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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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Sanaksenaho G, Mutanen A, Godbole N, Hukkinen M, Merras-Salmio L, Kivisaari R, Kyrönlahti A, Pihlajoki M, Lohi J, Heikinheimo M, Pakarinen MP. Compromised duodenal mucosal integrity in children with short bowel syndrome after adaptation to enteral autonomy. J Pediatr Surg 2021; 56:966-974. [PMID: 33131778 DOI: 10.1016/j.jpedsurg.2020.09.065] [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: 05/22/2020] [Revised: 08/23/2020] [Accepted: 09/21/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Intestinal adaptation has been extensively studied experimentally, but very limited data is available on human subjects. In this study we assessed intestinal adaption in humans with short bowel syndrome (SBS). METHODS We comparatively evaluated mucosal hyperplasia, inflammation, barrier function and nutrient transport using histology, immunohistochemistry and qPCR for selected 52 key genes in duodenal biopsies obtained from children with SBS after weaning off parenteral nutrition (n = 33), and matched controls without intestinal pathology (n = 12). Small bowel dilatation was assessed from contrast small bowel series. RESULTS Duodenal mucosa of SBS children showed increased histologic inflammation of lamina propria (p = 0.033) and mucosal mRNA expression of tumor necrosis factor (p = 0.027), transforming growth factor (TGF)-β2 (p = 0.006) and caveolin-1 (CAV1; p = 0.001). Villus height, crypt depth, enterocyte proliferation, apoptosis and expression of proliferation and nutrient transport genes remained unchanged. Pathologic small bowel dilatation reduced crypt depth (p = 0.045) and downregulated mRNA expression of interleukin (IL)-6 by three-fold (p = 0.008), while correlating negatively with IL6 (r = -0.609, p = 0.004). Loss of ileocecal valve (ICV) upregulated mRNA expression of toll-like receptor 4 (TLR4), TGF-β1, CAV1, several apoptosis regulating genes, and mRNA expression of zonulin (p < 0.05 for all). CONCLUSIONS Despite successful adaptation to enteral autonomy, duodenal mucosa of SBS children displayed histologic and molecular signs of abnormal inflammation and regulation of epithelial permeability, whereas no structural or molecular signs of adaptive hyperplasia or enhanced nutrient transport were observed. Excessive dilatation of the remaining small bowel paralleled impaired duodenal crypt homeostasis, while absence of ICV modified regulation of mucosal inflammation, regeneration and permeability. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Galina Sanaksenaho
- Division of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Annika Mutanen
- Division of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Nimish Godbole
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maria Hukkinen
- Division of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Laura Merras-Salmio
- Department of Pediatric Gastroenterology, Pediatric Liver and Gut Research Group, Children's Hospital, Pediatric Research Centre, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Reetta Kivisaari
- HUS Medical Imaging Center, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Antti Kyrönlahti
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marjut Pihlajoki
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jouko Lohi
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markku Heikinheimo
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko P Pakarinen
- Division of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
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Fatemizadeh R, Gollins L, Hagan J, Debuyserie A, King K, Vogel AM, Van Buren KL, Hair AB, Premkumar MH. In neonatal-onset surgical short bowel syndrome survival is high, and enteral autonomy is related to residual bowel length. JPEN J Parenter Enteral Nutr 2021; 46:339-347. [PMID: 33881791 DOI: 10.1002/jpen.2124] [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] [Indexed: 12/26/2022]
Abstract
BACKGROUND In an era of improved management and treatment options, this study aims to describe the long-term outcomes and factors predictive of outcomes of neonatal-onset intestinal failure (IF) due to surgical short bowel syndrome (SBS). METHODS Retrospective, single-center cohort study of infants born between January 2011 and December 2018 with inclusion criteria: <44 weeks postmenstrual age at SBS diagnosis, <28 days on admission, parenteral nutrition dependence >60 days, and documented intestinal resection. Primary outcomes included survival and achievement of enteral autonomy (EA). Data analysis utilized Fisher.s exact test, Kruskal-Wallis test, survival analysis methods, Cox proportional hazards regression, linear regression and logistic regression. RESULTS Ninety-five patients (males 56%) were studied with median follow-up of 38 months (IQR 19, 59). Survival at last follow-up was 96%, and EA was achieved in 85%. Forty-eight patients had documented residual bowel length (RBL) with median length of 49 cm (IQR 36, 80). Survival in patients with RBL of <30cm (n = 8), 30-59cm (n = 19), and >60cm (n = 21) was 100%, 95%, and 95% respectively. Shorter RBL was associated with longer time to achieve EA (p = 0.007), but not with survival (p = 0.81). Delay in achieving EA was associated with absence of ileocecal valve (p = 0.002) and bloodstream infections (p < 0.001). Peak conjugated bilirubin correlated with increased mortality (p = 0.002). CONCLUSION Overall high rate of survival and achievement of EA was found in neonatal onset IF due to SBS. EA but not survival was correlated with RBL. Ileocecal valve, bloodstream infections, and conjugated bilirubin levels were the other predictive factors of outcomes.
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Affiliation(s)
- Roxana Fatemizadeh
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Laura Gollins
- Clinical Nutrition Services, Texas Children's Hospital, Houston, Texas, USA
| | - Joseph Hagan
- Section of Neonatal-Perinatal Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Anne Debuyserie
- Section of Neonatal-Perinatal Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Kristi King
- Clinical Nutrition Services, Texas Children's Hospital, Houston, Texas, USA
| | - Adam M Vogel
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Kristin L Van Buren
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Amy B Hair
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Muralidhar H Premkumar
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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Capriati T, Mosca A, Alterio T, Spagnuolo MI, Gandullia P, Lezo A, Lionetti P, D’Antiga L, Fusaro F, Diamanti A. To Wean or Not to Wean: The Role of Autologous Reconstructive Surgery in the Natural History of Pediatric Short Bowel Syndrome on Behalf of Italian Society for Gastroenterology, Hepatology and Nutrition (SIGENP). Nutrients 2020; 12:E2136. [PMID: 32708377 PMCID: PMC7400841 DOI: 10.3390/nu12072136] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/13/2020] [Indexed: 12/15/2022] Open
Abstract
Pediatric Short Bowel Syndrome (SBS) can require prolonged parenteral nutrition (PN). Over the years, SBS management has been implemented by autologous gastrointestinal reconstructive surgery (AGIR). The primary objective of the present review was to assess the effect of AGIR on weaning off PN. We also evaluated how AGIR impacts survival, the need for transplantation (Tx) and the development of liver disease (LD). We conducted a systematic literature search to identify studies published from January 1999 to the present and 947 patients were identified. PN alone was weakly associated with higher probability of weaning from PN (OR = 1.1, p = 0.03) and of surviving (OR = 1.05, p = 0.01). Adjusting for age, the probability of weaning off PN but of not surviving remained significantly associated with PN alone (OR = 1.08, p = 0.03). Finally, adjusting for age and primary diagnosis (gastroschisis), any association was lost. The prevalence of TX and LD did not differ by groups. In conclusion, in view of the low benefit in terms of intestinal adaptation and of the not negligible rate of complications (20%), a careful selection of candidates for AGIR should be required. Bowel dilation associated with failure of advancing EN and poor growth, should be criteria to refer for AGIR.
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Affiliation(s)
- Teresa Capriati
- Artificial Nutrition Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy;
| | - Antonella Mosca
- Hepatology Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Tommaso Alterio
- Hepatology Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Maria Immacolata Spagnuolo
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, 80138 Naples, Italy;
| | - Paolo Gandullia
- Gastroenterology Unit, G.Gaslini Institute for Maternal and Child Health, IRCCS, 16145 Genova, Italy;
| | - Antonella Lezo
- Division of Nutrition, Regina Margherita Children’s Hospital, 10126 Turin, Italy;
| | - Paolo Lionetti
- Department of Neuroscience, Psychology, Pharmacology and Child’s Health, University of Florence, Meyer Hospital, 50139 Florence, Italy;
| | - Lorenzo D’Antiga
- Paediatric, Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Fabio Fusaro
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, 00165 Rome, Italy;
| | - Antonella Diamanti
- Artificial Nutrition Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy;
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Treatment in a Tertiary Intestinal Rehabilitation Center Improves Outcome for Children With Short Bowel Syndrome. Gastroenterol Nurs 2019; 42:165-168. [PMID: 30585910 DOI: 10.1097/sga.0000000000000324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The aim of this study was to determine prognostic factors in pediatric patients with short bowel syndrome and very short bowel syndrome (defined as less than 25 cm of the bowel with or without colon). This was a retrospective, single-center, observational study that included patients with intestinal failure. Thirty-eight children with short bowel syndrome were included in the study (mean age at diagnosis = 8.4 [range = 0-48] months; female/male = 20/18); 12 children (31.6%) had very short bowel syndrome. Weaning from parenteral nutrition was achieved in 29 (74.5%) of children with short bowel syndrome but only in 4 (33%) in the very short bowel syndrome group. Positive prognostic factors associated with successful weaning from parenteral nutrition were an absolute higher length of the residual intestine, a remnant of at least some part of the colon, and treatment in an experienced center from the diagnosis. Patients with short bowel syndrome and very short bowel syndrome should be treated in a center experienced in intestinal rehabilitation.
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Outcomes of Children With Chronic Intestinal Failure: Experience Over 2 Decades at a Tertiary Paediatric Hospital. J Pediatr Gastroenterol Nutr 2019; 69:e79-e87. [PMID: 31169663 DOI: 10.1097/mpg.0000000000002384] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS The aim of the study was to aid decisions on prognosis and transplantation; this study describes the outcome of children with intestinal failure managed by the multidisciplinary intestinal rehabilitation program at the Royal Children's Hospital, Melbourne. METHODS Retrospective review of children requiring parenteral nutrition (PN) for >3 months who were assessed for home PN between 1991 and 2011. RESULTS A total of 51 children were included. Forty-two (82%) had short bowel syndrome (SBS), 5 (10%) had chronic intestinal pseudo-obstruction syndrome, and 4 (8%) had congenital enteropathies. Median small bowel length for patients with SBS was 45 cm (interquartile range 30-80) or 23.9% of the expected length for age (interquartile range 17.0%-40.6%). Overall survival rate was 84% (43/51). Mortality in children (n = 7) occurred after a median of 13.2 months (range 6.2-29.2) with intestinal failure-associated liver disease (IFALD) being the only predictor (P = 0.001). Out of 50 children 21 (42%) had IFALD. Children who were premature (P = 0.013), had SBS (P = 0.038), and/or frequent sepsis (P = 0.014) were more likely to develop IFALD. PN weaning occurred in 27 of 35 (77%) SBS survivors, after a median of 10.8 months (up to 8.2 years), with longer residual small bowel (P = 0.025), preservation of the ileocecal valve (P = 0.013) and colon (P = 0.011) being predictors. None of 5 (0%) patients with chronic intestinal pseudo-obstruction syndrome and 2 of 4 (50%) patients with congenital enteropathies weaned off PN. Overall sepsis rate was 7.3 episodes/1000 line days. Frequency of sepsis and longevity of central lines improved with time as patients grew older (both P < 0.001). CONCLUSIONS Long-term PN with intestinal rehabilitation was effective in treating most children with intestinal failure. Children with severe refractory IFALD may have benefited from intestinal transplantation.
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Cheng W, Zhang S, Wang J, Zhou C, Li Y, Li J. Three-dimensional CT enterography versus barium follow-through examination in measurement of remnant small intestinal length in short bowel syndrome patients. Abdom Radiol (NY) 2018; 43:2955-2962. [PMID: 29700592 DOI: 10.1007/s00261-018-1597-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE To evaluate the feasibility and accuracy of remnant small intestinal length measured by barium follow-through (BaFT) examination and three-dimensional CT enterography (CTe). MATERIALS AND METHODS Twenty-nine consecutive short bowel syndrome patients (SBS) who underwent BaFT, CTe, and prior surgical measurements of small intestine were included. Measurements of total remnant small intestinal length on BaFT and CTe were compared to surgical measurements using Spearman's rank correlation coefficients, Bland-Altman plots, and paired t test. RESULTS The average remnant intestinal length was 73.1 ± 37.2 cm according to surgical measurement. There was a significant positive correlation between CTe and surgical measurement (r2 = 0.99; p < 0.0001), and a relatively weaker correlation between BaFT and surgical measurement (r2 = 0.71; p < 0.001). Compared with surgical measurement, the percentage differences of CTe and BaFT were 5.71 ± 6.71% and 27.14 ± 18.41% (mean ± SD), respectively. Furthermore, Bland-Altman plots showed good agreement between CTe and surgical measurement, whereas relatively poor agreement between BaFT and surgical measurement. However, significant difference was found among the three measurement methods by paired t test (p < 0.0001). CONCLUSIONS Assessment of remnant small intestinal length by CTe is accurate and acceptable for clinical application, whereas BaFT is less accurate although BaFT is more convenient and cheaper for clinical application. And CTe can provide a cost-effective and noninvasive determination of remnant small intestinal length in planning surgical and nutritional intervention in SBS patients.
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Affiliation(s)
- Wei Cheng
- Intestinal Rehabilitation and Transplant Center, Jinling Hospital, Medicine School of Nanjing University, Nanjing, 210002, China
| | - Shaoyi Zhang
- Intestinal Rehabilitation and Transplant Center, Jinling Hospital, Medicine School of Nanjing University, Nanjing, 210002, China
- Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian Wang
- Intestinal Rehabilitation and Transplant Center, Jinling Hospital, Medicine School of Nanjing University, Nanjing, 210002, China
| | - Changsheng Zhou
- Department of Medical Imaging, Jinling Hospital, Medicine School of Nanjing University, Nanjing, 210002, China
| | - Yousheng Li
- Intestinal Rehabilitation and Transplant Center, Jinling Hospital, Medicine School of Nanjing University, Nanjing, 210002, China.
- Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Jieshou Li
- Intestinal Rehabilitation and Transplant Center, Jinling Hospital, Medicine School of Nanjing University, Nanjing, 210002, China
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Merras-Salmio L, Mutanen A, Ylinen E, Rintala R, Koivusalo A, Pakarinen MP. Pediatric Intestinal Failure: The Key Outcomes for the First 100 Patients Treated in a National Tertiary Referral Center During 1984-2017. JPEN J Parenter Enteral Nutr 2018; 42:1304-1313. [DOI: 10.1002/jpen.1164] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 02/27/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Laura Merras-Salmio
- Department of Pediatric Gastroenterology; Helsinki University Children's Hospital; Helsinki Finland
- Pediatric Liver and Gut Research Group; University of Helsinki; Helsinki Finland
| | - Annika Mutanen
- Pediatric Liver and Gut Research Group; University of Helsinki; Helsinki Finland
- Department of Pediatric Surgery; Helsinki University Children's Hospital; Helsinki Finland
| | - Elisa Ylinen
- Department of Pediatric Nephrology and Transplantations, Helsinki University Children's Hospital; University of Helsinki; Helsinki Finland
| | - Risto Rintala
- Department of Pediatric Surgery; Helsinki University Children's Hospital; Helsinki Finland
| | - Antti Koivusalo
- Department of Pediatric Surgery; Helsinki University Children's Hospital; Helsinki Finland
| | - Mikko P. Pakarinen
- Pediatric Liver and Gut Research Group; University of Helsinki; Helsinki Finland
- Department of Pediatric Surgery; Helsinki University Children's Hospital; Helsinki Finland
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9
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Bjørnland K, Hinna M, Aksnes G, Stensrud KJ, Ertresvåg K, Bjørnstad-Østensen A, Sanengen T, Line PD, Aagenæs I, Aabakken L, Emblem R, Almaas R. Outcome for biliary atresia patients treated at a low-volume centre. Scand J Gastroenterol 2018; 53:471-474. [PMID: 29546790 DOI: 10.1080/00365521.2018.1439097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The importance of case load for treatment of extrahepatic biliary atresia (BA) is debated. The aim of this study was to register results of BA treatment in a small volume centre. METHODS Retrospective chart review study of patients with BA treated from 2000 to 2017. The institutional review board approved the study. RESULTS Forty-five babies were identified of which 42 (93%) are alive. Forty-one patients had a Kasai portoenterostomy (PE), two had a hepaticojejunostomy and two had a primary liver transplantation. The age at PE/hepaticojejunostomy was median 63 (4-145 days). Seven surgeons performed the operations, and the median duration of the diagnostic work-up was 8 (3-24) days. Clearance of jaundice was achieved in 23/43 (53%) babies, and 3- and 5-year native liver survival was 47% and 40%, respectively. Clearance of jaundice post-PE/hepaticojejunostomy was a strong predictor of native liver survival (adjusted OR: 0.027; 95%; p = .009). Plasma level of conjugated bilirubin at time of referral was also a significant predictor of native liver survival (adjusted OR: 1.053; p = .017). CONCLUSION A small volume centre may achieve satisfactory results for BA patients. The study has, however, identified factors that may further improve results; earlier referral, optimizing diagnostic work-up and establishing one dedicated surgical team.
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Affiliation(s)
- Kristin Bjørnland
- a Department of Gastro and Paediatric Surgery , Oslo University Hospital , Oslo , Norway.,b University of Oslo , Oslo , Norway
| | | | - Gunnar Aksnes
- a Department of Gastro and Paediatric Surgery , Oslo University Hospital , Oslo , Norway
| | - Kjetil Juul Stensrud
- a Department of Gastro and Paediatric Surgery , Oslo University Hospital , Oslo , Norway
| | - Kjetil Ertresvåg
- a Department of Gastro and Paediatric Surgery , Oslo University Hospital , Oslo , Norway
| | - Anniken Bjørnstad-Østensen
- a Department of Gastro and Paediatric Surgery , Oslo University Hospital , Oslo , Norway.,c Department of Paediatrics , Oslo University Hospital , Oslo , Norway
| | - Truls Sanengen
- c Department of Paediatrics , Oslo University Hospital , Oslo , Norway
| | - Pål-Dag Line
- b University of Oslo , Oslo , Norway.,d Department of Transplantation Medicine , Oslo University Hospital , Oslo , Norway
| | - Ingegerd Aagenæs
- e Department of Radiology , Oslo University Hospital , Oslo , Norway
| | - Lars Aabakken
- b University of Oslo , Oslo , Norway.,f Department of Medicine , Oslo University Hospital , Oslo , Norway
| | - Ragnhild Emblem
- a Department of Gastro and Paediatric Surgery , Oslo University Hospital , Oslo , Norway.,b University of Oslo , Oslo , Norway
| | - Runar Almaas
- c Department of Paediatrics , Oslo University Hospital , Oslo , Norway.,g Department of Pediatric Research , Oslo University Hospital , Oslo , Norway
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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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11
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Urokinase thrombolysis as a rescue treatment for midgut volvulus ischemia. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2017. [DOI: 10.1016/j.epsc.2017.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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12
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Duodenal Disaccharidase Activities During and After Weaning off Parenteral Nutrition in Pediatric Intestinal Failure. J Pediatr Gastroenterol Nutr 2017; 64:777-782. [PMID: 27482764 DOI: 10.1097/mpg.0000000000001347] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Data on factors affecting absorptive function in children with intestinal failure (IF) are sparse. We evaluated duodenal disaccharidase activities and inflammation in relation to parenteral nutrition (PN) and intestinal resection in pediatric onset IF. METHODS Disaccharidase (maltase, sucrase, and lactase) activities and histologic inflammation were evaluated from duodenal biopsies in 58 patients during PN (n = 23) or full enteral nutrition (n = 40) and in 43 matched controls. The first and the last postresection biopsies were analyzed separately after 4.3 (1.2-9.7) years and 6.5 (2.3-12.4) years, respectively. RESULTS During PN, maltase and sucrase activities were 1.6-fold lower and mucosal inflammation more frequent (22% vs 3%) when compared to matched controls (P < 0.05 for both). In patients on full enteral nutrition, activities of maltase and sucrase were significantly higher than that in patients receiving PN and comparable to those of matched controls. Postresection time correlated positively (r = 0.448 and r = 0.369) and percentage length of the remaining small intestine inversely (r = -0.337 and r = -0.407) with maltase and sucrase activity in patients on full enteral nutrition (P < 0.05 for all), whereas proportional length of remaining colon correlated positively with maltase and lactase activity (r = 0.424-0.544, P < 0.05) in patients receiving PN. CONCLUSIONS In children with IF, PN dependency associated with decreased duodenal maltase and sucrase activities and mucosal inflammation, which may disturb intestinal absorptive function. Localization and extent of intestinal resection and post-resection time correlated with duodenal disaccharidase activities.
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13
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Khasanov RR, Gumerov AA, Vessel LM. [The role of small intestine length in the development of short bowel syndrome]. Khirurgiia (Mosk) 2017:63-67. [PMID: 28209957 DOI: 10.17116/hirurgia2017163-67] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIM To define the the role of small bowel length in development of SBS. MATERIAL AND METHODS Seventeen patients with SBS after small bowel resection in neonatal period were included into the study. Total small bowel length ranged from 5 to 55 cm (11.8±5.59% from normal length for certain age). RESULTS Described small bowel length has high risk of SBS/IF development irrespective to other factors (specific segment of small bowel that was resected, preserved intestinal segment state, absence of colon and/or ileocecal valve). CONCLUSION It is required to perform further studies with greater amount of patients to discover exact small bowel length which is associated with SBS and other factors affecting small bowel state.
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Affiliation(s)
- R R Khasanov
- Department of Pediatric Surgery, Bashkir State Medical University, Ufa, Russia; Clinic of Pediatric Surgery, Mannheim University's Hospital, University of Heidelberg, Germany
| | - A A Gumerov
- Department of Pediatric Surgery, Bashkir State Medical University, Ufa, Russia
| | - L M Vessel
- Clinic of Pediatric Surgery, Mannheim University's Hospital, University of Heidelberg, Germany
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14
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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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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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16
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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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Pakarinen MP. Autologous intestinal reconstruction surgery as part of comprehensive management of intestinal failure. Pediatr Surg Int 2015; 31:453-64. [PMID: 25820764 DOI: 10.1007/s00383-015-3696-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2015] [Indexed: 12/21/2022]
Abstract
Pediatric intestinal failure (IF) remains to be associated with significant morbidity and mortality, the most frequent underlying etiologies being short bowel syndrome (SBS), and primary motility disorders. Management aims to assure growth and development, while preventing complications and facilitating weaning off parenteral support (PS) by fully utilizing adaptation potential of the remaining gut. Probability of survival and weaning off PS is improved by coordinated multidisciplinary intestinal rehabilitation combining individualized physiological enteral and parenteral nutrition (PN), meticulous central line care and medical management with carefully planned surgical care. Increasing evidence suggests that autologous intestinal reconstruction (AIR) surgery is effective treatment for selected short bowel patients. Bowel lengthening procedures normalize pathological adaptation-associated short bowel dilatation with potential to support intestinal absorption and liver function by various mechanisms. Although reversed small intestinal segment, designed to prolong accelerated intestinal transit, improves absorption in adult SBS, its feasibility in children remains unclear. Controlled bowel obstruction to induce dilatation followed by bowel lengthening aims to gain extra length in patients with the shortest duodenojejunal remnant. Reduced PS requirement limits the extent of complications, improving prognosis and quality of life. The great majority of children with SBS can be weaned from PS while prognosis of intractable primary motility disorders remains poor without intestinal transplantation, which serves as a salvage therapy for life-threatening complications such as liver failure, central vein thrombosis or recurrent bloodstream infections.
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Affiliation(s)
- Mikko P Pakarinen
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group Helsinki, Children's Hospital, University of Helsinki and Helsinki University Hospital, Stenbackinkatu 11, Po Box 281, 00029 HUS, Helsinki, Finland,
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