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Pironi L, Cuerda C, Jeppesen PB, Joly F, Jonkers C, Krznarić Ž, Lal S, Lamprecht G, Lichota M, Mundi MS, Schneider SM, Szczepanek K, Van Gossum A, Wanten G, Wheatley C, Weimann A. ESPEN guideline on chronic intestinal failure in adults - Update 2023. Clin Nutr 2023; 42:1940-2021. [PMID: 37639741 DOI: 10.1016/j.clnu.2023.07.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND & AIMS In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines. METHODS The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly. RESULTS The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%). CONCLUSIONS It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.
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Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Center for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy.
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Francisca Joly
- Center for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Cora Jonkers
- Nutrition Support Team, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Željko Krznarić
- Center of Clinical Nutrition, Department of Medicine, University Hospital Center, Zagreb, Croatia
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, United Kingdom
| | | | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), United Kingdom
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany
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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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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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Sakarellos P, Papalois A, Gakiopoulou H, Zacharioudaki I, Katsimpoulas M, Belia M, Moris D, Aggelou K, Vagios I, Davakis S, Vailas M, Liakakos T, Diamantis T, Felekouras E, Kontos M. Growth of Intestinal Neomucosa on Pedicled Gastric Wall Flap, a Novel Technique in an Animal Model. J INVEST SURG 2022; 35:1329-1339. [PMID: 35196939 DOI: 10.1080/08941939.2022.2034196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background: Short bowel syndrome (SBS) remains an unsolved issue in modern medicine. Numerous experimental surgical techniques have been proposed in the attempt to increase the intestinal absorptive capacity.Materials and Methods: Ten female Landrace pigs, divided in two groups of 5 (A and B), were explored through a midline incision. A spindle-shaped vascularized full-thickness gastric wall flap (GWF) consisting of part of the major curvature with the gastroepiploic arch preserved was de-epithelialized and then placed as a "patch" to cover an antimesenteric border defect of either a nonfunctional blind intestinal loop (group A) or a functional intestinal loop of the gastrointestinal tract (group B). A spindle-shaped curved, rigid, low density polyethylene (LDPE) splint was sutured on the external surface of the patch in order to prevent shrinkage of GWF and collapse of the intestinal wall in group A.Results: There was a decrease of both dimensions of the patch. Microscopically a thin layer of columnar epithelial cells covered the center of the patch, evolving in shorter, blunt, poorly developed villi with increasing maturation laterally. The patch surface was covered by nearly 90%. In the three animals that died prematurely the coverage of GWF was negligent or suboptimal directly dependent on the length of survival.Conclusions: The hereby-described patching technique demonstrated the growth of intestinal neomucosa on the GWF. The capability of the stomach to provide large flaps and the advantages of the use of native tissues render this animal model valuable for the future research in the field.
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Affiliation(s)
- Panagiotis Sakarellos
- First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Harikleia Gakiopoulou
- First Department of Pathology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Iro Zacharioudaki
- Experimental, Educational and Research Centre, ELPEN, Athens, Greece
| | - Michalis Katsimpoulas
- Experimental Surgery Unit, Center of Clinical, Experimental Surgery and Translational Research, Βιοmedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Marina Belia
- Department of Haematology and Bone Marrow Transplantation, Laiko General Hospital, National and Kapodistrian University of Athens, Athens Greece
| | - Dimitrios Moris
- First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Kyveli Aggelou
- Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ilias Vagios
- First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Spiridon Davakis
- First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Michail Vailas
- First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodoros Liakakos
- First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodoros Diamantis
- First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Felekouras
- First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Michael Kontos
- First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Morabito A, Ugolini S, Cianci MC, Coletta R. Current Surgical Concepts and Indications in the Management of the Short Bowel State: A Call for the Use of Multidisciplinary Intestinal Rehabilitation Programs. CHILDREN-BASEL 2021; 8:children8080654. [PMID: 34438545 PMCID: PMC8394303 DOI: 10.3390/children8080654] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 12/17/2022]
Abstract
The mainstay of management for short bowel syndrome (SBS) is to promote access to the best quality of care provided by the intestinal rehabilitation program (IRP) in specialized centres. When treating SBS patients, the main goal is to minimize disease-associated complications, as well as achieve enteral autonomy. Surgical strategies should be selected cautiously upon the actual state of the bowel with respect to what it is clinically relevant for that specific patient. To this aim, a personalized and multidisciplinary approach for such a complex syndrome is needed.
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Affiliation(s)
- Antonino Morabito
- Department of Pediatric Surgery, Meyer Children’s Hospital, University of Florence, 50139 Florence, Italy
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, 50121 Florence, Italy; (S.U.); (M.C.C.); (R.C.)
- School of Heath and Society, University of Salford, Manchester M6 6PU, UK
- Correspondence:
| | - Sara Ugolini
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, 50121 Florence, Italy; (S.U.); (M.C.C.); (R.C.)
| | - Maria Chiara Cianci
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, 50121 Florence, Italy; (S.U.); (M.C.C.); (R.C.)
| | - Riccardo Coletta
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, 50121 Florence, Italy; (S.U.); (M.C.C.); (R.C.)
- School of Heath and Society, University of Salford, Manchester M6 6PU, UK
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Mercer DF, Burnett TR, Hobson BD, Logan SJ, Gerhardt BK, Iwansky SN, Quiros-Tejeira RE. Repeat serial transverse enteroplasty leads to reduction in parenteral nutrition in children with short bowel syndrome. J Pediatr Surg 2021; 56:733-737. [PMID: 32736789 DOI: 10.1016/j.jpedsurg.2020.06.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/19/2020] [Accepted: 06/30/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/PURPOSE Following a serial transverse enteroplasty (STEP) procedure some children develop redilation of the small intestine leading to impaired enteral tolerance and inability to wean parenteral nutrition (PN). The benefit of a second STEP procedure (2STEP) has been controversial. METHODS We performed a retrospective review of our experience (2008-2018) performing 2STEP, with comparative analysis of nutritional outcomes pre- and postsurgery. RESULTS During this period 2STEP was performed in 23 patients (13 F:10 M) at a median (25%-75%) age of 2.2 (1.2-3.6) years. Median intestinal length was 68 (40-105) cm before and 85 (40-128) cm after 2STEP. Leading up to 2STEP, PN provided almost 75% of estimated calorie needs. By 24 weeks following 2STEP drops in mean PN percent approached statistical significance (p = 0.07) and at most recent follow up the mean PN percentage was statistically better than at the time of operation or 4 weeks prior to 2STEP, and was nearly significant compared with 12 weeks (p = 0.07) and 24 weeks (p = 0.06) prior. Thirteen children were completely off parenteral support. CONCLUSION When small intestine redilation occurs following a STEP procedure and where PN cannot otherwise be weaned we believe these data support performing a 2STEP. We cannot predict preoperatively which children will ultimately benefit. LEVEL OF EVIDENCE 3 (retrospective comparative study).
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Affiliation(s)
- David F Mercer
- Department of Surgery, University of Nebraska Medical Center, 983285 Nebraska Medical Center, Omaha, NE, USA 68198-3285.
| | - Tyler R Burnett
- Department of Surgery, University of Nebraska Medical Center, 983285 Nebraska Medical Center, Omaha, NE, USA 68198-3285
| | - Brandy D Hobson
- Department of Clinical Nutrition, University of Nebraska Medical Center, 983285 Nebraska Medical Center, Omaha, NE, USA 68198-3285
| | - Samantha J Logan
- Department of Clinical Nutrition, University of Nebraska Medical Center, 983285 Nebraska Medical Center, Omaha, NE, USA 68198-3285
| | - Brandi K Gerhardt
- Department of Surgery, University of Nebraska Medical Center, 983285 Nebraska Medical Center, Omaha, NE, USA 68198-3285
| | - Sarah N Iwansky
- Department of Surgery, University of Nebraska Medical Center, 983285 Nebraska Medical Center, Omaha, NE, USA 68198-3285
| | - Ruben E Quiros-Tejeira
- Department of Pediatrics, University of Nebraska Medical Center, 983285 Nebraska Medical Center, Omaha, NE, USA 68198-3285
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7
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Letter to the Editor. J Pediatr Surg 2020; 55:1984. [PMID: 25783290 DOI: 10.1016/j.jpedsurg.2013.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 09/20/2013] [Indexed: 11/24/2022]
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8
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Choudhury RA, Yoeli D, Hoeltzel G, Moore HB, Prins K, Kovler M, Goldstein SD, Holland-Cunz SG, Adams M, Roach J, Nydam TL, Vuille-Dit-Bille RN. STEP improves long-term survival for pediatric short bowel syndrome patients: A Markov decision analysis. J Pediatr Surg 2020; 55:1802-1808. [PMID: 32345501 DOI: 10.1016/j.jpedsurg.2020.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 01/31/2020] [Accepted: 03/22/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Increasingly, for pediatric patients with short bowel syndrome (SBS), intestinal lengthening procedures such as serial transverse enteroplasty (STEP) are being offered with the hope of improving patients' chances for achieving enteral autonomy. However, it remains unclear to what extent STEP reduces the long-term need for intestinal transplant or improves survival. METHODS Based on existing literature, a decision analytic Markov state transition model was created to simulate the life of 1,000 pediatric SBS patients. Two simulations were modeled: 1) No STEP: patients were listed for transplant once medical management failed and 2) STEP: patients underwent STEP therapy and subsequent transplant listing if enteral autonomy was not achieved. Sensitivity analysis of small bowel length and anatomy was completed. Base case patients were defined as neonates with a small bowel length of 30cm. RESULTS For base case patients with an ostomy and a NEC SBS etiology, STEP was associated with increased rates of enteral autonomy after 10 years for patients with an ICV (53.9% [STEP] vs. 51.1% [No STEP]) and without an ICV (43.4% [STEP] vs. 36.3% [No STEP]). Transplantation rates were also reduced following STEP therapy for both ICV (17.5% [STEP] vs. 18.2% [No STEP]) and non-ICV patients (20.2% [STEP] vs. 22.1% [No STEP]). 10-year survival was the highest in the (+) STEP and (+) ICV group (85.4%) and lowest in the (-) STEP and (-) ICV group (83.3%). CONCLUSIONS For SBS patients, according to our model, STEP increases rates of enteral autonomy, reduces need for intestinal transplantation, and improves long-term survival. TYPE OF STUDY Economic/Decision Analysis or Modeling Studies LEVEL OF EVIDENCE: Level III.
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Affiliation(s)
- Rashikh A Choudhury
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO.
| | - Dor Yoeli
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Gerard Hoeltzel
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Hunter B Moore
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Kas Prins
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Mark Kovler
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Seth D Goldstein
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Stephan G Holland-Cunz
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Megan Adams
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Jonathan Roach
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Trevor L Nydam
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Raphael N Vuille-Dit-Bille
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
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Elifranji M, Robinson A, Mammoo S, Zarroug A, Khalil BA. Radiologic Image-Guided Tube Stoma Insertion in Neonatal Short Bowel Syndrome: First Case Report in the Literature. J Laparoendosc Adv Surg Tech A 2019; 29:1330-1333. [PMID: 31436514 DOI: 10.1089/lap.2019.0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: The management of neonatal short bowel syndrome can be challenging, and it is critical that these babies are managed in a multidisciplinary team setting with specialists who are experienced in the complex management of these children. One of the surgical strategies, initially published by the Bianchi team in Manchester, UK, is controlled tissue expansion program (CTE) which is done via the insertion of catheters into the proximal and distal bowel in the form of tube stomas. The clamping of the proximal tube allows for an increase in length and circumferential diameter of the proximal bowel for a period of time, whilst the distal tube stoma allows for easy refeeding of proximal bowel contents into the distal bowel. Method: CTE is associated with the risk of dislodgement and exposing patients to further surgical procedures with the risk of losing more bowel length. This article describes a new method in the management of such a complication through a less invasive approach of an image-guided procedure by interventional radiologists. Conclusion: Radiologically guided tube stoma reinsertion in a child with ultrashort bowel syndrome is a promising technique and should be considered in a CTE program in the management of short bowel syndrome.
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Affiliation(s)
- Mohammed Elifranji
- Division of Paediatric and Thoracic Surgery, Sidra Medicine, Doha, Qatar
| | - Ashley Robinson
- Division of Paediatric Interventional Radiology, Sidra Medicine, Doha, Qatar
| | - Saleem Mammoo
- Division of Paediatric and Thoracic Surgery, Sidra Medicine, Doha, Qatar
| | - Abdalla Zarroug
- Division of Paediatric and Thoracic Surgery, Sidra Medicine, Doha, Qatar
| | - Basem A Khalil
- Division of Paediatric and Thoracic Surgery, Sidra Medicine, Doha, Qatar
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10
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Retracing our STEPs: Four decades of progress in intestinal lengthening procedures for short bowel syndrome. Am J Surg 2019; 217:772-782. [DOI: 10.1016/j.amjsurg.2018.11.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 11/07/2018] [Accepted: 11/19/2018] [Indexed: 02/06/2023]
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Pironi L, Corcos O, Forbes A, Holst M, Joly F, Jonkers C, Klek S, Lal S, Blaser AR, Rollins KE, Sasdelli AS, Shaffer J, Van Gossum A, Wanten G, Zanfi C, Lobo DN. Intestinal failure in adults: Recommendations from the ESPEN expert groups. Clin Nutr 2018; 37:1798-1809. [PMID: 30172658 DOI: 10.1016/j.clnu.2018.07.036] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 07/30/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Intestinal failure (IF) is defined as "the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth". Functionally, it may be classified as type I acute intestinal failure (AIF), type II prolonged AIF and type III chronic intestinal failure (CIF) The ESPEN Workshop on IF was held in Bologna, Italy, on 15-16 October 2017 and the aims of this document were to highlight the current state of the art and future directions for research in IF. METHODS This paper represents the opinion of experts in the field, based on current evidence. It is not a formal review, but encompasses the current evidence, with emphasis on epidemiology, classification, diagnosis and management. RESULTS IF is the rarest form of organ failure and can result from a variety of conditions that affect gastrointestinal anatomy and function adversely. Assessment, diagnosis, and short and long-term management involves a multidisciplinary team with diverse expertise in the field that aims to reduce complications, increase life expectancy and improve quality of life in patients. CONCLUSIONS Both AIF and CIF are relatively rare conditions and most of the published work presents evidence from small, single-centre studies. Much remains to be investigated to improve the diagnosis and management of IF and future studies should rely on multidisciplinary, multicentre and multinational collaborations that gather data from large cohorts of patients. Emphasis should also be placed on partnership with patients, carers and government agencies in order to improve the quality of research that focuses on patient-centred outcomes that will help to improve both outcomes and quality of life in patients with this devastating condition.
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Affiliation(s)
- Loris Pironi
- Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola Hospital, University of Bologna, Italy.
| | - Olivier Corcos
- Intestinal Stroke Center (SURVI)/ Gastroenterology, IBD and Nutrition Support Department, Beaujon Hospital, and Laboratory for Vascular Translational Science UMR 1148, University Paris VII, France
| | - Alastair Forbes
- Norwich Medical School, University of East Anglia, Bob Champion Building, Norwich Research Park, Norwich, NR4 7UQ, UK
| | - Mette Holst
- Center for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital and Department of Clinical Medicine, Aalborg University, Denmark
| | - Francisca Joly
- Gastroenterology, IBD and Nutrition Support Department, Beaujon Hospital, and Gastrointestinal and Metabolic Dysfunctions in Nutritional Pathologies UMR 1149, University Paris VII, France
| | - Cora Jonkers
- Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Stanislaw Klek
- Stanley Dudrick's Memorial Hospital, General Surgery Unit with Intestinal Failure Center, Skawina, Poland
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal & Manchester University, Manchester, UK
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia; Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Katie E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - Anna S Sasdelli
- Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola Hospital, University of Bologna, Italy
| | - Jon Shaffer
- Intestinal Failure Unit, Salford Royal & Manchester University, Manchester, UK
| | - Andre Van Gossum
- Clinic of Intestinal Diseases and Nutritional Support, Hopital Erasme, Free University of Brussels, Brussels, Belgium
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chiara Zanfi
- Department of Organ Failure and Transplantation, Sant'Orsola Hospital, University of Bologna, Italy
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
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Coletta R, Olivieri C, Persano G, Solari V, Inserra A, Morabito A. Expanding intestinal segment using osmotic hydrogel: An in vivo study. J Biomed Mater Res B Appl Biomater 2018; 107:1304-1309. [PMID: 30312527 DOI: 10.1002/jbm.b.34224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/19/2018] [Accepted: 08/12/2018] [Indexed: 12/13/2022]
Abstract
Intestinal circumferential expansion is essential for bowel lengthening in patients with Short Bowel Syndrome. We hypothesized use of an endoluminal osmotic hydrogel expander (EOHE) as a novel approach for intestinal expansion. An EOHE was introduced into an isolated intestinal segment of New Zealand rabbits, with a similar segment created as a control. After 4weeks, the segments were retrieved for analysis. Weight, inflammatory markers and fluoroscopy data was recorded weekly. EOHE allowed successful expansion of intestinal segments from 4.68 ± 0.35 to 9.79 ± 0.35 cm (p = 0.01). Increase in intestinal length was 167.8 ± 35.21% in segments with EOHE vs. 23.03 ± 4.2% in the control group (p < 0.01). A significant intestinal dilatation (214.4 ± 1.58 vs. 34.59 ± 1.23%, p < 0.01) was demonstrated. Hematoxylin and eosin stain revealed conservation of intestinal architecture with muscle hypertrophy and flattening of the epithelium possibly due to compression. No reduction of rabbit weight, inflammatory markers or liver damage was described. EOHE appears to produce safe intestinal expansion, achieving increased length and dilatation suitable for lengthening procedure. This approach may allow development of similar techniques to expand bowel in short bowel patients. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1304-1309, 2019.
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Affiliation(s)
- Riccardo Coletta
- Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK.,Paediatric Autologous Bowel Reconstruction and Rehabilitation Unit, Department of Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, UK.,Department of Pediatric Surgery, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Claudio Olivieri
- Division of General and Thoracic Surgery, Bambino Gesù Children Hospital, Rome, Italy
| | - Giorgio Persano
- Department of Pediatric Surgery, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Valeria Solari
- Paediatric Autologous Bowel Reconstruction and Rehabilitation Unit, Department of Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, UK
| | - Alessandro Inserra
- Division of General and Thoracic Surgery, Bambino Gesù Children Hospital, Rome, Italy
| | - Antonino Morabito
- Paediatric Autologous Bowel Reconstruction and Rehabilitation Unit, Department of Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, UK.,Division of General and Thoracic Surgery, Bambino Gesù Children Hospital, Rome, Italy.,Department of Pediatric Surgery, Meyer Children's Hospital, University of Florence, Florence, Italy.,Institute of Inflammation and Repair, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
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Batra A, Keys SC, Johnson MJ, Wheeler RA, Beattie RM. Epidemiology, management and outcome of ultrashort bowel syndrome in infancy. Arch Dis Child Fetal Neonatal Ed 2017; 102:F551-F556. [PMID: 28866623 PMCID: PMC5739827 DOI: 10.1136/archdischild-2016-311765] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/11/2017] [Accepted: 07/13/2017] [Indexed: 12/25/2022]
Abstract
Ultrashort bowel syndrome (USBS) is a group of heterogeneous disorders where the length of small bowel is less than 10 cm or 10% of expected for the age. It is caused by massive loss of the gut which in the neonatal period can be a result of vanishing gastroschisis or surgical resection following mid-gut volvulus, jejunoileal atresia and/or extensive necrotising enterocolitis. The exact prevalence of USBS is not known although there is a clear trend towards increasing numbers because of increased incidence and improved survival. Long-term parenteral nutrition (PN) is the mainstay of treatment and is best delivered by a multidisciplinary intestinal rehabilitation team. Promoting adaptation is vital to improving long-term survival and can be achieved by optimising feeds, reducing intestinal failure liver disease and catheter-related bloodstream infections. Surgical techniques that can promote enteral tolerance and hence improve outcome include establishing intestinal continuity and bowel lengthening procedures. The outcome for USBS is similar to patients with intestinal failure due to other causes and only a small proportion of children who develop irreversible complications of PN and will need intestinal transplantation. In this review, we will summarise the available evidence focusing particularly on the epidemiology, management strategies and outcome.
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Affiliation(s)
- Akshay Batra
- Department of Paediatric Gastroenterology, Southampton Children’s Hospital, Southampton, UK
| | - Simon Charlie Keys
- Wessex Regional Pediatric Surgery, Southampton Children’s Hospital, Southampton, UK
| | - Mark John Johnson
- Department of Neonatal Medicine, Southampton Children’s Hospital, Southampton, UK
| | - Robert A Wheeler
- Wessex Regional Pediatric Surgery, Southampton Children’s Hospital, Southampton, UK
| | - Robert Mark Beattie
- Department of Paediatric Gastroenterology, Southampton Children’s Hospital, Southampton, UK
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14
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Intestinal Rehabilitation Programs in the Management of Pediatric Intestinal Failure and Short Bowel Syndrome. J Pediatr Gastroenterol Nutr 2017; 65:588-596. [PMID: 28837507 DOI: 10.1097/mpg.0000000000001722] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Intestinal failure is a rare, debilitating condition that presents both acute and chronic medical management challenges. The condition is incompatible with life in the absence of the safe application of specialized and individualized medical therapy that includes surgery, medical equipment, nutritional products, and standard nursing care. Intestinal rehabilitation programs are best suited to provide such complex care with the goal of achieving enteral autonomy and oral feeding with or without intestinal transplantation. These programs almost all include pediatric surgeons, pediatric gastroenterologists, specialized nurses, and dietitians; many also include a variety of other medical and allied medical specialists. Intestinal rehabilitation programs provide integrated interdisciplinary care, more discussion of patient management by involved specialists, continuity of care through various treatment interventions, close follow-up of outpatients, improved patient and family education, earlier treatment of complications, and learning from the accumulated patient databases. Quality assurance and research collaboration among centers are also goals of many of these programs. The combined and coordinated talents and skills of multiple types of health care practitioners have the potential to ameliorate the impact of intestinal failure and improve health outcomes and quality of life.
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Botey M, Alastrué A, Haetta H, Fernández-Llamazares J, Clavell A, Moreno P. Long-Term Results of Serial Transverse Enteroplasty with Neovalve Creation for Extreme Short Bowel Syndrome: Report of Two Cases. Case Rep Gastroenterol 2017; 11:229-240. [PMID: 28559783 PMCID: PMC5437447 DOI: 10.1159/000452734] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 10/17/2016] [Indexed: 12/11/2022] Open
Abstract
Objective The aim of this article was to determine whether serial transverse enteroplasty (STEP) and the creation of a new ileocecal valve in extreme short bowel syndrome (SBS) cases (<45 cm) is effective in intestinal adaptation and improvement of nutritional parameters and serum citrulline levels. Patients and Methods We present 2 cases of SBS treated with STEP. Enterectomy was performed for massive intestinal ischemia secondary to a gastrointestinal stromal tumor in the first case and to catastrophic antiphospholipid syndrome in the second. After enterectomy, the short residual bowel measured 34 cm in the first patient and 45 cm in the second. In both cases STEP, cholecystectomy, and gastrostomy were performed. In the first case a Brooke neovalve was created, and in the other the ileocecal valve was preserved. Results Both patients could finally be weaned off total parenteral nutrition (TPN) and gastrostomy feeding, maintaining a good nutritional status 1 year after surgery. Conclusions In extreme SBS, a minimum length of 80–90 cm of functioning small bowel and an intact ileocecal valve are necessary. We plead for the use of STEP with preservation of the ileocecal valve or creation of a neovalve using the Brooke technique in order to achieve the ultimate goal, which is to wean patients off TPN. After a critical review of different surgical techniques, a treatment algorithm is proposed.
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Affiliation(s)
- Mireia Botey
- Hospital General de Catalunya, Sant Cugat del Vallès (Barcelona), Spain
| | | | - Henrik Haetta
- Hospital Germans Trias i Pujol, Badalona (Barcelona), Spain
| | | | | | - Pau Moreno
- Hospital Germans Trias i Pujol, Badalona (Barcelona), Spain
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Abstract
Extensive loss of small bowel in all age groups has significant morbidity and mortality consequences. Despite the astonishing ability of the small bowel to compensate for an extensive loss, long-term parenteral nutrition and enteral nutrition, tailored to the need of the patients in relation to the missing intestinal regions is needed. Organ-preserving surgical intervention becomes necessary in patients with a very short intestinal transit time and in an other group of patients with impaired propulsive peristalsis. Intestinal transplantation is indicated in recurrent septical infections or if nearly all of the small bowel is missing. This review discusses indications and risks of the organ-preserving surgical therapies in children with short bowel syndrome.
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Affiliation(s)
- Michael E Höllwarth
- University Clinic for Pediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 36, 8034, Graz, Austria.
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Ching YA, Gura K, Modi B, Jaksic T. Pediatric Intestinal Failure: Nutrition, Pharmacologic, and Surgical Approaches. Nutr Clin Pract 2017; 22:653-63. [DOI: 10.1177/0115426507022006653] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
| | - Kathleen Gura
- Children's Hospital of Boston, Boston, Massachusetts
| | - Biren Modi
- Children's Hospital of Boston, Boston, Massachusetts
| | - Tom Jaksic
- Children's Hospital of Boston, Boston, Massachusetts
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Thompson JS, Langenfeld SJ, Hewlett A, Chiruvella A, Crawford C, Armijo P, Oleynikov D. Surgical treatment of gastrointestinal motility disorders. Curr Probl Surg 2016; 53:503-549. [PMID: 27765162 DOI: 10.1067/j.cpsurg.2016.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 08/22/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Jon S Thompson
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE.
| | - Sean J Langenfeld
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Alexander Hewlett
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | | | | | | | - Dmitry Oleynikov
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
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Hubertus J, von Schweinitz D. Nekrotisierende Enterokolitis und Kurzdarmsyndrom. Monatsschr Kinderheilkd 2016. [DOI: 10.1007/s00112-016-0153-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Hommel MJ, van Baren R, Haveman JW. Surgical management and autologous intestinal reconstruction in short bowel syndrome. Best Pract Res Clin Gastroenterol 2016; 30:263-80. [PMID: 27086890 DOI: 10.1016/j.bpg.2016.03.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/05/2016] [Indexed: 01/31/2023]
Abstract
Short bowel syndrome (SBS) is a serious condition with considerable morbidity and mortality. When treatment with parenteral nutrition fails and life-threatening complications occur, autologous intestinal reconstruction (AIR) should be considered before intestinal transplantation (ITx). Single or combined ITx should be reserved for patients with severe liver disease and as last resort in the treatment of SBS. Longitudinal intestinal lengthening and tailoring (LILT) has proven its value in AIR, but its availability depends on the expertise of the surgeons. Serial transverse enteroplasty (STEP) has similar success rates as LILT and fewer patients progress to ITx. STEP is also applicable at small bowel dilatation in ultra-short bowel syndrome. The scope may be widened when duodenal dilatation can be treated as well. Spiral intestinal lengthening and tailoring (SILT) is a promising alternative. More research is needed to confirm these findings. Therefore we suggest an international data registry for all intestinal lengthening procedures.
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Affiliation(s)
- Matthijs J Hommel
- Department of Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
| | - Robertine van Baren
- Department of Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
| | - Jan Willem Haveman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
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Pironi L, Arends J, Bozzetti F, Cuerda C, Gillanders L, Jeppesen PB, Joly F, Kelly D, Lal S, Staun M, Szczepanek K, Van Gossum A, Wanten G, Schneider SM. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr 2016; 35:247-307. [PMID: 26944585 DOI: 10.1016/j.clnu.2016.01.020] [Citation(s) in RCA: 461] [Impact Index Per Article: 57.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 01/27/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Chronic Intestinal Failure (CIF) is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF. METHODS The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members. RESULTS The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%. CONCLUSIONS CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.
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Affiliation(s)
- Loris Pironi
- Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola-Malpighi University Hospital, Bologna, Italy.
| | - Jann Arends
- Department of Medicine, Oncology and Hematology, University of Freiburg, Germany
| | | | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Lyn Gillanders
- Nutrition Support Team, Auckland City Hospital, (AuSPEN) Auckland, New Zealand
| | | | - Francisca Joly
- Centre for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Darlene Kelly
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA; Oley Foundation for Home Parenteral and Enteral Nutrition, Albany, NY, USA
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Michael Staun
- Rigshospitalet, Department of Gastroenterology, Copenhagen, Denmark
| | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - André Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Stéphane Michel Schneider
- Gastroenterology and Clinical Nutrition, CHU of Nice, University of Nice Sophia Antipolis, Nice, France
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Intestinal Rehabilitation. CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0112-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Rege A. The Surgical Approach to Short Bowel Syndrome - Autologous Reconstruction versus Transplantation. VISZERALMEDIZIN 2015; 30:179-89. [PMID: 26288592 PMCID: PMC4513826 DOI: 10.1159/000363589] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Short bowel syndrome (SBS) is a state of malabsorption resulting from massive small bowel resection leading to parenteral nutrition (PN) dependency. Considerable advances have been achieved in the medical and surgical management of SBS over the last few decades. METHODS This review discusses in detail the surgical approach to SBS. RESULTS Widespread use of PN enables long-term survival in patients with intestinal failure but at the cost of PN-associated life-threatening complications including catheter-associated blood stream infection, venous thrombosis, and liver disease. The goal of management of intestinal failure due to SBS is to enable enteral autonomy and wean PN by means of a multi-disciplinary approach. Availability of modified enteral feeding formulas have simplified nutrition supplementation in SBS patients. Similarly, advances in the medical field have made medications like growth hormone and glucagon-like peptide (GLP2) available to improve water and nutrient absorption as well as to enable achieving enteral autonomy. Autologous gastrointestinal reconstruction (AGIR) includes various techniques which manipulate the bowel surgically to facilitate the bowel adaptation process and restoration of enteral nutrition. Ultimately, intestinal transplantation can serve as the last option for the cure of intestinal failure when selectively applied. CONCLUSION SBS continues to be a challenging medical problem. Best patient outcomes can be achieved through an individualized plan, using various AGIR techniques to complement each other, and intestinal transplantation as a last resort for cure. Maximum benefit and improved outcomes can be achieved by caring for SBS patients at highly specialized intestinal rehabilitation centers.
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Affiliation(s)
- Aparna Rege
- Division of Transplantation, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Coletta R, Khalil BA, Morabito A. Short bowel syndrome in children: surgical and medical perspectives. Semin Pediatr Surg 2014; 23:291-7. [PMID: 25459014 DOI: 10.1053/j.sempedsurg.2014.09.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The main cause of intestinal failure in children is due to short bowel syndrome (SBS) resulting from congenital or acquired intestinal lesions. From the first lengthening procedure introduced by Bianchi, the last three decades have seen lengthening procedures established as fundamental components of multidisciplinary intestinal rehabilitation programs. Debate on indications and timing of the procedures is still open leaving SBS surgical treatment a great challenge. However, enteral autonomy is possible only with an individualized approach remembering that each SBS patient is unique. Current literature on autologous gastrointestinal reconstruction technique was reviewed aiming to assess a comprehensive pathway in SBS non-transplant management.
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Affiliation(s)
- Riccardo Coletta
- Paediatric Autologous Bowel Reconstruction and Rehabilitation Unit, Royal Manchester Children׳s Hospital, Oxford Rd, Manchester M13 9WL, UK; School of Medicine, University of Manchester, Manchester, UK
| | - Basem A Khalil
- Paediatric Autologous Bowel Reconstruction and Rehabilitation Unit, Royal Manchester Children׳s Hospital, Oxford Rd, Manchester M13 9WL, UK; School of Medicine, University of Manchester, Manchester, UK
| | - Antonino Morabito
- Paediatric Autologous Bowel Reconstruction and Rehabilitation Unit, Royal Manchester Children׳s Hospital, Oxford Rd, Manchester M13 9WL, UK; School of Medicine, University of Manchester, Manchester, UK.
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Abstract
PURPOSE OF REVIEW This review will provide the practitioner with an understanding of the spectrum of nontransplant surgical options for managing patients with short bowel syndrome (SBS). RECENT FINDINGS Intestinal lengthening procedures are a promising therapy to allow autonomy from parenteral nutrition. The recently described serial transverse enteroplasty is an effective procedure that is easier to perform and has similar outcomes to the more standard longitudinal lengthening procedure described by Bianchi. SUMMARY There are several surgical options for management of the SBS, including construction of intestinal valves or reversed intestinal segments, interposition of segments of colon, or intestinal lengthening procedures. The choice of technique is dictated by the patient's underlying pathophysiology and includes such factors as intestinal transit time, length of remnant bowel, presence of intact colon, and degree of small bowel dilation. Nontransplant surgical interventions are important adjuncts to the elimination of parenteral nutrition dependence and need for intestinal transplantation.
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Affiliation(s)
- Kishore R. Iyer
- Adult and Pediatric Intestinal Transplant & Rehabilitation Program, Mount Sinai Medical Center, New York, New York
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Abstract
The goal of any treatment programme for short bowel syndrome SBS is to achieve nutritional enteral autonomy. This must begin with conservation of as much bowel as possible from the time of first presentation. Frequent causes of the short bowel syndrome are intestinal atresia, necrotizing enterocolitis, midgut volvulus, extended intestinal aganglionosis, 'vanished gut' often associated with gastroschisis and occasionally catastrophic trauma. Atresia is more amenable to successful surgery than other causes, except when associated with gastroschisis. Intrinsic dysmotility has a poor prognosis. Intestinal lengthening procedures are only indicated if there is sufficient bowel dilatation. Extended intestinal aganglionosis is rarely amenable to any form of non-transplant surgery. Options available are to conserve bowel, close stomas early (use all available bowel to the maximum or even re-feed stoma effluent into the distal unused bowel), release adhesions causing obstruction, resect strictures, taper or excise localized dilatations and finally address dilated bowel with lengthening and tailoring operations. These procedures aim to improve effective peristalsis, thereby reducing bacterial overgrowth and improving nutrient contact with enteral mucosa to maximize absorption and intestinal adaptation. The Bianchi longitudinal splicing operation and the serial transverse enteroplasty operations have stood the test of time in providing considerable improvement in enteral nutritional autonomy in around 60% of cases. In SBS without dilatation attempts at 'mechanically' delaying transit (nipple valves, reversed bowel segments, colon interposition) have had inconsistent outcomes. Growing neomucosa and lengthening bowel by longitudinal stretch are still experimental.
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Affiliation(s)
- Alastair J W Millar
- Department of Paediatric Surgery, University of Cape Town and Red Cross War Memorial Children's Hospital, Rondebosch, Cape Town, 7700, South Africa,
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Frongia G, Kessler M, Weih S, Nickkholgh A, Mehrabi A, Holland-Cunz S. Comparison of LILT and STEP procedures in children with short bowel syndrome -- a systematic review of the literature. J Pediatr Surg 2013; 48:1794-805. [PMID: 23932625 DOI: 10.1016/j.jpedsurg.2013.05.018] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 03/02/2013] [Accepted: 05/21/2013] [Indexed: 12/28/2022]
Abstract
PURPOSE To compare LILT and STEP, the two principal procedures to lengthen the native bowel in children with a short bowel syndrome (SBS), by discussing the indications and presenting the outcome from published data. METHODS A review of literature was performed. N=39 publications were reviewed. RESULTS For LILT and STEP, failure to achieve intestinal autonomy by conservative therapy represents the main indication, and end-stage liver disease the main contraindication. A sufficiently dilated intestinal segment is a common anatomical precondition for both procedures. STEP can be performed on shorter intestinal segments and on intricate segments such as the duodenum, which is technically not feasible for LILT. Both procedures have a similar extent of intestinal lengthening (approximately 70%) and result in improvement of enteral nutrition and reversal of complications of parenteral nutrition. STEP seems to have a lower mortality and overall progression to transplantation. CONCLUSIONS STEP and LILT are both accepted procedures for non-transplant surgical management of SBS in children. The outcome after STEP seems to be more favourable, but larger series are needed to further assess accurate selection of eligible patients and to estimate effectiveness of procedures. A considerably higher number of cases for evaluation might be accomplished through the widespread use of a centralised registry.
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Affiliation(s)
- Giovanni Frongia
- Department of Pediatric Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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King B, Carlson G, Khalil BA, Morabito A. Intestinal Bowel Lengthening in Children with Short Bowel Syndrome: Systematic Review of the Bianchi and STEP Procedures. World J Surg 2012; 37:694-704. [DOI: 10.1007/s00268-012-1879-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Rege AS, Sudan DL. Autologous gastrointestinal reconstruction: review of the optimal nontransplant surgical options for adults and children with short bowel syndrome. Nutr Clin Pract 2012; 28:65-74. [PMID: 23087264 DOI: 10.1177/0884533612460405] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Short bowel syndrome (SBS) results in loss of absorptive capacity of the development of gut, leading to malabsorption due to protein, energy, fluid, and electrolyte loss and imbalance while on enteral diet alone. Various nonsurgical and surgical therapeutic options that have emerged improve the survival outcome following SBS in both children and adults. An individualized, complex multidisciplinary approach to medical and surgical intestinal rehabilitation is needed to provide an opportunity for enteral autonomy to be possible in a patient with SBS. The remnant bowel plays a very pivotal role in autologous gastrointestinal reconstruction (AGIR) surgery. Intestinal transplantation, although promising and potentially life-saving for SBS, should be reserved for patients with failed AGIR or those who have no prospect for autologous enteral autonomy. This article reviews the evolution of nontransplant surgical management of patients with SBS.
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Oh JT, Koh H, Chang EY, Chang HK, Han SJ. Second serial transverse enteroplasty procedure in an infant with extreme short bowel syndrome. J Korean Med Sci 2012; 27:701-3. [PMID: 22690105 PMCID: PMC3369460 DOI: 10.3346/jkms.2012.27.6.701] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Accepted: 02/23/2012] [Indexed: 12/03/2022] Open
Abstract
The serial transverse enteroplasty (STEP) procedure is a novel technique to lengthen and taper the bowel in patients with short bowel syndrome. The advantages of STEP include not only technical ease and simplicity, but also the ability to repeat the procedure. Herein, we report a case of extreme short bowel syndrome that was successfully treated by the second STEP procedure. A 3-day old newborn girl underwent STEP because of jejunal atresia with the small bowel length of 15 cm, but her bowel elongation was not enough to escape from short bowel syndrome. At the age of 6 months, she underwent a second STEP procedure. The bowel lengthening by the second STEP made her tolerable to enteral feeding with body weight gain and rescued her from short bowel syndrome. This case showed that second STEP is very helpful in treatment of extreme short bowel syndrome.
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Affiliation(s)
- Jung-Tak Oh
- Department of Pediatric Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Thompson JS, Rochling FA, Weseman RA, Mercer DF. Current management of short bowel syndrome. Curr Probl Surg 2012; 49:52-115. [PMID: 22244264 DOI: 10.1067/j.cpsurg.2011.10.002] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Jon S Thompson
- University of Nebraska Medical Center, Omaha, Nebraska, USA
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Current practice and future perspectives in the treatment of short bowel syndrome in children—a systematic review. Langenbecks Arch Surg 2011; 397:1043-51. [DOI: 10.1007/s00423-011-0874-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 11/03/2011] [Indexed: 01/19/2023]
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Lee MD. Management Strategies for Patients with Chronic Intestinal Failure Who Are Potential Candidates for a Future Intestinal Transplant. KOREAN JOURNAL OF TRANSPLANTATION 2010. [DOI: 10.4285/jkstn.2010.24.4.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Myung Duk Lee
- Department of Pediatric Surgery, Seoul St. Mary's Hospital, Seoul, Korea
- Department of General Surgery, School of Medicine, The Catholic University of Korea, Seoul, Korea
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Intestinal lengthening in adult patients with short bowel syndrome. J Gastrointest Surg 2010; 14:1931-6. [PMID: 20734155 DOI: 10.1007/s11605-010-1291-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Accepted: 08/05/2010] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Limited information regarding the usefulness of bowel lengthening in adult patients with short bowel syndrome is available. METHODS Retrospective review of a single center series of intestinal lengthening over 15-year period in patients ≥ 18 years old. RESULTS Twenty adult patients underwent Bianchi (n = 6) or serial transverse enteroplasty (STEP) (n = 15). Median age was 38 (18-66) years and 11 were female. Indications were (a) to increase the enteral caloric intake thereby reduce or wean parenteral nutrition (PN) (n = 14) or (b) for bacterial overgrowth (n = 6). Twelve patients required additional procedures to relieve the anatomical blockade. Median remnant bowel length prior to surgery, length gained and final bowel length was 60, 20, and 80 cm, respectively. Survival was 90% with mean follow-up of 4.1 years (range = 1-7.9 years). Two patients died during follow-up. Intestinal transplant salvage was required in one patient 4.8 years after STEP. Overall, of 17 patients, ten (59%) patients achieved enteral autonomy and were off PN. Of seven patients who are on PN, three patients showed significant improvement in enteral caloric intake. All except one showed significant improvement in symptoms of bacterial overgrowth. CONCLUSIONS Bowel lengthening is technically feasible and effectively leads to weaning from PN in more than half of the adult patients. Lengthening procedures may be an underutilized treatment for adults with short bowel syndrome.
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Abstract
Multidisciplinary management of intestinal failure has progressed over the last 30 years, facilitating the transition to enteral autonomy in many pediatric patients. However, there remains a select group of patients who reach a plateau in advancement of their enteral nutrition. Numerous surgical options have been pursued to attempt to slow intestinal transit, taper dilated bowel, and promote intestinal adaptation. The purpose of this chapter is to review the current literature on autologous intestinal reconstruction surgery, including a brief historical perspective, descriptions of procedures, and reported surgical outcomes.
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Affiliation(s)
- Brian A Jones
- Center for Advanced Intestinal Rehabilitation, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts 02115, USA
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Gupta A, Vara D, Punshon G, Sales K, Winslet M, Seifalian A. In vitro small intestinal epithelial cell growth on a nanocomposite polycaprolactone scaffold. Biotechnol Appl Biochem 2009; 54:221-9. [PMID: 19860739 PMCID: PMC2825731 DOI: 10.1042/ba20090214] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2009] [Revised: 10/21/2009] [Accepted: 10/27/2009] [Indexed: 12/05/2022]
Abstract
Tissue engineering of the small intestine remains experimental despite worldwide attempts to develop a functional substitute for short bowel syndrome. Most published studies have reported predominant use of PLLA (poly-L-lactide acid)/PGA (polyglycolic acid) copolymer as the scaffold material, and studies have been limited by in vivo experiments. This lack of progress has inspired a fresh perspective and provoked further investigation and development in this field of tissue engineering. In the present paper, we exploit a relatively new nanocomposite of POSS (polyhedral oligomeric silsesquioxane) and PCL [poly(caprolactone-urea)urethane] as a material to develop porous scaffolds using a solvent casting/particulate leaching technique to fabricate porous scaffolds in different pore sizes and porosities. Scaffolds were characterized for pore morphology and porosity using scanning electron microscopy and micro-computed tomography. Rat intestinal epithelial cells were then seeded on to the polymer scaffolds for an in vitro study of cell compatibility and proliferation, which was assessed by Alamar Blue and lactate dehydrogenase assays performed for 21 days post-seeding. The results obtained demonstrate that POSS-PCL nanocomposite was produced as a macroporous scaffold with porosity over the range of 40-80% and pore size over the range of 150-250 microm. This scaffold was shown to support epithelial cell proliferation and growth. In conclusion, as a further step in investigating small intestinal tissue engineering, the nanocomposite employed in this study may prove to be a useful alternative to poly(lactic-co-glycolic acid) in the future.
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Key Words
- intestinal epithelial cell (iec)
- nanocomposite
- poly(caprolactone-urea)urethane (pcl)
- scaffold
- tissue engineering
- dmac, dimethylacetamide
- ftir, fourier-transform infrared
- iec, intestinal epithelial cell
- ldh, lactate dehydrogenase
- micro-ct, micro-computed tomography
- pcl, poly(caprolactone-urea)urethane
- pcu, poly(carbonate-urea)urethane
- pga, polyglycolic acid
- plga, poly(lactic-co-glycolic acid)
- pn, parenteral
- poss, polyhedral oligomeric silsesquioxane
- sbs, short bowel syndrome
- sem, scanning electron microscopy
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Affiliation(s)
- Ashish Gupta
- *Centre for Nanotechnology, Biomaterials and Tissue Engineering, University College London, London, U.K
- †Gastroenterology Research Group, UCL Division of Surgery and Interventional Science, University College London, London, U.K
| | - Dina S. Vara
- *Centre for Nanotechnology, Biomaterials and Tissue Engineering, University College London, London, U.K
| | - Geoffrey Punshon
- *Centre for Nanotechnology, Biomaterials and Tissue Engineering, University College London, London, U.K
- †Gastroenterology Research Group, UCL Division of Surgery and Interventional Science, University College London, London, U.K
| | - Kevin M. Sales
- ‡Stem Cells Research Group, University College London, London, U.K
| | - Marc C. Winslet
- †Gastroenterology Research Group, UCL Division of Surgery and Interventional Science, University College London, London, U.K
- §Royal Free Hampstead NHS Trust Hospital, London, U.K
- ∥University College London Hospital, London, U.K
| | - Alexander M. Seifalian
- *Centre for Nanotechnology, Biomaterials and Tissue Engineering, University College London, London, U.K
- †Gastroenterology Research Group, UCL Division of Surgery and Interventional Science, University College London, London, U.K
- ‡Stem Cells Research Group, University College London, London, U.K
- §Royal Free Hampstead NHS Trust Hospital, London, U.K
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Buluggiu A, Haddad M, Coste M, Louis-Borrione C, Ughetto F, Guys JM, de Lagausie P. Intestinal loop lengthening: early treatment of vanishing bowel. Pediatr Surg Int 2009; 25:449-50. [PMID: 19396606 DOI: 10.1007/s00383-009-2359-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2009] [Indexed: 10/20/2022]
Abstract
Bianchi's procedure experience for short bowel syndrome in children is positive. This technique is generally performed after the first year of life. Here the authors propose a case of gastroschisis with prenatal spontaneous closure of abdominal defect and vanishing gut presenting as intestinal atresia, absence of ileo-cecal valve, and residual short intestinal dilatation, treated by early gut lengthening (ILP).
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Affiliation(s)
- A Buluggiu
- Department of Pediatric Surgery, Hôpital Timone Enfant, 264, Rue Saint-Pierre, 13385, Marseille Cedex 05, France
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Ching YA, Fitzgibbons S, Valim C, Zhou J, Duggan C, Jaksic T, Kim HB. Long-term nutritional and clinical outcomes after serial transverse enteroplasty at a single institution. J Pediatr Surg 2009; 44:939-43. [PMID: 19433174 PMCID: PMC3217836 DOI: 10.1016/j.jpedsurg.2009.01.070] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
PURPOSE Serial transverse enteroplasty (STEP) is a novel technique to lengthen and taper bowel in patients with intestinal failure. First described in 2003, initial data and reports have demonstrated favorable short-term outcomes, but there is limited published data on long-term outcomes of the procedure. Our aim was to assess clinical and nutritional outcomes after the STEP procedure. METHODS After obtaining institutional review board approval, we reviewed all records of patients (n = 16) who underwent the STEP procedure at our institution from February 2002 to February 2008. Patients were observed for a median time of 23 months (range, 1-71) postoperatively. Analyses of z scores for weight, height, and weight-for-height, and progression of enteral calories were performed using longitudinal linear models with random effects. RESULTS Of the 16 patients (10 male), the median age at time of surgery was 12 months (interquartile range, 1.5-65.0). The mean increase in bowel length was 91% +/- 38%. After the STEP procedure, patients had increased weight-for-age z scores of 0.03 units per month (P = .0001), height for age z scores of 0.02 units per month (P = .004), and weight-for-height z scores of 0.04 units per month (P = .02). Patients had improved enteral tolerance of 1.4% per month (P < .0001). Six patients (38%) transitioned off parenteral nutrition (median, 248 days). Long-term complications included catheter-related bacteremia (n = 5), gastrointestinal bleeding (n = 3), and small bowel obstruction (n = 1). Two patients ultimately underwent transplantation. There were no deaths. CONCLUSIONS In pediatric patients with intestinal failure, the STEP procedure improves enteral tolerance, results in significant catch-up growth, and is not associated with increased mortality.
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Affiliation(s)
- Y. Avery Ching
- Center for Advanced Intestinal Rehabilitation, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
- Department of Surgery, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
| | - Shimae Fitzgibbons
- Center for Advanced Intestinal Rehabilitation, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
- Department of Surgery, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
| | - Clarissa Valim
- Department of Surgery, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
- Division of Biostatistics, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
| | - Jing Zhou
- Division of Biostatistics, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
| | - Christopher Duggan
- Center for Advanced Intestinal Rehabilitation, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
- Division of Gastroenterology and Nutrition, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
| | - Tom Jaksic
- Center for Advanced Intestinal Rehabilitation, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
- Department of Surgery, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
| | - Heung Bae Kim
- Department of Surgery, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
- Pediatric Transplant Center, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
- Corresponding author. Children’s Hospital Boston, Department of Surgery, 300 Longwood Ave, Fegan 3, Boston, Mass 02115. Tel.: +617 355 8544; fax: +617 730 0477. (H.B. Kim)
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Abstract
Our recommendation at this time is that surgical bowel lengthening be considered in any chronically PN-dependent patient when there is substantial bowel dilation, regardless of remnant bowel length. Timing is determined when maximal adaptation has been achieved or when the rate of progression in enteral calories is slow and hampered by bacterial overgrowth. Currently, it seems premature to recommend primary STEP in all patients in whom surgical lengthening is considered, but it is certainly technically easier than the Bianchi procedure. These procedures are clearly indicated in patients experiencing life-threatening complications of PN, but careful selection of patients without evidence of hepatic decompensation is important. Patients with advanced liver disease are poor candidates for lengthening and should be referred for intestinal transplantation instead.
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Affiliation(s)
- Jon Thompson
- Department of Surgery, University of Nebraska, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA.
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Furtado MCV, Silva ALD, Rena CDL, Barra ÂA, Felga AMG, Rossman FMC. Influência de válvulas artificiais sobre a morfometria intestinal de ratos. Rev Col Bras Cir 2008. [DOI: 10.1590/s0100-69912008000500008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJETIVO: Avaliar o papel de válvulas artificiais constituídas por seromiotomias circunferenciais duplas no comprimento dos vilos, no diâmetro do intestino delgado e no peso de ratos. MÉTODO: Foram utilizados 40 ratos, distribuídos em quatro grupos. Os animais do Grupo R foram submetidos à ressecção de 50% do intestino delgado, sem criação de válvulas. No Grupo RV associaram duas válvulas à ressecção intestinal. No Grupo V foram criadas duas válvulas, sem ressecção intestinal. O Grupo C forneceu a altura normal dos vilos. A eutanásia deu-se entre o décimo e o 14º dia pós-operatórios. RESULTADOS: Houve aumento no comprimento dos vilos nos grupos R, RV e V. Comparado ao Grupo R, o comprimento dos vilos nos grupos RV e V foi semelhante nos segmentos proximal e distal. No Grupo RV, os vilos do segmento proximal tiveram comprimento superior ao do distal. No Grupo V, o comprimento dos vilos do segmento proximal foi menor que do distal. A alça intestinal teve diâmetro maior que no pré-operatório no Grupo R e nos segmentos proximal à primeira válvula e distal à segunda, dos grupos RV e V. A ressecção intestinal levou à perda ponderal nos grupos R e RV, sem diferença entre os grupos. No Grupo V houve ganho de peso, significativo quando comparado aos grupos R e RV. Apesar de não impedirem a perda ponderal em animais submetidos à ressecção, as válvulas não determinaram perda superior à da ressecção isolada. CONCLUSÃO: Essas válvulas parecem influenciar positivamente a adaptação intestinal e podem ser incluídas entre as técnicas de reabilitação intestinal cirúrgica, isoladamente ou precedendo intervenções de alongamento do intestino.
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Collaborative strategies to reduce mortality and morbidity in patients with chronic intestinal failure including those who are referred for small bowel transplantation. Transplantation 2008; 85:1378-84. [PMID: 18497673 DOI: 10.1097/tp.0b013e31816dd513] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
UNLABELLED Intestinal transplant wait-list mortality is higher than for other organ transplants. The objective of this workshop was to identify the main problems contributing to high mortality in adults and children candidates for intestinal transplantation and provide recommendations on how to correct them. OUTCOME To facilitate this, 63 relevant articles identified from the medical literature from 1987 to 2007 were reviewed. Consensus was achieved on several important definitions relevant to this review. For children and adults on parenteral nutrition (PN) the main mortality risk factors were identified as were the main risks of mortality for those on the waiting list for intestinal transplants. RECOMMENDATIONS (1) Primary care givers managing intestinal failure patients should establish a link with an intestinal failure programs early and collaboration with intestinal failure programs should be initiated for patients whose PN requirements are anticipated to be more than 50% 3 months after initiating PN; (2) intestinal failure programs should include both intestinal rehabilitation and intestinal transplantation or have active collaborative relationships with centers performing intestinal transplantation; (3) National registries for intestinal failure patients should be established and organizations that provide home PN solutions should be expected to participate. CONCLUSION There are many unresolved issues in adults and children with PN dependent intestinal failure. To address these, a key recommendation of this group is to establish national intestinal failure databases that can support multicenter studies and lead to the adoption of universally accepted standards of patient care with the goal of improving outcomes in all long-term intestinal failure patients including those requiring intestinal transplantation.
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Sudan D, Thompson J, Botha J, Grant W, Antonson D, Raynor S, Langnas A. Comparison of intestinal lengthening procedures for patients with short bowel syndrome. Ann Surg 2007; 246:593-601; discussion 601-4. [PMID: 17893496 DOI: 10.1097/sla.0b013e318155aa0c] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Review the clinical results of 24 years of intestinal lengthening procedures at one institution. METHODS Retrospective review of a single center experience comparing the outcome of 2 intestinal lengthening procedures (Bianchi and serial transverse enteroplasty [STEP]) in terms of survival, total parenteral nutrition (TPN) weaning, and complications. RESULTS Sixty-four patients, including 14 adults, underwent 43 Bianchi and 34 STEP procedures between 1982 and 2007. Three patients had prior isolated liver transplants. The median (range) remnant bowel length before first lengthening was 45 (11-150) cm overall; (Bianchi=44 cm, STEP=45 cm) and 68 (20-250) cm after lengthening; (Bianchi=68 cm, STEP=65 cm). Actual survival is 91% overall (Bianchi 88%, STEP 95%) with median follow-up of 3.8 years (Bianchi=5.9 years, STEP=1.7 years). Average enteral caloric intake in pediatric patients was 15 kcal/kg before lengthening and 85 kcal/kg at 1 year after lengthening. Sixty-nine percent of patients are off TPN at most recent follow-up, including 8 who were weaned from TPN after intestinal transplantation. Liver disease (when present) was reversed in 80%. Surgical complications occurred in 10%, more commonly requiring reoperation after Bianchi than STEP. Intestinal transplantation salvage was required in 14% at a median of 2.9 years (range=8 months to 20.7 years) after lengthening. CONCLUSIONS Surgical lengthening with both Bianchi and STEP procedures results in improvement in enteral nutrition, reverses complications of TPN and avoids intestinal transplantation in the majority with few surgical complications. Intestinal transplantation can salvage most patients who later develop life-threatening complications or fail to wean TPN.
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Affiliation(s)
- Debra Sudan
- Department of Surgery, Nebraska Medical Center, Omaha, Nebraska 68198-3285, USA.
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45
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Abstract
PURPOSE The serial transverse enteroplasty procedure (STEP) procedure is a successful and safe approach to lengthen small bowel in patients with short bowel syndrome (SBS). However, postlengthening dilatation may occur, which can lead to bacterial overgrowth and malabsorption. We addressed this problem by reperforming the STEP in 2 patients. METHODS Two infants underwent the STEP procedure at 3 days and at 4 months of life for SBS secondary to intestinal atresia and gastroschisis. The patients' small bowel lengths were 20 and 32 cm before and 25 and 52 cm after the initial STEP. Nine and 8.5 months afterward, the patients developed dilatation of the small bowel and feeding intolerance. A second STEP procedure was undertaken with additional transverse firings of staplers between previously lengthened segments and tapering of redundant blind-ending portions of bowel. RESULTS At operation, the bowel lengths were 45 and 62 cm. The second STEP left the patients with 61 and 73 cm of small bowel with a normalization of intestinal diameter. The first patient is doing well 5 months after surgery, and the second child tolerated increased enteral intake but died 1 year later from total parenteral nutrition-related liver failure. CONCLUSIONS This is the first report of a successful application of a second STEP procedure to further lengthen small bowel in SBS patients. Reapplication of the procedure requires careful stapling and a removal of small blind-ending segments to avoid further stasis.
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Affiliation(s)
- Peter F Ehrlich
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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Modi BP, Javid PJ, Jaksic T, Piper H, Langer M, Duggan C, Kamin D, Kim HB. First report of the international serial transverse enteroplasty data registry: indications, efficacy, and complications. J Am Coll Surg 2007; 204:365-71. [PMID: 17324769 PMCID: PMC3217837 DOI: 10.1016/j.jamcollsurg.2006.12.033] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2006] [Revised: 11/27/2006] [Accepted: 12/19/2006] [Indexed: 11/25/2022]
Abstract
BACKGROUND Serial transverse enteroplasty (STEP) is a novel surgical therapy for short bowel syndrome and is being used with increasing frequency worldwide. Because no single center is likely to obtain sufficient experience for meaningful analysis, we created the International STEP Data Registry to allow for larger, multicenter patient accrual and followup. This report describes patient characteristics, operative parameters, and early results of STEP in the first 38 patients enrolled in the International STEP Data Registry. STUDY DESIGN After IRB approval, data were entered online through password-protected enrollment and followup forms. Patient and procedural characteristics were analyzed. Pre- and postoperative small bowel length and enteral feeding tolerance were compared with the paired t-test. RESULTS Between September 1, 2004, and April 30, 2006, 19 centers from 3 countries enrolled 38 patients. Median followup from STEP procedure to analysis was 12.6 months (range 0 to 66.9 months). Indications for STEP were short bowel syndrome (SBS, n=29), bacterial overgrowth (n=6), and neonatal atresia (n=3). Mean small intestine length was substantially increased in all groups (68+/-44 cm versus 115+/-87 cm, p < 0.0001, n=27). Notable complications included intraoperative staple line leak (n=2), bowel obstruction (n=2), and fluid collection or abscess (n=3). Late outcomes included progression to transplantation (n=3) and mortality (n=3). For the short bowel syndrome cohort, enteral tolerance was notably increased from 31%+/-31% to 67%+/-37% of calories (p < 0.01, n=21). CONCLUSIONS STEP has been performed at multiple centers with minimal complications and encouraging outcomes. Indications for the procedure have broadened beyond short bowel syndrome to include bacterial overgrowth and neonatal intestinal obstruction with dilated proximal intestine. Continued accrual and followup of patients in the International STEP Data Registry will elucidate the longterm safety and efficacy of the procedure, with the goal of improved patient selection and operative timing.
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Affiliation(s)
- Biren P Modi
- Center for Advanced Intestinal Rehabilitation, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
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Gupta A, Dixit A, Sales KM, Winslet MC, Seifalian AM. Tissue engineering of small intestine--current status. Biomacromolecules 2007; 7:2701-9. [PMID: 17025341 DOI: 10.1021/bm060383e] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Short bowel syndrome (SBS) has always posed a great threat to patients and has been one of the biggest challenges for doctors due to its high morbidity and mortality. So far, parenteral nutrition (PN) and small bowel transplantation remain the only viable therapeutic options. However, sepsis and liver failure associated with PN and limited availability of the donor organs and high graft rejection rates associated with transplantation have limited their use to a nonpermanent solution. Clearly, there is a need for an alternative therapy whereby increasing the absorptive surface area would help neonates and adults suffering from permanent intestinal failure. Techniques such as sequential intestinal lengthening are being explored in animal models with little success. Attempts to engineer small intestine since the late 1980s have achieved varying degrees of success in animal models with evolving refinements in biotechnology. The most encouraging results so far have been the generation of intestinal neomucosa in the form of cysts when intestinal epithelial organoid units isolated from neonatal rats were seeded onto biodegradable polymers before implantation in syngeneic adult rats' omentum. Although still experimental, continued attempts worldwide using cultured stem cells and improved polymer technology offer promise to provide an off-the-shelf artificial intestine as a novel therapy for patients with SBS. This article reviews the current status of progress in the field of small intestinal tissue engineering and addresses various types of cell sources and scaffold material having potential to be used in this field.
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Affiliation(s)
- Ashish Gupta
- Biomaterials and Tissue Engineering Centre, Academic Division of Surgery and Interventional Sciences, University College London, London NW3 2PF, United Kingdom
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48
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Affiliation(s)
- A Bianchi
- Royal Manchester Children's Hospital, Manchester
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49
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Goulet O, Ruemmele F. Causes and management of intestinal failure in children. Gastroenterology 2006; 130:S16-28. [PMID: 16473066 DOI: 10.1053/j.gastro.2005.12.002] [Citation(s) in RCA: 241] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2004] [Accepted: 06/06/2005] [Indexed: 12/28/2022]
Abstract
Intestinal failure is a condition requiring the use of parenteral nutrition as long as it persists. Causes of severe protracted intestinal failure include short bowel syndrome, congenital diseases of enterocyte development, and severe motility disorders (total or subtotal aganglionosis or chronic intestinal pseudo-obstruction syndrome). Intestinal failure may be irreversible in some patients, thus requiring permanent parenteral nutrition. Liver disease may develop with subsequent end-stage liver cirrhosis in patients with intestinal failure as a consequence of both underlying digestive disease and unadapted parenteral nutrition. Death will occur if combined liver-intestine transplantation is not performed. Catheter-related sepsis and/or extensive vascular thrombosis may impede the continuation of a safe and efficient parenteral nutrition and may also require intestinal transplantation in some selected cases. Thus management of patients with intestinal failure requires an early recognition of the condition and the analysis of its risk of irreversibility. Timing of referral for intestinal transplantation remains a crucial issue. As a consequence, management should include therapies adapted to each stage of intestinal failure based on a multidisciplinary approach in centers involving pediatric gastroenterology, parenteral nutrition expertise, home parenteral nutrition program, pediatric surgery, and liver intestinal transplantation program.
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Affiliation(s)
- Olivier Goulet
- Integrated Program of Intestinal Failure, Home Parenteral Nutrition and Intestinal Transplantation, National Reference Center for Rare Digestive Disease, Hôpital Necker-Enfants Malades, Université Reni Descartes, Paris, France.
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Bianchi A. From the cradle to enteral autonomy: the role of autologous gastrointestinal reconstruction. Gastroenterology 2006; 130:S138-46. [PMID: 16473062 DOI: 10.1053/j.gastro.2005.09.070] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2004] [Accepted: 09/21/2005] [Indexed: 12/02/2022]
Abstract
The short bowel state is treatable, with acceptable long-term quality of life. Management during the first 6-12 months of life is critical but, presently, frequently compromises long-term survival and prospects. At first presentation, primary caregivers, working with specialists at designated intestinal failure centers, should develop a structured individual-oriented management plan. Preservation of venous access, "hepatosparing" parenteral nutrition, and avoidance of liver sepsis are crucial to survival. Early surgery should be limited to conservation of autologous bowel, even short bowel lengths having great potential, and to facilitating natural intestinal adaptation. Bowel expansion may be relevant prior to delayed bowel reconstruction with single or combined techniques that include bowel lengthening and/or tailoring, reversed segments, and colon interposition. Bowel transplantation, as yet not recommended for primary management, offers survival and opportunity to those with no prospect of autologous bowel autonomy or following failed autologous gastrointestinal reconstruction. This paper reviews current surgery for the short bowel state and concludes that it is presently appropriate before bowel transplantation to offer autologous gastrointestinal reconstruction, with its prospect of enteral autonomy with quality life. It emphasizes the need for an individual-oriented management plan, developed jointly at the time of first presentation between the primary caregivers and a designated multidisciplinary intestinal failure center, to enhance the prospects for enteral autonomy preferably on autologous bowel. Autologous gastrointestinal reconstruction is in its infancy and requires resources, commitment, and research from dedicated bowel reconstructive surgeons toward a better opportunity for the child and family with short bowel.
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Affiliation(s)
- Adrian Bianchi
- The Royal Manchester Children's Hospital, Manchester, England.
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