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Norsa L, Goulet O, Alberti D, DeKooning B, Domellöf M, Haiden N, Hill S, Indrio F, Kӧglmeier J, Lapillonne A, Luque V, Moltu SJ, Saenz De Pipaon M, Savino F, Verduci E, Bronsky J. Nutrition and Intestinal Rehabilitation of Children With Short Bowel Syndrome: A Position Paper of the ESPGHAN Committee on Nutrition. Part 2: Long-Term Follow-Up on Home Parenteral Nutrition. J Pediatr Gastroenterol Nutr 2023; 77:298-314. [PMID: 37256821 DOI: 10.1097/mpg.0000000000003850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The preferred treatment for IF is parenteral nutrition which may be required until adulthood. The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their expertise. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. This second part of the position paper is dedicated to the long-term management of children with SBS-IF. The paper mainly focuses on how to achieve intestinal rehabilitation, treatment of complications, and on possible surgical and medical management to increase intestinal absorption.
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Affiliation(s)
- Lorenzo Norsa
- From the Department of Paediatric Hepatology, Gastroenterology and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Olivier Goulet
- the Department of Pediatric Gastroenterology-Hepatology-Nutrition, APHP Necker-Enfants Malades Hospital, Université Paris Cité, Paris, France
| | - Daniele Alberti
- the Department of Pediatric Surgery, ASST Spedali Civili, Brescia, Italy
- the Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Barbara DeKooning
- From the Department of Paediatric Hepatology, Gastroenterology and Transplantation, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Magnus Domellöf
- the Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Nadja Haiden
- the Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Susan Hill
- the Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Flavia Indrio
- the Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Jutta Kӧglmeier
- the Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Alexandre Lapillonne
- the Neonatal Intensive Care Unit, APHP Necker-Enfants Malades Hospital, Paris Cité University, Paris, France
- the CNRC, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Veronica Luque
- Serra Hunter, Universitat Rovira I Virgili, IISPV, Tarragona, Spain
| | - Sissel J Moltu
- the Department of Neonatology, Oslo University Hospital, Oslo, Norway
| | - Miguel Saenz De Pipaon
- the Department of Neonatology, Instituto de Investigación Sanitaria del Hospital Universitario La Paz - IdiPAZ, Hospital Universitario La Paz - Universidad Autónoma de Madrid, Madrid, Spain
| | - Francesco Savino
- the Dipartimento di Patologia e cura del bambino "Regina Margherita", A.U.O. Città delle Salute e della Scienza di Torino, Torino, Italy
| | - Elvira Verduci
- the Department of Pediatrics, Ospedale dei Bambini Vittore Buzzi University of Milan, Milan, Italy
| | - Jiri Bronsky
- the Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
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Nagelkerke SCJ, Poelgeest MYV, Wessel LM, Mutanen A, Langeveld HR, Hill S, Benninga MA, Tabbers MM, Bakx R. Bowel Lengthening Procedures in Children with Short Bowel Syndrome: A Systematic Review. Eur J Pediatr Surg 2022; 32:301-309. [PMID: 33663008 DOI: 10.1055/s-0041-1725187] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The aims of the study are to systematically assess and critically appraise the evidence concerning two surgical techniques to lengthen the bowel in children with short bowel syndrome (SBS), namely, the longitudinal intestinal lengthening and tailoring (LILT) and serial transverse enteroplasty (STEP), and to identify patient characteristics associated with a favorable outcome. MATERIALS AND METHODS MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched from inception till December 2019. No language restriction was used. RESULTS In all, 2,390 articles were found, of which 40 were included, discussing 782 patients. The median age of the patients at the primary bowel lengthening procedure was 16 months (range: 1-84 months). Meta-analysis could not be performed due to the incomparability of the groups, due to heterogeneous definitions and outcome reporting. After STEP, 46% of patients weaned off parenteral nutrition (PN) versus 52% after LILT. Mortality was 7% for STEP and 26% for LILT. Patient characteristics predictive for success (weaning or survival) were discussed in nine studies showing differing results. Quality of reporting was considered poor to fair. CONCLUSION LILT and STEP are both valuable treatment strategies used in the management of pediatric SBS. However, currently it is not possible to advise surgeons on accurate patient selection and to predict the result of either intervention. Homogenous, prospective, outcome reporting is necessary, for which an international network is needed.
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Affiliation(s)
- Sjoerd C J Nagelkerke
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Amsterdam, The Netherlands.,Amsterdam Reproduction and Development, Amsterdam, The Netherlands.,Amsterdam Gastroenterology and Metabolism, Amsterdam, The Netherlands
| | | | - L M Wessel
- Department of Pediatric Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - A Mutanen
- Department of Pediatric Surgery, The New Children's Hospital, University of Helsinki, Helsinki, Finland
| | - H R Langeveld
- Erasmus MC, Sophia's Children's Hospital, Department of Pediatric Surgery, Rotterdam, The Netherlands
| | - S Hill
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - M A Benninga
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Amsterdam, The Netherlands
| | - M M Tabbers
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Amsterdam, The Netherlands
| | - R Bakx
- Pediatric Surgical Centre, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Amsterdam, The Netherlands
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Early Bowel Lengthening Procedures: Bi-Institutional Experience and Review of the Literature. CHILDREN 2022; 9:children9020221. [PMID: 35204941 PMCID: PMC8870478 DOI: 10.3390/children9020221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/30/2022] [Accepted: 02/03/2022] [Indexed: 11/17/2022]
Abstract
Early bowel lengthening procedure (EBLP) has been defined as any bowel lengthening procedure performed before six months of age. The purpose of this paper is to compare our experience with literature on this subject to identify common indications. A bi-institutional retrospective analysis was performed. Diagnosis, type of surgery, age at procedure and outcomes were analysed. Eleven EBLP were performed in Manchester and Florence from 2006 to 2021. The median age at surgery was 126 days (102–180), pre-operative median short bowel (SB) length was 28 cm (17–49) with a post-operative median increase of 81%. Furthermore, a PubMed/Embase search was undertaken regarding bowel lengthening procedures performed in the last 40 years. Sixty-one EBLP were identified. The median age was 60 days (1–90). Serial transverse enteroplasty (STEP) was the most frequent procedure used, with a median increased bowel length of 57%. This study confirms that no clear consensus on indication or timing to perform early SB lengthening is reported. According to the gathered data, EBLP should be considered only in cases of actual necessity and performed in a qualified intestinal failure centre.
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Double barrel enteroplasty for the management of short bowel syndrome in children. Pediatr Surg Int 2021; 37:169-177. [PMID: 33104840 DOI: 10.1007/s00383-020-04767-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Currently, there are two well-established methods of bowel lengthening in patients with short bowel syndrome (SBS)-longitudinal intestinal lengthening and tailoring (LILT) and serial transverse enteroplasty (STEP) [1-4]. Both procedures may carry a high reported morbidity and mortality of 30.2% and 14.4%, respectively [5]. We report the outcomes of a novel technique: double barrel enteroplasty (DBE) for autologous intestinal reconstruction. METHODS We performed a retrospective review of all ten patients who underwent DBE at our institution since 2011. All patients have SBS and were dependent on parenteral nutrition (PN) at the time of surgery. Etiologies were gastroschisis (n = 4), bowel atresia (n = 3), necrotising enterocolitis (n = 1), volvulus (n = 1), and near-total intestinal aganglionosis (n = 1). Patient survival, complications, and subsequent enteral autonomy were evaluated. RESULTS All patients are alive with normal liver function. Five children achieved enteral autonomy, while the remaining are on weaning PN. There was no bleeding, anastomotic leak, perforation, infective complications, or intestinal necrosis. No patient has required a liver and/or intestinal transplant. CONCLUSIONS Double barrel enteroplasty is technically feasible and safe. It has similar efficacy and may have fewer complications when compared with other methods of autologous intestinal reconstruction.
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Shah AA, Petrosyan M, Franklin AL, Chahine AA, Torres C, Sandler AD. Autologous intestinal reconstruction: a single institution study of the serial transverse enteroplasty (STEP) and the longitudinal intestinal lengthening and tailoring (LILT). Pediatr Surg Int 2019; 35:649-655. [PMID: 30868210 DOI: 10.1007/s00383-019-04468-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE To review the effectiveness of the longitudinal intestinal lengthening and tailoring (LILT) and serial transverse enteroplasty (STEP) operations in a cohort of patients with short bowel syndrome (SBS). METHODS We conducted a retrospective analysis of children with SBS treated at our institution from 2004 until 2014. Children aged 0 days to 18 years with SBS who underwent autologous intestinal reconstruction were included in the study. RESULTS Twenty-two SBS patients underwent 31 different lengthening procedures (LP). Seventeen patients underwent their primary lengthening procedures at our institution: 9 (53%) patients underwent a LILT, 7 (41%) underwent a STEP and 1 (6%) had a simultaneous LILT and STEP procedure. 12/22 patients had a second STEP, two had a third STEP and one patient had an intestinal transplantation after the LP. Median intestinal length at the time of surgery was 25 cm (range 12-90 cm). There was no difference in gain of intestinal length after LILT vs. STEP (p = 0.74). Length of stay and initiation of feeds were similar. Serum albumin increased after autologous bowel lengthening (p < 0.001). 50% were weaned off parenteral nutrition (PN) (5/9 of the LILT, 1/7 of the STEP, 1/1 of the combined LILT/STEP). There were no surgical complications or deaths. CONCLUSION In patients with SBS, LILT and STEP procedures are effective for autologous intestinal reconstruction and enable intestinal rehabilitation.
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Affiliation(s)
- Adil A Shah
- Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA
- Department of Surgery, Howard University Hospital and College of Medicine, Washington, DC, USA
| | - Mikael Petrosyan
- Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA.
| | - Ashanti L Franklin
- Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA
| | - Alfred A Chahine
- Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA
| | - Clarivet Torres
- Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA
- Department of Gastroenterology, Hepatology, and Nutrition, Children's National Health System, Washington, DC, USA
| | - Anthony D Sandler
- Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA
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Strang BJ, Reddix BA, Wolk RA. Improvement in Parenteral Nutrition–Associated Cholestasis With the Use of Omegaven in an Infant With Short Bowel Syndrome. Nutr Clin Pract 2016; 31:647-53. [DOI: 10.1177/0884533616643697] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Abstract
PURPOSE OF REVIEW This review will provide the practitioner with an understanding of the spectrum of nontransplant surgical options for managing patients with short bowel syndrome (SBS). RECENT FINDINGS Intestinal lengthening procedures are a promising therapy to allow autonomy from parenteral nutrition. The recently described serial transverse enteroplasty is an effective procedure that is easier to perform and has similar outcomes to the more standard longitudinal lengthening procedure described by Bianchi. SUMMARY There are several surgical options for management of the SBS, including construction of intestinal valves or reversed intestinal segments, interposition of segments of colon, or intestinal lengthening procedures. The choice of technique is dictated by the patient's underlying pathophysiology and includes such factors as intestinal transit time, length of remnant bowel, presence of intact colon, and degree of small bowel dilation. Nontransplant surgical interventions are important adjuncts to the elimination of parenteral nutrition dependence and need for intestinal transplantation.
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Abstract
The goal of any treatment programme for short bowel syndrome SBS is to achieve nutritional enteral autonomy. This must begin with conservation of as much bowel as possible from the time of first presentation. Frequent causes of the short bowel syndrome are intestinal atresia, necrotizing enterocolitis, midgut volvulus, extended intestinal aganglionosis, 'vanished gut' often associated with gastroschisis and occasionally catastrophic trauma. Atresia is more amenable to successful surgery than other causes, except when associated with gastroschisis. Intrinsic dysmotility has a poor prognosis. Intestinal lengthening procedures are only indicated if there is sufficient bowel dilatation. Extended intestinal aganglionosis is rarely amenable to any form of non-transplant surgery. Options available are to conserve bowel, close stomas early (use all available bowel to the maximum or even re-feed stoma effluent into the distal unused bowel), release adhesions causing obstruction, resect strictures, taper or excise localized dilatations and finally address dilated bowel with lengthening and tailoring operations. These procedures aim to improve effective peristalsis, thereby reducing bacterial overgrowth and improving nutrient contact with enteral mucosa to maximize absorption and intestinal adaptation. The Bianchi longitudinal splicing operation and the serial transverse enteroplasty operations have stood the test of time in providing considerable improvement in enteral nutritional autonomy in around 60% of cases. In SBS without dilatation attempts at 'mechanically' delaying transit (nipple valves, reversed bowel segments, colon interposition) have had inconsistent outcomes. Growing neomucosa and lengthening bowel by longitudinal stretch are still experimental.
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Affiliation(s)
- Alastair J W Millar
- Department of Paediatric Surgery, University of Cape Town and Red Cross War Memorial Children's Hospital, Rondebosch, Cape Town, 7700, South Africa,
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