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Hirsch TI, Wang SZ, Fligor SC, Quigley M, Gura KM, Puder M, Tsikis ST. Fat malabsorption in short bowel syndrome: A review of pathophysiology and management. Nutr Clin Pract 2024; 39 Suppl 1:S17-S28. [PMID: 38429962 PMCID: PMC10914324 DOI: 10.1002/ncp.11119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/13/2023] [Accepted: 12/28/2023] [Indexed: 03/03/2024] Open
Abstract
Fat malabsorption is central to the pathophysiology of short bowel syndrome (SBS). It occurs in patients with insufficient intestinal surface area and/or function to maintain metabolic and growth demands. Rapid intestinal transit and impaired bile acid recycling further contribute to fat malabsorption. A significant portion of patients require parenteral nutrition (PN) for their survival but may develop sepsis and liver dysfunction as a result. Despite advancements in the treatment of SBS, fat malabsorption remains a chronic issue for this vulnerable patient population. Peer-reviewed literature was assessed on the topic of fat malabsorption in SBS. Current management of patients with SBS involves dietary considerations, PN management, antidiarrheals, glucagon-like peptide 2 agonists, and multidisciplinary teams. Clinical trials have focused on improving intestinal fat absorption by facilitating fat digestion with pancreatic enzymes. Targeting fat malabsorption in SBS is a potential pathway to improving lifestyle and reducing morbidity and mortality in this rare disease.
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Affiliation(s)
- Thomas I. Hirsch
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Z. Wang
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott C. Fligor
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Mikayla Quigley
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Kathleen M. Gura
- Department of Pharmacy and the Division of Gastroenterology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark Puder
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Savas T. Tsikis
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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Frongia G, Nickkholgh A, Hafezi M MR, Arvin J, Saffari A, Golriz M, Aydin E, Weih S, Kessler M, Emami G, Garoussi C, Okun JG, Schmidt K, Thiel C, Brune M, Günther P, Holland-Cunz S, Mehrabi A. Significance of the Extent of Intestinal Resection on the Outcome of a Short-bowel Syndrome in a Porcine Model. J INVEST SURG 2015; 29:57-65. [PMID: 26375577 DOI: 10.3109/08941939.2015.1057304] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
AIM OF THE STUDY Insufficient data are available to determine the most suitable extent of intestinal resection required to induce short-bowel syndrome (SBS) in pigs. This study aimed to compare the three main SBS-models published. METHODS A 75%, 90%, or 100% mid-intestinal resection was performed in groups of n = 5 pigs each. Clinical (body weight, stool consistency) and biochemical (serum eletrolytes, citrulline, albumin, prealbumin, and transferrin) parameters were determined daily, functional (D-xylose resorption) and histological (intestinal villus length) parameters were determined after 2 weeks. A t-test and ANOVA were used for statistical analysis. RESULTS Only in the 100% group, we observed a persistent weight loss (13.6 ± 3.8%) and diarrhea, as well as a decrease in prealbumin-levels (41%) and transferrin levels (33%). Serum electrolytes remained stable in all groups during the observation period. Citrulline stabilized at different levels (100% group 13.9 ± 1.0 μmol/L; 90% group 18.8 ± 1.0 μmol/L; 75% group 26.3 ± 1.4 μmol/L; all p < .05). D-xylose resorption was lowest in the 100%, followed by 90% and 75% group (100% group 32.8 ± 4.9 mg/L; 90% group 50.0 ± 19.6 mg/L; 75% group 57.8 ± 8.8 mg/L; p = .393). Intestinal villus length decreased in all groups (100% group 11.0%; 90% group 14.0%; 75% group 19.1%). CONCLUSIONS 75% intestinal resection is less suitable as an SBS model, as animals tend to recover remarkably. The 90% model is suitable for longer-term studies, as animals might survive longer due to partial compensation. Due to severe nutritional, biochemical, and physiological derangements, the 100% model can only be used for acute experiments and those immediately followed by small bowel transplantation.
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Affiliation(s)
- Giovanni Frongia
- a Division of Pediatric Surgery, University Hospital of Heidelberg , Heidelberg , Germany
| | - Arash Nickkholgh
- b Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg , Heidelberg , Germany
| | - Mohammad Reza Hafezi M
- b Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg , Heidelberg , Germany
| | - Jalal Arvin
- b Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg , Heidelberg , Germany
| | - Arash Saffari
- b Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg , Heidelberg , Germany
| | - Mohammad Golriz
- b Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg , Heidelberg , Germany
| | - Esvad Aydin
- b Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg , Heidelberg , Germany
| | - Sandra Weih
- a Division of Pediatric Surgery, University Hospital of Heidelberg , Heidelberg , Germany
| | - Markus Kessler
- a Division of Pediatric Surgery, University Hospital of Heidelberg , Heidelberg , Germany
| | - Golnaz Emami
- b Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg , Heidelberg , Germany
| | - Camelia Garoussi
- b Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg , Heidelberg , Germany
| | - Jürgen G Okun
- c Department of Pediatrics, University Hospital of Heidelberg , Heidelberg , Germany
| | - Kathrin Schmidt
- c Department of Pediatrics, University Hospital of Heidelberg , Heidelberg , Germany
| | - Christian Thiel
- c Department of Pediatrics, University Hospital of Heidelberg , Heidelberg , Germany
| | - Maik Brune
- d Department of Internal Medicine I and Clinical Chemistry, University Hospital of Heidelberg , Heidelberg , Germany
| | - Patrick Günther
- a Division of Pediatric Surgery, University Hospital of Heidelberg , Heidelberg , Germany
| | - Stefan Holland-Cunz
- a Division of Pediatric Surgery, University Hospital of Heidelberg , Heidelberg , Germany
| | - Arianeb Mehrabi
- b Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg , Heidelberg , Germany
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Koffeman GI, Hulscher JB, Schoots IG, van Gulik TM, Heij HA, van Gemert WG. Intestinal lengthening and reversed segment in a piglet short bowel syndrome model. J Surg Res 2015; 195:433-43. [DOI: 10.1016/j.jss.2014.12.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 12/07/2014] [Accepted: 12/11/2014] [Indexed: 01/23/2023]
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Sangild PT, Ney DM, Sigalet DL, Vegge A, Burrin D. Animal models of gastrointestinal and liver diseases. Animal models of infant short bowel syndrome: translational relevance and challenges. Am J Physiol Gastrointest Liver Physiol 2014; 307:G1147-68. [PMID: 25342047 PMCID: PMC4269678 DOI: 10.1152/ajpgi.00088.2014] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Intestinal failure (IF), due to short bowel syndrome (SBS), results from surgical resection of a major portion of the intestine, leading to reduced nutrient absorption and need for parenteral nutrition (PN). The incidence is highest in infants and relates to preterm birth, necrotizing enterocolitis, atresia, gastroschisis, volvulus, and aganglionosis. Patient outcomes have improved, but there is a need to develop new therapies for SBS and to understand intestinal adaptation after different diseases, resection types, and nutritional and pharmacological interventions. Animal studies are needed to carefully evaluate the cellular mechanisms, safety, and translational relevance of new procedures. Distal intestinal resection, without a functioning colon, results in the most severe complications and adaptation may depend on the age at resection (preterm, term, young, adult). Clinically relevant therapies have recently been suggested from studies in preterm and term PN-dependent SBS piglets, with or without a functional colon. Studies in rats and mice have specifically addressed the fundamental physiological processes underlying adaptation at the cellular level, such as regulation of mucosal proliferation, apoptosis, transport, and digestive enzyme expression, and easily allow exogenous or genetic manipulation of growth factors and their receptors (e.g., glucagon-like peptide 2, growth hormone, insulin-like growth factor 1, epidermal growth factor, keratinocyte growth factor). The greater size of rats, and especially young pigs, is an advantage for testing surgical procedures and nutritional interventions (e.g., PN, milk diets, long-/short-chain lipids, pre- and probiotics). Conversely, newborn pigs (preterm or term) and weanling rats provide better insights into the developmental aspects of treatment for SBS in infants owing to their immature intestines. The review shows that a balance among practical, economical, experimental, and ethical constraints will determine the choice of SBS model for each clinical or basic research question.
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Affiliation(s)
- Per T. Sangild
- 1Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Frederiksberg, Denmark; ,2Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark;
| | - Denise M. Ney
- 3Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin;
| | | | - Andreas Vegge
- 1Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Frederiksberg, Denmark; ,5Diabetes Pharmacology, Novo Nordisk, Måløv, Denmark; and
| | - Douglas Burrin
- 6USDA-ARS Children's Nutrition Research Center, Baylor College of Medicine, Houston, Texas
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Abstract
Our recommendation at this time is that surgical bowel lengthening be considered in any chronically PN-dependent patient when there is substantial bowel dilation, regardless of remnant bowel length. Timing is determined when maximal adaptation has been achieved or when the rate of progression in enteral calories is slow and hampered by bacterial overgrowth. Currently, it seems premature to recommend primary STEP in all patients in whom surgical lengthening is considered, but it is certainly technically easier than the Bianchi procedure. These procedures are clearly indicated in patients experiencing life-threatening complications of PN, but careful selection of patients without evidence of hepatic decompensation is important. Patients with advanced liver disease are poor candidates for lengthening and should be referred for intestinal transplantation instead.
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Affiliation(s)
- Jon Thompson
- Department of Surgery, University of Nebraska, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA.
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Vento P, Kiviluoto T, Pakarinen M, Lauronen J, Halttunen J, Kivilaakso E, Soinila S. Nerve terminals containing neuropeptides decrease in number after massive proximal small bowel resection in the piglet. Dig Dis Sci 1998; 43:1102-10. [PMID: 9590428 DOI: 10.1023/a:1018803423167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this study was to evaluate possible changes in the neuropeptide innervation pattern of the remaining porcine ileum following 75% proximal resection of the small intestine. Three-month-old piglets were operated on and two months postoperatively full-thickness specimens of the proximal part of the distal ileum wall were taken. Age-matched 3- and 5-month-old unoperated piglets were used as controls. The number and intensity of VIP-, galanin-, enkephalin-, substance P-, and somatostatin-containing nerve fibers were estimated in sections processed for immunofluorescence microscopy and subjected to quantitative scoring. The VIP-, galanin-, and enkephalin-immunoreactive fibers of the circular muscle layer and villi were also quantitated by computer-assisted morphometry. The number and intensity of VIP-immunoreactive fibers in the mucosa and circular muscle layer markedly decreased after resection as compared to 3-month-old and 5-month-old controls (P < 0.05). The galanin immunoreactivity index decreased significantly after resection in the circular muscle layer as compared to both control groups (P < 0.05). The increase in the number of enkephalin-immunoreactive nerve fibers that normally occurred from 3 to 5 months of age was inhibited by the resection. We were not able to see any differences in somatostatin or substance P immunoreactivity between the groups. The results suggest that massive resection induces significant changes in the neuropeptide-containing innervation of the remaining small intestine. These findings are compatible with altered motor activity and mucosa function in the remain intestine.
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Affiliation(s)
- P Vento
- II Department of Surgery, Helsinki University Central Hospital, Finland
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Abstract
The management of short bowel syndrome requires long-term nutritional support and monitoring, medication, and occasionally additional surgical procedures. Constant attention is required to ensure adequate adaptation of the gut. This article reviews the normal function of the small bowel, adaptation following resection, total parenteral and enteral nutrition, and the role of adjunctive surgical procedures in the management of short bowel syndrome.
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Affiliation(s)
- L K Shanbhogue
- Department of Paediatric Surgery, Sophia Children's Hospital, Rotterdam, The Netherlands
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