Short bowel syndrome in children and adults: from rehabilitation to transplantation

Nutritional Outcomes of Bowel Lengthening Procedure in Patients with Short Bowel Syndrome

BACKGROUND

Although parenteral nutrition (PN) significantly improves mortality rates in pediatric short bowel syndrome (SBS), long-term PN has many possible complications and impacts quality of life. Bowel lengthening procedures (BLPs) increase the contact surface of food and the intestinal mucosa and enable the better absorption of nutrients and liquids, possibly leading to a PN decrease.

METHODS

We retrospectively reviewed the data of patients with short bowel syndrome who underwent BLPs in the period from January 2016 to January 2022. Overall, eight patients, four male, five born prematurely, underwent BLPs.

RESULTS

There was a significant decrease in the percentage of total caloric intake provided via PN and PN volume after the BLPs. The more evident results were seen 6 months after the procedure and at the last follow-up, which was, on average, 31 months after the procedure. Two patients were weaned off PN after their BLPs. Patients remained well nourished during the follow-up.

CONCLUSIONS

The BLP led to a significant decrease in PN needs and an increase in the food intake; however, significant changes happened more than 6 months after the procedure.

Correlation between white blood cell count and intestinal resection in patients with acute mesenteric vein thrombosis

OBJECTIVE

Acute mesenteric vein thrombosis (AMVT) is an acute abdominal disease with onset, rapid progression, and extensive intestinal necrosis that requires immediate surgical resection. The purpose of this study was to determine the risk factors for nosocomial intestinal resection in patients with AMVT.

METHODS

We retrospectively analysed 64 patients with AMVT diagnosed by CTA at the Affiliated Hospital of Kunming University of Science and Technology from January 2013 to December 2021. We compared patients who underwent intestinal resection (42 patients) with those who did not undergo intestinal resection (22 patients). The area under the ROC curve was evaluated, and a forest map was drawn.

RESULTS

Among the 64 patients, 6 (9.38%) had a fever, 60 (93.75%) had abdominal pain, 9 (14.06%) had a history of diabetes, 8 (12.5%) had a history of deep vein thrombosis (DVT), and 25 (39.06%) had ascites suggested by B ultrasound or CT after admission. The mean age of all patients was 49.86 ± 16.25 years. The mean age of the patients in the enterectomy group was 47.71 ± 16.20 years. The mean age of the patients in the conservative treatment group (without enterectomy) was 53.95 ± 15.90 years. In the univariate analysis, there were statistically significant differences in leukocyte count (P = 0.003), neutrophil count (P = 0.001), AST (P = 0.048), total bilirubin (P = 0.047), fibrinogen (P = 0.022) and DD2 (P = 0.024) between the two groups. The multivariate logistic regression analysis showed that admission white blood cell count (OR = 1.153, 95% CI: 1.039-1.280, P = 0.007) was an independent risk factor for intestinal resection in patients with AMVT. The ROC curve showed that the white blood cell count (AUC = 0.759 95% CI: 0.620-0.897; P = 0.001; optimal threshold: 7.815; sensitivity: 0.881; specificity: 0.636) had good predictive value for emergency enterectomy for AMVT.

CONCLUSIONS

Among patients with AMVT, patients with a higher white blood cell count at admission were more likely to have intestinal necrosis and require emergency enterectomy. This study is helpful for clinicians to accurately determine whether emergency intestinal resection is needed in patients with AMVT after admission, prevent further intestinal necrosis, and improve the prognosis of patients.

Small bowel transplant - novel indications and recent progress

INTRODUCTION

Advances in the management of intestinal failure have led to a reduction in the number of intestinal transplants. The number of bowel transplants has been mainly stable even though a slight increase has been observed in the last 5 years.

AREAS COVERED

Standard indication includes patients with a reasonable life expectancy. Recent progress can be deduced by the increased number of intestine transplants in adults: this is due to the continuous improvement of 1-year graft survival worldwide (without differences in 3- and 5-year) associated with better abdominal wall closure techniques. This review aims to provide an update on new indications and changes in trends of pediatric and adult intestine transplantation. This analysis, which stretches through the past 5 years, is based on a collection of related manuscripts from PubMed.

EXPERT COMMENTARY

Intestinal transplants should be solely intended for a group of individuals for whom indications for transplantation are clear and both medical and surgical rehabilitations have failed. Nevertheless, many protocols developed over the years have not yet solved the key question represented by the over-immunosuppression. Novel indications and recent progress in the bowel transplant field, minimal yet consistent, represent a pathway to be followed.

The Outcomes of Treatment in Infants with Short Bowel Syndrome

Objective We reviewed 50 infant cases with short bowel syndrome (SBS) to examine the treatment outcome of SBS management in a tertiary hospital in Vietnam.

Material and Methods A case series was performed at the National Children's Hospital, Hanoi, Vietnam. A total of 50 cases with SBS were reviewed. Clinical and laboratory characteristics before and after treatment were collected.

Results The most common cause of SBS was necrotizing enterocolitis. Common clinical symptoms included watery stools, dehydration, and malnutrition. After treatment, the patient's weight, albumin, and prothrombin improved markedly. There are 72% of children with good or fair treatment results. The rate of sepsis was high (18%). There was one case with complications of catheter infection and one case of liver failure. Three children died during treatment, one died from septic shock and multiple organ failure, and two died from respiratory failure.

Conclusion This study showed promising treatment outcomes in pediatrics.

Nutrition of Infants with Bronchopulmonary Dysplasia before and after Discharge from the Neonatal Intensive Care Unit

Bronchopulmonary dysplasia (BPD) represents a severe sequela in neonates born very prematurely. The provision of adequate nutritional support in this high-risk population is challenging. The development of the lungs and physical growth are closely linked together in infants with BPD. Growth deficiency has been associated with pulmonary dysfunction, whereas improvement in respiratory status results in growth acceleration. Currently, there is not enough data regarding optimal nutritional strategies in this population. Nutrition in these infants should provide sufficient calories and nutrients to establish growth, avoid growth retardation and assist alveolarization of the lungs. Meticulous follow-up is mandatory during and after discharge from the Neonatal Intensive care Unit (NICU) to minimize growth retardation and improve lung function. Despite the significant literature supporting the contribution of growth and nutrition in the avoidance of BPD, there is limited research regarding interventions and management of infants with established BPD. Our aim was to review clinical strategies applied in everyday clinical practice and identify debates on the nutritional approach of newborns with BPD. Well-organized interventions and clinical trials regarding the somatic development and nutrition of infants with BPD are warranted.

Surgical Treatment of Short Bowel Syndrome—The Past, the Present and the Future, a Descriptive Review of the Literature

Short bowel syndrome (SBS) is a devastating disorder with both short- and long-term implications for patients. Unfortunately, the prevalence of SBS has doubled over the past 40 years. Broadly speaking, the etiology of SBS can be categorized as congenital or secondary, the latter typically due to extensive small bowel resection following diseases of the small intestine, e.g., necrotizing enterocolitis, Hirschsprung’s disease or intestinal atresia. As of yet, no cure exists, thus, conservative treatment, primarily parenteral nutrition (PN), is the first-line therapy. In some cases, weaning from PN is not possible and operative therapy is required. The invention of the longitudinal intestinal lengthening and tailoring (LILT or Bianchi) procedure in 1980 was a major step forward in patient care and spawned further techniques that continue to improve lives for patients with severe SBS (e.g., double barrel enteroplasty, serial transverse enteroplasty, etc.). With this review, we aim to provide an overview of the clinical implications of SBS, common conservative therapies and the development of operative techniques over the past six decades. We also provide a short outlook on the future of operative techniques, specifically with respect to regenerative medicine.

Need for transition medicine in pediatric surgery – health related quality of life in adolescents and young adults with congenital malformations

Survival rates of patients with visceral congenital malformations have increased considerably. However, long-term morbidity in these patients is high. In the last decades, these circumstances have led to a shift in goals of caretakers and researchers with a new focus on patients’ perspectives and long-term morbidity. Health-related quality of life (HrQoL) is the most commonly used patient-reported outcome measure to assess the impact of chronic symptoms on patients’ everyday lives. Most pediatric surgical conditions can cause a significantly decreased HrQoL in affected patients compared to the healthy population. In order to guarantee life-long care and to minimize the impact on HrQoL a regular interdisciplinary follow-up is obligatory. The period of transition from child-centered to adult-oriented medicine represents a critical phase in the long-term care of these complex patients. This scoping review aims to summarize relevant pediatric surgical conditions focusing on long-term-morbidity and HrQoL assessment in order to demonstrate the necessity for a well-structured and standardized transition for pediatric surgical patients.

Complementary and antagonistic effects of combined glucagon-like peptide-2 and glucagon-like peptide-1 receptor agonist administration on parameters relevant to short bowel syndrome

BACKGROUND

Short Bowel Syndrome (SBS) is characterized by debilitating malabsorption requiring parenteral nutrition. The intestinotrophic glucagon-like peptide-2 receptor agonist, h[Gly2]GLP2, is currently used to treat patients with SBS. Recent evidence suggests that GLP-1 receptor agonists such as Exendin-4 (Ex4) may also be beneficial in SBS given their ability to increase intestinal growth and delay gastric emptying (GE).

METHODS

Intestinal growth, body weight (BW), food intake (FI), GE, gastrointestinal (GI) transit, intestinal permeability, and glucose tolerance were investigated in male and female C57/BL6 mice following vehicle, h[Gly2]GLP2 or Ex4 treatment, alone or in combination at "low", "medium", and "high" doses (0.1, 0.5, 1.0 and 0.01, 0.05, 0.1 μg/g, respectively).

RESULTS

Only the h[Gly2]GLP2 low/Ex4 high-dose combination increased small intestinal (SI) weight, in an additive manner, compared to vehicle and both mono-agonists (P<0.01-0.001), via increases in villus height (P<0.01) and SI length (P<0.05), respectively. This combination had no effects on BW, FI and fat, liver, spleen, heart and kidney weights, but reduced GI transit (P<0.001) compared to low-dose h[Gly2]GLP2 mono-treatment, and abrogated the inhibitory effects of high-dose Ex4 on GE (P<0.01) and of low-dose h[Gly2]GLP2 on intestinal permeability (P<0.05). Ex4-induced improvements in glucose homeostasis were maintained upon combination with h[Gly2]GLP2 (P<0.001).

CONCLUSIONS

These findings suggest that combining specific doses of GLP-2-based therapies and GLP-1 receptor agonists additively improves SI growth and GI transit without detrimental effects on BW, FI, GE, and glucose homeostasis, and may therefore be a useful approach to the treatment of patients with SBS. This article is protected by copyright. All rights reserved.

Adaptation Processes of the Remaining Jejunum or Ileum after Extensive Intestinal Resection

PURPOSE

To compare the adaptation processes of the remaining jejunum or ileum after extensive intestinal resection in a growing animal model.

MATERIALS AND METHODS

Forty 21-day old rats were divided into four groups: JG: remaining jejunum group - ileal enterectomy; IG: ileum remaining group - jejunum enterectomy; SHAM: sham-operated group - open-and-close laparotomy; and NO: non-operated animals.

RESULTS

After 3 weeks, JG and IG animals had decreased weights comparing to SHAM and NO animals (p = 0.017 and p = 0.005, respectively). The histomorphometric analysis showed that in JG animals the villi were higher than in SHAM, NO, and IG animals (p = 0.007, p = 0.008, and p = 0.01), the depth of crypts in JG and IG animals was greater than in NO and SHAM animals (p = 0.03, p = 0.002, and p = 0.003 respectively), and muscle layer thickness of the jejunum of JG animals had values greater than SHAM and NO animals (p = 0.01 and p = 0.02, respectively). The Ki-67 expression in the ileum was higher in comparison with the jejunum (p = 0.014). The pro-apoptotic gene (Bax) expression was decreased in JG animals compared to IG, SHAM, and NO animals (p = 0.013, p = 0.024, and p = 0.021). The anti-apoptotic gene (Bcl-XL) expression was decreased in JG animals in comparison to IG and NO animals (p = 0.002 and p = 0.046) although it was increased in the colon of IG animals in comparison to JG, SHAM, and NO animals (p = 0.002, p = 0.001, and p = 0.001, respectively). The Bax/Bcl-XL ratio was higher in JG than in IG animals (p = 0.011).

CONCLUSION

Adaptive responses seemed to be more effective in the ileum than in the jejunum.

Proteomic biomarkers in short bowel syndrome : are we ready to use them in clinical activity?

Introduction: Short bowel syndrome (SBS) is a clinical condition that can affect childhood and adult patients. Biomarker research is expected to be a new frontier in the clinical application, helpful for patients and health-care systems.Areas covered: SBS is usually a consequence of a massive intestinal resection that leads to an intestinal failure because of the reduction of absorptive surface, bacterial overgrowth, and faster intestinal transit. This new condition requires a multidisciplinary expertise to achieve again digestive autonomy. Parental nutrition (PN) supports nutritional status in SBS patients while the new guidelines on intestinal transplantation confirm its strict indication only for patients at actual risk of death on PN. A PubMed literature review from the 1980s up to date was performed, highlighting proteomic biomarkers and growth factor therapies that have shown so far promising results in SBS patients.Expert opinion: Apart from a few specific biomarkers and growth factors, the discovery of specific molecular events is currently under investigation of the proteomic analysis and could potentially represent fundamental, future changes in prevention, diagnosis, therapeutic management, and experimental practices in SBS.

Long-term outcomes of various pediatric short bowel syndrome in China

PURPOSE

The goal of this study was to analyze long-term outcome of various pediatric short bowel syndrome (SBS) at an intestinal rehabilitation center in China.

METHODS

One hundred and fifty-seven children with SBS were enrolled in this study from October 1988 to July 2019. Their long-term follow-up outcome was analyzed according to the age of disease onset, parenteral nutrition (PN) duration, and anatomic types of short bowel, respectively. The clinical characteristics, which included demographics, the length of residual small bowel, PN duration, PN dependence, SBS-related complications such as IF-related liver disease (IFALD), catheter-related bloodstream infection (CRBI), and mortality were compared among the groups.

RESULTS

The main etiology for SBS were intestinal atresia, NEC, and volvulus. Five of 157 patients did not wean off PN. The incidence of IFALD and CRBI was 24.2 and 22.3%, respectively. Sixteen cases died because of infection and liver failure and eight patients lost to follow-up. The survival rate of the 157 patients was 84.7%. PN duration was longer in the infants and children group (284 ± 457 d vs. 110 ± 64 d, P = 0.021; R = 0.264, P = 0.001) and more patients did not wean off PN than in the neonates group (11.6% vs. 0, P = 0.001; R = 0.295, P < 0.001). Patients with PN with a duration of longer than 90 days had more CRBIs (30.6%, P = 0.025; R = 0.236, P = 0.003). Additionally, the rate of CRBI was higher in patients with stoma (30.0%, P = 0.032). There was no difference in mortality among the groups. In five PN dependence patients, none was SBS onset in neonates.

CONCLUSION

Pediatric patients with SBS could achieve favorable long-term survival and enteral autonomy. Different standards of SBS classification such as the age of disease onset, PN duration, and anatomic types of short bowel did not impact the overall mortality of pediatric SBS. Prolonged PN duration positively correlated with the age of disease onset and the incidence of CRBI. Patients with the complete continuity of intestinal tract suffered less from CRBI.

Clinicopathologic Features and Diagnostic Implications of Pyloric Gland Metaplasia in Intestinal Specimens

Pyloric gland metaplasia (PGM) is a histopathologic change usually seen after inflammatory injury and, although described in association with inflammatory bowel disease (IBD) and particularly Crohn disease (CD), its significance is still debated. We evaluated long-term correlates of PGM in a large cohort of 601 intestinal specimens, 227 (37.8%) biopsies, and 374 (62.2%) resections, from 567 different patients, 328 (57.8%) male and 239 (42.2%) female, with a mean age of 43.4±15.8 years. During mean clinical follow-up of 83.5±48.1 months, 511 (90.1%) patients were diagnosed with IBD, 457 (89.4%) with CD, and 53 (10.4%) with ulcerative colitis. In multivariate analysis, IBD patients with PGM were younger (P<0.001) and more often had severely active inflammation (P=0.002) compared with non-IBD patients, whereas, among IBD patients, those with ulcerative colitis were more likely to have PGM in a biopsy (P<0.001) or in the colorectum (P=0.009), compared with CD patients. Kaplan-Meier analyses showed that incidental PGM in a biopsy was more likely to predict IBD in patients younger than 50 years (P<0.001) and those without a history of bowel surgery (P<0.001) and also more likely to signify CD in patients younger than 50 years (P=0.004), those without a history of bowel surgery (P=0.020), and when identified in the small intestine (P=0.032). In conclusion, intestinal PGM warrants a high suspicion for IBD and specifically CD, however, it should be interpreted with caution, especially in older patients or those with a history of prior intestinal surgery and in colorectal biopsies or specimens lacking severely active inflammation.

Intestinal dysmotility after bowel resection in rats is associated with decreased ghrelin and vimentin expression and loss of intestinal cells of Cajal

This study provides novel insight into the mechanisms of intestinal dysmotility following massive small bowel resection. We show that 2 wk after bowel resection in rats, impaired intestinal motility was associated with loss of interstitial cells of Cajal (ICC; downregulation of transmembrane member 16A (TMEM16A) and c-kit expression) as well as with decreased vimentin, desmin, and ghrelin levels. Impaired intestinal motility led to a decrease in final body weight, suggesting less effective nutrient absorption. The purpose of this study was to evaluate the mechanisms of intestinal motility in a rat model of short bowel syndrome (SBS). Rats were divided into three groups: Sham rats underwent bowel transection; SBS-NSI rats underwent a 75% bowel resection and presented with normal intestinal size (NSI) at euthanasia and hypermotility patterns; SBS-DYS showed dysmotile (DYS) enlarged intestine and inhibited motility patterns. Animals were euthanized after 2 wk. Illumina's digital gene expression (DGE) analysis was used to determine the intestinal motility-related gene expression profiling in mucosal samples. Intestinal motility-related and ICC genes and protein expression in intestinal muscle layer were determined using real-time PCR, Western blotting, and immunohistochemistry. Gastrointestinal tract motility was studied by microcomputer tomography. From 10 Ca²⁺ signaling pathway-related genes, six genes in jejunum and seven genes in ileum were downregulated in SBS vs. Sham animals. Downregulation of TMEM16A mRNA and protein was confirmed by real-time PCR. Rapid intestinal transit time in SBS-NSI rats correlated with a mild decrease in TMEM16A, c-kit, and vimentin mRNA and protein expression (vs/. Sham animals). SBS-DYS rats demonstrated enlarged intestinal loops and delayed small intestinal emptying (on imaging studies) that were correlated with marked downregulation in TMEM16A, c-kit, vimentin, and ghrelin mRNA and protein levels compared with the other two groups. In conclusion, 2 wk following massive bowel resection in rats, impaired intestinal motility was associated with decreased vimentin and ghrelin gene and protein levels as well as loss of ICC (c-kit and TMEM16A).NEW & NOTEWORTHY This study provides novel insight into the mechanisms of intestinal dysmotility following massive small bowel resection. We show that 2 weeks after bowel resection in rats, impaired intestinal motility was associated with loss of interstitial cells of Cajal (downregulation of TMEM 16A, and c-kit expression) as well as with decreased vimentin, desmin, and ghrelin levels. Impaired intestinal motility led to decrease in final body weight, suggesting less effective nutrient absorption.

Anti-TNF-α Therapy Exerts Intestinal Anti-inflammatory and Anti-apoptotic Effects After Massive Bowel Resection in a Rat

OBJECTIVES

The aim of this study was to examine the effect of massive small bowel resection on proinflammatory cytokine intestinal expression and the effect of anti-TNF-α antibodies (ATA) on intestinal inflammation, epithelial cell turnover, and intestinal adaptation after bowel resection in rats.

METHODS

Male Sprague-Dawley rats were divided into 4 experimental groups: Sham-rats underwent bowel transection; Sham-ATA rats underwent bowel transection and were treated with ATA; SBS-animals underwent 75% bowel resection; and SBS-ATA rats underwent bowel resection and were treated with ATA similarly to Group B. Parameters of intestinal adaptation, enterocyte proliferation, and apoptosis were determined at sacrifice. TNF-α and apoptosis-related gene and protein levels were determined by Illumina's Digital Gene Expression (DGE) analysis, Real Time PCR, Western blotting, and immunohistochemistry.

RESULTS

From 25 genes related to TNF-α signalling that were investigated, 8 genes in the jejunum and 10 genes in the ileum were found to be up-regulated in resected versus sham animals. SBS rats demonstrated a significant increase in tissue and plasma TNF-α, IL-6 levels, intestinal mucosal TNF-α related gene expression, and microscopic parameters of inflammation. Treatment of resected animals with ATA resulted in a significant decrease in TNF-α levels, intestinal mucosal TNF-α-related gene expression, decreased number of intraepithelial lymphocytes and macrophages, and lower apoptotic index compared with SBS animals.

CONCLUSIONS

In a rat model of SBS, ATA decreased plasma and tissue TNF-α levels, diminished mucosal inflammation, and inhibited cell apoptosis. Anti-apoptotic effects of ATA appear to be associated with an inhibited extrinsic apoptotic pathway.

Guideline for Management of Mesenteric Ischemia: Shiraz Intestinal Failure Unit Protocol

We have recently established an intestinal rehabilitation unit (IRU) in Abu Ali Sina transplantation center affiliated to Shiraz University of Medical Sciences, Iran. Our intestinal failure rehabilitation and transplant program aims to provide state-of-the-art care for adult patients with different degrees of intestinal insufficiency and failure. In the IRU, we aimed to design an algorithmic approach to patients with small bowel ischemia and short bowel syndrome (SBS) based on our institutional experience in our country and based on other pioneering studies from other regions of the world.

Successful management of adhesion related small bowel ischemia without intestinal resection: A case report and review of literature

BACKGROUND

Intraabdominal adhesions develop spontaneously or after an inflammatory process or surgical procedure in the abdomen. They are the most common cause of small bowel obstruction (SBO). SBO occasionally leads to intestinal ischemia (InIs) which can be a life-threatening condition that requires management as soon as possible. We herein report a case of SBO with InIs presented in our institution and treated without intestinal resection.

CASE SUMMARY

A 34-year-old man presented at the emergency department after a 12-h-onset diffuse abdominal pain, bloating and nausea. He had a history of traumatic right hepatectomy 11 years ago as well as adhesiolysis and resection of a long part of small bowel 2 years ago. An abdominal computed tomography (CT) showed dilated loops that led to the diagnosis of SBO. Due to deteriorating lactic acidosis, the patient was operated. Torsion of the small bowel around an adhesion led to 2.30 m of ischemic ileum. After the application of N/S 40 °C for 20 min, the intestine showed signs of improvement and it was decided to avoid resection and instead temporary close the abdomen with vacuum-pack technique. At the second-look laparotomy 48 h later, the intestine appeared normal. The patient was discharged on the 8th post-op day in excellent condition.

CONCLUSION

In case of SBO caused by adhesions, extreme caution is needed if InIs is present, as the clinical signs are mild and you should rely for diagnosis in CT findings and lactate levels. Conservative surgical approach could reverse the effects of InIs, if performed quickly, so that intestinal resection is avoided and should be used even when minimum signs of viability are present.