Improved outcome of referrals for intestinal transplantation in the UK

Nutrition and Intestinal Rehabilitation of Children With Short Bowel Syndrome: A Position Paper of the ESPGHAN Committee on Nutrition. Part 1: From Intestinal Resection to Home Discharge

Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The mainstay of treatment for IF is parenteral nutrition (PN). The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their experience. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. The first part of this position paper focuses on the physiological mechanism of intestinal adaptation after surgical resection. It subsequently provides some clinical practice recommendations for the primary management of children with SBS from surgical resection until discharged home on PN.

Nutrition and Intestinal Rehabilitation of Children With Short Bowel Syndrome: A Position Paper of the ESPGHAN Committee on Nutrition. Part 2: Long-Term Follow-Up on Home Parenteral Nutrition

Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The preferred treatment for IF is parenteral nutrition which may be required until adulthood. The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their expertise. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. This second part of the position paper is dedicated to the long-term management of children with SBS-IF. The paper mainly focuses on how to achieve intestinal rehabilitation, treatment of complications, and on possible surgical and medical management to increase intestinal absorption.

Bridging Liver Transplantation in the Treatment of Intestinal Failure Associated Liver Disease in Infants-A Bridge Too Far?

Infants with intestinal failure associated liver disease (IFALD) requiring liver and bowel transplant have a high mortality on the transplant waiting list due to the scarcity of the size-matched donor organs. Bridging liver transplantation has been used to allow the children to grow to a reasonable size so that a combined liver and small bowel transplant could be performed in the future. We report on two children with irreversible intestinal failure (ultra-short bowel syndrome secondary to gastroschisis and microvillous inclusion disease) with IFALD who underwent bridging liver transplantation at our institution. Both patients made a good recovery from their initial surgery. One patient died 6 months following surgery from generalized sepsis, and the other patient survived in good condition to undergo a combined liver and small bowel transplant but died a few days post-transplant. In the current era of scarcity of donor organs, this raises an ethical dilemma for the team involved regarding appropriate utilisation of a scarce resource.

Gastroesophageal Reflux Disease and Foregut Dysmotility in Children with Intestinal Failure

Gastrointestinal dysmotility is a common problem in a subgroup of children with intestinal failure (IF), including short bowel syndrome (SBS) and pediatric intestinal pseudo-obstruction (PIPO). It contributes significantly to the increased morbidity and decreased quality of life in this patient population. Impaired gastrointestinal (GI) motility in IF arises from either loss of GI function due to the primary disorder (e.g., neuropathic or myopathic disorder in the PIPO syndrome) and/or a critical reduction in gut mass. Abnormalities of the anatomy, enteric hormone secretion and neural supply in IF can result in rapid transit, ineffective antegrade peristalsis, delayed gastric emptying or gastroesophageal reflux. Understanding the underlying pathophysiologic mechanism(s) of the enteric dysmotility in IF helps us to plan an appropriate diagnostic workup and apply individually tailored nutritional and pharmacological management, which might ultimately lead to an overall improvement in the quality of life and increase in enteral tolerance. In this review, we have focused on the pathogenesis of GI dysmotility in children with IF, as well as the management and treatment options.

Paediatric parenteral nutrition: current issues

Parenteral nutrition transformed the prognosis for infants and children with intestinal failure. Soon after its introduction into clinical care 50 years ago, parenteral nutrition was also rapidly adopted for use in the preterm infant, where immaturity of gastrointestinal motor function precluded enteral feeding. Preterm infants subsequently became the single largest group of patients to be fed in this way. Although the development of scientific knowledge and the lessons of clinical experience have reduced the risk of complications, some of the problems and difficulties associated with this form of nutritional support remain challenging. These include central venous catheter-related sepsis, thrombosis, liver disease, bone disease and metabolic disturbance. In an initiative to promote best practice, guidelines on parenteral nutrition were first published by the European Society for Paediatric Gastroenterology, Hepatology and Nutrition and collaborating organisations in 2005. These were constructed following a thorough review of the scientific literature, allowing a series of evidence-based recommendations to be made. The exercise was repeated just over 10 years later and updated guidelines published in 2018. This review summarises key elements from the new guideline, with a focus on what has changed since 2005.

Nutritional support in the recovery phase of critically ill children

PURPOSE OF REVIEW

The metabolic stress response of a critically ill child evolves over time and thus it seems reasonable that nutritional requirements change during their course of illness as well. This review proposes strategies and considerations for nutritional support during the recovery phase to gain optimal (catch-up) growth with preservation of lean body mass.

RECENT FINDINGS

Critical illness impairs nutritional status, muscle mass and function, and neurocognition, but early and high intakes of artificial nutrition during the acute phase cannot resolve this. Although (parenteral) nutrient restriction during the acute phase appears to be beneficial, persistent nutrient restriction, when the metabolic stress response resolves, has short-term and long-term detrimental consequences. Requirements increase markedly during the recovery phase to enable recovery and catch-up growth. Such large amounts of intake demand for alternate approach, especially when intestinal problems constitute a barrier for full enteral feeding. As part of the nutritional recovery, mobilization and exercise are essential to achieve catch-up growth with an optimal body composition.

SUMMARY

During the recovery phase of paediatric critical illness (catch-up) growth and muscle recovery require nutritional intakes at least two times the resting energy expenditure.

Etiology and prognosis of pediatric short bowel syndrome

Pediatric intestinal failure is a complex and devastating condition defined as the inability of the intestine to absorb an adequate amount of fluid and nutrients to sustain life. The primary goal of intestinal failure treatment is to achieve enteral autonomy with a customized treatment plan. Although recent improvements in intestinal failure patient care have led to significant improvements in the morbidity and mortality rate, children with intestinal failure are at risk for multiple complications such as intestinal failure associated liver disease, recurrent septic episodes, central line complications, metabolic bone disease, impaired kidney function, and failure to thrive. In this article, we review the current literature on the etiology and factors affecting prognosis of pediatric IF.

Hybrid interventions for catheter placement in pediatric intestinal rehabilitation patients with end-stage venous access

PURPOSE

The purpose of this study is to analyze the combined approach of endovascular and open surgical procedures for insertion of permanent central venous catheters in children with intestinal failure and end-stage venous access.

METHODS

Data of 14 children (16 interventions) with intestinal failure and end-stage venous access, treated within the pediatric intestinal rehabilitation program at our institution between September 2011 and November 2016, were retrospectively reviewed. The patients underwent hybrid endovascular/open surgical approaches for insertion of central venous catheters. Access to central veins was established through endovascular intervention; catheter placement was achieved with combined interventional and surgical measures depending on the individual vascular conditions.

RESULTS

Median age at intervention was 47months (interquartile range (IQR),29-74), median time for interventions was 66min (IQR,42-111). Catheter placement was successfully achieved in all patients. The median dose of irradiation during angiography was 0.2Gy*cm² (IQR, 0.2-0.6), no complications occurred during or after interventions.

CONCLUSIONS

Hybrid endovascular/open surgical procedures can be successfully applied for restoring or maintaining permanent central venous catheters in children with intestinal failure and end-stage venous access. These approaches are a valuable contribution in intestinal rehabilitation programs contributing to a further decrease of the need for intestinal transplantation in affected patients.

TYPE OF STUDY

Treatment Study.

LEVEL OF EVIDENCE

Level IV.

A meta-analysis of clinical outcome of intestinal transplantation in patients with total intestinal aganglionosis

AIM OF THE STUDY

Total intestinal aganglionosis (TIA) occurs in less than 1% of patients with Hirschsprung disease (HD), and TIA is the most severe form of HD. Survival has improved with the advent of parenteral nutrition and intestinal transplantation (ITx). The field of ITx has rapidly progressed in the last two decades and has now become an established treatment for patients with intestinal failure. The purpose of this meta-analysis was to determine the clinical outcome of ITx in patients with TIA.

METHODS

A systematic literature search for relevant articles was performed in four databases using the combinations of the following terms: "total intestinal aganglionosis", "intestinal transplantation", and "Hirschsprung disease/Hirschsprung's disease" for studies published between 2003 and 2016. The relevant cohorts of ITx in patients with TIA were systematically searched for clinical outcomes.

MAIN RESULTS

Thirteen studies met defined inclusion criteria, reporting a total of 63 patients who underwent ITx for TIA. Majority of patients were males (71.0%), and median age of ITx was 4.3 (range 0.25-17.6) years. Isolated ITx was performed in 37% patients and multivisceral ITx in 63%. Mean follow-up period was 40 months (range 1-154). Overall survival rate was 66%; the longest survivor was 12.8-year-old after ITx.

CONCLUSION

ITx appears promising in the management of TIA. ITx can be considered a feasible treatment option for patients with TIA who suffer from life-threatening complications of intestinal failure.

Impact of multidisciplinary teams for management of intestinal failure in children

PURPOSE OF REVIEW

To review the recent literature related to the impact of an intestinal rehabilitation program (IRP) on the management of intestinal failure in children.

RECENT FINDINGS

As publication of a systematic review of pediatric IRPs in 2013, there have been four publications further describing the impact of IRPs in children with intestinal failure. The results continue to support an improvement in survival and enteral autonomy, and a decrease in complications related to liver dysfunction, central venous catheters, and transplantation.

SUMMARY

Pediatric IRPs offer significant advantage to outcomes of children with intestinal failure. The literature is difficult to interpret because of methodological limitations. IRP collaboration is necessary to further advance the field.

Intestinal Failure: Adaptation, Rehabilitation, and Transplantation

Intestinal failure (IF) is a state in which the nutritional demands are not met by the gastrointestinal absorptive surface. A majority of IF cases are associated with short-bowel syndrome, which is a result of malabsorption after significant intestinal resection for numerous reasons, some of which include Crohn's disease, vascular thrombosis, and radiation enteritis. IF can also be caused by obstruction, dysmotility, and congenital defects. Recognition and management of IF can be challenging, given the complex nature of this condition. This review discusses the management of IF with a focus on intestinal rehabilitation, parenteral nutrition, and transplantation.

Weaning Off Prognosis Factors of Home Parenteral Nutrition for Children With Primary Digestive Disease

OBJECTIVES

The aim of the present study was to describe the indications for home parenteral nutrition (HPN) in children with primary digestive diseases and to identify factors associated with weaning off.

METHODS

All the children initially discharged on HPN between January 1, 2000, and December 31, 2009, for chronic intestinal failure (IF) were included. The associations between clinical factors and weaning off of HPN were assessed using a multivariable Cox regression model.

RESULTS

Among the 151 children (boys = 58%) included in this study, 98 (65%) presented with short bowel syndrome (SBS), 17 (11%) with digestive neuromuscular disorders, 14 (9%) with mucosal diseases, 13 (9%) with inflammatory bowel disease, and 9 (6%) with other primary digestive diseases. The probability of survival was ∼100%. At the end of the follow-up, the probability for weaning off of HPN was 0.73 (95% confidence interval 0.54-0.84) but varied according to the underlying cause of IF (for example, SBS and inflammatory bowel disease had a better prognosis). The median time until weaning off was 21 months (95% confidence interval 18-38 months). Unfavourable prognostic factors for weaning off of HPN included a bowel remnant of <40 cm, the presence of <50% of the colon, and daily lipid intakes >1.5 g · kg · day. Underlying disease was also associated with weaning off.

CONCLUSIONS

HPN is a safe therapeutic option for children with chronic IF requiring long-term nutritional management. Prognostic factors for weaning off of HPN were identified, and they highlight the relevance of SBS anatomy and parenteral nutrition caloric intake. The outcome of children on HPN was primarily dependent on the underlying disease.

Intestinal failure-associated liver disease: a position paper of the ESPGHAN Working Group of Intestinal Failure and Intestinal Transplantation

Intestinal failure-associated liver disease is the most prevalent complication affecting children with intestinal failure receiving long-term parenteral nutrition. This paper reviews the definition, diagnostic criteria, pathogenesis, and risk factors. The authors discuss the role of enteral nutrition, parenteral nutrition, and its components, especially lipid emulsions. The authors also discuss the surgical treatment, including intestinal transplantation, its indications, technique, and results, and emphasise the importance of specialised intestinal failure centres.

Assessment and outcome of children with intestinal failure referred for intestinal transplantation

BACKGROUND & AIMS

Chronic intestinal failure (CIF) requires long term parenteral nutrition (PN) and, in some patients, intestinal transplantation (ITx). Indications and timing for ITx remain poorly defined. In the present study we aimed to analyze causes and outcome of children with CIF.

METHODS

118 consecutive patients referred to our institution were assessed by a multidisciplinary team and four different categories were defined retrospectively based on their clinical course: Group 1: patients with reversible intestinal failure; group 2: patients unsuitable for ITx, group 3: patients listed for ITx; group 4: patients stable under PN. Analysis involved comparison between groups for nutritional status, central venous catheter (CVC) related complications, liver disease, and outcome after transplantation by using non parametric tests, Mann-Whitney tests, Kruskal-Wallis, Wilcoxon signed rank tests and chi square distribution for percentage.

RESULTS

118 children (72 boys) with a median age of 15 months at referral (2 months-16 years) were assessed. Etiology of IF was short bowel syndrome [n = 47], intractable diarrhea of infancy [n = 37], total intestinal aganglionosis [n = 18], and chronic intestinal pseudoobstruction [n = 17]. Most patients (89.8%) were totally PN dependent, with 48 children (40.7%) on home-PN prior to admission. Nutritional status was poor with a median body weight at -1.5 z-score (ranges: -5 to +2.5) and median length at -2.0 z-score (ranges: -5.5 to +2.3). The mean number of CVC inserted per patient was 5.2 (range 1-20) and the mean number of CRS per patient was 5.5 (median: 5; range 0-12) Fifty-five patients (46.6%) had thrombosis of ≥2 main venous axis. At admission 34.7% of patients had elevated bilirubin (≥50 μmol/l), and 19.5% had platelets <100,000/ml, and 15% had both. Liver biopsy performed in 79 children was normal (n = 4), or showed F1 or F2 fibrosis (n = 29), bridging fibrosis F3 (n = 20), or cirrhosis (n = 26). Group 1 included 10 children finally weaned from PN (7-years survival: 100%). Group 2 included 12 children with severe liver disease and associated disorders unsuitable for transplantation (7-years survival: 16.6%). Group 3 included 66 patients (56%) who were listed for small bowel or liver-small bowel transplantation, 62/66 have been transplanted (7 years survival: 74.6%). Factors influencing outcome after liver-ITx were body weight (p < .004), length (p < .001), pre-Tx bilirubin plasma level (p < .001) and thrombosis (p < .01) for isolated ITx, Group 4 included 30 children (25.4%) with irreversible IF considered as potential candidates for isolated ITx. Four children were lost from follow up and 3 died within 2 years (survival 88.5%). Among potential candidates, the following parameters improved significantly during the first 12 months of follow up: Body weight (p.0001), length (p < .0001) and bilirubin (p < .0001).

CONCLUSIONS

many patients had a poor nutritional status with severe complications especially liver disease. PN related complications were the most relevant indication for ITx, but also a negative predictor for outcome. Early patient referral for Tx-assessment might help to identify and separate children with irreversible IF from children with transient IF or uncomplicated long-term PN, allowing to adapt a patient-based treatment strategy including or not ITx.

Use of tissue expansion to facilitate liver and small bowel transplant in young children with contracted abdominal cavities

Liver and small bowel transplant is an established treatment for infants with IFALD. Despite organ reduction techniques, mortality on the waiting list remains high due to shortage of size-matched pediatric donors. Small abdominal cavity volume due to previous intestinal resection poses a significant challenge to achieve abdominal closure post-transplant. Seven children underwent tissue expansion of abdominal skin prior to multiorgan transplant. In total, 17 tissue expanders were placed subcutaneously in seven children. All seven subjects underwent re-exploration to deal with complications: hematoma, extrusion, infection, or port related. Three expanders had to be removed. Four children went on to have successful combined liver and small bowel transplant. Two children died on the waiting list of causes not related to the expander and one child died from sepsis attributed to an infected expander. Tissue expansion can generate skin to facilitate closure of abdomen post-transplant, thus allowing infants with small abdominal volumes to be considered for transplant surgery. Tissue expansion in children with end-stage liver disease and portal hypertension is associated with a very high complication rate and needs to be closely monitored during the expansion process.

Survival of patients evaluated for intestinal and multivisceral transplantation - the Scandinavian experience

OBJECTIVE

The current treatment of choice for patients with intestinal failure is parenteral nutrition, whereas medical therapy or resection is preferred for patients with neuroendocrine pancreatic tumors (NEPT) along with liver metastasis. As the survival of patients undergoing intestinal and multivisceral transplantation is improving, the discussion for expansion of treatment options has become a subject of debate. The aim was to investigate the outcome for patients referred for intestinal and multivisceral transplantation and to determine which patient group are the ones most likely to benefit the most from transplantation.

METHODS

The authors included all patients evaluated for intestinal and multivisceral transplantation at the Sahlgrenska University Hospital and The Queen Silvia Children's Hospital center between February 1998 and November 2009. Patients were classified according to proposed treatment strategy, and the outcome was evaluated.

RESULTS

A total of 43 adults and 19 children with either intestinal failure or NEPT with liver metastases were evaluated for transplantation. Of these patients, 15 adults and 5 children were transplanted. Transplantation was lifesaving for most children - all the children survived after transplantation, but 70% (4/6) died while awaiting transplantation. Among the adult patients with intestinal failure, the survival rate for patients considered to be stable on parenteral nutrition was higher than the transplanted adult patients. The survival rate of patients with NEPT was similar to the results seen among patients transplanted for intestinal failure.

CONCLUSION

The results confirm the poor prognosis of patients with intestinal failure awaiting transplantation and indicate that different transplantation criteria may be applied for adults and children, especially when early transplantation is the preferred treatment. The role of multivisceral transplantation in patients with NEPT remains uncertain.

The impact of multi-disciplinary intestinal rehabilitation programs on the outcome of pediatric patients with intestinal failure: a systematic review and meta-analysis

BACKGROUND

Pediatric intestinal failure (IF) is a complex clinical problem requiring coordinated multi-disciplinary care. Our objective was to review the evidence for the benefit of intestinal rehabilitation programs (IRP) in pediatric IF patients.

METHODS

A systematic review was performed on Medline (1950-2012), Pubmed (1966-2012), and Embase (1980-2012) conference proceedings and trial registries. The terms short bowel syndrome, intestinal rehabilitation, intestinal failure, patient care teams, and multi-disciplinary teams were used. Fifteen independent studies were included. Three studies that were cohort studies, including a comparison group, were included in a meta-analysis.

RESULTS

Compared to historical controls (n=103), implementation of an IRP (n=130) resulted in a reduction in septic episodes (0.3 vs. 0.5 event/month; p=0.01) and an increase in overall patient survival (22% to 42%). Non-significant improvements were seen in weaning from PN (RR=1.05, 0.88-1.25, p=0.62), incidence of IFALD (RR=0.2, 0-17.25, p=0.48), and relative risk of liver transplantation (3.99, 0.75-21.3, p=0.11). Other outcomes reported included a reduction in calories from parenteral nutrition (100% to 32%-56%), earlier surgical/transplant evaluation, and improved coordination of patient care.

CONCLUSION

For pediatric IF patients, IRPs are associated with reduced morbidity and mortality. Standardized clinical practice guidelines are necessary to provide uniform patient care and outcome assessment.

Waitlist characteristics of patients at a single-center intestinal and multivisceral transplant program

Intestinal transplantation (ITX) can be a successful treatment for patients with irreversible intestinal failure and associated severe complications. Because of long waiting periods and organ shortages, the precise identification of eligible patients and their early referral to centers that perform ITX is important. We retrospectively analyzed all patients who were referred to our center between 2000 and 2011 concerning their referral criteria, waitlist characteristics, and outcome. A total of 87 patients (47 male patients, 40 female patients; median age 39.8 ± 13.4 years) were referred to our center. All patients presented with intestinal failure caused by short bowel syndrome or motility disorders. About 80.5% of patients were evaluated for isolated ITX, modified multivisceral (mMVTX), or multivisceral transplantation (MVTX). About 56.3% were listed at EUROTRANSPLANT, 33.3% suffered from severe secondary organ failure requiring MVTX, and 34.5% were transplanted. 14.3% (all MVTX-candidates) died on the waitlist as a result of infectious complications. The high proportion of MVTX candidates underlines the need for early referral to specialized centers. MVTX-candidates have a high waitlist mortality for different reasons. However, the current allocation policy for MVTX does not mirror the severity of disease and may therefore contribute to high waitlist mortality.

Outcome on home parenteral nutrition for benign intestinal failure: a review of the literature and benchmarking with the European prospective survey of ESPEN

BACKGROUND & AIMS

Indications and timing for referral for intestinal transplantation (ITx) were investigated through a review of the literature on home parenteral nutrition (HPN) for benign intestinal failure and a benchmarking to the results of a prospective European survey which evaluated the appropriateness of the current indications for ITx.

METHODS

Manuscripts reporting outcomes of adults and children on HPN were retrieved through a PubMed search. Data from the European survey were compared with those on HPN reported in the literature, and with those on ITx reported by the USA registry and by the Pittsburgh center.

RESULTS

HPN is a safe treatment with a high probability of survival. The risk of death during HPN is increased by the absence of a specialist team, and appears greater during the early period of treatment. Survival probability is decreased in patients with: age >40 or <2 years, very short bowel remnant, presence of a stoma, chronic intestinal pseudo-obstruction of myopathic origin, systemic sclerosis, radiation enteritis, intra-abdominal desmoids, necrotizing enterocolitis, congenital mucosal diseases. Liver failure is the HPN-related complication with the greatest risk of death. Death related to venous catheter complications is rare. The benchmarking supported the results of the European survey.

Systematic review: medical and nutritional interventions for the management of intestinal failure and its resultant complications in children

BACKGROUND

Intestinal failure (IF) affects a growing number of children due to increasing numbers of preterm infants surviving intestinal resection for necrotising enterocolitis and improving surgical techniques for congenital gut anomalies. Parenteral nutrition (PN) is the mainstay of therapy; enteral nutrition may have trophic effects on the gut.

AIM

To review systematically evidence for the effectiveness of medical and nutritional interventions in the treatment of IF in children.

METHODS

Retrieval of data from studies of patients aged <18 years and receiving >28 days of PN. Outcome measures were improvement in intestinal function, intestinal adaptation, growth, prevention and treatment of IF-associated liver disease, and mortality. Cochrane Database (November 2009), MEDLINE (1950-November 2009) and CINAHL (1982-November 2009) electronic database searches were made using keyword and subject headings (MeSH): IF, Short Bowel Syndrome (SBS), PN and Child. The level of the evidence (EL) was assessed using SIGN (Scottish Intercollegiate Guidelines Network) methodology (http://www.sign.ac.uk).

RESULTS

From 1 607 620 hits, 720 abstracts were reviewed. Thirty-three original articles were included. No studies were of high methodological quality.

CONCLUSIONS

The evidence base for medical and nutritional interventions in paediatric IF is limited and of poor quality. In the absence of randomised-controlled trials, this evidence base can improve through case control and cohort research; and with better multiagency communication, the study of inter-centre differences is possible. Achievable short-term goals would include the study of: optimal ursodeoxycholic usage, novel intralipid formulations, cycled enteral antibiotics, enteral probiotics and new enteral feeding strategies.

Preventing parenteral nutrition liver disease

Parenteral nutrition liver disease (PNLD) develops in 40-60% of infants who require long-term PN for intestinal failure. The clinical spectrum includes hepatic steatosis, cholestasis, cholelithiasis, and hepatic fibrosis. Progression to biliary cirrhosis and the development of portal hypertension and liver failure occurs in a minority who require combined liver and intestinal transplantation. The pathogenesis is multifactorial and is related to prematurity, low birth weight, duration of PN, short bowel syndrome requiring multiple laparotomies and recurrent sepsis. Other important mechanisms include lack of enteral feeding which leads to reduced gut hormone secretion, reduction of bile flow and biliary stasis which leads to the development of cholestasis, biliary sludge and gallstones, which exacerbate hepatic dysfunction, especially in premature neonates with immature hepatic function. The use of lipid emulsions, particularly soy bean emulsions have been associated with hepatic cholestasis in children, although there are little data now to support toxicity from other PN components. Management strategies for the prevention of parenteral nutrition liver disease include consideration of early enteral feeding, a multidisciplinary approach to the management of parenteral nutrition with a specialized nutritional care team and aseptic catheter techniques to reduce sepsis. The use of specialized lipid emulsions such as fish oil emulsions and or SMOF (Soy bean/Medium Chain Triglyceride/Olive Oil/Fish oil) improves established cholestasis and may prevent the onset. Oral administration of ursodeoxycholic acid may improve bile flow and reduce gall bladder stasis, although there is little data to suggest that prophylactic use prevents the onset of PNLD. Survival following either isolated small bowel or combined liver and small bowel transplantation is approximately 50% at 5 years making this an acceptable therapeutic option in children with irreversible liver and intestinal failure.

Predicting liver failure in parenteral nutrition-dependent short bowel syndrome of infancy

OBJECTIVES

To test the hypothesis that early trends in common blood tests may delineate risks of liver failure (LF) in infants with parenteral nutrition-associated liver disease (PNALD) from short bowel syndrome and suggest criteria for transplant referral.

STUDY DESIGN

Total levels of bilirubin, gamma-glutamyl transferase, albumin, alanine aminotransferase, platelet count, and absolute neutrophil count were recorded every 3 months for 61 infants with PNALD who were being considered for intestinal transplant starting at age 3 months until death without transplant (n = 12), LF with transplant (n = 35), or liver recovery without transplant (n = 14). Probabilities of LF were determined with logistic regression.

RESULTS

Independent predictors of LF were, in descending order, total bilirubin level (odds ratio [OR] = 1.195), platelet count (OR = 0.992), and albumin level (OR = 0.248). Predicted probabilities of eventual LF varied from 36% to 38% at ages 3 to 6 months when the total bilirubin level was 6.0 mg/dL, platelet count was 220 x 10(3)/microL, and albumin level was 3.5 g/dL to 83% to 84% when the total bilirubin level was 11.7 mg/dL, platelet count was 168 x 10(3)/microL, and albumin level was 3.0 g/dL.

CONCLUSIONS

Transplant referral for a total bilirubin level of 6 mg/dL between 3 to 6 months of age is appropriate, because the probability of LF is at least 36%.

Innovative surgical techniques address the organ donation crisis, ... don't they?

PURPOSE OF REVIEW

Retrospectively analysing the role that innovative technique and strategies have played to face organ shortage during the last decades, and elaborating rationally about their potential contribution to expand organ availability in the coming future.

RECENT FINDINGS

Current organ donation crisis proceeds from both decreasing offers, qualitatively and quantitatively, and steadily increasing demand. Innovative surgical techniques using the existing donor pool have been extensively used for paediatric transplantation, but these techniques both have been insufficiently implemented in overall transplant activity to meet the demand, and are less usable on the emerging potential pool of donors ('extended-criteria' and nonheart-beating donors), as combining both approaches could carry a higher risk of complications.

SUMMARY

The future is emerging through complementary approaches and strategies in which innovative techniques have a role to play to match the existing pool with the paediatric demand, with an increasing attention to donor management and organ care and with development of preprocurement and postprocurement new therapies.

Update on paediatric lung transplantation

Lung transplantation is well-established in the treatment of end-stage lung disease in children. Our understanding of the problems associated with transplantation has increased rapidly over the past 25 years. Recent figures suggest this knowledge is starting to translate into improvements in management and survival. The common indications for lung transplantation in children, the process of assessment and the outcomes and complications of transplantation are reviewed. We discuss briefly some of the ethical issues relevant to lung transplantation and review strategies for the future. This information may help the respiratory paediatrician prepare potential candidates and their families for the process of assessment and help him or her anticipate common problems that may occur.

Intestinal transplantation for motility disorders

Intestinal transplantation (ITx) has now become an accepted form of replacement therapy for intestinal failure (IF) and its complications. Disorders of bowel motility may represent up to 25% of patients on waiting lists for ITx. Some patients with short bowel as a cause for IF may also have dysmotile bowel. Underlying pathology of the intestine is heterogeneous and may be due to abnormalities in the nerve supply, intestinal smooth muscle, or may be regarded as idiopathic (chronic intestinal pseudo-obstruction). Outcome after ITx for dysmotility has previously been guarded, but providing the appropriate graft is used and taking into account the functional motility of residual bowel, it should not be different from other indications. The subject is reviewed emphasizing the potential pitfalls in case selection and management. The results of the ITx unit in Birmingham, UK are briefly reviewed.

A meta-analysis of clinical outcome in patients with total intestinal aganglionosis

Total intestinal aganglionosis (TIA) is the most extreme and rare form of Hirschsprung disease (HD). Until few years ago TIA was considered to be a uniformly fatal condition. Survival has improved in the recent years with the advent of parenteral nutrition, innovative surgical techniques and small bowel transplantation. The purpose of this meta-analysis was to determine the clinical outcome of TIA following various surgical procedures. A meta-analysis of cases of TIA reported in the literature between 1985 and 2009 was performed. Detailed information was recorded regarding the extent of aganglionosis, surgical procedures performed and clinical outcome. In case of survivors, authors of reports were contacted to obtain the up-to-date clinical status of the patient. There were 68 cases of TIA reported worldwide, 40 (58.8%) males and 28 (41.2%) females. 6 (8.8%) patients had extension of aganglionosis up to the stomach, 19 (27.9%) up to the duodenum and 43 (63.2%) patients had aganglionosis up to 20 cm below the duodeno-jejunal flexure. Family history of HD was documented in 10 (14.7%) patients. RET-gene mutation were identified in 10 (71.4%) of the 14 patients investigated of RET germline mutations. Eleven patients (16.2%) died prior to surgical treatment, 25 patients (36.8%) only had jejunostomy, while 20 (29.4%) had Ziegler's myectomy-myotomy. 12 (17.6%) patients received intestinal transplantation (ITx) or combined liver-intestinal transplantation (LITx). Forty-five (66.2%) patients died at ages ranging from 1 day to 8 years. Twenty-three (33.8%) patients were alive; the longest survivor was 10 years old after LITx. Innovative surgical procedures and parenteral nutrition have improved clinical outcome of patients with TIA in recent years. Intestinal transplantation appears promising in the management of TIA.

Isolated liver transplantation for treatment of liver failure secondary to intestinal failure

Intestinal Failure is a permanent loss of digestive and absorptive functions as a consequence of short bowel syndrome and/or other primary intestinal conditions. Patients with intestinal failure (IF) require long term parenteral nutrition to survive. The only alternative to parenteral nutrition is intestinal transplantation which still entails high mortality. Children with intestinal failure on parenteral nutrition may develop liver failure (LF), as a consequence of central line infections and other conditions. In children with both irreversible IF and LF a combined transplantation is generally considered. Despite low survival rate, combined liver/intestine transplantation is associated to better intestinal graft survival and lower incidence and severity of rejection compared to isolated small bowel transplantation. Recently, isolated liver transplantation was proposed in children with IF and LF. This procedure may have a higher survival probability compared to isolated intestinal transplant, it may allow progressive weaning from PN in children in whom the remnant intestine has the potential for adaptation and offer a timely solution in children for whom intestinal graft is not immediately available. This innovative approach may prove a better option compared to combined transplantation in both the short and long term.

Symposium 6: Young people, artificial nutrition and transitional care. Transition in young people on home parenteral nutrition

Pharmacological, surgical and technological advances have resulted in children now surviving through adolescence into adulthood with conditions that were previously unseen by adult services. Arranging transition for young people on home parenteral nutrition (HPN) to the adult sector is one of greatest challenges for health services that care for young people. Transition is not only a key quality issue for health services, but is a multidimensional process covering psychosocial, educational and vocational aspects. Poorly-planned transition may result in difficulties when young people access adult specialist services. As a consequence, there may be increased risk of non-adherence or lack of follow-up, which carries dangers of morbidity and mortality as well as poor social and educational outcomes. Transition does not end at the exit from the paediatric clinic, but continues into the adult sector, which needs to provide developmentally-appropriate clinical care. Recent Department of Health initiatives are aimed at ensuring that young people do not miss out on healthcare during the transfer between paediatric and adult services. Transfer can be a major, often daunting, event for young people. Parents may also fear transfer and need to learn to 'let go' of some control, which may be particularly difficult with a young person on HPN.

Isolated liver transplant in infants with short bowel syndrome: insights into outcomes and prognostic factors

OBJECTIVE

Selected infants with short bowel syndrome (SBS) and progressive intestinal failure associated liver disease (IFALD) may benefit from isolated liver transplantation (iLTx). The aim of the study is to identify risk factors for unfavourable outcome in iLTx.

PATIENTS AND METHODS

A retrospective review of medical records from 1998 to 2005 was undertaken. Risk factors were assessed by comparing long-term survivors with those who died after iLTx.

RESULTS

Fifteen iLTx were performed in 14 infants with IFALD. All were parenteral nutrition (PN) dependent, but had tolerated enterally 54% (38-100) of energy intake before iLTx. Median residual bowel was 60 cm (30-200). Eight out of 14 had intact ileocaecal valve (ICV). Median bilirubin was 298 micromol/L (87-715) and all had portal hypertension. Eight out of 9 survivors were weaned from PN after median 15 months. In 4 out of 9 children, nontransplant surgery after iLTx facilitated intestinal adaptation. Growth velocity had improved at 3 years after iLTx (P=0.001). Five children who died had poor enteral tolerance following iLTx (P<0.002), which correlated with pretransplant dysmotility seen in 4 out of 5 children shown by contrast studies (P=0.02)and increased frequency of line infections before (>6/year P<0.04) and after (P<0.001) iLTx.

CONCLUSIONS

Isolated liver transplantation is a lifesaving option for selected children with SBS and IFALD. Revised criteria are proposed: progressive IFALD; 50 cm functional bowel in absence of ICV or 30 cm with ICV; 50% daily energy intake tolerated enterally for 4 weeks with satisfactory growth; and children with dysmotile bowel should be assessed for combined liver/bowel transplant unless the dysmotility is resolved and associated with minimal line infections.

Current status of small bowel and multivisceral transplantation

Intestinal transplantation has shown exceptional growth over the past 20 years with remarkable progress. As with other solid organ transplants, intestinal transplantation has moved out of the experimental realm to become the stan dard of care for many patients with intestinal failure. Intestinal transplantation may soon be extended routinely to patients who, although not strictly meeting the criteria for intestinal failure, may benefit from intestinal transplantation, such as patients who have nonresectable indolent tumors or diffuse thrombosis of the portomesenteric system. As clinical experience has increased with intestinal transplantation, outcomes have improved. The currently reported 1-year graft and patient survival rate is 80%, which approaches that for other solid abdominal organs. Unfortunately, most of the gains in survival are seen in the first postoperative year, with long-term survival remaining basically unchanged since the early 1990s. With improved outcomes, more centers have entered into the intestinal transplant arena. In the United States alone, 20 centers performed at least one intestinal transplant in 2007. Increase in access to intestinal transplantation and more widespread awareness of this option likely will result in a consistent increase in the number of yearly transplants for the foreseeable future. Immunosuppressive regimens continue to evolve, with induction therapy being the major change in the past 5 years. Although rejection rates in the first year after transplant have been reduced by induction therapy, long-term side effects of heavy immunosuppression continue to weigh negatively on transplant outcomes. The future for immunosuppression lies in two areas: (1) individual monitoring of the immunosuppression level for each individual patient and (2) development of serum and tissue markers for the early identification of rejection. It is likely that a combination of technologies will allow immunosuppression to be tailored to each recipient. Development of these approaches to immunosuppression is necessary to predict graft dysfunction ahead of irreversible graft injury and allows adjustments in immunosuppression before the onset of rejection. Intestinal transplantation continues to be performed only in situations in which all other therapeutic modalities have failed. No randomized trials compare intestinal transplantation to long-term PN to establish guidelines for a timely referral for this treatment option. Late referral remains a crippling problem in the field of intestinal transplantation, with a great number of patients in need of simultaneous liver transplantation at the time of listing for intestinal transplantation. Early referral for isolated intestinal transplant will reduce the need for simultaneous multiorgan transplants and increase the residual organs available for patients in need of (primarily) liver transplantation.

Collaborative strategies to reduce mortality and morbidity in patients with chronic intestinal failure including those who are referred for small bowel transplantation

Intestinal transplant wait-list mortality is higher than for other organ transplants. The objective of this workshop was to identify the main problems contributing to high mortality in adults and children candidates for intestinal transplantation and provide recommendations on how to correct them.

OUTCOME

To facilitate this, 63 relevant articles identified from the medical literature from 1987 to 2007 were reviewed. Consensus was achieved on several important definitions relevant to this review. For children and adults on parenteral nutrition (PN) the main mortality risk factors were identified as were the main risks of mortality for those on the waiting list for intestinal transplants.

RECOMMENDATIONS

(1) Primary care givers managing intestinal failure patients should establish a link with an intestinal failure programs early and collaboration with intestinal failure programs should be initiated for patients whose PN requirements are anticipated to be more than 50% 3 months after initiating PN; (2) intestinal failure programs should include both intestinal rehabilitation and intestinal transplantation or have active collaborative relationships with centers performing intestinal transplantation; (3) National registries for intestinal failure patients should be established and organizations that provide home PN solutions should be expected to participate.

CONCLUSION

There are many unresolved issues in adults and children with PN dependent intestinal failure. To address these, a key recommendation of this group is to establish national intestinal failure databases that can support multicenter studies and lead to the adoption of universally accepted standards of patient care with the goal of improving outcomes in all long-term intestinal failure patients including those requiring intestinal transplantation.

Future horizons in the treatment of enteric neuropathies

Enteric neuropathies comprise a vast and disparate array of congenital and acquired disorders of the enteric nervous system (ENS), reflecting both the complexity of its neuronal composition and the many interactions that modulate its function. Although present therapeutic strategies, largely limited to surgery and the provision of artificial nutrition, have transformed the early survival and life of sufferers, levels of morbidity and mortality remain unacceptably high. This highlights the need to develop new treatments for enteric neuropathies. In the last decade, the tremendous advances in molecular biology and genetics have significantly enhanced our understanding of ENS development and function. Coupled with equivalent progress in the fields of pharmacology and stem-cell biology, this has led to the identification of novel tools and targets for therapy, which either aim to optimise the function of the intrinsic ENS or replace/replenish components of an inadequate or dysfunctional ENS. This article reviews current work on a number of these interventions with a particular focus on the use of ENS stem cells as potential therapeutic tools for enteric neuropathies.