ESPEN guideline on chronic intestinal failure in adults - Update 2023

Essential fatty acid deficiency in parenteral nutrition: Historical perspective and modern solutions, a narrative review

Essential fatty acid deficiency (EFAD) may occur in the setting of inadequate fat intake, malabsorption, malnutrition, and altered fat metabolism. Humans lack the enzymes to synthesize the essential acids linoleic acid and alpha-linolenic acid, so they must be obtained from the diet. Patients dependent on parenteral nutrition need adequate amounts of these essential fatty acids supplied in lipid injectable emulsions (ILEs). With the increasing use of multicomponent ILEs that are lower in linoleic and alpha-linolenic acid, it is imperative that clinicians understand appropriate dosing to prevent EFAD. An understanding of fatty acid composition and metabolic pathways is important, as the use of the Holman Index (triene:tetraene ratio) alone may lead to an inaccurate diagnosis of EFAD.

Real-world experience of Teduglutide use in adults with short bowel syndrome: A seven-year international multicenter survey

BACKGROUND AND AIM

Teduglutide is a glucagon-like peptide-2 analogue used to promote intestinal rehabilitation and decrease the dependence from intravenous supplementation (IVS) in patients with short bowel syndrome and intestinal failure (SBS-IF). The aim of this study was to gain a better understanding of international real-world Teduglutide use since its launch.

METHODS

Data from an international multicenter database for chronic IF were analysed. All the adult patients with SBS-IF included by centers that treated at least one patient with Teduglutide during the study period (2015-2022) were investigated. The baseline characteristics and the outcome of patients treated with Teduglutide (n.269) were compared to those of patients not receiving the drug (Controls, n.3081). The center experience was categorized based on the number of patients treated with Teduglutide: <10 or ≥10.

RESULTS

Teduglutide cohort exhibited higher male prevalence, younger age, longer duration of HPN, higher percentage of SBS with jejunocolonic anastomosis, lower IVS volume, improved oral intake, and higher percentage of patients weaned from IVS. Controls showed higher percentages of patients deceased or lost to follow up. Centers with ≥10 patients treated with Teduglutide showed higher weaning rates and lower mortality rates.

CONCLUSIONS

This is the largest analysis of Teduglutide's real-world setting in SBS-IF. Clinicians preferentially selected for treatment patients with better prognostic indicators. Outcomes were significantly better in centers with higher Teduglutide treatment volumes, emphasizing the need for specialized referral centers to optimize care for SBS-IF patients.

Accurate urine sodium measurements at home using point of care testing in patients with short bowel syndrome

BACKGROUND AND AIMS

Measurement of the urine sodium concentration (USC) is a simple procedure that in many patients adequately indicates their hydration status. This is of particular importance in patients suffering from short bowel syndrome (SBS), who may very rapidly dehydrate and are at risk for permanently compromising their kidney function. A point of care testing (POCT) that allows reliable measurement of USC would enable these patients to effectively evaluate their sodium- and water balance in the at home setting, thereby avoiding hospital visits and delayed test results. In this study, a POCT device to assess USC was first analytically validated after which it was applied for the at home evaluation of the hydration status in patients with SBS.

METHODS

First, we validated the imprecision, bias and limit of quantification of USC as measured with the Fisic Medimate POCT device in comparison to an automated routine chemistry system. Next, the device was used for monitoring USC at home in 21 patients with SBS, including an evaluation of user friendliness System Usability Scale (SUS) and accuracy for detecting low sodium levels as compared to the routine chemistry system.

RESULTS

The imprecision of the POCT device at low USC was 6.1 %. In samples at the clinical decision threshold to identify patients at the verge of dehydration of 20 mmol/l as measured by routine chemistry USC, the POCT device demonstrated a mean estimation of USC of 20.6 mmol/l (95 % CI 18.8-22.4). Dehydration was detected with a sensitivity of 95 % when the medical decision limit for urinary sodium on the POCT device was set at a safe concentration of 30 mmol/l. Using the device was straightforward and easy to learn for patients with an overall System Usability Scale (SUS) score of 86.

CONCLUSION

USC measurements using this POCT device can be safely integrated into daily practice for early detection of dehydration in patients with SBS. Clear patient instructions to ensure accurate drop dispensing and a higher clinical decision threshold of USC of 30 mmol/l will allow a high sensitivity for detecting dehydration in patients with short bowel syndrome.

Chronic kidney disease - Epidemiology collaboration equations even using cystatin C overestimate renal function in patients with chronic intestinal failure on long-term parenteral nutrition

BACKGROUND & AIMS

Accurate determination of renal function is of utmost importance in chronic intestinal failure (CIF) patients on parenteral nutrition (PN) and creatinine based glomerular filtration rate (GFR) estimating equation is used in clinical practice. The aim of the present study is to evaluate the reliability of 3 CKD-EPI GFR estimating equations (eGFR) (creatinine, cystatin C or combined creatinine/cystatin C) compared with the reference method which is Iohexol plasma clearance (mGFR) in patients on long-term PN (>6 months) owing to CIF.

METHODS

Forty-eight patients (25 F) with a median age of 58 years (Interquartile Range:15) presenting CIF on PN for a median duration of 93 months (75) were included in this retrospective study. Concordance studies were performed by Pearson correlation and Bland-Altman method (Mean bias-Confidence Interval). Accuracy of the formulas was estimated with P30 representing the proportion of eGFR within 30 % of mGFR (±30 %).

RESULTS

Median mGFR was 65 (29) ml/min/1.73 m2 and the median eGFR was 85 (43) ml/min/1.73 m2 with 2009 CKD-EPIcreatinine, 74 (47) ml/min/1.73 m2 with 2012 CKD-EPIcystatin and 75 (48) ml/min/1.73 m2 with 2012 CKD-EPIcombined Cystatin C/Creatinine based formulas. The agreements were not acceptable for clinical practice. Median bias as well as lower and upper confidence intervals were for mGFR vs. eGFR (2009 CKD-EPIcreat): +21,1 (16.7,25.3), for mGFR vs. eGFR (2012 CKD-EPIcyst): +14.4 (12.9,20.5) and for mGFR vs. eGFR (2012 CKD-EPIcomb): +9.3 (7.9,15.5). Accuracy of all formulas estimated by P30 was less than 80 %. With the 3 eGFR equations, more than 46 % of patients were poorly stratified according to the classification of chronic kidney disease (CKD) with an overall tendency towards underestimation of the disease severity. Forty-seven percent of the patients had mGFR<60 ml/min/1.73 m2 corresponding to CKD Stage III or worse.

CONCLUSIONS

The eGFR estimating CKD-EPI equations significantly miscalculate the true levels of renal function in patients with CIF on PN and should be used with caution in daily clinical practice.

Diagnosis and management of acute mesenteric ischemia: What you need to know

ABSTRACT

Acute mesenteric ischemia (AMI) is associated with high mortality rates. There are multiple challenges to establishing an accurate early diagnosis and providing state-of-the-art care for AMI patients. A high index of suspicion is key for early diagnosis. Once suspicion is raised, a triphasic computed tomography angiography is the essential diagnostic tool. Avoiding delays, using hybrid operating rooms and contemporary revascularization techniques for arterial occlusive AMI, can significantly improve the prognosis. Regional health care systems should be developed to direct AMI patients into centers with sufficient capabilities for providing all aspects of care at all hours. The acute care surgeon has a central role in performing laparotomies and bowel resections when needed and coordinating the management flow in close collaboration with vascular surgeons and interventional radiologists for prompt and effective revascularization. A significant share of patients with an arterial occlusive AMI can be managed by endovascular revascularization without the need for a laparotomy. There are no reliable tools for predicting transmural bowel necrosis, and individual assessment and clinical experience are very important in decision-making when choosing between laparotomy and close observation. During laparotomy, an atherosclerotic occlusion at the root of the superior mesenteric artery can be stented by using a retrograde open mesenteric or percutaneous approach, and surgical bypass is seldom needed. Using hospital-specific management pathways is very useful for the standardization of care in arterial occlusive AMI. In venous AMI, systemic anticoagulation is sufficient in most cases. In patients whose symptoms do not resolve, there are various options for endovascular and surgical revascularization. In nonocclusive mesenteric ischemia, prevention by maintaining sufficient abdominal perfusion pressure is key. High-level evidence is scarce, but with current knowledge, the prognosis of AMI patients has plenty of room for improvement.

European Consensus on Malabsorption-UEG & SIGE, LGA, SPG, SRGH, CGS, ESPCG, EAGEN, ESPEN, and ESPGHAN: Part 2: Screening, Special Populations, Nutritional Goals, Supportive Care, Primary Care Perspective

Malabsorption is a complex and multifaceted condition characterised by the defective passage of nutrients into the blood and lymphatic streams. Several congenital or acquired disorders may cause either selective or global malabsorption in both children and adults, such as cystic fibrosis, exocrine pancreatic insufficiency (EPI), coeliac disease (CD) and other enteropathies, lactase deficiency, small intestinal bacterial overgrowth (SIBO), autoimmune atrophic gastritis, Crohn's disease, and gastric or small bowel resections. Early recognition of malabsorption is key for tailoring a proper diagnostic work-up for identifying the cause of malabsorption. Patient's medical and pharmacological history are essential for identifying risk factors. Several examinations like endoscopy with small intestinal biopsies, non-invasive functional tests, and radiologic imaging are useful in diagnosing malabsorption. Due to its high prevalence, CD should always be looked for in case of malabsorption with no other obvious explanations and in high-risk individuals. Nutritional support is key in management of patients with malabsorption; different options are available, including oral supplements, enteral or parenteral nutrition. In patients with short bowel syndrome, teduglutide proved effective in reducing the need for parenteral nutrition, thus improving the quality of life of these patients. Primary care physicians have a central role in early detection of malabsorption and should be involved into multidisciplinary teams for improving the overall management of these patients. In this European consensus, involving 10 scientific societies and several experts, we have dissected all the issues around malabsorption, including the definitions and diagnostic testing (Part 1), high-risk categories and special populations, nutritional assessment and management, and primary care perspective (Part 2).

Survival and parenteral nutrition dependence in patients aged 65 y and older with short bowel syndrome: a retrospective observational cohort study

BACKGROUND

Home parenteral support (PS) is the standard treatment of chronic intestinal failure (CIF) with short bowel syndrome (SBS) as the leading cause. However, outcomes of PS in older patients remain poorly studied.

METHODS

This retrospective observational study evaluated patients with newly diagnosed SBS-CIF initiating PS between 2015 and 2020 at a national French CIF referral center. Patients were stratified into 2 groups: 65 y or older (older group) and younger than 65 y (younger group). Multivariate Cox regression identified predictors of mortality and PS dependence in older patients.

RESULTS

We included 175 patients [median age: 61 y (IQR: 46-70 y); 58% female]. Mesenteric ischemia was the primary cause of CIF (32%). Surgical anatomy included jejunostomy (47%), jejunocolic (39%), and ileocolic anastomosis (14%). Older patients [n = 73 (42%); median age: 72 y; IQR: 68-76 y] had higher rates of arterial hypertension, dyslipidemia, cancer, and SBS-CIF caused by radiation enteritis, but fewer cases attributed to Crohn disease. After a median follow-up of 27 mo (95% confidence interval [CI]: 22, 32 mo), the probability of survival was 92% (95% CI: 88%, 97%), and the probability of PS dependence was 68% (95% CI: 60%, 785), with no significant difference between age groups. In older patients, the presence of a jejunostomy (hazard ratios [HR]: 3.4; 95% CI: 1.1, 10.6) was an independent predictor of PS dependence, and BMI of <22 kg/m2 (HR: 10.9; 95% CI: 1.4, 87.4) was an independent predictor of mortality. Fourteen patients (8%) were treated with teduglutide, with no significant difference between age groups.

CONCLUSIONS

Nearly half of patients with SBS-CIF on PS are aged 65 y or older, with PS dependence and survival rates comparable with those of younger patients. These findings suggest that age should not be a barrier to PS initiation.

Intestinal-Failure-Associated Liver Disease: Beyond Parenteral Nutrition

Short bowel syndrome (SBS), usually resulting from massive small bowel resections or congenital defects, may lead to intestinal failure (IF), requiring intravenous fluids and parenteral nutrition to preserve patients' nutritional status. Approximately 15% to 40% of subjects with SBS and IF develop chronic hepatic damage during their life, a condition referred to as intestinal-failure-associated liver disease (IFALD), which ranges from steatosis to fibrosis or end-stage liver disease. Parenteral nutrition has been largely pointed out as the main pathogenetic factor for IFALD. However, other elements, such as inflammation, bile acid metabolism, bacterial overgrowth and gut dysbiosis also contribute to the development of liver damage and may deserve specific treatment strategies. Indeed, in our review, we aim to explore IFALD pathogenesis beyond parenteral nutrition. By critically analyzing recent literature, we seek to delve with molecular mechanisms and metabolic pathways underlying liver damage in such a complex set of patients.

Optimizing vitamin supplementation via reference interval update of vitamins A, E, B1, and B6 using HPLC

Vitamins are essential micronutrients obtained from the diet, required by the body in small amounts daily for proper metabolism. Monitoring their levels is necessary for detecting deficiencies and guiding supplementation in certain clinical conditions. This study aimed to update the reference values for vitamins A, B1, B6, and E, and some related ratios, adjusted to the adult population of our health reference area using liquid chromatography in a direct approach calculation (n = 146, age: 21-64 years, 64% females). No significant differences in vitamin levels or ratios were observed based on age and sex. We obtained reliable and updated reference values: 1.1-2.8 ‍μmol/L and 18.9-42.2 ‍μmol/L for vitamins A and E respectively, 85.9-181.6 nmol/L and 57.0-165.7 nmol/L for vitamins B1 and B6 respectively; and related ratios of 246.2-561.1 ‍ng/g for vitamin B1 corrected by hemoglobin; 5.2-8.9 ‍μmol/mmol and 4.5-7.4 ‍μmol/mmol for vitamin E corrected by cholesterol and total lipids, respectively. These reference values significantly differ from those provided by the reagent manufacturer currently in use. While correcting vitamin E for lipids and vitamin B1 for hemoglobin is not recommended for the general population, these adjustments may be useful in interpreting results in certain pathological conditions.

Parenteral lipid emulsions: the state of the art

PURPOSE OF REVIEW

Several types of injectable lipid emulsions (ILEs) have become available for parenteral nutrition. The purpose of this review is to highlight the most recent and interesting articles in the field of ILEs.

RECENT FINDINGS

Recent literature has compared ILEs in various clinical scenarios (e.g. abdominal surgery, chronic intestinal failure, critical illness, and preterm birth). Favorable clinical effects of ILEs containing fish oil have been observed in studies on surgical patients with Crohn's disease, critically ill patients, and patients with intestinal failure-associated liver dysfunction, whereas other trials have shown no clear benefit. Ongoing research is focused on finding novel strategies to reduce liver toxicity of ILEs, including the use of 'artificial intelligence' tools and liver organoids. Promising new applications for ILEs are emerging, including the prevention of neonatal hypoxic brain injury.

SUMMARY

Although ILEs with the goal of reducing the levels of pro-inflammatory omega-6 fatty acids appear to confer some advantage in some settings (e.g. surgery), conclusive data on the superiority of one ILE over another are lacking. In particular, research is needed to compare different types of mixed-oil ILEs with each other and with pure fish oil ILEs.

The role of the social worker in the assessment and management of adults receiving Home Parenteral Nutrition

People diagnosed with Intestinal Failure (IF) requiring Home Parenteral Nutrition (HPN) have complex medical and nutritional requirements. To date, assessment for, and ongoing management of, HPN has relied on medical, nursing and dietetic input. However, success in assessing suitability for HPN and ongoing management is often reliant on non-medical factors. This paper aims to outline the critical clinical role the social worker can play and their scope of practice in assessing and managing people requiring HPN. This includes assessment across medical, psychosocial, financial, legal, quality-of-life and healthcare-related domains. This perspective paper highlights the vast scope in which the social worker can support people diagnosed with IF requiring HPN. More research is required to quantify the value of the social worker as a key member of the multidisciplinary IF team.

Lipids in Clinical Nutrition and Health: Narrative Review and Dietary Recommendations

Lipids are essential components of human health, serving as critical structural elements of cell membranes, energy sources, and precursors for bioactive molecules. This narrative review aims to examine the multifaceted roles of lipids in clinical nutrition and health, focusing on their impact on chronic disease prevention, management, and the potential of lipid-based therapies. A narrative review was conducted utilizing Scopus, Google Scholar, and Web of Science databases. Key terms such as lipids, dietary fats, and cholesterol were used to identify and analyze relevant studies. A total of 145 articles meeting inclusion criteria were reviewed for their insights into lipid metabolism, dietary sources, and clinical implications. The analysis highlighted the metabolic significance of various lipid classes-saturated, monounsaturated, and polyunsaturated fatty acids-along with evidence-based recommendations for their dietary intake. Lipids were shown to play a pivotal role in managing chronic diseases such as cardiovascular disease, obesity, and metabolic syndrome. Emerging therapies, including omega-3 fatty acids and medium-chain triglycerides, demonstrated potential benefits in clinical practice. By synthesizing current knowledge, this narrative review provides healthcare professionals with an updated understanding of the roles of lipids in clinical nutrition. The findings emphasize the importance of tailored dietary interventions and lipid-based therapies in optimizing health and managing chronic diseases effectively. Additionally, this review successfully presents practical dietary recommendations to guide clinical practice.

Development and validation of the Crohn's disease-intestinal failure-wean (CDIF-Wean) Score to predict outcomes of intestinal rehabilitation

BACKGROUND & AIMS

Enteral autonomy, a key outcome of intestinal rehabilitation in patients with intestinal failure (IF), is challenging to predict due to disease complexity and heterogeneity. The aim of this cohort study is to develop and validate a multivariate model to predict enteral autonomy in patients with IF caused by Crohn's disease (CDIF), and to derive an outcome-based severity classification for CDIF.

METHODS

The CDIF-Wean Score was constructed and internally validated in a cohort of 182 patients with CDIF from a tertiary IF unit. We performed stepwise backward selection to include relevant and significant clinical variables in a binomial regression with inverted probability of censoring weighting. The Score was externally validated in a separate cohort of 107 patients with CDIF from an independent tertiary IF unit. A severity classification, based on the CDIF-Wean Score, was evaluated with cumulative incidence curves for enteral autonomy and death during home parenteral support (HPS).

RESULTS

In the CDIF-Wean Score, age, HPS duration, chronicity of Crohn's disease, intestinal anatomy, and eligibility and type of reconstructive surgery was predictive of enteral autonomy. The Score performed well in discrimination and calibration, with 0.84 and 0.84 area under the receiver operating characteristic curve, and 0.13 and 0.16 Brier scores in internal and external validation, respectively. The CDIF severity classification was significantly associated with both short- and long-term prognosis, where mild patients had a 7.5, 5.8 and 5.2-fold higher probability of enteral autonomy than severe patients at 1, 5 and 10 years (p<0.0001).

CONCLUSION

The CDIF-Wean Score is the first validated prediction model for IF outcomes, and demonstrates accuracy, robustness and generalisability in the prognostication of CDIF patients.

Chronic Intestinal Failure and Short Bowel Syndrome in Adults: Principles and Perspectives for the Portuguese Health System

Background

Short bowel syndrome is a devastating malabsorptive condition and the most common cause of chronic intestinal failure (CIF). Patients need parenteral support for months or years. Ideally, it should be delivered at home, reducing limitations in everyday life activities.

Summary

The Portuguese Health Directive 017/2020 was the first step in the regulation of home CIF management, and more patients are now being treated in an ambulatory setting. However, much work still needs to be performed in this area. Our country lacks a network of units capable of providing home parenteral nutrition (HPN), and only a few centers have expertise to take care of these complex patients: fluid support, oral, enteral, and parenteral nutrition; disease/HPN-related complications; pharmacologic treatment; and surgical prevention/treatment. Providing adequate transition from pediatric to adult care is a mandatory issue that should only be addressed by expert centers.

Key Messages

Implementation of a national network, as well as the creation of an intestinal failure registry, with an initial focus on adult patients, will start a new era in the identification and management of these complex CIF patients.

Beyond Survival: Unveiling Psychological and Social Adaptation After Visceral Transplantation

AIM

To explore the meaning of adaptation after visceral transplantation in terms of patient experiences, symptoms, self-efficacy, transplant-specific and mental well-being.

DESIGN

A convergent parallel mixed-methods study, consisting of interviews and generic as well as transplant-specific questionnaires. Results were integrated using meta-inference.

METHODS

The study comprises a population of 17 visceral transplant recipients in Scandinavia, 12 women and 5 men with a mean age of 40.6 years (range 19-63 years) and an average follow-up of 9.4 years (range 0-25 years). Data were collected between May 2023 and January 2024 through open-ended in-depth interviews with 12 participants and analysed in accordance with phenomenological hermeneutics. Questionnaires from all 17 participants were analysed to measure transplant-specific well-being, symptoms, self-efficacy as well as anxiety and depressive symptoms.

RESULTS

Being a visceral transplant recipient is a dynamic and life-long adaptation process that comprises two distinct yet interconnected trajectories: coherence and endurance. Coherence involves the person's ability to make sense of their situation and find meaning despite the challenges and adversity of the chronic condition. In contrast, endurance involves a person's capacity to withstand hardship and endure unpleasant or difficult experiences. Both trajectories interact dynamically, influencing and reinforcing each other. Resilience based on coherence enabled acceptance and adjustment. Conversely, uncertainty, resignation and feeling unsupported resulted in a lack of acceptance, manifested as resistance. The challenge involved in adaptation was demonstrated by 47% showing borderline elevated or elevated levels of anxiety and 18% reporting symptoms of depression. Self-efficacy varied considerably.

CONCLUSION

The meaning of adaptation after visceral transplantation in terms of experiences, symptoms, transplant-specific and mental well-being is balancing between coherence and endurance facilitated by acceptance and hampered by resistance. The uncertainty inherent in being a visceral transplant recipient may lead to heightened self-rated anxiety symptoms and diminished self-efficacy.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

What problem did the study adress? This study adresses the challenges involved in being a visceral transplant recipient and adapting to life after a visceral transplantation. What were the main findings?

REPORTING METHOD

COREQ checklist (consolidated criteria for reporting qualitative research).

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution was organised.

Pharmacological Strategies for High-Output Ileostomies in Children: A Narrative Review

AIM

Nutritional measures often suffice for managing high-output ileostomy (HOI) in paediatric patients, but pharmacological treatment may be required to control ostomy output. This paper reviews the literature on the pharmacological management of paediatric HOI and provides recommendations.

METHODS

PubMed and Embase were searched for relevant articles up to 22 May 2024. Relevant articles were reviewed and recommendations were formulated.

RESULTS

No pharmacological studies involving paediatric ileostomy patients were identified, apart from two case reports on octreotide. The formulated recommendations are therefore based on data from adults or other intestinal failure conditions. The primary treatment suggestions are proton pump inhibitors and loperamide. Subcutaneous octreotide can be administered when complications persist. Codeine may be used in rare cases in children over 12 years old, but addiction risk and side effects limit its use. There is no or insufficient evidence for smectite, racecadotril, probiotics or prophylactic cycled antibiotics or clonidine. Bile acid sequestrants are not indicated in patients without a colon in continuity.

CONCLUSION

Pharmacological options for the treatment of HOI in children are limited and evidence for their use is lacking. Research in paediatric HOI patients is needed to validate the use of pharmacotherapy in this patient group.

Selective minimally invasive strategy for acute superior mesenteric artery obstruction

OBJECTIVE

Acute mesenteric artery obstruction is a severe cause of acute mesenteric ischemia, associated with significant morbidity and mortality. However, there is limited guidance on choosing between traditional and minimally invasive techniques comprehensively. This study introduces a selective, minimally invasive strategy designed to improve the survival and prognosis of patients with acute superior mesenteric artery obstruction.

METHODS

In this prospective, single-arm trial conducted between 2020 and 2023, patients with acute mesenteric ischemia due to acute superior mesenteric artery obstruction were enrolled. A total of 42 patients were included, meeting the predetermined sample size. The primary outcome was the 30-day chronic intestinal failure (CIF)-free survival rate. Based on an algorithm incorporating preoperative radiographic findings, physical signs, and laboratory markers, patients were assigned to one of three therapeutic pathways: traditional laparotomy with thrombectomy, laparoscopy combined with endovascular therapy, or endovascular therapy alone.

RESULTS

The CIF-free survival rates at 30 days and 2 years were 71% (30/42) and 60%, respectively. Short-term mortality, including 30-day and in-hospital mortality, was 11.9%, indicating an improvement compared with historical cohorts. The cumulative mortality rates at 6 months, 1 year, and 2 years were 26%, 32%, and 32%, respectively. The primary and assisted patency rates at 1 year were 90% and 97%, respectively. Transition to laparotomy was required in 43% of patients undergoing laparoscopic exploration. Improved blood supply was observed in 73% of the patients who underwent two laparoscopic procedures (15 patients), and bowel resection was avoided in 40% of cases. The median durations of hospitalization and intensive care unit stay were 19 days (interquartile range, 11-31 days) and 2 days (interquartile range, 0-6 days), respectively.

CONCLUSIONS

This selective, minimally invasive strategy for managing acute mesenteric ischemia demonstrated high 30-day CIF-free survival rates and reduced short-term mortality. These findings suggest the potential advantages of this approach in improving outcomes for patients with acute mesenteric ischemia.

The Natural History of Crohn's Disease Leading to Intestinal Failure: A Longitudinal Cohort Study from 1973 to 2018

BACKGROUND AND AIMS

The natural history of Crohn's disease leading to intestinal failure is not well characterised. This study aims to describe the clinical course of Crohn's disease preceding intestinal failure and to compare disease course and burden between Crohn's disease patients with and without intestinal failure.

METHODS

Patients with Crohn's disease complicated by intestinal failure from Rigshospitalet, Copenhagen [n = 182] and a nationwide Danish Crohn's disease cohort without intestinal failure [n = 22,845] were included. Using nationwide registries in Denmark, disease course was determined from hospitalisations, surgeries, and outpatient medications, and disease burden was determined from employment and mortality data.

RESULTS

The 10-year cumulative incidence of intestinal failure following Crohn's disease diagnosis declined from 2.7% prior to 1980 to 0.2% after 2000. Compared with Crohn's disease patients without intestinal failure, those with intestinal failure experienced significantly longer duration of severe disease [50 vs 19 years per 100 patient-years, p < 0.01], secondary to greater corticosteroid use [71% vs 60%, p = 0.02], inpatient contacts [98% vs 55%, p < 0.01], and abdominal surgeries [99% vs 48%, p < 0.01]. However, exposure to biologics was not different between the two groups [20.4% vs 21%, p = 0.95], and duration on biologics was shorter in Crohn's disease patients with intestinal failure [2068 vs 4126 days per 100 patient-years, p = 0.02]. Standard mortality ratio in Crohn's disease patients with intestinal failure was 3.66 (97.5% confidence interval [CI] 2.79, 4.72].

CONCLUSION

Patients with Crohn's disease complicated by intestinal failure experienced a more persistently severe preceding course of Crohn's disease but were not more likely to be treated with biological therapy.

Parenteral nutrition and bioelectrical impedance analysis estimated fat-free mass in adult patients with chronic intestinal failure: A descriptive cohort study

BACKGROUND

In patients with chronic intestinal failure, the content and type of parenteral nutrition are individually determined based on various factors, including body composition. In clinical practice, bioelectrical impedance analysis is used to assess body composition using standardized protocols. However, these protocols lack specific recommendations for patients receiving parenteral nutrition. Therefore, this study described the effect of parenteral nutrition infusion on fat-free mass as evaluated by single-frequency bioelectrical impedance analysis.

METHODS

We performed a descriptive cohort study using bioelectrical impedance analysis to assess adult patients with chronic intestinal failure receiving parenteral nutrition. Measurements were performed at baseline (before parenteral nutrition infusion) and 0, 1, 2, and 4 h after (usually) 18-h parenteral nutrition infusion using hand-to-foot single-frequency bioelectrical impedance analysis (Bodystat 500). The primary outcome of fat-free mass was calculated using the Kyle equation. A linear mixed model was used to compare baseline values with other time points. A difference of >1 kg in fat-free mass compared with baseline was considered clinically relevant.

RESULTS

Twenty patients (70% female) with a mean age of 58 (SD, 14) years and a median body mass index of 22.3 (IQR, 21.2-24.8) kg/m2 were included in the analysis. No significant change in fat-free mass after parenteral nutrition infusion was observed, and 90% (69/77 measurements) of all fat-free mass outcomes after parenteral nutrition infusion remained within the ≤1-kg clinically relevant range.

CONCLUSION

This study found that parenteral nutrition infusion does not affect fat-free mass estimation as assessed by hand-to-foot single-frequency bioelectrical impedance analysis.

Pantoea eucrina: Catheter-Related Bloodstream Infection in a Woman With Short Bowel Syndrome

Pantoea eucrina, a member of the Erwiniaceae family, is a rarely reported human pathogen primarily associated with plants. This study presents a documented case of catheter-related bloodstream infection caused by P. eucrina in a 60-year-old female receiving home parenteral nutrition. Despite presenting with only minor clinical symptoms, blood cultures from both central and peripheral sites confirmed the presence of P. eucrina, identified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) and whole-genome sequencing. The infection was successfully cleared following a 13-day course of gentamicin lock therapy and intravenous piperacillin-tazobactam, after which the catheter was removed.

A retrospective examination of risk factors for central line-associated bloodstream infections in home parenteral nutrition patients from a Queensland tertiary hospital

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) are a potential complication for home parenteral nutrition (HPN) patients.

AIM

We sought to analyse risk factors of developing HPN-related CLABSI and assess CLABSI management in the Australian context.

METHODS

A retrospective observational cohort study was conducted on 34 adult patients receiving HPN via a central venous catheter (CVC) at a Queensland tertiary referral centre between 2016 and 2023. Patient charts were reviewed, and Kaplan-Meier analysis was employed to determine associations between characteristics and time to CLABSI in the first CVC using Peto-Peto Prentice test.

RESULTS

A total of 39 CLABSI episodes occurred in 19 patients. Patients with ≥1 CLABSI used regular opioids more than those without CLABSI (P = 0.016). Fourteen (41%, n = 14/34) patients developed a CLABSI in their first CVC. No patient or line characteristics were found to be predictive of CLABSI in their first CVC. The CLABSI rate was 1.02/1000 catheter days. Most CLABSIs were caused by Enterobacterales (22%, n = 12/55) and Candida sp. (22%, n = 12/55). Empiric antimicrobial therapy was adequate in only 25% (n = 7/28), and the median time to effective antibiotic therapy was 22.7 h (interquartile range 4.8-29.8). There were three successful CVC salvages (8%, n = 3/39).

CONCLUSIONS

In this cohort of patients, regular opioid use was associated with increased risk of developing CLABSI. Based on our findings, an empiric antimicrobial regime of vancomycin, cefepime and caspofungin will provide adequate coverage for most HPN-related CLABSIs in Australian IF units with a similar antimicrobial distribution and resistance pattern.

Translating plasma citrulline concentration in clinical practice: Role of cross-sectional assessment in adult patients with short bowel syndrome

BACKGROUND

Cross-sectional plasma citrulline concentration (CIT) is considered a marker of enterocyte mass. The role of CIT in clinical practice in patients with short bowel syndrome (SBS) is not clearly defined.

AIM

To assess the accuracy of CIT to discriminate SBS from healthy controls (HC) and SBS with intestinal failure (SBS-IF), requiring intravenous supplementation (IVS), from SBS with intestinal insufficiency (SBS-II).

METHODS

Cross-sectional study on unselected outpatients (31 SBS-II, 113 SBS-IF) and 19 healthy controls (HC). Demographic data, SBS characteristics, nutritional status, oral intake, intestinal fat absorption, renal function and IF severity, categorized by the volume of the required IVS, were collected at time of CIT evaluation (µmol/L). Data as mean±SD.

RESULTS

CIT was 36.6 ± 6.0 in HC, 30.2 ± 14.0 in SBS-II and 18.8 ± 12.3 in SBS-IF (p < 0.001). CIT cutoff was 31 for the diagnosis of SBS (sensitivity 79 %, specificity 89 %), and 14 for the discrimination between SBS-IF and SBS-II (sensitivity 100 %, specificity 51 %). Wide ranges of CIT were observed in all SBS-IF severity categories.

CONCLUSIONS

In unselected SBS patients, CIT was accurate to diagnose SBS, had high sensitivity to diagnose SBS-IF but showed low specificity for SBS-II. In SBS-IF, CIT was not an accurate marker of IF severity.

Successful weaning from parenteral nutrition in a short bowel syndrome patient with high-output stoma through restricted oral diet: a case report

A restricted oral diet plays a significant role in the nutritional management of patients with Short Bowel Syndrome (SBS). SBS patients often experience increased intestinal output, especially if they are classified as net "secretors" (typically having less than 100 cm of residual jejunum). This means they lose more water and sodium from their stoma than they take in by mouth. In this report, we present the case of an SBS patient with 80 cm of remaining bowel, no colon in continuity, and a high-output stoma. The patient was managed with a restrictive oral diet in combination with parenteral nutrition, pharmacological treatment, and high patient compliance. Following this regimen, the patient's condition improved significantly, leading to a reduction in stoma output and an improvement in nutritional status, including stabilization and weight gain. Upon discharge from the hospital, the patient was maintaining an oral diet with specific nutritional recommendations and receiving parenteral saline. This case report suggests that the combined use of restricted oral intake and parenteral nutrition (PN), alongside appropriate pharmacological management and high patient compliance, can effectively manage high-output stomas and improve nutritional status, even in cases where the small bowel is less than 100 cm in length.

Home Parenteral Support in Chronic Intestinal Failure-First Results from a Pioneer Portuguese Intestinal Failure Center

BACKGROUND/OBJECTIVES

Home parenteral support (HPS) is the core of chronic intestinal failure (IF) treatment. For legal reasons, HPS in Portugal lags behind other European countries, and only a few patients were taken care of at home by nurses. Now, the legislation has changed, allowing patient self-care. The authors report their pioneer experience as the largest Portuguese IF center, evaluating the underlying conditions leading to IF, HPS nutritional impact, HPS-related complications and survival.

METHODS

This is a retrospective study including IF patients who underwent HPS in a Portuguese IF center. The data included demographics, underlying conditions, IF types, HPS duration, BMI at the beginning and end of HPS/follow-up, complications, microbiological agents of infectious complications and current status (deceased or alive with/without HPS). Survival was calculated until death or September 2024.

RESULTS

A total of 23 patients (52.2% female, mean age 57.3 years), all with type III IF, were included. Short bowel syndrome (SBS) was the most common cause of IF (69.6%). Of the included patients, 78.3% received home parenteral nutrition; the others received home parenteral hydration. The mean BMI increased significantly, from 19.1 kg/m2 to 22.5 kg/m2 (p < 0.001). Two patients received Teduglutide. The most common complication was catheter-related bloodstream infection (2.5/1000 catheter days). The complications did not increase with patient self-care. At the end of follow-up, 21.7% of patients remained on HPS, 34.8% were alive without HPS, and 43.5% died. The average survival was 43.4 months. One death (4.35%) was attributable to HPS-related complications.

CONCLUSIONS

The conditions underlying IF varied, with SBS being the most frequent condition. HPS improved the BMI, allowing considerable survival. Despite the complications and one attributable death, HPS was safe, even when relying on patient self-care.

Management Patterns of Teduglutide Use in Short Bowel Syndrome: A Survey of 70 Healthcare Professionals

BACKGROUND

This study aimed to gain real-world insights from healthcare professionals (HCPs) regarding the management of adult patients with short bowel syndrome and intestinal failure (SBS-IF) who received teduglutide and achieved parenteral support (PS) independence or PS volume stability for ≥12 months.

METHODS

This cross-sectional survey was conducted in five European countries and Canada via a self-reported questionnaire (November 2022-March 2023) among HCPs who manage patients with SBS-IF and who had prescribed teduglutide to ≥5 patients with SBS-IF receiving PS.

RESULTS

Of the 70 HCPs who completed the survey, almost all reported managing patients with SBS-IF who achieved PS independence or PS volume stability (99%, 69/70 and 97%, 68/70, respectively) and maintained the standard teduglutide dose, without changes. A total of 52 HCPs managed patients who achieved PS independence and discontinued teduglutide. Of these HCPs, 73% (38/52) anticipated that these patients would remain PS-independent, not requiring PS reintroduction. Of the remainder, 79% (11/14) estimated that ≤40% of these patients would require PS reintroduction. While many HCPs (81%, 42/52) would reintroduce teduglutide in patients who discontinued its use after achieving PS independence, none would do so for patients who discontinued teduglutide after achieving PS volume stability if a patient's condition worsened.

CONCLUSIONS

This survey found that patients with SBS-IF can achieve PS independence or PS volume stability with teduglutide treatment. However, some HCPs (27%, 14/52) believe that a proportion of patients discontinuing teduglutide after achieving PS independence will require PS reintroduction. This survey suggests that teduglutide treatment should continue uninterrupted, unless clinically indicated, but this requires confirmation in future studies.

Real-world experience with glucagon-like peptide 2 analogues in patients with short bowel syndrome and chronic intestinal failure: Results from an international survey in expert intestinal failure centers

BACKGROUND AND AIMS

Glucagon-like peptide 2 (GLP-2) analogues are the first available disease-modifying treatments for patients with intestinal failure (IF) due to short bowel syndrome (SBS). Efficacy in terms of reduction of parenteral support (PS) has been demonstrated in multiple studies and real-world reports. However, it remains unclear how many patients are eligible to receive the treatment, when treatment is started after intestinal resection, how treatment efficacy is assessed outside of clinical trials, and how the treatment is modified in case of non-response or adverse events. The aim of this study was to investigate the real-world management of patients treated with GLP-2 analogues in expert centers around the world.

METHODS

A survey questionnaire was developed by a multidisciplinary working group consisting of 52 questions related to various aspects of multidisciplinary care of SBS-IF patients. The 17 questions related to the use of GLP-2 analogues in clinical practice were analyzed for this study. The online survey was sent to 33 participating centers in a phase 3 study of a long-acting GLP-2 analogue. Only responses from countries with access to commercially available GLP-2 analogues were included in the study. A descriptive analysis was performed for each question. Results are presented as median (interquartile range).

RESULTS

The responses from the 19 expert IF centers with access to GLP-2 analogues indicated that 10 (10-20) % of patients with SBS-IF were treated with a GLP-2 analogue, which was less than the number of eligible patients (30 (25-40) %). In most centers (10 centers, 53 %), GLP-2 therapy was started 6-12 months after the last intestinal resection, with 5 centers (26 %) starting later (12-24 months). Multiple parameters were used in combination to determine the response to GLP-2 analogues of which the three most common were >20 % decrease in PS (95 %), at least 1 day of PS reduction per week (84 %) and increased urinary output (68 %). In non-responders GLP-2 therapy was stopped within the first year by 67 % of the centers. Finally, strategies in case of significant adverse events include stopping the GLP-2 analogue (used by 79 % of experts), dose reduction (67 %) and temporary treatment interruption (62 %).

CONCLUSION

The results of this survey completed by expert IF centers show the real-life use of GLP-2 analogues in clinical practice. Key learning points identified include the accounting for a period of intestinal adaptation before starting GLP-2 analogues and not stopping the treatment too early in case of non-response. The best strategy in case of adverse effects should be studied further.

A descriptive analysis of individually compounded home parenteral nutrition prescriptions provided to adults with chronic intestinal failure

BACKGROUND & AIMS

Home Parenteral Nutrition (HPN) prescriptions should be tailored to a patient's nutritional requirements and comprise of individually compounded regimens (IC-HPN) or standard licensed multi-chamber bags (MCB). There is a paucity of research exploring factors associated with admixture type. This study aimed to evaluate the nutrient composition of adult IC-HPN prescriptions and variance in nutrient dosing, make comparisons with the range of MCB available and dosing recommendations stated in international guidelines.

METHODS

This cross-sectional observational study analysed anonymised prescription data for adults under the care of a single home care company in England, commencing IC-HPN after January 2021.

RESULTS

There were 155 patient prescriptions (245 HPN bags) included, with body weight available in 82 (52.9 %) cases. Data were reported for each HPN bag, and summarised as an average daily amount, considering the number of different HPN bags and their daily frequency per patient prescription. A vast range of nutrients were prescribed, with variance in dosing highest for lipid, phosphate, and calcium; with coefficient of variance of 106 %, 74 % and 67 %, respectively. One-hundred-thirty-four (54.7 %) bags contained lipid, resulting in variable ratios of lipid to aqueous bags provided weekly. Negligible amounts of at least one electrolyte were prescribed in 93 (38.0 %) bags, of which 52 (21.2 %) contained ≤2 mmol calcium. Compared with MCB (65 bags), IC-HPN bags contained higher amounts of all nutrients, apart from nitrogen and phosphate. Mean sodium intake differed substantially between types of bags (IC-HPN 187.5, SD 100.1 mmol versus MCB 49.1, SD 31.7 mmol, p < 0.001). A substantial number of patients received HPN dosages beyond guideline recommendations, with higher amounts of sodium and fluid provided in 41 (50.0 %) cases; conversely, lower than recommended dosages were seen in 55 (67.1 %) for potassium and 61 (74.4 %) for calcium.

CONCLUSIONS

This study has demonstrated vast variance in IC-HPN parenteral nutrient dosing, with minimal or an omission of at least one nutrient seen. Further research is needed to explore factors that influence usage of IC-HPN, clinical reasons related to lipid dosing and around the variation in doses prescribed outside of guideline recommendations.

Significant Published Articles in 2023 for Pharmacy Nutrition Support Practice

Purpose: The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several board-certified nutrition support pharmacists aggregated a list of articles relevant to pharmacy nutrition support published in 2023. The list was compiled into a spreadsheet whereby the authors were asked to assess whether the article was considered important. A culled list of publications was then identified whereby at least 5 out of the 8 author participants considered the article to be important for pharmacists practicing in nutrition support. Guideline and consensus papers, important to practice but not ranked, were also included. Results: A total of 133 articles were identified; 9 from the primary literature were voted by the group to be of high importance. Fourteen guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were summarized and a narrative regarding its implications to pharmacy nutrition support practice were provided. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.

Sleep and home parenteral nutrition in adults: A narrative review

Infusions of home parenteral nutrition (HPN) are often cycled at night coinciding with sleep episodes. Adult consumers of HPN are known to experience poor sleep attributed to frequent awakenings and long durations of wakefulness after falling asleep. Consequently, most consumers do not meet recommendations for sleep duration and quality or daytime napping. The primary underlying pathophysiology resulting in sleep problems is nocturia; however, other factors also exist, including disruptions caused by medical equipment (ie, pump alarms), comorbid conditions, dysglycemia, and medication use. Early guidance on sleep is imperative because of the central role of sleep in physical health and wellbeing, including mitigating complications, such as infection risk, gastrointestinal problems, pain sensitivity, and fatigue. Clinicians should routinely inquire about the sleep of their patients and address factors known to perturb sleep. Nonpharmacologic opportunities to mitigate sleep problems include education on healthy sleep practices (ie, sleep hygiene); changes in infusion schedules, volumes, rates, and equipment; and, possibly, behavioral interventions, which have yet to be examined in this population. Addressing comorbid conditions, such as mood disorders, and nutrition deficiencies may also help. Pharmacologic interventions and technological advancement in HPN delivery are also needed. Research on sleep in this population is considered a priority, yet it remains limited at this time.

Operational recommendations for the implementation of home parenteral nutrition program of care according to the guidelines of the European society for clinical nutrition and metabolism

Home parenteral nutrition (HPN) is a complex therapy, which requires dedicated facilities and expertise. However, the management and provision of HPN differs significantly between countries and between HPN centers within countries. These differences lead to heterogeneity in the quality of care received by patients, with variable impact on the appropriateness, safety, and effectiveness of HPN, and resultant variability in the quality of life that a patient may expect. The European Society for Clinical Nutrition and Metabolism (ESPEN) have published guidelines on the appropriate and safe provision of HPN, with an associated practical version describing a short and precise way to implement the guidelines' recommendations in clinical practice. This educational paper suggests means of implementation of evidence supported HPN guidelines, using "operational recommendations" applitngto healthcare professionals, administrators and stakeholders, with the ultimate aim of enhancing equity of patient access to an appropriate and safe HPN program of care.

Gut instinct: Navigating the landscape of parenteral support in short bowel syndrome

Depending on the remaining bowel anatomy and the degree of bowel adaptation, patients with short bowel syndrome (SBS) may require parenteral nutrition (PN) and/or intravenous fluid support, sometimes temporarily and sometimes permanently. Although the use of parenteral support in SBS is often lifesaving, it is not without its limitations. Herein, we undertake a focused review of several issues related to use of parenteral support in patients with SBS, including initiation of parenteral support, considerations when formulating PN, select complications, short-term and long-term nutrition monitoring, and weaning strategies.

Quality-of-care standards in adult type 3 intestinal failure caused by benign disease: A European society of clinical nutrition and metabolism (ESPEN) position paper

BACKGROUND

Outcomes related to chronic intestinal failure (CIF) vary significantly within and between countries. While there are extensive European Society of Clinical Nutrition and Metabolism (ESPEN) guidelines on the delivery of optimal care in CIF, there are no international consensus recommendations on the structure or resources required, nor on the process and appropriate outcome measures for delivering such quality care in CIF.

AIM

The aim of this position paper is therefore to devise ESPEN-endorsed, internationally agreed quality of care standards, covering the resources, systems and standards that centres should aim for in order to deliver optimal CIF care.

METHODS

Members of the Home Artificial Nutrition-CIF Special Interest Group of ESPEN proposed an initial set of quality-of-care standards which was submitted to voting amongst clinicians from international CIF centres using a modified Delphi process, with participants rating each proposed statement as 'essential', 'recommended' or 'not required'. Any statement receiving 80% of more 'not required' responses was excluded.

RESULTS

All 30 proposed standards relating to the structure, 18 relating to the process and 16 to the outcome measures of CIF care were deemed to be essential or recommended in more than 80% of respondents.

CONCLUSION

This is the first paper to determine and describe internationally-agreed quality of care standards in CIF, which are now aimed at forming the basis for all CIF teams to develop and monitor their service, while also informing policymakers and payers on the infrastructure required for the optimal approach to multi-disciplinary team CIF care delivery. The recording of standardised outcomes should also allow internal and external benchmarking of care delivery within and between CIF centres.

Intestinal failure-associated liver disease: Current challenges in screening, diagnosis, and parenteral nutrition considerations

Intestinal failure-associated liver disease (IFALD) is a serious life-limiting complication that can occur throughout the clinical course of intestinal failure and its management by parenteral nutrition (PN). Despite this, there is a lack of a standardized definition for IFALD, which makes this insidious condition increasingly difficult to screen and diagnose in clinical practice. Attenuating the progression of liver disease before the onset of liver failure is key to improving morbidity and mortality in these patients. This requires timely detection and promptly addressing reversible factors. Although there are various noninvasive tools available to the clinician to detect early fibrosis or cirrhosis in various chronic liver disease states, these have not been validated in the patient population with IFALD. Such tools include biochemical composite scoring systems for fibrosis, transient elastography, and dynamic liver function tests. This review article aims to highlight the existing real need for an accurate, reproducible method to detect IFALD in its early stages. In addition, we also explore the role PN plays in the pathogenesis of this complex multifactorial condition. Various aspects of PN administration have been implicated in the etiology of IFALD, including the composition of the lipid component, nutrient excess and deficiency, and infusion timing. We aim to highlight the clinical relevance of these PN-associated factors in the development of IFALD and how these can be managed to mitigate the progression of IFALD.

The Epidemiology and Clinical Management of Short Bowel Syndrome and Chronic Intestinal Failure in Crohn's Disease in Italy: An IG-IBD Survey

BACKGROUND/OBJECTIVES

Limited data exist on the epidemiology and clinical management of short bowel syndrome (SBS) and chronic intestinal failure (CIF) in Crohn's disease (CD). This study aimed to evaluate these aspects in Italy.

METHODS

Members of the Italian Group for the Study of Inflammatory Bowel Disease (IG-IBD) were invited to complete a cross-sectional web survey. A subgroup analysis examined the influence of different clinical settings on SBS and CIF management in CD.

RESULTS

A total of 47/128 (36.7%) IG-IBD centers participated. Among them, 31.9% were teduglutide (TED) prescribers, and 48.9% were academic centers. The median estimated prevalence of CIF among small bowel CD patients was 1%, and it was significantly higher in academic centers (2.0% [IQR 1-5%] vs. 0.13% [IQR 0-1%], p = 0.02). Seventy-eight percent of centers managed fewer than 10 SBS and CD patients. Routine small bowel measurement and nutritional assessment were performed in only 15% and 42.6% of centers, respectively. TED was prescribed by 12 centers to 35 patients, with a treatment success rate exceeding 50% in 81.8% of centers.

CONCLUSIONS

The estimated prevalence of CIF in CD patients with small bowel involvement in Italy is 1%. The diagnosis and management practices for SBS and CIF are suboptimal, and TED use is limited.

A Multidisciplinary Approach to the Classification and Management of Intestinal Failure: Knowledge in Progress

Intestinal failure (IF) is a debilitating condition characterized by the insufficient function of the gastrointestinal tract to absorb nutrients and fluids essential for life. This review consolidates recent advancements and challenges in managing IF among adult and pediatric populations, highlighting differences in etiology, management, and outcomes. Over the recent years, significant strides have been made in the nutritional and medical management of IF, significantly reducing mortality rates and improving the quality of life for patients. Key advancements include the development and availability of glucagon-like peptide-2 (GLP-2) analogs, improved formulations of parenteral nutrition, and the establishment of specialized interdisciplinary centers. Short bowel syndrome (SBS) remains the predominant cause of IF globally. The pediatric segment is increasingly surviving into adulthood, presenting unique long-term management challenges that differ from adult-onset IF. These include the need for tailored nutritional support, management of IF-associated liver disease, and addressing growth and neurodevelopmental outcomes. The therapeutic landscape for IF continues to evolve with the development of new treatment modalities and better understanding of the condition's pathophysiology. However, disparities in treatment outcomes between children and adults suggest the need for age-specific management strategies. This review underscores the importance of a nuanced approach to IF, incorporating advancements in medical science with a deep understanding of the distinct needs.

Trends and development in perioperative enteral nutrition: a systematic bibliometric analysis

Background

This research aims to explore the intellectual landscape of studies in perioperative enteral nutrition (PEN) and identify trends and research frontiers in the field.

Methods

Scientometric research was conducted through the analysis of bibliographic records from the Web of Science Core Collection Database for the period 2014-2023. Analyses performed using CiteSpace software included cooperation network analysis, reference co-citation analysis, and keywords co-occurrence analysis.

Results

The analysis included 3,671 valid records in the final dataset. Findings indicate an upward trend in annual publications, with the United States leading in research output and Harvard University as the top publishing institution. The Journal of Parenteral and Enteral Nutrition was identified as the most productive journal. Notable research hotspots include enhanced recovery after surgery, early enteral nutrition, intestinal failure, short bowel syndrome, abdominal surgery. Evidence-based articles have emerged as the predominant literature type. Future research trends are anticipated to focus on gut microbiota and patients with congenital heart disease.

Conclusion

Our study provides a comprehensive analysis of the publication volume, contributions by country/region and institutions, journal outlets, and reference and keyword clusters in the field of PEN over the decade. The findings provide valuable insights for researchers, policymakers, and clinicians, helping them comprehend the research landscape, identify gaps, and shape future research directions in this field.

Avoiding the use of long-term parenteral support in patients without intestinal failure: A position paper from the European Society of Clinical Nutrition & Metabolism, the European Society of Neurogastroenterology and Motility and the Rome Foundation for Disorders of Gut-Brain Interaction

The role of long-term parenteral support in patients with underlying benign conditions who do not have intestinal failure (IF) is contentious, not least since there are clear benefits in utilising the oral or enteral route for nutritional support. Furthermore, the risks of long-term home parenteral nutrition (HPN) are significant, with significant impacts on morbidity and mortality. There has, however, been a recent upsurge of the use of HPN in patients with conditions such as gastro-intestinal neuromuscular disorders, opioid bowel dysfunction, disorders of gut-brain interaction and possibly eating disorders, who do not have IF. As a result, the European Society of Clinical Nutrition and Metabolism (ESPEN), the European Society of Neuro-gastroenterology and Motility (ESNM) and the Rome Foundation for Disorders of Gut Brain Interaction felt that a position statement is required to clarify - and hopefully reduce the potential for harm associated with - the use of long-term parenteral support in patients without IF. Consensus opinion is that HPN should not be prescribed for patients without IF, where the oral and/or enteral route can be utilised. On the rare occasions that PN commencement is required to treat life-threatening malnutrition in conditions such as those listed above, it should only be prescribed for a time-limited period to achieve nutritional safety, while the wider multi-disciplinary team focus on more appropriate biopsychosocial holistic and rehabilitative approaches to manage the patient's primary underlying condition.

Intestinal adaptation and rehabilitation in adults with short bowel syndrome

PURPOSE OF REVIEW

Over the past decade, trophic gastrointestinal hormonal factors have been included in the intestinal rehabilitation programs for short bowel syndrome (SBS). Up today the only trophic factor approved for clinical practice is the glucagon-like peptide-2 (GLP-2) analogue, teduglutide. A literature review on the last 2-year data on GLP-2 analogues for the treatment of SBS in adults has been performed.

RECENT FINDINGS

Several reports on real-world data on the efficacy and safety of teduglutide treatment for SBS, some case-reports on the use of teduglutide in non-SBS conditions as well as phase 2 trials on new GL-2 analogues on patients with SBS have been retrieved.

SUMMARY

Real-world data confirmed the teduglutide efficacy not only in weaning off IVS in accurately selected patients but also increased the alert on the risk of development of gastrointestinal polyps related to the drug; the impact of the therapy on patients' QoL deserves further studies and the cost-utility of the treatment is still uncertain. Some case reports highlighted the potential benefit of treatment with teduglutide in non-SBS gastrointestinal diseases, such as graft-versus-host disease, primary amyloidosis and refractory microscopic colitis. Phase 2 RCTs on safety and efficacy of two new long-acting GLP-2 analogues, glepaglutide and apraglutide, were published, and phase 3 RCTs have been completed.

Avoiding the use of long-term parenteral support in patients without intestinal failure: A position paper from the European Society of Clinical Nutrition & Metabolism, the European Society of Neurogastroenterology and Motility and the Rome Foundation for Disorders of Gut-Brain Interaction

The role of long-term parenteral support in patients with underlying benign conditions who do not have intestinal failure (IF) is contentious, not least since there are clear benefits in utilising the oral or enteral route for nutritional support. Furthermore, the risks of long-term home parenteral nutrition (HPN) are significant, with significant impacts on morbidity and mortality. There has, however, been a recent upsurge of the use of HPN in patients with conditions such as gastro-intestinal neuromuscular disorders, opioid bowel dysfunction, disorders of gut-brain interaction and possibly eating disorders, who do not have IF. As a result, the European Society of Clinical Nutrition and Metabolism (ESPEN), the European Society of Neuro-gastroenterology and Motility (ESNM) and the Rome Foundation for Disorders of Gut Brain Interaction felt that a position statement is required to clarify - and hopefully reduce the potential for harm associated with - the use of long-term parenteral support in patients without IF. Consensus opinion is that HPN should not be prescribed for patients without IF, where the oral and/or enteral route can be utilised. On the rare occasions that PN commencement is required to treat life-threatening malnutrition in conditions such as those listed above, it should only be prescribed for a time-limited period to achieve nutritional safety, while the wider multi-disciplinary team focus on more appropriate biopsychosocial holistic and rehabilitative approaches to manage the patient's primary underlying condition.

Usefulness of central venous catheter replacement with a guidewire in patients with intestinal failure: a single-center study

PURPOSE

Patients with intestinal failure (IF) require long-term parenteral nutrition using central venous catheters (CVCs), which often require replacement. We adopted a less fallible guidewire replacement (GWR) method and verified its effectiveness and validity.

METHODS

We enrolled 108 cases that underwent a CVC replacement with "GWR" method with IF at our department between 2013 and 2023. We retrospectively reviewed patients' clinical details with tunneled CVC (Hickman/Broviac catheter). For the analysis, we compared for the same time period the catheter exchange method "Primary placement"; newly inserted catheter by venipuncture.

RESULTS

The success rate of catheter replacement using GWR was 94.4%. There were six unsuccessful cases. A log-rank test showed no significant difference in catheter survival between primary placement and the GWR, and the time to first infection was significantly longer in the GWR (p = 0.001). Furthermore, no significant differences were observed between the two methods until the first infection, when the exchange indication was limited to infections. In the same way, when the indication was restricted to catheter-related bloodstream infection, there was no significant difference in catheter survival between the two approaches.

CONCLUSION

Our GWR procedure was easy to perform and stable, with a high success rate and almost no complications. Moreover, using a guidewire did not increase the frequency of catheter replacement and the infection rate.

Current Status of Chronic Intestinal Failure Management in Adults

BACKGROUND

Chronic intestinal failure (CIF) is a heterogeneous disease that affects pediatric and adult populations worldwide and requires complex multidisciplinary management. In recent years, many advances in intravenous supplementation support, surgical techniques, pharmacological management, and intestinal transplants have been published. Based on these advances, international societies have published multiple recommendations and guidelines for the management of these patients. The purpose of this paper is to show the differences that currently exist between the recommendations (ideal life) and the experiences published by different programs around the world.

METHODS

A review of the literature in PubMed from 1980 to 2024 was carried out using the following terms: intestinal failure, CIF, home parenteral nutrition, short bowel syndrome, chronic intestinal pseudo-obstruction, intestinal transplant, enterohormones, and glucagon-like peptide-2.

CONCLUSIONS

There is a difference between what is recommended in the guidelines and consensus and what is applied in real life. Most of the world's countries are not able to offer all of the steps needed to treat this pathology. The development of cooperative networks between countries is necessary to ensure access to comprehensive treatment for most patients on all continents, but especially in low-income countries.

Can we improve the management of inoperable malignant bowel obstruction? Results of a feasibility study of elemental diet as an alternative to parenteral nutrition in patients with advanced gynaecological cancer

PURPOSE

Nutrition support in inoperable bowel obstruction (IBO) remains challenging. Parenteral nutrition (PN) is recommended if the prognosis is > 2 months. An elemental diet (ED) is licensed for strictures in Crohn's disease but has not been used in malignant bowel obstruction. The aim of this study was to evaluate the use of ED in patients with IBO and provide a proof of concept of ED as an acceptable feeding option.

METHODS

This was a mixed-methods single-arm feasibility study. The primary endpoint was to provide a 'proof of concept' of ED as an acceptable feeding option for patients with IBO. Secondary endpoints included taste acceptability, incidences of vomiting and pain, the proportion of women who tolerated ED, the number of cartons drunk, quality of life (QOL) and the number of women treated with chemotherapy. Patients (> 18 years) with CT-confirmed IBO who could tolerate 500 ml of liquid in 24 h remained on the trial for 2 weeks.

RESULTS

A total of 29 patients were recruited; of those, 19 contributed to the analysis for the primary endpoint; 13 (68.4%) participants tolerated the ED; 26 patients contributed to MSAS and EORTC QLQ questionnaires at baseline to allow for the assessment of symptoms. At the start of the study, 18 (69%) of patients experienced vomiting, reducing to 4 (25%) by the end of day 15 of the study; 24 (92%) of patients reported pain at consent, reducing to 12 (75%) by the end of day 15. QOL scores improved from 36.2 (95% CI 27.7-44.7) at baseline to 53.1 (95% CI 40.3-66) at the end of day 15; 16 (84%) participants commenced chemotherapy within the first week of starting ED. The number of cartons across all participants showed a median of 1.3 cartons per day (range 0.8 to 2.5).

CONCLUSION

ED is well tolerated by patients with IBO caused by gynaecological malignancies and may have a positive effect on symptom burden and QOL.

Baseline Characteristics of Adult Patients Treated and Never Treated with Teduglutide in a Multinational Short Bowel Syndrome and Intestinal Failure Registry

The Short Bowel Syndrome (SBS) Registry (NCT01990040) is a multinational real-world study evaluating the long-term safety of teduglutide in patients with SBS and intestinal failure (SBS-IF) in routine clinical practice. This paper describes the study methodology and baseline characteristics of adult patients who have (ever-treated) or have never (never-treated) received teduglutide. A total of 1411 adult patients (679 ever-treated; 732 never-treated) were enrolled at 124 sites across 17 countries. The mean (standard deviation [SD]) age at enrollment was 55.4 (15.46) years, and 60.2% of patients were women. Crohn's disease was the most common cause of major intestinal resection in both ever-treated (34.1%) and never-treated patients (20.4%). A similar proportion of ever-treated and never-treated patients had a prior history of colorectal polyps (2.7% vs. 3.6%), whereas proportionally fewer ever-treated patients reported a history of colorectal cancer (1.8% vs. 6.2%) or any malignancy (17.7% vs. 30.0%) than never-treated patients. Never-treated patients received a numerically greater mean (SD) volume of parenteral nutrition and/or intravenous fluids than ever-treated patients (12.4 [8.02] vs. 10.1 [6.64] L/week). Ever-treated patients received a mean teduglutide dosage of 0.05 mg/kg/day. This is the first report of patient baseline characteristics from the SBS Registry, and the largest cohort of patients with SBS-IF to date. Overall, ever-treated and never-treated patients had similar baseline characteristics. Differences between treatment groups may reflect variations in patient selection and degree of monitoring.

Plasma metabolomics changes comparing daytime to overnight infusions of home parenteral nutrition in adult patients with short bowel syndrome: Secondary analysis of a clinical trial

BACKGROUND

Home parenteral nutrition (HPN) is often cycled nocturnally and is expected to result in glucose intolerance and sleep disruption partly due to circadian misalignment. This study aimed to define the metabolic response when HPN is cycled during the daytime compared to overnight.

METHODS

This secondary analysis leveraged samples from a clinical trial in adults with short bowel syndrome consuming HPN (ClinicalTrials.gov: NCT04743960). Enrolled patients received 1 week of HPN overnight followed by 1 week of HPN during the daytime. Fasting blood samples were collected following each study period and global metabolic profiles were examined from plasma samples. Differential metabolite abundance was determined from normalized and scaled data using adjusted Linear Models for MicroArray Data models followed by pathway enrichment analysis.

RESULTS

Nine patients (mean age, 52.6 years; 78% female; mean BMI 20.7 kg/m2) provided samples. Among 622 identified metabolites, changes were observed in 36 metabolites at Punadj < 0.05 with higher abundance of fatty acids, long-chain and polyunsaturated fatty acids (Dihomo-gamma-linolenic acid, arachidonate (20:4n6), docosahexaenoate (DHA; 22:6n3)) and glycerolipids with daytime infusions. Enrichment analysis identified changes in pathways related to the biosynthesis of unsaturated fatty acids, d-arginine, and d-ornithine metabolism, and linoleic acid metabolism (Punadj<0.05).

CONCLUSION

Daytime infusions of HPN may result in changes in circulating lipids and amino acid composing metabolic pathways previously implicated in circadian rhythms. As this is the first untargeted metabolomics study of HPN, larger studies are needed.

Body composition of adults with chronic intestinal failure receiving home parenteral nutrition: A descriptive cohort study

BACKGROUND

Chronic intestinal failure (CIF) refers to the long-lasting reduction of gut function below the minimum necessary to absorb macronutrients, water, and/or electrolytes. Patients with CIF likely develop various forms of malnutrition and dehydration, yet studies that focus primarily on body composition are lacking. Therefore, this study aimed to evaluate the body composition of adult patients with CIF.

METHODS

This retrospective descriptive cohort study was performed at the Radboud University Medical Center, a tertiary referral center for CIF treatment in the form of home parenteral nutrition. We collected available bioelectrical impedance analysis (BIA) data from routine care between 2019 and 2023. The primary outcome was body composition, which was evaluated by assessing body mass index (BMI), fat-free mass index (FFMI), and fat percentage (fat%).

RESULTS

Overall, 147 adult patients with CIF were included with a median (interquartile range) age of 58 (25-68) years; 69% were female. The mean (SD) BMI was 22.1 (4.3) kg/m2, FFMI was 14.2 (1.9) kg/m2 in females and 17.0 (2.0) kg/m2 in males, and fat% was 33.7% (6.8%) in females and 24.6% (6.4%) in males. 63% had an FFMI below references, and 48% had a high fat%.

CONCLUSION

This study found that most adult patients with CIF have an unfavorable body composition characterized by a high fat% and low FFMI despite having a normal mean BMI. These results highlight the necessity for in-depth nutrition assessment, including BIA measurement. Moreover, future studies should focus on exercise interventions to increase FFMI and improve body composition and function.

LLL 44 - Module 3: Micronutrients in Chronic disease

Micronutrients (MN), i.e. trace elements and vitamins, are essential organic molecules, which are required in the diet in relatively small amounts in any form of nutrition (oral, enteral, parenteral). The probability of MN depletion or deficiencies should be considered in all chronic illnesses, especially in those that can interfere with intake, digestion, or intestinal absorption. Low socio-economic status and food deprivation are recognized as the most prevalent reasons for MN deficiencies world-wide. Elderly multimorbid patients with multimodal therapy, as well as patients with long-lasting menu restrictions, are at high risk for both disease related malnutrition as well as multiple MN deficiencies, needing careful specific follow-up. The importance of monitoring MN blood levels along with CRP is essential for optimal care. Drug interactions are also highlighted. In patients with chronic conditions depending on medical nutrition therapy, the provision of adequate dietary reference intakes (DRI) of MN doses and monitoring of their adequacy belongs to standard of care.

Enhancing drug therapy in ostomy patients: Best practice recommendations for medication management

BACKGROUND

Ostomy surgery is a common procedure that poses various challenges for patients and healthcare professionals. There are numerous guidelines addressing different ostomy-related problems (ORPs) and supporting an interdisciplinary approach for ostomy care, but evidence-based literature for optimizing drug therapy after ostomy surgery is lacking.

AIM

To investigate and characterize typical ORPs in relation to drug therapy and provide best practice recommendations from a pharmaceutical point of view.

METHODS

Patients with an ileo- or colostomy were consecutively enrolled in a prospective, interventional monocentric cohort study during hospitalization, with particular attention to medication. A clinical pharmacist assessed DRPs by performing level 3 medication reviews and patient interviews. Pharmacists' interventions (PIs) were evaluated by two senior clinical pharmacists and documented in DokuPIK (Documentation of Pharmacists' Interventions in the Hospital). Following interdisciplinary discussions, physicians either accepted or rejected the proposed changes in drug therapy. Comparisons were made between ileostomy and colostomy patients regarding type and extent of PIs.

RESULTS

Out of the 80 patients included in the cohort, 54 (67.5%) had an ileostomy and 26 (32.5%) a colostomy. In this study, 288 PIs were documented (234 ileostomy vs. 54 colostomy), of wich 94.0% were accepted and implemented by the physicians. The most common reason for PIs in both subgroups (29.6% ileostomy vs. 26.1% colostomy) was a missing drug although indicated (e.g. no loperamide, but high stoma output). The proportion of PIs associated with the ostomy was higher in ileostomy patients (48.3% ileostomy vs. 31.5% colostomy; p = 0.025). Typical ORPs were extracted and analyzed as case studies including recommendations for their respective management and prevention.

CONCLUSION

This study highlights the importance of clinical pharmacists being a part of interdisciplinary teams to collaboratively improve ostomy care and patient safety. Especially ileostomy patients are more vulnerable for ORPs in the context of drug therapy and need to be monitored carefully.

Management of Short Bowel Syndrome With Chronic Intestinal Failure: A Single-Center Experience in Portugal

INTRODUCTION

Short bowel syndrome with chronic intestinal failure (SBS/CIF) is the inability to maintain protein-energy, fluid, electrolyte, or micronutrient balance due to a short bowel. Although SBS/CIF is rare, its clinical management is complex, challenging, expensive, and time-consuming.

AIM

This study aimed to analyze a single center's experience with SBS/CIF in adult patients treated with home parenteral nutrition (HPN).

MATERIALS AND METHODS

A retrospective single-center analysis of all 13 consecutive adult patients with SBS/CIF was included in an HPN program between January 1994 and August 2023.

RESULTS

Between 1992 and 2023, 13 patients were included in an HPN program. The primary underlying pathology was acute mesenteric ischemia. The median age of starting HPN was 44 years. Most were subjected to several surgeries of extensive intestinal resection with posterior intestinal reconstruction. Five of the 13 patients died while on HPN with a median duration of 42 months. The causes of death related to HPN were catheter sepsis, endocarditis with cardiac failure, or hepatic failure. One patient died due to underlying pathology: pelvic abscesses and bleeding related to radiotherapy. Eight patients remain alive, with a median time of HPN of 173 months. During the HPN support, the most frequent complications were venous catheter infection and venous territory thrombosis. None of the eight patients alive have hepatic failure. Two patients recently started teduglutide with good tolerance and need a reduction in HPN support. All eight patients have a satisfactory quality of life (parenteral support needs range between five and two nutrition bags per week).  Conclusion: Home parenteral nutrition remains the gold standard of SBS/CIF treatment, although teduglutide may reduce HPN needs and complications and provide a better quality of life. Despite the small number of patients, the results shown in this study are not inferior to those in large-volume centers. The existence of the commitment and interest of professionals involved in SBS/CIF at Centro Hospitalar Universitário de Santo António, Portugal, was a fundamental key to achieving those results. A multidisciplinary healthcare group for HPN support can be essential to ensuring these patients' survival and quality of life.