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Maselli KM, Carter IC, Matusko N, Warschausky S, Blackmer AB, Islam S, Rollins MD, Javid PJ, Arnold MA. Prevention of Parenteral Nutrition-associated Cholestasis Using Reduced Dose Soybean Lipid Emulsion: A Multicenter Randomized Trial. J Pediatr Surg 2024; 59:1369-1373. [PMID: 38614946 DOI: 10.1016/j.jpedsurg.2024.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 03/04/2024] [Indexed: 04/15/2024]
Abstract
INTRODUCTION Reducing soybean lipid emulsion (SLE) dose may prevent parenteral nutrition-associated cholestasis (PNAC) but effects on growth and neurodevelopment are unknown. The purpose of this study was to evaluate the effect of reduced dose SLE on growth and neurodevelopment. METHODS Surgical neonates at 4 centers were randomized to standard SLE (3 g/kg/day) or reduced SLE (1 g/kg/day) over a 12-week period. Bilirubin levels and growth parameters were measured baseline and weekly while on study. The effects of time and group on direct bilirubin and growth were evaluated with a linear mixed effects model. Neurodevelopmental outcomes were assessed at 12- and 24-months corrected gestational age. RESULTS Twenty-one individuals were randomized (standard dose = 9, reduced dose = 12). Subjects in the reduced dose group had slower rates of direct bilirubin increase and overall levels decreased earlier than those in the standard dose group. There was a trend toward a faster direct bilirubin decrease in the reduced dose group (p = 0.07 at day 84). There were no differences in the rates of change in weight (p = 0.352 at day 84) or height Z-scores (p = 0.11 at day 84) between groups. One subject in the reduced dose group had abnormal neurodevelopmental testing at 24 months. CONCLUSIONS Surgical neonates randomized to a reduced dose of SLE had improved trends in direct bilirubin levels without clinically significant differences in overall growth and neurodevelopment. TYPE OF STUDY Randomized Controlled Trial. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Kathryn M Maselli
- Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Irene C Carter
- Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Niki Matusko
- Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Seth Warschausky
- Department of Physical Medicine and Rehabilitation, Ann Arbor, MI 48109, USA
| | - Allison B Blackmer
- Department of Clinical Pharmacology, University of Colorado, Aurora, CO 80045, USA
| | - Saleem Islam
- Division of Pediatric Surgery, University of Florida, Gainesville, FL 32610, USA
| | - Michael D Rollins
- Divsion of Pediatric Surgery, University of Utah, Salt Lake City, UT 84113, USA
| | - Patrick J Javid
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA 98105, USA
| | - Meghan A Arnold
- Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI 48109, USA.
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Ghidini F, Tognon C, Verlato G, Duci M, Andreetta M, Leon FF, Gamba P. A survival analysis of cuffed tunneled silicon central venous catheters in children affected by short bowel syndrome: A lesson from the past. J Vasc Access 2023; 24:1158-1166. [PMID: 35081815 DOI: 10.1177/11297298211069458] [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] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Tunneled central venous catheters (CVC) are crucial in the management of children affected by short bowel syndrome (SBS). This work aims to investigate the outcomes of tunneled CVC and to identify factors influencing their survival. METHODS All the children diagnosed with SBS and undergone a procedure of insertion of a tunneled CVC from 2010 to 2019 were included. Demographic data and surgical information about the procedures were collected. Regression models and Kaplan-Meier analysis were performed to estimate the survival. RESULTS Eighteen patients, eight males (44%), with a median length of residual bowel measuring 72 cm (IQR 50-102 cm), were enrolled. Thirty-nine Broviac CVCs were inserted with a mean number of 2.2 CVCs per patient and 13365 line-days. The overall incidence of complications was 3.2/1000 line-days, and the incidence of central line associated bloodstream infections (CLABSI) was 1.1/1000 line-days. No episode of catheter thrombosis was reported. The median survival was 269 days (IQR 82-1814 days). The survival was negatively influenced by a younger age at insertion (R2 = 0.29; p < 0.001), 2.7 Fr diameter (median survival 76 days; p < 0.001) and the occurrence of complications (median survival 169 days; p = 0.002). The length of residual bowel was a mild risk factor for anticipated removal (OR 1.1; CI95 1.0-1.1; p = 0.05). CONCLUSION CVC-related complications negatively influenced the survival of the line. An elder age at insertion together with a larger CVC diameter increased the survival of the line, while a shorter residual bowel was associated with an anticipated removal due to complications.
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Affiliation(s)
- Filippo Ghidini
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Costanza Tognon
- Pediatric Anesthesiology, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Giovanna Verlato
- Neonatal Intensive Care and Pediatric Nutrition Service, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Miriam Duci
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Marina Andreetta
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Francesco Fascetti Leon
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Piergiorgio Gamba
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
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Sukhotnik I, Levi R, Moran-Lev H. Impact of Dietary Protein on the Management of Pediatric Short Bowel Syndrome. Nutrients 2023; 15:2826. [PMID: 37447153 DOI: 10.3390/nu15132826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/15/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Essential amino acids (AAs) play a key role in stimulating intestinal adaptation after massive small gut resection. The nutritional effect of dietary amino acids during intestinal regrowth has received considerable attention in recent years. This review explores the significance of dietary amino acids in the nutritional management of infants and children with intestinal failure and short bowel syndrome (SBS) as reported in the medical literature over the last three decades. A literature search was conducted using electronic databases. Breast milk emerged as the first-line enteral regimen recommended for infants with SBS. Hydrolyzed formulas (HFs) or amino acid formulas (AAFs) are recommended when breast milk is not available or if the infant cannot tolerate whole protein milk. The superiority of AAFs over HFs has never been demonstrated. Although glutamine (GLN) is the main fuel for enterocytes, GLN supplementation in infants with SBS showed no difference in the child's dependence upon parenteral nutrition (PN). Circulating citrulline is considered a major determinant of survival and nutritional prognosis of SBS patients. Early enteral nutrition and dietary supplementation of AAs following bowel resection in children are essential for the development of intestinal adaptation, thereby eliminating the need for PN.
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Affiliation(s)
- Igor Sukhotnik
- Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., Tel Aviv 6423906, Israel
| | - Reut Levi
- Department of Pediatric Gastroenterology, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., Tel Aviv 6423906, Israel
| | - Hadar Moran-Lev
- Department of Pediatric Gastroenterology, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., Tel Aviv 6423906, Israel
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Belza C, Wales PW. Intestinal failure among adults and children: Similarities and differences. Nutr Clin Pract 2023; 38 Suppl 1:S98-S113. [PMID: 37115028 DOI: 10.1002/ncp.10987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/27/2023] [Accepted: 03/05/2023] [Indexed: 04/29/2023] Open
Abstract
Intestinal failure (IF) is a complex medical condition that is caused by a constellation of disorders, resulting in the gut's inability to adequately absorb fluids and nutrients to sustain hydration, growth, and survival, thereby requiring the use of parenteral fluid and/or nutrition. Significant advancements in intestinal rehabilitation have resulted in improved survival rates for individuals with IF. There are distinct differences, however, related to etiology, adaptive potential and complications, and medical and surgical management when comparing children with adults. The purpose of this review is to contrast the similarities and differences between these two distinct groups and provide insight for future directions, as a growing population of pediatric patients will cross into the adult world for IF management.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
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Chen YC, Chou CM, Huang SY, Chen HC. Home Parenteral Nutrition for Children: What Are the Factors Indicating Dependence and Mortality? Nutrients 2023; 15:nu15030706. [PMID: 36771412 PMCID: PMC9919922 DOI: 10.3390/nu15030706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/26/2023] [Accepted: 01/29/2023] [Indexed: 02/03/2023] Open
Abstract
Parenteral nutrition (PN) in children with short bowel syndrome is crucial and lifesaving. Taking care of such patients requires interprofessional practice and multiple team resource management. Home PN (HPN) usage allows patients and families to live regular lives outside hospitals. We share our experiences for the last two decades and identify the risk factors for complications and mortality. A retrospective study of HPN patients was conducted between January 2000 and February 2022. Medical records of age, body weight, diagnosis, length of residual intestines, HPN period, central line attempts, complications, weaning, and survival were collected and analyzed. The patients were classified as HPN free, HPN dependent, and mortality groups. A total of 25 patients received HPN at our outpatient clinic, and one was excluded for the adult age of disease onset. There were 13 patients (54.1%) who were successfully weaned from HPN until the record-enroled date. The overall mortality rate was 20.8% (five patients). All mortality cases had prolonged cholestasis, Child Class B or C, and a positive Pediatric End-Stage Liver Disease (PELD) score. For HPN dependence, extended resection and multiple central line placement were two significant independent factors. Cholestasis, Child Class B or C, and positive PELD score were the most important risk factors for mortality. The central line-related complication rate was not different in all patient groups. The overall central line infection rate was 1.58 per 1000 catheter days. Caution should be addressed to prevent cholestasis and intestinal failure-associated liver disease during the HPN period, to prevent mortality. By understanding the risks of HPN dependence and mortality, preventive procedures could be addressed earlier.
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Affiliation(s)
- Ying-Cing Chen
- Department of Surgery, Taichung Veterans General Hospital, Taichung 407219, Taiwan
| | - Chia-Man Chou
- Division of Pediatric Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung 407219, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
- Division of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402202, Taiwan
| | - Sheng-Yang Huang
- Division of Pediatric Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung 407219, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
- Division of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402202, Taiwan
- Correspondence: ; Tel.: +886-4-23592525 (ext. 5183)
| | - Hou-Chuan Chen
- Division of Pediatric Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung 407219, Taiwan
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The role of gastrostomy feeding during intestinal rehabilitation for children with short bowel syndrome. Pediatr Surg Int 2022; 39:34. [PMID: 36462084 DOI: 10.1007/s00383-022-05311-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2022] [Indexed: 12/07/2022]
Abstract
PURPOSE Following extensive bowel resection, many children with short bowel syndrome (SBS) are routinely offered a placement of gastrostomy tube (G-tube) for feeding. This nutritional pathway is aimed to accommodate the gastric and small bowel motor disturbances related to SBS, and to promote weaning off parenteral nutrition (PN) to achieve enteral autonomy (EA). The aim of this study was to investigate the effect of gastrostomy feeding in outcomes of children with SBS. METHODS A retrospective cohort of all SBS children managed at our multidisciplinary Intestinal Rehabilitation Center as part of an Intestinal Rehabilitation Program. SBS was defined as PN dependence for more than six weeks following extensive bowel resection. Patients treated with G-tube feeding were compared with patients without G-tube in terms of PN duration, reaching EA, physical development, and surgical parameters. RESULTS A total of 36 SBS patients diagnosed between 2003 and 2022 were included. The most common etiologies included congenital intestinal atresia (31%) and necrotizing enterocolitis (25%). SBS-G-tube (group A) contained 20 children, and SBS (group B) contained 16 children. A total of 21 children reached EA (58%); ten from group A (50%), and 11 from group B (69%) (p > 0.05). Within EA patients, mean PN duration was 49 ± 44 months in group A, and 24 ± 33 months in group B (p > 0.05). Patients who reached EA had 22% longer residual small bowel when compared with PN-dependent patients (p = 0.003). However, the outcomes were adjusted for residual small and large bowel length and percentages, a residual ileocecal valve, and a colon in continuity with no differences between the groups. Two-thirds of children from group A reported G-tube related complications (mechanical, bleeding, or infections). We did not find differences in mean height and weight percentiles between the groups (p > 0.05). CONCLUSION We did not find significant advantage of gastrostomy feeding in reaching EA. Because there are surgical and mechanical complications related to this procedure, further prospective studies are required to determine G-tube relevance for children with SBS.
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Teduglutide in pediatric intestinal failure: A position statement of the Italian society of pediatric gastroenterology, hepatology and nutrition (SIGENP). Dig Liver Dis 2022; 54:1320-1327. [PMID: 35654733 DOI: 10.1016/j.dld.2022.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/05/2022] [Accepted: 04/29/2022] [Indexed: 12/29/2022]
Abstract
In recent years, the spectrum of possible treatments for Intestinal Failure (IF)-Short Bowel Syndrome (SBS) has been enriched by the implementation of GLP-2 analogues. In Italy, teduglutide (Ted), an analogue of GLP-2, was approved in January 2021 by the Italian Regulatory Agency for Drugs (AIFA) for IF-SBS patients ≥1 year old. According to the Agency indications, Ted can now be prescribed by regional reference centers, with costs fully charged to the National Health Service. Following pediatric-use approval in our country and in light of scarce evidence in childhood, the pediatric network for IF of the Italian Society for Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) planned to share management methods of Ted in pediatric IF. The main purpose was to identify the best candidates from a cost-effective perspective. Thus, focusing on available literature and on expert opinions, the present position statement provides consensus-based recommendations on the use of Ted for pediatric gastroenterologists and nutritionists treating children with SBS.
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Abstract
Intestinal failure (IF) secondary to short bowel syndrome is a challenging and complex medical condition with significant risk for surgical and medical complications. Significant advancements in the care of this patient population have led to improved survival rates. Due to their intensive medical needs children with IF are at risk for long-term complications that require comprehensive management and close monitoring. The purpose of this paper is to review the available literature emphasizing the surgical aspects of care for children with IF secondary to short bowel syndrome. A key priority in the surgical care of this patient population includes strategies to preserve available bowel and maximize its function. Utilization of novel surgical techniques and autologous bowel reconstruction can have a significant impact on children with IF secondary to short bowel syndrome related to the function of their bowel and ability to achieve enteral autonomy. It is also important to understand the potential long-term complications to ensure strategies are put in place to mitigate risk with early detection to improve long-term outcomes.
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Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, Cincinatti Children's Hospital Medical Center, University of Cincinnati, Cincinnatii, USA; Cincinnati Children's Intestinal Rehabilitation Program, Cincinnati Children's Hospital Medical Center, University of Cincinnati, 3333 Burnet Avenue, MLC 2023, Cincinnati, Ohio 45229, USA.
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Ivanics T, Vianna R, Kubal CA, Iyer KR, Mazariegos GV, Matsumoto CS, Mangus R, Beduschi T, Abouljoud M, Fridell JA, Nagai S. Impact of the acuity circle model for liver allocation on multivisceral transplant candidates. Am J Transplant 2022; 22:464-473. [PMID: 34403552 DOI: 10.1111/ajt.16803] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/22/2021] [Accepted: 08/11/2021] [Indexed: 01/25/2023]
Abstract
Liver allocation was updated on February 4, 2020, replacing a Donor Service Area (DSA) with acuity circles (AC). The impact on waitlist outcomes for patients listed for combined liver-intestine transplantation (multivisceral transplantation [MVT]) remains unknown. The Organ Procurement and Transplantation Network/United Network for Organ Sharing database was used to identify all candidates listed for both liver and intestine between January 1, 2018 and March 5, 2021. Two eras were defined: pre-AC (2018-2020) and post-AC (2020-2021). Outcomes included 90-day waitlist mortality and transplant probability. A total of 127 adult and 104 pediatric MVT listings were identified. In adults, the 90-day waitlist mortality was not statistically significantly different, but transplant probability was lower post-AC. After risk-adjustment, post-AC was associated with a higher albeit not statistically significantly different mortality hazard (sub-distribution hazard ratio[sHR]: 8.45, 95% CI: 0.96-74.05; p = .054), but a significantly lower transplant probability (sHR: 0.33, 95% CI: 0.15-0.75; p = .008). For pediatric patients, waitlist mortality and transplant probability were similar between eras. The proportion of patients who underwent transplant with exception points was lower post-AC both in adult (44% to 9%; p = .04) and pediatric recipients (65% to 15%; p = .002). A lower transplant probability observed in adults listed for MVT may ultimately result in increased waitlist mortality. Efforts should be taken to ensure equitable organ allocation in this vulnerable patient population.
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Affiliation(s)
- Tommy Ivanics
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Michigan, USA.,Department of Surgical Sciences, Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden
| | - Rodrigo Vianna
- Division of Liver/GI Transplant, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital/University of Miami, Miami, Florida, USA
| | - Chandrashekhar A Kubal
- Division of Abdominal Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kishore R Iyer
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Cal S Matsumoto
- Medstar Georgetown University Hospital, Medstar Georgetown Transplant Institute, Washington, DC, USA
| | - Richard Mangus
- Division of Abdominal Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Thiago Beduschi
- Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Marwan Abouljoud
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Michigan, USA
| | - Jonathan A Fridell
- Division of Abdominal Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shunji Nagai
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Michigan, USA
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Tazuke Y, Udagawa E, Mizushima T, Nakamura S, Fernandez J, Okuyama H. Real-world etiologies and treatments of pediatric short bowel syndrome in Japan. Pediatr Int 2022; 64:e15258. [PMID: 36163637 PMCID: PMC9828786 DOI: 10.1111/ped.15258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/20/2022] [Accepted: 05/25/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Short bowel syndrome (SBS) is a rare disease that can result in intestinal failure (IF). Short bowel syndrome intestinal failure leads to stunted growth and development and high mortality rates. The primary goal of treatment is to enhance intestinal adaptation and nutrient absorption. Parenteral nutrition (PN) is used to support this process until enteral autonomy can be restored. Some patients experience prolonged partial or complete dependency on PN and face an increased risk of life-threatening catheter-related bloodstream infections and intestinal failure-associated liver disease. This study aimed to provide real-world insights into the patient characteristics and treatment dynamics of PN-dependent children with SBS-IF in Japan. METHODS This retrospective observational study used anonymized information from a large hospital-based medical insurance database to identify pediatric patients who received PN for ≥6 months between April 2008 and January 2020. The primary endpoint was weaning from PN. Secondary endpoints included duration and complications of PN. RESULTS Forty-eight children (mean age, 2.9 years) were eligible for inclusion. The most common causes of SBS-IF were mechanical bowel obstruction, functional bowel disorders, and Hirschsprung's disease. Twenty-two patients (45.8%) were weaned from PN during the study. The mean time to first weaning was 464.2 days and five patients (22.7%) restarted PN. The mean total duration of PN was 692.6 days in weaned patients and 1,170.9 days in unweaned patients. The most frequent complications were sepsis, catheter infections (both 79.2%), and liver dysfunction (64.6%). CONCLUSIONS Pediatric patients with SBS-IF faced difficulties when weaning off PN and rates of life-threatening complications were high.
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Affiliation(s)
- Yuko Tazuke
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Eri Udagawa
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo, Japan
| | - Tsunekazu Mizushima
- Department of Therapeutics for Inflammatory Bowel Diseases, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shiro Nakamura
- 2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Jovelle Fernandez
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Modi BP, Galloway DP, Gura K, Nucci A, Plogsted S, Tucker A, Wales PW. ASPEN definitions in pediatric intestinal failure. JPEN J Parenter Enteral Nutr 2021; 46:42-59. [PMID: 34287974 DOI: 10.1002/jpen.2232] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 11/09/2022]
Abstract
Pediatric intestinal failure (PIF) is a relatively rare disease entity which requires focused interdisciplinary care and specialized nutrition management. There has long been a lack of consensus in the definition of key terms related to PIF due to its rarity and plethora of small studies rather than large trials. As such, the American Society for Parenteral and Enteral Nutrition (ASPEN) Pediatric Intestinal Failure Section, composed of clinicians from a variety of disciplines caring for children with intestinal failure, is uniquely poised to provide insight into this definition void. This document is the product of an effort by the Section to create evidence-based consensus definitions, with the goal of allowing for appropriate comparisons between clinical studies and measurement of longterm patient outcomes. This manuscript was approved by the ASPEN Board of Directors. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Biren P Modi
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David P Galloway
- Division of Gastroenterology, Hepatology and Nutrition, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kathleen Gura
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Anita Nucci
- Department of Nutrition, Georgia State University, Atlanta, Georgia, USA
| | | | - Alyssa Tucker
- Department of Clinical Nutrition, Children's National Medical Center, Washington, District of Columbia, USA
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment, Department of Surgery, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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12
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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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13
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Abstract
PURPOSE OF REVIEW Intestinal transplantation has evolved to be a viable treatment option for patients with intestinal failure. This review shows the most current tendencies and practices of intestinal transplant centers and an overall comparison to intestinal rehabilitation. RECENT FINDINGS This review outlines that timing for referral and advances in preoperative and postoperative care of intestinal and multivisceral transplant candidates are crucial to achieve results comparable to intestinal rehabilitation. SUMMARY Current practices have shown that intestinal transplantation continues to improve overall results and could be considered in patients with permanent home parenteral nutrition. Timing for referral and preoperative and postoperative management are crucial to optimize long-term results.
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Affiliation(s)
| | - Gennaro Selvaggi
- Departmetn of Surgery, Liver and Gastrointestinal Transplantation, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
| | - Akin Tekin
- Departmetn of Surgery, Liver and Gastrointestinal Transplantation, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
| | - Rodrigo Vianna
- Departmetn of Surgery, Liver and Gastrointestinal Transplantation, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
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Wendel D, Mezoff EA, Raghu VK, Kinberg S, Soden J, Avitzur Y, Rudolph JA, Gniadek M, Cohran VC, Venick RS, Cole CR. Management of Central Venous Access in Children With Intestinal Failure: A Position Paper From the NASPGHAN Intestinal Rehabilitation Special Interest Group. J Pediatr Gastroenterol Nutr 2021; 72:474-486. [PMID: 33399327 PMCID: PMC8260029 DOI: 10.1097/mpg.0000000000003036] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
ABSTRACT Intestinal failure requires the placement and maintenance of a long-term central venous catheter for the provision of fluids and/or nutrients. Complications associated with this access contribute to significant morbidity and mortality, while the loss of access is an increasingly common reason for intestinal transplant referral. As more emphasis has been placed on the prevention of central line-associated bloodstream infections and new technologies have developed, care for central lines has improved; however, because care has evolved independently in local centers, care of central venous access varies significantly in this vulnerable population. The present position paper from the Intestinal Failure Special Interest Group of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) reviews current evidence and provides recommendations for central line management in children with intestinal failure.
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Affiliation(s)
- Danielle Wendel
- Division of Gastroenterology and Hepatology, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Ethan A. Mezoff
- Division of Gastroenterology and Nutrition, Nationwide Children’s Hospital, Columbus, OH
| | - Vikram K. Raghu
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Sivan Kinberg
- Division of Gastroenterology, Hepatology, and Nutrition, New York-Presbyterian Morgan Stanley Children’s Hospital, Columbia University, New York, NY
| | - Jason Soden
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Jeffrey A. Rudolph
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Michelle Gniadek
- Division of Gastroenterology and Nutrition, Nationwide Children’s Hospital, Columbus, OH
| | - Valeria C. Cohran
- Division of Gastroenterology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Robert S. Venick
- Division of Gastroenterology, Hepatology, and Nutrition, UCLA Mattel Children’s Hospital, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Conrad R. Cole
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH
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15
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LaRusso K, Dumas MP, Schaack G, Sant'Anna A. Prolonged Use of Ethanol Lock Prophylaxis With Polyurethane Catheters in Children With Intestinal Failure: A Single-Center Experience. JPEN J Parenter Enteral Nutr 2020; 45:1425-1431. [PMID: 33274464 DOI: 10.1002/jpen.2056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/12/2020] [Accepted: 11/25/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Children with intestinal failure (IF) receiving home parenteral nutrition (HPN) require long-term central venous catheters (CVCs). Ethanol lock prophylaxis (ELP) can reduce central line-associated bloodstream infections, but there are some concerns of increased breakage rates when used with polyurethane catheters. We reviewed our experience using ethanol locks in both polyurethane and silicone CVCs. METHODS A 10-year retrospective study of children with IF receiving HPN that used ELP was conducted. Complications per 1000 catheter days were extracted and a multivariable, mixed-effects Poisson model was used to compare catheter breakage rates and other complications between polyurethane and silicone CVCs. RESULTS A total of 10 patients were included, comprising 85 CVCs and 13,227 catheter days. The most common cause of IF was necrotizing enterocolitis. Breakages were the most common complication: polyurethane 1.46/1000 vs silicone 3.76/1000 catheter days. Silicone catheters had a significantly higher breakage rate (adjusted rate ratio [RR], 2.86; 95% confidence interval [CI], 2.84-2.88; P < .001) whereas polyurethane catheters had higher rates of occlusion (adjusted RR, 0.14; 95% CI, 0.07-0.28; P < .001) and displacements. However, there were no differences in the overall catheter replacement rates and any other catheter-related outcomes. CONCLUSIONS In children with IF receiving long-term HPN, the use of ELP in polyurethane catheters was associated with a lower risk of breakages when compared with silicone CVCs. These results should be regarded as preliminary data, and further studies with a higher number of participants are necessary to provide a better level of evidence.
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Affiliation(s)
- Kathryn LaRusso
- Division of Pediatric General and Thoracic Surgery, Montreal Children's Hospital, McGill University Health Centre, Montreal, Québec, Canada
| | - Marie-Pier Dumas
- Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Québec, Canada
| | - Geraldine Schaack
- Nursing Education, Montreal Children's Hospital, McGill University Health Centre, Montreal, Québec, Canada
| | - Ana Sant'Anna
- Division of Pediatric Gastroenterology and Nutrition, Montreal Children's Hospital, McGill University Health Centre, Montreal, Québec, Canada
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16
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Onufer EJ, Aladegbami B, Imai T, Seiler K, Bajinting A, Courtney C, Sutton S, Bustos A, Yao J, Yeh CH, Sescleifer A, Wang LV, Guo J, Warner BW. EGFR in enterocytes & endothelium and HIF1α in enterocytes are dispensable for massive small bowel resection induced angiogenesis. PLoS One 2020; 15:e0236964. [PMID: 32931498 PMCID: PMC7491746 DOI: 10.1371/journal.pone.0236964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/16/2020] [Indexed: 12/15/2022] Open
Abstract
Background Short bowel syndrome (SBS) results from significant loss of small intestinal length. In response to this loss, adaptation occurs, with Epidermal Growth Factor Receptor (EGFR) being a key driver. Besides enhanced enterocyte proliferation, we have revealed that adaptation is associated with angiogenesis. Further, we have found that small bowel resection (SBR) is associated with diminished oxygen delivery and elevated levels of hypoxia-inducible factor 1-alpha (HIF1α). Methods We ablated EGFR in the epithelium and endothelium as well as HIF1α in the epithelium, ostensibly the most hypoxic element. Using these mice, we determined the effects of these genetic manipulations on intestinal blood flow after SBR using photoacoustic microscopy (PAM), intestinal adaptation and angiogenic responses. Then, given that endothelial cells require a stromal support cell for efficient vascularization, we ablated EGFR expression in intestinal subepithelial myofibroblasts (ISEMFs) to determine its effects on angiogenesis in a microfluidic model of human small intestine. Results Despite immediate increased demand in oxygen extraction fraction measured by PAM in all mouse lines, were no differences in enterocyte and endothelial cell EGFR knockouts or enterocyte HIF1α knockouts by POD3. Submucosal capillary density was also unchanged by POD7 in all mouse lines. Additionally, EGFR silencing in ISEMFs did not impact vascular network development in a microfluidic device of human small intestine. Conclusions Overall, despite the importance of EGFR in facilitating intestinal adaptation after SBR, it had no impact on angiogenesis in three cell types–enterocytes, endothelial cells, and ISEMFs. Epithelial ablation of HIF1α also had no impact on angiogenesis in the setting of SBS.
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Affiliation(s)
- Emily J. Onufer
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, United States of America
| | - Bola Aladegbami
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, United States of America
| | - Toru Imai
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States of America
- Department of Electrical Engineering, Caltech Optical Imaging Laboratory, Andrew and Peggy Cherng Department of Medical Engineering, California Institute of Technology, Pasadena, CA, United States of America
| | - Kristen Seiler
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, United States of America
| | - Adam Bajinting
- Saint Louis University School of Medicine, St. Louis, MO, United States of America
| | - Cathleen Courtney
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, United States of America
| | - Stephanie Sutton
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, United States of America
| | - Aiza Bustos
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, United States of America
| | - Junjie Yao
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States of America
| | - Cheng-Hung Yeh
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States of America
| | - Anne Sescleifer
- Saint Louis University School of Medicine, St. Louis, MO, United States of America
| | - Lihong V. Wang
- Department of Electrical Engineering, Caltech Optical Imaging Laboratory, Andrew and Peggy Cherng Department of Medical Engineering, California Institute of Technology, Pasadena, CA, United States of America
| | - Jun Guo
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, United States of America
| | - Brad W. Warner
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, United States of America
- * E-mail:
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17
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Park CJ, Shaughnessy MP, Zhang L, Armenia SJ, Caty MG, Cowles RA. National Survey of Pediatric Intestinal Rehabilitation Programs in the United States. JPEN J Parenter Enteral Nutr 2020; 45:1249-1258. [PMID: 32797633 DOI: 10.1002/jpen.1997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 07/08/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pediatric intestinal rehabilitation (PIR) programs are associated with improved outcomes in children with intestinal failure but remain heterogeneous nationally. This study characterizes PIR program components to aid those seeking to establish or expand a program. METHODS Members of the Children's Hospital Association reporting a PIR program to the US News and World Report completed a 14-item questionnaire using the Qualtrics Online Survey Software. Programs were categorized as small or large (≤50 vs >50 patients) and new or established (≤10 vs >10 years). RESULTS Seventy-one programs were identified and 61 surveys were returned for a response rate of 86%. Majority of programs had gastroenterology, surgery, nutrition, nursing, and social work services involved. Large programs (n = 34; 59%) were more likely to serve as referral centers; have greater participation by nursing, social work, and primary care; have more dedicated time by gastroenterology, surgery, nursing, nutrition, and social work; have more frequent meetings; and have various funding sources (P < .05). CONCLUSION Critical components of a PIR program include gastroenterology, surgery, and nutrition services with strong nursing and social work support. These data document the components of modern PIR programs, though further studies on the relationship between program structure and patient outcomes are warranted.
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Affiliation(s)
- Christine J Park
- Department of Surgery, Division of Pediatric Surgery at Yale University, New Haven, Connecticut, 06510, USA
| | - Matthew P Shaughnessy
- Department of Surgery, Division of Pediatric Surgery at Yale University, New Haven, Connecticut, 06510, USA
| | - Lucy Zhang
- Department of Surgery, Division of Pediatric Surgery at Yale University, New Haven, Connecticut, 06510, USA
| | - Sarah J Armenia
- Department of Surgery, Division of Pediatric Surgery at Yale University, New Haven, Connecticut, 06510, USA
| | - Michael G Caty
- Department of Surgery, Division of Pediatric Surgery at Yale University, New Haven, Connecticut, 06510, USA
| | - Robert A Cowles
- Department of Surgery, Division of Pediatric Surgery at Yale University, New Haven, Connecticut, 06510, USA
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18
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Quirt J, Belza C, Pai N, Clause R, Markovic F, Wong‐Sterling S, Avitzur Y, Wales PW. Reduction of Central Line–Associated Bloodstream Infections and Line Occlusions in Pediatric Intestinal Failure Patients Receiving Long‐Term Parenteral Nutrition Using an Alternative Locking Solution, 4% Tetrasodium Ethylenediaminetetraacetic Acid. JPEN J Parenter Enteral Nutr 2020; 45:1286-1292. [DOI: 10.1002/jpen.1989] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 07/15/2020] [Accepted: 07/28/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Jill Quirt
- Group for Improvement of Intestinal Function and Treatment The Hospital for Sick Children University of Toronto Toronto Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children University of Toronto Toronto Canada
| | - Christina Belza
- Group for Improvement of Intestinal Function and Treatment The Hospital for Sick Children University of Toronto Toronto Canada
| | - Nikhil Pai
- Division of Gastroenterology and Nutrition, McMaster Children's Hospital McMaster University Hamilton Canada
| | - Rose‐Frances Clause
- Division of Gastroenterology and Nutrition, McMaster Children's Hospital McMaster University Hamilton Canada
| | - Filip Markovic
- Division of Gastroenterology and Nutrition, McMaster Children's Hospital McMaster University Hamilton Canada
| | - Sylvia Wong‐Sterling
- Group for Improvement of Intestinal Function and Treatment The Hospital for Sick Children University of Toronto Toronto Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment The Hospital for Sick Children University of Toronto Toronto Canada
- Division of Gastroenterology, Hepatology, and Nutrition The Hospital for Sick Children University of Toronto Toronto Canada
| | - Paul W. Wales
- Group for Improvement of Intestinal Function and Treatment The Hospital for Sick Children University of Toronto Toronto Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children University of Toronto Toronto Canada
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19
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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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20
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Onufer EJ, Han YH, Czepielewski RS, Courtney CM, Sutton S, Randolph GJ, Warner BW. Effects of high-fat diet on liver injury after small bowel resection. J Pediatr Surg 2020; 55:1099-1106. [PMID: 32164985 PMCID: PMC7299751 DOI: 10.1016/j.jpedsurg.2020.02.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The optimal regimen for enteral nutritional support in the management of children with short bowel syndrome (SBS) is not well characterized. A high fat, enteral diet is theoretically beneficial due to increased caloric density and enhanced structural adaptation. We therefore sought to determine the long-term effects of a high fat diet (HFD) on liver injury, a common complication of SBS, compared to a standard chow (SC) diet. METHODS Using a parenteral nutrition-independent model of resection-associated liver injury, C57BL/6 mice underwent a sham operation or a 50% or 75% proximal small bowel resection (SBR). Mice in each group were then fed either a HFD (35% kcal fat) or SC (13% kcal fat). At post-operative week 15, markers of liver injury were quantified. RESULTS Liver triglyceride levels were increased from 7- to 19-fold in mice on the HFD compared to mice fed SC in the sham, 50%, and 75% resection groups. Serum ALT (2.2-fold increase in 75% resected mice compared to sham controls) and AST (2.0- and 2.7-fold increases in 50% and 75% resected mice, respectively) levels as well as fibrotic liver staining were elevated only in resected mice fed a HFD. CONCLUSION Long-term enteral feeding of HFD in our murine SBS model is associated with hepatic steatosis and liver injury. Our observation that liver steatosis and injury occur independent of parenteral nutrition suggests that enteral feeding composition and magnitude of intestinal loss may make a significant contribution to intestinal failure-associated liver disease.
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Affiliation(s)
- Emily J. Onufer
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Yong-Hyun Han
- Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, MO
| | - Rafael S. Czepielewski
- Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, MO
| | - Cathleen M. Courtney
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Stephanie Sutton
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Gwendalyn J. Randolph
- Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, MO
| | - Brad W. Warner
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO
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21
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Huff KA, Breckler F, Cruse W, Szeszycki E, Vanderpool C. Pediatric Smoflipid Therapy: Patient Response and Safety Concerns. JPEN J Parenter Enteral Nutr 2020; 45:792-799. [PMID: 32458457 DOI: 10.1002/jpen.1929] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/23/2020] [Accepted: 05/19/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Intestinal failure-associated liver disease (IFALD) occurs in ≤85% of neonates receiving prolonged parenteral nutrition. Strategies for treatment of IFALD include alternative lipid therapies, such as Smoflipid (Fresenius Kabi). In this study, we reviewed our institutional Smoflipid use, including predictors of patient response and safety concerns. METHODS This is a retrospective chart review of all pediatric patients who received Smoflipid therapy over a 2-year period at Riley Hospital for Children. Forty-two patients (89%) had cholestasis at the start of Smoflipid therapy and were included in group analysis. We compared patients based on response to Smoflipid therapy, identifying associations and predictors of patient response. We also documented patient safety concerns, including essential fatty acid deficiency (EFAD), rapid infusion, and compatibility/access issues. RESULTS Sixteen patients (38%) with cholestasis had resolution with Smoflipid. Those patients with resolution were older at initiation (58 vs 33.5 days; P = .010), treated with Smoflipid for longer (85.5 vs 41 days; P = .001), and had lower direct bilirubin at the start of Smoflipid therapy (3.7 vs 5.2 mg/dL; P = .035). We identified multiple safety concerns, including EFAD (54%), rapid infusion (17%), and missed doses (51%). No patient characteristics were found to correlate with Smofllpid therapy and diagnosis of EFAD. CONCLUSION In our patient population, Smoflipid therapy led to cholestasis resolution in patients with lower direct bilirubin or less-severe IFALD. Use of Smoflipid is also associated with significant safety concerns, and its use should be coupled with close monitoring in pediatric patients, particularly in neonates.
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Affiliation(s)
- Katie A Huff
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
| | - Francine Breckler
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
| | - Wendy Cruse
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
| | - Elaina Szeszycki
- Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
| | - Charles Vanderpool
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
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22
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Oliveira C, de Silva NT, Ungar WJ, Bayoumi AM, Avitzur Y, Hoch JS, Maxwell J, Wales PW. Health-related quality of life in neonates and infants: a conceptual framework. Qual Life Res 2020; 29:1159-1168. [PMID: 31997081 DOI: 10.1007/s11136-020-02432-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE With reduced mortality of neonatal conditions, health-related quality of life (HRQOL) has become an important clinical outcome. However, since the meaning of HRQOL in dependent, non-autonomous infants and neonates remains largely undefined, HRQOL measurement and economic evaluation are limited due to the lack of age-specific methodology. The objective was to construct a conceptual framework of neonatal and infant HRQOL (NIHRQOL) which identifies factors relevant to the neonate and infant, their relationship with each other and the caregiving environment. METHODS Using qualitative methods, a concept was developed based on in-depth analysis of verbatim records of two focus groups (6 caregivers, 6 healthcare providers) and five interviews with caregivers of chronically ill neonates/infants (n = 2), and healthcare professionals of a pediatric tertiary healthcare center (n = 3). Two analysts independently performed thematic analysis using an inductive and contextual approach. RESULTS The majority of participants regarded NIHRQOL as an individual entity, which was closely related and strongly influenced by caregivers and family. It may be gauged by the perceived degree of effort required to achieve expected normalcy in everyday life for the neonate/infant and its family. The importance of individual HRQOL factors is developmental stage-dependent. CONCLUSION Neonatal and infant HRQOL is a multidimensional, multilayered and interconnected concept, where the child's needs contribute most directly, and the caregiver's and society's ability to meet those needs characterize the interdependence between the child and its caregiving environment. Developmental stage-specific HRQOL instruments for premature and mature neonates, and infants are warranted to allow for valid HRQOL measurement.
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Affiliation(s)
- Carol Oliveira
- Group for Improvement of Intestinal Function and Treatment Program (GIFT), The Hospital for Sick Children, Toronto, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Nicole T de Silva
- Group for Improvement of Intestinal Function and Treatment Program (GIFT), The Hospital for Sick Children, Toronto, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada
| | - Wendy J Ungar
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
| | - Ahmed M Bayoumi
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Centre for Research On Inner City Health, Li Ka Shing Knowledge Institute and Division of General Internal Medicine, St. Michael's Hospital, Toronto, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment Program (GIFT), The Hospital for Sick Children, Toronto, Canada.,Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Jeffrey S Hoch
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Centre for Excellence in Economic Analysis Research (CLEAR), St. Michael's Hospital, Toronto, Canada
| | - Julia Maxwell
- Group for Improvement of Intestinal Function and Treatment Program (GIFT), The Hospital for Sick Children, Toronto, Canada
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment Program (GIFT), The Hospital for Sick Children, Toronto, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Vlug LE, Nagelkerke SCJ, Jonkers-Schuitema CF, Rings EHHM, Tabbers MM. The Role of a Nutrition Support Team in the Management of Intestinal Failure Patients. Nutrients 2020; 12:nu12010172. [PMID: 31936271 PMCID: PMC7019598 DOI: 10.3390/nu12010172] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/02/2020] [Accepted: 01/04/2020] [Indexed: 12/15/2022] Open
Abstract
Parenteral nutrition (PN) is a complex and specialized form of nutrition support that has revolutionized the care for both pediatric and adult patients with acute and chronic intestinal failure (IF). This has led to the development of multidisciplinary teams focused on the management of patients receiving PN: nutrition support teams (NSTs). In this review we aim to discuss the historical aspects of IF management and NST development, and the practice, composition, and effectiveness of multidisciplinary care by NSTs in patients with IF. We also discuss the experience of two IF centers as an example of contemporary NSTs at work. An NST usually consists of at least a physician, nurse, dietitian, and pharmacist. Multidisciplinary care by an NST leads to fewer complications including infection and electrolyte disturbances, and better survival for patients receiving short- and long-term PN. Furthermore, it leads to a decrease in inappropriate prescriptions of short-term PN leading to significant cost reduction. Complex care for patients receiving PN necessitates close collaboration between team members and NSTs from other centers to optimize safety and effectiveness of PN use.
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Affiliation(s)
- Lotte E. Vlug
- Erasmus Medical Center, Department of Pediatric Gastroenterology, Erasmus University Rotterdam, Sophia Children’s Hospital, 3015 GD Rotterdam, The Netherlands
- Correspondence: (L.E.V.); (S.C.J.N.)
| | - Sjoerd C. J. Nagelkerke
- Amsterdam UMC, Department of Pediatric Gastroenterology, University of Amsterdam, Emma Children’s Hospital, Hepatology and Nutrition, 1105 AZ Amsterdam, The Netherlands
- Correspondence: (L.E.V.); (S.C.J.N.)
| | - Cora F. Jonkers-Schuitema
- Amsterdam UMC, Department of Pediatric Gastroenterology, University of Amsterdam, Emma Children’s Hospital, Hepatology and Nutrition, 1105 AZ Amsterdam, The Netherlands
| | - Edmond H. H. M. Rings
- Erasmus Medical Center, Department of Pediatric Gastroenterology, Erasmus University Rotterdam, Sophia Children’s Hospital, 3015 GD Rotterdam, The Netherlands
- Department of Pediatric Gastroenterology, Leiden University Medical Center, University of Leiden, Willem Alexander Children’s Hospital, 2300 RC Leiden, The Netherlands
| | - Merit M. Tabbers
- Amsterdam UMC, Department of Pediatric Gastroenterology, University of Amsterdam, Emma Children’s Hospital, Hepatology and Nutrition, 1105 AZ Amsterdam, The Netherlands
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Belza C, Fitzgerald K, Silva N, Avitzur Y, Wales PW. Early Predictors of Enteral Autonomy in Pediatric Intestinal Failure Resulting From Short Bowel Syndrome: Development of a Disease Severity Scoring Tool. JPEN J Parenter Enteral Nutr 2019; 43:961-969. [DOI: 10.1002/jpen.1691] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 06/12/2019] [Accepted: 06/28/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and TreatmentUniversity of Toronto Toronto Canada
| | - Kevin Fitzgerald
- Group for Improvement of Intestinal Function and TreatmentUniversity of Toronto Toronto Canada
| | - Nicole Silva
- Group for Improvement of Intestinal Function and TreatmentUniversity of Toronto Toronto Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and TreatmentUniversity of Toronto Toronto Canada
- Division of Gastroenterology, Hepatology and NutritionUniversity of Toronto Toronto Canada
| | - Paul W. Wales
- Group for Improvement of Intestinal Function and TreatmentUniversity of Toronto Toronto Canada
- Division of General and Thoracic SurgeryThe Hospital for Sick ChildrenUniversity of Toronto Toronto Canada
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LaRusso K, Schaack G, Fung T, McGregor K, Long J, Dumas MP, Attari Z, Yousef Y, Girgis H, Raghunathan R, Sant'Anna A, Emil S. Should you pick the PICC? Prolonged use of peripherally inserted central venous catheters in children with intestinal failure. J Pediatr Surg 2019; 54:999-1004. [PMID: 30795912 DOI: 10.1016/j.jpedsurg.2019.01.052] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 01/27/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Prolonged central vascular access is a source of significant morbidity in children with intestinal failure (IF). In an effort to decrease morbidity, our multidisciplinary IF team has primarily used peripherally inserted central catheters (PICCs) for these patients. We compared outcomes of PICCs to Broviacs®. METHODS A review of children with IF (2006-2018) at an academic children's hospital was conducted. INCLUSION CRITERIA total parenteral nutrition duration >42 days or small bowel length < 25% of total for gestational age. Complications/1000 catheter days were extracted, and a Poisson model was used to compare complications between PICCs and Broviacs®. RESULTS Thirty-seven patients with IF were included, accounting for 19,452 catheter days. There were 209 PICCs (1.2-4F) and 39 Broviacs® (2.7-7F). The median duration of overall PICC access/patient was 166 days (range: 35 days-8 years). Incidences of central line associated blood stream infection and venous thrombosis were 3.95 and 0.55 per 1000 catheter days, respectively. There were no significant differences in complication rates per line per catheter day between PICCs and Broviacs® on multivariate analysis. Broviacs® showed a trend towards increased of catheter-related hospital admissions when compared to PICCs. CONCLUSIONS PICCs in children with intestinal failure have similar complication rates to Broviacs® but may reduce catheter-related hospital admissions. Use of tunneled PICCs and increasing experience with this vascular access method may allow it to realize its potential advantages. LEVEL OF EVIDENCE Retrospective study, level III.
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Affiliation(s)
- Kathryn LaRusso
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Geraldine Schaack
- Nursing Education, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Tiffany Fung
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Kevin McGregor
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Justin Long
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Marie-Pier Dumas
- Nursing Education, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Zahia Attari
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Yasmine Yousef
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Hidy Girgis
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Rajam Raghunathan
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Ana Sant'Anna
- Division of Pediatric Gastroenterology and Nutrition, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Sherif Emil
- Division of Pediatric General and Thoracic Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.
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Abstract
BACKGROUND Patients with gastroschisis and prolonged total (or partial) parenteral nutrition (PN) commonly develop direct hyperbilirubinemia (DH). OBJECTIVE To quantify the prevalence and severity of DH in newborns with gastroschisis and characterize the diagnostic work-up for DH in this patient population. DESIGN/METHODS Retrospective chart review of patients born with gastroschisis between 2005 and 2015 for the first 6 months of life. RESULTS 29 patients were identified with gastroschisis. Mean gestational age and birthweight were 36.4 (± 1.8) weeks and 2.5 (± 0.6) kg. 41% were treated with primary reduction versus staged closure. Peak total and direct bilirubin (DB) levels were 10.17 ± 6.21 mg/dL and 5.58 ± 3.94 mg/dL, respectively. 23 patients (79.3%) were diagnosed with DH and 78.2% underwent additional work-up for hyperbilirubinemia consisting of imaging and laboratory studies, none of which revealed a cause for DH other than the presumed PN-associated cholestasis. In all patients, DB began to decline within 1-10 days of initiation of enteral feeds. CONCLUSION(S) DH is common in patients with gastroschisis and is unlikely to be associated with pathology aside from PN. Additional work-up may lead to unnecessary resource utilization. LEVELS OF EVIDENCE Case series with no comparison group, Level IV.
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27
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Motor Proficiency and Generalized Self-Efficacy Toward Physical Activity in Children With Intestinal Failure. J Pediatr Gastroenterol Nutr 2019; 68:7-12. [PMID: 30052565 DOI: 10.1097/mpg.0000000000002107] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Survival rates of children with intestinal failure have increased; however, associated co-morbidities may affect long-term motor developmental outcomes. This study evaluates motor proficiency and generalized self-efficacy toward physical activity (PA) in children ages 6 to 12 years with intestinal failure. METHODS This is an observational, cross-sectional study of children followed in a multidisciplinary intestinal rehabilitation program. Motor proficiency was assessed using the Bruininks-Oseretsky Test of Motor Proficiency-2 Short Form (BOT-2 SF) and the Scales of Independent Behavior (parent-proxy report). Children completed the Children's Self-Perceptions of Adequacy in and Predilection for Physical Activity (CSAPPA) and a PA questionnaire. Relevant demographic and medical variables were correlated with assessment results. RESULTS Participants include 30 children (18 males), median age 7 years (interquartile range [IQR] 6-9) with gestational age 35 weeks (IQR 32-39) and birth weight 2.13 kg (IQR 1.68-2.77). Thirteen (43%) were dependent on parenteral nutrition. Fifteen (50%) scored below average on the BOT-2 SF. Lower BOT-2 SF scores were significantly associated with lower CSAPPA scores (r = 0.480, P = 0.01), with a common barrier to PA being the presence of a central line or enterostomy tube. Gestational age, height z scores, length of hospital admissions, and number of septic events were all significantly correlated with lower scores in motor proficiency. Number of septic events and total parenteral nutrition days were significant predictors of lower BOT-2 SF scores, when adjusting for birth weight. CONCLUSIONS Multiple medical variables related to intestinal failure may affect motor proficiency and PA self-efficacy. Developmental follow-up is important to optimize motor skill development and promote PA participation.
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Javid PJ, Wendel D, Horslen SP. Organization and outcomes of multidisciplinary intestinal failure teams. Semin Pediatr Surg 2018; 27:218-222. [PMID: 30342595 DOI: 10.1053/j.sempedsurg.2018.07.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Multidisciplinary intestinal failure programs have played a leading role in the improved outcomes observed in children with intestinal failure over the past two decades. These teams evolved from the world of transplantation and now provide comprehensive care of intestinal failure patients and their families. In addition, they provide the foundation for outcomes research and clinical trials in pediatric intestinal failure. The history and composition of multidisciplinary intestinal failure programs is outlined here with a particular emphasis on long-term patient outcomes as reported from the programs themselves. The care of children with intestinal failure has rapidly evolved over the past two decades. In the contemporary era, children with intestinal failure now have a favorable long-term prognosis, and survival is routinely greater than 90%. The improvement in outcomes in this population is secondary to a variety of advances including safe strategies to deliver chronic parenteral nutrition (PN), innovative bowel lengthening techniques, preservation of vascular access, and prevention of sepsis. However, the underlying driver of these advances in care is widely considered to be the advent of multidisciplinary intestinal failure and rehabilitation programs to manage these patients in a comprehensive fashion.
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Affiliation(s)
- Patrick J Javid
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, WA, USA.
| | - Danielle Wendel
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, WA, USA
| | - Simon P Horslen
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, WA, USA
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29
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Abstract
Pediatric intestinal failure is a complex and devastating condition defined as the inability of the intestine to absorb an adequate amount of fluid and nutrients to sustain life. The primary goal of intestinal failure treatment is to achieve enteral autonomy with a customized treatment plan. Although recent improvements in intestinal failure patient care have led to significant improvements in the morbidity and mortality rate, children with intestinal failure are at risk for multiple complications such as intestinal failure associated liver disease, recurrent septic episodes, central line complications, metabolic bone disease, impaired kidney function, and failure to thrive. In this article, we review the current literature on the etiology and factors affecting prognosis of pediatric IF.
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Affiliation(s)
- Annika Mutanen
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
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30
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Hawksworth JS, Desai CS, Khan KM, Kaufman SS, Yazigi N, Girlanda R, Kroemer A, Fishbein TM, Matsumoto CS. Visceral transplantation in patients with intestinal-failure associated liver disease: Evolving indications, graft selection, and outcomes. Am J Transplant 2018; 18:1312-1320. [PMID: 29498797 PMCID: PMC5992069 DOI: 10.1111/ajt.14715] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 12/11/2017] [Accepted: 02/04/2018] [Indexed: 01/25/2023]
Abstract
Intestinal failure (IF)-associated liver disease (IFALD) is widely recognized as a lethal complication of long-term parenteral nutrition. The pathophysiology of IFALD is poorly understood but appears to be multifactorial and related to the inflammatory state in the patient with IF. Visceral transplant for IFALD includes variants of intestine, liver, or combined liver-intestine allografts. Graft selection for an individual patient depends on the etiology of IF, abdominal and vascular anatomy, severity of IFALD, and potential for intestinal rehabilitation. The past decade has witnessed dramatic improvement in the management of IFALD, principally due to improved lipid emulsion formulations and the multidisciplinary care of the patient with IF. As the recognition and treatment of IFALD continue to improve, the requirement of liver-inclusive visceral grafts appears to be decreasing, representing a paradigm shift in the care of the patient with IF. This review highlights the current indications, graft selection, and outcomes of visceral transplantation for IFALD.
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Affiliation(s)
- Jason S. Hawksworth
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA,Walter Reed National Military Medical Center, Department of Surgery, Organ Transplant Service, Bethesda, MD USA
| | - Chirag S. Desai
- University of North Carolina, Department of Surgery, Division of Abdominal Transplant, Chapel Hill, NC USA
| | - Khalid M. Khan
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Stuart S. Kaufman
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Nada Yazigi
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Raffaele Girlanda
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Alexander Kroemer
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Thomas M. Fishbein
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Cal S. Matsumoto
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
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31
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Ladd MR, Martin LY, Werts A, Costello C, Sodhi CP, Fulton WB, March JC, Hackam DJ. The Development of Newborn Porcine Models for Evaluation of Tissue-Engineered Small Intestine. Tissue Eng Part C Methods 2018; 24:331-345. [PMID: 29638197 PMCID: PMC5998831 DOI: 10.1089/ten.tec.2018.0040] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 03/19/2018] [Indexed: 12/17/2022] Open
Abstract
Short bowel syndrome (SBS) is a major cause of morbidity and mortality in the pediatric population, for which treatment options are limited. To develop novel approaches for the treatment of SBS, we now focus on the development of a tissue-engineered intestine (also known as an "artificial intestine"), in which intestinal stem cells are cultured onto an absorbable bioscaffold, followed by implantation into the host. To enhance the translational potential of these preclinical studies, we have developed three clinically relevant models in neonatal piglets, which approximate the size of the human infant and were evaluated after implantation and establishment of intestinal continuity over the long term. The models included (1) a staged, multioperation approach; (2) a single operation with a de-functionalized loop of small intestine; and (3) a single operation with an intestinal bypass. The first model had complications related to multiple operations in a short time period, including surgical site infections and wound hernias. The second model avoided wound complications, but was associated with high ostomy output, local skin breakdown, and systemic dehydration with associated electrolyte imbalances. The third model was the most effective, although resulted in stoma prolapse. In summary, we have now developed and evaluated three operative methods for the long-term evaluation of the artificial intestine in the piglet, and conclude that a single operation with a de-functionalized loop of small intestine may be an optimal approach for evaluation over the long term.
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Affiliation(s)
- Mitchell R. Ladd
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura Y. Martin
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adam Werts
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cait Costello
- Department of Biomedical Engineering, Cornell University, Ithaca, New York
| | - Chhinder P. Sodhi
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - William B. Fulton
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John C. March
- Department of Biomedical Engineering, Cornell University, Ithaca, New York
| | - David J. Hackam
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Berman CM, Merritt RJ. Stoned-A Syndrome of D-Lactic Acidosis and Urolithiasis. Nutr Clin Pract 2018; 33:897-901. [DOI: 10.1002/ncp.10063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Casey M. Berman
- New York Presbyterian-Columbia University; New York New York USA
| | - Russell J. Merritt
- Children's Hospital Los Angeles; Keck School of Medicine; University of Southern California; Los Angeles California USA
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Meckmongkol TT, Costanzo C, Ciullo S, Prasad R, Arthur LG. Hidden morbidity of ethanol lock therapy. Pediatr Surg Int 2018; 34:71-74. [PMID: 29039051 DOI: 10.1007/s00383-017-4168-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2017] [Indexed: 11/30/2022]
Abstract
AIMS Long-term central venous catheters are essential in sustaining growth and development in patients with intestinal failure (IF). Several strategies have been developed to prevent and treat catheter-related blood stream infections (CRBSIs), including ethanol lock therapy. We sought to evaluate the efficacy of ethanol lock therapy in our IF population. METHOD This is a retrospective review of IF patients treated with ethanol lock therapy at a single institution from 2006 to 2013. We evaluated the number of catheter days, rate of CRBSI per 1000 catheter days, rate of central venous catheter (CVC) thrombosis, rate of CVC breakage, total number of CVC replacements, total number of hospital admissions, and total number days in the hospital. RESULT We identified 19 patients who underwent ethanol lock therapy for CRBSI. There was no difference in CRBSI rate prior to (5.6 per 1000 catheter days) and after (7 per 1000 catheter days) initiation of ethanol lock therapy. The mean rate of thrombosis increased from 0 to 3 per 1000 catheter days with ethanol lock therapy (p < 0.05). In addition, the CVC breakage rate increased from 0 to 13.7 per 1000 catheter days with ethanol lock therapy (p < 0.001). Hospital admissions and catheter-related ER visits increased following the initiation of ethanol lock therapy. CONCLUSIONS Contrary to other studies, there was no difference in CRBSI rate prior to and after initiation of ethanol lock therapy. Factors in the methodology of ethanol lock therapy may influence the effectiveness of infection prevention associated with ethanol lock therapy, as well as the rate of line breakage, line thrombosis, and the need for line replacement.
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Affiliation(s)
- Teerin T Meckmongkol
- Division of Pediatric Surgery, Department of Surgery, St. Christopher's Hospital for Children, 160 East Erie Avenue, Philadelphia, PA, 19134, USA.
| | - Caitlyn Costanzo
- Division of Pediatric Surgery, Department of Surgery, St. Christopher's Hospital for Children, 160 East Erie Avenue, Philadelphia, PA, 19134, USA
| | - Sean Ciullo
- Division of Pediatric Surgery, Department of Surgery, St. Christopher's Hospital for Children, 160 East Erie Avenue, Philadelphia, PA, 19134, USA
| | - Rajeev Prasad
- Division of Pediatric Surgery, Department of Surgery, St. Christopher's Hospital for Children, 160 East Erie Avenue, Philadelphia, PA, 19134, USA
| | - L Grier Arthur
- Division of Pediatric Surgery, Department of Surgery, St. Christopher's Hospital for Children, 160 East Erie Avenue, Philadelphia, PA, 19134, USA
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Martin LY, Ladd MR, Werts A, Sodhi CP, March JC, Hackam DJ. Tissue engineering for the treatment of short bowel syndrome in children. Pediatr Res 2018; 83:249-257. [PMID: 28937976 PMCID: PMC6002962 DOI: 10.1038/pr.2017.234] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 09/07/2017] [Indexed: 12/11/2022]
Abstract
Short bowel syndrome is a major cause of morbidity and mortality in children. Despite decades of experience in the management of short bowel syndrome, current therapy is primarily supportive. Definitive treatment often requires intestinal transplantation, which is associated with significant morbidity and mortality. In order to develop novel approaches to the treatment of short bowel syndrome, we and others have focused on the development of an artificial intestine, by placing intestinal stem cells on a bioscaffold that has an absorptive surface resembling native intestine, and taking advantage of neovascularization to develop a blood supply. This review will explore recent advances in biomaterials, vascularization, and progress toward development of a functional epithelium and mesenchymal niche, highlighting both success and ongoing challenges in the field.
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Affiliation(s)
- Laura Y. Martin
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Baltimore MD 21287
- Department of Surgery, Johns Hopkins University and Johns Hopkins children's Center, Baltimore MD 21287
| | - Mitchell R. Ladd
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Baltimore MD 21287
- Department of Surgery, Johns Hopkins University and Johns Hopkins children's Center, Baltimore MD 21287
| | - Adam Werts
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Baltimore MD 21287
- Department of Surgery, Johns Hopkins University and Johns Hopkins children's Center, Baltimore MD 21287
- Department of Molecular and Comparative Pathobiology, Johns Hopkins University and Johns Hopkins children's Center, Baltimore MD 21287
| | - Chhinder P. Sodhi
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Baltimore MD 21287
- Department of Surgery, Johns Hopkins University and Johns Hopkins children's Center, Baltimore MD 21287
| | - John C. March
- Department of Biomedical Engineering, Cornell University, Ithica, NY
| | - David J. Hackam
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Baltimore MD 21287
- Department of Surgery, Johns Hopkins University and Johns Hopkins children's Center, Baltimore MD 21287
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35
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Intestinal Rehabilitation Programs in the Management of Pediatric Intestinal Failure and Short Bowel Syndrome. J Pediatr Gastroenterol Nutr 2017; 65:588-596. [PMID: 28837507 DOI: 10.1097/mpg.0000000000001722] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Intestinal failure is a rare, debilitating condition that presents both acute and chronic medical management challenges. The condition is incompatible with life in the absence of the safe application of specialized and individualized medical therapy that includes surgery, medical equipment, nutritional products, and standard nursing care. Intestinal rehabilitation programs are best suited to provide such complex care with the goal of achieving enteral autonomy and oral feeding with or without intestinal transplantation. These programs almost all include pediatric surgeons, pediatric gastroenterologists, specialized nurses, and dietitians; many also include a variety of other medical and allied medical specialists. Intestinal rehabilitation programs provide integrated interdisciplinary care, more discussion of patient management by involved specialists, continuity of care through various treatment interventions, close follow-up of outpatients, improved patient and family education, earlier treatment of complications, and learning from the accumulated patient databases. Quality assurance and research collaboration among centers are also goals of many of these programs. The combined and coordinated talents and skills of multiple types of health care practitioners have the potential to ameliorate the impact of intestinal failure and improve health outcomes and quality of life.
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37
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Abstract
PURPOSE OF REVIEW To review the recent literature related to the impact of an intestinal rehabilitation program (IRP) on the management of intestinal failure in children. RECENT FINDINGS As publication of a systematic review of pediatric IRPs in 2013, there have been four publications further describing the impact of IRPs in children with intestinal failure. The results continue to support an improvement in survival and enteral autonomy, and a decrease in complications related to liver dysfunction, central venous catheters, and transplantation. SUMMARY Pediatric IRPs offer significant advantage to outcomes of children with intestinal failure. The literature is difficult to interpret because of methodological limitations. IRP collaboration is necessary to further advance the field.
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38
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So S, Patterson C, Gold A, Rogers A, Kosar C, de Silva N, Burghardt KM, Avitzur Y, Wales PW. Early neurodevelopmental outcomes of infants with intestinal failure. Early Hum Dev 2016; 101:11-6. [PMID: 27394169 DOI: 10.1016/j.earlhumdev.2016.05.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/10/2016] [Accepted: 05/10/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND The survival rate of infants and children with intestinal failure is increasing, necessitating a greater focus on their developmental trajectory. AIMS To evaluate neurodevelopmental outcomes in children with intestinal failure at 0-15months corrected age. STUDY DESIGN Analysis of clinical, demographic and developmental assessment results of 33 children followed in an intestinal rehabilitation program between 2011 and 2014. Outcome measures included: Prechtl's Assessment of General Movements, Movement Assessment of Infants, Alberta Infant Motor Scale and Mullen Scales of Early Learning. Clinical factors were correlated with poorer developmental outcomes at 12-15months corrected age. RESULTS Thirty-three infants (17 males), median gestational age 34weeks (interquartile range 29.5-36.0) with birth weight 1.98kg (interquartile range 1.17-2.50). Twenty-nine (88%) infants had abnormal General Movements. More than half had suspect or abnormal scores on the Alberta Infant Motor Scale and medium to high-risk scores for future neuromotor delay on the Movement Assessment of Infants. Delays were seen across all Mullen subscales, most notably in gross motor skills. Factors significantly associated with poorer outcomes at 12-15months included: prematurity, low birth weight, central nervous system co-morbidity, longer neonatal intensive care admission, necrotizing enterocolitis diagnosis, number of operations and conjugated hyperbilirubinemia. CONCLUSION Multiple risk factors contribute to early developmental delay in children with intestinal failure, highlighting the importance of close developmental follow-up.
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Affiliation(s)
- Stephanie So
- Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Catherine Patterson
- Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anna Gold
- Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alaine Rogers
- Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christina Kosar
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nicole de Silva
- Department of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Karolina Maria Burghardt
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
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Kawano T, Kaji T, Onishi S, Yamada K, Yamada W, Nakame K, Mukai M, Ieiri S. Efficacy of ethanol locks to reduce the incidence of catheter-related bloodstream infections for home parenteral nutrition pediatric patients: comparison of therapeutic treatment with prophylactic treatment. Pediatr Surg Int 2016; 32:863-7. [PMID: 27461433 DOI: 10.1007/s00383-016-3933-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE Children with intestinal failure (IF) requiring central venous catheters (CVCs) often experience frequent catheter-related bloodstream infections (CRBSIs), which is a serious and life-threatening complication. To reduce the incidence of CRBSI, prophylactic ethanol lock therapy (ELT) was initiated. METHODS Patients with IF received home parenteral nutrition via a silicone tunneled CVC. All of them had received therapeutic ELT from January 2009 (first period) and prophylactic ELT from December 2012 (second period). Prophylactic ELT refers to ethanol lock for 2 h during the monthly hospital visit. We compared the CRBSI rate and number of CVC replacements between both periods. RESULTS Four patients received 19 CVCs for a total of 5623 catheter days. In the first period, there were 12 CRBSIs in 1823 catheter days (rate 6.77 per 1000 catheter days). In the second period, there were 9 CRBSIs in 3800 catheter days (rate 3.13 per 1000 catheter days). Overall, the rate of CVC replacement decreased from 4.92 to 1.72 per 1000 catheter days (p = 0.04). No adverse reactions were experienced during ethanol instillation. CONCLUSION Monthly prophylactic ELT for IF patients is considered to be a safe and effective modality for reducing the replacement of CVCs due to CRBSIs.
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Affiliation(s)
- Takafumi Kawano
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima City, 890-8520, Japan
| | - Tatsuru Kaji
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima City, 890-8520, Japan
| | - Shun Onishi
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima City, 890-8520, Japan
| | - Koji Yamada
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima City, 890-8520, Japan
| | - Waka Yamada
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima City, 890-8520, Japan
| | - Kazuhiko Nakame
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima City, 890-8520, Japan
| | - Motoi Mukai
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima City, 890-8520, Japan
| | - Satoshi Ieiri
- Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima City, 890-8520, Japan.
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Change of Outcomes in Pediatric Intestinal Failure: Use of Time-Series Analysis to Assess the Evolution of an Intestinal Rehabilitation Program. J Am Coll Surg 2016; 222:1180-1188.e3. [DOI: 10.1016/j.jamcollsurg.2016.03.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 03/02/2016] [Accepted: 03/02/2016] [Indexed: 11/17/2022]
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Abstract
Cholestasis in preterm infants has a multifactorial etiology. Risk factors include degree of prematurity, lack of enteral feeding, intestinal injury, prolonged use of parenteral nutrition (PN), and sepsis. Soy-based parenteral lipid emulsions have been implicated in the pathophysiology of PN-associated liver injury. Inflammation plays an important role. Medical therapies are used; however, their effects have not consistently proven effective. Evaluation of cholestasis involves laboratory work; direct bilirubin levels are used for diagnosis and trending. Adverse outcomes include risk for hepatobiliary dysfunction, irreversible liver failure, and death. Early enteral feedings as tolerated is the best way to prevent and manage cholestasis.
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Affiliation(s)
- Katie Satrom
- Division of Neonatology, Department of Pediatrics, University of Minnesota, 2450 Riverside Avenue, 6th Floor, East Building, Delivery Code: 8952A, Minneapolis, MN 55454, USA.
| | - Glenn Gourley
- Pediatric Gastroenterology, Department of Pediatrics, University of Minnesota, 2450 Riverside Avenue, 6th Floor, East Building, 8952A, Minneapolis, MN 55454, USA
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Cost of ambulatory care for the pediatric intestinal failure patient: One-year follow-up after primary discharge. J Pediatr Surg 2016; 51:798-803. [PMID: 26932248 DOI: 10.1016/j.jpedsurg.2016.02.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 02/07/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Survival of children with intestinal failure has improved over the last decade, resulting in increased health care expenditures. Our objective was to determine outpatient costs for the first year after primary discharge. METHODS A retrospective analysis was performed in pediatric intestinal failure (PIF) patients between 2010 and 2012. Patients were stratified into 3 groups (1=enteral support with no devices [7 patients], 2=enteral support with devices (gastrostomy and/or ostomy) [19 patients], 3=home parenteral nutrition (HPN) [22 patients]). Data abstraction included clinical characteristics and costs related to medication, enteral/parenteral nutrition, and supplies were calculated. Data were analyzed using one way ANOVA. RESULTS Forty-eight patients (mean age 7.6months; 31 males [65%]) were studied. See attached table for results. HPN patients had significantly more ambulatory visits (p<0.0001), number of admitted days (p=0.01), and productive days lost (p<0.0001). Total cost of care was significantly higher for HPN patients (mean=$320,368.50, p<0.0001) when compared to other groups. Costs covered by the health care system were significantly higher for patients on HPN (mean=$316,101.56, p<0.0001). CONCLUSION The outpatient expenditures to care for PIF patients in the first year post primary discharge are significant. Our single payer health care system supports the majority of costs, but families are also incurring expenses related to travel and lost productivity. Children on HPN have more visits to hospital, but have access to more funding options. Children solely on gastrostomy or stoma therapy, however, have a significantly greater personal financial burden.
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Kosar C, De Silva N, Avitzur Y, Steinberg K, Courtney-Martin G, Chambers K, Fitzgerald K, Harvey E, Wales PW. Prevalence of renal abnormality in pediatric intestinal failure. J Pediatr Surg 2016; 51:794-7. [PMID: 26921935 DOI: 10.1016/j.jpedsurg.2016.02.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 02/07/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Outcomes of children with intestinal failure have improved over the last decade. However, with improved survival, other co-morbidities have become evident. The goal of our study was to evaluate the presence of renal nephrocalcinosis or increased echogenicity in a cohort of patients with pediatric intestinal failure (PIF). METHODS A cross-sectional prevalence design was performed in PIF patients followed by our intestinal rehabilitation program between 2013 and 2014. Renal function was evaluated using serum creatinine and urea, urine oxalate, creatinine, calcium, and calcium/creatinine ratios. Renal ultrasounds were performed to assess for echogenicity. Data was collected on intestinal failure related factors and nutritional intake. Data was analyzed using medians and Mann-Whitney U or proportions and chi square. RESULTS Fifty-four patients (median age 48months; 33 males (61%) were studied. Twenty-two patients (41%) had increased echogenicity or nephrocalcinosis on ultrasound. There were no differences in serum Creatinine or urea, but patients with nephrocalcinosis had statistically different calcium:creatinine ratio (1.69 vs 0.74; p=0.043), urine oxalate (108 vs 219; p=0.06), and serum phosphate (1.55 vs 1.75; p=0.044). Patients with echogenicity had a shorter colonic remnant (25cm vs 31cm; p=0.01), a history of longer PN exposure (928 vs 483days; p=0.05), percent PN calories (37 vs 0; p=0.05), PN h/day (13 vs 0; p=0.05), but no difference in PN Ca/phosphate/magnesium content (mmol/kg). CONCLUSION A large proportion of PIF patients have increased echogenicity/nephrocalcinosis on ultrasound that is associated with prolonged PN exposure. This has implications for long-term management. Regular surveillance is required, and further study is warranted to determine specific risk factors.
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Affiliation(s)
- Christina Kosar
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada
| | - Nicole De Silva
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Canada
| | - Karen Steinberg
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada
| | - Glenda Courtney-Martin
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada
| | - Kathryn Chambers
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada
| | - Kevin Fitzgerald
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada
| | - Elizabeth Harvey
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada; Division of Nephrology, The Hospital for Sick Children, University of Toronto, Canada
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Canada; Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Canada.
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Contreras-Ramírez MM, Giraldo-Villa A, Henao-Roldan C, Martínez-Volkmar MI, Valencia-Quintero AF, Montoya-Delgado DC, Ruiz-Navas P, García-Loboguerrero F. Progression in children with intestinal failure at a referral hospital in Medellín, Colombia. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2016; 81:21-7. [PMID: 26832759 DOI: 10.1016/j.rgmx.2015.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 12/03/2015] [Accepted: 12/10/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients with intestinal failure are unable to maintain adequate nutrition and hydration due to a reduction in the functional area of the intestine. Different strategies have the potential to benefit these patients by promoting intestinal autonomy, enhancing quality of life, and increasing survival. AIMS To describe the clinical characteristics of children with intestinal failure and disease progression in terms of intestinal autonomy and survival. MATERIALS AND METHODS A retrospective study was conducted, evaluating 33 pediatric patients with intestinal failure that were hospitalized within the time frame of December 2005 and December 2013 at a tertiary care referral center. Patient characteristics were described upon hospital admission, estimating the probability of achieving intestinal autonomy and calculating the survival rate. RESULTS Patient median age upon hospital admission was 2 months (interquartile range [IQR]: 1-4 months) and 54.5% of the patients were boys. Intestinal autonomy was achieved in 69.7% of the cases with a median time of 148 days (IQR: 63 - 431 days), which decreased to 63 days in patients with a spared ileocecal valve. Survival was 91% during a median follow-up of 281 days (IQR: 161 - 772 days). CONCLUSIONS Medical management of patients with intestinal failure is complex. Nutritional support and continuous monitoring are of the utmost importance and long-term morbidity and mortality depends on the early recognition and management of the associated complications.
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Affiliation(s)
- M M Contreras-Ramírez
- Grupo de Soporte Nutricional Pediátrico, Hospital Pablo Tobón Uribe, Medellín, Colombia.
| | - A Giraldo-Villa
- Epidemiología, Grupo de Soporte Nutricional Pediátrico, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - C Henao-Roldan
- Nutrición infantil, Grupo de Soporte Nutricional Pediátrico, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - M I Martínez-Volkmar
- Cuidado al niño en estado crítico de salud, Grupo de Soporte Nutricional Pediátrico, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - A F Valencia-Quintero
- Grupo de Soporte Nutricional Pediátrico, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - D C Montoya-Delgado
- Grupo de Soporte Nutricional Pediátrico, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - P Ruiz-Navas
- Grupo de Soporte Nutricional Pediátrico, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - F García-Loboguerrero
- Cuidado intensivo, Grupo de Soporte Nutricional Pediátrico, Hospital Pablo Tobón Uribe, Medellín, Colombia
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Normal Growth and Essential Fatty Acid Status in Children With Intestinal Failure on Lipid Limitation. J Pediatr Gastroenterol Nutr 2016; 62:335-40. [PMID: 26301616 DOI: 10.1097/mpg.0000000000000948] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Lipid limitation, that is, ≤1 g · kg⁻¹ · day⁻¹ of soy oil lipid emulsion (SOLE), has been suggested as a method to reduce the risk of intestinal failure (IF)-associated liver disease (IFALD). There are limited data as to the effects of this strategy on growth and essential fatty acid (EFA) status. The aim of the study was to assess growth, prevalence of cholestasis, and EFA deficiency in patients with IF who were provided daily SOLE at a dose ≤1 g · kg⁻¹ · day⁻¹. METHODS Medical records were retrospectively reviewed from 9 patients age 16 months to 8 years who had IF requiring parenteral nutrition support for >12 months. Parenteral nutrition supplied a mean of 53% of total energy (range 24%-86%). RESULTS Mean SOLE dose was 0.61 g · kg⁻¹ · day⁻¹ (range 0.4-0.81 g · kg⁻¹ · day⁻¹). After 1 month of lipid limitation between 2011 and 2014, no patient developed IFALD as defined by a direct bilirubin >2 mg/dL. The median direct bilirubin was 0.1 mg/dL (range 0.075-0.85 mg/dL). No patient developed EFA deficiency as defined by a triene-to-tetraene ratio >0.2 (median 0.026, range 0.017-0.076). Height z scores increased from mean of -2.568 (range -10.8 to 0.878) to -0.484 (range -3.546 to 0.822). Weight z scores increased from mean of -1.412 (range -5.871 to 0.906) to -0.595 (range -2.178 to 0.926). CONCLUSIONS In this case series, lipid limitation allowed normal growth while preventing the development of cholestasis and EFA deficiency.
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Recent Advances in the Management of Pediatric Short Bowel Syndrome: An Integrative Review of the Literature. CURRENT SURGERY REPORTS 2016. [DOI: 10.1007/s40137-015-0126-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Contreras-Ramírez M, Giraldo-Villa A, Henao-Roldan C, Martínez-Volkmar M, Valencia-Quintero A, Montoya-Delgado D, Ruiz-Navas P, García-Loboguerrero F. Progression in children with intestinal failure at a referral hospital in Medellín, Colombia. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2016. [DOI: 10.1016/j.rgmxen.2016.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Outcomes of Patients with Intestinal Failure after the Development and Implementation of a Multidisciplinary Team. Can J Gastroenterol Hepatol 2016; 2016:9132134. [PMID: 27446876 PMCID: PMC4904660 DOI: 10.1155/2016/9132134] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 05/09/2015] [Indexed: 11/17/2022] Open
Abstract
Aim. A multidisciplinary team was created in our institution to manage patients with intestinal failure (INFANT: INtestinal Failure Advanced Nutrition Team). We aimed to evaluate the impact of the implementation of the team on the outcomes of this patient population. Methods. Retrospective chart review of patients with intestinal failure over a 6-year period was performed. Outcomes of patients followed up by INFANT (2010-2012) were compared to a historical cohort (2007-2009). Results. Twenty-eight patients with intestinal failure were followed up by INFANT while the historical cohort was formed by 27 patients. There was no difference between the groups regarding remaining length of small and large bowel, presence of ICV, or number of infants who reached full enteral feeds. Patients followed up by INFANT took longer to attain full enteral feeds and had longer duration of PN, probably reflecting more complex cases. Overall mortality (14.8%/7.1%) was lower than other centers, probably illustrating our population of "early" intestinal failure patients. Conclusions. Our data demonstrates that the creation and implementation of a multidisciplinary program in a tertiary center without an intestinal and liver transplant program can lead to improvement in many aspects of their care.
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Sparks EA, Khan FA, Fisher JG, Fullerton BS, Hall A, Raphael BP, Duggan C, Modi BP, Jaksic T. Necrotizing enterocolitis is associated with earlier achievement of enteral autonomy in children with short bowel syndrome. J Pediatr Surg 2016; 51:92-5. [PMID: 26700691 PMCID: PMC4878438 DOI: 10.1016/j.jpedsurg.2015.10.023] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 10/07/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Necrotizing enterocolitis (NEC) remains one of the most common underlying diagnoses of short bowel syndrome (SBS) in children. The relationship between the etiology of SBS and ultimate enteral autonomy has not been well studied. This investigation sought to evaluate the rate of achievement of enteral autonomy in SBS patients with and without NEC. METHODS Following IRB approval, 109 patients (2002-2014) at a multidisciplinary intestinal rehabilitation program were reviewed. The primary outcome evaluated was achievement of enteral autonomy (i.e. fully weaning from parenteral nutrition). Patient demographics, primary diagnosis, residual small bowel length, percent expected small bowel length, median serum citrulline level, number of abdominal operations, status of the ileocecal valve (ICV), presence of ileostomy, liver function tests, and treatment for bacterial overgrowth were recorded for each patient. RESULTS Median age at PN onset was 0 weeks [IQR 0-0]. Median residual small bowel length was 33.5 cm [IQR 20-70]. NEC was present in 37 of 109 (33.9%) of patients. 45 patients (41%) achieved enteral autonomy after a median PN duration of 15.3 [IQR 7.2-38.4]months. Overall, 64.9% of patients with NEC achieved enteral autonomy compared to 29.2% of patients with a different primary diagnosis (p=0.001, Fig. 1). Patients with NEC remained more likely than those without NEC to achieve enteral autonomy after two (45.5% vs. 12.0%) and four (35.7% vs. 6.3%) years on PN (Fig. 1). Logistic regression analysis demonstrated the following parameters as independent predictors of enteral autonomy: diagnosis of NEC (p<0.002), median serum citrulline level (p<0.02), absence of a jejunostomy or ileostomy (p=0.013), and percent expected small bowel length (p=0.005). CONCLUSIONS Children with SBS because of NEC have a significantly higher likelihood of fully weaning from parenteral nutrition compared to children with other causes of SBS. Additionally, patients with NEC may attain enteral autonomy even after long durations of parenteral support.
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Affiliation(s)
- Eric A. Sparks
- Center for Advanced Intestinal Rehabilitation, Boston Children’s Hospital, Boston, MA,Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Faraz A. Khan
- Center for Advanced Intestinal Rehabilitation, Boston Children’s Hospital, Boston, MA,Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Jeremy G. Fisher
- Center for Advanced Intestinal Rehabilitation, Boston Children’s Hospital, Boston, MA,Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Brenna S. Fullerton
- Center for Advanced Intestinal Rehabilitation, Boston Children’s Hospital, Boston, MA,Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Amber Hall
- Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Bram P. Raphael
- Center for Advanced Intestinal Rehabilitation, Boston Children’s Hospital, Boston, MA,Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston MA
| | - Christopher Duggan
- Center for Advanced Intestinal Rehabilitation, Boston Children’s Hospital, Boston, MA,Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston MA
| | - Biren P. Modi
- Center for Advanced Intestinal Rehabilitation, Boston Children’s Hospital, Boston, MA,Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Tom Jaksic
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA, USA; Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Intestinal Rehabilitation. CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0112-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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