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Vanzant E, Thompson A, Mendoza A, Yeh D. Current fistula management. Curr Opin Crit Care 2024; 30:172-177. [PMID: 38441138 DOI: 10.1097/mcc.0000000000001147] [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: 03/12/2024]
Abstract
PURPOSE OF REVIEW Enterocutaneous fistulas (ECFs) pose a significant impact in the healthcare system, both financially and in resource utilization. Delivery of optimal care is complex and involves intensive wound care, complex nutritional delivery and multidisciplinary care teams for optimization. Recently, there have been pushes to modernize the traditional approach to ECF care to a new paradigm of protocol-based individualized delivery of care. RECENT FINDINGS There is an increased trend towards pushing enteral nutrition for the management of ECF patients. Adjuncts, including improved fistuloclysis devices, supplements and absorptive aides have challenged the conventional dogma of ECF treatment. There has also been increased focus on surgical prehabilitation and the ability to improve patient outcomes. SUMMARY ECF care is complex and requires a multidisciplinary approach focused on source control, nutritional optimization with focus on enteral nutrition, wound care and prehabilitation.
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Affiliation(s)
- Erin Vanzant
- University of Florida, Gainesville, Florida, USA
| | | | - April Mendoza
- University of California San Francisco-East Bay, Oakland, California
| | - Dante Yeh
- Denver Health Medical Center, Denver, Colorado
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2
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Sukhotnik I, Levi R, Moran-Lev H. Impact of Dietary Protein on the Management of Pediatric Short Bowel Syndrome. Nutrients 2023; 15:2826. [PMID: 37447153 DOI: 10.3390/nu15132826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/15/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Essential amino acids (AAs) play a key role in stimulating intestinal adaptation after massive small gut resection. The nutritional effect of dietary amino acids during intestinal regrowth has received considerable attention in recent years. This review explores the significance of dietary amino acids in the nutritional management of infants and children with intestinal failure and short bowel syndrome (SBS) as reported in the medical literature over the last three decades. A literature search was conducted using electronic databases. Breast milk emerged as the first-line enteral regimen recommended for infants with SBS. Hydrolyzed formulas (HFs) or amino acid formulas (AAFs) are recommended when breast milk is not available or if the infant cannot tolerate whole protein milk. The superiority of AAFs over HFs has never been demonstrated. Although glutamine (GLN) is the main fuel for enterocytes, GLN supplementation in infants with SBS showed no difference in the child's dependence upon parenteral nutrition (PN). Circulating citrulline is considered a major determinant of survival and nutritional prognosis of SBS patients. Early enteral nutrition and dietary supplementation of AAs following bowel resection in children are essential for the development of intestinal adaptation, thereby eliminating the need for PN.
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Affiliation(s)
- Igor Sukhotnik
- Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., Tel Aviv 6423906, Israel
| | - Reut Levi
- Department of Pediatric Gastroenterology, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., Tel Aviv 6423906, Israel
| | - Hadar Moran-Lev
- Department of Pediatric Gastroenterology, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., Tel Aviv 6423906, Israel
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3
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Modi BP, Galloway DP, Gura K, Nucci A, Plogsted S, Tucker A, Wales PW. ASPEN definitions in pediatric intestinal failure. JPEN J Parenter Enteral Nutr 2021; 46:42-59. [PMID: 34287974 DOI: 10.1002/jpen.2232] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 11/09/2022]
Abstract
Pediatric intestinal failure (PIF) is a relatively rare disease entity which requires focused interdisciplinary care and specialized nutrition management. There has long been a lack of consensus in the definition of key terms related to PIF due to its rarity and plethora of small studies rather than large trials. As such, the American Society for Parenteral and Enteral Nutrition (ASPEN) Pediatric Intestinal Failure Section, composed of clinicians from a variety of disciplines caring for children with intestinal failure, is uniquely poised to provide insight into this definition void. This document is the product of an effort by the Section to create evidence-based consensus definitions, with the goal of allowing for appropriate comparisons between clinical studies and measurement of longterm patient outcomes. This manuscript was approved by the ASPEN Board of Directors. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Biren P Modi
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David P Galloway
- Division of Gastroenterology, Hepatology and Nutrition, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kathleen Gura
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Anita Nucci
- Department of Nutrition, Georgia State University, Atlanta, Georgia, USA
| | | | - Alyssa Tucker
- Department of Clinical Nutrition, Children's National Medical Center, Washington, District of Columbia, USA
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment, Department of Surgery, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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4
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Plasma citrulline is not a biomarker for intestinal adaptation in short bowel syndrome, studied in piglets: a model for human neonates. Pediatr Surg Int 2019; 35:657-663. [PMID: 30937511 DOI: 10.1007/s00383-019-04475-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND There are no in vivo methods to measure adaptation in neonatal short bowel syndrome (SBS). We evaluated citrulline (Cit) levels in neonatal piglet surgical models of SBS. METHODS Piglets underwent 75% mid-intestinal resection with jejunoileal anastomosis (JI), 75% distal resection of ileum with jejunocolic anastomosis (JC) or sham surgery. Jugular and gastric catheters were inserted for parenteral and enteral nutrition. On D7, small intestine length and weight were measured, jejunum collected for histopathology and Cit level determined. RESULTS JI (n = 5) compared to JC (n = 5) had increased small intestinal length (JC - 17.5 cm; JI +22.0 cm; p = 0.02) and mass (JC 43.1 mg/cm/kg; JI 51.3 mg/cm/kg; p = 0.02), while Cit did not differ (JI 801.0 µM; JC 677.7 µM; p = 0.90). Including non-resected shams (n = 4), Cit correlated with length (R2 = 0.48; p = 0.006), but not for SBS alone (R2 = 0.11; p = 0.4), mass (R2 = 0.05; p = 0.5). A second experiment compared change in Cit levels from baseline to D7. Levels declined in sham (n = 8) and JC (n = 10) (sham - 110.1 µM; JC - 56.6 µM; p = 0.17), regardless of intestinal lengthening (sham 29.9 cm; JC - 10.4 cm; p = 0.002). CONCLUSION Citrulline levels predict large differences in intestinal length and 'identify' SBS. However, citrulline cannot discriminate between adaptation in JI and JC, nor predict intestinal lengthening.
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5
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Abstract
The growing population of intestinal transplant recipients present a unique challenge to the gastroenterologists responsible for their support and evaluation. Improvements in patient and graft survival are largely attributed to surgical advancements, refined antirejection therapy, and enhanced endoscopic surveillance protocols that better perceive rejection and other complications. This article reviews the endoscopic management and interventions provided for transplant recipients at the University of Illinois Hospital with complications, such as acute rejection, ischemia, bleeding, fistula, post-transplant lymphoproliferative disorder, and gastroparesis. Further research is needed on promising strategies currently used for related diseases to treat and sustain the intestinal graft.
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Affiliation(s)
- Robert E Carroll
- Department of Medicine, University of Illinois at Chicago, Chicago Veterans Administration Medical Center (West Side Division), 840 South Wood Street (M/C 787), Chicago, IL 60612, USA.
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6
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Aunsholt L, Qvist N, Sangild PT, Vegge A, Stoll B, Burrin DG, Jeppesen PB, Eriksen T, Husby S, Thymann T. Minimal Enteral Nutrition to Improve Adaptation After Intestinal Resection in Piglets and Infants. JPEN J Parenter Enteral Nutr 2017; 42:446-454. [PMID: 28786308 DOI: 10.1177/0148607117690527] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 01/01/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND Minimal enteral nutrition (MEN) may induce a diet-dependent stimulation of gut adaptation following intestinal resection. Bovine colostrum is rich in growth factors, and we hypothesized that MEN with colostrum would stimulate intestinal adaptation, compared with formula, and would be well tolerated in patients with short bowel syndrome. METHODS In experiment 1, 3-day-old piglets with 50% distal small intestinal resection were fed parenteral nutrition (PN, n = 10) or PN plus MEN given as either colostrum (PN-COL, n = 5) or formula (PN-FORM, n = 9) for 7 days. Intestinal nutrient absorption and histomorphometry were performed. In experiment 2, tolerance and feasibility of colostrum supplementation were tested in a pilot study on 5 infants who had undergone intestinal resection, and they were compared with 5 resected infants who served as controls. RESULTS In experiment 1, relative wet-weight absorption and intestinal villus height were higher in PN-COL vs PN (53% vs 23% and 362 ± 13 vs 329 ± 7 µm, P < .05). Crypt depth and tissue protein synthesis were higher in PN-COL (233 ± 7 µm, 22%/d) and PN-FORM (262 ± 13 µm, 22%/d) vs PN (190 ± 4 µm, 9%/d, both P < .05). In experiment 2, enteral colostrum supplementation was well tolerated, and no infants developed clinical signs of cow's milk allergy. CONCLUSION Minimal enteral nutrition feeding with bovine colostrum and formula induced similar intestinal adaptation after resection in piglets. Colostrum was well tolerated by newly resected infants, but the clinical indication for colostrum supplementation to infants subjected to intestinal resection remains to be determined.
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Affiliation(s)
- Lise Aunsholt
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Niels Qvist
- Department of Surgery, University Hospital of Odense, Odense, Denmark
| | - Per T Sangild
- Department of Veterinary Clinical and Animal Sciences, Frederiksberg C, Denmark.,Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen Ø, Denmark
| | - Andreas Vegge
- Department of Veterinary Clinical and Animal Sciences, Frederiksberg C, Denmark.,Global Research, Novo Nordisk, Måløv, Denmark
| | - Barbara Stoll
- Children's Nutrition Research Centre, Department of Paediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Douglas G Burrin
- Children's Nutrition Research Centre, Department of Paediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Thomas Eriksen
- Department of Veterinary Clinical and Animal Sciences, Frederiksberg C, Denmark
| | - Steffen Husby
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Thomas Thymann
- Department of Veterinary Clinical and Animal Sciences, Frederiksberg C, Denmark
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7
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Pereira-Fantini PM, Lapthorne S, Gahan CG, Joyce SA, Charles J, Fuller PJ, Bines JE. Farnesoid X Receptor Agonist Treatment Alters Bile Acid Metabolism but Exacerbates Liver Damage in a Piglet Model of Short-Bowel Syndrome. Cell Mol Gastroenterol Hepatol 2017; 4:65-74. [PMID: 28560290 PMCID: PMC5439235 DOI: 10.1016/j.jcmgh.2017.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 02/21/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Options for the prevention of short-bowel syndrome-associated liver disease (SBS-ALDs) are limited and often ineffective. The farnesoid X receptor (FXR) is a newly emerging pharmaceutical target and FXR agonists have been shown to ameliorate cholestasis and metabolic disorders. The aim of this study was to assess the efficacy of obeticholic acid (OCA) treatment in preventing SBS-ALDs. METHODS Piglets underwent 75% small-bowel resection (SBS) or sham surgery (sham) and were assigned to either a daily dose of OCA (2.4 mg/kg/day) or were untreated. Clinical measures included weight gain and stool studies. Histologic features were assessed. Ultraperformance liquid chromatography tandem mass spectrometry was used to determine bile acid composition in end point bile and portal serum samples. Gene expression of key FXR targets was assessed in intestinal and hepatic tissues via quantitative polymerase chain reaction. RESULTS OCA-treated SBS piglets showed decreased stool fat and altered liver histology when compared with nontreated SBS piglets. OCA prevented SBS-associated taurine depletion, however, further analysis of bile and portal serum samples indicated that OCA did not prevent SBS-associated alterations in bile acid composition. The expression of FXR target genes involved in bile acid transport and synthesis increased within the liver of SBS piglets after OCA administration whereas, paradoxically, intestinal expression of FXR target genes were decreased by OCA administration. CONCLUSIONS Administration of OCA in SBS reduced fat malabsorption and altered bile acid composition, but did not prevent the development of SBS-ALDs. We postulate that extensive small resection impacts the ability of the remnant intestine to respond to FXR activation.
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Key Words
- Bile Acids
- CDCA, chenodeoxycholic acid
- DCA, deoxycholic acid
- FGF19, fibroblast growth factor-19
- FXR, farnesoid X receptor
- Farnesoid X Receptor
- HCA, hyocholic acid
- HDCA, hyodeoxycholic acid
- Intestinal Failure–Associated Liver Disease
- LCA, lithocholic acid
- Liver Disease
- OCA, obeticholic acid
- Obeticholic Acid
- SBS, short-bowel syndrome
- SBS-ALD, short-bowel syndrome–associated liver disease
- Short-Bowel Syndrome
- UDCA, ursodeoxycholic acid
- UPLC, ultraperformance liquid chromatography
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Affiliation(s)
- Prue M. Pereira-Fantini
- Intestinal Failure and Clinical Nutrition Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Susan Lapthorne
- Intestinal Failure and Clinical Nutrition Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Cormac G.M. Gahan
- APC Microbiome Institute, University College Cork, Cork, Ireland,School of Microbiology, University College Cork, Cork, Ireland,School of Pharmacy, University College Cork, Cork, Ireland
| | - Susan A. Joyce
- APC Microbiome Institute, University College Cork, Cork, Ireland,School of Biochemistry, University College Cork, Cork, Ireland
| | - Jenny Charles
- Department of Veterinary and Agricultural Sciences, University of Melbourne, Parkville, Australia
| | - Peter J. Fuller
- Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Julie E. Bines
- Intestinal Failure and Clinical Nutrition Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia,Department of Paediatrics, University of Melbourne, Parkville, Australia,Department of Gastroenterology and Clinical Nutrition, Royal Children’s Hospital, Parkville, Victoria, Australia,Correspondence Address correspondence to: Julie E. Bines, MD, FRACP, Department of Paediatrics, The University of Melbourne, Royal Children’s Hospital, Level 2, 50 Flemington Road, Parkville, Victoria 3052, Australia. fax: (613) 9345-6667.Department of PaediatricsThe University of MelbourneRoyal Children’s HospitalLevel 2, 50 Flemington RoadParkvilleVictoria 3052Australia
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8
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Guo M, Lu C, Li Y. Early Intestinal Rehabilitation Therapy Ameliorates Intestinal Adaptation in Children with Short Bowel Syndrome: The Long-Term Outcome. Am Surg 2016. [DOI: 10.1177/000313481608201229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
In the management of short bowel syndrome (SBS), the benefits of treatment with growth hormone (GH), glutamine, and enteral nutrition (EN) on intestinal adaptation among children patients is still controversial. The aim of present study is to determine whether GH, glutamine, and EN have positive effect on intestinal adaptation in children with SBS. Sixteen children with SBS (small bowel remnant length, 56.75 ± 8.09 cm; mean ± SE) were treated with GH (0.05 mg/kg/d), glutamine (0.45 mg/kg/d), plus EN-enriched fiber diet for four weeks. After four weeks of treatment, patients were discharged home; GH was discontinued, but the EN with glutamine was continued. Repeated treatment was performed if there were lose weight, dysplasia, or severe diarrhea. All patients completed the treatment. Body weight, intestinal absorptive capacity, and plasma levels of proteins were significantly improved after complete treatment, without any major adverse effects. On follow-up, no death was reported. Treatment with GH, glutamine, and EN in early stage significantly improved intestinal adaptation in pediatric patients with SBS. Furthermore, the positive effect of the treatment does not seem to be sustained once GH discontinued until the residual intestinal adaptation reaches its maximum.
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Affiliation(s)
- Mingxiao Guo
- Department of Laparoscopic Surgery Center, Linyi People's Hospital, Shandong University, Linyi, China and
| | - Chunlei Lu
- Department of Laparoscopic Surgery Center, Linyi People's Hospital, Shandong University, Linyi, China and
| | - Yousheng Li
- Department of Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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9
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Pereira-Fantini PM, Bines JE, Lapthorne S, Fouhy F, Scurr M, Cotter PD, Gahan CG, Joyce SA. Short bowel syndrome (SBS)-associated alterations within the gut-liver axis evolve early and persist long-term in the piglet model of short bowel syndrome. J Gastroenterol Hepatol 2016; 31:1946-1955. [PMID: 27037739 DOI: 10.1111/jgh.13383] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/22/2016] [Accepted: 03/17/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIM Short bowel syndrome (SBS) is primarily characterized by malabsorption and malnutrition, resulting from loss of intestinal absorptive area following massive small bowel resection (SBR). Bile acids and the gut microbiota are functionally linked within the gut-liver axis; however, SBS-associated disturbances within the gut-liver axis remain largely unexplored. The aim of this study was to characterize the evolution of bile acid alterations within the gut-liver axis at both short-term and long-term time points and to relate these changes to alterations in colonic bacterial composition. METHODS Four-week-old piglets were assigned to 75% SBR, sham-operation or non-operation control groups. High throughput sequencing was employed to determine bacterial abundance in colonic content and ultra-performance liquid chromatography used to determine the bile acid concentration of gall bladder, portal serum, and fecal samples. RESULTS Bile acid complexity and relative abundance are altered in the SBS piglet model at two weeks post-SBR, and these changes persisted at six weeks post-SBR. Our examination of the microbial profile revealed an early and persistent loss in bacteria belonging to the Clostridiales order. CONCLUSIONS This study provides evidence of an early and persistent disturbance of the bile acid profile throughout the entero-hepatic circulation with an increase in the proportion of primary bile acids and a decrease in secondary bile acids following SBR. These changes were associated with a loss of bacteria belonging to the Clostridiales order consistent with a disturbance in the bile-microbial axis following SBR.
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Affiliation(s)
- Prue M Pereira-Fantini
- Intestinal Failure and Clinical Nutrition Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Julie E Bines
- Intestinal Failure and Clinical Nutrition Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Susan Lapthorne
- Intestinal Failure and Clinical Nutrition Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Fiona Fouhy
- School of Microbiology, University College Cork, Cork, Ireland.,Teagasc Food Research Centre, Moorepark, Fermoy, County Cork, Ireland
| | - Michelle Scurr
- Intestinal Failure and Clinical Nutrition Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Paul D Cotter
- Teagasc Food Research Centre, Moorepark, Fermoy, County Cork, Ireland.,APC Microbiome Institute, University College Cork, Cork, Ireland
| | - Cormac Gm Gahan
- School of Microbiology, University College Cork, Cork, Ireland.,APC Microbiome Institute, University College Cork, Cork, Ireland.,School of Pharmacy, University College Cork, Cork, Ireland
| | - Susan A Joyce
- APC Microbiome Institute, University College Cork, Cork, Ireland
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10
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Nosworthy MG, Dodge ME, Bertolo RF, Brunton JA. Enterally delivered dipeptides improve small intestinal inflammatory status in a piglet model of intestinal resection. Clin Nutr 2016; 35:852-8. [DOI: 10.1016/j.clnu.2015.05.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 04/23/2015] [Accepted: 05/24/2015] [Indexed: 11/24/2022]
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11
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Yang H, Xiong X, Yin Y. Metabolomic analysis of intestinal epithelial cell maturation along the crypt–villus axis. RSC Adv 2016. [DOI: 10.1039/c5ra27722a] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The present experiment showed a gradual change in the metabolism of intestinal epithelial cells during maturation along CVA. Metabolism of fatty acids, amino acids, and glucose was significantly different between villus and crypt cells.
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Affiliation(s)
- Huansheng Yang
- Chinese Academy of Science
- Institute of Subtropical Agriculture
- Research Center of Healthy Breeding Livestock & Poultry
- Human Engineering & Research Center of Animal & Poultry Science
- Key Lab Agroecology Processing Subtropical Region
| | - Xia Xiong
- Chinese Academy of Science
- Institute of Subtropical Agriculture
- Research Center of Healthy Breeding Livestock & Poultry
- Human Engineering & Research Center of Animal & Poultry Science
- Key Lab Agroecology Processing Subtropical Region
| | - Yulong Yin
- Chinese Academy of Science
- Institute of Subtropical Agriculture
- Research Center of Healthy Breeding Livestock & Poultry
- Human Engineering & Research Center of Animal & Poultry Science
- Key Lab Agroecology Processing Subtropical Region
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12
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Till H, Castellani C, Moissl-Eichinger C, Gorkiewicz G, Singer G. Disruptions of the intestinal microbiome in necrotizing enterocolitis, short bowel syndrome, and Hirschsprung's associated enterocolitis. Front Microbiol 2015; 6:1154. [PMID: 26528281 PMCID: PMC4607865 DOI: 10.3389/fmicb.2015.01154] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 10/05/2015] [Indexed: 12/22/2022] Open
Abstract
Next generation sequencing techniques are currently revealing novel insight into the microbiome of the human gut. This new area of research seems especially relevant for neonatal diseases, because the development of the intestinal microbiome already starts in the perinatal period and preterm infants with a still immature gut associated immune system may be harmed by a dysproportional microbial colonization. For most gastrointestinal diseases requiring pediatric surgery there is very limited information about the role of the intestinal microbiome. This review aims to summarize the current knowledge and outline future perspectives for important pathologies like necrotizing enterocolitis (NEC) of the newborn, short bowel syndrome (SBS), and Hirschsprung’s disease associated enterocolitis (HAEC). Only studies applying next generation sequencing techniques to analyze the diversity of the intestinal microbiome were included. In NEC patients intestinal dysbiosis could already be detected prior to any clinical evidence of the disease resulting in a reduction of the bacterial diversity. In SBS patients the diversity seems to be reduced compared to controls. In children with Hirschsprung’s disease the intestinal microbiome differs between those with and without episodes of enterocolitis. One common finding for all three diseases seems to be an overabundance of Proteobacteria. However, most human studies are based on fecal samples and experimental data question whether fecal samples actually represent the microbiome at the site of the diseased bowel and whether the luminal (transient) microbiome compares to the mucosal (resident) microbiome. In conclusion current studies already allow a preliminary understanding of the potential role of the intestinal microbiome in pediatric surgical diseases. Future investigations could clarify the interface between the intestinal epithelium, its immunological competence and mucosal microbiome. Advances in this field may have an impact on the understanding and non-operative treatment of such diseases in infancy.
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Affiliation(s)
- Holger Till
- Department of Paediatric and Adolescent Surgery, Medical University of Graz Graz, Austria
| | - Christoph Castellani
- Department of Paediatric and Adolescent Surgery, Medical University of Graz Graz, Austria
| | | | | | - Georg Singer
- Department of Paediatric and Adolescent Surgery, Medical University of Graz Graz, Austria
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13
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Aunsholt L, Thymann T, Qvist N, Sigalet D, Husby S, Sangild PT. Prematurity Reduces Functional Adaptation to Intestinal Resection in Piglets. JPEN J Parenter Enteral Nutr 2014; 39:668-76. [PMID: 24687966 DOI: 10.1177/0148607114528714] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 02/28/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Necrotizing enterocolitis and congenital gastrointestinal malformations in infants often require intestinal resection, with a subsequent risk of short bowel syndrome (SBS). We hypothesized that immediate intestinal adaptation following resection of the distal intestine with placement of a jejunostomy differs between preterm and term neonates. METHODS Preterm or term piglets were born by cesarean section and fed enterally for 2 days. On day 2, piglets were subjected to 50% distal intestinal resection with placement of a jejunostomy. On the following 4-5 days, piglets received parenteral nutrition with gradually increasing doses of enteral nutrition (bovine colostrum). Intestinal tissue samples were collected at delivery and 2 and 6-7 days after birth for histological examination and assessment of digestive enzyme activities. RESULTS Preterm and term piglets showed similar increases in intestinal weight and digestive enzyme activities from birth to 2 days. On days 6-7 after birth, the remnant intestine showed a similar density (g/cm) and mucosal mass in term and preterm piglets, but villus height, crypt depth, enzyme activities (sucrase, maltase, dipeptidyl peptidase IV [DPPIV]), and hexose uptake capacity were significantly higher in term piglets (P < .05). Preterm piglets were more prone to develop hypoglycemia, respiratory distress syndrome, dehydration, and circulatory instability after surgery compared with term piglets. CONCLUSION Studies on intestinal adaptation after resection are feasible in both preterm and term piglets, but intensive clinical support is required when rearing preterm piglets with SBS. Physiological instability and immaturity of the intestine may explain the fact that immediate adaptation after resection is reduced in preterm vs term neonates.
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Affiliation(s)
- Lise Aunsholt
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Thomas Thymann
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Niels Qvist
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - David Sigalet
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Steffen Husby
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Per Torp Sangild
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
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14
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Abstract
Short bowel syndrome (SBS) is a reduction in functioning bowel length which is most often a result of surgical resection. Risk factors in the neonatal period include necrotising enterocolitis, small bowel atresia and gastroschisis. With increasing survival of preterm infants there is an increase in incidence. Management is dependent on the use of parenteral nutrition to maintain fluid and electrolyte homeostasis and promote growth and development with the longer term aim being to promote intestinal adaptation to achieve partial or complete enteral autonomy. In this review we discuss the incidence, aetiology, pathophysiology, medical and surgical treatments and outcome.
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Lapthorne S, Pereira-Fantini PM, Fouhy F, Wilson G, Thomas SL, Dellios NL, Scurr M, O’Sullivan O, Ross RP, Stanton C, Fitzgerald GF, Cotter PD, Bines JE. Gut microbial diversity is reduced and is associated with colonic inflammation in a piglet model of short bowel syndrome. Gut Microbes 2013; 4:212-21. [PMID: 23549027 PMCID: PMC3669166 DOI: 10.4161/gmic.24372] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Following small bowel resection (SBR), the luminal environment is altered, which contributes to clinical manifestations of short bowel syndrome (SBS) including malabsorption, mucosal inflammation and bacterial overgrowth. However, the impact of SBR on the colon has not been well-defined. The aims of this study were to characterize the colonic microbiota following SBR and to assess the impact of SBR on mucosal inflammation in the colon. RESULTS Analysis of the colonic microbiota demonstrated that there was a significant level of dysbiosis both two and six weeks post-SBR, particularly in the phylum Firmicutes, coupled with a decrease in overall bacterial diversity in the colon. This decrease in diversity was associated with an increase in colonic inflammation six weeks post-surgery. METHODS Female (4-week old) piglets (5-6/group) received a 75% SBR, a transection (sham) or no surgery. Compositional analysis of the colonic microbiota was performed by high-throughput sequencing, two- and six-weeks post-surgery. The gene expression of the pro-inflammatory cytokines interleukin (IL)-1β, IL-6, IL-8, IL-18 and tumor necrosis factor (TNF)-α in the colonic mucosa was assessed by qRT-PCR and the number of macrophages and percentage inducible nitric oxide synthase (iNOS) staining in the colonic epithelium were quantified by immunohistochemistry. CONCLUSIONS SBR significantly decreased the diversity of the colonic microbiota and this was associated with an increase in colonic mucosal inflammation. This study supports the hypothesis that SBR has a significant impact on the colon and that this may play an important role in defining clinical outcome.
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Affiliation(s)
- Susan Lapthorne
- Intestinal Failure and Clinical Nutrition Group; Murdoch Childrens Research Institute; Parkville, Australia,Correspondence to: Susan Lapthorne,
| | - Prue M. Pereira-Fantini
- Intestinal Failure and Clinical Nutrition Group; Murdoch Childrens Research Institute; Parkville, Australia
| | - Fiona Fouhy
- Teagasc Food Research Centre; Moorepark; Fermoy, Ireland,Department of Microbiology; University College Cork; Cork, Ireland
| | - Guineva Wilson
- Intestinal Failure and Clinical Nutrition Group; Murdoch Childrens Research Institute; Parkville, Australia
| | - Sarah L. Thomas
- Intestinal Failure and Clinical Nutrition Group; Murdoch Childrens Research Institute; Parkville, Australia
| | - Nicole L. Dellios
- Intestinal Failure and Clinical Nutrition Group; Murdoch Childrens Research Institute; Parkville, Australia
| | - Michelle Scurr
- Intestinal Failure and Clinical Nutrition Group; Murdoch Childrens Research Institute; Parkville, Australia
| | | | - R. Paul Ross
- Teagasc Food Research Centre; Moorepark; Fermoy, Ireland,Alimentary Pharmabiotic Centre; University College Cork; Cork, Ireland
| | - Catherine Stanton
- Teagasc Food Research Centre; Moorepark; Fermoy, Ireland,Alimentary Pharmabiotic Centre; University College Cork; Cork, Ireland
| | - Gerald F. Fitzgerald
- Department of Microbiology; University College Cork; Cork, Ireland,Alimentary Pharmabiotic Centre; University College Cork; Cork, Ireland
| | - Paul D. Cotter
- Teagasc Food Research Centre; Moorepark; Fermoy, Ireland,Alimentary Pharmabiotic Centre; University College Cork; Cork, Ireland
| | - Julie E. Bines
- Intestinal Failure and Clinical Nutrition Group; Murdoch Childrens Research Institute; Parkville, Australia,Department of Paediatrics; University of Melbourne; Parkville, Australia,Department of Gastroenterology and Clinical Nutrition; Royal Children’s Hospital; Parkville, Australia
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Reddy VS, Patole SK, Rao S. Role of probiotics in short bowel syndrome in infants and children--a systematic review. Nutrients 2013; 5:679-99. [PMID: 23462584 PMCID: PMC3705313 DOI: 10.3390/nu5030679] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 02/11/2013] [Accepted: 02/19/2013] [Indexed: 12/24/2022] Open
Abstract
Short bowel syndrome (SBS) is a cause of significant morbidity and mortality in children. Probiotics, due to their beneficial effects on the gastrointestinal tract (e.g., improving gut barrier function, motility, facilitation of intestinal adaptation and decreasing pathogen load and inflammation) may have a therapeutic role in the management of SBS. To conduct a systematic review of the current evidence for the effects of probiotic supplementation in children with SBS, the standard Cochrane methodology for systematic reviews was used. The databases, Pubmed, Embase, ACTR, CENTRAL, and the international trial registry, and reference lists of articles were searched for randomised (RCT) or quasi-randomised controlled trials reporting on the use of probiotics in SBS. Our search revealed no RCTs on the use of probiotics in children with SBS. We found one small cross-over RCT (placebo controlled crossover clinical trial), one case control study and nine case reports on the use of probiotics in children with SBS. In the crossover RCT, there was no consistent effect on intestinal permeability (primary outcome) after supplementation with Lactobacillus rhamnosus (LGG) in nine children with SBS. The case control study (four cases: four controls) reported a trend for increase in height and weight velocity and improvement in non-clinical outcomes, such as gut flora, lymphocyte count and serum prealbumin. Five of the nine case reports showed that children (n = 12) with SBS were benefited (e.g., cessation of diarrhoea, improved faecal flora, weight gain and weaning from parenteral nutrition) by probiotic supplementation. The remaining four reported on the adverse effects, such as Lactobacillus sepsis (n = 3) and D-lactic acidosis (n = 2). There is insufficient evidence on the effects of probiotics in children with SBS. The safety and efficacy of probiotic supplementation in this high-risk cohort needs to be evaluated in large definitive trials.
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Affiliation(s)
- Vudum S. Reddy
- Department of Neonatology, King Edward Memorial Hospital for Women, Subiaco, Perth, WA 6008, Australia; E-Mail:
| | - Sanjay K. Patole
- Department of Neonatology, King Edward Memorial Hospital for Women, Subiaco, Perth, WA 6008, Australia; E-Mail:
- Centre for Neonatal Research and Education, University of Western Australia, Perth, WA 6008, Australia; E-Mail:
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +61-8-93401260, Fax: +61-8-93401266
| | - Shripada Rao
- Centre for Neonatal Research and Education, University of Western Australia, Perth, WA 6008, Australia; E-Mail:
- Department of Neonatology, Princess Margaret Hospital, Perth, WA 6008, Australia
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Abstract
Short bowel syndrome (SBS) is the most common cause of intestinal failure in infants. In neonates and young infants, necrotizing enterocolitis, gastroschisis, intestinal atresia, and intestinal malrotation/volvulus are the leading causes of SBS. Following an acute postsurgical phase, the residual gastrointestinal tract adapts with reorganization of the crypt-villus histoarchitecture and functional changes in nutrient absorption and motility. A cohesive, multidisciplinary approach can allow most neonates with SBS to transition to full enteral feeds and achieve normal growth and development. In this article, the clinical features, management, complications, and prognostic factors in SBS are reviewed.
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Hübner S, Efthymiadis A. Recent progress in histochemistry and cell biology. Histochem Cell Biol 2012; 137:403-57. [PMID: 22366957 DOI: 10.1007/s00418-012-0933-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2012] [Indexed: 01/06/2023]
Abstract
Studies published in Histochemistry and Cell Biology in the year 2011 represent once more a manifest of established and newly sophisticated techniques being exploited to put tissue- and cell type-specific molecules into a functional context. The review is therefore the Histochemistry and Cell Biology's yearly intention to provide interested readers appropriate summaries of investigations touching the areas of tissue biology, developmental biology, the biology of the immune system, stem cell research, the biology of subcellular compartments, in order to put the message of such studies into natural scientific-/human- and also pathological-relevant correlations.
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Affiliation(s)
- Stefan Hübner
- Institute of Anatomy and Cell Biology, University of Würzburg, Würzburg, Germany.
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19
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Peretti N, Loras-Duclaux I, Kassai B, Restier-Miron L, Guimber D, Gottrand F, Coopman S, Michaud L, Marinier E, Yantren H, Michalski MC, Aubert F, Mercier C, Pelosse M, Lopez M, Chatelain P, Lachaux A. Growth hormone to improve short bowel syndrome intestinal autonomy: a pediatric randomized open-label clinical trial. JPEN J Parenter Enteral Nutr 2011; 35:723-31. [PMID: 21975668 DOI: 10.1177/0148607111415531] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The ability of growth hormone (GH) to promote the weaning-off of parenteral nutrition (PN) in short bowel syndrome (SBS) is unclear. No randomized controlled study is available in children. This study was undertaken to determine if GH could enhance the weaning off of PN in PN-dependent children with SBS. METHODS A prospective randomized open-label multicenter study was performed in 14 patients (mean age, 9 ± 1.4 years) with SBS (average small bowel length, 33 cm) and long-term PN dependency (8 years) on an unrestricted diet. A standardized PN decrease with and without GH (0.14 mg/kg/d) was conducted. The patients were randomized to either a GH group (4 months of GH) or a control (CTR) group (4 months without GH, followed by 4 months with GH). Blood tests and a nutrition assessment of enteral and parenteral intakes were performed. Groups were compared with the Wilcoxon test. RESULTS Treatment with GH did not improve the weaning off of PN (decrease in PN caloric intake of 32.5% ± 9.6% in the GH group vs 35.2% ± 8.7% in the CTR group, nonsignificant). In the CTR group, GH treatment induced an additional but not statistically significant decrease of 8.8% ± 12.4% in daily calories. Parenteral needs returned to near basal rates 6 months after GH discontinuation (GH: 77.6% ± 10.6% vs CTR: 73.2% ± 7.4%). Weight decreased slightly in both groups. No biological parameters varied significantly. CONCLUSIONS GH did not improve the weaning off of PN in PN-dependent children with SBS.
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Affiliation(s)
- Noel Peretti
- Université Lyon 1, Faculté de Médecine Lyon Est, Lyon, France.
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Pereira-Fantini PM, Thomas SL, Wilson G, Taylor RG, Sourial M, Bines JE. Short- and long-term effects of small bowel resection: a unique histological study in a piglet model of short bowel syndrome. Histochem Cell Biol 2011; 135:195-202. [DOI: 10.1007/s00418-011-0778-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2011] [Indexed: 01/13/2023]
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Barclay AR, Beattie LM, Weaver LT, Wilson DC. Systematic review: medical and nutritional interventions for the management of intestinal failure and its resultant complications in children. Aliment Pharmacol Ther 2011; 33:175-84. [PMID: 21091524 DOI: 10.1111/j.1365-2036.2010.04514.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intestinal failure (IF) affects a growing number of children due to increasing numbers of preterm infants surviving intestinal resection for necrotising enterocolitis and improving surgical techniques for congenital gut anomalies. Parenteral nutrition (PN) is the mainstay of therapy; enteral nutrition may have trophic effects on the gut. AIM To review systematically evidence for the effectiveness of medical and nutritional interventions in the treatment of IF in children. METHODS Retrieval of data from studies of patients aged <18 years and receiving >28 days of PN. Outcome measures were improvement in intestinal function, intestinal adaptation, growth, prevention and treatment of IF-associated liver disease, and mortality. Cochrane Database (November 2009), MEDLINE (1950-November 2009) and CINAHL (1982-November 2009) electronic database searches were made using keyword and subject headings (MeSH): IF, Short Bowel Syndrome (SBS), PN and Child. The level of the evidence (EL) was assessed using SIGN (Scottish Intercollegiate Guidelines Network) methodology (http://www.sign.ac.uk). RESULTS From 1 607 620 hits, 720 abstracts were reviewed. Thirty-three original articles were included. No studies were of high methodological quality. CONCLUSIONS The evidence base for medical and nutritional interventions in paediatric IF is limited and of poor quality. In the absence of randomised-controlled trials, this evidence base can improve through case control and cohort research; and with better multiagency communication, the study of inter-centre differences is possible. Achievable short-term goals would include the study of: optimal ursodeoxycholic usage, novel intralipid formulations, cycled enteral antibiotics, enteral probiotics and new enteral feeding strategies.
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Affiliation(s)
- A R Barclay
- Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Glasgow, UK.
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Morphological and functional changes in the colon after massive small bowel resection. J Pediatr Surg 2010; 45:1581-90. [PMID: 20713204 DOI: 10.1016/j.jpedsurg.2010.02.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Revised: 02/03/2010] [Accepted: 02/03/2010] [Indexed: 12/17/2022]
Abstract
PURPOSE Anecdotal evidence suggests that the colon plays an important role after small bowel resection (SBR). However, colonic changes have not previously been studied. The aim of this study was to characterize morphological and functional changes within the colon after SBR and elucidate the influence of diet complexity on adaptation. METHOD In study 1, 4-week-old piglets underwent a 75% SBR or sham operation and were studied at 2, 4, and 6 weeks postoperation to allow analysis of early and late adaptation responses. Piglets received a polymeric infant formula (PIF). In study 2, SBR piglets received an elemental diet and were studied at 6 weeks postoperation and compared with SBR + PIF piglets from study 1. For both studies, immunohistochemistry was used to quantitate intestinal cell types. Changes in functional proteins were measured by Western blot, enteroendocrine/peptide YY (PYY), enterocyte/liver fatty acid binding protein (L-FABP), and goblet cells/trefoil factor 3 (TFF3). RESULTS In study 1, early and late adaptation-related changes were observed after SBR. Early adaptation included increased numbers of enterocytes (P = .0001), whereas late adaptation included increased proliferative cell numbers (P = .02). Enteroendocrine, goblet, and apoptotic cells numbers were significantly elevated in the resected group at all time-points studied (P < .05). Functional changes included increased levels of L-FABP (P = .04) and PYY (P = .03). There was no change in TFF3 expression. In study 2, feeding with an elemental diet resulted in suboptimal adaptation as evidenced by reduced rate of weight gain and significant reductions in total cell numbers (P = .0001), proliferative (P = .0001) and apoptotic cells (P = .04), enteroendocrine cells (P = .001), and PYY expression (P .004). CONCLUSION These findings indicate that significant morphological and functional changes occur in the colon after massive SBR and that these occur as early and late adaptation responses. Elemental diet was associated with suboptimal adaptation suggesting an effect of diet complexity on colonic adaptation.
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Effects of Thyroid Hormone on the Adaptation in Short Bowel Syndrome. J Surg Res 2009; 155:116-24. [PMID: 19111325 DOI: 10.1016/j.jss.2008.07.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Revised: 07/09/2008] [Accepted: 07/22/2008] [Indexed: 02/08/2023]
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Abstract
Short bowel syndrome (SBS) is the most common cause of intestinal failure. This article discusses the prognostic factors that predict weaning from parenteral nutrition in SBS. The article also delineates an approach to enteral feeding in SBS.
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Pereira-Fantini PM, Thomas SL, Taylor RG, Nagy E, Sourial M, Fuller PJ, Bines JE. Colostrum supplementation restores insulin-like growth factor -1 levels and alters muscle morphology following massive small bowel resection. JPEN J Parenter Enteral Nutr 2008; 32:266-75. [PMID: 18443138 DOI: 10.1177/0148607108316197] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Colostrum protein concentrate (CPC) contains a high level of insulin-like growth factor-1 (IGF-1). IGF-1 and IGF binding protein (IGFBPs) may play an important role during the postresection adaptation response. As smooth muscle is an important site for IGF-1 action in the intestine, this study aims to (1) investigate the effect of CPC supplementation on circulating levels and tissue expression of IGF-1, IGF-1 receptor, and IGFBPs following massive small bowel resection (MSBR), and (2) characterize the effect of CPC on the muscular adaptation response following MSBR. METHODS Four-week-old piglets underwent either a 75% MSBR or sham operation. Piglets received either a polymeric infant formula (PIF) diet or PIF supplemented with CPC for 8 weeks. Serum was analyzed by enzyme-linked immunosorbent assay, and ileal tissue assessed by molecular and histological analysis. RESULTS There was no difference in IGF-1 or IGFBPs mRNA among groups. CPC treatment resulted in significant increases in circulating levels of IGF-1 and IGFBPs and a concurrent increase in muscle width and the number of muscle cells, but did not alter muscle cell size. CONCLUSIONS Strategies aimed at increasing muscular adaptation may decrease Gl transit and allow greater mucosal contact time for absorption. We have shown that CPC supplementation following resection results in increased levels of circulating IGF-1, IGFBP-2, and IGFBP-3 and muscular hypertrophy. Our results suggest that IGF-1 and its mediators may play a role in the muscular adaptation response and warrant further exploration as a treatment option for short bowel syndrome.
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Affiliation(s)
- Prue M Pereira-Fantini
- Intestinal Failure and Clinical Nutrition Group, Murdoch Childrens Research Institute, Atlantic Philanthropy Building, Flemington Road, Parkville 3052, Victoria, Australia.
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Schaart MW, de Bruijn ACJM, Tibboel D, Renes IB, van Goudoever JB. Dietary protein absorption of the small intestine in human neonates. JPEN J Parenter Enteral Nutr 2008; 31:482-6. [PMID: 17947603 DOI: 10.1177/0148607107031006482] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The intestine plays a key role in the absorption of dietary proteins, which determines growth of human neonates. Bowel resection in the neonatal period brings loss of absorptive and protective surface and may consequently lead to malabsorption of dietary nutrients. However, there are no data on net dietary protein absorption of the small intestine in the period after intestinal surgery in human neonates. We therefore evaluated dietary feeding tolerance and quantified net dietary protein absorption capacity of the small intestine in human neonates in whom a temporary jejunostomy or ileostomy was created. METHODS Seventeen patients were included in the study. We collected small intestinal outflow fluid at the level of the enterostomy weekly for 24-48 hours during weeks 3 through 6 postoperatively. Protein levels in the intestinal outflow fluid were determined by bicinchoninic acid (BCA) assay. RESULTS In 14 patients, an enteral intake of >100 mL/kg/d was reached at a median of 17 days (range, 8-32 days) postoperatively. Three patients did not reach this level within the study period. Overall, the net dietary protein absorption capacity was 70%-90% of the total enteral protein intake. CONCLUSIONS This study demonstrates that the dietary protein absorption capacity of the small intestine is intact in most human neonates after intestinal surgery in a very critical period of their lives. Furthermore, our results do not support the use of hydrolyzed or elemental formula in newborns with an enterostomy to improve amino acid uptake.
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Affiliation(s)
- Maaike W Schaart
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Pereira PM, Bines JE. New growth factor therapies aimed at improving intestinal adaptation in short bowel syndrome. J Gastroenterol Hepatol 2006; 21:932-40. [PMID: 16724975 DOI: 10.1111/j.1440-1746.2006.04351.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Short bowel syndrome (SBS) is used to describe a condition of malabsorption and malnutrition resulting from the loss of absorptive area following massive small bowel resection. The key to improved clinical outcome after massive small bowel resection is the ability of the residual bowel to adapt. Although still in experimental stages, a major goal in the management of SBS may be the augmented use of growth factors to promote increased adaptation. A number of growth factors have been implicated in promoting the adaptation process. The best-described growth factors are reviewed: glucagon-like peptide-2 (GLP-2), epidermal growth factor (EGF), and growth hormone (GH). This article reviews the ability of recombinant GLP-2, EGF and GH to modulate structural and functional aspects of intestinal adaptation following small bowel resection. Although these growth factors have shown promise, small sample size, inconsistent measurement parameters and uncontrolled study designs have hampered the acquisition of strong data advocating the use of growth factor treatment for SBS. Multicenter trials using well-defined outcome measures to assess clinical efficacy are needed to direct the clinical indications, timing and duration of therapy and assess potential risks associated with growth factor therapies.
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Affiliation(s)
- Prue M Pereira
- Murdoch Children's Research Institute, Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Flemington Road, Parkville, Melbourne, Victoria 3052, Australia.
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Ladd AP, Grosfeld JL, Pescovitz OH, Johnson NB. The effect of growth hormone supplementation on late nutritional independence in pediatric patients with short bowel syndrome. J Pediatr Surg 2005; 40:442-5. [PMID: 15750945 DOI: 10.1016/j.jpedsurg.2004.10.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE The use of growth hormone (GH) supplementation for intestinal adaptation among adult patients with short bowel syndrome (SBS) has provided mixed results. This report examines the effect of GH supplementation on SBS in pediatric patients. METHODS Two girls with SBS from neonatal gastrointestinal catastrophes received exogenous GH at 0.3 mg/kg per week subcutaneously and concurrent glutamine supplementation, beginning at 6 and 6(1/2) years of age. Changes in growth (height and weight) and changes in enteral and parenteral energy requirements were evaluated. RESULTS Treatment duration was 8 and 2.5 years, respectively. Patient weights increased from the 5th to the 41st percentile and from the 17th to the 23rd percentile, respectively. Height increased from the 1st to the 57th percentile in the former patient and increased from less than the 1st to the 17th percentile in the latter. Both patients are independent of parenteral nutrition and take enteral nutrition alone. Tolerance for enteral diets was significantly improved in each girl, with only 2 stools per day maintained in one patient. CONCLUSIONS The data show that late exogenous treatment with GH and glutamine supplementation improved growth parameters in pediatric patients with SBS. Growth hormone and glutamine supplementation may be beneficial in promoting late intestinal adaptation in pediatric patients with SBS. These data also suggest that these adjuncts may be useful in the early phases of intestinal adaptation.
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Affiliation(s)
- Alan P Ladd
- Section of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine and Riley Children's Hospital, Indianapolis, IN 46202, USA.
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Abstract
Intestinal failure (IF) can be defined as the reduction of functional gut mass below the minimal amount necessary for digestion and absorption adequate to satisfy the nutrient and fluid requirements for maintenance in adults or growth in children. In developed countries, IF mainly includes individuals with the congenital or early onset of conditions requiring protracted or indefinite parenteral nutrition (PN). Short bowel syndrome was the first commonly recognized cause of protracted IF. The normal physiologic process of intestinal adaptation after extensive resection usually allows for recovery of sufficient intestinal function within weeks to months. During this time, patients can be sustained on parenteral nutrition. Only a few children have permanent intestinal insufficiency and life-long dependency on PN. Non-transplant surgery including small bowel tapering and lengthening may allow weaning from PN in some cases. Hormonal therapy with recombinant human growth hormone has produced poor results while therapy with glucagon-like peptide-2 holds promise. Congenital diseases of enterocyte development such as microvillus inclusion disease or intestinal epithelial dysplasia cause permanent IF for which no curative medical treatment is currently available. Severe and extensive motility disorders such as total or subtotal intestinal aganglionosis (long segment Hirschsprung disease) or chronic intestinal pseudo-obstruction syndrome may also cause permanent IF. PN and home-PN remain are the mainstays of therapy regardless of the cause of IF. Some patients develop complications while receiving long-term PN for IF especially catheter related complications (thrombosis, sepsis) and liver disease. These patients may be candidates for intestinal transplantation. This review discusses the causes of irreversible IF and emphasizes the specific medico-surgical strategies for prevention and treatment of these conditions at several stages of IF.
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Affiliation(s)
- Olivier Goulet
- Département de Gastroentérologie, Hépatologie et Nutrition Pédiatriques, Hôpital Necker- Infants Malades and INSERM, Faculté de Necker, Paris, France.
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