Limited ileal resection in infancy: the long-term consequences

Providing the Best Parenteral Nutrition before and after Surgery for NEC: Macro and Micronutrients Intakes

Necrotizing enterocolitis (NEC) is the main gastrointestinal emergency of preterm infants for whom bowel rest and parenteral nutrition (PN) is essential. Despite the improvements in neonatal care, the incidence of NEC remains high (11% in preterm newborns with a birth weight <1500 g) and up to 20−50% of cases still require surgery. In this narrative review, we report how to optimize PN in severe NEC requiring surgery. PN should begin as soon as possible in the acute phase: close fluid monitoring is advocated to maintain volemia, however fluid overload and electrolytes abnormalities should be prevented. Macronutrients intake (protein, glucose, and lipids) should be adequately guaranteed and is essential in each phase of the disease. Composite lipid emulsion should be the first choice to reduce the risk of parenteral nutrition associated liver disease (PNALD). Vitamin and trace elements deficiency or overload are frequent in long-term PN, therefore careful monitoring should be planned starting from the recovery phase to adjust their parenteral intake. Neonatologists must be aware of the role of nutrition especially in patients requiring long-term PN to sustain growth, limiting possible adverse effects and long-term deficiencies.

Gastrointestinal sequelae after surgery for necrotising enterocolitis: a systematic review and meta-analysis

OBJECTIVES

To document what types of gastrointestinal sequelae were described after surgery for necrotising enterocolitis (NEC) and to analyse their frequency.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, EMBASE and the Cochrane library (CENTRAL) from 1990 to October 2016.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included studies, which provided original data on the occurrence of gastrointestinal sequelae in patients surviving surgery for NEC. Meta-analysis and metaregression to assess heterogeneity were performed for studies including 10 or more patients with gastrointestinal strictures, recurrence of NEC, intestinal failure (IF) and adhesion ileus.

RESULTS

Altogether 58 studies, including 4260 patients, met the inclusion criteria. Strictures were reported to occur in 24% (95% CI 17% to 31%) of surviving patients, recurrence of NEC in 8% (95% CI 3% to 15%), IF in 13% (95% CI 7% to 19%) and adhesion ileus in 6% (95% CI 4% to 9%). Strictures were more common following enterostomy (30%; 95% CI 23% to 37%) than after primary anastomosis (8%; 95% CI 0% to 23%) and occurred more often after enterostomy without bowel resection than with bowel resection. We found considerable heterogeneity in the weighted average frequency of all sequelae (I² range: 38%-90%). Intestinal outcomes were poorly defined, there were important differences in study populations and designs, and the reported findings bear a substantial risk of bias.

CONCLUSIONS

Gastrointestinal sequelae in neonates surviving surgery for NEC are frequent. Long-term follow-up assessing defined gastrointestinal outcomes is warranted.

How to feed a baby recovering from necrotising enterocolitis when maternal milk is not available

Necrotising enterocolitis (NEC) is a devastating disease with significant mortality and serious adverse outcomes in at least 50% including short gut and poor neurodevelopment. Research and management are complicated by a lack of robust clinical markers, and without histological confirmation, there is a risk of both underdiagnosis and overdiagnosis. Interunit variations in the thresholds for surgical referral, laparotomy and postmortem rates mean the actual incidence is difficult to determine, especially because the histological term 'NEC' is used in practice to describe a heterogeneous clinical syndrome. In this article, we discuss issues relating to choice of milk feed type following a clinical diagnosis of 'NEC' where mother's own milk is not available. We review common clinical concerns relating to feeding following NEC and the rationale for modifications of the macronutrient composition and quality of formula milk.

Ileocaecal valve syndrome after surgery in adult patients: myth or reality?

AIM

The onset of symptoms after removal of the ileocaecal valve (ICV) may be perceived as an unwanted effect of surgery and induce patients to bring unnecessary litigation against surgeons. The aim of our study is to assess the real impact on the quality of life of patients whose ICV has been surgically removed, using three validated questionnaires.

METHOD

In patients who had their ICV removed surgically, the Gastrointestinal Quality of life (GIQLI) questionnaire and those used by the European Organization for research and Treatment of Cancer (EORTC) were administered before and after surgery. The empirical rule effect size method was used to evaluate the clinical significance of the statistical data.

RESULTS

We interviewed 225 patients. Data collected through the three questionnaires highlighted a trend towards postoperative improvement of the selected gastrointestinal symptoms compared with the baseline. The GIQLI questionnaire showed a statistically significant improvement in 'pain', 'nausea' and 'constipation' during the follow-up. Constipation appeared more frequently in patients older than 70 years compared with younger ones. The EORTC-QLQ-C30 questionnaire showed a significant correlation between diarrhoea and extended right colectomy at 3 months after surgery, which was not confirmed at 6 months. The EORTC QLQ-CR29 questionnaire showed a slight deterioration of 'leakage of stools from the anal opening' at 6 months after surgery, but this symptom was not deemed clinically significant.

CONCLUSION

We found that bowel functions in most patients after surgical removal of the ICV were satisfactory. Providing patients with a comprehensive and exhaustive informed consent during preoperative consultations could promote patient trust and avoid misunderstandings.

Short bowel syndrome in children: current and potential therapies

Short bowel syndrome (SBS) reflects a state of malabsorption that occurs due to loss of a significant portion of the small bowel. The pathophysiology of SBS is determined largely by the process of adaptation, which is the innate attempt by the remnant portions of the intestine to increase fluid and nutrient reabsorption. In recent years, emphasis has been placed on intestinal rehabilitation with multidisciplinary teams as a comprehensive approach to the management of patients with SBS. In our institution, the multidisciplinary team members include pediatric gastroenterologists, pediatric surgeons, pediatric dieticians, physical therapists, occupational therapists, neonatologists (especially for patients still under their care), transplant surgeons, transplant coordinators and social workers. Parenteral nutrition plays a significant role in the management of SBS, but its use is associated with many potential complications, including cholestatic liver disease. Fish oil-based lipid emulsions have shown promise in their ability to reverse and also prevent the development of cholestasis in these patients. Clinical trials have shown that growth factors and other trophic hormones facilitate the process of adaptation. The most significant impact has been shown with the use of glucagon-like peptide-2 and its analog (teduglutide). Surgical interventions remain an important part of the management of SBS to facilitate adaptation and treat complications. Intestinal transplantation is a last resort option when the process of adaptation is unsuccessful. This review article is intended to provide an overview of the conventional and emerging therapies for pediatric SBS.

An alternative management option for colonic atresia preventing loss of the ileocecal valve

PURPOSE

Management of colonic atresia is contentious, with primary anastomosis having a notable risk of anastomotic leak. In addition, resection of the terminal ileum and ileocecal (i-c) valve is frequently performed, risking side effects such as diarrhea, vitamin B(12) deficiency, and gall stone formation.

METHODS

The hospital coding system was searched for all patients with a diagnosis of colonic atresia between July 2005 and July 2008. Four term neonates were managed by formation of an ileostomy, a "blow hole" stoma just proximal to the atresia, and a mucus fistula distal to the atresia.

RESULTS

Average time to full feeds was 7.5 days (range, 3-12 days), and average length of stay was 23 days (range, 13-47 days). Stoma management, problematic in 2 infants, was individualized by a specialist stoma nurse. Ileostomy output was refed into the mucus fistula. Complications included 3 episodes of prolapse of the blow hole stoma in infant 2. All of the infants returned to the operating theater at 1 to 3 months of age for restoration of bowel continuity and closure of the ileostomy. The atretic segment was resected, and an end-to-end anastomosis was performed. Recovery was straightforward in all cases.

CONCLUSION

A procedure that retains the i-c valve and most of the colon through creation of a blow hole stoma in the distended proximal colon with a diverting ileostomy and mucus fistula is described. The technique is recommended in selected infants as bowel length and anatomy can be preserved, despite the use of multiple stomas.

Nutritional deficiencies in intestinal failure

Intestinal failure (IF) is the ultimate malabsorption state, with multiple causes, requiring long-term therapy with enteral or intravenous fluids and nutrient supplements. The primary goal during management of children with potentially reversible IF is to promote intestinal autonomy while supporting normal growth, nutrient status, and preventing complications from parenteral nutrition therapy. This article presents how an improved understanding of digestive pathophysiology is essential for diagnosis, successful management, and prevention of nutrient deficiencies in children with IF.

Prevalence and outcome of anemia after restorative proctocolectomy: a clinical literature review

PURPOSE

Iron and/or vitamin B12 deficiency anemias, which have adverse effects on patients' quality of life, are commonly observed and often overlooked complications after restorative proctocolectomy. We performed a systematic review of publications on the prevalence of anemia as well as on the impact of anemia on a range of clinical, functional, quality of life, and economic outcomes in restorative proctocolectomy patients. This information is important to help healthcare providers through a comprehensive overview to increase awareness about a condition that could require therapy to improve patient healthcare and quality of life.

METHODS

We reviewed the English language publications on the incidence of anemia and its adverse effect after restorative proctocolectomy The United States National Library of Medicine database (MEDLINE), the Excerpta Medica database (EMBASE), the Cochran Library, and the Google search engine were searched for published articles on the prevalence and impact of anemia in post-restorative proctocolectomy surgical patients.

RESULTS

The long-term complication most frequently described after RPC is pouchitis. Pouchitis is significantly associated with iron deficiency anemia caused by pouch mucosal bleeding. Other causes are insufficient and/or impaired iron absorption. It has also been observed, however, that restorative proctocolectomy patients with underlying familial adenomatous polyposis rarely develop pouchitis yet show higher rates of iron deficiency anemia compared to those patients with underlying ulcerative colitis. Other causes shown as independent risk factors for iron deficiency anemia in restorative proctocolectomy patients are malignancy, desmoid tumors, and J-pouch configuration. Vitamin B12 deficiency anemia is also common after restorative proctocolectomy. About one-third of restorative proctocolectomy patients show abnormal Schilling test and 5 percent have low referenced serum cobalamin. It has been observed that the degree resection of the terminal-ileum, malabsorption, bacterial overgrowth, and dietary factors are among the known causes of cobalamin deficiency. Folate deficiency has not been reported in restorative proctocolectomy patients. Describing restorative proctocolectomy surgery and its outcomes, in patients without anemia, the quality of life is reported excellent regardless of operative technique.

CONCLUSIONS

Anemia is not uncommon following restorative proctocolectomy and has been shown to have negative effects on the patient's quality of life and the economy and may substantially increase healthcare costs. The treatment of anemia and its underlying causes is important to improving clinical and economic outcomes.

Vitamin B12 malabsorption in patients with limited ileal resection

OBJECTIVES

Patients with Crohn's disease who have terminal ileal resections are at risk for vitamin B12 malabsorption. Our aim was to determine whether the length of terminal ileum resected correlated with an abnormal Schilling test result.

METHODS

Patients with a history of ileal resection had the length of small bowel removed determined by review of their pathology report. Patients who had a Schilling test within 3 mo of surgery or who had a documented normal terminal ileum at the time of the Schilling test were included in the study.

RESULTS

Fifty-six patients were included in the study. Patients who had <20 cm of terminal ileum resected (n = 14) did not develop abnormal Schilling test results; 52% of the remainder (n = 42) had abnormal Schilling test results and there was no clear correlation between resection length and abnormal Schilling test result.

CONCLUSIONS

Patients with Crohn's disease and terminal ileal resections <20 cm are not at risk of developing vitamin B12 deficiency. For patients with resections of 20-60 cm, options include doing a Schilling test and treating those with abnormal results, empirically treating patients on the presumption that they are at high risk of developing deficiency, or monitoring for biochemical evidence of deficiency. Further studies are needed to determine whether oral supplementation is effective in these patients.

Abdominal drain placement versus laparotomy for necrotizing enterocolitis with perforation

Perforated NEC in the fragile, premature infant remains a complex neonatal and surgical problem. Future investigation into the basic mechanisms of the intestinal inflammatory response in the premature neonate may allow for preventive strategies in the management of NEC. Until then, surgical management for perforated NEC will remain a necessary intervention to treat the complications of this disease. The two most commonly used surgical strategies for perforated NEC are laparotomy, bowel resection, and enterostomy versus primary peritoneal drainage. There are no compelling, prospective, controlled data supporting one procedure over the other. Although there are several surgical options for treating perforated NEC, definitive evidence-based guidelines for the best surgical treatment in terms of survival outcome remain to be determined.

Gallstone composition: are children different?

During a 5-year period (1997-2002) 20 consecutive children (11 boys; median age, 8 years; range, 0.3-13.9 years) underwent cholecystectomy for cholelithiasis at a regional pediatric surgical center. Multiple stones were present in 16 patients (80%). All stones were collected prospectively. Composition studies were performed after grinding an aliquot of stone and examining a layer of crushed powder by Fourier transform infrared microspectroscopy. The relative proportions of each major stone component were assessed: cholesterol, protein and calcium salts of bilirubin, fatty acids, carbonate, and hydroxyapatite. Of the 20 children, 10 had black pigment stones, 2 had cholesterol stones, 1 had brown pigment stones, and 7 had calcium carbonate stones; the latter are exceptionally rare in adults. The composition of pediatric gallstones in this series differs from that found in adults.

Short bowel syndrome in infants and children: an overview

Short bowel syndrome is a spectrum of malnutrition resulting from inadequate bowel length. In infant and pediatric patients, the most common causes are necrotizing enterocolitis, abdominal wall defects, jejunal ileal atresia, and mid gut volvulus. There appear to be regional variations in etiology. Since the publication of Wilmore's classic monograph in 1972, there have been significant improvements in monitoring and nutritional support. In the modern era, survival rate ranges from 80% to 94%, and the presence or absence the ileal cecal valve appears to not impact on mortality rate, but does significantly affect the length of time on total parenteral nutrition TPN. The most common morbidities remain sepsis, both central line related and bacterial overgrowth, and TPN cholestasis. Long-term recovery of these children often is remarkably normal, but there is a 10% to 15% incidence of neurologic and developmental defects. The clinical and ethical considerations around the care of infants with 20 to 40 cm of residual bowel remains controversial, as does the place of intestinal transplantation, especially in patients developing gut failure in infancy. Perioperative surgical decision making plays a critical role in the long-term outcome of these patients. This chapter presents an overview of the current status of care and outcome in this difficult population; these topics are further expanded in subsequent chapters.