Intestinal adaptation in short bowel syndrome without tube feeding or home parenteral nutrition: report of four consecutive cases

Nutritional management of infants with short bowel syndrome

The prevalence of short bowel syndrome appears to be increasing because of more aggressive surgical and medical approaches to the management of neonatal intraabdominal catastrophies. Hence, a large cohort of neonates with intestinal failure occupies neonatal intensive care units, requiring chronic total parenteral nutrition (TPN) in hopes that the residual bowel will adapt, thereby permitting weaning of TPN. Alternatively, when there is no hope for adaptation, these infants are maintained on TPN in hopes that they will grow to a size and state of general health satisfactory for either isolated intestinal transplant when liver function is preserved or combined liver-intestinal transplantation when the liver is irreparably damaged. Thus, it is imperative to provide enough parenteral nutrition to facilitate growth while minimizing TPN constituents predisposing to liver damage. Liver disease associated with intestinal failure (IFALD) seems to occur due to a variety of host factors combined with deleterious components of TPN. Host factors include an immature bile secretory mechanism, bile stasis due to fasting, and repeated septic episodes resulting in endotoxemia. Many constituents of TPN are associated with liver damage. Excessive glucose may result in fatty liver and/or hepatic fibrosis, excessive protein may lead to reduced bile flow, and phytosterols present in intravenous lipid may produce direct oxidant damage to the liver or may impede cholesterol synthesis and subsequent bile acid synthesis. Parenteral strategies employed to minimize TPN damage include reducing glucose infusion rates, reducing parenteral protein load, and reducing parenteral lipid load. Furthermore, preliminary studies suggest that fish oil-based lipid solutions may have a salutary effect on IFALD. Ultimately, provision of enteral nutrition is imperative for preventing or reversing IFALD as well as facilitating bowel adaptation. While studies of trophic hormones are ongoing, the most reliable current method to facilitate adaptation is to provide enteral nutrition. Continuous enteral feeding remains the mainstay of enteral nutrition support.

The management of patients with the short bowel syndrome

The surgeon is invariably the primary specialist involved in managing patients with short bowel syndrome. Because of this they will play an important role in co-ordinating the management of these patients. The principal aims at the initial surgery are to preserve life, then to preserve gut length, and maintain its continuity. In the immediate postoperative period, there needs to be a balance between keeping the patient alive through the use of TPN and antisecretory agents and promoting gut adaptation with the use of oral nutrition. If the gut fails to adapt during this period, then the patient may require therapy with more specific agents to promote gut adaptation such as growth factors and glutamine. If following this, the patient still has a short gut syndrome, then the principal options remain either long term TPN, or intestinal transplantation which remains a difficult and challenging procedure with a high mortality and morbidity due to rejection.

Virtue ethics in a pluralistic world

The practice of pediatric surgery is at the crossroads of 2 specialties, pediatrics and surgery. At that vantage point, many ethical dilemmas can be seen. It is important for the pediatric surgeon to understand the special place of ethics in the care of children and how that care is influenced by society. The purpose of this report is to introduce the perspective of virtue ethics as an avenue to problem solving in ethical dilemmas in pediatric surgery. Virtue ethics relies more on the physician-focused view of character and ideal behavior as opposed to more patient-based rules of action. This ethical theory must be placed on the background of our changing society with an increasing plurality of values. The medical community of pediatric surgery must remain involved in the dialogue concerning these dilemmas in the care of children.