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Irtan S, Reignier PL, Durandy A, Hervieux E, Constant I, Lemale J, Soreze Y, Leger PL, Audry G, Rambaud J, Guellec I. Feasibility of open abdomen surgery treatment for near fatal necrotizing enterocolitis in preterm infants. J Pediatr Surg 2022; 57:1336-1341. [PMID: 34696919 DOI: 10.1016/j.jpedsurg.2021.09.044] [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: 05/04/2021] [Revised: 09/24/2021] [Accepted: 09/26/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Necrotizing Enterocolitis (NEC) remained a dramatic complication leading to death or neonatal morbidities in preterms. For some, Intra-Abdominal Hypertension (IAH) and Abdominal Compartment Syndrome worsened the multi-organ failure. An open abdomen surgery could be an alternative to conventional surgical treatment to move beyond this stage. OBJECTIVES To retrospectively describe the clinical course, pre- and post-operative features of preterms suffering from severe NEC with IAH treated by open abdomen surgery and referred to our center from October 2007 to September 2019. Our secondary objective is to identify various risk factors for mortality in this population. METHODS Data on neonatal, clinical, biological, pre and post-operative features and outcome were collected. Univariate analyses were performed to compare their pre and post-operative features stratifying on outcome. RESULTS Among 29 included patients, 14 (48%) survived to discharge without short bowel syndrome. Death was associated with an earlier postnatal age at NEC (16.3 ± 9.1 versus 31.3 ± 25.9 days; p = 0.004) and followed a withdrawal of treatment in 60% of cases. Surgery was associated with a significant improvement of respiratory and hemodynamic features (decrease of mean ventilator pressure from 13.1 ± 5.4 to 11.3 ± 4.0 cmH2O, p < 0.001), oxygen requirement (mean FiO2 decreased from 65.0% ± 31.2 to 49.0% ± 24.6, p < 0.001) and inotropic score (from 38.6 ± 70.1 to 29.9 ± 64.3, p < 0.001). In the survival group, pre and post-operative findings exhibited a significant increase of serum lactate concentrations from 2.7 ± 1.6 to 11.0 ± 20.3 mmol/L (p = 0.02) but a similar pH. CONCLUSION Open abdomen surgery could be considered to rescue preterms with near fatal NEC. IAH and Abdominal Compartment Syndrome in these preterms should be investigated through further studies. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Sabine Irtan
- Department of Visceral and Neonatal Pediatric Surgery, Sorbonne University, Armand Trousseau University Hospital, APHP.6, Paris, France
| | - Pierre-Louis Reignier
- Department of Visceral and Neonatal Pediatric Surgery, Sorbonne University, Armand Trousseau University Hospital, APHP.6, Paris, France
| | - Amélie Durandy
- Neonatal Intensive Care Unit, CH Poissy Saint-Germain-en-Laye, Poissy, France
| | - Erik Hervieux
- Department of Visceral and Neonatal Pediatric Surgery, Sorbonne University, Armand Trousseau University Hospital, APHP.6, Paris, France
| | - Isabelle Constant
- Department of Anesthesiology and Intensive Care, Sorbonne University, Armand Trousseau University Hospital, GRC 29, APHP.6, Paris, France
| | - Julie Lemale
- Nutrition and Gastroenteterology, Pediatric Department, Sorbonne University, Armand Trousseau University Hospital, APHP.6, France
| | - Yohan Soreze
- Neonatal and Pediatric Care Unit, Sorbonne University, Armand Trousseau University Hospital, AP-HP.6, Paris, France
| | - Pierre-Louis Leger
- Neonatal and Pediatric Care Unit, Sorbonne University, Armand Trousseau University Hospital, AP-HP.6, Paris, France
| | - Georges Audry
- Department of Visceral and Neonatal Pediatric Surgery, Sorbonne University, Armand Trousseau University Hospital, APHP.6, Paris, France
| | - Jérôme Rambaud
- Neonatal and Pediatric Care Unit, Sorbonne University, Armand Trousseau University Hospital, AP-HP.6, Paris, France
| | - Isabelle Guellec
- Neonatal and Pediatric Care Unit, Sorbonne University, Armand Trousseau University Hospital, AP-HP.6, Paris, France.
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Hong HS, Kim SS, Park GY. Oral Administration of Nonionic Water-Soluble Contrast Media to Treat Meconium Obstruction in Premature Infants: A Preliminary Study. NEONATAL MEDICINE 2021. [DOI: 10.5385/nm.2021.28.1.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Cassir N, Simeoni U, La Scola B. Gut microbiota and the pathogenesis of necrotizing enterocolitis in preterm neonates. Future Microbiol 2016; 11:273-92. [PMID: 26855351 DOI: 10.2217/fmb.15.136] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Necrotizing enterocolitis (NEC) remains a devastating intestinal disease in preterm neonates. In this population, disruption of the gut microbiota development, mainly due to organ immaturity, antibiotic use and hospital microbial environment, plays a key role in the pathogenesis of NEC. This gut dysbiosis has been associated with opportunistic pathogens overgrowth, expression of virulence factors, altered metabolic functions and inflammatory dysregulated responses. In this review, we provide an updated summary of the host and gut microbiota interactions during the formative early life. We also explore the key determinants of gut dysbiosis in preterm neonates with NEC. Finally, we discuss the promising role of bacteriotherapy in the management of NEC, the aim being to shape or restore the beneficial gut bacterial communities.
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Affiliation(s)
- Nadim Cassir
- Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes (URMITE), UM63, CNRS 7278, IRD 198, INSERM U1095, Facultés de Médecine et de Pharmacie, Aix-Marseille Université, Marseille, France
| | - Umberto Simeoni
- Service de Pédiatrie, Centre Hospitalier Universitaire Vaudois, Lausanne, Suisse, Switzerland
| | - Bernard La Scola
- Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes (URMITE), UM63, CNRS 7278, IRD 198, INSERM U1095, Facultés de Médecine et de Pharmacie, Aix-Marseille Université, Marseille, France
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Kim HY, Kim SH, Cho YH, Byun SY, Han YM, Kim AY. Meconium-related ileus in very low birth weight and extremely low birth weight infants: immediate and one-year postoperative outcomes. Ann Surg Treat Res 2015; 89:151-7. [PMID: 26366385 PMCID: PMC4559618 DOI: 10.4174/astr.2015.89.3.151] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 03/20/2015] [Accepted: 04/24/2015] [Indexed: 11/30/2022] Open
Abstract
PURPOSE One of the major causes of bowel obstruction in extremely premature infants is a meconium obstruction. However, there are many challenges not only in the recognition and diagnosis, but also in the management of meconium obstruction. This study aimed to find perioperative clinical features and determine the postoperative course of meconium-related ileus in very low birth weight (VLBW) and extremely low birth weight (ELBW) infants. METHODS We retrospectively reviewed the clinical data of premature infants (n = 11, VLBW infnats; n = 16, ELBW infants) with a meconium-related ileus who underwent operation for intractable ileus between January 2009 and May 2013. RESULTS The average duration of conservative management was longer and postnatal age was older in ELBW infants than VLBW infants: 19.9 days vs. 11.5 days and 34.9 days vs. 19.2 days. The immediate postoperative course (day that beginning feeding and full feeding) was not significantly different based on birth weight, but the ELBW infants had slightly higher mortality. At 12 months of corrected age after operation, both average body weight and average height was below 10th percentile for growth in most infants (61.1%). CONCLUSION There was a slightly high mortality in the ELBW infants, but two groups did not experience significant differences in the immediate postoperative course of meconium-related ileus. Nevertheless, considering their growth patterns, it is necessary to do a close follow-up and more aggressive nutritional management to achieve optimal growth and development in both patient groups.
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Affiliation(s)
- Hae-Young Kim
- Division of Pediatric Surgery, Department of Surgery, Pusan National University School of Medicine, Yangsan, Korea. ; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Soo-Hong Kim
- Division of Pediatric Surgery, Department of Surgery, Pusan National University School of Medicine, Yangsan, Korea
| | - Yong-Hoon Cho
- Division of Pediatric Surgery, Department of Surgery, Pusan National University School of Medicine, Yangsan, Korea. ; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Shin-Yun Byun
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
| | - Young-Mi Han
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
| | - Ah-Young Kim
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
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Cho HH, Cheon JE, Choi YH, Lee SM, Kim WS, Kim IO, Shin SM, Kim EK, Kim HS, Choi JH, You SK. Ultrasound-guided contrast enema for meconium obstruction in very low birth weight infants: Factors that affect treatment success. Eur J Radiol 2015; 84:2024-31. [PMID: 26159485 DOI: 10.1016/j.ejrad.2015.06.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 05/27/2015] [Accepted: 06/04/2015] [Indexed: 12/16/2022]
Abstract
INTRODUCTION This study aimed to assess the therapeutic results of ultrasound (US)-guided water-soluble contrast enema in very low birth weight (VLBW) preterm infants (<1,500 g) with meconium obstruction and to study factors that affect therapeutic results. METHODS This study included a total of 33 consecutive VLBW infants with clinically diagnosed meconium obstruction underwent US-guided water-soluble contrast enema, from April 2007 to March 2014. Patients were classified into two groups based on to procedure outcome: the success group (evacuation of the meconium plug resolution followed by improved bowel distention within 2 days of the procedure, without additional interventions), and the failure group (the contrast enema failed to relieve the obstruction, or other procedure-related complications occurred). Patient- and mother-related clinical factors and procedure-related factors were compared between both groups. RESULTS Overall success rate was 54.5%, with 18 successful (M:F=10:8), and 15 failure (M:F=7:8) cases. When compared with the failure group, the success group patients showed statistically significant older gestational age (29(+1) vs. 27 weeks; p=0.028), larger birth weight (1023.1g vs. 790.3g; p=0.048), and higher body weight on the day of the procedure (1036.2g vs. 801.6g, p=0.049). However, no statistically significant differences were seen between other patient and maternal factors. Among the procedure-related factors, retrial of contrast injection during the procedure was associated with significantly higher success than the single trial (p=0.027). The presence of refluxed contrast into the distal ileum was the statistically significant predictor for success of the procedure (p=0.038). There were three cases of bowel perforation (9.1% per person). CONCLUSION US-guided water-soluble contrast enema in VLBW infants with meconium obstruction showed a 54.5% success rate and a 9.1% perforation rate per person. Among the procedure-related factors, retrial of contrast injection during the procedure and the presence of refluxed contrast into the distal ileum were related to the success of the procedure.
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Affiliation(s)
- Hyun-Hae Cho
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, South Korea
| | - Jung-Eun Cheon
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, South Korea; Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul 110-799, South Korea; Institute of Radiation Medicine, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul 110-799, Republic of Korea.
| | - Young Hun Choi
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, South Korea; Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul 110-799, South Korea
| | - So Mi Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, South Korea
| | - Woo Sun Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, South Korea; Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul 110-799, South Korea; Institute of Radiation Medicine, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul 110-799, Republic of Korea
| | - In-One Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, South Korea; Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul 110-799, South Korea; Institute of Radiation Medicine, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul 110-799, Republic of Korea
| | - Su-Mi Shin
- Department of Radiology, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, South Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jung-Hwan Choi
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Sun Kyoung You
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, South Korea
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Hatanaka A, Nakahara S, Takeyama E, Iwanaka T, Ishida K. Management of extremely low birth weight neonates with bowel obstruction within 2 weeks after birth. Surg Today 2014; 44:2269-74. [DOI: 10.1007/s00595-013-0824-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 12/10/2013] [Indexed: 11/30/2022]
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Kim YJ, Kim EK, Kim ES, Kim HS, Choi JH, Cheon JE, Kim WS, Kim IO, Park KW. Recognition, diagnosis and treatment of meconium obstruction in extremely low birth weight infants. Neonatology 2012; 101:172-8. [PMID: 22024741 DOI: 10.1159/000330850] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 07/16/2011] [Indexed: 12/24/2022]
Abstract
BACKGROUND Meconium obstruction (MO) of prematurity can result in increased morbidity or mortality and prolonged hospitalization if not diagnosed and treated appropriately. OBJECTIVES The aims of our study were to identify the incidence and risk factors associated with MO and to review the treatment outcomes. METHODS A retrospective analysis was undertaken of 101 extremely low birth weight infants (ELBWIs) who were born between January 1, 2007, and April 1, 2009, at Seoul National University Hospital. Prenatal and neonatal factors were compared between the MO and control groups. The treatment outcomes were also reviewed. RESULTS Twenty-two (22%) patients were diagnosed as having MO. Eighteen of these patients (82%) had prenatal risk factors for MO. Respiratory distress syndrome was more prevalent in the MO group than in the control group (p = 0.001). Overall, 17 of the 22 patients (77%) were relieved with medical treatment and the rest underwent ileostomy. The times to full enteral feeding did not differ between the medically treated group and the control group. However, the surgically treated group required more time to achieve full enteral feeding, and some patients had persistent gastrointestinal problems. CONCLUSION MO is not a rare condition in ELBWIs, and the majority of ELBWIs have prenatal risk factors. Medical management was effective, and medically manageable cases had good prognoses for subsequent feeding, whereas some surgically managed cases had persistent gastrointestinal problems.
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Affiliation(s)
- Yoon-Joo Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
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Chan KL, Wong KF, Luk JM. Role of LPS/CD14/TLR4-mediated inflammation in necrotizing enterocolitis: pathogenesis and therapeutic implications. World J Gastroenterol 2010; 15:4745-52. [PMID: 19824106 PMCID: PMC2761550 DOI: 10.3748/wjg.15.4745] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To establish the roles of lipopolysaccharide (LPS)/CD14/toll-like receptor 4 (TLR4)-mediated inflammation in a rat model of human necrotizing enterocolitis (NEC). METHODS Six pairs of intestinal samples from human NEC were collected before and after recovery for histological and molecular analysis of inflammatory cytokines and signaling components. In the rat NEC model, we isolated 10-cm jejunum segments and divided them into six groups (n = 6) for sham operation, treatment with LPS, bowel distension, combined bowel distension and LPS stimulation, and two therapeutic groups. The potential efficacy of a recombinant CD18 peptide and a monoclonal CD14 antibody was evaluated in the latter two groups. The serum and tissue levels of several inflammatory mediators were quantified by real-time polymerase chain reaction, ELISA and immunoblotting. RESULTS Human acute phase NEC tissues displayed significant increases (P < 0.05) in levels of TLR4, CD14, myeloid differentiation protein (MD)-2, tumor necrosis factor (TNF)-alpha and nuclear factor-kappaB when compared to those after recovery. The histological and inflammatory picture of human NEC was reproduced in rats that were treated with combined bowel distension and LPS, but not in the sham-operated and other control rats. Serum levels of interleukin-6 and TNF-alpha were also elevated. The NEC pathology was attenuated by treating the NEC rats with a monoclonal CD14 antibody or an LPS-neutralizing peptide. CONCLUSION LPS and distension are required to produce the histological and inflammatory features of NEC. A potential treatment option is blocking LPS activation and leukocyte infiltration.
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Affiliation(s)
- Kwong L Chan
- Department of Surgery, The University of Hong Kong, Hong Kong, China.
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Thymann T, Møller HK, Stoll B, Støy ACF, Buddington RK, Bering SB, Jensen BB, Olutoye OO, Siggers RH, Mølbak L, Sangild PT, Burrin DG. Carbohydrate maldigestion induces necrotizing enterocolitis in preterm pigs. Am J Physiol Gastrointest Liver Physiol 2009; 297:G1115-25. [PMID: 19808655 PMCID: PMC2850085 DOI: 10.1152/ajpgi.00261.2009] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Necrotizing enterocolitis (NEC) remains the most severe gastrointestinal disorder in preterm infants. It is associated with the initiation of enteral nutrition and may be related to immature carbohydrate digestive capacity. We tested the hypothesis that a formula containing maltodextrin vs. a formula containing lactose as the principal source of carbohydrate would predispose preterm pigs to a higher NEC incidence. Cesarean-derived preterm pigs were given total parenteral nutrition for 48 h followed by total enteral nutrition with a lactose-based (n = 11) or maltodextrin-based (n = 11) formula for 36 h. A higher incidence (91% vs. 27%) and severity (score of 3.3 vs. 1.8) of NEC were observed in the maltodextrin than in the lactose group. This higher incidence of NEC in the maltodextrin group was associated with significantly lower activities of lactase, maltase, and aminopeptidase; reduced villus height; transiently reduced in vivo aldohexose uptake; and reduced ex vivo aldohexose uptake capacity in the middle region of the small intestine. Bacterial diversity was low for both diets, but alterations in bacterial composition and luminal concentrations of short-chain fatty acids were observed in the maltodextrin group. In a second study, we quantified net portal absorption of aldohexoses (glucose and galactose) during acute jejunal infusion of a maltodextrin- or a lactose-based formula (n = 8) into preterm pigs. We found lower net portal aldohexose absorption (4% vs. 42%) and greater intestinal recovery of undigested carbohydrate (68% vs. 27%) in pigs acutely perfused with the maltodextrin-based formula than those perfused with the lactose-based formula. The higher digestibility of the lactose than the maltodextrin in the formulas can be attributed to a 5- to 20-fold higher hydrolytic activity of tissue-specific lactase than maltases. We conclude that carbohydrate maldigestion is sufficient to increase the incidence and severity of NEC in preterm pigs.
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Affiliation(s)
- Thomas Thymann
- 1Department of Human Nutrition, University of Copenhagen, Frederiksberg,
| | - Hanne K. Møller
- 1Department of Human Nutrition, University of Copenhagen, Frederiksberg, ,2Department of Systems Biology, Technical University of Denmark, Lyngby,
| | - Barbara Stoll
- 3US Department of Agriculture Children's Nutrition Research Center and
| | - Ann Cathrine F. Støy
- 7National Veterinary Institute, Technical University of Denmark, Copenhagen, and
| | - Randal K. Buddington
- 4Department of Health and Sports Sciences, University of Memphis, Memphis, Tennessee
| | - Stine B. Bering
- 1Department of Human Nutrition, University of Copenhagen, Frederiksberg,
| | - Bent B. Jensen
- 5Faculty of Agricultural Sciences, University of Aarhus, Tjele, Denmark;
| | - Oluyinka O. Olutoye
- 6Texas Children's Hospital, Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; and
| | - Richard H. Siggers
- 1Department of Human Nutrition, University of Copenhagen, Frederiksberg,
| | - Lars Mølbak
- 7National Veterinary Institute, Technical University of Denmark, Copenhagen, and
| | - Per T. Sangild
- 1Department of Human Nutrition, University of Copenhagen, Frederiksberg,
| | - Douglas G. Burrin
- 3US Department of Agriculture Children's Nutrition Research Center and
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Schnabl KL, Aerde JEV, Thomson ABR, Clandinin MT. Necrotizing enterocolitis: A multifactorial disease with no cure. World J Gastroenterol 2008; 14:2142-61. [PMID: 18407587 PMCID: PMC2703838 DOI: 10.3748/wjg.14.2142] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Necrotizing enterocolitis is an inflammatory bowel disease of neonates with significant morbidity and mortality in preterm infants. Due to the multifactorial nature of the disease and limitations in disease models, early diagnosis remains challenging and the pathogenesis elusive. Although preterm birth, hypoxic-ischemic events, formula feeding, and abnormal bacteria colonization are established risk factors, the role of genetics and vasoactive/inflammatory mediators is unclear. Consequently, treatments do not target the specific underlying disease processes and are symptomatic and surgically invasive. Breast-feeding is the most effective preventative measure. Recent advances in the prevention of necrotizing enterocolitis have focused on bioactive nutrients and trophic factors in human milk. Development of new disease models including the aspect of prematurity that consistently predisposes neonates to the disease with multiple risk factors will improve our understanding of the pathogenesis and lead to discovery of innovative therapeutics.
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Siggers RH, Thymann T, Jensen BB, Mølbak L, Heegaard PMH, Schmidt M, Buddington RK, Sangild PT. Elective cesarean delivery affects gut maturation and delays microbial colonization but does not increase necrotizing enterocolitis in preterm pigs. Am J Physiol Regul Integr Comp Physiol 2008; 294:R929-38. [DOI: 10.1152/ajpregu.00705.2007] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Although preterm birth and formula feeding increase the risk of necrotizing enterocolitis (NEC), the influences of cesarean section (CS) and vaginal delivery (VD) are unknown. Therefore, gut characteristics and NEC incidence and severity were evaluated in preterm pigs (92% gestation) delivered by CS or VD. An initial study showed that newborn CS pigs ( n = 6) had decreased gastric acid secretion, absorption of intact proteins, activity of brush-border enzymes and pancreatic hydrolases, plasma cortisol, rectal temperature, and changes in blood chemistry, indicating impaired respiratory function, compared with VD littermates ( n = 6). In a second experiment, preterm CS ( n = 16) and VD ( n = 16) pigs were given total parenteral nutrition (36 h) then fed porcine colostrum (VD-COL, n = 6; CS-COL, n = 6) or infant milk formula (VD-FORM, n = 10; CS-FORM, n = 10) for 2 days. Across delivery, FORM pigs showed significantly higher NEC incidence, tissue proinflammatory cytokines (IFN-γ and IL-6), Clostridium colonization, and impaired intestinal function, compared with COL pigs. NEC incidence was equal for CS (6/16) and VD (6/16) pigs, CS pigs had decreased bacterial diversity and density, higher villus heights, and increased brush-border enzyme activities (lactase, aminopeptidases) compared with VD pigs. In particular, VD-FORM pigs showed reduced mucosal proportions, reduced lactase and aminopeptidases, and increased proinflammatory cytokine IL-6 compared with CS-FORM ( P < 0.06). Despite the initial improvement of intestinal and metabolic functions following VD, gut function, and inflammation were similar, or more negatively affected in VD neonates than CS neonates. Both delivery modes exhibited positive and negative influences on the preterm gut, which may explain the similar NEC incidence.
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Abstract
Necrotizing enterocolitis (NEC) is a devastating intra-abdominal emergency in the newborn period. The disease involves bowel wall inflammation, ischemic necrosis, eventual perforation, and the need for urgent surgical intervention. Unrecognized or left untreated, the neonate can decompensate quickly, often progressing to shock, multisystem organ failure, and eventual death. During the past several years, a number of basic science and clinical trials have been established in an attempt to understand the pathophysiology of NEC. As many researchers feel that NEC develops as an uncontrolled inflammatory response that leads to intestinal ischemia, a large number of studies have been focused on the inflammatory cascade and the role that cytokines play within that cascade. Although a large amount of data has been generated from these studies, the events leading to the ischemic injury of the intestine are still not fully understood. This article will therefore focus on the key cytokines involved with NEC, in an attempt to present the current literature and studies that support their involvement.
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Affiliation(s)
- Troy A Markel
- Department of Surgery, Indiana University School of Medicine, the Indiana Center for Vascular Biology and Medicine, Indianapolis, IN, USA
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Turner D, Hammerman C, Rudensky B, Schlesinger Y, Wine E, Muise A, Schimmel MS. Low levels of procalcitonin during episodes of necrotizing enterocolitis. Dig Dis Sci 2007; 52:2972-6. [PMID: 17393328 DOI: 10.1007/s10620-007-9763-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2006] [Accepted: 01/03/2007] [Indexed: 12/13/2022]
Abstract
The pathogenesis of necrotizing enterocolitis (NEC) remains poorly understood. We aimed to assess the extent of bacterial infection in the pathogenesis of NEC using serial procalcitonin measurements. Blood samples were drawn during the first 4 days following every clinical event requiring a workup for presumed NEC. Eight episodes were confirmed as NEC, 7 of which showed procalcitonin levels <1 ng/ml at presentation and <1.3 ng/ml thereafter, comparable to 24 healthy controls. The one infant with elevated procalcitonin had bacteremia in addition to NEC. Procalcitonin levels of 24 matched septic infants were higher than those of NEC infants, peaking at 4.1 ng/ml. We conclude that low procalcitonin values are the rule during episodes of NEC and provide further evidence that overactive local immune response, and not active infection, is primarily responsible for the mucosal damage in NEC.
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Affiliation(s)
- Dan Turner
- Department of Pediatrics, Shaare Zedek Medical Center, Jerusalem, Israel.
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Patole S. Prevention and treatment of necrotising enterocolitis in preterm neonates. Early Hum Dev 2007; 83:635-42. [PMID: 17826009 DOI: 10.1016/j.earlhumdev.2007.07.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Accepted: 07/30/2007] [Indexed: 01/10/2023]
Abstract
Prevention and treatment of NEC has become an area of priority for research due to the increasing number of preterm survivors at risk, and the significant mortality and morbidity related to the illness. Probiotic supplementation appears to be a promising option for primary prevention of NEC but further large trials are necessary for documenting their safety in terms of sepsis as well as long-term neurodevelopmental outcomes and immune function. As new frontiers including immunomodulating agents like pentoxifylline continue to be explored, the impact of well-established simple strategies like antenatal glucocorticoid therapy, and early and preferential use of breast milk must not be forgotten. Clinical research on manifestations of ileus of prematurity, and feeding in the presence of common risk factors such as IUGR is needed. Safety of minimal enteral feeds in terms of NEC and benefits of standardised feeding regimens need to be confirmed. Association of common clinical practices such as red cell transfusions, H2 receptor blockade, and thickening of feeds with NEC warrants attention. An approach utilising a package of potentially better practices seems to be the most appropriate strategy for the prevention and treatment of NEC.
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Affiliation(s)
- Sanjay Patole
- Department of Neonatal Paediatrics, KEM Hospital for Women, Perth, Australia.
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Kim WY, Kim IO, Kim WS, Yeon KM, Kim GI, Lee SW, Suh JS, Choi HY, Chang KJ. Sonographic findings in a model of ischemia-induced necrotizing enterocolitis with pathological correlations. Invest Radiol 2007; 42:312-8. [PMID: 17414527 DOI: 10.1097/01.rli.0000258681.14275.19] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate sonographic findings in ischemic enterocolitis (IEC) and correlate with pathologic findings in an experimental study. MATERIALS AND METHODS Ischemic enterocolitis was induced with ligation of the superior mesenteric artery in 20 rabbits. Plain radiography and ultrasonography (US) were performed. US was done hourly after the ligation using 10 MHz linear probe. US findings were categorized into 2 groups according to the bowel wall echogenicity; the echogenic dots (ED) group and the circumferential granular echogenicity (CGE) group. US findings were compared with the specimen radiography and the histopathology. RESULTS On US, ED were seen in the bowel of all rabbits after SMA ligation (2.2 +/- 1.3 hours [standard deviation]) and CGE in 16 rabbits (4.1 +/- 0.9 hours). On the specimen radiographs, multiple radiolucent air bubbles were present. Comparing the ED and CGE group, histopathological findings revealed the CGE group had severer injury of the bowel wall than the ED group. On plain radiography, there was progressive bowel distention, but pneumatosis intestinalis (PI) was not evident. CONCLUSION ED or CGE are the sonographic findings of ischemic enterocolitis, and bowel wall echogenicity might reflect the degree of ischemic injury.
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Affiliation(s)
- Wha-Young Kim
- Department of Radiology, CHA Hospital, College of Medicine, Pochon CHA University, Korea
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16
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Abstract
Preterm birth is associated with immature digestive function that may require the use of total parenteral nutrition and special oral feeding regimens. Little is known about the responses to oral food in the preterm neonate and how enteral nutrients affect the immature gastrointestinal tract (GIT). In vivo studies are difficult to perform in laboratory rodents because of their small body size and that of immature organs at birth, and this makes the large farm animals (e.g., pigs, cattle, sheep) more attractive models in this field. In these species, preterm delivery at 88%-95% gestation is associated clinical complications and degrees of GIT immaturity similar to those in infants born at 70%-90% gestation. Studies in both animals and infants indicate that the immature GIT responds to the first enteral food with rapid increases in gut mass and surface area, blood flow, motility, digestive capacity, and nutrient absorption. To a large extent, the enteral food responses are birth independent, and can be elicited also in utero, at least during late gestation. Nevertheless, preterm neonates show compromised GIT structure, function, and immunology, particularly when delivered by caesarean section and fed diets other than mother's milk. Formula-fed preterm infants are thus at increased risk of developing diseases such as necrotizing enterocolitis, unless special care is taken to avoid excessive nutrient fermentation and bacterial overgrowth. The extent to which results obtained in preterm animals (most notably the pig) can be used to reflect similar conditions in preterm infants is discussed.
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Affiliation(s)
- Per T Sangild
- Department of Human Nutrition, Royal Veterinary and Agricultural and Veterinary University, 30 Rolighedsvej, Frederiksberg C, Denmark.
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Sangild PT, Siggers RH, Schmidt M, Elnif J, Bjornvad CR, Thymann T, Grondahl ML, Hansen AK, Jensen SK, Boye M, Moelbak L, Buddington RK, Weström BR, Holst JJ, Burrin DG. Diet- and colonization-dependent intestinal dysfunction predisposes to necrotizing enterocolitis in preterm pigs. Gastroenterology 2006; 130:1776-92. [PMID: 16697741 DOI: 10.1053/j.gastro.2006.02.026] [Citation(s) in RCA: 211] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2005] [Accepted: 02/01/2006] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Preterm birth and formula feeding are key risk factors associated with necrotizing enterocolitis (NEC) in infants, but little is known about intestinal conditions that predispose to disease. Thus, structural, functional, and microbiologic indices were used to investigate the etiology of spontaneous NEC development in preterm pigs. METHODS Piglets were delivered by cesarean section at 92% gestation, reared in infant incubators, and fed infant formula or colostrum every 3 hours (n = 120) until tissue collection at 1-2 days of age. RESULTS Clinical and histopathologic signs of NEC were observed in 57% of pigs fed FORMULA (26/46) and in 5% of pigs fed COLOSTRUM (2/38) (P < .05). Relative to COLOSTRUM, both healthy and sick FORMULA pigs had reduced intestinal villous heights, enzyme activities, nutrient absorption, and antioxidant levels and higher inducible nitric oxide synthetase activity (P < .05). In healthy pigs, mucosal microbial diversity remained low and diet independent. NEC pigs showed bacterial overgrowth, and a high mucosal density of Clostridium perfringens was detected in some but not all pigs. Germ-free conditions and antiserum against Clostridium perfringens toxin prevented intestinal dysfunction and NEC in formula-fed pigs, whereas the gut trophic factors, epidermal growth factor, and glucagon-like peptide 2 had limited effects. CONCLUSIONS A subclinical, formula-induced mucosal atrophy and dysfunction predispose to NEC and bacterial overgrowth. The adverse feeding effects are colonization dependent and may be reduced by factors in colostrum that include antibodies against aggressive toxins such as those of Clostridium perfringens.
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MESH Headings
- Animals
- Animals, Newborn
- Base Sequence
- Biopsy, Needle
- Causality
- Colony Count, Microbial
- Colostrum
- DNA, Bacterial/analysis
- Enterocolitis, Necrotizing/epidemiology
- Enterocolitis, Necrotizing/pathology
- Enterocolitis, Necrotizing/prevention & control
- Female
- Gastrointestinal Tract/microbiology
- Immunohistochemistry
- Infant Formula/administration & dosage
- Intestinal Absorption/physiology
- Intestinal Mucosa/microbiology
- Intestinal Mucosa/pathology
- Intestine, Small/embryology
- Intestine, Small/metabolism
- Intestine, Small/pathology
- Molecular Sequence Data
- Polymerase Chain Reaction/methods
- Pregnancy
- Pregnancy, Animal
- Premature Birth
- Probability
- Risk Factors
- Sensitivity and Specificity
- Swine
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Affiliation(s)
- Per T Sangild
- Divisions of Nutrition and Reproduction, Royal Veterinary and Agricultural University, Frederiksberg, Denmark.
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Bjornvad CR, Schmidt M, Petersen YM, Jensen SK, Offenberg H, Elnif J, Sangild PT. Preterm birth makes the immature intestine sensitive to feeding-induced intestinal atrophy. Am J Physiol Regul Integr Comp Physiol 2005; 289:R1212-22. [PMID: 15961526 DOI: 10.1152/ajpregu.00776.2004] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Preterm birth and formula feeding predispose to small intestinal dysfunction, which may lead to necrotizing enterocolitis (NEC). In piglets, we tested whether the physiological and environmental transitions occurring at birth affect the response of the immature intestine to enteral feeding. Pig fetuses (106 days gestation, term = 115 days) were prepared with esophageal feeding tubes and fed either sow's colostrum (n = 8) or infant formula (n = 7) in utero. After 24 h of oral feeding, the pig fetuses were delivered by cesarean section and their gastrointestinal morphology and function were compared with those of preterm newborn (NB) littermates that were not fed (n = 8) or fed colostrum (n = 7) or formula (n = 13) for 24 h after birth. Before birth, both colostrum and formula feeding resulted in marked increases in intestinal mass, brush-border enzyme activities, and plasma glucagon-like peptide 2 concentrations, to levels similar to those in NB colostrum-fed piglets. In contrast, NB formula-fed piglets showed reduced intestinal growth, decreased brush-border enzyme activities, and intestinal lesions, reflecting NEC. NB formula-fed pigs also showed impaired enterocyte endocytotic function and decreased antioxidative capacity, whereas brush-border enzyme mRNA levels were unaltered, relative to NB colostrum-fed pigs. Our results indicate that the feeding-induced growth and enzyme maturation of the immature intestine are not birth dependent. However, with a suboptimal diet (milk formula), factors related to preterm birth (e.g., microbial colonization and metabolic and endocrine changes) make the immature intestine sensitive to atrophy and development of NEC.
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Affiliation(s)
- Charlotte Reinhard Bjornvad
- Department of Human Nutrition, Royal Veterinary and Agricultural University, Rolighedsvej 30, DK-1958 Frederiksberg C., Denmark
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Abstract
Necrotizing enterocolitis (NEC) is one of the diagnoses for which donor human milk is regularly prescribed. The role of human milk in both prevention and treatment of NEC has long been recognized. Human milk, whether mother's own or donor, provides significant protection against many of the known risk factors of NECas well as therapeutic protection for the infant recovering from NEC. In the absence of mother's own milk, donor human milk could be life saving to fragile preterm infants, who are at highest risk of developing NEC.
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