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Maklad M, Mazariegos G, Ganoza A. Pediatric intestine and multivisceral transplant. Curr Opin Organ Transplant 2023; 28:316-325. [PMID: 37418582 DOI: 10.1097/mot.0000000000001082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2023]
Abstract
PURPOSE OF REVIEW Intestinal and multivisceral transplantation (ITx, MVTx) is the cornerstone in treatment of irreversible intestinal failure (IF) and complications related to parenteral nutrition. This review aims to highlight the unique aspects of the subject in pediatrics. RECENT FINDINGS Etiology of intestinal failure (IF) in children shares some similarity with adults but several unique considerations when being evaluated for transplantation will be discussed. Owing to significant advancement in IF management and home parenteral nutrition (PN), indication criteria for pediatric transplantation continues to be updated. Outcomes have continued to improve with current long-term patient and graft survival in multicenter registry reports reported at 66.1% and 48.8% at 5 years, respectively. Pediatric specific surgical challenges such abdominal closure, post transplantation outcomes, and quality of life are discussed in this review. SUMMARY ITx and MVTx remain lifesaving treatment for many children with IF. However long-term graft function is still a major challenge.
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Affiliation(s)
- Mohamed Maklad
- Hillman Center for Pediatric Transplantation, Thomas E. Starzl Transplantation Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Factors influencing enteral autonomy after autologous gastrointestinal reconstructive surgery: A two-centre UK perspective. J Pediatr Surg 2023; 58:223-227. [PMID: 36404184 DOI: 10.1016/j.jpedsurg.2022.10.030] [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] [Received: 10/09/2022] [Accepted: 10/11/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIMS The implementation of multidisciplinary care and improvements in parenteral nutrition (PN) in patients with short bowel syndrome (SBS) have led to better outcomes and higher survivability. Autologous gastrointestinal reconstructive (AGIR) surgery can reduce the duration on PN and lead to earlier enteral autonomy (EA). Our aim was to investigate the effect of SBS aetiology and other predictors on the achievement of enteral autonomy following AGIR surgery. METHODS Retrospective review of all patients undergoing AGIR surgery in two tertiary paediatric surgical units, between 2010 and 2021. Continuous data is presented as median (range). RESULTS Twenty-seven patients underwent 29 AGIR procedures (20 serial transverse enteroplasties (STEP), 9 longitudinal intestinal lengthening and tailoring (LILT)) at an age of 6.6 months (1.5 - 104.5). EA rate was 44% at 13.6 months after surgery (1 - 32.8). AGIR procedures achieved an increase in small bowel length of 70% (pre-operative 46.5 vs 77 cm, p = 0.003). No difference was found between STEP and LILT (p = 0.84). Percentage of expected small bowel length (based on the child's weight) was a strong predictor of EA (bowel length >15% - EA 80% vs bowel length ≤15% - EA 17%, p = 0.008). A diagnosis of gastroschisis showed a negative non-significant correlation with the ability to achieve EA (25% vs 60%, p = 0.12). Overall survival rate was 96%. CONCLUSION AGIR surgery is an important tool in the multidisciplinary management of children with SBS. Percentage of expected small length and aetiology of SBS are likely predictors of achievement of EA in patients undergoing AGIR surgery. LEVEL OF EVIDENCE IV: Retrospective Case-Series.
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Improved Mortality of Patients with Gastroschisis: A Historical Literature Review of Advances in Surgery and Critical Care from 1960-2020. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9101504. [PMID: 36291440 PMCID: PMC9600704 DOI: 10.3390/children9101504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/22/2022] [Accepted: 09/30/2022] [Indexed: 12/02/2022]
Abstract
The improved survival of gastroschisis patients is a notable pediatric success story. Over the past 60 years, gastroschisis evolved from uniformly fatal to a treatable condition with over 95% survival. We explored the historical effect of four specific clinical innovations—mechanical ventilation, preformed silos, parenteral nutrition, and pulmonary surfactant—that contributed to mortality decline among gastroschisis infants. A literature review was performed to extract mortality rates from six decades of contemporary literature from 1960 to 2020. A total of 2417 publications were screened, and 162 published studies (98,090 patients with gastroschisis) were included. Mortality decreased over time and has largely been <10% since 1993. Mechanical ventilation was introduced in 1965, preformed silo implementation in 1967, parenteral nutrition in 1968, and pulmonary surfactant therapy in 1980. Gastroschisis infants now carry a mortality rate of <5% as a result of these interventions. Other factors, such as timing of delivery, complex gastroschisis, and management in low- and middle-income countries were also explored in relation to gastroschisis mortality. Overall, improved gastroschisis outcomes serve as an illustration of the benefits of clinical advances and multidisciplinary care, leading to a drastic decline in infant mortality among these patients.
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Abstract
Due to recent advances, the mortality due to short bowel syndrome (SBS) has significantly decreased, but the morbidities are still high. Morbidities arising specifically due to dysmotility in SBS include feeding intolerance, prolonged dependence on parenteral nutrition, and associated complications such as intestinal failure associated liver disease, and bloodstream infections. The understanding of the pathogenesis of dysmotility in SBS has improved vastly. However, the tools to diagnose dysmotility in SBS in infants are restrictive, and the medical therapies to treat dysmotility are limited. Surgical techniques available for the treatment after failure of conservative management of dysmotility offer hope but carry their associated risks. The evidence to support either the medical therapies or the surgical techniques to treat dysmotility in SBS in children is scarce and weak. Development of newer therapies and efforts to build evidence to support currently available treatments in treating dysmotility in SBS is needed.
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Affiliation(s)
- Muralidhar H Premkumar
- Associate Professor, Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin, Suite 6104, Houston, TX 77030, USA.
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Merritt RJ. Gastroschisis: Progress and Challenges. J Pediatr 2022; 243:8-11. [PMID: 34958830 DOI: 10.1016/j.jpeds.2021.12.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/21/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Russell J Merritt
- Department of Pediatrics, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California.
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Joharifard S, Trudeau MO, Miyata S, Malo J, Bouchard S, Beaunoyer M, Brocks R, Lemoine C, Villeneuve A. Implementing a standardized gastroschisis protocol significantly increases the rate of primary sutureless closure without compromising closure success or early clinical outcomes. J Pediatr Surg 2022; 57:12-17. [PMID: 34654548 DOI: 10.1016/j.jpedsurg.2021.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 09/08/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Standardized protocols have been shown to improve outcomes in several pediatric surgical conditions. We implemented a multi-disciplinary gastroschisis practice bundle at our institution in 2013. We sought to evaluate its impact on closure type and early clinical outcomes. METHODS We performed a retrospective review of uncomplicated gastroschisis patients treated at our institution between 2008-2019. Patients were divided into two groups: pre- and post-protocol implementation. Multivariate logistic regression was used to compare closure location, method, and success. RESULTS Neonates (pre-implementation n = 53, post-implementation n = 43) were similar across baseline variables. Successful immediate closure rates were comparable (75.5% vs. 72.1%, p = 0.71). The proportion of bedside closures increased significantly after protocol implementation (35.3% vs. 95.4%, p < 0.01), as did the proportion of sutureless closures (32.5% vs. 71.0%, p < 0.01). Median postoperative mechanical ventilation decreased significantly (4 days IQR [3, 5] vs. 2 days IQR [1, 3], p < 0.01). Postoperative complications and duration of parenteral nutrition were equivalent. After controlling for potential confounding, infants in the post-implementation group had a 44.0 times higher odds of undergoing bedside closure (95% CI: 9.0, 215.2, p < 0.01) and a 7.7 times higher odds of undergoing sutureless closure (95% CI: 2.3, 25.1, p < 0.01). CONCLUSIONS Implementing a standardized gastroschisis protocol significantly increased the proportion of immediate bedside sutureless closures and decreased the duration of mechanical ventilation, without increasing postoperative complications. Level of Evidence III Type of Study Retrospective comparative study.
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Affiliation(s)
- Shahrzad Joharifard
- The University of British Columbia, Department of Surgery, Vancouver, British Columbia, Canada V6H3V4.
| | - Maeve O'Neill Trudeau
- Division of Pediatric Surgery, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Shin Miyata
- Division of Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, Saint Louis University, St. Louis, MO, USA
| | - Josianne Malo
- Department of Pharmacy, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Sarah Bouchard
- Division of Pediatric Surgery, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Mona Beaunoyer
- Division of Pediatric Surgery, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Rebecca Brocks
- Division of Pediatric Surgery, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Caroline Lemoine
- Division of Transplant Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Andréanne Villeneuve
- Division of Neonatology, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, QC, Canada
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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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Sukhotnik I, Ben-Shahar Y, Pollak Y, Cohen S, Moran-Lev H, Koppelmann T, Gorenberg M. Intestinal dysmotility after bowel resection in rats is associated with decreased ghrelin and vimentin expression and loss of intestinal cells of Cajal. Am J Physiol Gastrointest Liver Physiol 2021; 320:G283-G294. [PMID: 33325807 PMCID: PMC8609566 DOI: 10.1152/ajpgi.00223.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
This study provides novel insight into the mechanisms of intestinal dysmotility following massive small bowel resection. We show that 2 wk after bowel resection in rats, impaired intestinal motility was associated with loss of interstitial cells of Cajal (ICC; downregulation of transmembrane member 16A (TMEM16A) and c-kit expression) as well as with decreased vimentin, desmin, and ghrelin levels. Impaired intestinal motility led to a decrease in final body weight, suggesting less effective nutrient absorption. The purpose of this study was to evaluate the mechanisms of intestinal motility in a rat model of short bowel syndrome (SBS). Rats were divided into three groups: Sham rats underwent bowel transection; SBS-NSI rats underwent a 75% bowel resection and presented with normal intestinal size (NSI) at euthanasia and hypermotility patterns; SBS-DYS showed dysmotile (DYS) enlarged intestine and inhibited motility patterns. Animals were euthanized after 2 wk. Illumina's digital gene expression (DGE) analysis was used to determine the intestinal motility-related gene expression profiling in mucosal samples. Intestinal motility-related and ICC genes and protein expression in intestinal muscle layer were determined using real-time PCR, Western blotting, and immunohistochemistry. Gastrointestinal tract motility was studied by microcomputer tomography. From 10 Ca2+ signaling pathway-related genes, six genes in jejunum and seven genes in ileum were downregulated in SBS vs. Sham animals. Downregulation of TMEM16A mRNA and protein was confirmed by real-time PCR. Rapid intestinal transit time in SBS-NSI rats correlated with a mild decrease in TMEM16A, c-kit, and vimentin mRNA and protein expression (vs/. Sham animals). SBS-DYS rats demonstrated enlarged intestinal loops and delayed small intestinal emptying (on imaging studies) that were correlated with marked downregulation in TMEM16A, c-kit, vimentin, and ghrelin mRNA and protein levels compared with the other two groups. In conclusion, 2 wk following massive bowel resection in rats, impaired intestinal motility was associated with decreased vimentin and ghrelin gene and protein levels as well as loss of ICC (c-kit and TMEM16A).NEW & NOTEWORTHY This study provides novel insight into the mechanisms of intestinal dysmotility following massive small bowel resection. We show that 2 weeks after bowel resection in rats, impaired intestinal motility was associated with loss of interstitial cells of Cajal (downregulation of TMEM 16A, and c-kit expression) as well as with decreased vimentin, desmin, and ghrelin levels. Impaired intestinal motility led to decrease in final body weight, suggesting less effective nutrient absorption.
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Affiliation(s)
- Igor Sukhotnik
- 1Laboratory of Intestinal Adaptation and Recovery, Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,3Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Ben-Shahar
- 1Laboratory of Intestinal Adaptation and Recovery, Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,4The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Yulia Pollak
- 1Laboratory of Intestinal Adaptation and Recovery, Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shlomi Cohen
- 2Pediatric Gastroenterology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,3Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadar Moran-Lev
- 2Pediatric Gastroenterology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel,3Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Koppelmann
- 1Laboratory of Intestinal Adaptation and Recovery, Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Migel Gorenberg
- 4The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Cisapride Use in Pediatric Patients With Intestinal Failure and Its Impact on Progression of Enteral Nutrition. J Pediatr Gastroenterol Nutr 2021; 72:43-48. [PMID: 32740525 DOI: 10.1097/mpg.0000000000002868] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Gastrointestinal dysmotility is common in patients with pediatric intestinal failure (PIF), leading to delays in advancement of enteral nutrition (EN). Few studies have been published regarding the safety and efficacy of cisapride for improvement of enteral tolerance and ability to wean parenteral nutrition. Our objective was to describe a single center experience on the use of cisapride in patients with PIF. METHODS Retrospective chart review of patients was performed. Demographic, intestinal anatomy, and outcome data were collected. Percentage of EN before initiation of cisapride, progression of EN at 3 and 6 months, and ability to wean parenteral nutrition after initiation of cisapride were calculated. RESULTS Prokinetics were used in 61 of 106 patients (56.6%); 29 of 60 patients (48.3%) failed to progress EN on other prokinetics and started on cisapride. Before cisapride the progress of EN plateaued for a mean of 42.3 (standard deviation [SD] 60.2) days. The rate of feed progression was 0.14% (SD 0.19)/day pre-cisapride and 0.69%/day (SD 0.31) after cisapride initiation (P < 0.001). Percentage of EN improved significantly from baseline to 3 months postinitiation (23.9% vs 79.4%, respectively; P < 0.001). Electrocardiogram was performed on initiation of cisapride and after every dose change. Medication was discontinued in 2 of 29 (6.8%). CONCLUSION This retrospective study suggests that cisapride may be beneficial in PIF patients who fail to progress EN on first line prokinetics. The most significant period of improvement occurs within 3 months of cisapride initiation. Cardiac side effects in our cohort were lower than previously reported; however, cardiac monitoring is still recommended.
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Rybak A, Sethuraman A, Nikaki K, Koeglmeier J, Lindley K, Borrelli O. Gastroesophageal Reflux Disease and Foregut Dysmotility in Children with Intestinal Failure. Nutrients 2020; 12:nu12113536. [PMID: 33217928 PMCID: PMC7698758 DOI: 10.3390/nu12113536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/09/2020] [Accepted: 11/12/2020] [Indexed: 12/16/2022] Open
Abstract
Gastrointestinal dysmotility is a common problem in a subgroup of children with intestinal failure (IF), including short bowel syndrome (SBS) and pediatric intestinal pseudo-obstruction (PIPO). It contributes significantly to the increased morbidity and decreased quality of life in this patient population. Impaired gastrointestinal (GI) motility in IF arises from either loss of GI function due to the primary disorder (e.g., neuropathic or myopathic disorder in the PIPO syndrome) and/or a critical reduction in gut mass. Abnormalities of the anatomy, enteric hormone secretion and neural supply in IF can result in rapid transit, ineffective antegrade peristalsis, delayed gastric emptying or gastroesophageal reflux. Understanding the underlying pathophysiologic mechanism(s) of the enteric dysmotility in IF helps us to plan an appropriate diagnostic workup and apply individually tailored nutritional and pharmacological management, which might ultimately lead to an overall improvement in the quality of life and increase in enteral tolerance. In this review, we have focused on the pathogenesis of GI dysmotility in children with IF, as well as the management and treatment options.
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Affiliation(s)
- Anna Rybak
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
- Correspondence:
| | - Aruna Sethuraman
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
| | - Kornilia Nikaki
- Wingate Institute of Neurogastroenterology, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, 26 Ashfield Street, Whitechapel, London E1 2AJ, UK;
| | - Jutta Koeglmeier
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
| | - Keith Lindley
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
| | - Osvaldo Borrelli
- Department of Gastroenterology, the Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK; (A.S.); (J.K.); (K.L.); (O.B.)
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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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Lap CCMM, Pistorius LR, Mulder EJH, Aliasi M, Kramer WLM, Bilardo CM, Cohen‐Overbeek TE, Pajkrt E, Tibboel D, Wijnen RMH, Visser GHA, Manten GTR. Ultrasound markers for prediction of complex gastroschisis and adverse outcome: longitudinal prospective nationwide cohort study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:776-785. [PMID: 31613023 PMCID: PMC7318303 DOI: 10.1002/uog.21888] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To identify antenatal ultrasound markers that can differentiate between simple and complex gastroschisis and assess their predictive value. METHODS This was a prospective nationwide study of pregnancies with isolated fetal gastroschisis that underwent serial longitudinal ultrasound examination at regular specified intervals between 20 and 37 weeks' gestation. The primary outcome was simple or complex (i.e. involving bowel atresia, volvulus, perforation or necrosis) gastroschisis at birth. Fetal biometry (abdominal circumference and estimated fetal weight), the occurrence of polyhydramnios, intra- and extra-abdominal bowel diameters and the pulsatility index (PI) of the superior mesenteric artery (SMA) were assessed. Linear mixed modeling was used to compare the individual trajectories of cases with simple and those with complex gastroschisis, and logistic regression analysis was used to estimate the strength of association between the ultrasound parameters and outcome. RESULTS Of 104 pregnancies with isolated fetal gastroschisis included, four ended in intrauterine death. Eighty-one (81%) liveborn infants with simple and 19 (19%) with complex gastroschisis were included in the analysis. We found no relationship between fetal biometric variables and complex gastroschisis. The SMA-PI was significantly lower in fetuses with gastroschisis than in healthy controls, but did not differentiate between simple and complex gastroschisis. Both intra- and extra-abdominal bowel diameters were larger in cases with complex, compared to those with simple, gastroschisis (P < 0.001 and P < 0.005, respectively). The presence of intra-abdominal bowel diameter ≥ 97.7th percentile on at least three occasions, not necessarily on successive examinations, was associated with an increased risk of the fetus having complex gastroschisis (relative risk, 1.56 (95% CI, 1.02-2.10); P = 0.006; positive predictive value, 50.0%; negative predictive value, 81.4%). CONCLUSIONS This large prospective longitudinal study found that intra-abdominal bowel dilatation when present repeatedly during fetal development can differentiate between simple and complex gastroschisis; however, the positive predictive value is low, and therefore the clinical usefulness of this marker is limited. © 2019 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C. C. M. M. Lap
- Department of Obstetrics, Division Woman and BabyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - L. R. Pistorius
- Department of Obstetrics and GynecologyUniversity of StellenboschStellenboschSouth Africa
| | - E. J. H. Mulder
- Department of Obstetrics, Division Woman and BabyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - M. Aliasi
- Department of Obstetrics, Division Woman and BabyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - W. L. M. Kramer
- Department of Pediatric SurgeryUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - C. M. Bilardo
- Department of Obstetrics and GynecologyAmsterdam University Medical Centers, University of Amsterdam, Amsterdam Reproduction and Development Research InstituteAmsterdamThe Netherlands
- Department of Obstetrics and Gynaecology, University Medical Centre GroningenUniversity of GroningenGroningenThe Netherlands
| | - T. E. Cohen‐Overbeek
- Department of Obstetrics and Gynecology, Division of Obstetrics and Prenatal MedicineErasmus MC, Sophia Children's HospitalRotterdamThe Netherlands
| | - E. Pajkrt
- Department of Obstetrics and GynecologyAmsterdam University Medical Centers, University of Amsterdam, Amsterdam Reproduction and Development Research InstituteAmsterdamThe Netherlands
| | - D. Tibboel
- Department of Pediatric Surgery and Intensive Care ChildrenErasmus Medical Center, Sophia Children's HospitalRotterdamThe Netherlands
| | - R. M. H. Wijnen
- Department of Pediatric Surgery and Intensive Care ChildrenErasmus Medical Center, Sophia Children's HospitalRotterdamThe Netherlands
| | - G. H. A. Visser
- Department of Obstetrics, Division Woman and BabyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - G. T. R. Manten
- Department of Obstetrics, Division Woman and BabyUniversity Medical Center UtrechtUtrechtThe Netherlands
- Department of ObstetricsIsala Women and Children's HospitalZwolleThe Netherlands
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Abstract
Currently, the most important determinant of gastroschisis outcomes in high resource settings is whether the condition is associated with intestinal complications, such as atresia, necrosis, perforation, or volvulus. This form of the anomaly, known as complex gastroschisis, accounts for most of the mortality and a disproportionate burden of the morbidity from gastroschisis. There is some disagreement about what constitutes complex gastroschisis, and little consensus on the type and timing of surgical interventions. This article establishes a clear definition of complex gastroschisis. Surgical approaches to treatment of the diverse presentations of complex gastroschisis will be described and the timing of such interventions will be discussed. Contemporary outcomes of complex gastroschisis will be reviewed. Finally, a non-congenital intestinal complications that may arise in gastroschisis patients will be discussed.
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Affiliation(s)
- Sherif Emil
- Department of Pediatric Surgery; The Montreal Children's Hospital, McGill University Health Centre, Room B04.2028, 1001 Decarie Boulevard, Montreal, QC, Canada H4A 3J1.
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14
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Pederiva F, Sgrò A, Coletta R, Khalil B, Morabito A. Outcomes in patients with short bowel syndrome after autologous intestinal reconstruction: Does etiology matter? J Pediatr Surg 2018; 53:1345-1350. [PMID: 29628209 DOI: 10.1016/j.jpedsurg.2018.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 02/26/2018] [Accepted: 03/01/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND Short bowel syndrome (SBS) is the most common cause of intestinal failure in children. Many factors have been investigated in an attempt to define which parameters influence most survival and ability to wean off parenteral nutrition (PN). The aim of this study was to investigate if aetiology of SBS affects the outcomes in paediatric patients treated with autologous gastrointestinal reconstructive surgery. METHODS All children with SBS who underwent autologous gastrointestinal reconstructive surgery between 2002 and 2012 were retrospectively reviewed and outcome measures were recorded. RESULTS Forty-three patients were divided into 4 groups according to aetiology (gastroschisis, volvulus, necrotizing enterocolitis (NEC), intestinal atresia). No significant differences were found among groups regarding survival and median age at surgery. The volvulus group had a lower pre-operative bowel length in comparison with gastroschisis and intestinal atresia and the lowest percentage of patients off PN (30%). Gastroschisis had the lowest rate of preserved ileocaecal valve (10%), while intestinal atresia had the highest (66%). For children who weaned off PN, intestinal atresia had also the longest time to achieve enteral autonomy (14.5months), while NEC had the shortest (3.5months), followed by gastroschisis (8.5months). None of the patients needed transplant. CONCLUSIONS In our experience it does not appear that diagnosis is significantly related to outcome and this is consistent with the conclusions of other reviews. However, it should be noted that in our series patients with volvulus had the worse outcome in terms of weaning off PN when compared with intestinal atresia. TYPE OF STUDY Retrospective Study. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Federica Pederiva
- Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, UK.
| | | | - Riccardo Coletta
- Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, UK; University of Salford, Lancashire, UK
| | - Basem Khalil
- Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, UK; University of Manchester, Faculty of Medical and Human sciences, Manchester Medical School, Manchester, UK; University of Salford, Lancashire, UK
| | - Antonino Morabito
- Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, UK; University of Manchester, Faculty of Medical and Human sciences, Manchester Medical School, Manchester, UK; University of Salford, Lancashire, UK.
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15
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Abstract
The growing population of intestinal transplant recipients present a unique challenge to the gastroenterologists responsible for their support and evaluation. Improvements in patient and graft survival are largely attributed to surgical advancements, refined antirejection therapy, and enhanced endoscopic surveillance protocols that better perceive rejection and other complications. This article reviews the endoscopic management and interventions provided for transplant recipients at the University of Illinois Hospital with complications, such as acute rejection, ischemia, bleeding, fistula, post-transplant lymphoproliferative disorder, and gastroparesis. Further research is needed on promising strategies currently used for related diseases to treat and sustain the intestinal graft.
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Affiliation(s)
- Robert E Carroll
- Department of Medicine, University of Illinois at Chicago, Chicago Veterans Administration Medical Center (West Side Division), 840 South Wood Street (M/C 787), Chicago, IL 60612, USA.
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16
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Sukhotnik I, Shahar YB, Pollak Y, Dorfman T, Shefer HK, Assi ZE, Mor-Vaknin N, Coran AG. The role of intermediate filaments in maintaining integrity and function of intestinal epithelial cells after massive bowel resection in a rat. Pediatr Surg Int 2018; 34:217-225. [PMID: 29043445 DOI: 10.1007/s00383-017-4192-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2017] [Indexed: 01/22/2023]
Abstract
PURPOSE Intermediate filaments (IFs) are a part of the cytoskeleton that extend throughout the cytoplasm of all cells and function in the maintenance of cell-shape by bearing tension and serving as structural components of the nuclear lamina. In normal intestine, IFs provide a tissue-specific three-dimensional scaffolding with unique context-dependent organizational features. The purpose of this study was to evaluate the role of IFs during intestinal adaptation in a rat model of short bowel syndrome (SBS). MATERIALS AND METHODS Male rats were divided into two groups: Sham rats underwent bowel transection and SBS rats underwent a 75% bowel resection. Parameters of intestinal adaptation, enterocyte proliferation and apoptosis were determined 2 weeks after operation. Illumina's Digital Gene Expression (DGE) analysis was used to determine the cytoskeleton-related gene expression profiling. IF-related genes and protein expression were determined using real-time PCR, Western blotting and immunohistochemistry. RESULTS Massive small bowel resection resulted in a significant increase in enterocyte proliferation and concomitant increase in cell apoptosis. From the total number of 20,000 probes, 16 cytoskeleton-related genes were investigated. Between these genes, only myosin and tubulin levels were upregulated in SBS compared to sham animals. Between IF-related genes, desmin, vimentin and lamin levels were down-regulated and keratin and neurofilament remain unchanged. The levels of TGF-β, vimentin and desmin gene and protein were down-regulated in resected rats (vs sham animals). CONCLUSIONS Two weeks following massive bowel resection in rats, the accelerated cell turnover was accompanied by a stimulated microfilaments and microtubules, and by inhibited intermediate filaments. Resistance to cell compression rather that maintenance of cell-shape by bearing tension are responsible for contraction, motility and postmitotic cell separation in a late stage of intestinal adaptation.
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Affiliation(s)
- I Sukhotnik
- Laboratory of Intestinal Adaptation and Recovery, The Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
- Department of Pediatric Surgery, Bnai Zion Medical Center, Golomb St., P.O.B. 4940, 31048, Haifa, Israel.
| | - Y Ben Shahar
- Laboratory of Intestinal Adaptation and Recovery, The Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Department of Pediatric Surgery, Bnai Zion Medical Center, Golomb St., P.O.B. 4940, 31048, Haifa, Israel
| | - Y Pollak
- Laboratory of Intestinal Adaptation and Recovery, The Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - T Dorfman
- Laboratory of Intestinal Adaptation and Recovery, The Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - H Kreizman Shefer
- Laboratory of Intestinal Adaptation and Recovery, The Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Z E Assi
- Laboratory of Intestinal Adaptation and Recovery, The Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Department of Pediatric Surgery, Bnai Zion Medical Center, Golomb St., P.O.B. 4940, 31048, Haifa, Israel
| | - N Mor-Vaknin
- Department of Internal Medicine, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - A G Coran
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Soltys KA, Bond G, Sindhi R, Rassmussen SK, Ganoza A, Khanna A, Mazariegos G. Pediatric intestinal transplantation. Semin Pediatr Surg 2017; 26:241-249. [PMID: 28964480 DOI: 10.1053/j.sempedsurg.2017.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The field of intestinal transplantation has experienced dramatic growth since the first reported cases 3 decades ago. Improvements in operative technique, donor assessment and immunosuppressive protocols have afforded children who suffer from life-threatening complications of intestinal failure a chance at long-term survival. As experience has grown, newer diseases, with more systemic manifestations have arisen as potential indications for transplant. After discussing the historical developments of intestinal transplant as a backdrop, this review focuses on the specific pre-operative indications for transplant as well as the great success that intestinal rehabilitation has witnessed over the past decade. A detailed discussion of evolution of immunosuppressive strategies is followed a general review of the common infectious complications experienced by children after intestinal transplant as well as the current long- and short-term results, including a section on new research on the quality of life in this challenging population of patients.
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Affiliation(s)
- Kyle A Soltys
- The Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, 4401 Penn Ave, 6 FP, Pittsburgh, PA 15224.
| | - Geoff Bond
- The Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, 4401 Penn Ave, 6 FP, Pittsburgh, PA 15224
| | - Rakesh Sindhi
- The Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, 4401 Penn Ave, 6 FP, Pittsburgh, PA 15224
| | | | - Armando Ganoza
- The Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, 4401 Penn Ave, 6 FP, Pittsburgh, PA 15224
| | - Ajai Khanna
- The Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, 4401 Penn Ave, 6 FP, Pittsburgh, PA 15224
| | - George Mazariegos
- The Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, 4401 Penn Ave, 6 FP, Pittsburgh, PA 15224
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18
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Martillotti G, Boucoiran I, Damphousse A, Grignon A, Dubé E, Moussa A, Bouchard S, Morin L. Predicting Perinatal Outcome from Prenatal Ultrasound Characteristics in Pregnancies Complicated by Gastroschisis. Fetal Diagn Ther 2015; 39:279-86. [DOI: 10.1159/000440699] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 08/25/2015] [Indexed: 11/19/2022]
Abstract
Introduction: The objective of the study was to establish the predictive value of prenatal ultrasound markers for complex gastroschisis (GS) in the first 10 days of life. Material and Methods: In this retrospective cohort study over 11 years (2000-2011) of 117 GS cases, the following prenatal ultrasound signs were analyzed at the last second- and third-trimester ultrasounds: intrauterine growth restriction, intra-abdominal bowel dilatation (IABD) adjusted for gestational age, extra-abdominal bowel dilatation (EABD) ≥25 mm, stomach dilatation, stomach herniation, perturbed mesenteric circulation, absence of bowel lumen and echogenic dilated bowel loops (EDBL). Results: Among 114 live births, 16 newborns had complex GS (14.0%). Death was seen in 16 cases (13.7%): 3 intrauterine fetal deaths, 9 complex GS and 4 simple GS. Second-trimester markers had limited predictive value. Third-trimester IABD, EABD, EDBL, absence of intestinal lumen and perturbed mesenteric circulation were statistically associated with complex GS and death. IABD was able to predict complex GS with a sensitivity of 50%, a specificity of 91%, a positive predictive value of 47% and a negative predictive value of 92%. Discussion: Third-trimester IABD adjusted for gestational age appears to be the prenatal ultrasound marker most strongly associated with adverse outcome in GS.
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D'Antonio F, Virgone C, Rizzo G, Khalil A, Baud D, Cohen-Overbeek TE, Kuleva M, Salomon LJ, Flacco ME, Manzoli L, Giuliani S. Prenatal Risk Factors and Outcomes in Gastroschisis: A Meta-Analysis. Pediatrics 2015; 136:e159-69. [PMID: 26122809 DOI: 10.1542/peds.2015-0017] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Gastroschisis is a congenital anomaly with increasing incidence, easy prenatal diagnosis and extremely variable postnatal outcomes. Our objective was to systematically review the evidence regarding the association between prenatal ultrasound signs (intraabdominal bowel dilatation [IABD], extraabdominal bowel dilatation, gastric dilatation [GD], bowel wall thickness, polyhydramnios, and small for gestational age) and perinatal outcomes in gastroschisis (bowel atresia, intra uterine death, neonatal death, time to full enteral feeding, length of total parenteral nutrition and length of in hospital stay). METHODS Medline, Embase, and Cochrane databases were searched electronically. Studies exploring the association between antenatal ultrasound signs and outcomes in gastroschisis were considered suitable for inclusion. Two reviewers independently extracted relevant data regarding study characteristics and pregnancy outcome. All meta-analyses were computed using individual data random-effect logistic regression, with single study as the cluster unit. RESULTS Twenty-six studies, including 2023 fetuses, were included. We found significant positive associations between IABD and bowel atresia (odds ratio [OR]: 5.48, 95% confidence interval [CI] 3.1-9.8), polyhydramnios and bowel atresia (OR: 3.76, 95% CI 1.7-8.3), and GD and neonatal death (OR: 5.58, 95% CI 1.3-24.1). No other ultrasound sign was significantly related to any other outcome. CONCLUSIONS IABD, polyhydramnios, and GD can be used to an extent to identify a subgroup of neonates with a prenatal diagnosis of gastroschisis at higher risk to develop postnatal complications. Data are still inconclusive on the predictive ability of several signs combined, and large prospective studies are needed to improve the quality of prenatal counseling and the neonatal care for this condition.
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Affiliation(s)
- Francesco D'Antonio
- Fetal Medicine Unit, Division of Developmental Sciences, St George's University of London, London, United Kingdom
| | - Calogero Virgone
- Department of Paediatric and Neonatal Surgery, St George's Healthcare National Health Service Trust and University of London, London, United Kingdom
| | - Giuseppe Rizzo
- Department of Obstetrics and Gynecology, Università di Roma Tor Vergata, Roma, Italy
| | - Asma Khalil
- Fetal Medicine Unit, Division of Developmental Sciences, St George's University of London, London, United Kingdom
| | - David Baud
- Materno-Fetal and Obstetrics Research Unit, Department of Obstetrics and Gynaecology, University Hospital, Lausanne, Switzerland
| | - Titia E Cohen-Overbeek
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Marina Kuleva
- Maternité, Hôpital Necker-Enfants Malades, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Laurent J Salomon
- Maternité, Hôpital Necker-Enfants Malades, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Maria Elena Flacco
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Chieti, Italy; and EMISAC (Epidemiologia e Management dell'Invecchiamento, e Salubrità degli Ambienti Confinati), CeSI Biotech, Chieti, Italy
| | - Lamberto Manzoli
- Department of Medicine and Aging Sciences, University of Chieti-Pescara, Chieti, Italy; and EMISAC (Epidemiologia e Management dell'Invecchiamento, e Salubrità degli Ambienti Confinati), CeSI Biotech, Chieti, Italy
| | - Stefano Giuliani
- Department of Paediatric and Neonatal Surgery, St George's Healthcare National Health Service Trust and University of London, London, United Kingdom;
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20
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Zani-Ruttenstock E, Zani A, Paul A, Diaz-Cano S, Ade-Ajayi N. Interstitial cells of Cajal are decreased in patients with gastroschisis associated intestinal dysmotility. J Pediatr Surg 2015; 50:750-4. [PMID: 25783375 DOI: 10.1016/j.jpedsurg.2015.02.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 02/13/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Gastroschisis associated intestinal dysmotility (GAID) is poorly understood. Animal experiments suggest that interstitial cells of Cajal (ICC), play an important role. METHODS Infants with gastroschisis (GS) and GAID (time to full feed >42days) were selected. Age matched GS and control (NEC, ileal atresia, malrotation, and volvulus) samples from primary (T1) and secondary (T2) time points underwent standard histopathology and immunohistochemistry for identification of ICC, followed by evaluation of ICC numbers, distribution, morphology, relation to ganglion cells, and myenteric plexus architecture. Groups were compared using parametric and nonparametric tests. MAIN RESULTS Twelve patients had samples available for histopathological evaluation. GAID patients had a significantly lower total number of ICCs than controls (3 vs. 8, P<0.0029). ICC number at T1 was 2.5 vs. 6 (P=0.0629) and significantly lower at T2. (3.5 vs. 11, P=0.0124). GAID patients did not show a significant increase of ICC from T1 to T2. Controls showed a significant increase of ICC over time (6 vs. 11, P=0.0408). CONCLUSION Intestinal samples from infants with GAID who underwent stoma formation demonstrated fewer ICC than controls. There was no improvement or cell recovery during the study period. The ability to modulate ICC may have significant implications for the management of GAID.
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Affiliation(s)
| | - Augusto Zani
- Department of Paediatric Surgery, King's College Hospital, London, UK
| | - Anu Paul
- Department of Paediatric Surgery, King's College Hospital, London, UK
| | | | - Niyi Ade-Ajayi
- Department of Paediatric Surgery, King's College Hospital, London, UK.
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21
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Frybova B, Vlk R, Kokesova A, Rygl M. Isolated prenatal ultrasound findings predict the postnatal course in gastroschisis. Pediatr Surg Int 2015; 31:381-7. [PMID: 25697276 DOI: 10.1007/s00383-015-3675-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2015] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of the study was to identify which prenatal ultrasonographic findings in fetuses with gastroschisis correlate with complicated postnatal outcome. METHODS Ultrasound findings at the 30th week of pregnancy and medical reports were statistically analyzed to identify independent prenatal ultrasonographic predictors of postnatal outcome. RESULTS Completed prenatal data were gathered from 64 pregnancies. Prenatal intra-abdominal bowel dilatation (cutoff 10 mm) correlated with the presence of atresia (p < 0.01), longer administration of parenteral nutrition, extended hospital stay (median 53 vs. 21 days; 68 vs. 36 days, both p < 0.05), and greater number of additional surgical procedures (p < 0.05). Infants with antenatal presence of thickened bowel wall (greater than or equal to 3 mm) required longer administration of parenteral nutrition (median 34 vs. 20 days; p < 0.01) and prolonged stay (median 44 vs. 37 days; p < 0.05). Presence of oligohydramnion (amniotic fluid index below 8 cm) was connected with longer administration of parenteral nutrition in newborns (median 30 vs. 16 days; p < 0.05). CONCLUSION The isolated presence of oligohydramnion with amniotic fluid index below 8 cm, thickened bowel wall equal to or more than 3 mm and the prenatal intra-abdominal dilatation with 10 mm cutoff had significant predictive value for the adverse postnatal outcome of patients with gastroschisis.
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Affiliation(s)
- Barbora Frybova
- Department of Paediatric Surgery, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, 15006, Prague 5, Czech Republic,
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22
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Krebs T, Boettcher M, Schäfer H, Eschenburg G, Wenke K, Appl B, Roth B, Andreas T, Schmitz C, Fahje R, Jacobsen B, Tiemann B, Reinshagen K, Hecher K, Bergholz R. Gut inflammation and expression of ICC in a fetal lamb model of fetoscopic intervention for gastroschisis. Surg Endosc 2014; 28:2437-42. [DOI: 10.1007/s00464-014-3494-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 02/20/2014] [Indexed: 11/30/2022]
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Lepigeon K, Van Mieghem T, Vasseur Maurer S, Giannoni E, Baud D. Gastroschisis--what should be told to parents? Prenat Diagn 2014; 34:316-26. [PMID: 24375446 DOI: 10.1002/pd.4305] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 12/13/2013] [Accepted: 12/14/2013] [Indexed: 11/09/2022]
Abstract
Gastroschisis is a common congenital abdominal wall defect. It is almost always diagnosed prenatally thanks to routine maternal serum screening and ultrasound screening programs. In the majority of cases, the condition is isolated (i.e. not associated with chromosomal or other anatomical anomalies). Prenatal diagnosis allows for planning the timing, mode and location of delivery. Controversies persist concerning the optimal antenatal monitoring strategy. Compelling evidence supports elective delivery at 37 weeks' gestation in a tertiary pediatric center. Cesarean section should be reserved for routine obstetrical indications. Prognosis of infants with gastroschisis is primarily determined by the degree of bowel injury, which is difficult to assess antenatally. Prenatal counseling usually addresses gastroschisis issues. However, parental concerns are mainly focused on long-term postnatal outcomes including gastrointestinal function and neurodevelopment. Although infants born with gastroschisis often endure a difficult neonatal course, they experience few long-term complications. This manuscript, which is structured around common parental questions and concerns, reviews the evidence pertaining to the antenatal, neonatal and long-term implications of a fetal gastroschisis diagnosis and is aimed at helping healthcare professionals counsel expecting parents.
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Affiliation(s)
- Karine Lepigeon
- Materno-fetal & Obstetrics Research Unit, Department of Obstetrics and Gynecology, University Hospital, 1011, Lausanne, Switzerland
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Autologous intestinal reconstructive surgery to reduce bowel dilatation improves intestinal adaptation in children with short bowel syndrome. J Pediatr Gastroenterol Nutr 2013; 56:631-4. [PMID: 23343940 DOI: 10.1097/mpg.0b013e318287de8d] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Intestinal failure (IF) is a common consequence of neonatal small bowel pathology. In our experience, bowel dilatation is often responsible for the IF state in patients who fail to adapt despite adequate residual bowel length. The aim of the present study was to investigate the role of surgery to reduce bowel dilatation, and thus favour PN independence, for these children. METHODS Data were collected prospectively for all of the patients referred to our unit for a 7-year period (2004-2011). Eight patients (2 congenital atresia, 2 gastroschisis with atresia, 1 simple gastroschisis, 3 necrotising enterocolitis) with gut dilatation who failed adaptation despite a bowel length >40 cm were identified. Preoperatively, all patients were totally dependent on parenteral nutrition (PN). Patients were managed by longitudinal intestinal lengthening and tailoring (n = 3), serial transverse enteroplasty (n = 2), or tapering enteroplasty (n = 3). RESULTS Median age at time of surgery was 273 days (103-1059). Mean gut length increased from 51 (35-75) to 73 cm (45-120) following surgery (P = 0.02). Incidence of sepsis (P = 0.01) and peak serum bilirubin levels (P = 0.005) were reduced postoperatively. PN was discontinued after a median of 110 days (35-537) for 7 patients; 1 patient remains on PN 497 days after surgery. CONCLUSIONS These data indicate that reconstructive surgery to reduce bowel diameter may be an effective technique for treating IF in patients with short bowel syndrome, without sacrificing intestinal length. We suggest that this technique may reduce the need for bowel transplantation in this group of patients.
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Javid PJ, Sanchez SE, Horslen SP, Healey PJ. Intestinal lengthening and nutritional outcomes in children with short bowel syndrome. Am J Surg 2013; 205:576-80. [PMID: 23497916 DOI: 10.1016/j.amjsurg.2013.01.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 01/08/2013] [Accepted: 01/14/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intestinal lengthening remains a treatment option in pediatric short bowel syndrome. However, clinical indications and nutritional outcomes from bowel lengthening are not well defined. METHODS A retrospective review of a prospective database was conducted of patients who underwent bowel lengthening using serial transverse enteroplasty (STEP) at a single center. RESULTS Sixteen children who underwent 19 STEP procedures were identified. STEP increased median small bowel length from 84 cm (range, 19 to 295 cm) to 103 cm (range, 24 to 375 cm) (P = .0001). Caloric provisions from parenteral nutrition were decreased after STEP (69% vs 0%, P < .01). Of 15 subjects in the nutritional analysis, 12 (80%) had improved enteral tolerance, and 9 (60%) achieved enteral autonomy after STEP. Six STEP procedures were not associated with improvements in enteral nutrition, and 5 (83%) were performed in children with gastroschisis. CONCLUSIONS A majority of children with short bowel syndrome were weaned off parenteral nutrition after STEP. Gastroschisis may portend a less optimal outcome from the procedure.
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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.
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Valdovinos D, Cadena J, Montijo E, Zárate F, Cazares M, Toro E, Cervantes R, Ramírez-Mayans J. [Short bowel syndrome in children: a diagnosis and management update]. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2012; 77:130-40. [PMID: 22921210 DOI: 10.1016/j.rgmx.2012.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 06/29/2012] [Accepted: 06/29/2012] [Indexed: 10/28/2022]
Abstract
Short bowel syndrome (SBS) refers to the sum of the functional alterations that are the result of a critical reduction in the length of the intestine, which in the absence of adequate treatment, presents as chronic diarrhea, chronic dehydration, malnutrition, weight loss, nutriment and electrolyte deficiency, along with a failure to grow that is present with greater frequency during the neonatal period. The aim was to carry out a review of the literature encompassing the definition and the most frequent causes of SBS, together with an understanding of its physiopathology, prognostic factors, and treatment. An Internet search of PubMed articles was carried out for the existing information published over the last 20 years on SBS in children, using the keywords "short bowel syndrome". From a total of 784 potential articles, 82 articles were chosen for the literature review. The treatment of patients presenting with SBS is quite a challenge and therefore it is necessary to establish multidisciplinary management with a focus on maintaining optimal nutritional support that covers the necessities of growth and development and at the same time provides a maximum reduction of short, medium, and long-term complications. The diagnosis and treatment of a child with SBS require a team of professionals that are experts in gastroenterologic, pediatric, and nutritional management. The outcome for the child will be directly related to opportune management, as well as to the length of the intestinal resection and the presence or absence of the ileocecal valve.
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Affiliation(s)
- D Valdovinos
- Servicio de Gastroenterología, Instituto Nacional de Pediatría, México DF, México.
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Emil S, Canvasser N, Chen T, Friedrich E, Su W. Contemporary 2-year outcomes of complex gastroschisis. J Pediatr Surg 2012; 47:1521-8. [PMID: 22901911 DOI: 10.1016/j.jpedsurg.2011.12.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 12/20/2011] [Accepted: 12/21/2011] [Indexed: 11/18/2022]
Abstract
PURPOSE Outcomes of gastroschisis are influenced by associated intestinal complications. We present a detailed analysis of complex gastroschisis. METHODS A retrospective study of all patients with gastroschisis treated at 2 university neonatal intensive care units between January 1, 2001, and March 31, 2007, was performed. RESULTS Of 83 patients, 19 (23%) had complex gastroschisis, including atresias (68%), gangrene (37%), closing gastroschisis (32%), perforation (21%), strictures (21%), and volvulus (11%). Prenatal ultrasound did not predict complications. Fifty-three percent underwent primary closure. Duration of mechanical ventilation and total parenteral nutrition (TPN) was 14.4 ± 1.9 days and 90.7 ± 9.0 days, respectively. Enteral feeds started at 35.9 ± 4.6 days. Hospital stay was 104.4 ± 9.6 days. Patients underwent a median of 3 abdominal procedures (range, 2-5) before discharge. Ninety-five percent survived to discharge; 33% and 67% were discharged on TPN and gastrostomy feeds, respectively. Two-year survival was 89%, with 82% on full oral feeding, 12% on a combination of oral and gastrostomy feeding, and 1 patient (who received a liver/bowel transplant) on a combination of enteral and parenteral nutrition. CONCLUSIONS Complex gastroschisis continues to produce significant morbidity. However, most of the patients are TPN free by 2 years of age.
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Affiliation(s)
- Sherif Emil
- Division of Pediatric Surgery, University of California Irvine School of Medicine, Orange, California, USA.
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The Eccentricities of Nourishing the Infant With Abdominal Anomalies. TOP CLIN NUTR 2012. [DOI: 10.1097/tin.0b013e3182628933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bogie AL, Guthrie C. High-Technology Gastroenterology Disorders in Children. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2012. [DOI: 10.1016/j.cpem.2012.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bowel-defect disproportion in gastroschisis: does the need to extend the fascial defect predict outcome? Pediatr Surg Int 2012; 28:495-500. [PMID: 22331201 DOI: 10.1007/s00383-012-3055-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND/PURPOSE Validated outcome prediction for gastroschisis (GS) permits early risk stratification. The aim of our study was to determine whether the need for GS defect extension: (a) correlates with bowel injury severity at birth, and (b) predicts outcome. METHODS A national dataset was used to study GS babies born between 2005 and 2010. The primary outcome was days of parenteral nutrition (PN). Outcomes were analyzed according to the need for fascial extension to facilitate closure or silo placement as follows: Group 1, no extension; Group 2A, extension <2 cm; Group 2B, extension >2 cm. Univariate and where appropriate, multivariate analyses were used. RESULTS Of 507 cases, 402 had complete defect extension data: Group 1, 297 (73%); Group 2A, 67 (17%); Group 2B, 42 (10%). Group 2B patients had higher rates of atresia, perforation and severe matting (P = 0.001) and required more days on PN compared to Group 1 (63.0 ± 100.4 vs. 39.7 ± 44.5 days: CI 1.2-45.1; P = 0.03). Multivariate analysis revealed that the presence of atresia (P = 0.01) and surgical site (P = 0.001) or bloodstream (P = 0.001) infections were predictive of prolonged PN; however, the need for fascial extension was not. CONCLUSIONS GS newborns who require fascial extension are more likely to have complicated GS and are at greater risk for adverse outcome, although it is not an independent predictor of the latter.
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Ghionzoli M, James CP, David AL, Shah D, Tan AWC, Iskaros J, Drake DP, Curry JI, Kiely EM, Cross K, Eaton S, De Coppi P, Pierro A. Gastroschisis with intestinal atresia--predictive value of antenatal diagnosis and outcome of postnatal treatment. J Pediatr Surg 2012; 47:322-8. [PMID: 22325384 DOI: 10.1016/j.jpedsurg.2011.11.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Accepted: 11/10/2011] [Indexed: 11/24/2022]
Abstract
PURPOSE The purpose of this study is to evaluate (1) the predictive value of fetal bowel dilatation (FBD) for intestinal atresia in gastroschisis and (2) the postnatal management and outcome of this condition. METHODS A retrospective review of all gastroschisis cases diagnosed in our fetal medicine unit between 1992 and 2010 and treated postnatally in our center was performed. RESULTS One hundred thirty cases had full postnatal data available. Intestinal atresia was found at surgery in 14 neonates (jejunum, n = 6; ileum, n = 3; ascending colon, n = 3; multiple, n = 2). Polyhydramnios and FBD were more likely in the atresia group compared with infants with no atresia (P = .0003 and P = .005, respectively). Fetal bowel dilatation had 99% negative predictive value (95% confidence interval, 0.9-0.99) and 17% positive predictive value (95% confidence interval, 0.1-0.3) for atresia. Treatment of intestinal atresia included primary anastomosis (n = 5), delayed anastomosis (n = 2), and stoma formation followed by anastomosis (n = 7). Infants with atresia had longer duration of parenteral nutrition, higher incidence of sepsis, and cholestasis compared with infants with no atresia (P = .0003). However, the presence of atresia did not increase mortality. CONCLUSIONS Polyhydramnios and FBD are associated with atresia. Absence of FBD in gastroschisis excludes intestinal atresia. In our experience, atresia is associated with a longer duration of parenteral nutrition but does not influence mortality. These findings may be relevant for antenatal counseling.
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Affiliation(s)
- Marco Ghionzoli
- Surgery Unit, Institute of Child Health and Great Ormond Street Hospital, London, WC1N 1EH, England
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Tannuri ACA, Silva LM, Leal AJG, Moraes ACFD, Tannuri U. Does administering albumin to postoperative gastroschisis patients improve outcome? Clinics (Sao Paulo) 2012; 67:107-11. [PMID: 22358234 PMCID: PMC3275118 DOI: 10.6061/clinics/2012(02)04] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 09/21/2011] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES Newborns who undergo surgery for gastroschisis correction may present with oliguria, anasarca, prolonged postoperative ileus, and infection. New postoperative therapeutic procedures were tested with the objective of improving postoperative outcome. PATIENTS AND METHODS One hundred thirty-six newborns participated in one of two phases. Newborns in the first phase received infusions of large volumes of crystalloid solution and integral enteral formula, and newborns in the second phase received crystalloid solutions in smaller volumes, with albumin solution infusion when necessary and the late introduction of a semi-elemental diet. The studied variables were serum sodium and albumin levels, the need for albumin solution expansion, the occurrence of anasarca, the length of time on parenteral nutrition, the length of time before initiating an enteral diet and reaching a full enteral diet, orotracheal intubation time, length of hospitalization, and survival rates. RESULTS Serum sodium levels were higher in newborns in the second phase. There was a correlation between low serum sodium levels and orotracheal intubation time; additionally, low serum albumin levels correlated with the length of time before the initiation of an oral diet and the time until a full enteral diet was reached. However, the discharge weights of newborns in the second phase were higher than in the first phase. The other studied variables, including survival rates (83.4% and 92.0%, respectively), were similar for both phases. CONCLUSIONS The administration of an albumin solution to newborns in the early postoperative period following gastroschisis repair increased their low serum sodium levels but did not improve the final outcome. The introduction of a semi-elemental diet promoted an increase in body weight at the time of discharge.
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Affiliation(s)
- Ana Cristina A Tannuri
- Faculdade de Medicina, Universidade de São Paulo, Pediatric Surgery Division, Pediatric Liver Transplantation Unit, Brazil
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Dicken BJ, Sergi C, Rescorla FJ, Breckler F, Sigalet D. Medical management of motility disorders in patients with intestinal failure: a focus on necrotizing enterocolitis, gastroschisis, and intestinal atresia. J Pediatr Surg 2011; 46:1618-30. [PMID: 21843732 DOI: 10.1016/j.jpedsurg.2011.04.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 03/31/2011] [Accepted: 04/05/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND Intestinal failure (IF) is the dependence upon parenteral nutrition to maintain minimal energy requirements for growth and development. It may occur secondary to a loss of bowel length, disorders of motility, or both. Short bowel syndrome (SBS) is a malabsorptive state resulting from surgical resection, congenital defect, or diseases associated with loss of absorptive surface area. A particularly vexing problem is associated with whole bowel and/or segmental intestinal dysmotility. Motility disorders within the context of SBS and IF may relate to rapid intestinal transit secondary to loss of intestinal length, dysmotility associated with loss or poor antegrade peristalsis, or gastroparesis. Therapy may be classified into medical (prokinetic and antidiarrheal agents) and surgical to deal with the overdistended poorly motile bowel. METHODS We performed a systematic review of the literature pertaining to IF, SBS, and dysmotility in the pediatric population with gastroschisis, necrotizing enterocolitis, and intestinal atresia. In addition to the available treatment options, we have provided a review of the literature and a summary of the available evidence. CONCLUSION Despite relatively poor level of evidence regarding the application of promotility and antidiarrheal medications in patients with SBS and IF, these agents continue to be used. Herein, we provide a review of the physiology and pathophysiology of intestinal motility/dysmotility and available strategies for the use of promotility and antidiarrheal agents in patients with IF/SBS.
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Affiliation(s)
- Bryan J Dicken
- Division of Pediatric Surgery, Stollery Children's Hospital, University of Alberta Hospital, Edmonton, Alberta, Canada.
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Raphael BP, Nurko S, Jiang H, Hart K, Kamin DS, Jaksic T, Duggan C. Cisapride improves enteral tolerance in pediatric short-bowel syndrome with dysmotility. J Pediatr Gastroenterol Nutr 2011; 52:590-4. [PMID: 21502831 PMCID: PMC3079853 DOI: 10.1097/mpg.0b013e3181fe2d7a] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Gastrointestinal dysmotility is common in pediatric short-bowel syndrome, leading to prolonged parenteral nutrition dependence. There is limited literature regarding the safety and efficacy of cisapride for this indication. The aim of the study was to describe the safety and efficacy of cisapride for enteral intolerance in pediatric short-bowel syndrome. METHODS Open-labeled pilot study in a limited access program for cisapride. Indications were short-bowel syndrome with underlying dysmotility and difficulty advancing enteral feeds despite standard therapies and without evidence of anatomic obstruction. Patients received cisapride 0.1 to 0.2 mg/kg per dose for 3 to 4 doses per day. We collected electrocardiogram, nutrition, and anthropometric data prospectively at study visits. RESULTS Ten patients with mean (SD) age of 30.3 (30.5) months were enrolled in our multidisciplinary pediatric intestinal rehabilitation program. Median (interquartile range [IQR]) duration of follow-up was 8.7 (3.1-14.3) months. Median (IQR) residual bowel length was 102 (85-130) cm. Median (IQR) citrulline level was 14.5 (10.5-31.3) μmol/L. Diagnoses included isolated gastroschisis (n = 3), gastroschisis with intestinal atresia (n = 4), necrotizing enterocolitis (n = 2), and long-segment Hirschsprung disease (n = 1). Six subjects had at least 1 prior bowel-lengthening procedure. Median (IQR) change in percentage enteral energy intake was 19.9% (15.4%-29.8%) during follow-up (P = 0.01). Seven patients improved in enteral tolerance during treatment and 2 were weaned completely from parenteral nutrition. Complications during therapy were prolonged corrected QT interval (n = 2), gastrointestinal bleeding (n = 2), D-lactic acidosis (n = 1), and death due to presumed sepsis (n = 1). Longitudinal analysis (general estimating equation model) showed a strong positive association between cisapride duration and improved enteral tolerance. Mean percentage of enteral intake increased by 2.9% for every month of cisapride treatment (P < 0.0001). CONCLUSIONS Cisapride is a potentially useful therapy in patients with pediatric short-bowel syndrome with gastrointestinal dysmotility. We observed modest improvement in feeding tolerance where prior treatments failed; however, patients treated with cisapride require careful cardiac monitoring because corrected QT prolongation occurred in 20% of our cohort.
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Affiliation(s)
- Bram P. Raphael
- Division of Gastroenterology and Nutrition, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA 02115
- Center for Advanced Intestinal Rehabilitation, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA 02115
| | - Samuel Nurko
- Division of Gastroenterology and Nutrition, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA 02115
- Center for Motility and Functional Gastrointestinal Disorders, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA 02115
| | - Hongyu Jiang
- Clinical Research Program, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA 02115
| | - Kristen Hart
- Division of Gastroenterology and Nutrition, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA 02115
- Center for Motility and Functional Gastrointestinal Disorders, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA 02115
| | - Daniel S. Kamin
- Division of Gastroenterology and Nutrition, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA 02115
- Center for Advanced Intestinal Rehabilitation, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA 02115
| | - Tom Jaksic
- Center for Advanced Intestinal Rehabilitation, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA 02115
- Department of Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA 02115
| | - Christopher Duggan
- Division of Gastroenterology and Nutrition, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA 02115
- Center for Advanced Intestinal Rehabilitation, Children’s Hospital Boston, Harvard Medical School, Boston, MA, USA 02115
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Tannuri ACA, Sbragia L, Tannuri U, Silva LM, Leal AJG, Schmidt AFS, Oliveira-Filho AG, Bustorff-Silva JM, Vicente YAMVA, Tazima MDFGS, Pileggi FO, Camperoni AL. Evolution of critically ill patients with gastroschisis from three tertiary centers. Clinics (Sao Paulo) 2011; 66:17-20. [PMID: 21437430 PMCID: PMC3045707 DOI: 10.1590/s1807-59322011000100004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 10/01/2010] [Indexed: 12/13/2022] Open
Abstract
UNLABELLED OBJECTIVES AND INTRODUCTION: Gastroschisis is a congenital abdominal wall defect with increasing occurrence worldwide over the past 20-30 years. Our aim was to analyze the morbidity of newborns after gastroschisis closure, with emphasis on metabolic and hydroelectrolyte disturbances in patients at three tertiary university centers. METHODS From January 2003 to June 2009, the following patient data were collected retrospectively: (A) Background maternal and neonatal data: maternal age, prenatal diagnosis, type of delivery, Apgar scores, birth weight, gestational age and sex; (B) Surgical modalities: primary or staged closure; and (C) Hospital course: levels of serum sodium and levels of serum albumin in the two first postoperative days, number of ventilation days, other postoperative variables and survival. Statistical analyses were used to examine the associations between some variables. RESULTS 163 newborns were included in the study. Primary closure of the abdominal defect was performed in 111 cases (68.1%). The mean serum sodium level was 127.4 ± 6.7 mEq/L, and the mean serum albumin level was 2.35 ± 0.5 g/dL. Among the correlations between variables, it was verified that hyponatremia and hypoalbuminemia correlated with the number of days on the ventilator but not with the number of days on total parenteral nutrition (TPN); mortality rate correlated with infection. The final survival rate was 85.9%. CONCLUSION In newborns with gastroschisis, more aggressive attention to hyponatremia and hypoalbuminemia would improve the outcome.
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Affiliation(s)
- Ana Cristina A Tannuri
- Pediatric Surgery Division Pediatric Liver Transplantation Unit Laboratory of Research in Pediatric Surgery, Medical School, University of Sao Paulo, Sao Paulo, Brazil.
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Saxena AK. Congenital Anomalies of Soft Tissues: Birth Defects Depending on Tissue Engineering Solutions and Present Advances in Regenerative Medicine. TISSUE ENGINEERING PART B-REVIEWS 2010; 16:455-66. [DOI: 10.1089/ten.teb.2009.0700] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Amulya K. Saxena
- Department of Pediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria
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Kronfli R, Bradnock TJ, Sabharwal A. Intestinal atresia in association with gastroschisis: a 26-year review. Pediatr Surg Int 2010; 26:891-4. [PMID: 20676892 DOI: 10.1007/s00383-010-2676-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2010] [Indexed: 11/26/2022]
Abstract
PURPOSE We reviewed our experience with gastroschisis (GS) complicated by intestinal atresia over the last 26 years. Our aim was to determine the effect of different management strategies employed and the morbidity associated with this condition in our unit. METHODS A retrospective casenote review was carried out. Data regarding the operative management of the GS and atresia was recorded. Primary outcome measures included time to commence and establish full enteral feeds, duration of parenteral nutrition, complications and outcome. RESULTS Of 179 neonates with GS, 23 also had intestinal atresia. 13 underwent primary closure of the defect, 5 had patch closure and 5 had a silo placed. 4 atresias were 'missed' at first operation. The 19 recognised atresias were managed either by stoma formation, primary anastomosis or deferred management with subsequent primary anastomosis. There was wide variation in the outcomes of patients in each group. CONCLUSION Differences in outcome between the management strategies are likely to reflect an inherent variability in patient condition, site of atresia, and bowel suitability for anastomosis at first surgery, rather than the mode of surgical management. Individual management plans should be tailored to the clinical condition of each patient.
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Abstract
The management of the child with intestinal failure is complex, and it is developing into a multispecialty field of its own led by expert teams of both transplant and nontransplant surgeons, gastroenterologists, and dieticians. Patients are at risk for medical, surgical, and nutritional complications that should be anticipated so that they can be prevented or managed appropriately. Catheter associated infections and intestinal failure associated liver diseases are important complications that impact the likelihood of bowel adaptation and long-term survival. The clinical assessment of a pediatric intestinal failure patient should include evaluation of the child within the context of recognized prognostic factors.
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Affiliation(s)
- Jason S Soden
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Colorado Denver School of Medicine and The Children's Hospital, Aurora, Colorado 80045, USA.
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Sala D, Chomto S, Hill S. Long-Term Outcomes of Short Bowel Syndrome Requiring Long-Term/Home Intravenous Nutrition Compared in Children With Gastroschisis and Those With Volvulus. Transplant Proc 2010; 42:5-8. [DOI: 10.1016/j.transproceed.2009.12.033] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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