1
|
Spector Cohen I, Belza C, Courtney-Martin G, Srbely V, Wales PW, Muise A, Avitzur Y. Improved long-term outcome of children with congenital diarrhea followed by an intestinal rehabilitation program. J Pediatr Gastroenterol Nutr 2024. [PMID: 38828718 DOI: 10.1002/jpn3.12275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 04/28/2024] [Accepted: 05/14/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Long-term outcomes of congenital diarrheas and enteropathies (CODE) are poorly described. We evaluated the morbidity and mortality of children with CODE followed by an intestinal rehabilitation program (IRP) compared to children with short bowel syndrome (SBS). METHODS Matched case-control study of children with intestinal failure (IF) due to CODE (diagnosed between 2006 and 2020; N = 15) and SBS (N = 42), matched 1:3, based on age at diagnosis and duration of parenteral nutrition (PN). Nutritional status, growth, and IF-related complications were compared. Survival and enteral autonomy were compared to a nonmatched SBS cohort (N = 177). RESULTS Fifteen CODE patients (five males, median age 3.2 years) were followed for a median of 2.9 years. Eleven children were alive at the end of the follow-up, and two achieved enteral autonomy. The CODE group had higher median PN fluid and calorie requirements than their matched SBS controls at the end of the follow-up (83 vs. 45 mL/kg/day, p = 0.01; 54 vs. 30.5 kcal/kg/day, p < 0.01), but had similar rates of growth parameters, intestinal failure associated liver disease (IFALD), central venous catheter (CVC) complications and nephrocalcinosis. Kaplan-Meier (KM) analyses of 10-year survival and enteral autonomy were significantly lower in CODE patients compared to the nonmatched SBS population (60% vs. 89% and 30% vs. 87%, respectively; log-rank p < 0.008). CONCLUSIONS Despite higher PN needs in CODE, rates of IF complications were similar to matched children with SBS. Enteral autonomy and survival rates were lower in CODE patients. Treatment by IRP can mitigate IF-related complications and improve CODE patient's outcome.
Collapse
Affiliation(s)
- Inna Spector Cohen
- Group for Improvement of Intestinal Function and Treatment (GIFT), Toronto, Ontario, Canada
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Pediatric Gastroenterology and Nutrition Institute, Ruth Children's Hospital of Haifa, Rambam Medical Center, Haifa, Israel
| | - Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), Toronto, Ontario, Canada
| | - Glenda Courtney-Martin
- Group for Improvement of Intestinal Function and Treatment (GIFT), Toronto, Ontario, Canada
| | - Victoria Srbely
- Group for Improvement of Intestinal Function and Treatment (GIFT), Toronto, Ontario, Canada
| | - Paul W Wales
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati, Ohio, USA
- Division of General and Thoracic Surgery, Department of Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Aleixo Muise
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), Toronto, Ontario, Canada
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
2
|
Pauline ML, Labonne E, Wizzard PR, Turner JM, Wales PW. Association between 4%-tetrasodium EDTA and sepsis in neonatal piglets: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2024; 48:495-501. [PMID: 38400572 DOI: 10.1002/jpen.2609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 01/10/2024] [Accepted: 01/28/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Central line-associated bloodstream infections are a major concern for children with intestinal failure and in animal research using parenteral nutrition (PN). In neonatal piglets receiving PN, we compared sepsis, line occlusions, line replacements, mortality, and costs with and without the use of a 4%-tetrasodium ethylenediaminetetraacetic acid (T-EDTA) locking solution. METHODS We performed a retrospective review of piglets with a central venous jugular catheter enrolled in 14-day exclusive PN (TPN) trials or in 7-day short bowel syndrome (SBS) trials, before and after initiation of T-EDTA. Lines were locked with a 1-ml solution for 2 h daily (T-EDTATPN, n = 17; T-EDTASBS, n = 48) and compared with our prior standard of care using 1.5-ml heparin flushes twice daily (CONTPN, n = 34; CONSBS, n = 48). Line patency and signs of sepsis were checked twice daily. Jugular catheters were replaced for occlusions whenever possible. Humane end points were used for sepsis not responding to antibiotic treatment or unresolved catheter occlusions. RESULTS Compared with CON, sepsis was reduced using T-EDTA, significantly for TPN (P = 0.006) and with a trend for SBS piglets (P = 0.059). Line occlusions necessitating line changes were reduced 15% in TPN studies (P = 0.16), and no line occlusions occurred for T-EDTA SBS piglets. CONCLUSION In our neonatal piglet research, use of T-EDTA locking solution decreased sepsis and, although not statistically significant, reduced occlusions requiring line replacements. Given the expense of animal research, adding a locking solution must be cost-effective, and we were able to show that T-EDTA significantly reduced total research costs and improved animal welfare.
Collapse
Affiliation(s)
- Mirielle L Pauline
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Evan Labonne
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela R Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Paul W Wales
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati, Ohio, USA
- Department of Surgery, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| |
Collapse
|
3
|
Sabra HK, Remeih GS, Kereet IM, Hamad M, Ahmed YA, Jahangir K, Bakr MA, Alagelli FA, Sherif H, Elsaid M. Efficacy and safety of glucagon-like peptide 2 in patients with short bowel syndrome: A systematic review and network meta-analysis. J Gastrointest Surg 2024:S1091-255X(24)00412-8. [PMID: 38663565 DOI: 10.1016/j.gassur.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 04/03/2024] [Accepted: 04/12/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Glucagon-like peptide 2 (GLP-2) is a highly conserved enteroendocrine hormone that seems to be a regulator promoting intestinal adaptation. This study aimed to summarize the evidence on the efficacy and safety of exogenous GLP-2 in patients with short bowel syndrome (SBS). METHODS A database search was performed on PubMed, Web of Science Core Collection, Scopus, Ovid, and the Cochrane Central Register of Controlled Trials in November 2022. Clinical trials on the effect of GLP-2 on patients with SBS were included. The Cochrane Risk of Bias 2 and Risk Of Bias In Non-randomized Studies - of Interventions tools for quality assessment of randomized and nonrandomized trials were used. The extracted data were analyzed qualitatively and quantitatively using a network meta-analysis model. RESULTS This study included 23 clinical trials with 843 patients. The patients' ages ranged from 4.0 to 62.4 years. The treatment doses were 0.1, 0.05, and 0.025 mg/kg/day for teduglutide; 5 and 10 mg/week for apraglutide, and 0.1, 1, and 10 mg/day for glepaglutide. The treatment duration ranged from 1 to 32 weeks. Regarding citrulline level, 0.1 mg/kg/day of teduglutide had the highest mean difference (MD; 14.77; 95% CI, 10.20-19.33), followed by 0.05 mg/kg/day (13.04; 95% CI, 9.79-16.2) and 0.025 mg/kg/day (7.84; 95% CI, 2.42-13.26) of teduglutide. In addition, the effect estimate showed significant differences between all teduglutide dose groups and the control group. Different doses of glepaglutide were analyzed to assess the effect on alkaline phosphatase (ALP) levels, in which 0.1 mg/day of glepaglutide showed a significantly higher MD (20.71; 95% CI, 2.62-38.80) than 1 mg/day (the reference) and 10 mg/day (8.45; 95% CI, -10.72 to 27.62) of glepaglutide. However, 0.1 vs 10 mg of glepaglutide has an MD of -14.57 (95% CI, -437.24 to 148.11) for the indirect estimate, whereas 10 mg of glepaglutide has an MD of 8.45 (95% CI, -10.72 to 27.62) for the network estimate. Regarding safety outcomes, there was no significant difference among all teduglutide and apraglutide dose groups compared with the control group. Catheter-related bloodstream infection was the most common adverse event reported with the use of apraglutide, teduglutide, and glepaglutide. CONCLUSION Despite the small number of patients in the included studies and variable follow-up duration, GLP-2 seems to be safe and effective in patients with SBS. GLP-2 showed a positive effect on increasing plasma citrulline level and decreasing ALP level.
Collapse
Affiliation(s)
- Hamdy Khaled Sabra
- Faculty of Medicine, Tanta University, Tanta, Egypt; Medical Research Platform, Giza, Egypt
| | - Gehad S Remeih
- Medical Research Platform, Giza, Egypt; Faculty of Pharmacy, Assiut University, Assiut, Egypt
| | - Ibraheem M Kereet
- Medical Research Platform, Giza, Egypt; Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohammad Hamad
- Medical Research Platform, Giza, Egypt; Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Yassmien Ali Ahmed
- Medical Research Platform, Giza, Egypt; Faculty of Physical Therapy, October 6 University, October, Egypt
| | - Kainat Jahangir
- Medical Research Platform, Giza, Egypt; Faculty of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Fatma Assad Alagelli
- Medical Research Platform, Giza, Egypt; Faculty of Medicine, University of Tripoli, Tripoli, Libya
| | - Hadeer Sherif
- Medical Research Platform, Giza, Egypt; Faculty of Medicine, Kasr Al-Ainy University, Cairo, Egypt
| | - Mohamed Elsaid
- Medical Research Platform, Giza, Egypt; Department of Pediatrics, Faculty of Medicine, Delta University for Science and Technology, Dakahlia, Egypt.
| |
Collapse
|
4
|
Andrews A, Fraser-Irwin C, Herbison K, Han DY, Evans HM, Roberts AJ. Ethnicity and socio-economic deprivation in children with intestinal failure in New Zealand: Disparities in incidence, but not in outcomes. J Paediatr Child Health 2024; 60:132-138. [PMID: 38655775 DOI: 10.1111/jpc.16550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 01/10/2024] [Accepted: 04/14/2024] [Indexed: 04/26/2024]
Abstract
AIMS The New Zealand National Intestinal Failure and Rehabilitation Service (NZ-NIFRS) was established in October 2015 to gather longitudinal data on the aetiology, clinical course and outcomes of children with intestinal failure (IF). One main objective is to achieve health equity for patients with IF in NZ. METHODS Clinical outcomes (enteral autonomy, parenteral nutrition (PN) dependence, death or intestinal transplantation) for IF patients diagnosed from October 2015 to 2018 were analysed; comparisons were made by ethnicity and socio-economic status (SES) using published 'prioritised-ethnicity' health data and the NZ index of deprivation, respectively. The Cox proportional-hazards model was used to assess time to enteral autonomy. RESULTS Of the 208 patients (55.77% male, 43.75% preterm), 170 (81.73%) achieved enteral autonomy and 14 (6.73%) remained PN dependent. Pacific and Māori children accounted for 12.98% and 27.88% of the patient cohort, respectively, compared to 9.46% and 25.65% of the NZ paediatric population. More significantly, IF patients with a high NZ socio-economic deprivation score were overrepresented, with 35.92% in the highest deprivation quintile and 10.19% in the least deprived quintile, compared to 23.53% and 20.31%, respectively, of the NZ paediatric population. There were no significant differences in primary clinical outcomes for any patients based on ethnicity or SES. CONCLUSION While disparities in ethnicity and social deprivation do exist in the incidence of IF in NZ children, clinical outcomes are similar for children regardless of ethnicity or SES. NZ-NIFRS has achieved one of its core objectives: to achieve health equity for all patients with IF nationwide.
Collapse
Affiliation(s)
- Amy Andrews
- New Zealand National Intestinal Failure & Rehabilitation Service (NZ-NIFRS), Auckland, New Zealand
- Department of Paediatric Gastroenterology, Starship Child Health, Auckland, New Zealand
| | - Cate Fraser-Irwin
- New Zealand National Intestinal Failure & Rehabilitation Service (NZ-NIFRS), Auckland, New Zealand
| | - Kim Herbison
- New Zealand National Intestinal Failure & Rehabilitation Service (NZ-NIFRS), Auckland, New Zealand
- Department of Paediatric Gastroenterology, Starship Child Health, Auckland, New Zealand
| | - Dug Y Han
- Clinical Research Office, Te Toka Tumai - Auckland, Auckland, New Zealand
| | - Helen M Evans
- New Zealand National Intestinal Failure & Rehabilitation Service (NZ-NIFRS), Auckland, New Zealand
- Department of Paediatric Gastroenterology, Starship Child Health, Auckland, New Zealand
- Department of Paediatrics, University of Auckland, Auckland, New Zealand
| | - Amin J Roberts
- New Zealand National Intestinal Failure & Rehabilitation Service (NZ-NIFRS), Auckland, New Zealand
- Department of Paediatric Gastroenterology, Starship Child Health, Auckland, New Zealand
- Department of Paediatrics, University of Auckland, Auckland, New Zealand
| |
Collapse
|
5
|
Sandy NS, Roberts AJ, Wales PW, Toma RK, Belza C, Dogra H, Evans HM, Gattini D, Hind J, Mercer D, Povondra JM, Turner J, Yap J, Wong T, Avitzur Y. Small and large bowel anatomy is associated with enteral autonomy in infants with short bowel syndrome: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2024; 48:231-238. [PMID: 38062898 DOI: 10.1002/jpen.2587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 11/14/2023] [Accepted: 11/28/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Achievement of enteral autonomy (EA) is the ultimate treatment goal in pediatric intestinal failure (IF). We aimed to assess predictors of EA in pediatric short bowel syndrome (SBS) and explore the impact of residual small bowel (SB) and large bowel (LB) length on EA. METHODS A retrospective cohort study was performed on infants aged <12 months (n = 367, six centers) with SBS referred between 2010 and 2015. The cohort was stratified based on the achievement of EA. Statistical testing was completed using t-test, chi-square, Cox proportional hazards regression model, and Kaplan-Meier analysis. RESULTS EA was achieved in 229 patients. In the multivariable analysis, the percentage of residual LB (hazard ratio [HR] = 1.02; 95% CI = 1.01-1.02) and SB (HR = 1.01; 95% CI = 1.01-1.02) length, presence of the ileocecal valve (HR = 2.02; 95% CI=1.41-2.88), and not coming from a high-volume transplantation center (HR = 2.42; 95% CI = 1.68-3.49) were positively associated with EA, whereas a negative association was seen with the presence of stoma at the time when shortest remnant was documented (HR = 0.72; 95% CI = 0.52-1.00). EA achievement was significantly different between the anatomical subgroups (log-rank test P < 0.001) with an EA rate of 80.4% in infants with ≥50% SB and LB (median time 209 days); 62.5% with ≥50% SB and <50% LB (397 days); 58.3% with <50% SB and ≥50% LB (1192 days), and 25.9% with <50% SB and LB. Necrotizing enterocolitis (NEC) was not associated with a better achievement of EA (NEC vs other etiologies: log-rank test P = 0.33). CONCLUSIONS Overall, 62% of infants with IF secondary to SBS achieved EA over a mean time of follow-up of 2.3 years. A colon length of >50% can compensate for the loss of small bowel (<50%) and account for similar EA rates as those in children with residual SB > 50%.
Collapse
Affiliation(s)
- Natascha S Sandy
- Group for Improvement of Intestinal Function and Treatment (GIFT), Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, University of São Paulo (USP), São Paulo, Brazil
| | - Amin J Roberts
- Department of Paediatric Gastroenterology, Starship Child Health, University of Auckland, Auckland, New Zealand
- National Intestinal Failure & Rehabilitation Service (NIFRS), Auckland, New Zealand
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Ricardo K Toma
- Department of Pediatrics, University of São Paulo (USP), São Paulo, Brazil
| | - Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Harween Dogra
- Paediatric Liver, GI & Nutrition Centre, King's College Hospital, London, UK
| | - Helen M Evans
- Department of Paediatric Gastroenterology, Starship Child Health, University of Auckland, Auckland, New Zealand
- National Intestinal Failure & Rehabilitation Service (NIFRS), Auckland, New Zealand
| | - Daniela Gattini
- Group for Improvement of Intestinal Function and Treatment (GIFT), Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Hind
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - David Mercer
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jill M Povondra
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Justine Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jason Yap
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Theodoric Wong
- Department of Gastroenterology and Nutrition, Nutrition Support and Intestinal Failure team, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
6
|
Gattini D, Yan H, Belza C, Avitzur Y, Wales PW. Cost-utility analysis of 4% tetrasodium ethylenediaminetetraacetic acid, taurolidine, and heparin lock to prevent central line-associated bloodstream infections in children with intestinal failure. JPEN J Parenter Enteral Nutr 2024; 48:47-56. [PMID: 37465871 DOI: 10.1002/jpen.2551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 07/17/2023] [Accepted: 07/17/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSI) are a serious complication in children with intestinal failure. This study assessed the incremental costs of 4% tetrasodium ethylenediaminetetraacetic acid (EDTA) compared with taurolidine lock and heparin lock per quality-adjusted life-year (QALY) gained in children with intestinal failure from the healthcare payer and societal perspective. METHODS A Markov cohort model of a 1-year-old child with intestinal failure was simulated until the age of 17 years (time horizon), with a cycle length of 1 month. The health outcome measure was QALYs, with results expressed in terms of incremental costs and QALYs. Model parameters were obtained from published literature and institutional data. Deterministic, probabilistic, and scenario sensitivity analyses were performed. RESULTS 4% Tetrasodium EDTA was dominant (more effective and less expensive) compared with taurolidine and heparin, yielding an additional 0.17 QALYs with savings of CAD$88,277 compared with heparin, and an additional 0.06 QALYs with savings of CAD$52,120 compared with taurolidine lock from the healthcare payer perspective. From the societal perspective, 4% tetrasodium EDTA resulted in savings of CAD$90,696 compared with heparin and savings of CAD$36,973 compared with taurolidine lock. CONCLUSIONS This model-based analysis indicates that 4% tetrasodium EDTA can be considered the optimal strategy compared with taurolidine and heparin in terms of cost-effectiveness. The decision uncertainty can be reduced by conducting further research on the model input parameters. An expected value of perfect information analysis can identify what model input parameters would be most valuable to focus on.
Collapse
Affiliation(s)
- Daniela Gattini
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment, Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Han Yan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christina Belza
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment, Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment, Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Paul W Wales
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Toronto, Cincinnati, Ohio, United States
- Cincinnati Center of Excellence for Intestinal Rehabilitation, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| |
Collapse
|
7
|
Nieminen O, Hukkinen M, Kivisaari R, Mutanen A, Merras-Salmio L, Pakarinen MP. Cutoffs and Characteristics of Abnormal Bowel Dilatation in Pediatric Short Bowel Syndrome. J Pediatr Gastroenterol Nutr 2023; 77:720-725. [PMID: 37679875 DOI: 10.1097/mpg.0000000000003934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVES Although excessive intestinal dilatation associates with worsened outcomes in pediatric short bowel syndrome (SBS), little is known about the natural history and definition of pathological dilatation. We addressed fore-, mid-, and hind-gut dilatation in children with SBS, who had not undergone autologous intestinal reconstructive (AIR) surgery, in relation to controls. METHODS SBS children without history of AIR surgery (n = 59) and age-matched controls without any disclosed intestinal pathology (n = 140) were included. Maximum diameter of duodenum, small bowel (SB), and colon were measured in each intestinal contrast series during 2002 to 2020 and expressed as diameter ratio (DR) to L5 vertebrae height. Predictive ability of DR for weaning off parenteral nutrition (PN) was analyzed with Cox proportional hazards regression models using multiple cutoffs. RESULTS Duodenum (DDR), SB (SBDR), and colon (CDR) DR were 53%, 183%, and 23% higher in SBS patients compared to controls ( P < 0.01 for all). The maximal DDR and SBDR measured during follow-up is associated with current PN dependence and young age. DDR correlated with SBDR ( r = 0.586, P < 0.01). Patients with maximal DDR less than 1.5, which was also the 99th percentile for controls, were 2.5-fold more likely to wean off PN ( P = 0.005), whereas SBDR and CDR were not predictive for PN duration. CONCLUSIONS All segments of remaining bowel, especially SB, dilate above normal levels in children with SBS. In SBS children without AIR surgery, PN dependence and young age is associated with duodenal and small intestinal dilatation, while duodenal dilatation also predicted prolonged PN.
Collapse
Affiliation(s)
- Oona Nieminen
- From the Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Maria Hukkinen
- From the Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Reetta Kivisaari
- the Department of Pediatric Radiology, Medical Imaging Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Annika Mutanen
- From the Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Laura Merras-Salmio
- the Department of Pediatric Gastroenterology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mikko P Pakarinen
- From the Department of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- the Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| |
Collapse
|
8
|
Ghidini F, Tognon C, Verlato G, Duci M, Andreetta M, Leon FF, Gamba P. A survival analysis of cuffed tunneled silicon central venous catheters in children affected by short bowel syndrome: A lesson from the past. J Vasc Access 2023; 24:1158-1166. [PMID: 35081815 DOI: 10.1177/11297298211069458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Tunneled central venous catheters (CVC) are crucial in the management of children affected by short bowel syndrome (SBS). This work aims to investigate the outcomes of tunneled CVC and to identify factors influencing their survival. METHODS All the children diagnosed with SBS and undergone a procedure of insertion of a tunneled CVC from 2010 to 2019 were included. Demographic data and surgical information about the procedures were collected. Regression models and Kaplan-Meier analysis were performed to estimate the survival. RESULTS Eighteen patients, eight males (44%), with a median length of residual bowel measuring 72 cm (IQR 50-102 cm), were enrolled. Thirty-nine Broviac CVCs were inserted with a mean number of 2.2 CVCs per patient and 13365 line-days. The overall incidence of complications was 3.2/1000 line-days, and the incidence of central line associated bloodstream infections (CLABSI) was 1.1/1000 line-days. No episode of catheter thrombosis was reported. The median survival was 269 days (IQR 82-1814 days). The survival was negatively influenced by a younger age at insertion (R2 = 0.29; p < 0.001), 2.7 Fr diameter (median survival 76 days; p < 0.001) and the occurrence of complications (median survival 169 days; p = 0.002). The length of residual bowel was a mild risk factor for anticipated removal (OR 1.1; CI95 1.0-1.1; p = 0.05). CONCLUSION CVC-related complications negatively influenced the survival of the line. An elder age at insertion together with a larger CVC diameter increased the survival of the line, while a shorter residual bowel was associated with an anticipated removal due to complications.
Collapse
Affiliation(s)
- Filippo Ghidini
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Costanza Tognon
- Pediatric Anesthesiology, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Giovanna Verlato
- Neonatal Intensive Care and Pediatric Nutrition Service, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Miriam Duci
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Marina Andreetta
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Francesco Fascetti Leon
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Piergiorgio Gamba
- Pediatric Surgery, Department of Women's and Children's Health, University of Padua, Padua, Italy
| |
Collapse
|
9
|
Itriago E, Trahan KF, Massieu LA, Garg PM, Premkumar MH. Current Practices, Challenges, and Recommendations in Enteral Nutrition After Necrotizing Enterocolitis. Clin Perinatol 2023; 50:683-698. [PMID: 37536772 DOI: 10.1016/j.clp.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Necrotizing enterocolitis (NEC) is a neonatal disease with high mortality and morbidity. There is a lack of evidence-based recommendations on nutritional rehabilitation following NEC, and much of the current practice is guided by institutional policies and expert opinions. After a diagnosis of NEC, infants are exposed to an extended period of bowel rest and a prolonged course of antibiotics. Recognizing the patient characteristics that predict nutritional tolerance, early initiation of enteral nutrition, minimizing periods of bowel rest and antibiotic exposure, and standardization of dietary practices are the mainstay of post-NEC nutrition.
Collapse
Affiliation(s)
- Elena Itriago
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Kimberly Fernandez Trahan
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Leonor Adriana Massieu
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Parvesh M Garg
- Wake Forest School of Medicine, Brenner Children's Hospital, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Muralidhar H Premkumar
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| |
Collapse
|
10
|
Moran-Lev H, Kocoshis SA, Oliveira SB, Helmrath M, Cole CR. Chronic Mucosal Inflammation in Pediatric Intestinal Failure Patients-A Unique Phenomenon. J Pediatr Gastroenterol Nutr 2023; 77:e29-e35. [PMID: 37098159 DOI: 10.1097/mpg.0000000000003811] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
INTRODUCTION/OBJECTIVES As intestinal failure (IF) management improves and long-term survival rate increases, its physiological complications have become more apparent. The development of chronic intestinal inflammation resembling inflammatory bowel disease (IBD) in this population has been reported, but the literature describing it in detail is sparse. The present study was designed to characterize children with IF who developed chronic intestinal inflammation and identify the potential predisposing clinical factors. METHODS This retrospective study was based on the electronic medical records of pediatric patients seen at the Cincinnati Children's Hospital Medical Center between January 2000 and July 2022. Demographic and medical history data were collected and compared between children with IF that developed chronic intestinal inflammation and children with IF that did not develop chronic intestinal inflammation. RESULTS During the follow-up period, 23 children were diagnosed with chronic intestinal inflammation. Of these, 12 (52%) were males, with a median age of 4.5 (3-7) years at diagnosis. Nearly one-third of the patients had gastroschisis (31%), followed by necrotizing enterocolitis (26%), and malrotation and volvulus (21.7%). More children in the chronic intestinal inflammation group lacked an ileocecal valve (ICV) and adjoining distal ileum as compared to the short bowel syndrome (SBS)-IF control group (15 patients, 65% vs 8 patients, 33%). Moreover, more children in the chronic intestinal inflammation group had undergone a prior lengthening procedure than the SBS-IF control group (5 patients, 21.7% vs. 0, respectively). DISCUSSION SBS patients are at risk of relatively early onset chronic intestinal inflammation. The absence of an ICV (and adjoin ileum) and prior lengthening procedures emerge as factors associated with the risk of IBD in these patients.
Collapse
Affiliation(s)
- Hadar Moran-Lev
- From the Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH
- the Division of Gastroenterology, Hepatology and Nutrition, Dana Dwek Children's Hospital, affiliated to Tel Aviv University, Tel Aviv, Israel
| | - Samuel A Kocoshis
- From the Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Stephanie B Oliveira
- From the Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Michael Helmrath
- the Division of Pediatric Surgery, Department of Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Conrad R Cole
- From the Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH
| |
Collapse
|
11
|
Mutanen A, Engstrand Lilja H, Wester T, Norrby H, Borg H, Persson S, Bjornland K, Brun AC, Telborn L, Stenström P, Pakarinen MP. A nordic multicenter study on contemporary outcomes of pediatric short bowel syndrome in 208 patients. Clin Nutr 2023; 42:1095-1103. [PMID: 37270343 DOI: 10.1016/j.clnu.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/05/2023] [Accepted: 05/21/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND & AIMS Despite advances in the management of short bowel syndrome related intestinal failure (SBS-IF), large-scale contemporary pediatric studies are scarce. The aim of this multicenter study was to assess key outcomes and clinical prognostic factors in a recent Nordic pediatric SBS-IF population. METHODS Patients with SBS-IF treated during 2010-2019, whose parenteral support (PS) started at age <1 year and continued >60 consecutive days were included and retrospectively reviewed. All six participating centers followed multidisciplinary SBS-IF management. Risk factors for PS dependency, intestinal failure associated liver disease (IFALD) and mortality were assessed with Cox regression and Kaplan Meier analyses. IFALD was defined with serum liver biochemistry levels. RESULTS Among 208 patients, SBS-IF resulted from NEC in 49%, gastroschisis w/wo atresia in 14%, small bowel atresia in 12%, volvulus in 11%, and other diagnoses in 14%. Median age-adjusted small bowel length was 43% (IQR 21-80%). After median follow up of 4.4 years (IQR 2.5-6.9), enteral autonomy was reached by 76%, none had undergone intestinal transplantation, and overall survival was 96%. Half of deaths (4/8) were caused by septic complications. Although biochemical cholestasis occurred only in 3% at latest follow-up and none of deaths were directly caused by IFALD, elevated liver biochemistry (HR 0.136; P = 0.017) and shorter remaining small bowel (HR 0.941; P = 0.040) predicted mortality. Shorter remaining small bowel and colon, and presence of end-ostomy were the main predictors of PS dependency, but not IFALD. Patients with NEC reached enteral autonomy more efficiently and had decreased incidence of IFALD compared to other etiologies. CONCLUSIONS Although with current multidisciplinary management, prognosis of pediatric SBS is encouraging, septic complications and IFALD still associated with the remaining low mortality rate.
Collapse
Affiliation(s)
- Annika Mutanen
- Department of Pediatric Surgery, The New Children's Hospital, University of Helsinki, Stenbäckinkatu 9, 00029 HUS, Helsinki, Finland.
| | - Helene Engstrand Lilja
- Department of Pediatric Surgery, University Children's Hospital, Uppsala University, Uppsala, Sweden
| | - Tomas Wester
- Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Women's and Children's Health, Karoliska Institutet, Stockholm, Sweden
| | - Heimir Norrby
- Unit of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Helena Borg
- Department of Pediatric Surgery, The Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Sara Persson
- Department of Pediatric Surgery, The Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Kristin Bjornland
- Department of Pediatric Surgery, Oslo University Hospital and University of Oslo, Oslo, Norway
| | | | - Lovisa Telborn
- Department of Pediatric Surgery, Skane University Hospital, Lund University, Lund, Sweden
| | - Pernilla Stenström
- Department of Pediatric Surgery, Skane University Hospital, Lund University, Lund, Sweden
| | - Mikko P Pakarinen
- Department of Pediatric Surgery, The New Children's Hospital, University of Helsinki, Stenbäckinkatu 9, 00029 HUS, Helsinki, Finland; Department of Women's and Children's Health, Karoliska Institutet, Stockholm, Sweden
| |
Collapse
|
12
|
Caporilli C, Giannì G, Grassi F, Esposito S. An Overview of Short-Bowel Syndrome in Pediatric Patients: Focus on Clinical Management and Prevention of Complications. Nutrients 2023; 15:nu15102341. [PMID: 37242224 DOI: 10.3390/nu15102341] [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: 02/09/2023] [Revised: 04/26/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
Short-bowel syndrome (SBS) in pediatric age is defined as a malabsorptive state, resulting from congenital malformations, significant small intestine surgical resection or disease-associated loss of absorption. SBS is the leading cause of intestinal failure in children and the underlying cause in 50% of patients on home parental nutrition. It is a life-altering and life-threatening disease due to the inability of the residual intestinal function to maintain nutritional homeostasis of protein, fluid, electrolyte or micronutrient without parenteral or enteral supplementation. The use of parenteral nutrition (PN) has improved medical care in SBS, decreasing mortality and improving the overall prognosis. However, the long-term use of PN is associated with the incidence of many complications, including liver disease and catheter-associated malfunction and bloodstream infections (CRBSIs). This manuscript is a narrative review of the current available evidence on the management of SBS in the pediatric population, focusing on prognostic factors and outcome. The literature review showed that in recent years, the standardization of management has demonstrated to improve the quality of life in these complex patients. Moreover, the development of knowledge in clinical practice has led to a reduction in mortality and morbidity. Diagnostic and therapeutic decisions should be made by a multidisciplinary team that includes neonatologists, pediatric surgeons, gastroenterologists, pediatricians, nutritionists and nurses. A significant improvement in prognosis can occur through the careful monitoring of nutritional status, avoiding dependence on PN and favoring an early introduction of enteral nutrition, and through the prevention, diagnosis and aggressive treatment of CRSBIs and SIBO. Multicenter initiatives, such as research consortium or data registries, are mandatory in order to personalize the management of these patients, improve their quality of life and reduce the cost of care.
Collapse
Affiliation(s)
- Chiara Caporilli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Giuliana Giannì
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Federica Grassi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| |
Collapse
|
13
|
Belza C, Wales PW. Intestinal failure among adults and children: Similarities and differences. Nutr Clin Pract 2023; 38 Suppl 1:S98-S113. [PMID: 37115028 DOI: 10.1002/ncp.10987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/27/2023] [Accepted: 03/05/2023] [Indexed: 04/29/2023] Open
Abstract
Intestinal failure (IF) is a complex medical condition that is caused by a constellation of disorders, resulting in the gut's inability to adequately absorb fluids and nutrients to sustain hydration, growth, and survival, thereby requiring the use of parenteral fluid and/or nutrition. Significant advancements in intestinal rehabilitation have resulted in improved survival rates for individuals with IF. There are distinct differences, however, related to etiology, adaptive potential and complications, and medical and surgical management when comparing children with adults. The purpose of this review is to contrast the similarities and differences between these two distinct groups and provide insight for future directions, as a growing population of pediatric patients will cross into the adult world for IF management.
Collapse
Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Paul W Wales
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| |
Collapse
|
14
|
Belza C, Avitzur Y, Ungar WJ, Stremler R, Fehlings D, Wales PW. Stress, anxiety, depression, and health-related quality of life in caregivers of children with intestinal failure receiving parenteral nutrition: A cross-sectional survey study. JPEN J Parenter Enteral Nutr 2023; 47:342-353. [PMID: 36336350 DOI: 10.1002/jpen.2461] [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: 06/22/2022] [Revised: 10/26/2022] [Accepted: 11/01/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Improved survival rates for children with intestinal failure (IF) have resulted in an increased population of children receiving long-term parenteral nutrition (PN). Our objective was to determine burden on caregivers of children with IF receiving long-term PN. METHODS We performed a cross-sectional study of caregivers of children with IF receiving long-term PN in our intestinal rehabilitation program. A healthy comparison group matched on age of the child was enrolled. All participants completed standardized questionnaires, including the Parental Stress Index - Short Form (PSI-SF), Hospital Anxiety and Depression Scale (HADS), and PedsQL Family Impact Module (PedsQL FIM). Univariate analysis was completed using a Student t test and chi-square, with an alpha value of <0.05 considered significant. RESULTS Thirty-eight caregivers of children with IF and 29 caregivers of healthy children consented, with response rates of 89% and 96.5%, respectively. Our study demonstrated increased stress for caregivers compared with comparison parents (PSI-SF total score of 83 [SD = 26.8] vs 62.9 [SD = 13.5]; P < 0.01). Caregivers had increased anxiety (HADS anxiety score of 9.3 [SD = 4.8] vs 6.7 [SD = 3.2]; P = 0.02) and higher depression scores (HADS depression score of 6.3 [SD = 4.3] vs 4.1 [SD = 2.6]; P = 0.02) compared with the comparison group. Caregivers of children with IF demonstrated decreased health-related quality of life (HRQoL) (reduced PedsQL FIM total score of 50.6 [SD = 18.2] vs 84.1 [SD = 20.5]; P < 0.01). CONCLUSIONS Our results demonstrated significant burden of care in caregivers of children with IF receiving long-term PN, with elevated stress, anxiety, and depression and decreased HRQoL.
Collapse
Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada.,Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Wendy J Ungar
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, Canada
| | - Robyn Stremler
- Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Darcy Fehlings
- Holland Bloorview Rehabilitation Hospital, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, Canada.,Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA.,Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati, Ohio, USA
| |
Collapse
|
15
|
Smith A, Namjoshi S, Kerner JA, Dunn JCY. Importance of Ileum and Colon in Children with Short Bowel Syndrome. J Pediatr Surg 2023:S0022-3468(23)00089-1. [PMID: 36894441 DOI: 10.1016/j.jpedsurg.2023.01.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/25/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND It is well known that small bowel length is a dominant prognostic indicator in patients with short bowel syndrome (SBS). The relative importance of jejunum, ileum, and colon is less well defined in children with SBS. Here we review the outcome of children with SBS with respect to the type of remnant intestine. METHODS A retrospective review of 51 children with SBS was conducted at a single institution. The duration of parenteral nutrition use was the main outcome variable. The length of the remaining intestine as well as the type of intestine were recorded for each patient. Kaplan-Meier analyses were conducted to compare the subgroups. RESULTS Children with greater than 10% expected small bowel length or more than 30 cm of small bowel achieved enteral autonomy faster than those with less. The presence of ileocecal valve enhanced the ability to wean from parenteral nutrition. The presence of ileum significantly enhanced the ability to wean from parenteral nutrition. Patients with the entire colon also achieved enteral autonomy sooner than those with partial colon. CONCLUSIONS The preservation of ileum and colon is important in patients with SBS. Approaches to preserve or lengthen ileum and colon may be beneficial for these patients. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Asia Smith
- Division of Pediatric Surgery, Department of Surgery, Stanford University, Stanford, CA, USA
| | - Shweta Namjoshi
- Division of Gastroenterology, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - John A Kerner
- Division of Gastroenterology, Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - James C Y Dunn
- Division of Pediatric Surgery, Department of Surgery, Stanford University, Stanford, CA, USA.
| |
Collapse
|
16
|
Huysentruyt K, Belza C, Wong-Sterling S, Chami R, Siddiqui I, Wales PW, Avitzur Y. Use of a combined transient elastography and biochemical strategy to determine liver fibrosis in pediatric intestinal failure. Clin Nutr 2023; 42:136-142. [PMID: 36563562 DOI: 10.1016/j.clnu.2022.12.002] [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: 06/14/2022] [Revised: 11/02/2022] [Accepted: 12/04/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Non-invasive monitoring of intestinal failure (IF) associated liver disease is an ongoing challenge in children with IF. Our objective was to develop a combined algorithm of clinical, transient elastography (TE) and biochemical parameters to identify liver fibrosis in this population. METHODS A retrospective cohort study of IF patients followed by our intestinal rehabilitation program between November 2015 to October 2019. Patients with a liver biopsy and TE were included. Demographic and liver function tests were collected. Fibrosis on liver biopsies was graded using the modified Scheuer score. Decision tree based algorithms classified low (F0-F1) versus high (F2-F4) fibrosis scores based on a combination of TE, biochemical and demographic parameters, using 6-fold classification error, sensitivity and specificity cross-validation (CV) scores. RESULTS 42 patients (74% male, median age 7.6 (4.6; 42.7) months) were evaluated. Median length of PN therapy was 182 (121; 556) days. High fibrosis was present in 40.5% with a median TE of 12.1 (6.7; 12.9) kPa in high fibrosis children. An algorithm, based on cut-off values for TE of 11.3 kPa and AST of 40 U/L, and grouping of the underlying etiology resulted in a correct classification of 88.1% of the pathology scores; with sensitivity 0.82 (95% CI 0.57; 0.96), specificity 0.92 (95% CI 0.74; 0.99), positive predictive value 0.88 (95% CI 0.64; 0.96) and negative predictive value 0.88 (95% CI 0.73; 0.96). The CV classification error was 28.6%, CV sensitivity 72.2% and CV specificity 75.5%. CONCLUSIONS This algorithm shows promising results that could simplify non-invasive monitoring of liver fibrosis in children with IF. Validation in additional IF cohorts is needed.
Collapse
Affiliation(s)
- Koen Huysentruyt
- The Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Brussels Centrum for Intestinal Failure in Children (B-CIRC), Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Christina Belza
- The Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sylvia Wong-Sterling
- The Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rose Chami
- Division of Pathology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Iram Siddiqui
- Division of Pathology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Paul W Wales
- The Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States
| | - Yaron Avitzur
- The Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
17
|
Nutritional Management of Intestinal Failure due to Short Bowel Syndrome in Children. Nutrients 2022; 15:nu15010062. [PMID: 36615720 PMCID: PMC9823779 DOI: 10.3390/nu15010062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The most common cause of intestinal failure (IF) in childhood remains short bowel syndrome (SBS), where bowel mass is significantly reduced due to a congenital atresia or resection and parenteral nutrition (PN) needed. Home PN has improved outcome and quality of life, but the long-term therapeutic goal is to achieve enteral autonomy whilst avoiding long term complications. This paper is aimed at discussing nutritional strategies available to clinicians caring for these patients. METHODS A literature search was performed from 1992 to 2022 using Pubmed, MEDLINE and Cochrane Database of Systematic Reviews, and recent guidelines were reviewed. In the absence of evidence, recommendations reflect the authors' expert opinion. RESULTS Consensus on the best possible way of feeding children with IF-SBS is lacking and practice varies widely between centres. Feeding should commence as soon as possible following surgery. Oral feeding is the preferred route and breast milk (BM) the first milk of choice in infants. Donor BM, standard preterm or term formula are alternatives in the absence of maternal BM. Extensively hydrolysed or amino acid-based feeds are used when these are not tolerated. Solids should be introduced as soon as clinically appropriate. Children are encouraged to eat by mouth and experience different tastes and textures to avoid oral aversion. Aggressive weaning of PN and tube (over-) feeding are now discouraged. CONCLUSIONS To date, uniform agreement on the optimal type of feed, timing of food introduction and feeding regime used is lacking and great difference in practice remains. There is need for more research to establish common treatment protocols.
Collapse
|
18
|
Cerdó T, García-Santos JA, Rodríguez-Pöhnlein A, García-Ricobaraza M, Nieto-Ruíz A, G. Bermúdez M, Campoy C. Impact of Total Parenteral Nutrition on Gut Microbiota in Pediatric Population Suffering Intestinal Disorders. Nutrients 2022; 14:4691. [PMID: 36364953 PMCID: PMC9658482 DOI: 10.3390/nu14214691] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 08/10/2023] Open
Abstract
Parenteral nutrition (PN) is a life-saving therapy providing nutritional support in patients with digestive tract complications, particularly in preterm neonates due to their gut immaturity during the first postnatal weeks. Despite this, PN can also result in several gastrointestinal complications that are the cause or consequence of gut mucosal atrophy and gut microbiota dysbiosis, which may further aggravate gastrointestinal disorders. Consequently, the use of PN presents many unique challenges, notably in terms of the potential role of the gut microbiota on the functional and clinical outcomes associated with the long-term use of PN. In this review, we synthesize the current evidence on the effects of PN on gut microbiome in infants and children suffering from diverse gastrointestinal diseases, including necrotizing enterocolitis (NEC), short bowel syndrome (SBS) and subsequent intestinal failure, liver disease and inflammatory bowel disease (IBD). Moreover, we discuss the potential use of pre-, pro- and/or synbiotics as promising therapeutic strategies to reduce the risk of severe gastrointestinal disorders and mortality. The findings discussed here highlight the need for more well-designed studies, and harmonize the methods and its interpretation, which are critical to better understand the role of the gut microbiota in PN-related diseases and the development of efficient and personalized approaches based on pro- and/or prebiotics.
Collapse
Affiliation(s)
- Tomás Cerdó
- Maimonides Institute for Research in Biomedicine of Córdoba (IMIBIC), Reina Sofia University Hospital, University of Córdoba, 14004 Córdoba, Spain
| | - José Antonio García-Santos
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - Anna Rodríguez-Pöhnlein
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - María García-Ricobaraza
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - Ana Nieto-Ruíz
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - Mercedes G. Bermúdez
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
| | - Cristina Campoy
- EURISTIKOS Excellence Centre for Paediatric Research, Biomedical Research Centre, University of Granada, 18016 Granada, Spain
- Department of Paediatrics, School of Medicine, University of Granada, Avda. Investigación 11, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria Ibs-GRANADA, Health Sciences Technological Park, 18012 Granada, Spain
- Spanish Network of Biomedical Research in Epidemiology and Public Health (CIBERESP), Granada’s Node, Carlos III Health Institute, Avda. Monforte de Lemos 5, 28028 Madrid, Spain
| |
Collapse
|
19
|
Roberts AJ, Wales PW, Beath SV, Evans HM, Hind J, Mercer D, Wong T, Yap J, Belza C, Avitzur Y. An international multicenter validation study of the Toronto listing criteria for pediatric intestinal transplantation. Am J Transplant 2022; 22:2608-2615. [PMID: 35833730 DOI: 10.1111/ajt.17150] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/21/2022] [Accepted: 07/10/2022] [Indexed: 01/25/2023]
Abstract
Deciding which patients would benefit from intestinal transplantation (IT) remains an ethical/clinical dilemma. New criteria* were proposed in 2015: ≥2 intensive care unit (ICU) admissions, loss of ≥3 central venous catheter (CVC) sites, and persistently elevated conjugated bilirubin (CB ≥ 75 μmol/L) despite 6 weeks of lipid modification strategies. We performed a retrospective, international, multicenter validation study of 443 children (61% male, median gestational age 34 weeks [IQR 29-37]), diagnosed with IF between 2010 and 2015. Primary outcome measure was death or IT. Sensitivity, specificity, NPV, PPV, and probability of death/transplant (OR, 95% confidence intervals) were calculated for each criterion. Median age at IF diagnosis was 0.1 years (IQR 0.03-0.14) with median follow-up of 3.8 years (IQR 2.3-5.3). Forty of 443 (9%) patients died, 53 of 443 (12%) were transplanted; 11 died posttransplant. The validated criteria had a high predictive value of death/IT; ≥2 ICU admissions (p < .0001, OR 10.2, 95% CI 4.0-25.6), persistent CB ≥ 75 μmol/L (p < .0001, OR 8.2, 95% CI 4.8-13.9). and loss of ≥3 CVC sites (p = .0003, OR 5.7, 95% CI 2.2-14.7). This large, multicenter, international study in a contemporary cohort confirms the validity of the Toronto criteria. These validated criteria should guide listing decisions in pediatric IT.
Collapse
Affiliation(s)
- Amin J Roberts
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada.,New Zealand National Intestinal Failure and Rehabilitation Service (NZ-NIFRS), Starship Child Health, Auckland, New Zealand
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada.,Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sue V Beath
- The Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Helen M Evans
- New Zealand National Intestinal Failure and Rehabilitation Service (NZ-NIFRS), Starship Child Health, Auckland, New Zealand
| | - Jonathan Hind
- Paediatric Liver, GI & Nutrition Centre, King's College Hospital, London, UK
| | - David Mercer
- Division of Transplantation, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Theodoric Wong
- Department of Gastroenterology and Nutrition, Nutritional Support and Intestinal Failure Team, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Jason Yap
- Division of Pediatric Gastroenterology, University of Alberta, Edmonton, Canada.,Department of Paediatric Gastroenterology and Nutrition, The Royal Children's Hospital, Melbourne, Australia
| | - Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Hospital for Sick Children, Toronto, Canada.,Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Canada
| |
Collapse
|
20
|
Impact of Pancreatic Enzymes on Enteral Fat and Nitrogen Absorption in Short Bowel Syndrome. J Pediatr Gastroenterol Nutr 2022; 75:36-41. [PMID: 35622082 DOI: 10.1097/mpg.0000000000003465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Patients with short bowel syndrome (SBS) can have a high morbidity rate. To minimize morbidity, enteral autonomy is the primary goal in clinical management of patients with SBS. This is often difficult to achieve because of significant malabsorption. To date, there are limited therapies that improve absorption in patients with SBS. The impact of pancreatic enzyme replacement treatment on enteral absorption has not been studied in this population and was the primary aim of this study. SUBJECTS/METHODS This was an interventional study in 11 subjects (6 pediatric subjects ages 4.0-17.9 years, 5 adult subjects 18-75 years) that compared enteral absorption in each subject before and after pancreatic enzyme medication (Creon). Coefficient of fat absorption (CFA) and coefficient of nitrogen absorption (CNA) were used as markers of enteral absorption of fat and protein, respectively. RESULTS There was no statistically significant mean change in CFA and CNA before and after pancreatic enzyme medication therapy. Six subjects demonstrated an increase in CFA and 8 subjects demonstrated an increase in CNA after the use of pancreatic enzyme medication therapy. CONCLUSIONS There was no statistically significant improvement in enteral fat and protein absorption in the cohort as a whole, though several subjects demonstrated an improvement. These results suggest that some patients with SBS may benefit from treatment with pancreatic enzymes. Further studies are needed to better evaluate the effect of pancreatic enzyme therapy on enteral absorption in subjects with SBS and to characterize factors that may predict a positive response.
Collapse
|
21
|
Premkumar MH, Soraisham A, Bagga N, Massieu LA, Maheshwari A. Nutritional Management of Short Bowel Syndrome. Clin Perinatol 2022; 49:557-572. [PMID: 35659103 DOI: 10.1016/j.clp.2022.02.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Short bowel syndrome (SBS) of infancy is a cause of prolonged morbidity with intolerance to enteral feeding, specialized nutritional needs, and partial/total dependence on parenteral nutrition. These infants can benefit from individualized nutritional strategies to support and enhance the process of intestinal adaptation. Early introduction of enteral feeds during the period of intestinal adaptation is crucial, even though the enteral feedings may need to be supplemented with an effective, safe, and nutritionally adequate parenteral nutritional regimen. Newer generation intravenous lipid emulsions can be effective in preventing and treating intestinal failure-associated liver disease. Prevention of infection(s), pharmaceutical interventions to enhance bowel motility and prevent/mitigate bacteria overgrowth, and specialized multidisciplinary care to minimize the injury to other organs such as the liver, kidneys, and the brain can assist in nutritional rehabilitation and lower the morbidity in SBS.
Collapse
Affiliation(s)
- Muralidhar H Premkumar
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin, Suite 6104, Houston, TX 77030, USA.
| | - Amuchou Soraisham
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nitasha Bagga
- Department of Neonatology, Rainbow Children's Hospital, Hyderabad, India
| | - L Adriana Massieu
- Department of Clinical Nutrition Services, Texas Children's Hospital, Houston, TX, USA
| | - Akhil Maheshwari
- Global Newborn Society (https://www.globalnewbornsociety.org/), Clarksville, MD, USA
| |
Collapse
|
22
|
Vlug LE, Delhanty PJD, Neelis EG, Huisman M, Visser JA, Rings EHHM, Wijnen RMH, Nagelkerke SCJ, Tabbers MM, Hulst JM, de Koning BAE. Ghrelin Levels in Children With Intestinal Failure Receiving Long-Term Parenteral Nutrition. Front Nutr 2022; 9:896328. [PMID: 35634374 PMCID: PMC9131070 DOI: 10.3389/fnut.2022.896328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/22/2022] [Indexed: 12/02/2022] Open
Abstract
Background Children with intestinal failure (IF) require parenteral nutrition (PN). Transition to oral and enteral nutrition (EN) can be difficult also due to abnormal gastrointestinal motility. The gut hormone ghrelin is increased in states of negative energy balance, functioning to preserve euglycemia, and also has appetite stimulating and prokinetic properties. We aimed to evaluate and compare ghrelin levels in children with IF, and to assess the relationship with PN-dependency. Methods In this exploratory prospective multicenter study, plasma acylated (AG) and unacylated (UAG) ghrelin levels were measured in children with short bowel syndrome (SBS) and with functional IF (pseudo-obstruction or any enteropathy) and compared with healthy control subjects. Spearman’s rho (rs) was used to assess correlations of AG and UAG with PN-dependency (%PN) and parenteral glucose intake. Results Sixty-four samples from 36 IF-patients were analyzed. Median baseline AG and UAG levels were respectively 279.2 and 101.0 pg/mL in children with SBS (n = 16), 126.4 and 84.5 pg/mL in children with functional IF (n = 20) and 82.4 and 157.3 pg/mL in healthy children (n = 39). AG levels were higher in children with SBS and functional IF than in healthy children (p = 0.002 and p = 0.023, respectively). In SBS, AG positively correlated with %PN (rs = 0.5, p = 0.005) and parenteral glucose intake (rs = 0.6, p = 0.003). These correlations were not observed in functional IF. Conclusion Children with IF had raised AG levels which could be related to starvation of the gut. The positive correlation between AG and glucose infusion rate in SBS suggests an altered glucoregulatory function.
Collapse
Affiliation(s)
- Lotte E. Vlug
- Division of Gastroenterology, Department of Pediatrics, Erasmus MC Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Patric J. D. Delhanty
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Esther G. Neelis
- Division of Gastroenterology, Department of Pediatrics, Erasmus MC Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Martin Huisman
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jenny A. Visser
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Edmond H. H. M. Rings
- Division of Gastroenterology, Department of Pediatrics, Erasmus MC Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Division of Gastroenterology, Department of Pediatrics, Willem Alexander Children’s Hospital, Leiden University Medical Center, Leiden, Netherlands
| | - René M. H. Wijnen
- Department of Pediatric Surgery, Erasmus MC Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sjoerd C. J. Nagelkerke
- Division of Gastroenterology, Department of Pediatrics, Emma Children’s Hospital, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Merit M. Tabbers
- Division of Gastroenterology, Department of Pediatrics, Emma Children’s Hospital, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Jessie M. Hulst
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
| | - Barbara A. E. de Koning
- Division of Gastroenterology, Department of Pediatrics, Erasmus MC Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- *Correspondence: Barbara A. E. de Koning,
| |
Collapse
|
23
|
Pauline M, Fouhse J, Hinchliffe T, Wizzard P, Patrick Nation, Huynh H, Wales P, Willing B, Turner J. Probiotic Treatment Versus Empiric Oral Antibiotics for Managing Dysbiosis in Short Bowel Syndrome: Impact on the Mucosal and Stool Microbiota, Short Chain Fatty Acids and Adaptation. JPEN J Parenter Enteral Nutr 2022; 46:1828-1838. [PMID: 35383975 DOI: 10.1002/jpen.2377] [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: 01/17/2022] [Revised: 03/22/2022] [Accepted: 03/25/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Infants and children with short bowel syndrome (SBS) are presumed to be at risk of gut microbial dysbiosis with potential sequelae of bacterial overgrowth that include sepsis, D-lactic acidosis, mucosal inflammation and malabsorption. In neonatal piglets with SBS, we compared intestinal microbial composition, short chain fatty acids (SCFA) and adaptation given probiotic treatment (Lactobacillus and Bifidobacterium spp.) versus oral metronidazole. METHODS Following 75% distal small intestinal resection, piglets were allocated to: probiotic (PRO, 500mg BID n=7), metronidazole (MET, 15mg/kg BID n=8) and placebo (PLA, 500mg BID n=8). After 10 days of parenteral and enteral nutrition, 16S rRNA gene amplicon sequencing (colon tissue and stool) were undertaken and SCFA analysis (stool and colon effluent) performed using gas chromatography. RESULTS In colon, Shannon diversity was higher for PRO compared to MET and PLA (p=0.002). PRO and PLA increased abundance of Bacteroidetes species (e.g. Bacteroides fragilis), compared to MET (p<0.001). PRO compared to PLA increased abundance of Firmicutes species (e.g. Lactobacillus fermentum) (p<0.001). MET increased abundance of Proteobacteria members, predominately Enterobacteriaceae compared to PRO (p=0.004). In stool, microbial findings were similar and SCFA (butyrate) concentrations were highest for PRO (p=0.003) compared to MET. CONCLUSION In pediatric SBS, the empiric use of oral antibiotics, such as metronidazole, is common for presumed clinical consequences of microbial dysbiosis. In this study of SBS piglets, that approach was associated with decreased microbial diversity and increased abundance of potentially inflammatory Proteobacteria. In contrast, a probiotic treatment using Lactobacillus and Bifidobacterium spp. increased both diversity and SCFAs. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Mirielle Pauline
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Janelle Fouhse
- Faculty of Agriculture, Life and Environmental Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Tierah Hinchliffe
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Patrick Nation
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Hien Huynh
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Paul Wales
- Department of Surgery, Cincinnati Children's Hospital Medical Center and University of Cincinnati
| | - Benjamin Willing
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Justine Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
24
|
Peters FB, Bone JN, Van Oerle R, Albersheim S, Casey L, Piper H. The Importance of the ileocecal valve and colon in achieving intestinal independence in infants with short bowel syndrome. J Pediatr Surg 2022; 57:117-121. [PMID: 34696920 DOI: 10.1016/j.jpedsurg.2021.09.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/08/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE Infants with short bowel syndrome (SBS) wean from parenteral nutrition (PN) support at variable rates. Small bowel length is a predictor, but the importance of the ileocecal valve (ICV) and colon are unclear. We aim to determine if the ICV and/or colon predict enteral autonomy. METHODS Infants from a single intestinal rehabilitation program were retrospectively reviewed. Etiology of SBS, intestinal anatomy, and duration of nutritional support were collected for three years. The primary outcome was time to full enteral nutrition. ANCOVA and Cox proportional hazards model were used, with p < 0.05 significant. RESULTS 55 infants with SBS were included. After accounting for the effect of small bowel, PN duration was shorter for infants with the ICV compared to those without (mean 218 vs. 538 days, p = 0.003), and had a more significant effect on infants with ≤50% of small bowel. Increased small bowel length was a positive predictor of weaning. Patients with ≤50% of colon spent less time on PN with the ICV, compared to without (mean 220 vs 715 days, p = 0.009). CONCLUSIONS Preservation of the ICV was associated with shorter duration of PN support, while colon was not. Small bowel length is a positive predictor of enteral autonomy. LEVEL OF EVIDENCE Level III retrospective comparative study TYPE OF STUDY: Retrospective review.
Collapse
Affiliation(s)
- Francesca Bell Peters
- Faculty of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC V6T1Z3, Canada.
| | - Jeffrey N Bone
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Rhonda Van Oerle
- Division of Neonatology, University of British Columbia/BC Women's Hospital and Health Center, Vancouver, BC, Canada
| | - Susan Albersheim
- Division of Neonatology, University of British Columbia/BC Women's Hospital and Health Center, Vancouver, BC, Canada
| | - Linda Casey
- Department of Pediatrics, University of British Columbia/BC Children's Hospital, Vancouver, BC, Canada
| | - Hannah Piper
- Division of Pediatric Surgery, University of British Columbia/BC Children's Hospital, Vancouver, BC, Canada.
| |
Collapse
|
25
|
Jiang W, Chen G, Wang Y, Zhong W, Zhou C, Zhang J, Lv X, Du C, Zhu Z, Geng Q, Tang W. Multi-Center Analysis of Predictive Factors of Enteral Autonomy and Risk Factors of Complications of Pediatric Intestinal Failure in China. Front Pediatr 2022; 10:813865. [PMID: 35186808 PMCID: PMC8848277 DOI: 10.3389/fped.2022.813865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/10/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The aim of this study was to identify predictors for enteral autonomy and intestinal failure (IF)-related complications and evaluate the outcomes of a multi-center pediatric cohort in China. METHODS The medical records of pediatric patients with IF treated at four medical centers in China from January 1, 2012 to November 31, 2020 were retrospectively reviewed. Enteral autonomy was defined as sustained growth and cessation of parenteral nutrition for >90 days. Multivariate logistic regression analysis was used to identify factors predictive of enteral autonomy and the risk factors of complications, such as IF-associated liver disease (IFALD) and catheter-related bloodstream infection (CRBSI). RESULTS The study cohort of 92 pediatric patients with IF included 71 (77%) who underwent surgery and 21 (23%) who received non-surgical treatment. Eventually, 63 (68.5%) patients achieved enteral autonomy by the end of the follow-up period. Multivariate logistic regression analysis indicated that longer duration of parenteral nutrition (PN), sepsis, and non-breastfeeding were risk factors for enteral autonomy. When considering the detailed intraoperative data, the presence of an ileocecal valve (ICV) and greater residual small bowel (RSB) length were reaffirmed as predictors of achieving enteral autonomy. Medium/long-chain (MCT/LCT) lipids or sepsis were identified as negative predictors for IFALD. Univariate analysis revealed that the use of MCT/LCT lipids was associated with a greater likelihood of CRBSI. CONCLUSION In this cohort, enteral autonomy was achieved at a percentage of 68.5%, and the risk factors for not achieving enteral autonomy were a longer duration of PN, sepsis, and non-breastfeeding. The presence of an ICV and a greater RSB length were important predictors of achieving enteral autonomy.
Collapse
Affiliation(s)
- Weiwei Jiang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Guanglin Chen
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ying Wang
- Division of Pediatric Gastroenterology and Nutrition, Shanghai Jiaotong University School of Medicine Xinhua Hospital, Shanghai, China
| | - Wei Zhong
- Department of Neonatal Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Chonggao Zhou
- Department of Neonatal Surgery, Hunan Children's Hospital, Changsha, China
| | - Jie Zhang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaofeng Lv
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Chunxia Du
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Zhongxian Zhu
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Qiming Geng
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Weibing Tang
- Department of Pediatric Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| |
Collapse
|
26
|
Savarino G, Carta M, Cimador M, Corsello A, Giuffrè M, Schierz IAM, Serra G, Corsello G. Necrotizing enterocolitis in the preterm: newborns medical and nutritional Management in a Single-Center Study. Ital J Pediatr 2021; 47:226. [PMID: 34775993 PMCID: PMC8591939 DOI: 10.1186/s13052-021-01180-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/26/2021] [Indexed: 11/10/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is a typical disorder of preterm newborns, with a high mortality and morbidity rate. The therapeutic and nutritional management of disease depends on several factors. Its prognosis is linked, in addition to the severity of the disease and the need for surgery, to a correct enteral feeding in these patients. This study aims to identify the clinical characteristics of 18 patients with NEC, evaluating the different therapeutic paths undertaken, the type of formula used and the survival rate of this population. Average time of enteral nutrition before the NEC onset was 11,3 ± 11,6 days, with an average fasting period since the onset of 24 ± 18.9 days. 77.8% of patients received surgery and resumed enteral nutrition 17.7 ± 17.9 days after the intervention. The overall survival rate of our cohort was 55.5%. More prospective studies are needed to evaluate the long-term outcomes of survived children with NEC.
Collapse
Affiliation(s)
- Giovanni Savarino
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University Hospital "P. Giaccone", Palermo, Italy.
| | - Maurizio Carta
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University Hospital "P. Giaccone", Palermo, Italy
| | - Marcello Cimador
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University Hospital "P. Giaccone", Palermo, Italy
| | | | - Mario Giuffrè
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University Hospital "P. Giaccone", Palermo, Italy
| | - Ingrid Anne Mandy Schierz
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University Hospital "P. Giaccone", Palermo, Italy
| | - Gregorio Serra
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University Hospital "P. Giaccone", Palermo, Italy
| | - Giovanni Corsello
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University Hospital "P. Giaccone", Palermo, Italy
| |
Collapse
|
27
|
Verlato G, Hill S, Jonkers-Schuitema C, Macdonald S, Guimber D, Echochard-Dugelay E, Pulvirenti R, Lambe C, Tabbers M. Results of an International Survey on Feeding Management in Infants With Short Bowel Syndrome-Associated Intestinal Failure. J Pediatr Gastroenterol Nutr 2021; 73:647-653. [PMID: 34338235 DOI: 10.1097/mpg.0000000000003269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Short bowel syndrome (SBS) is a complex and rare condition (incidence 1200/100,000 live births) that requires a multidisciplinary team approach to management. In January 2019, the first European Reference Network on Rare and Inherited Congenital Anomalies (ERNICA) Intestinal Failure (IF) workshop was held. Several questions about the strategies used in managing IF associated with SBS were devised. The aim of our study was to collect data on the enteral feeding strategies adopted by the ERNICA centres. METHODS A questionnaire (36 questions) about strategies used to introduce enteral nutrition post-operatively and start complementary food/solids in infants with SBS associated IF was developed and sent to 24 centres in 15 countries that participated in the ERNICA-IF workshop. The answers were collated and compared with the literature. RESULTS There was a 100% response rate. In infants, enteral nutrition was introduced as soon as possible, ideally within 24-48 hours post-small intestinal surgical resection. In 10 of 24 centres, bolus feeding was used, in nine continuous, and in five a combination of both. Twenty-three centres used mothers' own milk as the first choice of feed with extensively hydrolysed feed, amino acid-based feed, donor human milk or standard preterm/term formula as the second choice. Although 22 centres introduced complementary/solid food by 6 months of age, food choice varied greatly between centres and appeared to be culturally based. CONCLUSIONS There is diversity in post-surgical enteral feeding strategies among centres in Europe. Further multi-centre studies could help to increase evidence-based medicine and management on this topic.
Collapse
Affiliation(s)
- Giovanna Verlato
- Paediatric Nutrition Service-Neonatal Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Susan Hill
- Department of Gastroenterology, Great Ormond Street Hospital for Children, London, UK
| | - Cora Jonkers-Schuitema
- Paediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam UMC - University of Amsterdam, Amsterdam, The Netherlands
| | - Sarah Macdonald
- Department of Gastroenterology, Great Ormond Street Hospital for Children, London, UK
| | - Dominique Guimber
- Gastroenterology Hepatology and Nutrition Unit, University Hospital of Lille, Lille, France
| | | | - Rebecca Pulvirenti
- Paediatric Surgery Unit, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Cecile Lambe
- Division of Paediatric Gastroenterology Hepatology and Nutrition, Necker-Enfants Malades University of Paris, Paris, France
| | - Merit Tabbers
- Paediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam UMC - University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
28
|
Gattini D, Roberts AJ, Wales PW, Beath SV, Evans HM, Hind J, Mercer D, Wong T, Yap J, Belza C, Huysentruyt K, Avitzur Y. Trends in Pediatric Intestinal Failure: A Multicenter, Multinational Study. J Pediatr 2021; 237:16-23.e4. [PMID: 34153281 DOI: 10.1016/j.jpeds.2021.06.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To assess the natural history and outcomes of children with intestinal failure in a large, multicenter, geographically diverse contemporary cohort (2010-2015) from 6 pediatric intestinal failure programs. STUDY DESIGN Retrospective analysis of a multicenter intestinal failure cohort (n = 443). Competing-risk analysis was used to obtain cumulative incidence rates for the primary outcome (enteral autonomy, transplantation, or death). The χ2 test and Cox proportional hazard regression were used for bivariate and multivariable analyses. RESULTS The study cohort comprised 443 patients (61.2% male). Primary etiologies included short bowel syndrome (SBS), 84.9%; dysmotility disorder, 7.2%; and mucosal enteropathy, 7.9%. Cumulative incidences for enteral autonomy, transplantation, and death at 6 years of follow-up were 53.0%, 16.7%, and 10.5%, respectively. Enteral autonomy was associated with SBS, ≥50% of small bowel length, presence of an ileocecal valve (ICV), absence of portal hypertension, and follow-up in a non-high-volume transplantation center. The composite outcome of transplantation/death was associated with persistent advanced cholestasis and hypoalbuminemia; age <1 year at diagnosis, ICV, and intact colon were protective. CONCLUSIONS The rates of death and transplantation in children with intestinal failure have decreased; however, the number of children achieving enteral autonomy has not changed significantly, and a larger proportion of patients remain parenteral nutrition dependent. New strategies to achieve enteral autonomy are needed to improve patient outcomes.
Collapse
Affiliation(s)
- Daniela Gattini
- Group for Improvement of Intestinal Function and Treatment, Transplant Centre, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Amin J Roberts
- Group for Improvement of Intestinal Function and Treatment, Transplant Centre, Toronto, Ontario, Canada; Department of Paediatric Gastroenterology, Starship Child Health, University of Auckland, Auckland, New Zealand
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment, Transplant Centre, Toronto, Ontario, Canada; Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sue V Beath
- Department of Gastroenterology and Nutrition, Nutrition Support and Intestinal Failure team, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - Helen M Evans
- Department of Paediatric Gastroenterology, Starship Child Health, University of Auckland, Auckland, New Zealand
| | - Jonathan Hind
- Paediatric Liver, GI, and Nutrition Centre, King's College Hospital, London, United Kingdom
| | - David Mercer
- Organ Transplant Center, University of Nebraska Medical Center, Omaha, NE
| | - Theodoric Wong
- Department of Gastroenterology and Nutrition, Nutrition Support and Intestinal Failure team, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - Jason Yap
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Christina Belza
- Group for Improvement of Intestinal Function and Treatment, Transplant Centre, Toronto, Ontario, Canada
| | - Koen Huysentruyt
- Group for Improvement of Intestinal Function and Treatment, Transplant Centre, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment, Transplant Centre, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
29
|
Yanchis D, Belza C, Harrison D, Wong-Sterling S, Kean P, So S, Patterson C, Wales PW, Avitzur Y, Courtney-Martin G. Normal anthropometry does not equal normal body composition in pediatric intestinal failure. JPEN J Parenter Enteral Nutr 2021; 46:207-214. [PMID: 34510469 DOI: 10.1002/jpen.2265] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/24/2021] [Accepted: 09/08/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Published reports on abnormal body composition in pediatric patients with intestinal failure have been in patients with poor growth. The goal of the current study is to report the body composition of normally growing patients with intestinal failure. METHODS Children 8-18 years old with a dual-energy x-ray absorptiometry (DXA) between January 1, 2013, and July 15, 2018, were included in the study. Data were retrospectively collected from the medical charts and included demographics, residual bowel anatomy, nutrition support, height, and weight. DXA data, including total body less head bone mineral density (BMD), fat mass (FM), and fat-free mass (FFM), were collected and compared with published literature controls matched for age and sex. RESULTS Thirty-four children met inclusion criteria. Mean age at the time of DXA was 9.6 ± 1.8 years. Weight- and height-for-age z-scores were -0.4 ± 0.9 and -0.5 ± 1.0, respectively. Mean BMD z-score was -1.0 ± 1.3. Twenty-six percent of patients (n = 9) had reduced BMD. Patients with intestinal failure had higher FM (P = .02) and lower FFM (P = .02) compared with controls. CONCLUSIONS These data show that, despite reference range z-scores for height and weight, children with intestinal failure are at risk for abnormal body composition. Body composition should be routinely measured in children with intestinal failure to direct nutrition interventions.
Collapse
Affiliation(s)
- Dianna Yanchis
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Christina Belza
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Debra Harrison
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Sylvia Wong-Sterling
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Penni Kean
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada
| | - Stephanie So
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada.,Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, ON, Canada
| | - Catherine Patterson
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada.,Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, ON, Canada
| | - Paul W Wales
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Yaron Avitzur
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Glenda Courtney-Martin
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, Toronto, ON, Canada.,Faculty of Kinesiology, University of Toronto, Toronto, ON, Canada.,Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
30
|
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.
Collapse
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
| |
Collapse
|
31
|
Lansing M, Slim G, Wizzard P, Rafii M, Pencharz PB, Nation PN, Beggs MR, Alexander RT, Wales PW, Turner JM, Ball RO. Intestinal resection affects whole-body arginine synthesis in neonatal piglets. Pediatr Res 2021; 89:1420-1426. [PMID: 32920606 DOI: 10.1038/s41390-020-01139-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/01/2020] [Accepted: 08/06/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Previous studies in piglets show a direct relationship between intestinal mass and arginine (Arg) synthesis. We aimed to study the effects of 75% intestinal resection on whole-body Arg synthesis. METHODS Piglets were allocated to sham or jejunocolic (JC) surgery and to enteral nutrition (EN) at 20% [sham (n = 8), JC (n = 10)], or 40% [sham (n = 4), JC (n = 5)]. A gastric tube was placed for EN and a venous catheter for parenteral nutrition and blood sampling. On day 6, a primed bolus and constant infusion of Arg m + 2 label and proline m + 1 label was delivered. In addition, 40% EN piglets received a citrulline (Cit) m + 3 tracer. Blood sampling was undertaken and whole-body Arg synthesis was calculated. On day 7, intestinal length was measured, and samples were collected for gene expression (PCR quantification) and histopathology. RESULTS On Day 7, sham piglets showed intestinal lengthening compared to JC (p = 0.02). Whole-body Arg synthesis was similar between groups (p = 0.50). Adjusting for absolute small intestinal length, JC piglets had greater Arg synthesis (p = 0.01). Expression of arginosuccinase was upregulated in the jejunum of JC compared to sham on 20% EN (p = 0.03). CONCLUSION This demonstrates for the first-time adaptive changes in intestinal Arg synthesis following intestinal resection. IMPACT The intestine makes a critical contribution to whole-body arginine synthesis, particularly in neonates, a human population at risk for short bowel syndrome. Therefore, we studied intestinal arginine synthesis in a neonatal piglet model of short bowel syndrome and demonstrated adaptive changes in the intestine that may preserve whole-body arginine synthesis, despite loss of intestinal mass. This research adds new information to our understanding of the effects a massive intestinal resection has on amino acid metabolism during neonatal development.
Collapse
Affiliation(s)
- Marihan Lansing
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - George Slim
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Pamela Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Mahroukh Rafii
- Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Paul B Pencharz
- Departments of Pediatrics and Nutritional Sciences, University of Toronto, Toronto, ON, Canada
| | - Patrick N Nation
- Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Megan R Beggs
- Department of Physiology at the University of Alberta, Edmonton, AB, Canada
| | - R Todd Alexander
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Physiology at the University of Alberta, Edmonton, AB, Canada
| | - Paul W Wales
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Division of General and Thoracic Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.
| | - Ron O Ball
- Department of Agricultural, Life & Environmental Sciences, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
32
|
Sanaksenaho G, Mutanen A, Godbole N, Hukkinen M, Merras-Salmio L, Kivisaari R, Kyrönlahti A, Pihlajoki M, Lohi J, Heikinheimo M, Pakarinen MP. Compromised duodenal mucosal integrity in children with short bowel syndrome after adaptation to enteral autonomy. J Pediatr Surg 2021; 56:966-974. [PMID: 33131778 DOI: 10.1016/j.jpedsurg.2020.09.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/23/2020] [Accepted: 09/21/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Intestinal adaptation has been extensively studied experimentally, but very limited data is available on human subjects. In this study we assessed intestinal adaption in humans with short bowel syndrome (SBS). METHODS We comparatively evaluated mucosal hyperplasia, inflammation, barrier function and nutrient transport using histology, immunohistochemistry and qPCR for selected 52 key genes in duodenal biopsies obtained from children with SBS after weaning off parenteral nutrition (n = 33), and matched controls without intestinal pathology (n = 12). Small bowel dilatation was assessed from contrast small bowel series. RESULTS Duodenal mucosa of SBS children showed increased histologic inflammation of lamina propria (p = 0.033) and mucosal mRNA expression of tumor necrosis factor (p = 0.027), transforming growth factor (TGF)-β2 (p = 0.006) and caveolin-1 (CAV1; p = 0.001). Villus height, crypt depth, enterocyte proliferation, apoptosis and expression of proliferation and nutrient transport genes remained unchanged. Pathologic small bowel dilatation reduced crypt depth (p = 0.045) and downregulated mRNA expression of interleukin (IL)-6 by three-fold (p = 0.008), while correlating negatively with IL6 (r = -0.609, p = 0.004). Loss of ileocecal valve (ICV) upregulated mRNA expression of toll-like receptor 4 (TLR4), TGF-β1, CAV1, several apoptosis regulating genes, and mRNA expression of zonulin (p < 0.05 for all). CONCLUSIONS Despite successful adaptation to enteral autonomy, duodenal mucosa of SBS children displayed histologic and molecular signs of abnormal inflammation and regulation of epithelial permeability, whereas no structural or molecular signs of adaptive hyperplasia or enhanced nutrient transport were observed. Excessive dilatation of the remaining small bowel paralleled impaired duodenal crypt homeostasis, while absence of ICV modified regulation of mucosal inflammation, regeneration and permeability. LEVEL OF EVIDENCE II.
Collapse
Affiliation(s)
- Galina Sanaksenaho
- Division of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Annika Mutanen
- Division of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Nimish Godbole
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maria Hukkinen
- Division of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Laura Merras-Salmio
- Department of Pediatric Gastroenterology, Pediatric Liver and Gut Research Group, Children's Hospital, Pediatric Research Centre, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Reetta Kivisaari
- HUS Medical Imaging Center, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Antti Kyrönlahti
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marjut Pihlajoki
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jouko Lohi
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markku Heikinheimo
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko P Pakarinen
- Division of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| |
Collapse
|
33
|
Fatemizadeh R, Gollins L, Hagan J, Debuyserie A, King K, Vogel AM, Van Buren KL, Hair AB, Premkumar MH. In neonatal-onset surgical short bowel syndrome survival is high, and enteral autonomy is related to residual bowel length. JPEN J Parenter Enteral Nutr 2021; 46:339-347. [PMID: 33881791 DOI: 10.1002/jpen.2124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND In an era of improved management and treatment options, this study aims to describe the long-term outcomes and factors predictive of outcomes of neonatal-onset intestinal failure (IF) due to surgical short bowel syndrome (SBS). METHODS Retrospective, single-center cohort study of infants born between January 2011 and December 2018 with inclusion criteria: <44 weeks postmenstrual age at SBS diagnosis, <28 days on admission, parenteral nutrition dependence >60 days, and documented intestinal resection. Primary outcomes included survival and achievement of enteral autonomy (EA). Data analysis utilized Fisher.s exact test, Kruskal-Wallis test, survival analysis methods, Cox proportional hazards regression, linear regression and logistic regression. RESULTS Ninety-five patients (males 56%) were studied with median follow-up of 38 months (IQR 19, 59). Survival at last follow-up was 96%, and EA was achieved in 85%. Forty-eight patients had documented residual bowel length (RBL) with median length of 49 cm (IQR 36, 80). Survival in patients with RBL of <30cm (n = 8), 30-59cm (n = 19), and >60cm (n = 21) was 100%, 95%, and 95% respectively. Shorter RBL was associated with longer time to achieve EA (p = 0.007), but not with survival (p = 0.81). Delay in achieving EA was associated with absence of ileocecal valve (p = 0.002) and bloodstream infections (p < 0.001). Peak conjugated bilirubin correlated with increased mortality (p = 0.002). CONCLUSION Overall high rate of survival and achievement of EA was found in neonatal onset IF due to SBS. EA but not survival was correlated with RBL. Ileocecal valve, bloodstream infections, and conjugated bilirubin levels were the other predictive factors of outcomes.
Collapse
Affiliation(s)
- Roxana Fatemizadeh
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Laura Gollins
- Clinical Nutrition Services, Texas Children's Hospital, Houston, Texas, USA
| | - Joseph Hagan
- Section of Neonatal-Perinatal Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Anne Debuyserie
- Section of Neonatal-Perinatal Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Kristi King
- Clinical Nutrition Services, Texas Children's Hospital, Houston, Texas, USA
| | - Adam M Vogel
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Kristin L Van Buren
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Amy B Hair
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Muralidhar H Premkumar
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| |
Collapse
|
34
|
Dariel A, Faure A, Martinez L, Morini F, Pini Prato A, Friedmacher F, Coste ME. European Pediatric Surgeon' Association Survey on the Management of Short-Bowel Syndrome. Eur J Pediatr Surg 2021; 31:8-13. [PMID: 33197945 DOI: 10.1055/s-0040-1721040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The aim of this study was to assess the management of short-bowel syndrome (SBS) at the time of primary surgery, and the strategies used to facilitate enteral autonomy depending on the institutional expertise. MATERIALS AND METHODS An online questionnaire was sent in 2019 to members of The European Pediatric Surgeons' Association. RESULTS Among the 65 responding members (26 countries, 85% from university hospitals), 57% manage less than three new patients with SBS per year (group A), and 43% at least three patients (group B). The cut-off of three patients treated yearly used in our study was defined after statistical analysis of different cut-offs. A multidisciplinary intestinal rehabilitation program is significantly more frequent in group B than in group A (85 and 53%, respectively; p = 0.009). Considering the primary surgical management of multiple intestinal atresia and congenital ultra-short bowel with jejunal atresia, primary surgical strategies to optimize bowel length are more often used in group B than group A (p = 0.09 and p = 0.04, respectively). A minimum of one intestinal lengthening procedure every 2 to 3 years is significantly more frequent in group B than group A (95 and 45%, respectively; p = 0.0013). Among the strategies used to promote intestinal adaptation, group B (35%) uses significantly more often glucagon-like peptide 2 analogs than group A (10%) (p = 0.02). CONCLUSION Based on our survey, a minimum number of SBS patients treated yearly is required to manage this challenging disease according to up-to-date medical and surgical strategies. However, whatever their level of expertise is in managing SBS, most of pediatric surgeons are involved in the primary surgery. Medical education programs about SBS should be more largely available to pediatric surgeons.
Collapse
Affiliation(s)
- Anne Dariel
- Department of Pediatric Surgery, Assistance Publique des Hôpitaux de Marseille, Hôpital Timone Enfants, Marseille, France
| | - Alice Faure
- Department of Pediatric Surgery, Assistance Publique des Hôpitaux de Marseille, Hôpital Timone Enfants, Marseille, France
| | - Leopoldo Martinez
- Department of Pediatric Surgery, Hospiltal Infantil La Paz, Madrid, Spain
| | - Francesco Morini
- Department of Medical and Surgical Neonatology, Bambino Gesu Children's Research Hospital, Rome, Italy
| | - Alessio Pini Prato
- Department of Pediatric Surgery, Alessandria Children Hospital, Alessandria, Italy
| | - Florian Friedmacher
- Department of Pediatric Surgery, University Hospital of Frankfurt, Frankfurt, Germany
| | - Marie-Edith Coste
- Department of Pediatrics, Intestinal Failure Program, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| |
Collapse
|
35
|
Moschino L, Duci M, Fascetti Leon F, Bonadies L, Priante E, Baraldi E, Verlato G. Optimizing Nutritional Strategies to Prevent Necrotizing Enterocolitis and Growth Failure after Bowel Resection. Nutrients 2021; 13:nu13020340. [PMID: 33498880 PMCID: PMC7910892 DOI: 10.3390/nu13020340] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 02/07/2023] Open
Abstract
Necrotizing enterocolitis (NEC), the first cause of short bowel syndrome (SBS) in the neonate, is a serious neonatal gastrointestinal disease with an incidence of up to 11% in preterm newborns less than 1500 g of birth weight. The rate of severe NEC requiring surgery remains high, and it is estimated between 20–50%. Newborns who develop SBS need prolonged parenteral nutrition (PN), experience nutrient deficiency, failure to thrive and are at risk of neurodevelopmental impairment. Prevention of NEC is therefore mandatory to avoid SBS and its associated morbidities. In this regard, nutritional practices seem to play a key role in early life. Individualized medical and surgical therapies, as well as intestinal rehabilitation programs, are fundamental in the achievement of enteral autonomy in infants with acquired SBS. In this descriptive review, we describe the most recent evidence on nutritional practices to prevent NEC, the available tools to early detect it, the surgical management to limit bowel resection and the best nutrition to sustain growth and intestinal function.
Collapse
MESH Headings
- Enterocolitis, Necrotizing/complications
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/prevention & control
- Enterocolitis, Necrotizing/surgery
- Failure to Thrive/prevention & control
- Humans
- Infant
- Infant Nutritional Physiological Phenomena
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/prevention & control
- Infant, Premature, Diseases/surgery
- Intestines/surgery
- Short Bowel Syndrome/etiology
- Short Bowel Syndrome/prevention & control
Collapse
Affiliation(s)
- Laura Moschino
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Miriam Duci
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Francesco Fascetti Leon
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Luca Bonadies
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Elena Priante
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Giovanna Verlato
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
- Correspondence: ; Tel.: +39-0498211428
| |
Collapse
|
36
|
Muto M, Kaji T, Onishi S, Yano K, Yamada W, Ieiri S. An overview of the current management of short-bowel syndrome in pediatric patients. Surg Today 2021; 52:12-21. [PMID: 33464414 DOI: 10.1007/s00595-020-02207-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 11/29/2020] [Indexed: 12/13/2022]
Abstract
Short-bowel syndrome (SBS) is defined as a state of malabsorption after resection or loss of a major portion of the bowel due to congenital or acquired factors. This article presents an overview on the recent management of pediatric SBS. The pediatric SBS population is very heterogeneous. The incidence of SBS is estimated to be 24.5 per 100,000 live births. The nutritional, medical, and surgical therapies available require a comprehensive evaluation. Thus, multidisciplinary intestinal rehabilitation programs (IRPs) are necessary for the management of these complex patients. The key points of focus in IRP management are hepato-protective strategies to minimize intestinal failure-associated liver disease; the aggressive prevention of catheter-related bloodstream infections; strategic nutritional supply to optimize the absorption of enteral calories; and the management and prevention of small bowel bacterial overgrowth, nephrocalcinosis, and metabolic bone disease. As the survival rate of children with SBS currently exceeds 90%, the application of small bowel transplantation has been evolving. The introduction of innovative treatments, such as combined therapy of intestinotrophic hormones, including glucagon-like peptide-2, may lead to further improvements in patients' quality of life.
Collapse
Affiliation(s)
- Mitsuru Muto
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Tatsuru Kaji
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima city, Kagoshima, 890-8520, Japan
| | - Shun Onishi
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Keisuke Yano
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima city, Kagoshima, 890-8520, Japan
| | - Waka Yamada
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima city, Kagoshima, 890-8520, Japan
| | - Satoshi Ieiri
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.
| |
Collapse
|
37
|
Abstract
BACKGROUND Outcomes of pediatric intestinal failure (PIF) have improved recently, with other comorbidities, such as increased echogenicity/nephrocalcinosis on ultrasound (US) in long-term survivors now evident. We evaluated the significance of nephrocalcinosis over time in PIF and its impact on renal function. METHODS Retrospective analysis on a cohort of PIF patients was performed. Presence of nephrocalcinosis and/or increased renal echogenicity (identified on US), estimated glomerular filtration rate (eGFR; ml · min · 1.73 m2), renal tubular function, PN volume (ml · kg · day) and PN exposure time (hours/day) were reviewed annually over a follow-up period of 2 years. Outcomes in the nephrocalcinosis versus normal US groups were compared. RESULTS Forty patients (28 boys, median age 2.7 years) were followed for 2 years. Fifteen (38%) had either increased echogenicity or nephrocalcinosis (group 1) at initial US. US were normal in the remaining 25 (62%) on initial assessment (group 2). eGFR did not differ between group 1 and group 2 at baseline (118 vs 133, P = 0.51) and year 2 (130 vs 131, P = 1.00). The percentage of patients with abnormal markers of tubular function was similar in both groups at year 2 (high urine calcium: creatinine 33 versus 30, P = 0.83; high urine calcium: citrate 39 versus 42, P = 0.87; low urine citrate: creatinine 15 versus 17, P = 1.00; high urine oxalate: creatinine 39 versus 25, P = 0.77). CONCLUSIONS A large proportion of PIF patients with a history of parenteral nutrition (PN) exposure have nephrocalcinosis and/or increased echogenicity on US. Over a 2-year follow-up period, however, these abnormalities had no impact on eGFR or renal tubular function.
Collapse
|
38
|
Hinchliffe T, Pauline ML, Wizzard PR, Nation PN, Brubaker P, Campbell JR, Kim Y, Dimitriadou V, Wales PW, Turner JM. Durability of Linear Small-Intestinal Growth Following Treatment Discontinuation of Long-Acting Glucagon-Like Peptide 2 (GLP-2) Analogues. JPEN J Parenter Enteral Nutr 2020; 45:1466-1474. [PMID: 33241564 DOI: 10.1002/jpen.2053] [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: 07/26/2020] [Revised: 10/23/2020] [Accepted: 11/17/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Short-bowel syndrome is the leading cause of pediatric intestinal failure, resulting in dependency on long-term parenteral nutrition (PN). To promote enteral autonomy in neonates, a key outcome may be intestinal growth in length. The purpose of this study was to determine if intestinal lengthening persists following discontinuation of treatment with 1 of 2 GLP-2 analogues with different pharmacokinetic profiles. METHODS Neonatal short-bowel piglets were assigned to saline control (S), 7-day treatment with teduglutide (T) (0.05 mg/kg twice daily), or 7-day treatment with apraglutide (A) (5 mg/kg twice weekly). Comparisons were made between day 7 and day 14 endpoints using analysis of variance. Data included small-intestine length, weight, histology, and quantitative polymerase chain reaction analysis of mucosal transcripts for peptide growth factors and their receptors, nutrient transporters, and tight-junction proteins. RESULTS Compared with control, 7 days of GLP-2 analogue treatment induced mucosal adaptation based on villus hyperplasia (P = .003), which was not durable 7 days after treatment cessation (day 14; P = .081). Treatment increased intestinal growth in length by day 7 (P = .005), which was maintained (by T) or further increased (by A) at day 14 (P < .001). No significant differences in mucosal transcripts were detected. CONCLUSION Unlike mucosal adaptation, intestinal growth appears to be a lasting outcome of treatment with long-acting GLP-2 analogues in a neonatal piglet short-bowel model. This has significant clinical implications for neonates, given their potential for intestinal growth. Intestinal lengthening varies between analogues with different half-lives; however, molecular mechanisms require further elucidation.
Collapse
Affiliation(s)
- Tierah Hinchliffe
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Mirielle L Pauline
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela R Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Patrick N Nation
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Patricia Brubaker
- Departments of Physiology and Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jhenielle R Campbell
- Departments of Physiology and Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yunji Kim
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Paul W Wales
- Department of Surgery, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
39
|
Abstract
OBJECTIVE The aim of the study was to evaluate the outcome and to identify predictors for survival and enteral autonomy in neonatal intestinal failure (IF). METHODS A retrospective observational study in a Swedish tertiary centre of children born between 1995 and 2016 with neonatal IF, defined as dependency on parenteral nutrition (PN) ≥60 days, starting with PN before the age of 44 gestational weeks. Data were extracted from medical records and predictors for survival and enteral autonomy were identified by the Cox regression model. Time to death and weaning off PN analysis were performed with Kaplan-Meier curves including log rank test. RESULTS In total, 105 children were included. Median gestational age was 28 weeks (22-42), 50% were born extremely preterm (<28 gestational weeks). PN started at a median age of 2 days (0-147) with a median duration of 196 days (60-3091). Necrotizing enterocolitis was the dominating cause of IF (61%). Overall survival was 88%, 5 children died of sepsis and 4 of intestinal failure-associated liver disease. Survival increased from 75% during 1995 to 2008 to 96% during 2009 to 2016 (P = 0.0040). Age-adjusted small bowel length of >50% and birth 2009 to 2016 were predictors for survival. Enteral autonomy was achieved in 87%, with positive prediction by small bowel length of >25% of expected for gestational age and remaining ileocecal valve. CONCLUSIONS Preterm neonates with IF, at high risk of IF-associated morbidity, showed a high overall survival rate. Small-bowel length and being born 2009 to 2016 were predictors for survival and remaining ICV and small-bowel length were predictors for enteral autonomy.
Collapse
|
40
|
Capriati T, Mosca A, Alterio T, Spagnuolo MI, Gandullia P, Lezo A, Lionetti P, D’Antiga L, Fusaro F, Diamanti A. To Wean or Not to Wean: The Role of Autologous Reconstructive Surgery in the Natural History of Pediatric Short Bowel Syndrome on Behalf of Italian Society for Gastroenterology, Hepatology and Nutrition (SIGENP). Nutrients 2020; 12:E2136. [PMID: 32708377 PMCID: PMC7400841 DOI: 10.3390/nu12072136] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/13/2020] [Indexed: 12/15/2022] Open
Abstract
Pediatric Short Bowel Syndrome (SBS) can require prolonged parenteral nutrition (PN). Over the years, SBS management has been implemented by autologous gastrointestinal reconstructive surgery (AGIR). The primary objective of the present review was to assess the effect of AGIR on weaning off PN. We also evaluated how AGIR impacts survival, the need for transplantation (Tx) and the development of liver disease (LD). We conducted a systematic literature search to identify studies published from January 1999 to the present and 947 patients were identified. PN alone was weakly associated with higher probability of weaning from PN (OR = 1.1, p = 0.03) and of surviving (OR = 1.05, p = 0.01). Adjusting for age, the probability of weaning off PN but of not surviving remained significantly associated with PN alone (OR = 1.08, p = 0.03). Finally, adjusting for age and primary diagnosis (gastroschisis), any association was lost. The prevalence of TX and LD did not differ by groups. In conclusion, in view of the low benefit in terms of intestinal adaptation and of the not negligible rate of complications (20%), a careful selection of candidates for AGIR should be required. Bowel dilation associated with failure of advancing EN and poor growth, should be criteria to refer for AGIR.
Collapse
Affiliation(s)
- Teresa Capriati
- Artificial Nutrition Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy;
| | - Antonella Mosca
- Hepatology Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Tommaso Alterio
- Hepatology Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Maria Immacolata Spagnuolo
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, 80138 Naples, Italy;
| | - Paolo Gandullia
- Gastroenterology Unit, G.Gaslini Institute for Maternal and Child Health, IRCCS, 16145 Genova, Italy;
| | - Antonella Lezo
- Division of Nutrition, Regina Margherita Children’s Hospital, 10126 Turin, Italy;
| | - Paolo Lionetti
- Department of Neuroscience, Psychology, Pharmacology and Child’s Health, University of Florence, Meyer Hospital, 50139 Florence, Italy;
| | - Lorenzo D’Antiga
- Paediatric, Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Fabio Fusaro
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, 00165 Rome, Italy;
| | - Antonella Diamanti
- Artificial Nutrition Unit, Bambino Gesù Children Hospital, 00165 Rome, Italy;
| |
Collapse
|
41
|
Pauline ML, Nation PN, Wizzard PR, Hinchliffe T, Wu T, Dimitriadou V, Turner JM, Wales PW. Comparing the Intestinotrophic Effects of 2 Glucagon-Like Peptide-2 Analogues in the Treatment of Short-Bowel Syndrome in Neonatal Piglets. JPEN J Parenter Enteral Nutr 2020; 45:538-545. [PMID: 32437048 DOI: 10.1002/jpen.1853] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/06/2020] [Accepted: 04/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND In treating short-bowel syndrome (SBS), autonomy from parenteral nutrition (PN) relies upon intestinal adaptation, which can be augmented by glucagon-like peptide-2 (GLP-2) analogues. In neonatal piglets with SBS, we compared intestinal adaptation following treatment with 2 GLP-2 analogues: teduglutide (TED) and apraglutide (APRA) METHODS: Following 75% distal small-intestinal resection, piglets were allocated to 4 treatment groups: saline (CON: n = 8), twice weekly APRA (5 mg/kg/dose; n = 8), and TED once daily (TED, 0.05 mg/kg/dose; n = 8) or twice daily (TEDBID, 0.05 mg/kg/dose; n = 7). Pharmacokinetic (PK) studies were undertaken, and on day 7, small-intestinal length and weight were measured and jejunal tissue collected for histology. RESULTS PK profiles were different between the 2 analogues. To achieve a comparable exposure to APRA, TED requires twice daily injection (TEDBID). Compared with CON, APRA and TEDBID increased small-bowel length (cm) (CON: 141, APRA: 166, TED: 153, TEDBID: 165; P = .004), whereas APRA increased small-bowel weight (g) (CON: 26, APRA: 33, TED: 28, TEDBID: 31; P = .007) and villus height (mm) (CON: 0.59, APRA: 0.90, TED: 0.58, TEDBID: 0.74; P < .001). CONCLUSION APRA injected only twice during the 7 consecutive days demonstrated a superior intestinotrophic effect compared with TED injected once daily. Even at more comparable drug exposure, when TED was injected twice a day, APRA showed superior trophic activity at the mucosal level. This is highly relevant for the treatment of pediatric SBS, given the markedly lower dose frequency by subcutaneous injection of APRA.
Collapse
Affiliation(s)
- Mirielle L Pauline
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Patrick N Nation
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela R Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Tierah Hinchliffe
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Tong Wu
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,Shanghai Medical College, Fudan University, Shanghai, China
| | | | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Paul W Wales
- Department of Surgery, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
42
|
Belza C, Betts Z, de Silva N, Avitzur Y, Wales PW. Factors Related to the Development of Small-Bowel Bacterial Overgrowth in Pediatric Intestinal Failure: A Retrospective Cohort Study. JPEN J Parenter Enteral Nutr 2020; 44:1280-1284. [PMID: 32167608 DOI: 10.1002/jpen.1809] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 01/27/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Small bowel bacterial overgrowth (SBBO) is a challenge in the management of pediatric intestinal failure (PIF). Our goal was to determine the proportion of patients treated for SBBO and factors related to its development. METHODS We completed a retrospective analysis of PIF patients referred between 2008 and 2014. Data were collected on factors related to intestinal failure (IF) and SBBO. The cohort was stratified on the diagnosis of SBBO and refractory SBBO. Statistical testing completed using t-test, χ2 test, and logistic regression. RESULTS Thirty-five of 102 patients developed SBBO (34%), and 16 (16%) had refractory SBBO. SBBO was more likely in gastroschisis (40.0% vs 19.4%, P = .025), a shorter residual small bowel (SB) (45.4% vs 66.5%, P = .004), and patients were less likely to wean from parenteral nutrition (PN) (51.4% vs 85.1%, P < .0001). Refractory SBBO patients were likely to have gastroschisis (50.0% vs 22.1%, P = .020) and a shorter residual SB and large bowel remaining (23.2% vs 65.9%, P < .0001 and 60.6% vs 79.4%, P = .03, respectively) and less likely to wean from PN (37.5% vs 80.2%, P = .001). Logistic regression demonstrated that longer SB residual was protective (P = .001; odds ratio [OR], 0.95; 95% CI, 0.93-0.99), and short bowel syndrome (SBS) as a cause of IF was a risk factor (P = .001; OR, 0.04; 95% CI, 0.01-0.27). CONCLUSION A longer SB remnant was protective against SBBO. Patients with SBBO were more likely to have PIF caused by SBS.
Collapse
Affiliation(s)
- Christina Belza
- Transplant and Regenerative Medicine Centre, Toronto, Canada
| | - Zachary Betts
- Transplant and Regenerative Medicine Centre, Toronto, Canada
| | | | - Yaron Avitzur
- Transplant and Regenerative Medicine Centre, Toronto, Canada.,Division of Neonatology, Toronto, Canada
| | - Paul W Wales
- Transplant and Regenerative Medicine Centre, Toronto, Canada.,Division of Gastroenterology, Hepatology and Nutrition, Toronto, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| |
Collapse
|
43
|
Ou J, Courtney CM, Steinberger AE, Tecos ME, Warner BW. Nutrition in Necrotizing Enterocolitis and Following Intestinal Resection. Nutrients 2020; 12:nu12020520. [PMID: 32085587 PMCID: PMC7071274 DOI: 10.3390/nu12020520] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 12/25/2022] Open
Abstract
This review aims to discuss the role of nutrition and feeding practices in necrotizing enterocolitis (NEC), NEC prevention, and its complications, including surgical treatment. A thorough PubMed search was performed with a focus on meta-analyses and randomized controlled trials when available. There are several variables in nutrition and the feeding of preterm infants with the intention of preventing necrotizing enterocolitis (NEC). Starting feeds later rather than earlier, advancing feeds slowly and continuous feeds have not been shown to prevent NEC and breast milk remains the only effective prevention strategy. The lack of medical treatment options for NEC often leads to disease progression requiring surgical resection. Following resection, intestinal adaptation occurs, during which villi lengthen and crypts deepen to increase the functional capacity of remaining bowel. The effect of macronutrients on intestinal adaptation has been extensively studied in animal models. Clinically, the length and portion of intestine that is resected may lead to patients requiring parenteral nutrition, which is also reviewed here. There remain significant gaps in knowledge surrounding many of the nutritional aspects of NEC and more research is needed to determine optimal feeding approaches to prevent NEC, particularly in infants younger than 28 weeks and <1000 grams. Additional research is also needed to identify biomarkers reflecting intestinal recovery following NEC diagnosis individualize when feedings should be safely resumed for each patient.
Collapse
Affiliation(s)
- Jocelyn Ou
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA;
| | - Cathleen M. Courtney
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
| | - Allie E. Steinberger
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
| | - Maria E. Tecos
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
| | - Brad W. Warner
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
- Correspondence: ; Tel.: 314-454-6022
| |
Collapse
|
44
|
Sanaksenaho G, Mutanen A, Godbole N, Kyrönlahti A, Koivusalo A, Lohi J, Pihlajoki M, Heikinheimo M, Pakarinen MP. Parenteral Nutrition-Dependent Children With Short-Bowel Syndrome Lack Duodenal-Adaptive Hyperplasia but Show Molecular Signs of Altered Mucosal Function. JPEN J Parenter Enteral Nutr 2020; 44:1291-1300. [PMID: 31985858 DOI: 10.1002/jpen.1763] [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: 09/01/2019] [Revised: 10/30/2019] [Accepted: 12/04/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although adaptive mucosal growth of the remaining small intestine is an essential compensatory mechanism to bowel resection in experimental short-bowel syndrome (SBS), only scarce clinical data are available. We studied structural and molecular mechanisms of intestinal adaptation in children with SBS. METHODS Fourteen patients, who had been dependent on parenteral nutrition (PN) since neonatal period for a median (interquartile range)1.4 (0.7-6.5) years, were studied at the age of 1.5 (1.0-6.5) years. Median length of remaining small bowel was 33 (12-60) cm, and 6 patients had their ileocecal valve preserved. Six children without gastrointestinal disorders served as age-matched and gender-matched controls. All patients underwent duodenal biopsies. Mucosal microarchitecture, proliferation, apoptosis, inflammation, and epithelial-barrier function were addressed using histology, immunohistochemistry, and quantitative real-time polymerase chain reaction. RESULTS Villus height, crypt depth, enterocyte proliferation, and apoptosis were similar in patients and matched controls. Messenger RNA (mRNA) expression of numerous genes regulating gut epithelial-barrier function (TGFB2, CAV1, CLDN1, MUC2, and NLRC4) was significantly altered. Of various nutrient transporters studied, only expression of SLC2A1 encoding facilitative glucose transporter GLUT1 was increased among patients, whereas RNA expression of genes encoding sodium-dependent glucose, sterol, fatty-acid, and peptide transport remained unchanged. CONCLUSION Duodenal mucosal hyperplasia has a limited role in mediating physiological adaptation following intestinal resection among PN-dependent children with SBS. Further clinical studies addressing functional significance of the observed alterations in mucosal RNA expression are warranted.
Collapse
Affiliation(s)
- Galina Sanaksenaho
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Annika Mutanen
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Nimish Godbole
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti Kyrönlahti
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti Koivusalo
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jouko Lohi
- Department of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marjut Pihlajoki
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markku Heikinheimo
- Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko P Pakarinen
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group, Pediatric Research Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
45
|
Belza C, Wales PW. Multidisciplinary Management in Pediatric Ultrashort Bowel Syndrome. J Multidiscip Healthc 2020; 13:9-17. [PMID: 32021230 PMCID: PMC6957105 DOI: 10.2147/jmdh.s236130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 12/27/2019] [Indexed: 12/28/2022] Open
Abstract
Pediatric intestinal failure (IF) remains a complex and devastating condition resulting in the inability of the gastrointestinal tract to absorb adequate fluids and nutrients to sustain life. The goal in the management of IF is to achieve enteral autonomy and when not possible to avoid and minimize the development of long-term complications. Survival rates for children with IF have continued to improve resulting in an increased population of children with more altered anatomy. While IF remains a rare disease, children with IF secondary to ultrashort bowel syndrome comprise an even smaller patient population. The goal of this article is to review the recent literature related to the impact of multidisciplinary intestinal rehabilitation programs (IRPs) on the management and outcomes of intestinal failure in children with ultrashort bowel syndrome and potential avenues to further improve the long-term outcomes of this patient population.
Collapse
Affiliation(s)
- Christina Belza
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Paul W Wales
- Group for Improvement of Intestinal Function and Treatment (GIFT), The Hospital for Sick Children, University of Toronto, Toronto, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| |
Collapse
|
46
|
Kocoshis SA, Merritt RJ, Hill S, Protheroe S, Carter BA, Horslen S, Hu S, Kaufman SS, Mercer DF, Pakarinen MP, Venick RS, Wales PW, Grimm AA. Safety and Efficacy of Teduglutide in Pediatric Patients With Intestinal Failure due to Short Bowel Syndrome: A 24-Week, Phase III Study. JPEN J Parenter Enteral Nutr 2019; 44:621-631. [PMID: 31495952 PMCID: PMC7318247 DOI: 10.1002/jpen.1690] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/08/2019] [Indexed: 12/27/2022]
Abstract
Background This study evaluated the safety and efficacy of teduglutide in pediatric patients with short bowel syndrome–associated intestinal failure (SBS‐IF). Methods A 24‐week, phase III trial with 2 randomized, double‐blind teduglutide dose groups and a nonblinded standard of care (SOC) arm was used; patients received 0.025 mg/kg or 0.05 mg/kg teduglutide once daily. Safety end points included treatment‐emergent adverse events (TEAEs) and growth parameters. The primary efficacy/pharmacodynamic end point was the number of patients who achieved a ≥20% reduction in parenteral support (PS) from baseline at week 24. Results All 59 enrolled patients completed the study (0.025 mg/kg, n = 24; 0.05 mg/kg, n = 26; SOC, n = 9). Baseline demographics and disease characteristics were comparable among groups. TEAEs were reported by 98% and 100% of patients in the teduglutide and SOC groups, respectively. The most common TEAEs in the teduglutide‐treated groups were pyrexia and vomiting. The primary end point was achieved by 13 (54.2%), 18 (69.2%), and 1 (11.1%) patients who received 0.025 mg/kg teduglutide, 0.05 mg/kg teduglutide, and SOC, respectively (P < 0.05 vs SOC). Both 0.025‐mg/kg and 0.05‐mg/kg teduglutide groups showed clinically significant reductions in PS volume (P < 0.05 vs SOC), PS calories, days per week and hours per day of PS infusions, and increases in enteral nutrition and plasma citrulline at week 24 compared with baseline. Two (8.3%, 0.025 mg/kg teduglutide) and 3 patients (11.5%, 0.05 mg/kg teduglutide) achieved enteral autonomy. Conclusion The safety profile of teduglutide was similar to that reported previously in children and adults. Treatment with teduglutide was associated with significant reductions in PS for pediatric patients with SBS‐IF over 24 weeks.
Collapse
Affiliation(s)
- Samuel A Kocoshis
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Russell J Merritt
- Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Susan Hill
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Susan Protheroe
- Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Beth A Carter
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Simon Horslen
- Seattle Children's Hospital and University of Washington School of Medicine, Seattle, Washington, USA
| | - Simin Hu
- Shire Human Genetic Therapies, Inc, Lexington, Massachusetts, USA
| | - Stuart S Kaufman
- MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - David F Mercer
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Mikko P Pakarinen
- Children's Hospital, Pediatric Research Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Robert S Venick
- Mattel Children's Hospital UCLA, Department of Pediatrics, Los Angeles, California, USA
| | - Paul W Wales
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andrew A Grimm
- Shire Human Genetic Therapies, Inc, Cambridge, Massachusetts, USA
| |
Collapse
|
47
|
Belza C, Wales JC, Courtney-Martin G, de Silva N, Avitzur Y, Wales PW. An Observational Study of Smoflipid vs Intralipid on the Evolution of Intestinal Failure-Associated Liver Disease in Infants With Intestinal Failure. JPEN J Parenter Enteral Nutr 2019; 44:688-696. [PMID: 31448447 DOI: 10.1002/jpen.1692] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 07/23/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND SMOFlipid has a more diverse lipid profile than traditional Intralipid and has become the standard lipid for patients in our intestinal rehabilitation program. Our objective was to compare outcomes in neonates with intestinal failure (IF) who received SMOFlipid against those receiving Intralipid. METHODS This was a retrospective cohort study of infants with IF with a minimum follow-up of 12 months in 2008-2016. Patients were stratified into 2 groups: group 1 received SMOFlipid; group 2 was a historical cohort who received Intralipid. The primary outcome was liver function evaluated using conjugated bilirubin (CB) levels. Statistical analysis included the Mann-Whitney U and χ2 tests, with an α value < 0.05 considered significant. Approval was obtained from our institutional review board. RESULTS Thirty-seven patients were evaluated (17 = SMOFlipid, 20 = Intralipid). SMOFlipid patients were less likely to reach CB of 34 (24% vs 55%, P = 0.05), 50 µmol/L (11.8% vs 45%; P = 0.028), and did not require Omegaven (0% vs 30%; P = 0.014). CB level at 3 months after initiation of parenteral nutrition (PN) was lower in patients receiving SMOFlipid (0 vs 36 µmol/L; P = 0.01). Weight z-scores were improved for patients receiving SMOFlipid at 3 months (-0.932 vs -2.092; P = 0.028) and 6 months (-0.633 vs -1.614; P = 0.018). There were no differences in PN-supported patients or demographics between the groups. CONCLUSION Use of SMOFlipid resulted in decreased development of IF-associated liver disease in patients with IF when assessed using biochemical tests.
Collapse
Affiliation(s)
- Christina Belza
- Research Institute, University of Toronto, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), University of Toronto, Toronto, Canada.,Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Canada
| | - John C Wales
- Research Institute, University of Toronto, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), University of Toronto, Toronto, Canada
| | - Glenda Courtney-Martin
- Research Institute, University of Toronto, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), University of Toronto, Toronto, Canada.,Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Canada
| | - Nicole de Silva
- Research Institute, University of Toronto, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), University of Toronto, Toronto, Canada
| | - Yaron Avitzur
- Research Institute, University of Toronto, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), University of Toronto, Toronto, Canada.,Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Canada.,Division of Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Canada
| | - Paul W Wales
- Research Institute, University of Toronto, Toronto, Canada.,Group for Improvement of Intestinal Function and Treatment (GIFT), University of Toronto, Toronto, Canada.,Transplant and Regenerative Medicine Centre, University of Toronto, Toronto, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Canada
| |
Collapse
|
48
|
Goulet O, Abi Nader E, Pigneur B, Lambe C. Short Bowel Syndrome as the Leading Cause of Intestinal Failure in Early Life: Some Insights into the Management. Pediatr Gastroenterol Hepatol Nutr 2019; 22:303-329. [PMID: 31338307 PMCID: PMC6629594 DOI: 10.5223/pghn.2019.22.4.303] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/11/2019] [Indexed: 12/13/2022] Open
Abstract
Intestinal failure (IF) is the critical reduction of the gut mass or its function below the minimum needed to absorb nutrients and fluids required for adequate growth in children. Severe IF requires parenteral nutrition (PN). Pediatric IF is most commonly due to congenital or neonatal intestinal diseases or malformations divided into 3 groups: 1) reduced intestinal length and consequently reduced absorptive surface, such as in short bowel syndrome (SBS) or extensive aganglionosis; 2) abnormal development of the intestinal mucosa such as congenital diseases of enterocyte development; 3) extensive motility dysfunction such as chronic intestinal pseudo-obstruction syndromes. The leading cause of IF in childhood is the SBS. In clinical practice the degree of IF may be indirectly measured by the level of PN required for normal or catch up growth. Other indicators such as serum citrulline have not proven to be highly reliable prognostic factors in children. The last decades have allowed the development of highly sophisticated nutrient solutions consisting of optimal combinations of macronutrients and micronutrients as well as guidelines, promoting PN as a safe and efficient feeding technique. However, IF that requires long-term PN may be associated with various complications including infections, growth failure, metabolic disorders, and bone disease. IF Associated Liver Disease may be a limiting factor. However, changes in the global management of IF pediatric patients, especially since the setup of intestinal rehabilitation centres did change the prognosis thus limiting "nutritional failure" which is considered as a major indication for intestinal transplantation (ITx) or combined liver-ITx.
Collapse
Affiliation(s)
- Olivier Goulet
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Digestive Diseases, Pediatric Intestinal Failure Rehabilitation Center, Hôpital Necker-Enfants Malades, University Sorbonne-Paris-Cité Paris Descartes Medical School, Paris, France
| | - Elie Abi Nader
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Digestive Diseases, Pediatric Intestinal Failure Rehabilitation Center, Hôpital Necker-Enfants Malades, University Sorbonne-Paris-Cité Paris Descartes Medical School, Paris, France
| | - Bénédicte Pigneur
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Digestive Diseases, Pediatric Intestinal Failure Rehabilitation Center, Hôpital Necker-Enfants Malades, University Sorbonne-Paris-Cité Paris Descartes Medical School, Paris, France
| | - Cécile Lambe
- Department of Pediatric Gastroenterology-Hepatology-Nutrition, National Reference Center for Rare Digestive Diseases, Pediatric Intestinal Failure Rehabilitation Center, Hôpital Necker-Enfants Malades, University Sorbonne-Paris-Cité Paris Descartes Medical School, Paris, France
| |
Collapse
|
49
|
Plasma citrulline is not a biomarker for intestinal adaptation in short bowel syndrome, studied in piglets: a model for human neonates. Pediatr Surg Int 2019; 35:657-663. [PMID: 30937511 DOI: 10.1007/s00383-019-04475-4] [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] [Accepted: 03/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND There are no in vivo methods to measure adaptation in neonatal short bowel syndrome (SBS). We evaluated citrulline (Cit) levels in neonatal piglet surgical models of SBS. METHODS Piglets underwent 75% mid-intestinal resection with jejunoileal anastomosis (JI), 75% distal resection of ileum with jejunocolic anastomosis (JC) or sham surgery. Jugular and gastric catheters were inserted for parenteral and enteral nutrition. On D7, small intestine length and weight were measured, jejunum collected for histopathology and Cit level determined. RESULTS JI (n = 5) compared to JC (n = 5) had increased small intestinal length (JC - 17.5 cm; JI +22.0 cm; p = 0.02) and mass (JC 43.1 mg/cm/kg; JI 51.3 mg/cm/kg; p = 0.02), while Cit did not differ (JI 801.0 µM; JC 677.7 µM; p = 0.90). Including non-resected shams (n = 4), Cit correlated with length (R2 = 0.48; p = 0.006), but not for SBS alone (R2 = 0.11; p = 0.4), mass (R2 = 0.05; p = 0.5). A second experiment compared change in Cit levels from baseline to D7. Levels declined in sham (n = 8) and JC (n = 10) (sham - 110.1 µM; JC - 56.6 µM; p = 0.17), regardless of intestinal lengthening (sham 29.9 cm; JC - 10.4 cm; p = 0.002). CONCLUSION Citrulline levels predict large differences in intestinal length and 'identify' SBS. However, citrulline cannot discriminate between adaptation in JI and JC, nor predict intestinal lengthening.
Collapse
|
50
|
Wang H, Wang Y, Deng C, Li L, Guo C. Prediction of intestinal failure from necrotizing enterocolitis following surgery: A multicenter retrospective review. Medicine (Baltimore) 2019; 98:e15568. [PMID: 31083227 PMCID: PMC6531265 DOI: 10.1097/md.0000000000015568] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of the present study was to identify risk factors for intestinal failure (IF) in infants who received surgery for necrotizing enterocolitis (NEC).A retrospective multicenter case-series study was conducted in a sample of 91 infants admitted to Children's Hospital of Chongqing Medical University between January 2010 and December 2017. The occurrence of IF was defined as the dependence on parenteral nutrition for ≥90 days. Logistic regression was used to investigate the predictors of IF.Of 179 patients reviewed, excluding those with intestinal malformation and inadequate information, 91 were included in the study, and of these cases, 32 (35.2%) developed IF. Controlling for other factors, multivariate analysis showed that birth weight (OR = 0.999; 95% CI, 0.998-1.000; P = .010), the length of the bowel resected (OR = 1.109; 95% CI, 1.048-1.173; P = .000), and the percentage of small bowel resected (OR = 1.305; 95% CI, 1.133-1.504; P = .000) were factors that increased the chances of IF occurrence.Our data demonstrated that variables characteristic of severe NEC, including lower birth weight, greater extent of bowel resection, and larger percentage of small bowel resection were associated with the incidence of IF.
Collapse
Affiliation(s)
- Huan Wang
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing
- Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Yan Wang
- Department of Neonatology, Yongchuan Hospital, Chongqing Medical University
- Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Chun Deng
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing
- Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Lei Li
- Department of Neonatology, Jinan Maternity and Child Care Hospital, Jinan, Shandong Province
- Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| | - Chunbao Guo
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing
- Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital, Chongqing Medical University, Chongqing, P.R. China
| |
Collapse
|