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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: 5] [Impact Index Per Article: 5.0] [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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2
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Kudo H, Wada M. Pediatric intestinal rehabilitation. Curr Opin Organ Transplant 2023; 28:237-241. [PMID: 37053076 DOI: 10.1097/mot.0000000000001062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
PURPOSE OF REVIEW The intestinal rehabilitation program (IRP) is a comprehensive treatment strategy that employs various approaches implemented by multidisciplinary teams to treat intestinal failure in children. This program has shown promising results, such as reducing complications and improving prognosis and quality of life (QOL). In this review, we discuss the current status of this program and relevant topics. RECENT FINDINGS IRP includes the prevention and treatment of various complications such as intestinal failure associated liver disease, catheter-related bloodstream infection or sepsis, and venous thromboembolism. In addition, treatment strategies such as glucagon-like peptide-2 analogs, surgical interventions, and intestinal transplantation have evolved over time and have contributed to improved outcomes. In addition, the scope and regions for IRP activities have expanded. SUMMARY IRP improves the prognosis and QOL of children with intestinal failure. The development of new drugs, surgical methods, and treatment strategies is expected to improve the current and future status of pediatric patients with intestinal failure. Furthermore, international institutions must collaborate, share knowledge, conduct joint research, and establish patient registries to advance IRP progress.
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Affiliation(s)
- Hironori Kudo
- Department of Pediatric Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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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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Surgical Treatment of Short Bowel Syndrome—The Past, the Present and the Future, a Descriptive Review of the Literature. CHILDREN 2022; 9:children9071024. [PMID: 35884008 PMCID: PMC9322125 DOI: 10.3390/children9071024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/26/2022] [Accepted: 07/07/2022] [Indexed: 12/27/2022]
Abstract
Short bowel syndrome (SBS) is a devastating disorder with both short- and long-term implications for patients. Unfortunately, the prevalence of SBS has doubled over the past 40 years. Broadly speaking, the etiology of SBS can be categorized as congenital or secondary, the latter typically due to extensive small bowel resection following diseases of the small intestine, e.g., necrotizing enterocolitis, Hirschsprung’s disease or intestinal atresia. As of yet, no cure exists, thus, conservative treatment, primarily parenteral nutrition (PN), is the first-line therapy. In some cases, weaning from PN is not possible and operative therapy is required. The invention of the longitudinal intestinal lengthening and tailoring (LILT or Bianchi) procedure in 1980 was a major step forward in patient care and spawned further techniques that continue to improve lives for patients with severe SBS (e.g., double barrel enteroplasty, serial transverse enteroplasty, etc.). With this review, we aim to provide an overview of the clinical implications of SBS, common conservative therapies and the development of operative techniques over the past six decades. We also provide a short outlook on the future of operative techniques, specifically with respect to regenerative medicine.
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Lauro A, Santoro A, Cirocchi R, Michelini M, Zorzetti N, Cianci MC, Bellini MI, Casadei C, Ripoli MC, Coletta R, Khouzam S, Marino IR, D'Andrea V, Morabito A. Serial transverse enteroplasty (STEP) in case of short bowel syndrome: did we achieve our goal? A systematic review. Updates Surg 2022; 74:1209-1223. [PMID: 35804224 DOI: 10.1007/s13304-022-01316-3] [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: 02/03/2022] [Accepted: 06/14/2022] [Indexed: 11/25/2022]
Abstract
Surveys on Serial Transverse Enteroplasty (STEP) published in international literature (1 January 2003- 31 May 2021) were searched. Articles were included from 17 countries: 1/23 comparative and 22/23 cohort studies. STEP was performed on 308 patients: pediatrics, adults, and mixed ages. Pediatric group included 16 studies and the adult 6. Pre-STEP residual small bowell (SB) length for pediatrics and adults ranged from 18 to 26 cm and from 30 to 70 cm, respectively. Post-STEP increased SB length for pediatrics and adults ranged between 42 and 100% and 50% and 176%, respectively. For pediatrics, enteral autonomy was reached in 32.22% of cases, parenteral nutrition (PN) dependence was 36.11%, a repeated STEP procedure (Re-STEP) was needed in 17.22%, and a bowel transplant was performed in 6.11%. In adults, enteral autonomy was achieved in 52.38%, while PN dependence was 37.1%, and no Re-STEP or transplantation were required. For the mixed group, post-STEP bowel length increased from 2 to 50 cm, enteral autonomy was obtained in 43%, PN dependence was 57%, without reported Re-STEP or transplantation. Mortality rates were between 5.55% (pediatric) and 7.14% (adults). Preoperative length with preservation of ileocecal valve represented the main predictive factors to achieve enteral autonomy.
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Affiliation(s)
- A Lauro
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy.
| | - A Santoro
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - R Cirocchi
- Department of Surgery and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - M Michelini
- Department of Surgery and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - N Zorzetti
- Ospedale Civile "A. Costa", Porretta Terme, Bologna, Italy
| | - M C Cianci
- Department of Paediatric Surgery, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - M I Bellini
- Azienda Ospedaliera "San Camillo-Forlanini", Rome, Italy
| | - C Casadei
- IRCCS Azienda Ospedaliero, Universitaria Di Bologna, Bologna, Italy
| | - M C Ripoli
- Ospedale "Ceccarini", Riccione, Rimini, Italy
| | - R Coletta
- Department of Paediatric Surgery, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - S Khouzam
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - I R Marino
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - V D'Andrea
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - A Morabito
- Department of Paediatric Surgery, Meyer Children's Hospital, University of Florence, Florence, Italy
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6
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Boroni G, Parolini F, Stern MV, Moglia C, Alberti D. Autologous Intestinal Reconstruction Surgery in Short Bowel Syndrome: Which, When, and Why. Front Nutr 2022; 9:861093. [PMID: 35463997 PMCID: PMC9023091 DOI: 10.3389/fnut.2022.861093] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
Short bowel syndrome (SBS), secondary to any natural loss or after any extensive bowel resection for congenital malformations or acquired disease, is the most common cause of intestinal failure in children. Extensive introduction of parenteral nutrition (PN) has dramatically changed the outcome of these patients, allowing for long-term survival. The main goal in children with SBS remains to be increasing enteral tolerance and weaning from PN support. Post resection intestinal adaptation allows for achievement of enteral autonomy in a subset of these patients, but the inability to progress in enteral tolerance exposes others to long-term complications of PN. Autologous intestinal reconstruction surgery (AIRS) can facilitate the fulfilment of enteral autonomy, maximizing the absorptive potential of the remaining gut. All the different intestinal reconstruction techniques, from simple procedures like tapering, reversed segments, and colon interposition, to more complex lengthening procedures (LILT: longitudinal intestinal lengthening and tailoring, STEP: serial transverse enteroplasty, and SILT: spiral intestinal lengthening and tailoring) and techniques designed for peculiar problems like controlled intestinal tissue expansion or duodenal lengthening are presented. AIRS indications, clinical applications, and results reported in the literature are reviewed.
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Affiliation(s)
- Giovanni Boroni
- Department of Paediatric Surgery, ASST Spedali Civili di Brescia, Brescia, Italy
- *Correspondence: Giovanni Boroni,
| | - Filippo Parolini
- Department of Paediatric Surgery, ASST Spedali Civili di Brescia, Brescia, Italy
| | | | - Cristina Moglia
- Department of Paediatric Surgery, University of Brescia, Brescia, Italy
| | - Daniele Alberti
- Department of Paediatric Surgery, ASST Spedali Civili di Brescia, Brescia, Italy
- Department of Paediatric Surgery, University of Brescia, Brescia, Italy
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Abstract
PURPOSE OF REVIEW Intestinal failure secondary to short bowel syndrome is still a very serious condition. Treatment consists of parenteral nutrition to provide nutrients and maintain body weight. During the last decades, intestinal lengthening procedures have become more available. The goal of this review is to discuss the results of the literature on the most commonly performed intestinal lengthening procedures. RECENT FINDINGS Longitudinal Intestinal Lengthening, Serial Transverse Enteroplasty (STEP), and Spiral Intestinal Lengthening and Tailoring (SILT) are currently the most frequently reported intestinal lengthening procedures. The most recent literature of these procedures is described with respect to indication, technical details, complications, short and long-term outcome, and PN independence. SUMMARY On the basis of indication, surgical complexity, complications, and clinical success, we conclude that the STEP procedure is probably the best choice for most centers.
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Affiliation(s)
- Jasper B van Praagh
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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8
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Gondolesi GE, Ortega M, Martinez MI, Rumbo C, Solar H. Autologous gastrointestinal reconstruction surgery for short bowel syndrome: the cornerstone for intestinal rehabilitation. Curr Opin Organ Transplant 2022; 27:148-153. [PMID: 35153280 DOI: 10.1097/mot.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Intestinal failure (IF) evolved from being the last recognized organ failure, to become one of the most progressive fields in terms of therapeutic alternatives and results. Short bowel syndrome (SBS) is the main cause of IF in adults and children. The use of surgery allowed patients with unfavorable anatomy type and length to be wean off parenteral nutrition. We aim to evaluate its current impact on intestinal rehabilitation. RECENT FINDINGS Autologous gastro-intestinal reconstructive surgery (AGIRS), including bowel lengthening contributes by converting patient's anatomy to a more favorable one, improving quality of life, and modifying the natural history of the disease, allowing to recover intestinal autonomy in approximately 70% of the adults and 50% of the children's with SBS-IF. The current use of postsurgical medical rehabilitation strategies including the use of enterohormones complement the path to sufficiency, increasing the chances of success in both age group of patients. SUMMARY The development of AGIRS has changed the outcome of SBS-IF patients, becoming the main surgical procedure prescribed in multidisciplinary units, allowing to enhance the number of patients achieving intestinal autonomy throughout rehabilitation, leaving transplantation as the last surgical alternative.
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Affiliation(s)
- Gabriel E Gondolesi
- Servicio de Cirugía General
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante Intestinal Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - Mariana Ortega
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante Intestinal Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - Maria I Martinez
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante Intestinal Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - Carolina Rumbo
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante Intestinal Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - Héctor Solar
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante Intestinal Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
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Shafiekhani M, Azadeh N, Ashrafzadeh K, Esmaeili M, Nikoupour H. Serial transverse enteroplasty and nipple valve construction, two life saving techniques for patients with short bowel syndrome, a report of 5 cases. BMC Surg 2021; 21:446. [PMID: 34969388 PMCID: PMC8717644 DOI: 10.1186/s12893-021-01454-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/24/2021] [Indexed: 11/29/2022] Open
Abstract
Background Various abdominal pathologies end up with surgical resection of small intestine. When the small intestine remnant is too short for adequate fluid and micronutrients absorption, short bowel syndrome is diagnosed. The disabling condition needs a multidisciplinary approach to design parenteral nutrition, care for thrombotic, hepatic and infectious complications and gradually wean the patient from parenteral nutrition. Various surgical techniques have been introduced to increase absorptive mucosa and enhance the intestinal adaptation process. Serial transverse enteroplasty and nipple valve reconstruction are among the procedures, which will be discussed in the current article. Case presentation Herein, we presented 5 cases of short bowel syndrome as a consequence of abdominal laparotomies, patients were referred to our center to receive parenteral nutrition and to be prepared for the final autologous gastrointestinal reconstruction or intestinal transplantation, if indicated. Conclusion Patient’s age, performance status and bowel remnant length determines the appropriate technique for autologous gastrointestinal reconstruction. Serial transverse enteroplasty is designed to increase bowel’s length by creating zigzag patterns through dilated bowel loops. Presence of ileocecal valve is crucial to delay intestinal transit time and to prevent colonic bacterial transfer to ileum. Patient’s with ileocecal valve loss benefit from creating an artificial valve, namely, nipple valve.
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Affiliation(s)
- Mojtaba Shafiekhani
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nazanin Azadeh
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Kiarash Ashrafzadeh
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Esmaeili
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamed Nikoupour
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
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Torres C, Badalyan V, Mohan P. Twelve-year outcomes of intestinal failure-associated liver disease in children with short-bowel syndrome: 97% transplant-free survival and 81% enteral autonomy. JPEN J Parenter Enteral Nutr 2021; 46:197-206. [PMID: 33794031 DOI: 10.1002/jpen.2112] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 03/19/2021] [Accepted: 03/25/2021] [Indexed: 01/28/2023]
Abstract
Our aim was to analyze the outcomes in children with short-bowel syndrome (SBS), parenteral nutrition dependence (PND), and intestinal failure-associated liver disease (IFALD) treated in our Intestinal Rehabilitation Program (IRP) during 2007-2018. We retrospectively reviewed charts of 135 patients with SBS-PND at the time of enrollment in IRP; of these, 89 (66%) had IFALD, defined as conjugated bilirubin (CB) of ≥2 mg/dl at enrollment and/or abnormal liver biopsy showing stage 2-4 fibrosis. Outcomes included resolution of CB, enteral autonomy, laboratory parameters (platelets, aspartate aminotransferase to platelet ratio index), growth trends, transplant rates, and mortality. Of the 89 patients, 74 had elevated CB at enrollment; the other 15 had normalized CB but had fibrosis on liver biopsy. Thirty-eight patients had liver biopsies: 36 (95%) had fibrosis, including 21/36 with bridging fibrosis/cirrhosis. The median proportion of residual small bowel was 23% (interquartile range, 13%-38%) of the expected length for age and median, daily energy requirement by PN was 100%. Two received a transplant, three died (one posttransplant), and the remaining 85 survived; 69 (81%) achieved enteral autonomy. Seventy-three (99%) of the 74 patients with hyperbilirubinemia normalized their CB with medical treatment. In a subset of eight of 89 patients with initial platelet count of <100,000/μl(median 50,500/μl) and median CB of 21 mg/dl, seven achieved CB normalization and had improved platelet count. Overall survival was 97% (censored 96.3%). We demonstrate high transplant-free survival and enteral autonomy rates among children with SBS-IFALD relying on low-dose soybean lipid emulsion.
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Affiliation(s)
- Clarivet Torres
- Intestinal Rehabilitation Program, Division of Gastroenterology, Hepatology, and Nutrition, Children's National Hospital, Washington, DC, USA.,George Washington University School of Medicine, Washington, DC, USA
| | - Vahe Badalyan
- Intestinal Rehabilitation Program, Division of Gastroenterology, Hepatology, and Nutrition, Children's National Hospital, Washington, DC, USA.,George Washington University School of Medicine, Washington, DC, USA
| | - Parvathi Mohan
- Intestinal Rehabilitation Program, Division of Gastroenterology, Hepatology, and Nutrition, Children's National Hospital, Washington, DC, USA.,George Washington University School of Medicine, Washington, DC, USA
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11
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Muto M, Kaji T, Onishi S, Yano K, Yamada W, Ieiri S. An overview of the current management of short-bowel syndrome in pediatric patients. Surg Today 2021; 52:12-21. [PMID: 33464414 DOI: 10.1007/s00595-020-02207-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 11/29/2020] [Indexed: 12/13/2022]
Abstract
Short-bowel syndrome (SBS) is defined as a state of malabsorption after resection or loss of a major portion of the bowel due to congenital or acquired factors. This article presents an overview on the recent management of pediatric SBS. The pediatric SBS population is very heterogeneous. The incidence of SBS is estimated to be 24.5 per 100,000 live births. The nutritional, medical, and surgical therapies available require a comprehensive evaluation. Thus, multidisciplinary intestinal rehabilitation programs (IRPs) are necessary for the management of these complex patients. The key points of focus in IRP management are hepato-protective strategies to minimize intestinal failure-associated liver disease; the aggressive prevention of catheter-related bloodstream infections; strategic nutritional supply to optimize the absorption of enteral calories; and the management and prevention of small bowel bacterial overgrowth, nephrocalcinosis, and metabolic bone disease. As the survival rate of children with SBS currently exceeds 90%, the application of small bowel transplantation has been evolving. The introduction of innovative treatments, such as combined therapy of intestinotrophic hormones, including glucagon-like peptide-2, may lead to further improvements in patients' quality of life.
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Affiliation(s)
- Mitsuru Muto
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Tatsuru Kaji
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima city, Kagoshima, 890-8520, Japan
| | - Shun Onishi
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Keisuke Yano
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima city, Kagoshima, 890-8520, Japan
| | - Waka Yamada
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima city, Kagoshima, 890-8520, Japan
| | - Satoshi Ieiri
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.
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12
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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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Capriati T, Mosca A, Alterio T, Spagnuolo MI, Gandullia P, Lezo A, Lionetti P, D’Antiga L, Fusaro F, Diamanti A. To Wean or Not to Wean: The Role of Autologous Reconstructive Surgery in the Natural History of Pediatric Short Bowel Syndrome on Behalf of Italian Society for Gastroenterology, Hepatology and Nutrition (SIGENP). Nutrients 2020; 12:E2136. [PMID: 32708377 PMCID: PMC7400841 DOI: 10.3390/nu12072136] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/13/2020] [Indexed: 12/15/2022] Open
Abstract
Pediatric Short Bowel Syndrome (SBS) can require prolonged parenteral nutrition (PN). Over the years, SBS management has been implemented by autologous gastrointestinal reconstructive surgery (AGIR). The primary objective of the present review was to assess the effect of AGIR on weaning off PN. We also evaluated how AGIR impacts survival, the need for transplantation (Tx) and the development of liver disease (LD). We conducted a systematic literature search to identify studies published from January 1999 to the present and 947 patients were identified. PN alone was weakly associated with higher probability of weaning from PN (OR = 1.1, p = 0.03) and of surviving (OR = 1.05, p = 0.01). Adjusting for age, the probability of weaning off PN but of not surviving remained significantly associated with PN alone (OR = 1.08, p = 0.03). Finally, adjusting for age and primary diagnosis (gastroschisis), any association was lost. The prevalence of TX and LD did not differ by groups. In conclusion, in view of the low benefit in terms of intestinal adaptation and of the not negligible rate of complications (20%), a careful selection of candidates for AGIR should be required. Bowel dilation associated with failure of advancing EN and poor growth, should be criteria to refer for AGIR.
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Affiliation(s)
- Teresa Capriati
- Artificial Nutrition Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy;
| | - Antonella Mosca
- Hepatology Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Tommaso Alterio
- Hepatology Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Maria Immacolata Spagnuolo
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, 80138 Naples, Italy;
| | - Paolo Gandullia
- Gastroenterology Unit, G.Gaslini Institute for Maternal and Child Health, IRCCS, 16145 Genova, Italy;
| | - Antonella Lezo
- Division of Nutrition, Regina Margherita Children’s Hospital, 10126 Turin, Italy;
| | - Paolo Lionetti
- Department of Neuroscience, Psychology, Pharmacology and Child’s Health, University of Florence, Meyer Hospital, 50139 Florence, Italy;
| | - Lorenzo D’Antiga
- Paediatric, Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Fabio Fusaro
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, 00165 Rome, Italy;
| | - Antonella Diamanti
- Artificial Nutrition Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy;
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