A Therapeutic Approach to Wean Total Parenteral Nutrition in the Management of Short Bowel Syndrome: Three Cases Using Nocturnal Enteral Rehydration

The role of gastrostomy feeding during intestinal rehabilitation for children with short bowel syndrome

PURPOSE

Following extensive bowel resection, many children with short bowel syndrome (SBS) are routinely offered a placement of gastrostomy tube (G-tube) for feeding. This nutritional pathway is aimed to accommodate the gastric and small bowel motor disturbances related to SBS, and to promote weaning off parenteral nutrition (PN) to achieve enteral autonomy (EA). The aim of this study was to investigate the effect of gastrostomy feeding in outcomes of children with SBS.

METHODS

A retrospective cohort of all SBS children managed at our multidisciplinary Intestinal Rehabilitation Center as part of an Intestinal Rehabilitation Program. SBS was defined as PN dependence for more than six weeks following extensive bowel resection. Patients treated with G-tube feeding were compared with patients without G-tube in terms of PN duration, reaching EA, physical development, and surgical parameters.

RESULTS

A total of 36 SBS patients diagnosed between 2003 and 2022 were included. The most common etiologies included congenital intestinal atresia (31%) and necrotizing enterocolitis (25%). SBS-G-tube (group A) contained 20 children, and SBS (group B) contained 16 children. A total of 21 children reached EA (58%); ten from group A (50%), and 11 from group B (69%) (p > 0.05). Within EA patients, mean PN duration was 49 ± 44 months in group A, and 24 ± 33 months in group B (p > 0.05). Patients who reached EA had 22% longer residual small bowel when compared with PN-dependent patients (p = 0.003). However, the outcomes were adjusted for residual small and large bowel length and percentages, a residual ileocecal valve, and a colon in continuity with no differences between the groups. Two-thirds of children from group A reported G-tube related complications (mechanical, bleeding, or infections). We did not find differences in mean height and weight percentiles between the groups (p > 0.05).

CONCLUSION

We did not find significant advantage of gastrostomy feeding in reaching EA. Because there are surgical and mechanical complications related to this procedure, further prospective studies are required to determine G-tube relevance for children with SBS.

Criteria for the Use of Recombinant Human Growth Hormone in Short Bowel Syndrome

Extensive resection of the intestinal tract with resulting malabsorption is known as short bowel syndrome (SBS). Adaptation and rehabilitation of the remaining small bowel occurs spontaneously after resection and can be enhanced by diet, medications, and use of intestinal trophic factors such as recombinant human growth hormone (r-hGH). Many trials have been published on the influence of r-hGH therapy in SBS patients, with varying results. Analysis of the trials has produced a set of criteria that can be used to define the patient most likely to benefit from r-hGH therapy.

Oral Rehydration Therapy and Feeding Replaces Total Parenteral Nutrition: A Clinical Vignette

A 27-year-old patient with spina bifida and a high output loss of water and electrolytes from her ileostomy was successfully liberated from dependency on total parenteral nutrition and intravenous fluid and electrolyte replacement by the use of a rice-based oral rehydration therapy (ORT). This allowed her to return home to the care of her mother. We suggest that ORT can be effective in the context of modern high-technology settings, as well as in resource-poor situations.

Oral antibiotics attenuate bowel segment reversal-induced systemic inflammatory response and body weight loss in massively bowel-resected rats

BACKGROUND

Using a massively bowel-resected rat model, our previous study demonstrated that small bowel segment reversal stimulates jejunal hyperplasia but may also increase the possibility of bacterial translocation and the elevation of circulating white blood cells and serum interleukin-6 that may reduce the whole-body anabolism. The aim of this study is to investigate whether oral antibiotics might attenuate the inflammatory responses and might therefore facilitate the beneficial effects of bowel segment reversal.

METHODS

Male Wistar rats (approximately 270 g) underwent a 70% small bowel resection with (REV group) or without (CON group) a 3-cm small bowel segment reversal, or underwent a sham operation (SHAM group). After surgeries, half of the animals in the REV group were given oral clindamycin plus amoxicillin (50 plus 50 mg/kg/d, ANT group) for 3 weeks.

RESULTS

Oral antibiotics administration significantly attenuated the decreases in feeding efficiency (g of body weight/100 kcal diet) and increases in the circulation of white blood cells, serum nitric oxide, and interleukin-6 (1-way ANOVA, p < .05), which are associated with bowel segment reversal. In addition, antibiotics significantly increased serum concentrations of insulin-like growth factor-I, significantly decreased the total numbers of bacteria in the intestine, and tended to reduce the extent of jejunal hyperplasia in rats with bowel segment reversal.

CONCLUSIONS

Our results suggest that oral antibiotics may be used as an adjuvant to attenuate the inflammatory responses and to enhance the anabolic responses in massively bowel-resected patients with bowel segment reversal.

Use of percutaneous endoscopic gastrostomy or percutaneous endoscopic jejunostomy in short bowel syndrome

Patients who have short bowel syndrome (SBS) and concomitant intestinal failure have insufficient functional capacity to absorb sufficient nutrients, electrolytes, and/or fluid to sustain independent life. As such, these patients require specialized nutritional support. Although parenteral nutrition is often necessary, at least initially, the therapeutic goal should be to enhance intestinal adaption and enteral nutrient assimilation, and thereby reduce parenteral nutrition requirements. The induction of hyperphagia is critical. Enteral intake also can be enhanced through enteric tube feeding. There are, however, insufficient data to recommend the universal use of a peptide-based formula (versus a polymeric formula), although the use of such a formula may be considered in individual patients in whom the clinician has compared nutritional outcome with the two types of formulas.