy and remnant bowel length are prognostic for HPN dependency, and enteral autonomy confers a survival advantage. Health economic data confirm that PN-related costs are higher for hospitalizations than at home; yet significant healthcare resource utilization is necessary for successful HPN, and patients and families report substantial financial distress that impacts quality of life (QOL). An important advancement in QOL measurement is the validation of HPN- and SBS-specific QOL questionnaires. In addition to the known factors negatively impacting QOL, such as diarrhea, pain, nocturia, fatigue, depression, and narcotic dependency, research has shown that the volume and number of PN infusions per week is associated with QOL. Although traditional QOL measurements describe how underlying disease and therapy influence life, they do not assess how symptoms and functional limitations affect the QOL of patients and caregivers. Patient-centered measures and conversation focused on psychosocial issues helps patients with SBS and HPN dependency better cope with their disease and treatment. This article presents a brief overview of SBS, including epidemiology, survival, costs, and QOL.
Collapse
Affiliation(s)
- Marion Winkler
- Department of Surgery/Nutrition Support, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Kelly Tappenden
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois, USA
| |
Collapse
|
5
|
Clermont-Dejean NM, Schwenger KJP, Arca C, Somlaw N, Alhanaee A, Hortencio TDR, Jin J, Jung H, Lou W, Ma D, Allard JP. Comparing mixed oil to soybean oil lipid emulsion in patients on home parenteral nutrition: a pilot prospective double-blind, crossover, randomized trial. Pilot Feasibility Stud 2023; 9:64. [PMID: 37081524 PMCID: PMC10116729 DOI: 10.1186/s40814-023-01295-1] [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: 02/01/2022] [Accepted: 04/10/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Home parenteral nutrition (HPN) can be associated with increased liver enzymes, catheter-related bloodstream infections (CRBSI), and hospitalizations. Mixed oil (MO) versus soybean oil (SO) lipid emulsion reduces risks in hospitalized patients, but there are no randomized double-blinded controlled trials in HPN. Therefore, the primary objective was to test the study's feasibility such as recruitment and retention in the HPN population and the secondary objective was to assess changes in liver enzymes between MO and SO as well as other clinical and biochemical outcomes. METHODS This 13-month prospective double-blind crossover randomized pilot trial took place in Toronto, Canada. Participants were HPN patients who were a part of the HPN program at Toronto General Hospital. We recruited patients from the HPN program. HPN patients receiving SO were randomized to either MO or SO, and the study duration was 6 months in each arm (MO or SO) with a 1-month washout period resuming SO. As this is a crossover trial design, the patient is his/her own control. The main outcome measures were descriptions of study feasibility, namely the study recruitment and retention. We also collected biochemical parameters, CRSBI, hospitalization rate, antibiotic use, and mortality. Demographic, nutritional, clinical, and laboratory data were collected at baseline, 3 and 6 months of each arm. The primary analysis population was defined as the per-protocol population who completed the trial including all lipid measurements. RESULTS A total of 65 HPN patients were assessed, and 60 met the inclusion criteria for the study. Thirty-five percent (21/60) were randomized using a computer-generated random number sequence generator: 10 participants were randomized to receive SO first while 11 were randomized to receive MO first. At 13 months, 3/10 who received SO first completed the study, whereas 9/11 who received MO first completed the study. This did not meet our a priori criteria for success in recruitment and retention. Between types of lipid emulsions, there were no significant differences in changes in liver enzymes or biochemical and clinical outcomes, despite significant changes in plasma free fatty acid composition reflecting MO or SO. CONCLUSIONS Overall, this pilot trial demonstrated that the use of a prospective double-blind, crossover, randomized trial design was not feasible to conduct in the HPN population because of difficulties in recruiting and retaining patients. In addition, there was no significant impact of MO versus SO lipid emulsion on liver enzymes or most parameters. The lack of significance may be attributed to low sample size from low recruitment and high drop-out rate, short study duration (6 months/arm), and complex care. In a future definitive trial, a multicenter study of longer duration and a larger sample size is recommended, and drop-outs may be reduced by using a parallel study design. TRIAL REGISTRATION ClinicalTrials.gov, NCT02796833. Registered on 13 June 2016-retrospectively registered.
Collapse
Affiliation(s)
- Nayima M Clermont-Dejean
- Department of Medicine, Toronto General Hospital, University of Toronto, 585 University Avenue, 9N-973, Toronto, ON, M5G 2N2, Canada
| | - Katherine J P Schwenger
- Department of Medicine, Toronto General Hospital, University of Toronto, 585 University Avenue, 9N-973, Toronto, ON, M5G 2N2, Canada
| | - Celeste Arca
- Department of Medicine, Toronto General Hospital, University of Toronto, 585 University Avenue, 9N-973, Toronto, ON, M5G 2N2, Canada
| | - Nicha Somlaw
- Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Amnah Alhanaee
- Tawam Hospital, Abu Dhabi Health Authority, Abu Dhabi, United Arab Emirates
| | - Taís Daiene Russo Hortencio
- State University of Campinas, Unicamp, São Paulo, Brazil
- Sao Leopoldo Mandic Institute and Research Center, Campinas, São Paulo, Brazil
| | - Jennifer Jin
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Hyejung Jung
- Dalla Lana Public Health Department, University of Toronto, Toronto, ON, Canada
| | - Wendy Lou
- Dalla Lana Public Health Department, University of Toronto, Toronto, ON, Canada
| | - David Ma
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, Canada
| | - Johane P Allard
- Department of Medicine, Toronto General Hospital, University of Toronto, 585 University Avenue, 9N-973, Toronto, ON, M5G 2N2, Canada.
| |
Collapse
|
6
|
D'Eusebio C, Merlo FD, Ossola M, Bioletto F, Ippolito M, Locatelli M, De Francesco A, Anrò M, Romagnoli R, Strignano P, Bo S, Aimasso U. Mortality and parenteral nutrition weaning in patients with chronic intestinal failure on home parenteral nutrition: A 30-year retrospective cohort study. Nutrition 2023; 107:111915. [PMID: 36566610 DOI: 10.1016/j.nut.2022.111915] [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: 08/18/2022] [Revised: 11/06/2022] [Accepted: 11/13/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Home parenteral nutrition (HPN) is the standard treatment for patients with chronic intestinal failure (CIF). Mortality and weaning rates of these patients differ widely among cohorts; however, these outcomes were often considered independent-rather than competing-events, leading to an upward bias of the retrieved estimates. OBJECTIVES The aim of this retrospective cohort study was to evaluate, evaluating through a competing risk analysis, the rates and predictors of mortality and weaning in CIF patients from an Italian referral center. METHODS All adult patients with CIF receiving > 3 mo HPN from 1985 until 2016 were enrolled. Clinical information was collected from the database of the Intestinal Failure Unit of Torino, Italy. Patients were stratified according to the presence or not of short bowel syndrome (SBS). RESULTS The cumulative incidences of death and weaning were 27.3% and 32.3% and 39.0% and 33.7% at 5 and 10 y from HPN initiation, respectively. At multivariable competing risk analyses, mortality was predicted by age (sub-distribution hazard ratio [SHR] = 1.65 per 10-y increase; 95% CI, 1.35-2.01), type 3 SBS (SHR = 0.38; 0.15-0.94), small bowel length ≥ 100 cm (SHR = 0.42; 0.22-0.83), and reconstructive surgery (SHR = 0.11; 0.02-0.64) in SBS patients, and by age (SHR = 1.38 per 10-y increase; 1.16-1.64) and presence of stoma (SHR = 0.30; 0.12-0.78) in non-SBS patients. In the same model, weaning was predicted by type 3 SBS (SHR = 6.86; 3.10-15.16), small bowel length ≥ 100 cm (SHR = 3.54; 1.99-6.30), and reconstructive surgery (SHR = 2.86; 1.44-5.71) in SBS patients, and by age (SHR = 0.79 per 10-y increase; 0.66-0.94) and presence of stoma (SHR = 2.64; 1.38-5.07) in non-SBS patients. CONCLUSIONS Surgical procedures strongly affected mortality and weaning risk in CIF patients.
Collapse
Affiliation(s)
- Chiara D'Eusebio
- Department of Medical Science, University of Torino, 10124 Torino, Italy
| | - Fabio Dario Merlo
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy.
| | - Marta Ossola
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Fabio Bioletto
- Department of Medical Science, University of Torino, 10124 Torino, Italy
| | - Mirko Ippolito
- Department of Medical Science, University of Torino, 10124 Torino, Italy
| | - Monica Locatelli
- Food Chemistry, Biotechnology and Nutrition Unit, University of Piemonte Orientale, 28100 Novara, Italy
| | - Antonella De Francesco
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Marta Anrò
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Renato Romagnoli
- General Surgery 2U, Liver Transplantation Unit, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Paolo Strignano
- General Surgery 2U, Liver Transplantation Unit, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Simona Bo
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy.
| | - Umberto Aimasso
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| |
Collapse
|
7
|
Clermont-Dejean NM, Schwenger KJP, Salazar E, Colombo FF, Lu Z, Lou W, Gramlich L, Whittaker S, Armstrong D, Jurewitsch B, Raman M, Duerksen DR, McHattie JD, Murthy S, Allard JP. Home parenteral nutrition patients on mixed oil lipid emulsion have a higher rate of hospitalizations compare to those on soybean oil- a prospective 2-year cohort study. Clin Nutr 2021; 40:4616-4623. [PMID: 34229267 DOI: 10.1016/j.clnu.2021.06.012] [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: 03/25/2021] [Revised: 06/03/2021] [Accepted: 06/07/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND & AIMS Mixed oil intravenous lipid emulsion (MO ILE) that contains 30% soybean oil (SO), 30% medium chain triglycerides, 25% olive oil and 15% fish oil can benefit hospitalized patients receiving parenteral nutrition (PN) but there are very few studies on its long-term use. Our goal was to evaluate the clinical outcomes of adults receiving home PN (HPN) with MO versus those receiving SO ILE over a 2-year period. METHOD This is a retrospective analysis of data collected prospectively from a cohort of patients recorded in the Canadian HPN Registry over a 2-year period. HPN patients from academic programs across Canada were entered in the Registry according to a validated protocol. For this study, demographic, nutritional, laboratory and clinical data were extracted from January 1st 2015, when MO lipid emulsion became available in Canada, to July 24th 2019. Clinical data for each patient included: number of hospitalizations, number of hospitalizations related to HPN and number of hospitalization days related to HPN, over a year; incidence of line sepsis per 1000 catheter days and mortality. Data are presented as median (1st, 3rd quartile) for continuous variables and frequency (percentage) for categorical variables. Comparisons between groups were performed using two sample t-test or Wilcoxon Rank Sum tests for continuous variables and Chi-square tests or Fisher's exact tests for categorical variables. Univariate and multiple linear regressions were also carried out. Statistical significance is set at a p-value <0.05. RESULTS A total of 120 patients were included (MO n = 68, SO n = 52). Significant differences at baseline between the two groups were a higher use of Hickman line (62.12% vs 42%, p = 0.038) and more western Canada based hospital care with MO (75% vs 42.31%, p = 0.0002). The MO group had significantly more hospitalizations (p = 0.001), more hospitalizations related to HPN (p = 0.012) and more hospitalization days related to HPN (p = 0.016) per patient per year compared to SO patients. There was no significant difference between groups for line sepsis per 1000 catheter days (MO: 0.05 (0.0, 1.0) vs SO: 0.0 (0.0, 0.22), p = 0.053) or mortality. All other variables, including biochemical variables, were similar between groups. In a multiple regression analysis, the following factors were significantly associated with a greater number of hospitalizations per patient per year: use of MO, high blood glucose from the last recorded value and having died by the end of the study period. CONCLUSION This 2-year prospective cohort study suggests an increased risk of hospitalization in HPN patients receiving MO lipid emulsion. The long-term effect of using MO lipid emulsion in HPN patients should be further evaluated using a large randomized controlled trial. THE STUDY WAS REGISTERED IN CLINICALTRIALS.GOV: (NCT02299466).
Collapse
Affiliation(s)
| | | | | | | | - Zihang Lu
- Department of Public Health Sciences, Queen's University, ON, Canada
| | - Wendy Lou
- Dalla Lana Public Health Department, University of Toronto, Ontario, Canada
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Scott Whittaker
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - David Armstrong
- Division of Gastroenterology & Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Brian Jurewitsch
- Department of Pharmacy, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maitreyi Raman
- Division of Gastroenterology and Hepatology, University of Calgary, Alberta, Canada
| | - Donald R Duerksen
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Sanjay Murthy
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Johane P Allard
- Department of Medicine, Toronto General Hospital, University of Toronto, Ontario, Canada.
| |
Collapse
|
8
|
Vasant DH, Lal S. Recent Advances in the Management of Severe Gastrointestinal Dysmotility. Clin Exp Gastroenterol 2021; 14:163-172. [PMID: 34007199 PMCID: PMC8121621 DOI: 10.2147/ceg.s249877] [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: 03/14/2021] [Accepted: 04/15/2021] [Indexed: 11/23/2022] Open
Abstract
Severe gastrointestinal motility disorders with small bowel involvement continue to pose a major clinical challenge to clinicians, particularly because of the limitations of diagnostic tests and the lack of efficacious treatment options. In this article, we review current understanding and the utility of diagnostic modalities and therapeutic approaches, and describe how their limitations may potentially exacerbate prolonged suffering with debilitating symptoms, diagnostic delays, the risk of iatrogenic harm and increased healthcare utilisation in this group of patients. Moreover, observations from intestinal failure units worldwide suggest that this problem could be set to increase in the future, with reported trends of increasing numbers of patients presenting with nutritional consequences. Unfortunately, until recently, there has been a lack of consensus recommendations and guidance to support clinicians with their management approach. The aim of this narrative review is to summarise recent developments in this field following publication of an international census of experts, and subsequent clinical guidelines, which have emphasized the importance of holistic, multidisciplinary care. This is particularly important in achieving good clinical outcomes and ensuring the appropriate use of artificial nutritional support, in order to prevent iatrogenic harm. We discuss how these recent developments may impact clinical practice by supporting the development of specialised clinical services to deliver optimal care, and highlight areas where further research is needed.
Collapse
Affiliation(s)
- Dipesh H Vasant
- Neurogastroenterology Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - Simon Lal
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| |
Collapse
|
9
|
Vasant DH, Pironi L, Barbara G, Bozzetti F, Cuerda C, Joly F, Mundi M, Paine P, Staun M, Szczepanek K, Van Gossum A, Wanten G, Lal S. An international survey on clinicians' perspectives on the diagnosis and management of chronic intestinal pseudo-obstruction and enteric dysmotility. Neurogastroenterol Motil 2020; 32:e13937. [PMID: 32696607 DOI: 10.1111/nmo.13937] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/10/2020] [Accepted: 06/17/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic intestinal pseudo-obstruction (CIPO) and enteric dysmotility (ED) are small intestinal motility disorders defined by radiological and manometric criteria. In the absence of consensus guidelines, we surveyed opinions on the diagnosis and management of CIPO and ED among experts from different countries. METHODS A survey questionnaire was circulated electronically to members of the European society for Clinical Nutrition and Metabolism, European Society of Neurogastroenterology and Motility, and United European Gastroenterology. Only responses from participants completing all required components were included. KEY RESULTS Of 154 participants, 93% agreed that CIPO and ED should be classified separately. Overall, 73% reported an increasing incidence of CIPO and ED, with hypermobile Ehlers-Danlos Syndrome the group with the largest increase in referrals (37%), particularly in the UK (P < .0001). The majority (95%) find diagnosing CIPO and ED difficult. Notably, antroduodenal manometry, a test mandated to diagnose ED, is infrequently used (only 21% respondents use in >50% cases) and full thickness biopsies were reported to seldom influence medical treatment, nutritional management, and prognosis. Respondents reported that very few treatments are useful for most patients, with bacterial overgrowth treatment, prucalopride, and psychological therapies felt to be the most useful. While only 23% of clinicians felt that parenteral nutrition (PN) improves gastrointestinal symptoms in >50% of cases, 68% reported PN dependency at 5 years in the majority of cases. CONCLUSIONS AND INFERENCES These data highlight the difficulties with diagnosing and managing CIPO and ED and underscore the urgent need for international, multidisciplinary, clinical practice guidelines.
Collapse
Affiliation(s)
- Dipesh H Vasant
- Manchester University NHS Foundation Trust, Manchester, UK.,University of Manchester, Manchester, UK
| | | | | | | | | | | | | | - Peter Paine
- University of Manchester, Manchester, UK.,Salford Royal NHS Foundation Trust, Salford, UK
| | | | | | | | - Geert Wanten
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Simon Lal
- University of Manchester, Manchester, UK.,Salford Royal NHS Foundation Trust, Salford, UK
| |
Collapse
|