1
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de Vries FEE, Claessen JJM, van Hasselt-Gooijer EMS, van Ruler O, Jonkers C, Kuin W, van Arum I, van der Werf GM, Serlie MJ, Boermeester MA. Bridging-to-Surgery in Patients with Type 2 Intestinal Failure. J Gastrointest Surg 2021; 25:1545-1555. [PMID: 32700102 PMCID: PMC8203517 DOI: 10.1007/s11605-020-04741-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 07/07/2020] [Indexed: 01/31/2023]
Abstract
AIM Type 2 intestinal failure (IF) is characterized by the need for longer-term parenteral nutrition (PN). During this so-called bridging-to-surgery period, morbidity and mortality rates are high. This study aimed to evaluate to what extent a multidisciplinary IF team is capable to safely guide patients towards reconstructive surgery. METHODS A consecutive series of patients with type 2 IF followed up by a specialized IF team between January 1st, 2011, and March 1st, 2016, was analyzed. Data on their first outpatient clinic visit (T1) and their last visit before reconstructive surgery (T2) was collected. The primary outcome was a combined endpoint of a patient being able to recover at home, have (partial) oral intake, and a normal albumin level (> 35 g/L) before surgery. RESULTS Ninety-three patients were included. The median number of previous abdominal procedures was 4. At T2 (last visit prior to reconstructive surgery), significantly more patients met the combined primary endpoint compared with T1 (first IF team consultation) (66.7% vs. 28.0% (p < 0.0001), respectively); 86% had home PN. During "bridging-to-surgery," acute hospitalization rate was 40.9% and acute surgery was 4.3%. Postoperatively, 44.1% experienced a major complication, 5.4% had a fistula, and in-hospital mortality was 6.5%. Of the cohort, 86% regained enteral autonomy, and when excluding in-hospital mortality and incomplete follow-up, this was 94.1%. An albumin level < 35 g/L at T2 and weight loss of > 10% at T2 compared with preadmission weight were significant risk factors for major complications. CONCLUSION Bridging-to-surgery of type 2 IF patients under the guidance of an IF team resulted in the majority of patients being managed at home, having oral intake, and restored albumin levels prior to reconstructive surgery compared with their first IF consultation.
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Affiliation(s)
- Fleur E. E. de Vries
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam University Medical Centers, location AMC, Postbox 22660, 1100 DD Amsterdam, The Netherlands
| | - Jeroen J. M. Claessen
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam University Medical Centers, location AMC, Postbox 22660, 1100 DD Amsterdam, The Netherlands
| | - Elina M. S. van Hasselt-Gooijer
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam University Medical Centers, location AMC, Postbox 22660, 1100 DD Amsterdam, The Netherlands
| | - Oddeke van Ruler
- grid.414559.80000 0004 0501 4532Department of Surgery, IJsselland Ziekenhuis, Capelle a/d IJssel, The Netherlands
| | - Cora Jonkers
- grid.509540.d0000 0004 6880 3010Nutrition Support Team, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Wanda Kuin
- grid.509540.d0000 0004 6880 3010Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Irene van Arum
- grid.509540.d0000 0004 6880 3010Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - G. Miriam van der Werf
- grid.509540.d0000 0004 6880 3010Nutrition Support Team, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Mireille J. Serlie
- grid.509540.d0000 0004 6880 3010Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Marja A. Boermeester
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam University Medical Centers, location AMC, Postbox 22660, 1100 DD Amsterdam, The Netherlands
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2
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Jung SM, Lee S, Park HJ, Kim HJ, Min JK, Seo JM. Multidisciplinary intestinal rehabilitation in acute type II intestinal failure: Results from an intestinal rehabilitation team. Asian J Surg 2020; 44:549-552. [PMID: 33262044 DOI: 10.1016/j.asjsur.2020.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Type II (acute) intestinal failure (IF) is usually caused by complications of abdominal surgery resulting in enteric fistulas or proximal stomas and requires parenteral nutrition (PN) for several months. This study aimed to evaluate clinical management and outcome of type II IF patients in a single center. METHODS Medical records of patients referred to the Intestinal Rehabilitation Team (IRT) at Samsung Medical Center (Seoul, Korea) were retrospectively analyzed. RESULTS From 2014 to 2019, 34 patients with IF were referred. 28 patients were type II IF and were included in the analysis. There were 17 males and 11 females. Mean age of patients was 56.7 years. Pathophysiology of IF were high-output stoma in 16 cases, extensive bowel resection (with bowel in continuity) in 7 cases, and enterocutaneous fistula in 5 cases. The catastrophic events necessitating abdominal surgery in the patients were adhesive ileus in 9 cases, superior mesenteric artery thrombosis in 8 cases, internal herniation of bowel in 5 cases, traumatic bowel injury in 3 cases, and ischemic enteritis in 3 cases. Following medical and surgical rehabilitation, 10 patients (35.7%) were weaned off PN and overall mortality was 28.5%. Deaths were related to progression of underlying malignancies in 4 cases, liver failure in 3 cases, and sepsis in 1 case. Thirteen patients underwent surgery to restore bowel continuity. Six postoperative complications occurred in 4 patients (30.7%) and there were no postoperative mortalities. CONCLUSION Standardized care including restorative surgery resulted in successful outcomes in type II IF patients in this cohort.
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Affiliation(s)
- Soo-Min Jung
- Intestinal Rehabilitation Team, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea; Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Sanghoon Lee
- Intestinal Rehabilitation Team, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea; Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea.
| | - Hyo Jung Park
- Intestinal Rehabilitation Team, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea; Departments of Pharmaceutical Services, Samsung Medical Center, Seoul, South Korea
| | - Hyun-Jung Kim
- Intestinal Rehabilitation Team, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea; Departments of Dietetics, Samsung Medical Center, Seoul, South Korea
| | - Ja-Kyung Min
- Intestinal Rehabilitation Team, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea; Departments of Nursing, Samsung Medical Center, Seoul, South Korea
| | - Jeong-Meen Seo
- Intestinal Rehabilitation Team, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea; Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
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3
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Massironi S, Cavalcoli F, Rausa E, Invernizzi P, Braga M, Vecchi M. Understanding short bowel syndrome: Current status and future perspectives. Dig Liver Dis 2020; 52:253-261. [PMID: 31892505 DOI: 10.1016/j.dld.2019.11.013] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/08/2019] [Accepted: 11/18/2019] [Indexed: 02/08/2023]
Abstract
Short bowel syndrome (SBS) is a rare malabsorptive disorder as a result of the loss of bowel mass mostly secondary to surgical resection of the small intestine. Other causes are vascular diseases, neoplasms or inflammatory bowel disease. The spectrum of the disease is widely variable from single micronutrient malabsorption to complete intestinal failure, depending on the remaining length of the small intestine, the anatomical portion of intestine and the function of the remnant bowel. Over the last years, the management of affected patients has remarkably improved with the increase in patients' quality of life and survival, mainly thanks to advances in home-based parenteral nutrition (PN). In the last ten years new treatment strategies have become available together with increasing experience and the encouraging results with new drugs, such as teduglutide, have added a new dimension to the management of SBS. This review aims to summarize the knowledge available in the current literature on SBS epidemiology, pathophysiology, and its surgical (including intestinal lengthening procedures and intestinal transplantation) and medical management with emphasis on the recent advances. Moreover, this review attempts to provide the new understanding and recent approaches to SBS complications such as sepsis, catheter thrombosis, and intestinal failure-associated liver disease.
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Affiliation(s)
- Sara Massironi
- Gastroenterology and Endoscopy Unit, IRCCS Ca' Granda Foundation, Policlinico Hospital, University of the Study of Milan, Italy.
| | | | - Emanuele Rausa
- Division of Surgical Oncology, ASST Bergamo Ovest, Treviglio, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, San Gerardo Hospital, University of Milano, Bicocca School of Medicine, Monza, Italy
| | - Marco Braga
- Division of Surgery, San Gerardo Hospital, University of Milano - Bicocca School of Medicine, Monza, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, IRCCS Ca' Granda Foundation, Policlinico Hospital, University of the Study of Milan, Italy
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4
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Yuda Handaya A, Werdana VAP, Rifqi Fauzi A. Nurse supervised combined refeeding and home parenteral nutrition in traumatic intestinal failure: A case series. Int J Surg Case Rep 2019; 61:199-201. [PMID: 31377543 PMCID: PMC6698642 DOI: 10.1016/j.ijscr.2019.07.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/13/2019] [Accepted: 07/17/2019] [Indexed: 11/19/2022] Open
Abstract
Combined refeeding and home parenteral nutrition in traumatic intestinal failure. Peritonitis due to abdominal trauma. Received Hartman’s procedure and jejunostomy. Parenteral nutrition at home. Prevent prolonged length of stay at hospital.
Background Intestinal failure is a decrease in intestinal function under the minimum absorption requirements of macronutrients, water, and electrolytes. Hartman's procedure with jejunostomy is used as a surgical procedure to prevent further damage in cases of abdominal trauma. Providing parenteral nutrition at home is needed to prevent nutritional deficiencies and prolonged length of stay. Presentation of case We reported two cases, involving two men aged 25 and 14 years old who had peritonitis due to abdominal trauma and received laparotomy. Both patients had Hartman’s procedures and jejunostomy less than 60 cm from the Treitz ligament. Both patients were diagnosed as bowel failure with an SGA C score. Supervised home parenteral nutrition was done by refeeding jejunostomy at the distal stoma. After supervision of parenteral nutrition, the SGA score increased from C to B. Three months later the patients underwent jejunal reanastomosis. Patients went home one week later without complications. At postoperative follow-up at one month and one year, both patients did not experience any complications. Discussion HPN is now a method used to provide nutritional support for patients with IF. This helps patients to meet their nutritional needs, also preventing psychosocial disorders and reduction of their quality of life. Conclusions Based on these two cases, nurse supervised combined refeeding and home parenteral nutrition showed good results with an increase in nutritional status of SGA C to SGA B. Supervision of home parenteral nutrition can be considered as adjunctive therapy in patients with high intestinal failure before undergoing reanastomosis.
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Affiliation(s)
- Adeodatus Yuda Handaya
- Digestive Surgery Division, Department of Surgery, Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Jl. Kesehatan No. 1, Yogyakarta 55281, Indonesia.
| | | | - Aditya Rifqi Fauzi
- Faculty of Medicine, Universitas Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta 55281, Indonesia.
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González-Salazar L, Guevara-Cruz M, Serralde-Zúñiga A. Tratamiento médico y nutricional en el paciente adulto con fallo intestinal agudo. Rev Clin Esp 2019; 219:151-160. [DOI: 10.1016/j.rce.2018.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/16/2018] [Accepted: 08/20/2018] [Indexed: 10/28/2022]
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6
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González-Salazar L, Guevara-Cruz M, Serralde-Zúñiga A. Medical and nutritional treatment in adult patients with acute intestinal failure. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2018.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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7
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Grainger JT, Maeda Y, Donnelly SC, Vaizey CJ. Assessment and management of patients with intestinal failure: a multidisciplinary approach. Clin Exp Gastroenterol 2018; 11:233-241. [PMID: 29928141 PMCID: PMC6003282 DOI: 10.2147/ceg.s122868] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Intestinal failure (IF) is a condition characterized by the inability to maintain a state of adequate nutrition, or fluid and electrolyte balance due to an anatomical or a physiological disorder of the gastrointestinal system. IF can be an extremely debilitating condition, significantly affecting the quality of life of those affected. The surgical management of patients with acute and chronic IF requires a specialist team who has the expertise in terms of technical challenges and decision-making. A dedicated IF unit will have the expertise in patient selection for surgery, investigative workup and planning, operative risk assessment with relevant anesthetic expertise, and a multidisciplinary team with support such as nutritional expertise and interventional radiology. This article covers the details of IF management, including the classification of IF, etiology, prevention of IF, and initial management of IF, focusing on sepsis treatment and nutritional support. It also covers the surgical aspects of IF such as intestinal reconstruction, abdominal wall reconstruction, and intestinal transplantation.
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Affiliation(s)
- Jennie T Grainger
- The Lennard Jones Intestinal Failure Unit, St. Mark's Hospital, Harrow, UK
| | - Yasuko Maeda
- The Lennard Jones Intestinal Failure Unit, St. Mark's Hospital, Harrow, UK.,Faculty of Medicine, Imperial College London, London, UK
| | - Suzanne C Donnelly
- The Lennard Jones Intestinal Failure Unit, St. Mark's Hospital, Harrow, UK
| | - Carolynne J Vaizey
- The Lennard Jones Intestinal Failure Unit, St. Mark's Hospital, Harrow, UK.,Faculty of Medicine, Imperial College London, London, UK
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8
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Du Toit A, Boutall ABT, Blaauw R. Opinions of South African dietitians on fistuloclysis as a treatment option for intestinal failure patients. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2017. [DOI: 10.1080/16070658.2017.1345430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- A Du Toit
- Division of Human Nutrition, Stellenbosch University, Stellenbosch, South Africa
- Department of Dietetics, Groote Schuur Hospital, Cape Town, South Africa
| | - ABT Boutall
- Department of Surgery, Groote Schuur Hospital, Cape Town, South Africa
| | - R Blaauw
- Division of Human Nutrition, Stellenbosch University, Stellenbosch, South Africa
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9
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de Vries FEE, Reeskamp LF, van Ruler O, van Arum I, Kuin W, Dijksta G, Haveman JW, Boermeester MA, Serlie MJ. Systematic review: pharmacotherapy for high-output enterostomies or enteral fistulas. Aliment Pharmacol Ther 2017; 46:266-273. [PMID: 28613003 DOI: 10.1111/apt.14136] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/02/2017] [Accepted: 04/15/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND High-output enterocutaneous fistula or enterostomies can cause intestinal failure. There is a wide variety of options in medical management of patients with high output. AIM To systematically review the literature on available pharmacotherapy to reduce output and to propose an algorithm for standard of care. METHODS Relevant databases were systematically reviewed to identify studies on pharmacotherapy for reduction in (high-) output enterostomies or fistula. Randomised controlled trials and within subjects controlled prospective trials were included. An algorithm for standard of care was generated based on the outcomes of the systematic review. RESULTS Two studies on proton pump inhibitors, six on anti-motility agents, three on histamine receptor antagonists, one on an α2- receptor agonist and eight on somatostatin (analogues) were included. One study examined a proton pump inhibitor and a histamine receptor antagonist within the same patients. Overall, we found evidence for the following medical therapies to be effective: omeprazole, loperamide and codeine, ranitidine and cimetidine. On the basis of these outcomes and clinical experience, we proposed an algorithm for standard of care which consists of high-dose proton pump inhibitors combined with high-dose loperamide as the first step followed by addition of codeine in case of insufficient output reduction. So far, there is insufficient evidence for the standard use of somatostatin (analogues). CONCLUSIONS The available evidence on the efficacy of medication to reduce enterostomy or enterocutaneous fistula output is hampered by low quality studies. We propose an algorithm for standard of care output reduction in these patients.
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Affiliation(s)
- F E E de Vries
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - L F Reeskamp
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - O van Ruler
- Department of Surgery, IJsselland Ziekenhuis, Cappele a/d Ijssel, The Netherlands
| | - I van Arum
- Department of Endocrinology and Metabolism, Academic Medical Centre, Amsterdam, The Netherlands
| | - W Kuin
- Department of Endocrinology and Metabolism, Academic Medical Centre, Amsterdam, The Netherlands
| | - G Dijksta
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - J W Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - M A Boermeester
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - M J Serlie
- Department of Endocrinology and Metabolism, Academic Medical Centre, Amsterdam, The Netherlands
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10
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Jian XD, Yu GC. Digestive system damage in acute poisoning and treatment strategy. Shijie Huaren Xiaohua Zazhi 2016; 24:4766-4771. [DOI: 10.11569/wcjd.v24.i36.4766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Acute intoxication is a common critical clinical condition. Poisoning patients tend to have an urgent onset, critical illness and rapid progression. If timely and reasonable treatment is not given, there will be a serious threat to patients' life. Drugs, alcohol, pesticides, and poisonous chemicals are clinically common toxic substances, and oral suicide is a major cause of poisoning. Therefore, suicidal patients absorb poison mainly through the digestive tract, and digestive system damage is common and serious. Awareness of digestive system damage in patients with acute poisoning and treatment measures has important clinical significance for improving the overall prognosis of these patients. This paper discusses the latest research progress in understanding digestive system damage in acute poisoning and treatment strategy.
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11
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de Jong PR, González-Navajas JM, Jansen NJG. The digestive tract as the origin of systemic inflammation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:279. [PMID: 27751165 PMCID: PMC5067918 DOI: 10.1186/s13054-016-1458-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Failure of gut homeostasis is an important factor in the pathogenesis and progression of systemic inflammation, which can culminate in multiple organ failure and fatality. Pathogenic events in critically ill patients include mesenteric hypoperfusion, dysregulation of gut motility, and failure of the gut barrier with resultant translocation of luminal substrates. This is followed by the exacerbation of local and systemic immune responses. All these events can contribute to pathogenic crosstalk between the gut, circulating cells, and other organs like the liver, pancreas, and lungs. Here we review recent insights into the identity of the cellular and biochemical players from the gut that have key roles in the pathogenic turn of events in these organ systems that derange the systemic inflammatory homeostasis. In particular, we discuss the dangers from within the gastrointestinal tract, including metabolic products from the liver (bile acids), digestive enzymes produced by the pancreas, and inflammatory components of the mesenteric lymph.
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Affiliation(s)
- Petrus R de Jong
- Department of Pediatric Intensive Care, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands. .,Sanford Burnham Prebys Medical Discovery Institute, 10901 N Torrey Pines Rd, La Jolla, CA, 92037, USA.
| | - José M González-Navajas
- Networked Biomedical Research Center for Hepatic and Digestive Diseases (CIBERehd), Hospital General Universitario de Alicante, Alicante, Spain.,Alicante Institute of Health and Biomedical Research (ISABIAL - FISABIO Foundation), Alicante, Spain
| | - Nicolaas J G Jansen
- Department of Pediatric Intensive Care, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
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12
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Atema JJ, Mirck B, Van Arum I, Ten Dam SM, Serlie MJ, Boermeester MA. Outcome of acute intestinal failure. Br J Surg 2016; 103:701-708. [PMID: 26999497 DOI: 10.1002/bjs.10094] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 11/03/2015] [Accepted: 12/01/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND Type 2 acute intestinal failure is characterized by the need for parenteral nutrition (PN) for several months, and is typically caused by complications of abdominal surgery with enteric fistulas or proximal stomas. This study aimed to evaluate clinical management according to quality indicators established by the Association of Surgeons of Great Britain and Ireland. METHODS Consecutive patients with type 2 intestinal failure referred to a specialized centre were analysed. Outcomes included the rate of discontinuation of PN, morbidity and mortality. RESULTS Eighty-nine patients were analysed, of whom 57 had an enteric fistula, 29 a proximal stoma (6 with distal fistulas), and three had intestinal failure owing to other causes. One patient was deemed inoperable, and nine patients died from underlying illness during initial management. Before reconstructive surgery, 94 per cent (65 of 66 operated and 3 patients scheduled for surgery) spent the period of rehabilitation at home. Discontinuation of PN owing to restoration of enteral autonomy was achieved in 65 (73 per cent) of 89 patients. Seven patients developed a recurrent fistula, which was successfully managed with a further operation in four, resulting in successful fistula takedown in 41 of 44 patients undergoing fistula resection. Three patients (5 per cent) died in hospital after reconstructive surgery. The overall mortality rate in this series, including preoperative deaths from underlying diseases, was 16 per cent (14 patients). CONCLUSION Intestinal failure care and reconstructive surgery resulted in successful discontinuation of PN in the majority of patients, although disease-related mortality was considerable.
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Affiliation(s)
- J J Atema
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - B Mirck
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - I Van Arum
- Departments of Endocrinology and Metabolism, Academic Medical Centre, Amsterdam, The Netherlands
| | - S M Ten Dam
- Departments of Dietetics, Academic Medical Centre, Amsterdam, The Netherlands
| | - M J Serlie
- Departments of Endocrinology and Metabolism, Academic Medical Centre, Amsterdam, The Netherlands
| | - M A Boermeester
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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13
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Corbee RJ, Kerkhoven WJSV. Nutritional Support of Dogs and Cats after Surgery or Illness. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ojvm.2014.44006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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14
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Slade DAJ, Carlson GL. Takedown of Enterocutaneous Fistula and Complex Abdominal Wall Reconstruction. Surg Clin North Am 2013; 93:1163-83. [DOI: 10.1016/j.suc.2013.06.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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15
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Carlson GL, Patrick H, Amin AI, McPherson G, MacLennan G, Afolabi E, Mowatt G, Campbell B. Management of the open abdomen: a national study of clinical outcome and safety of negative pressure wound therapy. Ann Surg 2013; 257:1154-9. [PMID: 23478532 DOI: 10.1097/sla.0b013e31828b8bc8] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To determine clinical outcome of open abdomen therapy and assess the influence of negative pressure wound therapy on outcome. BACKGROUND Leaving the abdomen open (laparostomy) is an option following laparotomy for severe abdominal sepsis or trauma. Negative pressure wound therapy (NPWT) has become a popular means of managing laparostomy wounds. It may facilitate nursing care and delayed primary wound closure but the evidence to support its use is poor and concern has arisen about the risk of intestinal fistulation from exposed bowel, leading to an increased risk of death. METHODS Prospective observational study of 578 patients treated with an open abdomen in 105 hospitals in the United Kingdom between January 1, 2010, and June 30, 2011. Propensity analysis was used to compare adverse outcomes (fistulation, death, intestinal failure, bleeding requiring intervention) and delayed primary closure rates in patients who did and did not receive NPWT. FINDINGS The most common indication for an open abdomen (n = 398, 68.9%) was abdominal sepsis. Overall hospital mortality was 28.2%. The majority of patients (n = 355, 61.4%) were treated with NPWT. Intestinal fistulation [relative risk (RR) = 0.83, 95% confidence interval (CI): 0.44-1.58], death (RR = 0.87, 95% CI: 0.64-1.20), bleeding (RR = 0.74, 95% CI: 0.45-1.23), and intestinal failure (RR = 1.00, 95% CI: 0.64-1.57) were no more common in patients receiving NPWT, but the rate of delayed primary closure was significantly lower (RR = 0.74, 95% CI: 0.60-0.90, P = 0.002) when NPWT was used. CONCLUSIONS The indications for an open abdomen in the United Kingdom appear to be significantly different to those described in N. America, where its use in the management of trauma predominates. NPWT in patients with an open abdomen is not associated with an increase in mortality or intestinal fistulation. It is, however, associated with a reduced rate of delayed primary closure. Although this may be related to patient selection, NPWT may leave patients with abdominal wall defects that require further treatment.
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Affiliation(s)
- Gordon L Carlson
- National Intestinal Failure Centre, Department of Surgery, Salford Royal NHS Foundation Trust, Salford, United Kingdom.
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16
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The financial cost of managing patients with type 2 intestinal failure; experience from a regional centre. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.clnme.2013.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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17
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Stevens P, Burden S, Delicata R, Carlson G, Lal S. Somatostatin analogues for treatment of enterocutaneous fistula. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [DOI: 10.1002/14651858.cd010489] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Philip Stevens
- Salford Royal NHS Foundation Trust; Surgery; Stott Lane Salford UK M6 8HD
| | - Sorrel Burden
- University of Manchester; School of Nursing, Midwifery and Social Work; Room 6.32, Jean McFarlane Building, Oxford Road Manchester UK M13 9PL
| | - Raymond Delicata
- Gwent Healthcare NHS Healthboard ? Nevill Hall Hospital; General Surgery; Brecon Road Abergavenny UK NP7 7EG
| | - Gordon Carlson
- Salford Royal NHS Foundation Trust; General Surgery; Stott Lane Salford UK M6 8HD
| | - Simon Lal
- Salford Royal Foundation Trust; Intestinal Failure Unit; Salford UK M6 8HD
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18
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Lambe G, Russell C, West C, Kalaiselvan R, Slade DAJ, Anderson ID, Watson JS, Carlson GL. Autologous reconstruction of massive enteroatmospheric fistulation with a pedicled subtotal lateral thigh flap. Br J Surg 2012; 99:964-72. [DOI: 10.1002/bjs.8759] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2012] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Reconstruction of massive contaminated abdominal wall defects associated with enteroatmospheric fistulation represents a technical challenge. An effective technique that allows closure of intestinal fistulas and reconstruction of the abdominal wall, with a good functional and cosmetic result, has yet to be described. The present study is a retrospective review of simultaneous reconstruction of extensive gastrointestinal tract fistulation and large full-thickness abdominal wall defects, using a novel pedicled subtotal thigh flap.
Methods
The flap, based on branches of the lateral circumflex femoral artery, was used to reconstruct the abdominal wall in six patients who were dependent on artificial nutritional support, with a median (range) of 4·5 (3–23) separate intestinal fistulas, within open abdominal wounds with a surface area of 564·5 (204–792) cm2. Intestinal reconstruction was staged, with delayed closure of a loop jejunostomy. Median follow-up was 93·5 (10–174) weeks.
Results
Successful healing occurred in all patients, with no flap loss or gastrointestinal complications. One patient died from complications of sepsis unrelated to the surgical treatment. All surviving patients gained complete nutritional autonomy following closure of the loop jejunostomy.
Conclusion
Replacement of almost the entire native abdominal wall in patients with massive contaminated abdominal wall defects is possible, without the need for prosthetic material or microvascular free flaps. The subtotal pedicled thigh flap is a safe and effective method of providing definitive treatment for patients with massive enteroatmospheric fistulation.
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Affiliation(s)
- G Lambe
- Department of Plastic and Reconstructive Surgery, University Hospital of South Manchester, Manchester, UK
| | - C Russell
- Department of Plastic and Reconstructive Surgery, University Hospital of South Manchester, Manchester, UK
| | - C West
- Department of Plastic and Reconstructive Surgery, University Hospital of South Manchester, Manchester, UK
| | - R Kalaiselvan
- National Intestinal Failure Centre, Salford Royal NHS Foundation Trust, Salford, UK
| | - D A J Slade
- National Intestinal Failure Centre, Salford Royal NHS Foundation Trust, Salford, UK
| | - I D Anderson
- National Intestinal Failure Centre, Salford Royal NHS Foundation Trust, Salford, UK
| | - J S Watson
- Department of Plastic and Reconstructive Surgery, University Hospital of South Manchester, Manchester, UK
| | - G L Carlson
- National Intestinal Failure Centre, Salford Royal NHS Foundation Trust, Salford, UK
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19
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Proinflammatory chemokines in the intestinal lumen contribute to intestinal dysfunction during endotoxemia. Shock 2012; 37:63-9. [PMID: 22089201 DOI: 10.1097/shk.0b013e31823cbff1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Intestinal failure is common in patients with septic shock, with dysfunction of the gut often manifesting as both a cause and consequence of their critical illness. Most studies investigating the pathogenesis of intestinal failure focus on the systemic aspect, although few data examine the inflammatory signaling in the intestinal lumen. Having previously demonstrated apical/luminal chemokine secretion in an in vitro model of intestinal inflammation, we hypothesized that endotoxemia would induce secretion of proinflammatory chemokines into the intestinal lumen. In addition, we examined the contribution of these mediators to intestinal dysmotility. C57/BL6 male mice were injected intraperitoneally with LPS. Serum, intestinal tissue, and intestinal luminal contents were harvested for cytokine analysis. For intestinal motility studies, a transit assay was performed after oral gavage of chemokines. Caco-2 cells grown on Transwell culture inserts were used to examine the role of the intestinal epithelium in chemokine secretion. Monocyte chemoattractant protein 1 (MCP-1/CCL2) and macrophage-derived chemokine (MDC/CCL22) were secreted into the lumen of multiple segments of the gut during endotoxemia in mice. In vitro work showed that the intestinal epithelium participates in monocyte chemoattractant protein 1 and MDC secretion and expresses the CCR2 and CCR4 receptors for these chemokines. Intestinal transit studies show that oral gavage of MDC results in impaired gut motility. This study demonstrates that the intestinal lumen is an active compartment in the gut's inflammatory response. Proinflammatory chemokines are secreted into the intestinal lumen during endotoxemia. These intraluminal chemokines contribute to intestinal dysmotility, complicating intestinal failure.
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Dicken BJ, Sergi C, Rescorla FJ, Breckler F, Sigalet D. Medical management of motility disorders in patients with intestinal failure: a focus on necrotizing enterocolitis, gastroschisis, and intestinal atresia. J Pediatr Surg 2011; 46:1618-30. [PMID: 21843732 DOI: 10.1016/j.jpedsurg.2011.04.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 03/31/2011] [Accepted: 04/05/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND Intestinal failure (IF) is the dependence upon parenteral nutrition to maintain minimal energy requirements for growth and development. It may occur secondary to a loss of bowel length, disorders of motility, or both. Short bowel syndrome (SBS) is a malabsorptive state resulting from surgical resection, congenital defect, or diseases associated with loss of absorptive surface area. A particularly vexing problem is associated with whole bowel and/or segmental intestinal dysmotility. Motility disorders within the context of SBS and IF may relate to rapid intestinal transit secondary to loss of intestinal length, dysmotility associated with loss or poor antegrade peristalsis, or gastroparesis. Therapy may be classified into medical (prokinetic and antidiarrheal agents) and surgical to deal with the overdistended poorly motile bowel. METHODS We performed a systematic review of the literature pertaining to IF, SBS, and dysmotility in the pediatric population with gastroschisis, necrotizing enterocolitis, and intestinal atresia. In addition to the available treatment options, we have provided a review of the literature and a summary of the available evidence. CONCLUSION Despite relatively poor level of evidence regarding the application of promotility and antidiarrheal medications in patients with SBS and IF, these agents continue to be used. Herein, we provide a review of the physiology and pathophysiology of intestinal motility/dysmotility and available strategies for the use of promotility and antidiarrheal agents in patients with IF/SBS.
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Affiliation(s)
- Bryan J Dicken
- Division of Pediatric Surgery, Stollery Children's Hospital, University of Alberta Hospital, Edmonton, Alberta, Canada.
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21
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Abstract
Intestinal failure (IF) occurs when intestinal absorptive function is inadequate to maintain hydration and nutrition without enteral or parenteral supplements. It has been classified into three types depending on duration of nutrition support and reversibility. Type 1 IF is commonly seen in the peri-operative period as ileus and usually spontaneously resolves within 14 d. Type 2 IF is uncommon and is often associated with an intra-abdominal catastrophe, intestinal resection, sepsis, metabolic disturbances and undernutrition. Type 3 IF is a chronic condition in a metabolically stable patient, which usually requires long-term parenteral nutrition. This paper focuses on Types 1 and 2 IF (or acute IF) that are usually found in surgical wards. The objectives of this paper are to review the incidence, aetiology, prevention, management principles and outcome of acute IF. The paper discusses the resources necessary to manage acute IF, the indications for inter-hospital transfer and the practicalities of how to transfer and receive a patient with acute IF.
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22
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Reed RL. Prevention of Hospital-Acquired Infections by Selective Digestive Decontamination. Surg Infect (Larchmt) 2011; 12:221-9. [DOI: 10.1089/sur.2011.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- R. Lawrence Reed
- Department of Trauma Services, IU Health Methodist Hospital, Indiana University, Indianapolis, Indiana
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