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Phelps HM, Swanson KA, Steinberger AE, Guo J, King AC, Siddappa CM, Davidson NO, Rubin DC, Warner BW. Intestinal Knockout of Peroxisome Proliferator-Activated Receptor-Alpha Affects Structural Adaptation but not Liver Injury Following Massive Enterectomy. J Pediatr Surg 2023; 58:1170-1177. [PMID: 36922278 PMCID: PMC10347420 DOI: 10.1016/j.jpedsurg.2023.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 02/09/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Resection-associated liver steatosis, injury, and fibrosis is a devastating complication associated with massive small bowel resection (SBR). Peroxisome proliferator-activated receptor-alpha (PPARα) is a key regulator of intestinal lipid transport and metabolism whose expression is selectively increased after SBR. Here we asked if attenuating intestinal PPARα signaling would prevent steatosis and liver injury after SBR. METHODS Pparα was deleted selectively in adult mouse intestine using a tamoxifen-inducible Cre-LoxP breeding schema. Mice underwent 50% SBR. At 10 weeks post-operatively, metabolic phenotyping, body composition analysis, in vivo assessment of lipid absorption and intestinal permeability, and assessment of adaptation and liver injury was completed. RESULTS Pparα intestinal knockout and littermate control mice were phenotypically similar in terms of weight trends and body composition after SBR. All mice demonstrated intestinal adaptation with increased villus height and crypt depth; however, Pparα intestinal knockout mice exhibited decreased villus growth at 10 weeks compared to littermate controls. Liver injury and fibrosis were similar between groups as assessed by serum AST and ALT levels, Sirius Red staining, and hepatic expression of Col1a1 and Acta2. CONCLUSIONS Inducible intestinal deletion of Pparα influences structural adaptation but does not mitigate liver injury after SBR. These findings suggest that enterocyte PPARα signaling in adult mice is dispensable for resection-induced liver injury. The results are critical for understanding the contribution of intestinal lipid metabolic signaling pathways to the pathogenesis of hepatic injury associated with short bowel syndrome.
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Affiliation(s)
- Hannah M Phelps
- Division of Pediatric Surgery, Washington University in St. Louis School of Medicine, One Children's Place, Suite 6110, St. Louis, MO, 63110, USA.
| | - Kerry A Swanson
- Division of Pediatric Surgery, Washington University in St. Louis School of Medicine, One Children's Place, Suite 6110, St. Louis, MO, 63110, USA
| | - Allie E Steinberger
- Division of Pediatric Surgery, Washington University in St. Louis School of Medicine, One Children's Place, Suite 6110, St. Louis, MO, 63110, USA
| | - Jun Guo
- Division of Pediatric Surgery, Washington University in St. Louis School of Medicine, One Children's Place, Suite 6110, St. Louis, MO, 63110, USA
| | - Ashley C King
- Division of Pediatric Surgery, Washington University in St. Louis School of Medicine, One Children's Place, Suite 6110, St. Louis, MO, 63110, USA
| | - Chidananda Mudalagiriyappa Siddappa
- Division of Pediatric Surgery, Washington University in St. Louis School of Medicine, One Children's Place, Suite 6110, St. Louis, MO, 63110, USA
| | - Nicholas O Davidson
- Division of Gastroenterology, Washington University in St. Louis School of Medicine, St. Louis, MO, 63110, USA
| | - Deborah C Rubin
- Division of Gastroenterology, Washington University in St. Louis School of Medicine, St. Louis, MO, 63110, USA
| | - Brad W Warner
- Division of Pediatric Surgery, Washington University in St. Louis School of Medicine, One Children's Place, Suite 6110, St. Louis, MO, 63110, USA
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Predictors of Social-Emotional Development and Adaptive Functioning in School-Age Children with Intestinal Failure. J Clin Psychol Med Settings 2022:10.1007/s10880-022-09919-z. [PMID: 36371790 DOI: 10.1007/s10880-022-09919-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Despite a focus on neurocognition in pediatric intestinal failure (IF) to date, we examined social-emotional and adaptive functioning. METHODS Children (N = 63) in our IF rehabilitation program underwent neuropsychological assessments including caregiver- and teacher-reported questionnaires. Results were compared to norms using z-tests. Caregiver and teacher reports were compared using t tests. Medical and demographic factors were examined in an exploratory manner using correlation and targeted regression analyses, adjusting for gestational age and full-scale IQ. RESULTS Caregiver and teacher reports indicated poorer executive, internalizing, behavioral, and adaptive functioning compared to norms. Teachers reported more executive dysfunctions than caregivers. Necrotizing enterocolitis diagnosis predicted internalizing emotional problems. Immigrant status predicted poorer social and practical adaptive functioning. Living with biological parents predicted fewer externalizing emotional and behavioral problems. CONCLUSIONS The group displayed social-emotional and adaptive functioning concerns. Identifying medical and demographic risks can allow for screening and intervention.
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Saayman BD, Millar AJW, van Niekerk E. Nutritional interventions and outcomes of children with short bowel syndrome in a tertiary hospital setting in South Africa. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2022. [DOI: 10.1080/16070658.2022.2114404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- BD Saayman
- Department of Dietetics, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - AJW Millar
- Department of Pediatric Surgery, University of Cape Town and Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
| | - E van Niekerk
- Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
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Difficult Vascular Access in Children with Short Bowel Syndrome: What to Do Next? CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9050688. [PMID: 35626867 PMCID: PMC9139311 DOI: 10.3390/children9050688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/27/2022] [Accepted: 05/05/2022] [Indexed: 12/19/2022]
Abstract
Short Bowel Syndrome and intestinal failure are chronic and severe conditions that may require life-long parenteral nutrition in children. Survival of these children rely on the correct functioning of central venous catheters; therefore, careful management, prevention, and treatment of complications is of paramount importance. Despite a growing awareness of preserving the vascular real estate, a certain number of patients still experience a progressive and life-threatening exhaustion of vascular access. We searched the literature to highlight the current management of children with vascular exhaustion, specifically focusing on vascular access salvage strategies and last-resource alternative routes to central veins. Given the paucity of data, results are reported in the form of a narrative review.
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Early Bowel Lengthening Procedures: Bi-Institutional Experience and Review of the Literature. CHILDREN 2022; 9:children9020221. [PMID: 35204941 PMCID: PMC8870478 DOI: 10.3390/children9020221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/30/2022] [Accepted: 02/03/2022] [Indexed: 11/17/2022]
Abstract
Early bowel lengthening procedure (EBLP) has been defined as any bowel lengthening procedure performed before six months of age. The purpose of this paper is to compare our experience with literature on this subject to identify common indications. A bi-institutional retrospective analysis was performed. Diagnosis, type of surgery, age at procedure and outcomes were analysed. Eleven EBLP were performed in Manchester and Florence from 2006 to 2021. The median age at surgery was 126 days (102–180), pre-operative median short bowel (SB) length was 28 cm (17–49) with a post-operative median increase of 81%. Furthermore, a PubMed/Embase search was undertaken regarding bowel lengthening procedures performed in the last 40 years. Sixty-one EBLP were identified. The median age was 60 days (1–90). Serial transverse enteroplasty (STEP) was the most frequent procedure used, with a median increased bowel length of 57%. This study confirms that no clear consensus on indication or timing to perform early SB lengthening is reported. According to the gathered data, EBLP should be considered only in cases of actual necessity and performed in a qualified intestinal failure centre.
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Morabito A, Ugolini S, Cianci MC, Coletta R. Current Surgical Concepts and Indications in the Management of the Short Bowel State: A Call for the Use of Multidisciplinary Intestinal Rehabilitation Programs. CHILDREN-BASEL 2021; 8:children8080654. [PMID: 34438545 PMCID: PMC8394303 DOI: 10.3390/children8080654] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 12/17/2022]
Abstract
The mainstay of management for short bowel syndrome (SBS) is to promote access to the best quality of care provided by the intestinal rehabilitation program (IRP) in specialized centres. When treating SBS patients, the main goal is to minimize disease-associated complications, as well as achieve enteral autonomy. Surgical strategies should be selected cautiously upon the actual state of the bowel with respect to what it is clinically relevant for that specific patient. To this aim, a personalized and multidisciplinary approach for such a complex syndrome is needed.
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Affiliation(s)
- Antonino Morabito
- Department of Pediatric Surgery, Meyer Children’s Hospital, University of Florence, 50139 Florence, Italy
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, 50121 Florence, Italy; (S.U.); (M.C.C.); (R.C.)
- School of Heath and Society, University of Salford, Manchester M6 6PU, UK
- Correspondence:
| | - Sara Ugolini
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, 50121 Florence, Italy; (S.U.); (M.C.C.); (R.C.)
| | - Maria Chiara Cianci
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, 50121 Florence, Italy; (S.U.); (M.C.C.); (R.C.)
| | - Riccardo Coletta
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, 50121 Florence, Italy; (S.U.); (M.C.C.); (R.C.)
- School of Heath and Society, University of Salford, Manchester M6 6PU, UK
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Onufer EJ, Han YH, Courtney C, Steinberger A, Tecos M, Sutton S, Sescleifer A, Ou J, Sanguinetti Czepielewski R, Randolph GJ, Warner BW. Liver injury after small bowel resection is prevented in obesity-resistant 129S1/SvImJ mice. Am J Physiol Gastrointest Liver Physiol 2021; 320:G907-G918. [PMID: 33729834 PMCID: PMC8202193 DOI: 10.1152/ajpgi.00284.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Intestinal failure-associated liver disease is a major morbidity associated with short bowel syndrome. We sought to determine if the obesity-resistant mouse strain (129S1/SvImJ) conferred protection from liver injury after small bowel resection (SBR). Using a parenteral nutrition-independent model of resection-associated liver injury, C57BL/6J and 129S1/SvImJ mice underwent a 50% proximal SBR or sham operation. At postoperative week 10, hepatic steatosis, fibrosis, and cholestasis were assessed. Hepatic and systemic inflammatory pathways were evaluated using oxidative markers and abundance of tissue macrophages. Potential mechanisms of endotoxin resistance were also explored. Serum lipid levels were elevated in all mouse lines. Hepatic triglyceride levels were no different between mouse strains, but there was an increased accumulation of free fatty acids in the C57BL/6J mice. Histological and serum markers of hepatic fibrosis, steatosis, and cholestasis were significantly elevated in resected C57BL/6J SBR mice as well as oxidative stress markers and macrophage recruitment in both the liver and visceral white fat in C57BL/6J mice compared with sham controls and the 129S1/SvImJ mouse line. Serum endotoxin levels were significantly elevated in C57BL/6J mice with significant elevation of hepatic TLR4 and reduction in PPARα expression levels. Despite high levels of serum lipids, 129S1/SvImJ mice did not develop liver inflammation, fibrosis, or cholestasis after SBR, unlike C57BL/6J mice. These data suggest that the accumulation of hepatic free fatty acids as well as increased endotoxin-driven inflammatory pathways through PPARα and TLR4 contribute to the liver injury seen in C57BL/6J mice with short bowel syndrome.NEW & NOTEWORTHY Unlike C57BL/6 mice, the 129S1/SvImJ strain is resistant to liver inflammation and injury after small bowel resection. These disparate outcomes are likely due to the accumulation of hepatic free fatty acids as well as increased endotoxin-driven inflammatory pathways through PPARα and TLR4 in C57BL/6 mice with short bowel syndrome.
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Affiliation(s)
- Emily J. Onufer
- 1Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Yong-Hyun Han
- 2Laboratory of Pathology and Physiology, College of Pharmacy,
Kangwon National University, Chuncheon, South Korea,3Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Cathleen Courtney
- 1Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Allie Steinberger
- 1Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Maria Tecos
- 1Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Stephanie Sutton
- 1Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Anne Sescleifer
- 1Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jocelyn Ou
- 1Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | - Gwendalyn J. Randolph
- 3Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Brad W. Warner
- 1Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
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Zain M, Abdelkader M, Azab A, Kotb M. Congenital short bowel syndrome: a rare cause of neonatal intestinal obstruction. J Int Med Res 2020; 48:300060520954726. [PMID: 32951488 PMCID: PMC7509730 DOI: 10.1177/0300060520954726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/10/2020] [Indexed: 11/15/2022] Open
Abstract
Congenital short bowel syndrome (CSBS) is an uncommon gastrointestinal disorder in which an unclear aetiology causes considerable intrauterine reduction in small bowel length. As a result of reduced absorptive intestinal length, chronic diarrhoea, vomiting, and consequently, failure to thrive are likely. We report a case of CSBS in a 26-day-old girl who had malrotation and a short bowel with a length of bowel from the pylorus to the ileocecal junction of approximately 40 cm. The patient underwent Ladd's procedure, but she is still dependent on parenteral nutrition.
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Affiliation(s)
- Mostafa Zain
- Pediatric Surgery, Alexandria Faculty of Medicine, Alexandria, Egypt
| | | | - Ahmed Azab
- Pediatric Surgery, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Mostafa Kotb
- Pediatric Surgery, Alexandria Faculty of Medicine, Alexandria, Egypt
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9
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Onufer EJ, Han YH, Czepielewski RS, Courtney CM, Sutton S, Randolph GJ, Warner BW. Effects of high-fat diet on liver injury after small bowel resection. J Pediatr Surg 2020; 55:1099-1106. [PMID: 32164985 PMCID: PMC7299751 DOI: 10.1016/j.jpedsurg.2020.02.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The optimal regimen for enteral nutritional support in the management of children with short bowel syndrome (SBS) is not well characterized. A high fat, enteral diet is theoretically beneficial due to increased caloric density and enhanced structural adaptation. We therefore sought to determine the long-term effects of a high fat diet (HFD) on liver injury, a common complication of SBS, compared to a standard chow (SC) diet. METHODS Using a parenteral nutrition-independent model of resection-associated liver injury, C57BL/6 mice underwent a sham operation or a 50% or 75% proximal small bowel resection (SBR). Mice in each group were then fed either a HFD (35% kcal fat) or SC (13% kcal fat). At post-operative week 15, markers of liver injury were quantified. RESULTS Liver triglyceride levels were increased from 7- to 19-fold in mice on the HFD compared to mice fed SC in the sham, 50%, and 75% resection groups. Serum ALT (2.2-fold increase in 75% resected mice compared to sham controls) and AST (2.0- and 2.7-fold increases in 50% and 75% resected mice, respectively) levels as well as fibrotic liver staining were elevated only in resected mice fed a HFD. CONCLUSION Long-term enteral feeding of HFD in our murine SBS model is associated with hepatic steatosis and liver injury. Our observation that liver steatosis and injury occur independent of parenteral nutrition suggests that enteral feeding composition and magnitude of intestinal loss may make a significant contribution to intestinal failure-associated liver disease.
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Affiliation(s)
- Emily J. Onufer
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Yong-Hyun Han
- Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, MO
| | - Rafael S. Czepielewski
- Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, MO
| | - Cathleen M. Courtney
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Stephanie Sutton
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Gwendalyn J. Randolph
- Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, MO
| | - Brad W. Warner
- Division of Pediatric Surgery, Department of Surgery, St. Louis Children’s Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO
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10
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Lawrence AE, Dienhart M, Cooper JN, Lodwick D, Lopez JJ, Fung B, Smith S, Warren P, Mezoff E, Balint J, Minneci PC. Ultrasound Elastography as a Non-Invasive Method to Monitor Liver Disease in Children with Short Bowel Syndrome: Updated Results. J Pediatr Surg 2019; 54:1179-1183. [PMID: 30885560 DOI: 10.1016/j.jpedsurg.2019.02.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 02/21/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE The purpose of the study was to determine the accuracy of acoustic radiation force impulse (ARFI) ultrasound elastography in assessing the degree of liver disease in children with short bowel syndrome (SBS). METHODS A prospective observational cohort study of patients with SBS who underwent a liver biopsy and ARFI elastography was performed. Mean shear wave speed (SWS) and stage of fibrosis was evaluated using t-tests. Receiver operating characteristic curves (ROC) were generated and the area under the curves (AUC) estimated in order to assess the accuracy of SWS measurements to discriminate between stages of fibrosis. RESULTS Thirty-seven paired elastography and biopsy samples from 31 patients were included. The median age was 0.6 years, and 61% were male. There was a significant positive correlation between stage of fibrosis and mean SWS (β=0.16 m/s increase per stage, p=<0.001). ROC analysis revealed that mean SWS had good accuracy for discriminating between mild liver fibrosis (F0-F1) and moderate to severe fibrosis (F2-F4) (AUC=0.80, 95% CI 0.65-0.95). In addition, ROC analysis demonstrated that mean SWS can also accurately discriminate between mild to moderate fibrosis (F0-F2) and more severe fibrosis (F3-F4) (AUC=0.84, 95% CI 0.71-0.96). CONCLUSION ARFI elastography is an accurate, non-invasive method to monitor liver disease in children with SBS. TYPE OF STUDY Retrospective Cohort Study LEVEL OF EVIDENCE: II.
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Affiliation(s)
- Amy E Lawrence
- Department of Pediatric Surgery and the Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Molly Dienhart
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Jennifer N Cooper
- Department of Pediatric Surgery and the Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Daniel Lodwick
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - Joseph J Lopez
- Department of Surgery, New York Medical College, Valhalla, NY
| | - Bonita Fung
- Department of Pathology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Sally Smith
- Department of Radiology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Patrick Warren
- Department of Radiology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Ethan Mezoff
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Jane Balint
- Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Peter C Minneci
- Department of Pediatric Surgery and the Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH.
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So S, Patterson C, Gold A, Rogers A, Belza C, de Silva N, Avitzur Y, Wales PW. Neurodevelopmental outcomes of infants with intestinal failure at 12 and 26 months corrected age. Early Hum Dev 2019; 130:38-43. [PMID: 30660017 DOI: 10.1016/j.earlhumdev.2018.12.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 12/28/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Survival rates of infants with intestinal failure (IF) are increasing, yet multiple medical factors may impact development. AIMS This study examines neurodevelopmental outcomes at 12-15 and 26-32 months corrected age in a cohort of children with IF. STUDY DESIGN Prospective single centre neurodevelopmental assessments of children admitted to an intestinal rehabilitation program between 2011 and 2013. Outcome measures include: Mullen Scales of Early Learning (12 and 26 months), and Vineland-II Adaptive Behaviour Scales - Caregiver Report (26 months). Standard scores were correlated with medical and demographic factors. RESULTS Thirty-one children (17 males), median gestational age 34 weeks (IQR 30-36) with birth weight (BW) 2.12 kg (IQR 1.24-2.52). Ten (32.2%) were dependent on parental nutrition (PN) at the second assessment. At 12 months, 11/30 (36.7%) scored below average (>1SD below mean) on the early learning composite and 24/30 (80%) were below average on the gross motor subscale. Comparatively, at 26 months, mean early learning scores were significantly lower with >50% scoring below average. Mean gross motor scores remained low, and 14/27 (51.9%) were below average on the Vineland-II motor domain. At 12 months, factors significantly associated with lower scores are primarily related to prematurity. At 26 months, the impact of IF-related variables such as bowel length and PN days are more apparent. CONCLUSION Children with IF are at risk of developmental delay in multiple domains. While gross motor skills appear to be most significantly affected, cognitive deficits become more apparent at 26 months, highlighting the importance of early developmental follow up.
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Affiliation(s)
- Stephanie So
- Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, Ontario, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Catherine Patterson
- Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, Ontario, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anna Gold
- Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alaine Rogers
- Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, Ontario, Canada; Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christina Belza
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nicole de Silva
- Department of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
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12
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Coletta R, Morabito A. Non-transplant Surgical Management of Short Bowel Syndrome in Children: An Overview. Curr Pediatr Rev 2019; 15:106-110. [PMID: 30499416 DOI: 10.2174/1573396315666181129164112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 10/12/2018] [Accepted: 11/24/2018] [Indexed: 01/02/2023]
Abstract
Management of severe Short Bowel Syndrome (SBS) is still one of the largest challenges of the medicine. Vast majority of the short bowel patients are children, the conditions that lead to this possible outcome most often are necrotizing enterocolitis (NEC), small intestinal volvulus as a result of intestinal malrotation, gastroschisis and the "apple peel" syndrome. Therefore, paediatricians and paediatric surgeons face this challenge most often. The nontransplant treatment appears to be effective using surgical procedure to increase absorptive surface and to reduce the transit time, but in some cases these procedures are enough to weaning of TPN. The aim of this review was to summarize the modern non-stransplant surgical management of short bowel syndrome.
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Affiliation(s)
- Riccardo Coletta
- Department of Paediatric Surgery, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Antonino Morabito
- Department of Paediatric Surgery, Meyer Children's Hospital, University of Florence, Florence, Italy
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13
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Motor Proficiency and Generalized Self-Efficacy Toward Physical Activity in Children With Intestinal Failure. J Pediatr Gastroenterol Nutr 2019; 68:7-12. [PMID: 30052565 DOI: 10.1097/mpg.0000000000002107] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Survival rates of children with intestinal failure have increased; however, associated co-morbidities may affect long-term motor developmental outcomes. This study evaluates motor proficiency and generalized self-efficacy toward physical activity (PA) in children ages 6 to 12 years with intestinal failure. METHODS This is an observational, cross-sectional study of children followed in a multidisciplinary intestinal rehabilitation program. Motor proficiency was assessed using the Bruininks-Oseretsky Test of Motor Proficiency-2 Short Form (BOT-2 SF) and the Scales of Independent Behavior (parent-proxy report). Children completed the Children's Self-Perceptions of Adequacy in and Predilection for Physical Activity (CSAPPA) and a PA questionnaire. Relevant demographic and medical variables were correlated with assessment results. RESULTS Participants include 30 children (18 males), median age 7 years (interquartile range [IQR] 6-9) with gestational age 35 weeks (IQR 32-39) and birth weight 2.13 kg (IQR 1.68-2.77). Thirteen (43%) were dependent on parenteral nutrition. Fifteen (50%) scored below average on the BOT-2 SF. Lower BOT-2 SF scores were significantly associated with lower CSAPPA scores (r = 0.480, P = 0.01), with a common barrier to PA being the presence of a central line or enterostomy tube. Gestational age, height z scores, length of hospital admissions, and number of septic events were all significantly correlated with lower scores in motor proficiency. Number of septic events and total parenteral nutrition days were significant predictors of lower BOT-2 SF scores, when adjusting for birth weight. CONCLUSIONS Multiple medical variables related to intestinal failure may affect motor proficiency and PA self-efficacy. Developmental follow-up is important to optimize motor skill development and promote PA participation.
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Lavallee CM, Wizzard PR, Lansing M, Vine DF, Nation PN, Yap JY, Willing BP, Wales PW, Turner JM. Surgical Anatomy Does Not Affect the Progression of Intestinal Failure-Associated Liver Disease in Neonatal Piglets. JPEN J Parenter Enteral Nutr 2017; 42:14-23. [PMID: 28719764 DOI: 10.1177/0148607117718478] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 06/05/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Intestinal failure-associated liver disease (IFALD) causes significant morbidity in neonates with short bowel syndrome (SBS) dependent on parenteral nutrition (PN). Resected ileum, with loss of the ileocecal valve (ICV), is the most common anatomy in SBS, yet its impact on IFALD has not been adequately studied. METHODS Neonatal piglets were randomized to 75% intestinal resection with jejunocolic anastomosis (JC, n = 12), 75% resection with jejunoileal anastomosis and intact ICV (JI, n = 13), PN-fed sham (sham, n = 14), or sow-fed control (SF, n = 8). Surgical and sham piglets received 100% PN for 14 days before bile flow was measured and blood chemistry, liver pathology, jejunal permeability, and bacterial translocation were assessed. RESULTS Bile flow was lower for PN-fed compared with SF (P = .002) but not different between the PN-fed groups. Total bilirubin (P = .03) and liver pathology (P < .001) were greater in PN-fed than SF groups but not different between PN-fed groups. Serum bile acids were increased in sham (P = .01) but not different between SBS groups. PN-fed piglets with sepsis had lower bile flow (P = .001) and increased bilirubin (P = .04). Neither jejunal permeability nor bacterial translocation were different between JC, JI, or sham groups. CONCLUSION Contrary to our hypothesis, the remnant anatomy does not appear to worsen the progression of IFALD. However, the role of sepsis in IFALD should be further explored, in addition to other mechanisms, including PN factors, host immune responses, and intestinal bacterial dysbiosis.
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Affiliation(s)
- Celeste M Lavallee
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela R Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Marihan Lansing
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Donna F Vine
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - Patrick N Nation
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Jason Y Yap
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Benjamin P Willing
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada
| | - Paul W Wales
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Capriati T, Nobili V, Stronati L, Cucchiara S, Laureti F, Liguori A, Tyndall E, Diamanti A. Enteral nutrition in pediatric intestinal failure: does initial feeding impact on intestinal adaptation? Expert Rev Gastroenterol Hepatol 2017; 11:741-748. [PMID: 28562106 DOI: 10.1080/17474124.2017.1335196] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Primary IF can be due to impaired gut length or impaired gut function; short bowel syndrome (SBS) is the leading cause of IF. In IF patients complete enteral starvation should be avoided whenever possible and enteral/oral nutrition (EN/ON) should be employed at the maximum tolerated amount in each phase of the clinical evolution of IF. Intraluminal nutrients have stimulatory effects on epithelial cells and on trophism that enhance intestinal adaptation. Areas covered: Evidence for nutritional interventions in pediatric IF is limited and of poor quality. Clinical practice in SBS feeding are more 'experience-based' rather than 'evidence-based' and this dearth of clinical evidence is partly due to the rarity of this condition. This review updates knowledge concerning the impact of the initial diet with EN/ON in neonatal onset SBS in the process of bowel adaption. Expert commentary: Human milk resulted the preferred starting diet and it is generally combined with amino-acids (AAs) in Northern America and with hydrolyzed proteins (HFs) in Europe; polymeric diet is rarely employed. HFs were not more effective than AAs in promoting intestinal adaptation.
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Affiliation(s)
- Teresa Capriati
- a Department of Pediatrics , Pediatric Hospital "Bambino Gesù" , Rome , Italy
| | - Valerio Nobili
- b Liver Res Unit , IRCCS, Bambino Gesu Children Hosp , Rome , Italy
| | - Laura Stronati
- c Department of Pediatrics , Universita degli Studi di Roma La Sapienza Facolta di Medicina e Psicologia , Rome , Italy
| | | | - Francesca Laureti
- a Department of Pediatrics , Pediatric Hospital "Bambino Gesù" , Rome , Italy
| | - Alessandra Liguori
- a Department of Pediatrics , Pediatric Hospital "Bambino Gesù" , Rome , Italy
| | - Elaine Tyndall
- a Department of Pediatrics , Pediatric Hospital "Bambino Gesù" , Rome , Italy
| | - Antonella Diamanti
- a Department of Pediatrics , Pediatric Hospital "Bambino Gesù" , Rome , Italy
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17
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So S, Patterson C, Gold A, Rogers A, Kosar C, de Silva N, Burghardt KM, Avitzur Y, Wales PW. Early neurodevelopmental outcomes of infants with intestinal failure. Early Hum Dev 2016; 101:11-6. [PMID: 27394169 DOI: 10.1016/j.earlhumdev.2016.05.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/10/2016] [Accepted: 05/10/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND The survival rate of infants and children with intestinal failure is increasing, necessitating a greater focus on their developmental trajectory. AIMS To evaluate neurodevelopmental outcomes in children with intestinal failure at 0-15months corrected age. STUDY DESIGN Analysis of clinical, demographic and developmental assessment results of 33 children followed in an intestinal rehabilitation program between 2011 and 2014. Outcome measures included: Prechtl's Assessment of General Movements, Movement Assessment of Infants, Alberta Infant Motor Scale and Mullen Scales of Early Learning. Clinical factors were correlated with poorer developmental outcomes at 12-15months corrected age. RESULTS Thirty-three infants (17 males), median gestational age 34weeks (interquartile range 29.5-36.0) with birth weight 1.98kg (interquartile range 1.17-2.50). Twenty-nine (88%) infants had abnormal General Movements. More than half had suspect or abnormal scores on the Alberta Infant Motor Scale and medium to high-risk scores for future neuromotor delay on the Movement Assessment of Infants. Delays were seen across all Mullen subscales, most notably in gross motor skills. Factors significantly associated with poorer outcomes at 12-15months included: prematurity, low birth weight, central nervous system co-morbidity, longer neonatal intensive care admission, necrotizing enterocolitis diagnosis, number of operations and conjugated hyperbilirubinemia. CONCLUSION Multiple risk factors contribute to early developmental delay in children with intestinal failure, highlighting the importance of close developmental follow-up.
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Affiliation(s)
- Stephanie So
- Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Catherine Patterson
- Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anna Gold
- Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alaine Rogers
- Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christina Kosar
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nicole de Silva
- Department of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Karolina Maria Burghardt
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Ontario, Canada
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Hommel MJ, van Baren R, Haveman JW. Surgical management and autologous intestinal reconstruction in short bowel syndrome. Best Pract Res Clin Gastroenterol 2016; 30:263-80. [PMID: 27086890 DOI: 10.1016/j.bpg.2016.03.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/05/2016] [Indexed: 01/31/2023]
Abstract
Short bowel syndrome (SBS) is a serious condition with considerable morbidity and mortality. When treatment with parenteral nutrition fails and life-threatening complications occur, autologous intestinal reconstruction (AIR) should be considered before intestinal transplantation (ITx). Single or combined ITx should be reserved for patients with severe liver disease and as last resort in the treatment of SBS. Longitudinal intestinal lengthening and tailoring (LILT) has proven its value in AIR, but its availability depends on the expertise of the surgeons. Serial transverse enteroplasty (STEP) has similar success rates as LILT and fewer patients progress to ITx. STEP is also applicable at small bowel dilatation in ultra-short bowel syndrome. The scope may be widened when duodenal dilatation can be treated as well. Spiral intestinal lengthening and tailoring (SILT) is a promising alternative. More research is needed to confirm these findings. Therefore we suggest an international data registry for all intestinal lengthening procedures.
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Affiliation(s)
- Matthijs J Hommel
- Department of Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
| | - Robertine van Baren
- Department of Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
| | - Jan Willem Haveman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
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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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21
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Rege A. The Surgical Approach to Short Bowel Syndrome - Autologous Reconstruction versus Transplantation. VISZERALMEDIZIN 2015; 30:179-89. [PMID: 26288592 PMCID: PMC4513826 DOI: 10.1159/000363589] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Short bowel syndrome (SBS) is a state of malabsorption resulting from massive small bowel resection leading to parenteral nutrition (PN) dependency. Considerable advances have been achieved in the medical and surgical management of SBS over the last few decades. METHODS This review discusses in detail the surgical approach to SBS. RESULTS Widespread use of PN enables long-term survival in patients with intestinal failure but at the cost of PN-associated life-threatening complications including catheter-associated blood stream infection, venous thrombosis, and liver disease. The goal of management of intestinal failure due to SBS is to enable enteral autonomy and wean PN by means of a multi-disciplinary approach. Availability of modified enteral feeding formulas have simplified nutrition supplementation in SBS patients. Similarly, advances in the medical field have made medications like growth hormone and glucagon-like peptide (GLP2) available to improve water and nutrient absorption as well as to enable achieving enteral autonomy. Autologous gastrointestinal reconstruction (AGIR) includes various techniques which manipulate the bowel surgically to facilitate the bowel adaptation process and restoration of enteral nutrition. Ultimately, intestinal transplantation can serve as the last option for the cure of intestinal failure when selectively applied. CONCLUSION SBS continues to be a challenging medical problem. Best patient outcomes can be achieved through an individualized plan, using various AGIR techniques to complement each other, and intestinal transplantation as a last resort for cure. Maximum benefit and improved outcomes can be achieved by caring for SBS patients at highly specialized intestinal rehabilitation centers.
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Affiliation(s)
- Aparna Rege
- Division of Transplantation, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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22
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Abstract
OBJECTIVE Management of short bowel syndrome (SBS) has significantly evolved recently. We present our single-center, 25-year experience focusing on the implementation of a refined multidisciplinary SBS care protocol. METHODS This is a retrospective review of the patients with SBS treated at our tertiary center from 1988 to 2014, with either <25% short bowel remaining or duration of parenteral nutrition (PN) >3 months. Patients with primary intestinal motility disorders were excluded. Clinical characteristics, including intestinal anatomy, markers of cholestasis, and catheter-related infections (CRIs), were analyzed. The implementation of a refined modern uniform management protocol in 2009 divided the cohort into 2 subgroups, whose outcomes are compared. RESULTS Forty-eight patients with SBS were identified (median gestational age 33 weeks). Of them, 22 were born between 2009 and 2014. The main causes of SBS were necrotizing enterocolitis (46%) and midgut volvulus (23%). Median remaining small bowel length was 36 cm. The overall survival was 23 of 26 (88%) before 2009 and 21 of 22 (95%) thereafter, whereas none were transplanted. Duration of PN shortened from a median of 15 to 6 months (P = 0.0015) in the latter cohort, whereas frequency of autologous intestinal reconstruction surgery (31%) remained unchanged. Frequency of neonatal cholestasis was similar in both groups (75%), but cleared in all after 2009. Before 2009, 2 patients died of progressive cholestatic liver failure. The CRI rates decreased from 1.7 to 0.7 per 1000 catheter-days between 2000-2008 and 2009-2014, respectively (P = 0.0178). CONCLUSIONS Uniform refined multidisciplinary approach decreased the duration of PN and CRI rates with high transplant-free survival and avoidance of liver failure, although the frequency of transient neonatal cholestasis remained unchanged.
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Chan CF, Wu TC. Recent advances in the management of pediatric intestinal failure. Pediatr Neonatol 2014; 55:426-30. [PMID: 24594083 DOI: 10.1016/j.pedneo.2013.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 10/13/2013] [Accepted: 11/04/2013] [Indexed: 11/29/2022] Open
Abstract
Intestinal failure is a chronic condition in which the intestinal tract has lost most of its function. Prognosis depends on the severity and underlying etiologies. Although many patients survive under parenteral nutrition support, they often suffer from fatal complications such as progressive cholestasis and frequent sepsis. In addition, to decide the proper time to refer selected patients to bowel transplantation remains difficult. A noninvasive biomarker developed to evaluate functional enterocyte mass and the extent of intestinal adaptation is plasma citrulline level. It is shown that serum citrulline correlates with small bowel length, oral tolerance, and parenteral nutrition dependency. Recent evidence has revealed that the use of fish oil containing lipid emulsions to substitute traditional soybean-based formula may reverse a patient's cholestasis and improve lipid profiles. A new method used to prevent catheter-related bloodstream infection is ethanol lock therapy. With both antimicrobial and fibrinolytic activities, studies have shown that ethanol locks can effectively decrease catheter infection and replacement rate with no known resistance reported. As part of intestinal rehabilitation, auxiliary surgeries such as longitudinal intestinal lengthening and tailoring, serial transverse enteroplasty, and tapering enteroplasty can be beneficial for selected patients before bridging to bowel transplantation. With the introduction of these new medical and surgical modalities, patients with intestinal failure are having better outcomes than in the past.
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Affiliation(s)
- Chan-Fai Chan
- Department of Pediatrics, National Yang-Ming University Hospital, Yilan, Taiwan; Division of Gastroenterology, Children's Medical Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tzee-Chung Wu
- Division of Gastroenterology, Children's Medical Center, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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Kyle UG, Shekerdemian LS, Coss-Bu JA. Growth failure and nutrition considerations in chronic childhood wasting diseases. Nutr Clin Pract 2014; 30:227-38. [PMID: 25378356 DOI: 10.1177/0884533614555234] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Growth failure is a common problem in many children with chronic diseases. This article is an overview of the most common causes of growth failure/growth retardation that affect children with a number of chronic diseases. We also briefly review the nutrition considerations and treatment goals. Growth failure is multifactorial in children with chronic conditions, including patients with cystic fibrosis, chronic kidney disease, chronic liver disease, congenital heart disease, human immunodeficiency virus, inflammatory bowel disease, short bowel syndrome, and muscular dystrophies. Important contributory factors to growth failure include increased energy needs, increased energy loss, malabsorption, decreased energy intake, anorexia, pain, vomiting, intestinal obstruction, and inflammatory cytokines. Various metabolic and pathologic abnormalities that are characteristic of chronic diseases further lead to significant malnutrition and growth failure. In addition to treating disease-specific abnormalities, treatment should address the energy and protein deficits, including vitamin and mineral supplements to correct deficiencies, correct metabolic and endocrinologic abnormalities, and include long-term monitoring of weight and growth. Individualized, age-appropriate nutrition intervention will minimize the malnutrition and growth failure seen in children with chronic diseases.
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Affiliation(s)
- Ursula G Kyle
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Lara S Shekerdemian
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Jorge A Coss-Bu
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
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Mutanen A, Nissinen MJ, Lohi J, Heikkilä P, Gylling H, Pakarinen MP. Serum plant sterols, cholestanol, and cholesterol precursors associate with histological liver injury in pediatric onset intestinal failure. Am J Clin Nutr 2014; 100:1085-94. [PMID: 25099547 DOI: 10.3945/ajcn.114.088781] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Increased serum concentrations of plant sterols, including stigmasterol, during parenteral nutrition (PN) have been linked with serum biochemical signs of intestinal failure-associated liver disease (IFALD), whereas clinical data on their correlation to histologic liver injury have been limited. OBJECTIVE We studied interrelations between serum noncholesterol sterols and histologic liver injury in pediatric-onset intestinal failure (IF). DESIGN Serum plant sterols (stigmasterol, avenasterol, sitosterol, and campesterol), cholestanol, and cholesterol precursors (cholestenol, lathosterol, and desmosterol) were measured in 50 IF patients at a median age 7.3 y and in 86 matched controls. Forty patients underwent liver biopsies. Sixteen patients had been receiving PN for 45 mo, and 34 patients had received PN for 9.1 mo but had not received PN for 5.4 y. RESULTS Serum plant sterols were higher in patients who were currently receiving PN than in controls and were related to conjugated bilirubin (r = 0.799-0.541, P < 0.05). During PN, the ratio of serum stigmasterol to cholesterol was 3.3-fold higher in patients with portal inflammation, and the ratio of avenasterol to cholesterol was 3.9-fold higher in patients with cholestasis (P < 0.05 for both). Ratios of stigmasterol and avenasterol to cholesterol were correlated with portal inflammation (r = 0.549-0.510, P < 0.05), cholestasis (r = 0.501-0.491, P = 0.048-0.053), and serum bile acids (r = 0.591-0.608, P < 0.05). The median (IQR) ratio of serum cholestanol to cholesterol was higher during (269 100× μg/mg cholesterol; 203-402 100× μg/mg cholesterol) than after (175 100× μg/mg cholesterol; 156-206 100× μg/mg cholesterol; P < 0.001) weaning off PN and was correlated with cholestasis (r = 0.428), portal inflammation (r = 0.511), and fibrosis (r = 0.323, P < 0.05 for all). After weaning off PN, ratios of cholestenol and lathosterol to cholesterol were >2-fold higher in patients with persistent liver steatosis than in those without steatosis or controls (P < 0.01 for all), whereas lathosterol was correlated with the steatosis grade (r = 0.320, P < 0.050). CONCLUSIONS Increased serum stigmasterol and avenasterol concentrations parallel the portal inflammation and cholestasis during PN, thereby reinforcing their contribution to IFALD. A bile acid malabsorption-driven increase in cholesterol synthesis underpins persistent liver steatosis after weaning off PN. Serum cholestanol reflects liver injury in IF patients.
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Affiliation(s)
- Annika Mutanen
- From the Section of Pediatric Surgery, Pediatric Liver and Gut Research Group Helsinki, Children's Hospital (AM and MPP), and the Department of Pathology, HUSLAB (JL and PH), Helsinki University Central Hospital, and the Department of Medicine, Division of Gastroenterology and Internal Medicine (MJN and HG), University of Helsinki, Helsinki, Finland
| | - Markku J Nissinen
- From the Section of Pediatric Surgery, Pediatric Liver and Gut Research Group Helsinki, Children's Hospital (AM and MPP), and the Department of Pathology, HUSLAB (JL and PH), Helsinki University Central Hospital, and the Department of Medicine, Division of Gastroenterology and Internal Medicine (MJN and HG), University of Helsinki, Helsinki, Finland
| | - Jouko Lohi
- From the Section of Pediatric Surgery, Pediatric Liver and Gut Research Group Helsinki, Children's Hospital (AM and MPP), and the Department of Pathology, HUSLAB (JL and PH), Helsinki University Central Hospital, and the Department of Medicine, Division of Gastroenterology and Internal Medicine (MJN and HG), University of Helsinki, Helsinki, Finland
| | - Päivi Heikkilä
- From the Section of Pediatric Surgery, Pediatric Liver and Gut Research Group Helsinki, Children's Hospital (AM and MPP), and the Department of Pathology, HUSLAB (JL and PH), Helsinki University Central Hospital, and the Department of Medicine, Division of Gastroenterology and Internal Medicine (MJN and HG), University of Helsinki, Helsinki, Finland
| | - Helena Gylling
- From the Section of Pediatric Surgery, Pediatric Liver and Gut Research Group Helsinki, Children's Hospital (AM and MPP), and the Department of Pathology, HUSLAB (JL and PH), Helsinki University Central Hospital, and the Department of Medicine, Division of Gastroenterology and Internal Medicine (MJN and HG), University of Helsinki, Helsinki, Finland
| | - Mikko P Pakarinen
- From the Section of Pediatric Surgery, Pediatric Liver and Gut Research Group Helsinki, Children's Hospital (AM and MPP), and the Department of Pathology, HUSLAB (JL and PH), Helsinki University Central Hospital, and the Department of Medicine, Division of Gastroenterology and Internal Medicine (MJN and HG), University of Helsinki, Helsinki, Finland
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Coletta R, Khalil BA, Morabito A. Short bowel syndrome in children: surgical and medical perspectives. Semin Pediatr Surg 2014; 23:291-7. [PMID: 25459014 DOI: 10.1053/j.sempedsurg.2014.09.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The main cause of intestinal failure in children is due to short bowel syndrome (SBS) resulting from congenital or acquired intestinal lesions. From the first lengthening procedure introduced by Bianchi, the last three decades have seen lengthening procedures established as fundamental components of multidisciplinary intestinal rehabilitation programs. Debate on indications and timing of the procedures is still open leaving SBS surgical treatment a great challenge. However, enteral autonomy is possible only with an individualized approach remembering that each SBS patient is unique. Current literature on autologous gastrointestinal reconstruction technique was reviewed aiming to assess a comprehensive pathway in SBS non-transplant management.
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Affiliation(s)
- Riccardo Coletta
- Paediatric Autologous Bowel Reconstruction and Rehabilitation Unit, Royal Manchester Children׳s Hospital, Oxford Rd, Manchester M13 9WL, UK; School of Medicine, University of Manchester, Manchester, UK
| | - Basem A Khalil
- Paediatric Autologous Bowel Reconstruction and Rehabilitation Unit, Royal Manchester Children׳s Hospital, Oxford Rd, Manchester M13 9WL, UK; School of Medicine, University of Manchester, Manchester, UK
| | - Antonino Morabito
- Paediatric Autologous Bowel Reconstruction and Rehabilitation Unit, Royal Manchester Children׳s Hospital, Oxford Rd, Manchester M13 9WL, UK; School of Medicine, University of Manchester, Manchester, UK.
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Roy CC, Groleau V, Bouthillier L, Pineault M, Thibault M, Marchand V. Short bowel syndrome in infants: the critical role of luminal nutrients in a management program. Appl Physiol Nutr Metab 2014; 39:745-53. [DOI: 10.1139/apnm-2013-0211] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Short bowel syndrome develops when the remnant mass of functioning enterocytes following massive resections cannot support growth or maintain fluid–electrolyte balance and requires parenteral nutrition. Resection itself stimulates the intestine’s inherent ability to adapt morphologically and functionally. The capacity to change is very much related to the high turnover rate of enterocytes and is mediated by several signals; these signals are mediated in large part by enteral nutrition. Early initiation of enteral feeding, close clinical monitoring, and ongoing assessment of intestinal adaptation are key to the prevention of irreversible intestinal failure. The length of the functional small bowel remnant is the most important variable affecting outcome. The major objective of intestinal rehabilitation programs is to achieve early oral nutritional autonomy while maintaining normal growth and nutrition status and minimizing total parenteral nutrition related comorbidities such as chronic progressive liver disease. Remarkable progress has been made in terms of survivability and quality of life, especially in the context of coordinated multidisciplinary programs, but much work remains to be done.
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Affiliation(s)
- Claude C. Roy
- Département de Pédiatrie, Service de gastroentérologie, hépatologie et nutrition, CHU Sainte-Justine et Université de Montréal, 3175 chemin de la Côte Ste-Catherine, Montréal, QC H3T 1C5, Canada
| | - Véronique Groleau
- Département de Pédiatrie, Service de gastroentérologie, hépatologie et nutrition, CHU Sainte-Justine et Université de Montréal, 3175 chemin de la Côte Ste-Catherine, Montréal, QC H3T 1C5, Canada
| | - Lise Bouthillier
- Service de nutrition, CHU Sainte-Justine, Montréal, QC H3T 1C5, Canada
| | - Marjolain Pineault
- Département de pharmacie, CHU Sainte-Justine, Montréal, QC H3T 1C5, Canada
| | - Maxime Thibault
- Département de pharmacie, CHU Sainte-Justine, Montréal, QC H3T 1C5, Canada
| | - Valérie Marchand
- Département de Pédiatrie, Service de gastroentérologie, hépatologie et nutrition, CHU Sainte-Justine et Université de Montréal, 3175 chemin de la Côte Ste-Catherine, Montréal, QC H3T 1C5, Canada
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Abstract
Most intestinal failure in children is due to short bowel syndrome (SBS) where congenital or acquired lesions have led to an extensive loss of intestinal mass. The vast majority of morbidity and mortality of patients with SBS is due to complications secondary to their long term dependence on parenteral nutrition. In response to SBS, the intestine undergoes a process of remodeling termed adaptation. Principles guiding the medical management of SBS include providing adequate parenteral nutrition, fluids and electrolytes for growth and normal development, promoting small bowel adaptation, and preventing and treating complications related to the patient's underlying disease and their parenteral nutrition. Catheter associated blood stream infection (CABSI) is major source of morbidity and mortality in patients with intestinal failure from SBS. Intestinal failure associated liver disease (IFALD)is another major source of morbidity and mortality in patients with SBS. IFALD is the most consistent negative predictor of outcome including death and continued parenteral nutrition dependence. Enteral nutrition is critical for intestinal adaptation and preventing IFALD. Patients with SBS who develop dilated dysmotile segments may benefit from autologous intestinal reconstruction surgery (AIRS) with the goal of decreasing stasis and disordered motility through intestinal narrowing and lengthening. Patients with SBS should be referred for transplantation if they have failed intestinal rehabilitation including AIRS, have no reasonable chance for enteral feeding tolerance, develop irreversible IFALD, have recurrent sepsis, or have exhausted their central venous access sites. With improvements in medical and surgical care, overall survival of patients with SBS now exceeds 90%.
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Affiliation(s)
- Jason P Sulkowski
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital and Department of Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Peter C Minneci
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital and Department of Surgery, Nationwide Children's Hospital, Columbus, OH, United States.
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Ubesie AC, Kocoshis SA, Mezoff AG, Henderson CJ, Helmrath MA, Cole CR. Multiple micronutrient deficiencies among patients with intestinal failure during and after transition to enteral nutrition. J Pediatr 2013; 163:1692-6. [PMID: 23978355 PMCID: PMC3842410 DOI: 10.1016/j.jpeds.2013.07.015] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 05/20/2013] [Accepted: 07/09/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To determine the prevalence of deficiencies of specific micronutrients (iron, zinc, magnesium, phosphorus, selenium, copper, folate, and vitamins A, D, E, and B12) in children with intestinal failure (IF), and to identify risk factors associated with developing these deficiencies. STUDY DESIGN This study was a retrospective review of prospectively collected data from 178 children with IF managed by the Intestinal Care Center of Cincinnati Children's Hospital Medical Center between August 1, 2007, and July 31, 2012. Transition to full enteral nutrition (FEN) was defined as the period during which the patient received between 20% and 100% of estimated required nutrition enterally. FEN was defined as the patient's ability to tolerate 100% estimated required nutrition enterally for >2 weeks. RESULTS Necrotizing enterocolitis was the most common cause of IF (27.5%). Iron was the most common micronutrient deficiency identified both during (83.9%) and after (61%) successful transition to FEN, with a significant reduction in the percentage of patients with iron deficiency between these 2 periods (P = .003). Predictors of micronutrient deficiency after successful transition to FEN included birth weight (P = .03), weight percentile (P = .02), height percentile (P = .04), and duration of parenteral nutrition (PN) (P = .013). After multivariate adjustments, only duration of PN remained statistically significant (P = .03). CONCLUSION Micronutrient deficiencies persist in patients with IF during and after transition to FEN. These data support the need for routine monitoring and supplementation of these patients, especially those on prolonged PN.
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Affiliation(s)
- Agozie C Ubesie
- Intestinal Rehabilitation Program, Intestinal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu, Nigeria.
| | - Samuel A Kocoshis
- Intestinal Rehabilitation Program, Intestinal Care Center, Cincinnati Children’s Hospital Medical Center,Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Adam G Mezoff
- Intestinal Rehabilitation Program, Intestinal Care Center, Cincinnati Children’s Hospital Medical Center,Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Carol J Henderson
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael A Helmrath
- Intestinal Rehabilitation Program, Intestinal Care Center, Cincinnati Children’s Hospital Medical Center,Division of Pediatric and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Conrad R Cole
- Intestinal Rehabilitation Program, Intestinal Care Center, Cincinnati Children’s Hospital Medical Center,Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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Ubesie AC, Cole CR, Nathan JD, Tiao GM, Alonso MH, Mezoff AG, Henderson CJ, Kocoshis SA. Micronutrient deficiencies in pediatric and young adult intestinal transplant patients. Pediatr Transplant 2013; 17:638-45. [PMID: 23919810 PMCID: PMC3795992 DOI: 10.1111/petr.12132] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2013] [Indexed: 01/15/2023]
Abstract
Intestinal transplant recipients are at risk of micronutrient deficiency due to the slow process of post-transplant adaptation. Another contributing factor is calcineurin inhibitor-induced renal tubular dysfunction. Patients are typically supplemented with micronutrients during PN; however, the risk of deficiency may persist even after a successful transition to FEN. The goal was to determine the prevalence of, and associated risk factors for, iron, zinc, magnesium, phosphorus, selenium, copper, folate, and vitamins A, D, E, and B12 deficiency in pediatric intestinal transplant recipients after successful transition to FEN. A retrospective review of prospectively collected data from children who underwent intestinal transplantation at Cincinnati Children's Hospital Medical Center was done. Deficiencies of various micronutrients were defined using the hospital reference values. Twenty-one intestinal transplant recipients, aged one to 23 yr, who were successfully transitioned to FEN were included in the study. The prevalence of micronutrient deficiency was 95.2%. The common deficient micronutrients were iron (94.7%) and magnesium (90.5%). Age ≤ 10 yr (p = 0.002) and tube feeding (p = 0.02) were significant risk factors for micronutrient deficiencies. Pediatric intestinal transplant recipients have a high risk of micronutrient and mineral deficiencies. These deficiencies were more common among younger patients and those who received jejunal feeding.
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Affiliation(s)
- Agozie C Ubesie
- Intestinal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA, Department of Paediatrics, University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu, Nigeria
| | - Conrad R Cole
- Intestinal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA, Division of Gastroenterology, Hepatology and Nutrition, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio , USA
| | - Jaimie D Nathan
- Intestinal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA, Intestinal Transplant Program, Division of Pediatric and Thoracic Surgery, University of Cincinnati College of Medicine and Cincinnati Children Hospital Medical Center, Cincinnati, Ohio, USA
| | - Greg M Tiao
- Intestinal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA, Intestinal Transplant Program, Division of Pediatric and Thoracic Surgery, University of Cincinnati College of Medicine and Cincinnati Children Hospital Medical Center, Cincinnati, Ohio, USA
| | - Maria H Alonso
- Intestinal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA, Intestinal Transplant Program, Division of Pediatric and Thoracic Surgery, University of Cincinnati College of Medicine and Cincinnati Children Hospital Medical Center, Cincinnati, Ohio, USA
| | - Adam G Mezoff
- Intestinal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA, Division of Gastroenterology, Hepatology and Nutrition, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio , USA
| | - Carol J Henderson
- Division of Gastroenterology, Hepatology and Nutrition, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio , USA
| | - Samuel A Kocoshis
- Intestinal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA, Division of Gastroenterology, Hepatology and Nutrition, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio , USA
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Lauriti G, Zani A, Aufieri R, Cananzi M, Chiesa PL, Eaton S, Pierro A. Incidence, prevention, and treatment of parenteral nutrition-associated cholestasis and intestinal failure-associated liver disease in infants and children: a systematic review. JPEN J Parenter Enteral Nutr 2013; 38:70-85. [PMID: 23894170 DOI: 10.1177/0148607113496280] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Cholestasis is a significant life-threatening complication in children on parenteral nutrition (PN). Strategies to prevent/treat PN-associated cholestasis (PNAC) and intestinal failure-associated liver disease (IFALD) have reached moderate success with little supporting evidence. Aims of this systematic review were (1) to determine the incidence of PNAC/IFALD in children receiving PN for ≥ 14 days and (2) to review the efficacy of measures to prevent/treat PNAC/IFALD. METHODS Of 4696 abstracts screened, 406 relevant articles were reviewed, and studies on children with PN ≥ 14 days and cholestasis (conjugated bilirubin ≥ 2 mg/dL) were included. Analyzed parameters were (1) PNAC/IFALD incidence by decade and by PN length and (2) PNAC/IFALD prevention and treatment (prospective studies). RESULTS Twenty-three articles (3280 patients) showed an incidence of 28.2% and 49.8% of PNAC and IFALD, respectively, with no evident alteration over the last decades. The incidence of PNAC was directly proportional to the length of PN (from 15.7% for PN ≤ 1 month up to 60.9% for PN ≥ 2 months; P < .0001). Ten studies on PNAC met inclusion criteria. High or intermediate-dose of oral erythromycin and aminoacid-free PN with enteral whey protein gained significant benefits in preterm neonates (P < .05, P = .003, and P < .001, respectively). None of the studies reviewed met inclusion criteria for treatment. CONCLUSIONS The incidence of PNAC/IFALD in children has no obvious decrease over time. PNAC is directly correlated to the length of PN. Erythromycin and aminoacid-free PN with enteral whey protein have shown to prevent PNAC in preterm neonates. There is a lack of high-quality prospective studies, especially on IFALD.
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Affiliation(s)
- Giuseppe Lauriti
- Department of Surgery, UCL Institute of Child Health, London, UK
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Goulet O, Olieman J, Ksiazyk J, Spolidoro J, Tibboe D, Köhler H, Yagci RV, Falconer J, Grimble G, Beattie RM. Neonatal short bowel syndrome as a model of intestinal failure: physiological background for enteral feeding. Clin Nutr 2012; 32:162-71. [PMID: 23159212 DOI: 10.1016/j.clnu.2012.09.007] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2012] [Revised: 08/26/2012] [Accepted: 09/12/2012] [Indexed: 01/17/2023]
Abstract
Intestinal failure (IF) is a well identified clinical condition, which is characterised by the reduction of functional gut capacity below the minimum needed for adequate digestion and absorption of nutrients for normal growth in children. Short bowel syndrome (SBS) is the leading cause of IF in neonates, infants and young children usually as a result of extensive intestinal resection during the neonatal period. Simultaneously maintaining optimal nutritional status and achieving intestinal adaptation is a clinical challenge in short bowel patients. Both growth and development of the child as well as gut adaptation should be considered synergistically as primary outcome parameters. Enteral nutrition (EN) can be introduced orally and/or by tube feeding (TF). Several controversies over nutritional treatment of children with SBS related intestinal failure remain. As reported from different centres around the world, most practices are more "experienced based" rather than "evidence based". This is partly due to the small number of patients with this condition. This review (based on a consensus) discusses the physiological principles and nutritional management, including the type of diet and route of delivery. Perspectives in optimizing intestinal adaptation and reducing the consequences of small intestinal bacterial overgrowth are also discussed.
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Affiliation(s)
- O Goulet
- Department of Pediatric Gastroenterology-Hepatology and Nutrition, Reference Center for Rare Digestive Diseases, Intestinal Failure Rehabilitation Center, Hôpital Necker-Enfants Malades, University of Paris Descartes, France.
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Intestinal rehabilitation and bowel reconstructive surgery: improved outcomes in children with short bowel syndrome. J Pediatr Gastroenterol Nutr 2012; 54:505-9. [PMID: 21832945 DOI: 10.1097/mpg.0b013e318230c27e] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Short bowel syndrome poses a great challenge to pediatric teams. Several innovative techniques in the management of total parenteral nutrition (TPN) and bowel reconstructive surgery have improved the outcomes of these children. The authors present their experience during the last decade as a specialist unit using improved techniques and multidisciplinary approaches in the management of this condition. METHODS All of the children presenting with short bowel syndrome between 2000 and 2009 were identified. Diagnosis, length of residual gut, age at definitive surgery, length of gut prelengthening, length of gut postlengthening, TPN status, and survival were recorded. Median values were calculated. RESULTS Twenty-seven children were identified (14 boys, 13 girls). Overall survival was 92%. Two children died. Nineteen children required bowel lengthening and 8 children had simple bowel reconstruction while on our protocol. Overall median age at definitive surgery was 12 months. Overall median residual gut length for these was 35.5 cm, whereas the median residual gut length for patients undergoing bowel lengthening was 25 cm. Postbowel lengthening, the median gut length was 90 cm. TPN data were unavailable for 2 patients. Overall, excluding the 2 patients who died and the 2 we have no TPN data on, of 23 patients, 21 (91%) are now off TPN. CONCLUSIONS Our series shows improved results not only with survival but also in the number of patients that are off TPN. Multidisciplinary approach consisting of both medical and surgical expertise is necessary in the management of these patients. The authors advocate centralisation of short gut services to experienced centers with multidisciplinary expertise.
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Hess RA, Welch KB, Brown PI, Teitelbaum DH. Survival Outcomes of Pediatric Intestinal Failure Patients: Analysis of Factors Contributing to Improved Survival Over the Past Two Decades. J Surg Res 2011; 170:27-31. [DOI: 10.1016/j.jss.2011.03.037] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 02/09/2011] [Accepted: 03/15/2011] [Indexed: 01/14/2023]
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Affiliation(s)
- Jeffrey J Dehmer
- Department of Surgery, University of North Carolina at Chapel Hill, 4032 Burnett-Womack Building, CB# 7050, Chapel Hill, NC 27599-7050, USA
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