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Niseteo T, Šalamon Janečić M, Sila S, Torić A, Serdar L, Višnjić S, Tolete Velcek F, Mesić M, Hojsak I. Nutritional Outcomes of Bowel Lengthening Procedure in Patients with Short Bowel Syndrome. Nutrients 2024; 16:1456. [PMID: 38794694 PMCID: PMC11124483 DOI: 10.3390/nu16101456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Although parenteral nutrition (PN) significantly improves mortality rates in pediatric short bowel syndrome (SBS), long-term PN has many possible complications and impacts quality of life. Bowel lengthening procedures (BLPs) increase the contact surface of food and the intestinal mucosa and enable the better absorption of nutrients and liquids, possibly leading to a PN decrease. METHODS We retrospectively reviewed the data of patients with short bowel syndrome who underwent BLPs in the period from January 2016 to January 2022. Overall, eight patients, four male, five born prematurely, underwent BLPs. RESULTS There was a significant decrease in the percentage of total caloric intake provided via PN and PN volume after the BLPs. The more evident results were seen 6 months after the procedure and at the last follow-up, which was, on average, 31 months after the procedure. Two patients were weaned off PN after their BLPs. Patients remained well nourished during the follow-up. CONCLUSIONS The BLP led to a significant decrease in PN needs and an increase in the food intake; however, significant changes happened more than 6 months after the procedure.
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Affiliation(s)
- Tena Niseteo
- Referral Center for Pediatric Gastroenterology and Nutrition, Children’s Hospital Zagreb, 10000 Zagreb, Croatia; (T.N.); (M.Š.J.); (S.S.)
| | - Mia Šalamon Janečić
- Referral Center for Pediatric Gastroenterology and Nutrition, Children’s Hospital Zagreb, 10000 Zagreb, Croatia; (T.N.); (M.Š.J.); (S.S.)
| | - Sara Sila
- Referral Center for Pediatric Gastroenterology and Nutrition, Children’s Hospital Zagreb, 10000 Zagreb, Croatia; (T.N.); (M.Š.J.); (S.S.)
| | - Anuka Torić
- Pharmacy Unit, Children’s Hospital Zagreb, 10000 Zagreb, Croatia; (A.T.); (L.S.)
| | - Laura Serdar
- Pharmacy Unit, Children’s Hospital Zagreb, 10000 Zagreb, Croatia; (A.T.); (L.S.)
| | - Stjepan Višnjić
- Department of Surgery, Children’s Hospital Zagreb, 10000 Zagreb, Croatia; (S.V.); (M.M.)
- Department of Surgery, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Francisca Tolete Velcek
- Division of Pediatric Surgery, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA;
| | - Marko Mesić
- Department of Surgery, Children’s Hospital Zagreb, 10000 Zagreb, Croatia; (S.V.); (M.M.)
| | - Iva Hojsak
- Referral Center for Pediatric Gastroenterology and Nutrition, Children’s Hospital Zagreb, 10000 Zagreb, Croatia; (T.N.); (M.Š.J.); (S.S.)
- Department of Pediatrics, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
- Department of Pediatrics, School of Medicine, University J.J. Strossmayer, 31000 Osijek, Croatia
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Nagelkerke SCJ, Poelgeest MYV, Wessel LM, Mutanen A, Langeveld HR, Hill S, Benninga MA, Tabbers MM, Bakx R. Bowel Lengthening Procedures in Children with Short Bowel Syndrome: A Systematic Review. Eur J Pediatr Surg 2022; 32:301-309. [PMID: 33663008 DOI: 10.1055/s-0041-1725187] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The aims of the study are to systematically assess and critically appraise the evidence concerning two surgical techniques to lengthen the bowel in children with short bowel syndrome (SBS), namely, the longitudinal intestinal lengthening and tailoring (LILT) and serial transverse enteroplasty (STEP), and to identify patient characteristics associated with a favorable outcome. MATERIALS AND METHODS MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched from inception till December 2019. No language restriction was used. RESULTS In all, 2,390 articles were found, of which 40 were included, discussing 782 patients. The median age of the patients at the primary bowel lengthening procedure was 16 months (range: 1-84 months). Meta-analysis could not be performed due to the incomparability of the groups, due to heterogeneous definitions and outcome reporting. After STEP, 46% of patients weaned off parenteral nutrition (PN) versus 52% after LILT. Mortality was 7% for STEP and 26% for LILT. Patient characteristics predictive for success (weaning or survival) were discussed in nine studies showing differing results. Quality of reporting was considered poor to fair. CONCLUSION LILT and STEP are both valuable treatment strategies used in the management of pediatric SBS. However, currently it is not possible to advise surgeons on accurate patient selection and to predict the result of either intervention. Homogenous, prospective, outcome reporting is necessary, for which an international network is needed.
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Affiliation(s)
- Sjoerd C J Nagelkerke
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Amsterdam, The Netherlands.,Amsterdam Reproduction and Development, Amsterdam, The Netherlands.,Amsterdam Gastroenterology and Metabolism, Amsterdam, The Netherlands
| | | | - L M Wessel
- Department of Pediatric Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - A Mutanen
- Department of Pediatric Surgery, The New Children's Hospital, University of Helsinki, Helsinki, Finland
| | - H R Langeveld
- Erasmus MC, Sophia's Children's Hospital, Department of Pediatric Surgery, Rotterdam, The Netherlands
| | - S Hill
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - M A Benninga
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Amsterdam, The Netherlands
| | - M M Tabbers
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Amsterdam, The Netherlands
| | - R Bakx
- Pediatric Surgical Centre, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Amsterdam, The Netherlands
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Merritt RJ. Gastroschisis: Progress and Challenges. J Pediatr 2022; 243:8-11. [PMID: 34958830 DOI: 10.1016/j.jpeds.2021.12.049] [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: 11/29/2021] [Accepted: 12/21/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Russell J Merritt
- Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California.
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Lemoine C, Larkin K, Brennan K, Zoller-Thompson C, Cohran V, Superina R. Repeat serial transverse enteroplasty procedure (reSTEP): Is it worth it? J Pediatr Surg 2021; 56:951-960. [PMID: 33455806 DOI: 10.1016/j.jpedsurg.2020.12.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 12/10/2020] [Accepted: 12/24/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The utility of repeat serial transverse enteroplasty (reSTEP) has been questioned after patients failed to achieve enteral autonomy. We compared the outcomes after reSTEP to one lifetime STEP (oneSTEP), and tried to identify patients at risk for reSTEP failure. METHODS All STEPs done at our institution were reviewed. Growth, enteral autonomy, bowel-derived bloodstream infection hospital admissions, complications, and need for bowel transplantation were evaluated (p<0.05 considered significant). RESULTS 24 patients underwent 32 STEP (16 oneSTEP, 8 reSTEP). reSTEP patients were younger at first surgery (1.01±1.05 vs. oneSTEP 3.06±4.73 years, p = 0.24). Median time to reSTEP was 1.1 year (0.6-5.7). Weight-for-length z-scores improved after reSTEP (0.02±1.40 to 0.22±1.42, p = 0.81). Bowel-derived bloodstream infections decreased after surgery (oneSTEP 1.50±2.25 to 0.94±1.73, p = 0.50; reSTEP 1.88±2.10 to 1.66±2.32, p = 0.52). 37.5% (9/24) patients achieved enteral autonomy at last follow-up: 7/16 oneSTEP, 2/8 reSTEP (p = 0.37). Two complications occurred after oneSTEP (staple line ulcer, leak), none following reSTEP. Three patients (oneSTEP 1/16, reSTEP 2/8, p = 0.19) underwent bowel transplantation (all gastroschisis). CONCLUSION Similar postoperative outcomes after reSTEP and single STEP (improved enteral tolerance, reduced rates of infections) support the use of reSTEP when clinically indicated, although reSTEP in young infants with a history of gastroschisis may need further evaluation.
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Affiliation(s)
- Caroline Lemoine
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kevin Larkin
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Katherine Brennan
- Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Carmyn Zoller-Thompson
- Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Valeria Cohran
- Division of Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Riccardo Superina
- Division of Transplant and Advanced Hepatobiliary Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Capriati T, Mosca A, Alterio T, Spagnuolo MI, Gandullia P, Lezo A, Lionetti P, D’Antiga L, Fusaro F, Diamanti A. To Wean or Not to Wean: The Role of Autologous Reconstructive Surgery in the Natural History of Pediatric Short Bowel Syndrome on Behalf of Italian Society for Gastroenterology, Hepatology and Nutrition (SIGENP). Nutrients 2020; 12:E2136. [PMID: 32708377 PMCID: PMC7400841 DOI: 10.3390/nu12072136] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/13/2020] [Indexed: 12/15/2022] Open
Abstract
Pediatric Short Bowel Syndrome (SBS) can require prolonged parenteral nutrition (PN). Over the years, SBS management has been implemented by autologous gastrointestinal reconstructive surgery (AGIR). The primary objective of the present review was to assess the effect of AGIR on weaning off PN. We also evaluated how AGIR impacts survival, the need for transplantation (Tx) and the development of liver disease (LD). We conducted a systematic literature search to identify studies published from January 1999 to the present and 947 patients were identified. PN alone was weakly associated with higher probability of weaning from PN (OR = 1.1, p = 0.03) and of surviving (OR = 1.05, p = 0.01). Adjusting for age, the probability of weaning off PN but of not surviving remained significantly associated with PN alone (OR = 1.08, p = 0.03). Finally, adjusting for age and primary diagnosis (gastroschisis), any association was lost. The prevalence of TX and LD did not differ by groups. In conclusion, in view of the low benefit in terms of intestinal adaptation and of the not negligible rate of complications (20%), a careful selection of candidates for AGIR should be required. Bowel dilation associated with failure of advancing EN and poor growth, should be criteria to refer for AGIR.
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Affiliation(s)
- Teresa Capriati
- Artificial Nutrition Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy;
| | - Antonella Mosca
- Hepatology Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Tommaso Alterio
- Hepatology Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Maria Immacolata Spagnuolo
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, 80138 Naples, Italy;
| | - Paolo Gandullia
- Gastroenterology Unit, G.Gaslini Institute for Maternal and Child Health, IRCCS, 16145 Genova, Italy;
| | - Antonella Lezo
- Division of Nutrition, Regina Margherita Children’s Hospital, 10126 Turin, Italy;
| | - Paolo Lionetti
- Department of Neuroscience, Psychology, Pharmacology and Child’s Health, University of Florence, Meyer Hospital, 50139 Florence, Italy;
| | - Lorenzo D’Antiga
- Paediatric, Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Fabio Fusaro
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, 00165 Rome, Italy;
| | - Antonella Diamanti
- Artificial Nutrition Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy;
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Generating an Artificial Intestine for the Treatment of Short Bowel Syndrome. Gastroenterol Clin North Am 2019; 48:585-605. [PMID: 31668185 DOI: 10.1016/j.gtc.2019.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Intestinal failure is defined as the inability to maintain fluid, nutrition, energy, and micronutrient balance that leads to the inability to gain or maintain weight, resulting in malnutrition and dehydration. Causes of intestinal failure include short bowel syndrome (ie, the physical loss of intestinal surface area and severe intestinal dysmotility). For patients with intestinal failure who fail to achieve enteral autonomy through intestinal rehabilitation programs, the current treatment options are expensive and associated with severe complications. Therefore, the need persists for next-generation therapies, including cell-based therapy, to increase intestinal regeneration, and development of the tissue-engineered small intestine.
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Shah AA, Petrosyan M, Franklin AL, Chahine AA, Torres C, Sandler AD. Autologous intestinal reconstruction: a single institution study of the serial transverse enteroplasty (STEP) and the longitudinal intestinal lengthening and tailoring (LILT). Pediatr Surg Int 2019; 35:649-655. [PMID: 30868210 DOI: 10.1007/s00383-019-04468-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE To review the effectiveness of the longitudinal intestinal lengthening and tailoring (LILT) and serial transverse enteroplasty (STEP) operations in a cohort of patients with short bowel syndrome (SBS). METHODS We conducted a retrospective analysis of children with SBS treated at our institution from 2004 until 2014. Children aged 0 days to 18 years with SBS who underwent autologous intestinal reconstruction were included in the study. RESULTS Twenty-two SBS patients underwent 31 different lengthening procedures (LP). Seventeen patients underwent their primary lengthening procedures at our institution: 9 (53%) patients underwent a LILT, 7 (41%) underwent a STEP and 1 (6%) had a simultaneous LILT and STEP procedure. 12/22 patients had a second STEP, two had a third STEP and one patient had an intestinal transplantation after the LP. Median intestinal length at the time of surgery was 25 cm (range 12-90 cm). There was no difference in gain of intestinal length after LILT vs. STEP (p = 0.74). Length of stay and initiation of feeds were similar. Serum albumin increased after autologous bowel lengthening (p < 0.001). 50% were weaned off parenteral nutrition (PN) (5/9 of the LILT, 1/7 of the STEP, 1/1 of the combined LILT/STEP). There were no surgical complications or deaths. CONCLUSION In patients with SBS, LILT and STEP procedures are effective for autologous intestinal reconstruction and enable intestinal rehabilitation.
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Affiliation(s)
- Adil A Shah
- Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA
- Department of Surgery, Howard University Hospital and College of Medicine, Washington, DC, USA
| | - Mikael Petrosyan
- Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA.
| | - Ashanti L Franklin
- Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA
| | - Alfred A Chahine
- Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA
| | - Clarivet Torres
- Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA
- Department of Gastroenterology, Hepatology, and Nutrition, Children's National Health System, Washington, DC, USA
| | - Anthony D Sandler
- Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA
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Abstract
The management of short bowel syndrome has mainly been focused on intestinal rehabilitation as part of multidisciplinary team approach in specialized centers. While some patients go through a process of bowel adaptation that allows them to reach enteral autonomy, others reach a plateau before this and require prolonged parenteral nutrition and/or intestinal transplantation. Various autologous intestinal reconstruction procedures centered on bowel tapering have been described to increase functional intestinal area and help gain enteral autonomy. This review discusses the surgical techniques, advantages, limitations, and general outcomes of each procedure.
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Affiliation(s)
- Gabriel Ramos-Gonzalez
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3 Boston, MA 02115, United States
| | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3 Boston, MA 02115, United States.
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9
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Pederiva F, Sgrò A, Coletta R, Khalil B, Morabito A. Outcomes in patients with short bowel syndrome after autologous intestinal reconstruction: Does etiology matter? J Pediatr Surg 2018; 53:1345-1350. [PMID: 29628209 DOI: 10.1016/j.jpedsurg.2018.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 02/26/2018] [Accepted: 03/01/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND Short bowel syndrome (SBS) is the most common cause of intestinal failure in children. Many factors have been investigated in an attempt to define which parameters influence most survival and ability to wean off parenteral nutrition (PN). The aim of this study was to investigate if aetiology of SBS affects the outcomes in paediatric patients treated with autologous gastrointestinal reconstructive surgery. METHODS All children with SBS who underwent autologous gastrointestinal reconstructive surgery between 2002 and 2012 were retrospectively reviewed and outcome measures were recorded. RESULTS Forty-three patients were divided into 4 groups according to aetiology (gastroschisis, volvulus, necrotizing enterocolitis (NEC), intestinal atresia). No significant differences were found among groups regarding survival and median age at surgery. The volvulus group had a lower pre-operative bowel length in comparison with gastroschisis and intestinal atresia and the lowest percentage of patients off PN (30%). Gastroschisis had the lowest rate of preserved ileocaecal valve (10%), while intestinal atresia had the highest (66%). For children who weaned off PN, intestinal atresia had also the longest time to achieve enteral autonomy (14.5months), while NEC had the shortest (3.5months), followed by gastroschisis (8.5months). None of the patients needed transplant. CONCLUSIONS In our experience it does not appear that diagnosis is significantly related to outcome and this is consistent with the conclusions of other reviews. However, it should be noted that in our series patients with volvulus had the worse outcome in terms of weaning off PN when compared with intestinal atresia. TYPE OF STUDY Retrospective Study. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Federica Pederiva
- Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, UK.
| | | | - Riccardo Coletta
- Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, UK; University of Salford, Lancashire, UK
| | - Basem Khalil
- Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, UK; University of Manchester, Faculty of Medical and Human sciences, Manchester Medical School, Manchester, UK; University of Salford, Lancashire, UK
| | - Antonino Morabito
- Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, UK; University of Manchester, Faculty of Medical and Human sciences, Manchester Medical School, Manchester, UK; University of Salford, Lancashire, UK.
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10
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Baxter KJ, Srinivasan JK, Ziegler TR, Dhere T, Ricketts RR, Durham MM. Pediatric short bowel syndrome and subsequent development of inflammatory bowel disease: an illustrative case and literature review. Pediatr Surg Int 2017; 33:731-736. [PMID: 28378134 DOI: 10.1007/s00383-017-4080-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2017] [Indexed: 12/11/2022]
Abstract
Short bowel syndrome (SBS) in neonates is an uncommon but highly morbid condition. As SBS survival increases, physiologic complications become more apparent. Few reports in the literature elucidate outcomes for adults with a pediatric history of SBS. We present a case report of a patient, born with complicated gastroschisis resulting in SBS at birth, who subsequently developed symptoms and pathologic changes of inflammatory bowel disease (IBD) as an adult. The patient lived from age 7, after a Bianchi intestinal lengthening procedure, to age 34 independent of parenteral nutrition (PN), but requiring hydration fluid via G-tube. He was then diagnosed with IBD, after presenting with weight loss, diarrhea, and malabsorption, which required resumption of PN and infliximab treatment. This report adds to a small body of the literature which points to a connection between SBS in neonates and subsequent diagnosis of IBD. Recent evidence suggests that SBS and IBD have shared features of mucosal immune dysfunction and altered intestinal microbiota. We review current treatment options for pediatric SBS as well as multidisciplinary and coordinated transition strategies. We conclude that there may be an etiologic connection between SBS and IBD and that this knowledge may impact outcomes and approaches to care.
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Affiliation(s)
- Katherine J Baxter
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, 1405 Clifton Road NE, Atlanta, GA, 30322, USA.
| | - Jahnavi K Srinivasan
- Division of General and GI Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Thomas R Ziegler
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Tanvi Dhere
- Division of Gastroenterology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Richard R Ricketts
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, 1405 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Megan M Durham
- Division of Pediatric Surgery, Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, 1405 Clifton Road NE, Atlanta, GA, 30322, USA
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11
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Gondolesi GE, Fernandez A, Burghardt KM, Nowakowski S, Kaufman SS, Pascher A, Florescu D, Ruiz P, Vianna R, Clarke S, Oltean M, Rumbo M, Mazariegos G, Sudan DL, Farmer DG. Meeting Report of the XIV International Small Bowel Transplant Symposium: Summary of Presentations, Workshops, and Debates From a Comprehensive Meeting on Intestinal Failure, Rehabilitation, and Transplantation, Buenos Aires, Argentina, June 10-13, 2015. JPEN J Parenter Enteral Nutr 2017; 42:477-489. [PMID: 28437160 DOI: 10.1177/0148607117701696] [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: 01/19/2017] [Accepted: 02/23/2017] [Indexed: 11/16/2022]
Abstract
The 2015 meeting of the Intestinal Transplant Association was held in Buenos Aires, Argentina. This was the 14th International Small Bowel Transplant Symposium, and it was the first meeting organized as a joint venture of the Transplantation Society, the Intestinal Transplant Association, and the Argentinean Transplant Society (Sociedad Argentina de Trasplantes). Innovative aspects of the classic meeting format included workshops sessions, debates, and multicenter studies. This report highlights the most prominent scientific contributions and results of the first such symposium in a Latin American country.
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Affiliation(s)
| | | | | | | | | | - Andreas Pascher
- Campus Virchow and Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Diana Florescu
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Phillip Ruiz
- University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
| | - Rodrigo Vianna
- University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
| | - Sara Clarke
- Birmingham Children's Hospital, Steelhouse Lane, Birmingham, UK
| | | | - Martin Rumbo
- Facultad de Ciencias Exactas, Universidad Nacional de La Plata, La Plata, Argentina
| | - George Mazariegos
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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12
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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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13
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Absent ileocecal valve predicts the need for repeated step in children. Surgery 2017; 161:818-822. [DOI: 10.1016/j.surg.2016.09.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 09/10/2016] [Accepted: 09/12/2016] [Indexed: 12/12/2022]
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14
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Fung JJ. William Hunter Harridge lecture: The changing face of short-gut syndrome management. Am J Surg 2017; 213:448-451. [PMID: 28159115 DOI: 10.1016/j.amjsurg.2017.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 01/10/2017] [Indexed: 02/06/2023]
Abstract
The evolution of managing short gut syndrome optimizes management and decision making of intestinal failure by way of a multidisciplinary team utilizing the latest advances in therapeutic options. Only the minority of patients referred for small bowel transplantation will actually need a transplant. Many of these patients can be rehabilitated without the need for transplant, by way of early referral, and thus the likelihood of medical therapy increases. On the other hand, in those patients with little likelihood of success with medical therapy, early referral decreases the morbidity and mortality associated with long-term total parenteral nutrition and associated complications and will improve their overall survival outcomes.
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Affiliation(s)
- John J Fung
- University of Chicago, Pritzker School of Medicine, USA.
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15
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Fernandes MA, Usatin D, Allen IE, Rhee S, Vu L. Improved enteral tolerance following step procedure: systematic literature review and meta-analysis. Pediatr Surg Int 2016; 32:921-6. [PMID: 27461428 DOI: 10.1007/s00383-016-3927-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2016] [Indexed: 10/21/2022]
Abstract
Surgical management of children with short bowel syndrome (SBS) changed with the introduction of the serial transverse enteroplasty procedure (STEP). We conducted a systematic review and meta-analysis using MEDLINE and SCOPUS to determine if children with SBS had improved enteral tolerance following STEP. Studies were included if information about a child's pre- and post-STEP enteral tolerance was provided. A random effects meta-analysis provided a summary estimate of the proportion of children with enteral tolerance increase following STEP. From 766 abstracts, seven case series involving 86 children were included. Mean percent tolerance of enteral nutrition improved from 35.1 to 69.5. Sixteen children had no enteral improvement following STEP. A summary estimate showed that 87 % (95 % CI 77-95 %) of children who underwent STEP had an increase in enteral tolerance. Compilation of the literature supports the belief that SBS subjects' enteral tolerance improves following STEP. Enteral nutritional tolerance is a measure of efficacy of STEP and should be presented as a primary or secondary outcome. By standardizing data collection on children undergoing STEP procedure, better determination of nutritional benefit from STEP can be ascertained.
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Affiliation(s)
- Melissa A Fernandes
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, USA
| | - Danielle Usatin
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, USA
| | - Isabel E Allen
- Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, San Francisco, USA
| | - Sue Rhee
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, USA
| | - Lan Vu
- Division of Pediatric Surgery, Department of Surgery, Benioff Children's Hospital, University of California, San Francisco, 550 16th Street 5th Floor, San Francisco, CA, 94143, USA.
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Strang BJ, Reddix BA, Wolk RA. Improvement in Parenteral Nutrition–Associated Cholestasis With the Use of Omegaven in an Infant With Short Bowel Syndrome. Nutr Clin Pract 2016; 31:647-53. [DOI: 10.1177/0884533616643697] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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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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Demehri FR, Utter B, Freeman JJ, Fukatsu Y, Luntz J, Brei D, Teitelbaum DH. Development of an endoluminal intestinal attachment for a clinically applicable distraction enterogenesis device. J Pediatr Surg 2016; 51:101-6. [PMID: 26552895 PMCID: PMC4713322 DOI: 10.1016/j.jpedsurg.2015.10.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 10/07/2015] [Indexed: 01/17/2023]
Abstract
PURPOSE Previous methods of distraction enterogenesis have relied upon blind-ending intestinal segments or transmural device fixation, requiring multiple operations and potential bowel injury. We hypothesized that using a novel attachment would allow reversible device coupling to the luminal bowel surface, achieving effective endoluminal distraction. METHODS A telescopic hydraulic device was designed with latex balloon attachments covered with high-friction mesh and a dilating fenestrated elastic mask (DFM attachment), allowing mesh-to-mucosa contact only with inflation. Yorkshire pigs underwent jejunal Roux-en-Y limb creation and device placement via jejunostomy. Devices underwent 3 cycles of balloon inflation and hydraulic extension/retraction per day for 7 days and then explanted and studied for efficacy. RESULTS DFM attachment allowed reversible, high-strength endoluminal coupling without tissue injury or reduction in bowel perfusion. After 7 day implant, distracted bowel achieved a 44 ± 2% increase in length vs. fed, nondistracted bowel, corresponding to a gain of 7.1 ± 0.3 cm. Distracted bowel demonstrated increased epithelial cell proliferation vs. control bowel. Attachment sites demonstrated villus flattening, increased crypt depth, thicker muscularis mucosa, and unchanged muscularis propria thickness vs. CONCLUSION Novel high-strength, reversible attachments enabled fully endoluminal distraction enterogenesis, achieving length gains comparable to open surgical techniques. This approach may allow development of clinically applicable technology for SBS treatment.
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Affiliation(s)
- Farokh R Demehri
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, USA
| | - Brent Utter
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, USA
| | - Jennifer J Freeman
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, USA
| | - Yumi Fukatsu
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, USA
| | - Jonathan Luntz
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, USA
| | - Diann Brei
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, USA
| | - Daniel H Teitelbaum
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, USA.
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Demehri FR, Freeman JJ, Fukatsu Y, Luntz J, Teitelbaum DH. Development of an endoluminal intestinal lengthening device using a geometric intestinal attachment approach. Surgery 2015; 158:802-11. [PMID: 26008962 DOI: 10.1016/j.surg.2015.03.055] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/30/2015] [Accepted: 03/31/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Distraction enterogenesis may provide a novel therapy for short bowel syndrome. Previously described methods have relied on isolated intestinal segments or transmural fixation because of ineffective endoluminal attachment. We hypothesized that a novel approach of geometric coupling between a tapering device and the mesenteric curvature would allow trans-stomal distraction enterogenesis. METHODS A catheter device was designed with tapering stiffness, consisting of a stiff catheter with a taper to a flexible latex tip to prevent perforation. Yorkshire pigs underwent creation of a jejunal Roux limb with device placed via jejunostomy. Intestinal attachment was achieved without a substantial decrease in bowel perfusion as measured by laser Doppler. An external clamp was secured at the stoma to provide external fixation of the device. The catheter was advanced 1 cm/day for either 7 or 14 days before explant. RESULTS After 7 days, the distracted segment achieved a mean ± SD increase in length of 37 ± 6% versus fed, nondistracted bowel, corresponding to an absolute gain of 10.6 ± 1.7 cm (1.5 cm/day). After 14 days, the Roux limb achieved an 80 ± 2% increase in length versus fed control bowel, corresponding to an absolute gain of 16.8 ± 3.0 cm (1.2 cm/day). No perforation or stoma-related complication occurred. CONCLUSION We describe a novel catheter device with tapering stiffness allowing for endoluminal distraction enterogenesis via geometric coupling. This approach may allow development of clinically applicable technology for the treatment of patients with short bowel syndrome.
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Affiliation(s)
- Farokh R Demehri
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Jennifer J Freeman
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Yumi Fukatsu
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Jonathan Luntz
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI
| | - Daniel H Teitelbaum
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI.
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Bueno J, Redecillas S, GarcÍa L, Lara A, Giné C, Molino JA, Broto J, Segarra O. Duodenal lengthening in short bowel with dilated duodenum. J Pediatr Surg 2015; 50:493-6. [PMID: 25746715 DOI: 10.1016/j.jpedsurg.2014.11.047] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 11/02/2014] [Accepted: 11/25/2014] [Indexed: 12/28/2022]
Abstract
UNLABELLED Although duodenal dilatation occurs in children with short bowel syndrome (SBS) facilitating dismotility and bacterial overgrowth, the duodenum has been an untouchable intestinal segment for lengthening procedures owing to its close relationship with bilio-pancreatic structures and blood supply shared with the pancreas. Three children (age range, 0.5-7 years) with SBS and dilated duodenum underwent a novel surgical procedure of duodenal lengthening combined with a technical modification of serial transverse enteroplasty (STEP). Pre-STEP, jejunum length was 5, 35 and 45cm, respectively. Duodenal lengthening was performed with sequential transverse applications of an endoscopic stapler on the anterior and posterior wall of the duodenum to avoid bilio-pancreatic structure injury. Two patients underwent 3 duodenal firings (stapler of 35mm) and the third 5 firings (stapler of 45mm). Duodenal firings were 17%, 21% and 83% of the total firings. RESULTS No surgical complications occurred. One patient developed transient episodes of D-lactic acidosis. Two patients (5 and 45cm) were weaned off parenteral nutrition at 12months post-surgery and the remaining patient´s (35cm) parenteral calorie requirements have decreased by 60%. CONCLUSION Duodenal lengthening is effective since it tailors and increases the absorptive surface of the duodenum, even in cases of extreme SBS.
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Affiliation(s)
- Javier Bueno
- Digestive Surgery and Transplantation Unit, Pediatric Surgery Department, Hospital Universitario Valle de Hebron, Autonomous University of Barcelona, Barcelona, Spain.
| | - Susana Redecillas
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Hospital Universitario Valle de Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Laura GarcÍa
- Digestive Surgery and Transplantation Unit, Pediatric Surgery Department, Hospital Universitario Valle de Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Alba Lara
- Digestive Surgery and Transplantation Unit, Pediatric Surgery Department, Hospital Universitario Valle de Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Carlos Giné
- Digestive Surgery and Transplantation Unit, Pediatric Surgery Department, Hospital Universitario Valle de Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - José A Molino
- Digestive Surgery and Transplantation Unit, Pediatric Surgery Department, Hospital Universitario Valle de Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Jesús Broto
- Digestive Surgery and Transplantation Unit, Pediatric Surgery Department, Hospital Universitario Valle de Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Oscar Segarra
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Hospital Universitario Valle de Hebron, Autonomous University of Barcelona, Barcelona, Spain
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Oh PS, Fingeret AL, Shah MY, Ventura KA, Brodlie S, Ovchinsky N, Martinez M, Lobritto SJ, Cowles RA. Improved tolerance for enteral nutrition after serial transverse enteroplasty (STEP) in infants and children with short bowel syndrome--a seven-year single-center experience. J Pediatr Surg 2014; 49:1589-92. [PMID: 25475799 DOI: 10.1016/j.jpedsurg.2014.07.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 07/07/2014] [Accepted: 07/08/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Serial transverse enteroplasty (STEP) was designed to lengthen and taper the small intestine in patients with short bowel syndrome (SBS) and dilated small bowel. We hypothesized that tolerance for enteral nutrition (EN) improves after STEP. METHODS Patients who underwent STEP between March 2004 and January 2011 were identified. Candidates for STEP had radiographic evidence of dilated small bowel and either failed to advance EN or demonstrated deterioration in tolerance for EN. Clinical and nutritional data were analyzed pre- and post-STEP. EN was defined as the percentage of calories administered enterally. Statistical analysis employed the signed rank test with significance assumed when p<0.05. RESULTS Twenty STEPs were performed at a median age of 13.7 months. Median pre-STEP bowel length was 30 cm with a median increase in bowel length of 42%. Five patients achieved enteral autonomy at a median of 6.5 months post-STEP. EN increased in 75%, while 25% exhibited unchanged or decreased EN post-STEP. In aggregate, median EN tolerance increased from 22% at one month pre-STEP to 61% at six months post-STEP (p=0.003). CONCLUSIONS The STEP is an effective adjunct in the treatment of patients with intestinal failure. While enteral autonomy is eventually possible in some patients, improved enteral tolerance can be achieved in a majority of cases.
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Affiliation(s)
- Pilyung S Oh
- Division of Pediatric Surgery, Department of Surgery Columbia University College of Physicians and Surgeons and Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY 10032, United States
| | - Abbey L Fingeret
- Division of Pediatric Surgery, Department of Surgery Columbia University College of Physicians and Surgeons and Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY 10032, United States
| | - Manan Y Shah
- Gaming Laboratories International, LLC, Lakewood, NJ 08701, United States
| | - Kara A Ventura
- Center for Liver Disease and Transplantation, Department of Surgery Columbia University College of Physicians and Surgeons and Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY 10032, United States
| | - Susan Brodlie
- Center for Liver Disease and Transplantation, Department of Surgery Columbia University College of Physicians and Surgeons and Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY 10032, United States
| | - Nadia Ovchinsky
- Center for Liver Disease and Transplantation, Department of Surgery Columbia University College of Physicians and Surgeons and Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY 10032, United States
| | - Mercedes Martinez
- Center for Liver Disease and Transplantation, Department of Surgery Columbia University College of Physicians and Surgeons and Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY 10032, United States
| | - Steven J Lobritto
- Center for Liver Disease and Transplantation, Department of Surgery Columbia University College of Physicians and Surgeons and Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY 10032, United States
| | - Robert A Cowles
- Division of Pediatric Surgery, Department of Surgery Columbia University College of Physicians and Surgeons and Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY 10032, United States; Section of Pediatric Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT 06520, United States.
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Wester T, Borg H, Naji H, Stenström P, Westbacke G, Lilja HE. Serial transverse enteroplasty to facilitate enteral autonomy in selected children with short bowel syndrome. Br J Surg 2014; 101:1329-33. [PMID: 25043139 PMCID: PMC4282069 DOI: 10.1002/bjs.9583] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 01/10/2014] [Accepted: 05/08/2014] [Indexed: 12/25/2022]
Abstract
Background Serial transverse enteroplasty (STEP) was first described in 2003 as a method for lengthening and tapering of the bowel in short bowel syndrome. The aim of this multicentre study was to review the outcome of a Swedish cohort of children who underwent STEP. Methods All children who had a STEP procedure at one of the four centres of paediatric surgery in Sweden between September 2005 and January 2013 were included in this observational cohort study. Demographic details, and data from the time of STEP and at follow-up were collected from the case records and analysed. Results Twelve patients had a total of 16 STEP procedures; four children underwent a second STEP. The first STEP was performed at a median age of 5·8 (range 0·9–19·0) months. There was no death at a median follow-up of 37·2 (range 3·0–87·5) months and no child had small bowel transplantation. Seven of the 12 children were weaned from parenteral nutrition at a median of 19·5 (range 2·3–42·9) months after STEP. Conclusion STEP is a useful procedure for selected patients with short bowel syndrome and seems to facilitate weaning from parenteral nutrition. At mid-term follow-up a majority of the children had achieved enteral autonomy. The study is limited by the small sample size and lack of a control group. Good results in selected children
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Affiliation(s)
- T Wester
- Department of Paediatric Surgery, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
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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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Borschel MW, Antonson DL, Murray ND, Oliva-Hemker M, Mattis LE, Kerzner B, Tolia V, Baggs G. Two single group, prospective, baseline-controlled feeding studies in infants and children with chronic diarrhea fed a hypoallergenic free amino acid-based formula. BMC Pediatr 2014; 14:136. [PMID: 24885833 PMCID: PMC4061110 DOI: 10.1186/1471-2431-14-136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 05/16/2014] [Indexed: 11/30/2022] Open
Abstract
Background Infants and children with chronic diarrhea (CD) often require specialized foods or parenteral nutrition (PN) to achieve adequate nutrient intakes to support growth and development. We assessed the efficacy of an amino acid-based formula (AAF) in supporting growth and improving symptoms in infants and children with CD from multiple etiologies. Methods Two studies were conducted: CD study in children (CD-C) and CD study in infants (CD-I). Each was a single group, baseline-controlled study in which each subject served as his/her own control. At enrollment, all subjects had CD lasting > 2 weeks and had ≥ 4 stools/day. Subjects were fed an AAF for 80 days starting at SD5, and were assessed at SD 28 and 84. Results CD-C: 18 of 19 subjects completed the study. At enrollment, the mean age was 5.6 ± 0.7 years, the most common diagnosis was short bowel syndrome (SBS) (n = 13), and 5 subjects with SBS were on PN. Subjects achieved significant increases in weight-for-age z-scores (p = 0.026). Over 50% of subjects achieved improvements in clinical outcomes targeted most frequently by their physicians. Of the five subjects on PN at enrollment, four had substantial weight gain and four had their PN requirements decreased. CD-I: 22 of 27 subjects completed the study. At enrollment, the mean age was 3.3 ± 0.3 months, the most common diagnosis was food allergy (n = 20), and no subjects were on PN. Subjects achieved significant increases in weight-for-age z-scores (p = 0.0023), significant decreases in the number of stools/day (p = 0.0012), and improvements in stool consistency (p = 0.0024). Over 80% of subjects achieved improvements in the clinical outcomes targeted most frequently by their physicians. Conclusions Infants and children with CD fed an AAF for three months displayed significant improvements in weight-for-age z-scores and clinical symptoms. Children dependent on PN also grew well and four of five decreased their dependence on PN. Trial registration Both trials were registered on ClinTrials.gov (CD-C, NCT01812629; CD-I, NCT01820494).
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Affiliation(s)
- Marlene W Borschel
- Scientific & Medical Affairs, Abbott Nutrition, Abbott Laboratories, 3300 Stelzer Road, Columbus, Ohio 43219, USA.
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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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