Short bowel syndrome in infants and children

Complementary food introduction practices in infants with intestinal failure

BACKGROUND

Oral intake in infants with intestinal failure (IF) may be limited due to intolerance or feeding difficulties. Guidelines for the introduction of semisolid or solid complementary foods (CFs) to infants with IF do not exist. CF intake and caloric contribution from CF is difficult to assess due to malabsorption and incomplete recording. The aim of this study was to identify institutional approaches to introducing CF to infants with IF.

METHODS

The American Society for Parenteral and Enteral Nutriton (ASPEN) Pediatric Intestinal Failure Section Registered Dietitian/Nutritionist (RDN) working group designed a 10-question online cloud-based survey to assess group member practice related to the introduction of CF to infants with IF.

RESULTS

Twenty-six surveys were completed. Thirteen (50%) RDNs recommend introduction of CF between 4 and 6 months of age. Nineteen (76%) recommend adding pureed foods to gastrostomy tube feedings. Seventeen (65%) follow standard infant feeding practice guidelines with half citing the American Academy of Pediatrics. Approximately half (44%) recommend introducing vegetables first and the majority (80%) recommend delaying the introduction of fruits. The vast majority (92%) recommend specific foods to minimize stool output including green beans, bananas, infant cereals, and meats/protein.

CONCLUSION

Institutional practices related to the introduction of CF to infants with IF vary. Similarities with first food choice and foods to avoid were observed. Evidenced-based practice guidelines for the introduction of CF to infants with IF need to be established to determine best practices for reducing stool output, encouraging weaning from parenteral nutrition, and achieving enteral autonomy.

ASPEN definitions in pediatric intestinal failure

Pediatric intestinal failure (PIF) is a relatively rare disease entity which requires focused interdisciplinary care and specialized nutrition management. There has long been a lack of consensus in the definition of key terms related to PIF due to its rarity and plethora of small studies rather than large trials. As such, the American Society for Parenteral and Enteral Nutrition (ASPEN) Pediatric Intestinal Failure Section, composed of clinicians from a variety of disciplines caring for children with intestinal failure, is uniquely poised to provide insight into this definition void. This document is the product of an effort by the Section to create evidence-based consensus definitions, with the goal of allowing for appropriate comparisons between clinical studies and measurement of longterm patient outcomes. This manuscript was approved by the ASPEN Board of Directors. This article is protected by copyright. All rights reserved.

Epidemiologic Associations Between Short-Bowel Syndrome and Bloodstream Infection Among Hospitalized Children

BACKGROUND

Children with short bowel syndrome (SBS) suffer from strikingly high rates of morbidity and mortality, due in part to their susceptibility to life-threatening infectious diseases. Few large, multisite studies have evaluated patient-specific factors associated with bacteremia in hospitalized children with and without SBS.

METHODS

We conducted a case-control study to examine the epidemiological associations between SBS and bloodstream infections (BSI) in hospitalized children. Pediatric BSI cases and controls were selected from a prospective cohort study conducted at 3 New York City hospitals.

RESULTS

Among 40 723 hospital admissions of 30 179 children, 1047 diagnoses of BSI were identified. A total of 64 children had a diagnosis of SBS. BSI was identified frequently among hospitalizations for children admitted with SBS (n = 207/450, 46%) compared to hospitalizations for children without the condition (n = 840/40 273, 2.1%, P < .001). While this population represented only 0.2% of our overall cohort, it accounted for nearly 20% of all hospital admissions with BSI. Multivariable analysis identified 8 factors significantly associated with pediatric hospitalizations with BSI. These included a diagnosis of SBS (odds ratio [OR] 19.0), ages 1-5 years (OR 1.33), presence of a non-Broviac-Hickman central venous catheter (OR 6.36), immunosuppression (OR 0.53), kidney injury (OR 6.67), organ transplantation (OR 4.44), admission from a skilled nursing facility (OR 2.66), and cirrhosis (OR 7.23).

CONCLUSIONS

While several clinical characteristics are contributory to the risk of BSI in children, SBS remains the single strongest predictor. Further research into the mediators of this risk will be essential for the development of prevention strategies for this vulnerable population.

Adult zebrafish intestine resection: a novel model of short bowel syndrome, adaptation, and intestinal stem cell regeneration

Loss of significant intestinal length from congenital anomaly or disease may lead to short bowel syndrome (SBS); intestinal failure may be partially offset by a gain in epithelial surface area, termed adaptation. Current in vivo models of SBS are costly and technically challenging. Operative times and survival rates have slowed extension to transgenic models. We created a new reproducible in vivo model of SBS in zebrafish, a tractable vertebrate model, to facilitate investigation of the mechanisms of intestinal adaptation. Proximal intestinal diversion at segment 1 (S1, equivalent to jejunum) was performed in adult male zebrafish. SBS fish emptied distal intestinal contents via stoma as in the human disease. After 2 wk, S1 was dilated compared with controls and villus ridges had increased complexity, contributing to greater villus epithelial perimeter. The number of intervillus pockets, the intestinal stem cell zone of the zebrafish increased and contained a higher number of bromodeoxyuridine (BrdU)-labeled cells after 2 wk of SBS. Egf receptor and a subset of its ligands, also drivers of adaptation, were upregulated in SBS fish. Igf has been reported as a driver of intestinal adaptation in other animal models, and SBS fish exposed to a pharmacological inhibitor of the Igf receptor failed to demonstrate signs of intestinal adaptation, such as increased inner epithelial perimeter and BrdU incorporation. We describe a technically feasible model of human SBS in the zebrafish, a faster and less expensive tool to investigate intestinal stem cell plasticity as well as the mechanisms that drive intestinal adaptation.

Increased Anti-Flagellin and Anti-Lipopolysaccharide Immunoglobulins in Pediatric Intestinal Failure: Associations With Fever and Central Line-Associated Bloodstream Infections

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) pose a significant challenge in the lives of patients with intestinal failure (IF). We hypothesized that plasma immunoglobulins against flagellin (FLiC) and lipopolysaccharide (LPS) would be able to differentiate CLABSIs from nonbacterial febrile episodes and that levels would increase with infection and decline following appropriate antibiotic treatment.

MATERIALS AND METHODS

Patients with IF, due to short bowel syndrome, between the ages of 3 months and 4 years of age, were recruited at Cincinnati Children's Hospital Medical Center. Anti-FLiC and anti-LPS plasma antibody levels were measured in 13 children with IF at baseline, during febrile events, and also following treatment with antibiotics. These were also measured in 11 healthy children without IF who were recruited as controls.

RESULTS

Plasma anti-FLiC IgA levels increased during febrile episodes in all patients with IF (baseline mean of 1.10 vs febrile episode mean of 1.32 optical density units, respectively; P = .046). Neither plasma anti-FLiC nor anti-LPS IgA or IgG levels distinguished CLABSI from nonbacterial febrile episodes compared with baseline levels. Compared with controls, patients with IF had significantly higher plasma levels of anti-FLiC and anti-LPS IgA at baseline.

CONCLUSION

Plasma anti-FLiC IgA antibody levels rise during febrile episodes but do not differentiate between nonbacterial febrile illnesses and CLABSIs in pediatric IF. However, the upregulation of these antibodies in IF suggests the baseline systemic presence of Gram-negative bacterial products.

Bloodstream infections in very low birth weight infants with intestinal failure

OBJECTIVE

To examine pathogens and other characteristics associated with late-onset bloodstream infections (BSIs) in infants with intestinal failure (IF) as a consequence of necrotizing enterocolitis (NEC).

STUDY DESIGN

Infants weighing 401-1500 g at birth who survived for >72 hours and received care at Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network centers were studied. The frequency of culture-positive BSI and pathogens were compared in infants with medically managed NEC, NEC managed surgically without IF, and surgical IF. Among infants with IF, the duration of parenteral nutrition (PN) and other outcomes were evaluated.

RESULTS

A total of 932 infants were studied (IF, n = 78; surgical NEC without IF, n = 452; medical NEC, n = 402). The proportion with BSI after diagnosis of NEC was higher in the infants with IF than in those with surgical NEC (P = .007) or medical NEC (P < .001). Gram-positive pathogens were most frequent. Among infants with IF, an increased number of infections was associated with longer hospitalization and duration of PN (median stay: 172 for those with 0 infections, 188 days for those with 1 infection, and 260 days for those with ≥2 infections [P = .06]; median duration of PN: 90, 112, and 115 days, respectively [P = .003]) and decreased achievement of full feeds during hospitalization (87%, 67%, and 50%, respectively; P = .03).

CONCLUSION

Recurrent BSIs are common in very low birth weight infants with IF. Gram-positive bacteria were the most commonly identified organisms in these infants.

The rate of bloodstream infection is high in infants with short bowel syndrome: relationship with small bowel bacterial overgrowth, enteral feeding, and inflammatory and immune responses

OBJECTIVE

This pilot study in parenteral nutrition-dependent infants with short bowel syndrome (SBS) evaluated the impact of feeding route and intestinal permeability on bloodstream infection (BSI), small bowel bacterial overgrowth (SBBO), and systemic immune responses, as well as fecal calprotectin as a biomarker for SBBO.

STUDY DESIGN

Ten infants (ages 4.2-15.4 months) with SBS caused by necrotizing enterocolitis were evaluated. Nutritional assessment, breath hydrogen testing, intestinal permeability, fecal calprotectin, serum flagellin- and lipopolysaccharide-specific antibody titers, and proinflammatory cytokine concentrations (tumor necrosis factor-alpha [TNF-alpha], interleukin-1 beta, -6, and -8) were performed at baseline and at 60 and 120 days. Healthy, age-matched control subjects (n = 5) were recruited.

RESULTS

BSI incidence was high (80%), and SBBO was common (50%). SBBO increased the odds for BSI (>7-fold; P = .009). Calprotectin levels were higher in children with SBS and SBBO versus those without SBBO and healthy control subjects (P < .05). Serum TNF-alpha, was elevated at baseline versus controls. Serum TNF-alpha and interleukin-1 beta, -6, and -8 levels diminished with increased enteral nutrition. Anti-flagellin and anti-lipopolysaccharide immunoglobulin G levels in children with SBS were lower versus control subjects and rose over time.

CONCLUSION

In children with SBS, SBBO increases the risk for BSI, and systemic proinflammatory response decreases with increasing enteral feeding and weaning parenteral nutrition.

Pediatric short-bowel syndrome: the cost of comprehensive care

BACKGROUND

Little information is available about the financial charges incurred by patients with short-bowel syndrome (SBS). This is particularly true for pediatric SBS patients who receive some of the most complex medical care.

OBJECTIVES

The aims of this study were to determine the total cost of care for these patients and to analyze their utilization of home and hospital-based health care services.

DESIGN

This was a retrospective review of the total charges incurred by 41 children with SBS over the past decade, encompassing both inpatient and home-care charges.

RESULTS

The mean (+/- SD) total cost of care for pediatric SBS was US$505 250 +/- US$248 398 (corrected for inflation to the year 2005) for the first year of care alone. Inpatient hospitalization accounted for most of these expenses (US$416 818 +/- US$242 689, or 82% of the total), and this was attributable to prolonged requirements for intensive care resources, numerous surgical procedures, and multiple readmissions during the first year of diagnosis. Hospital-based costs steadily declined in subsequent years, but home-care services, in stark contrast, unexpectedly increased every year for the first 5 y of diagnosis-a trend that was highly significant (P < 0.005), reaching US$184 520 +/- US$111 075 for the fifth year of home care. This increasing cost was attributable to increasing complications of parenteral nutrition, especially infectious complications. Although per-patient charges varied widely, the mean total cost of care per child over a 5-y period was US$1 619 851 +/- US$1 028 985. A strong correlation was found between higher charges and infants with <10% of predicted small-bowel length.

CONCLUSIONS

This study was the first to calculate the total costs for pediatric SBS patients and to provide an in-depth analysis of these patients' actual utilization of health care services. This information may help guide health care providers and families who have children with SBS. The comprehensive care of pediatric SBS patients costs significantly more than has previously been estimated. Contrary to previous views, home care significantly increases each year after diagnosis.

Very low birth weight preterm infants with surgical short bowel syndrome: incidence, morbidity and mortality, and growth outcomes at 18 to 22 months

OBJECTIVES

The objective of this study was to determine the (1) incidence of short bowel syndrome in very low birth weight (<1500 g) infants, (2) associated morbidity and mortality during initial hospitalization, and (3) impact on short-term growth and nutrition in extremely low birth weight (<1000 g) infants.

METHODS

Infants who were born from January 1, 2002, through June 30, 2005, and enrolled in the National Institute of Child Health and Human Development Neonatal Research Network were studied. Risk factors for developing short bowel syndrome as a result of partial bowel resection (surgical short bowel syndrome) and outcomes were evaluated for all neonates until hospital discharge, death, or 120 days. Extremely low birth weight survivors were further evaluated at 18 to 22 months' corrected age for feeding methods and growth.

RESULTS

The incidence of surgical short bowel syndrome in this cohort of 12316 very low birth weight infants was 0.7%. Necrotizing enterocolitis was the most common diagnosis associated with surgical short bowel syndrome. More very low birth weight infants with short bowel syndrome (20%) died during initial hospitalization than those without necrotizing enterocolitis or short bowel syndrome (12%) but fewer than the infants with surgical necrotizing enterocolitis without short bowel syndrome (53%). Among 5657 extremely low birth weight infants, the incidence of surgical short bowel syndrome was 1.1%. At 18 to 22 months, extremely low birth weight infants with short bowel syndrome were more likely to still require tube feeding (33%) and to have been rehospitalized (79%). Moreover, these infants had growth delay with shorter lengths and smaller head circumferences than infants without necrotizing enterocolitis or short bowel syndrome.

CONCLUSIONS

Short bowel syndrome is rare in neonates but has a high mortality rate. At 18 to 22 months' corrected age, extremely low birth weight infants with short bowel syndrome were more likely to have growth failure than infants without short bowel syndrome.

Small bowel bacterial overgrowth: a negative factor in gut adaptation in pediatric SBS

Small bowel bacterial overgrowth (SBBO) is common in infants and children with short bowel syndrome (SBS). Its occurrence is due to alterations in anatomy, motility, and secretion, which promote the abnormal growth of bacteria. SBBO is associated with significant clinical problems, including prolonged dependence on parenteral nutrition, liver injury, and malabsorption. A major clinical challenge is in making the correct diagnosis of bacterial overgrowth. Management of this disorder is still poorly understood and should be evaluated adequately. This review addresses the current understanding of bacteria in the intestines and issues related to bacterial overgrowth in pediatric SBS.

A case study utilizing an enteral refeeding technique in a premature infant with short bowel syndrome

Premature and full-term infants may be born with congenital abnormalities or develop acquired lesions of the gastrointestinal tract that require the placement of an enterostomy. Enterostomies can result in significant segments of excluded small bowel, creating a functional short bowel syndrome. Infants with enterostomies can develop dehydration, electrolyte imbalance, and failure to thrive. An illustrative case report of a premature infant with short bowel syndrome treated with enteral refeedings via a mucous fistula is presented. This report highlights the lessons learned from the interdisciplinary team's collective 10-year experience with enteral refeeding in infants with enterostomies. The physiologic basis for this approach is reviewed and literature reports are outlined. The specific nursing care and step-by-step techniques to deliver enteral refeeding through the mucous fistula are provided along with implications for clinical practice, education, and research.

The anabolic effects of recombinant human growth hormone and glutamine on parenterally fed, short bowel rats

AIM: To evaluate the metabolic effects associated with administration of rhGH and/or Gln in parenterally fed, short-bowel rats.

METHODS: Forty SD rats subjected to 75% intestinal resection and maintained with parenteral nutrition were randomly divided into 4 groups as follows: -rhGH, -Gln; -rhGH, +Gln; +rhGH, -Gln; +rhGH, +Gln. Body weight and nitrogen balance were evaluated daily. After 6 d of PN, rats were killed, various organs were dissected and weighted, the carcasses were used for analysis of body composition. Serum GH and IGF-1 were determined by RIA method.

RESULTS: Weight loss in rats with rhGH (17.4 ± 12.8 g) and rhGH+Gln (23.8 ± 3.5 g) was significantly less than rats with PN alone (29.6 ± 6.9 g) and rats with Gln-supplemented PN (31.85 ± 12.8 g), P < 0.05. The accumulated NB in rats with rhGH (1252.9 ± 294.3 mg N/d) and rhGH+Gln (1261.7 ± 85.5 mg N/d) was significantly greater than those with PN alone (704.8 ± 379.0 mg N/d) and with Gln-supplemented PN (856.7 ± 284.4 mg N/d), P < 0.05. The absolute weight of gastrocnemius muscle in rats with rhGH (2683.9 ± 341.6 mg) and rhGH+Gln (2579.1 ± 359.5 mg) was greater than those with PN alone (2176.3 ± 167.1 mg) and with Gln-supplemented PN (2141.9 ± 353.6 mg). Although the absolute weight of remnant small intestine itself was not significantly different in 4 experimental groups, the weight/length of the segments was greater in rats with rhGH and/or Gln (48.7 ± 5.5, 52.7 ± 4.1 and 67.4 ± 5.3 respectively) than those with PN alone (47.8 ± 5.0), there were synergistic effects between rhGH and Gln in improvement of the weight/length of remnant small intestine, P < 0.05. Analyses of body carcass composition showed that a higher percentage of carcass weight as protein and a lower percentage of carcass weight as fat were occurred in rats with rhGH (20.8 ± 4.0, 6.0 ± 2.6) and rhGH+Gln (21.3 ± 2.4, 4.4 ± 1.5) than those with PN alone (16.4 ± 2.4, 9.2 ± 3.7) and with Gln-supplemented PN (17.8 ± 3.0, 6.3 ± 2.0), rhGH had significant effects on alteration of body composition, P < 0.05. Serum GH and IGF-1 concentration in rats with rhGH (5.221 ± 0.8 and 425.1 ± 19.2 ng/mL respectively) and rhGH+Gln (5.507 ± 1.0 and 461.1 ± 49.9 ng/mL respectively) were greater than those with PN alone (3.327 ± 1.7 and 325.8 ± 29.6 ng/mL respectively) and with Gln-supplemented PN (3.433 ± 0.1 and 347.7 ± 55.7 ng/mL respectively), P < 0.01.

CONCLUSION: rhGH significantly improves the anabolism in parenterally fed. Short bowel rats, anabolic effect with Gln is less dramatic, there is no synergistic effect between rhGH and Gln in improvement of whole body anabolism. IGF-1 plays an important part in growth-promoting effects of rhGH.

Intestinal adaptation in short bowel syndrome

Regaining enteral autonomy after extensive small bowel resection is dependent on intestinal adaptation. This adaptational process is characterized by hyperplastic growth of the remaining gut, which is accompanied by both an increase of cell division at the level of the crypt cells and by an increased rate of programmed cell death (apoptosis). Apart from the absorptive function, the small bowel also has a barrier function and plays an important role in interorgan metabolism. Also, these functions are greatly affected by a massive intestinal resection and subsequent recovery by intestinal adaptation. This review aims to give an overview of the debilitating effects of massive intestinal resection on gut function and subsequently discusses intestinal adaptation and possible factors stimulating adaptation.

Coordinated interdisciplinary management of pediatric intestinal failure: a 2-year review

BACKGROUND/PURPOSE

Intestinal failure is a complex metabolic process that results from malabsorption and malnutrition and provides challenges for a variety of pediatric subspecialists. The purpose of this study was to evaluate the effect of coordinated interdisciplinary team management of children with intestinal failure on nutritional outcome measures.

METHODS

The Intestinal Care Center (ICC) is staffed with an interdisciplinary team of pediatric specialists including a gastroenterologist, pediatric surgeon, transplant surgeon, clinical dietitians, and a nutrition support nurse. Using an established registry, the authors conducted a comprehensive evaluation of patient data including anthropometric measures, organ system function, and mode of nutrition support. Disease-associated complications including micronutrient deficiencies, growth delay, and death also were monitored. Nutritional outcome was assessed by transition from enteral to oral feeding, cessation of total parenteral nutrition (TPN), and maintenance of linear growth.

RESULTS

Since the inception of the ICC in 1996, 103 patients (69 boys, 34 girls) with intestinal failure have been evaluated with a median age of 2.6 years (range, 0.2 to 21.3 years). Mode of nutritional therapy on initial consultation included TPN (n = 76, 74%), enteral feedings (n = 6, 6%) and oral intake (n = 21, 20%). After intensive management of the 76 patients who were TPN dependent, 22 (29%) subsequently have been weaned from TPN (duration, 0.2 to 17.5 years) to oral (n = 14), oral-enteral (n = 4) or enteral feedings (n = 4). Of the 6 patients who were receiving enteral feedings, 4 (67%) were transitioned to oral feedings. Sixty-eight patients (66%) had evidence of hepatic disease. Of these, 10 underwent transplant, and 23 died (2 posttransplant). Linear growth velocity of neither pre- nor postpubescent patients significantly improved during the 2-year study period.

CONCLUSION

Data registry establishment and concurrent interdisciplinary team management of children with intestinal failure provides for innovative treatment approaches and a foundation for retrospective or prospective assessment of children with disease.

Insulinlike growth factor 1 and insulinlike growth factor 3: indices of intestinal failure in children

BACKGROUND/PURPOSE

A number of pediatric patients with short bowel syndrome (SBS) manifest growth failure despite aggressive nutritional support. Exogenous growth hormone (GH) therapy in children with SBS has proved disappointing. The purpose of this study was to determine if there were characteristic patterns of GH, IGF-1, or IGFBP-3 levels in pediatric SBS patients with profound growth failure in an effort to elucidate an early strategic approach to management of SBS in the subpopulation.

METHODS

Forty patients (29 boys, 11 girls; mean age, 5.3 years; range, 0.5 to 18.6 years) with SBS (<30% total bowel length) who received intensive nutrition support and follow-up underwent serological tests for GH, IGF-1, IGFBP-3, and thyroid function. Height (HT), weight (WT), and bone age were assessed relative to age-appropriate percentiles. Growth failure was defined as a HT and WT at less than the fifth percentile and bone age > or = 2 standard deviations below actual age. Residual small bowel length was determined by review of pathological and operative reports. Comparisons between the growth factors, bowel length, and anthropometric data were analyzed by chi2.

RESULTS

Two distinct subgroups of patients emerged from our study. Thirty-eight percent of patients (n = 11) had growth failure by anthropometry that was associated significantly with low IGF-1 independently and with both IGF-1 and IGFBP-3 levels (P< 0.05). There were no significant associations with GH level, thyroid function, small bowel length, or the amount of parenteral versus enteral intake in either subgroup of these patients. Low IGF-1 and IGFBP-3 but not GH levels may be indices of intestinal failure in pediatric SBS. Growth in this subpopulation is refractory to aggressive standard approaches to nutritional support and may require early interventions.

CONCLUSION

Exogenous IGF-1 and IGFBP-3, not GH, may be beneficial to treat this subpopulation.

Enhancement of intestinal adaptation by hepatocyte growth factor

BACKGROUND/PURPOSE

Hepatocyte growth factor (HGF) was originally shown to enhance hepatocyte DNA synthesis. Recently, the expression of HGF and its receptor (c-met) were observed in the intestinal tract. In a previous study, we demonstrated that HGF can increase normal rat intestinal epithelial mass and function in vivo. This study was designed to determine if HGF, given either systemically or luminally, can enhance intestinal epithelial mass and function beyond the normal adaptive response after massive small bowel resection.

METHODS

Twenty young adult male Sprague-Dawley rats underwent an 80% small bowel resection. Seven days after resection, systemic infusion (via the jugular vein) or luminal perfusion (via the jejunum) were performed using subcutaneously placed osmotic minipumps. The rats were divided into four groups: group 1, systemic saline, (control, n=5); group 2, systemic HGF at 150 microg/kg/d (n=5); group 3, luminal saline, (control, n=5); and group 4, luminal HGF at 75 microg/kg/d (n=5). After a 14-day infusion, [C14] galactose and [C14] glycine absorption (micromol/cm2 intestine), mucosal DNA content (microg/mg mucosa) and protein content (microg/mg mucosa) were measured in the remaining small intestine of each rat.

RESULTS

Systemic infusion of HGF increased galactose absorption 68% (P<.05), glycine absorption 57% (P<.05), DNA content 17% (P<.01), and protein content 57% (P<.01), when compared with the appropriate control. Luminal perfusion of HGF also increased galactose absorption 114% (P<.01), glycine absorption 126% (P<.01), DNA content 32% (P<.01), and protein content 45% (P<.01), when compared with the appropriate control.

CONCLUSIONS

These data demonstrate for the first time that HGF can significantly enhance intestinal epithelial cell function and mucosal mass beyond the normal adaptive response. Luminal administration appeared to produce a greater response when compared with systemic administration but was significant only for galactose absorption (P<.05). HGF may be clinically useful in patients with short bowel syndrome.

Fetal intestinal transplant as an accessory enteral segment

Fetal tissue transplantation has gathered considerable interest among researchers dealing with organ transplantation. A large number of studies concerning fetal intestinal transplantation have been published in the past 2 decades, almost all of them aiming to determine the feasibility of a properly functioning fetal transplant in continuity with the host's own enteral system. This study was designed to determine the absorptive capacity of the neogut in vivo, without anastomosing the transplant to the host's intestine, and to evaluate its use as an accessory enteral segment. Intestinal segments taken from Wistar albino fetuses were transplanted subcutaneously into the abdominal wall of 20 Sprague-Dawley rats. Immunosuppression was maintained by daily cyclosporin A (Cy A) 10 mg/kg injections s.c. and evaluated by determination of serum Cy A level and T-helper/T-suppressor cell ratio. The neogut was converted into a Thiry-Vella loop 2 weeks after transplantation. A test solution composed of 20% glucose and Trophamine was perfused via the stomas; glucose and amino acid absorption gradients were calculated. The gamma-glutamyl transferase (GGT) activity and mitotic index of the neogut were determined. Results were compared to those obtained from the host. There was no significant difference (P > 0.05) in glucose absorption between the neogut and the host tissue. Amino acid absorption and specific GGT activity were significantly less (P < 0.01) in the neogut. There was no significant difference (P > 0.05) between neogut and host intestine in mitotic index. Our data support the idea of using a transplanted fetal intestinal segment as an accessory feeding route.

A home parenteral nutrition program for infants

Infants with short bowel syndrome and other acquired or congenital gastrointestinal disorders are able to survive their neonatal period, in part, because of the use of parenteral nutrition (PN). An increasing number of these children are being cared for at home while receiving PN. This article reviews a home PN program for infants, including identification of patients, discharge planning, and outpatient care.

Short bowel syndrome: metabolic and surgical management

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.

Pediatric liver transplantation. History, recent innovations, and outlook for the future

Pediatric liver transplantation has advanced remarkably over the past three decades. One-year survival has progressively increased to nearly 90% in patients transplanted for most forms of liver disease. Parallel advances in organ procurement, operative technique, immunosuppression, and infection control are responsible for improved patient survival. Among the most important advances are use of the University of Wisconsin (UW) organ preservation solution, the employment of venovenous bypass and/or "piggyback" operative technique, the development of cyclosporine A (CyA) and FK506, and the emergence of acyclovir, ganciclovir, foscarnet, and alpha interferon to combat life-threatening viral infections. The current organ shortage is being addressed by "cutdown" liver transplantation, "split liver" transplantation, and living-related donations. The next decade is likely to see advances in multi-visceral transplantation, induction of chimerism by simultaneous bone marrow-solid organ transplantation, and performance of cross-species xenografting.

Potential candidates for small bowel transplantation

The number of potential candidates for small bowel transplantation in the UK is unknown. Potential recipients are those with irreversible small intestinal failure, including those treated with permanent parenteral nutrition. This study of one of the largest groups of patients receiving such nutrition identified ten of 25 adult patients as possible recipients. The remaining 15 were considered unsuitable, mainly because of multiple previous abdominal operations or abscesses. Extrapolation of these data to national figures on the incidence of irreversible small intestinal failure suggests that each year up to 20 new adult patients in the UK might benefit from small bowel transplantation.

Human amniotic membrane as an intestinal patch for neomucosal growth in the rabbit model

This experiment was carried out as a preliminary study, an attempt to grow new intestinal mucosa on human amniotic membrane in the terminal ileum in 37 rabbits. After ketamin sulfate anesthesia at laparatomy, 5-cm ileal defects were patched with human amniotic membrane (5 x 2 cm). These patched intestines were investigated on the first postoperative day and the 2nd, 5th, 10th, and 20th weeks corresponding to 4, 5, 5, 10, and 10 rabbits, respectively. Only three rabbits died in the early postoperative period. There was no evidence of intestinal obstruction or dilatation with barium meal. Microscopically, the neomucosa consisted of a thin layer of columnar epithelial cells at 2 weeks with more maturity of the villi and less irregularity and branching by 20 weeks. All patches were covered with neomucosa commencing at 2 weeks and covering the whole patch area by 20 weeks. This technique's advantages are the large size and the ease of the availability of the human amniotic membrane for neonates at risk without jeopardizing the neonates tissues. It is hoped that this method might be considered when neonatal material is scarce.

Short-bowel syndrome: a collective review

Neonates can now be expected to survive with very short lengths of bowel because of advances in pediatric neonatal care and in parenteral and enteral nutrition. Most pediatric surgeons have only a few patients with this problem under their care, so individual experience is limited. This collective survey, carried out by postal questionnaires to pediatric surgeons in the British Association of Paediatric Surgeons in the United Kingdom with an interest in the gastrointestinal tract, documents current techniques of management, the complications encountered, and reviews the clinical and economic consequences of prolonged total parenteral nutrition. We conclude that within the limitations of resources and our understanding of prognosis, neonates, especially if less than 35 weeks' gestation, with remaining jejunoileal segment of greater than 20 cm with an intact ileocecal valve (ICV) or greater than 30 cm without an ICV, should be considered salvageable.

Outcome and intestinal adaptation in neonatal short-bowel syndrome

We reviewed 52 consecutive patients with short-bowel syndrome (SBS) treated with long-term parenteral nutrition (PN) from 1978 through 1990. The SBS etiologies included necrotizing enterocolitis (NEC) in 26 patients (50%), abdominal wall defects in 11 (22%), jejunoileal atresia in 6 (12%), midgut volvulus in 4 (8%), Hirschsprung's disease in 3 (6%), and segmental volvulus and cloacal exstrophy in 1 (2%) each. The average initial small bowel length was 48.1 cm, and only 31% of the patients retained an ileocecal valve (ICV). The mean duration of PN therapy was 16.6 months, and 39 patients (75%) were successfully weaned from it. Forty-three patients (83%) survived. Significant differences between the initial 20 patients treated from 1978 through 1984 and the next 32 from 1985 through 1990 were duration of PN therapy (25.1 v 11.4 months; P = .04), incidence of PN-associated jaundice (80% v 31%; P = .001), and survival (65% v 94%; P = .02). NEC patients had a significantly lower mean birthweight than those with other etiologies (mean, 1,367 v 2,544 g; P less than .0001) but did not differ in initial small bowel length, ICV retention rate, duration of PN treatment, incidence of successful PN weaning, or outcome. The presence of an ICV did not correlate with successful PN weaning but did affect the mean duration of PN therapy (7.2 months with ICV v 21.6 months without; P = .03).(ABSTRACT TRUNCATED AT 250 WORDS)

Electrophysiologic and histological monitoring of MHC-matched and mismatched canine intestinal allografts

Intestinal transplantation (ITx) has potential applications for the treatment of short-bowel syndrome (SBS). A major obstacle to its clinical use is rejection, which may partly be overcome by major histocompatibility complex (MHC) matching. At present, it is impossible to predict accurately the early onset of rejection. The aim of this study was to assess the value of in vivo measurements of transepithelial potential difference (PD) for the determination of rejection in MHC-matched and -mismatched canine ITx. A heterotopic ITx was performed in MHC tissue-typed Beagle dogs. Two ileostomies were created for PD monitoring and histology. Via one ileostomy, a well-defined segment of the IT, was isolated by a double balloon catheter and the intraluminal PD was measured in reference to a subcutaneous electrode. The PD responses during perfusion of a theophylline solution (crypt cell stimulation, PD theophylline) and during perfusion of a glucose solution (villus cell stimulation, PD glucose) were assessed. The results of in vivo PD measurements were compared with simultaneously obtained histology specimens. Four groups of dogs were studied: group 1 (controls, n = 10) ileal autotransplants; group 2 (n = 6) ileal allotransplants, fully mismatched; group 3 (n = 3) ileal allotransplants, 1 haplotype identical; and group 4 (n = 5), ileal allotransplants, fully matched. No immunosuppression was given. All dogs of group 1 survived indefinitely and both PD and histology showed no abnormalities. In group 2, 3, and 4 the onset of histological changes related to rejection corresponded well with decreased PD responses.(ABSTRACT TRUNCATED AT 250 WORDS)

Short-bowel syndrome: a review of the role of nutrition support

Advances in long-term venous access devices and in parenteral nutrition solutions have made it possible for patients with severe short bowel syndrome to survive and to live in our society. The spectrum of this disease is such that some patients may be able to lessen their dependence or even become free from parenteral therapy. This review will discuss the role of nutrition support in the patient with short bowel syndrome.

Adaptation of jejunal to colonic mucosal autografts in experimentally induced short bowel syndrome

The behavior of jejunal to colonic mucosal autografts was studied in an experimental animal model of short bowel syndrome (SBS). Histological appearances, enterocyte enzyme activities, and in vitro glucose transport were studied at the donor and recipient graft sites in control, short-bowel syndrome, and gastrocolic fistula 5-week-old Sprague-Dawley rats. Small intestinal function was maintained in the jejunocolonic graft after 80% small bowel resection; animals in which small bowel was not resected showed loss of graft function and enzyme activity. This effect is dependent on the presence of jejunal chyme: after gastrocolic fistulae, the jejunum to colon grafts lost jejunal functional activities. Total parenteral nutrition did not alter graft behavior but improved the postoperative mortality of the procedures. The results provide additional information on intestinal adaptation in SBS.