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Hibi T. Nontransplant options for portomesenteric thrombosis. Curr Opin Organ Transplant 2022; 27:144-147. [PMID: 35143434 DOI: 10.1097/mot.0000000000000964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Portomesenteric thrombosis (PMT) is a serious condition encountered mainly in cirrhotic patients awaiting liver transplantation. More recently, this potentially fatal complication has been described after bariatric surgery and inflammatory bowel disease. Several consensus guidelines have been published over the past few years and this mini review was conducted to discuss updated nontransplant treatment options based on currently available evidence. RECENT FINDINGS Anticoagulation is the mainstay of treatment for PMT involving <50% of the main portal vein. Transjugular intrahepatic portosystemic shunt are usually preserved for patients with more extensive disease or those with clinically significant portal hypertension that are treatment refractory. SUMMARY The extent of PMT, response to therapy, and complications related with PMT are the determinants of therapy.
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Affiliation(s)
- Taizo Hibi
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
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Dumronggittigule W, Marcus EA, DuBray BJ, Venick RS, Dutson E, Farmer DG. Intestinal failure after bariatric surgery: Treatment and outcome at a single-intestinal rehabilitation and transplant center. Surg Obes Relat Dis 2019; 15:98-108. [PMID: 30658947 DOI: 10.1016/j.soard.2018.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/15/2018] [Accepted: 10/18/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Though intestinal failure (IF) after bariatric surgery (BS) is uncommon, its prevalence is increasing. However, data on the outcomes for these patients are limited. OBJECTIVES To analyze the outcomes of treatment for patients with IF after BS. SETTING University hospital. METHODS A single-center analysis (1991-2016) of outcomes according to treatment arms established by a multidisciplinary team. RESULTS Twenty-five IF patients were identified (median age 45 yr). BS was 92% Roux-en-Y gastric bypass. The major cause of IF was volvulus/internal hernia (72%). Median time from BS to IF was 48 months. Treatment arms were intestinal rehabilitation (IR, n = 15), transplantation (TXP, n = 5), and parenteral nutrition (PN, n = 5). For IR, median bowel length was 60 cm. Forty-six percent ultimately discontinued PN. Twenty-seven percent were partially weaned PN and 27% failed IR. Common surgical rehabilitation was Roux-en-Y gastric bypass reversal and restoration of gastrointestinal continuity. The 5-year overall survival was 74%. For TXP, 7 patients were listed for TXP (5 initially and 2 after failed IR). Three underwent TXP, 2 isolated intestine and 1 isolated liver. Three were delisted (1 improvement and 2 death). For PN, 6 patients required long-term PN (5 initially and 1 after failed IR). Four patients are alive currently. CONCLUSIONS IF after BS is an increasing problem facing IR centers. Internal hernia is the major cause. Surgical IR is the first-line therapy and affords the best outcome. TXP is reserved for rescuing patients who failed IR or develop PN complications. Long-term PN is suitable for patients in whom IR or TXP is impractical.
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Affiliation(s)
- Wethit Dumronggittigule
- The Dumont UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, California; Hepato-Pancreato-Biliary and Transplant Surgery Unit, Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Nakhon Pathom, Thailand
| | - Elizabeth A Marcus
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Mattel Children's Hospital, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Bernard J DuBray
- The Dumont UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, California
| | - Robert S Venick
- Hepato-Pancreato-Biliary and Transplant Surgery Unit, Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Nakhon Pathom, Thailand
| | - Erik Dutson
- Division of General Surgery, Department of Surgery, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, California
| | - Douglas G Farmer
- The Dumont UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, California.
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Home parenteral nutrition (HPN) in patients with post-bariatric surgery complications. Clin Nutr 2017; 36:1345-1348. [DOI: 10.1016/j.clnu.2016.08.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 08/25/2016] [Accepted: 08/31/2016] [Indexed: 01/14/2023]
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Mundi MS, Vallumsetla N, Davidson JB, McMahon MT, Bonnes SL, Hurt RT. Use of Home Parenteral Nutrition in Post-Bariatric Surgery-Related Malnutrition. JPEN J Parenter Enteral Nutr 2016; 41:1119-1124. [PMID: 27208038 DOI: 10.1177/0148607116649222] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Bariatric surgery is one of the most effective techniques for achieving sustained weight loss but can be associated with surgical complications or malabsorption so significant that it leads to malnutrition. Parenteral nutrition (PN) may be necessary to help treat surgical complications or malnutrition from these procedures. There are limited data describing this patient population and role for home PN (HPN). METHODS A retrospective review of our HPN database was conducted to identify patients who were initiated on HPN between January 1, 2003, and August 31, 2015, and had a history of bariatric surgery. RESULTS A total of 54 HPN patients (6.3%) had a history of bariatric surgery. Average age was 52.1 ± 12.8 years, and 80% were female. The most common surgical procedure was Roux-en-Y gastric bypass (72%), with malnutrition or failure to thrive being the most common HPN indication (57%). Weight at the time of HPN initiation was 71.9 ± 20.4 kg and significantly increased to 78.9 ± 24.4 kg by the end of treatment ( P = .0001). Serum albumin levels rose from 2.8 ± 0.77 g/dL to 3.7 ± 0.58 g/dL by the end of HPN ( P < .0001). Forty-five of 54 patients (83.3%) went on to revision surgery. CONCLUSION The results of this retrospective review support initiation of HPN in the malnourished post-bariatric surgery patient both nutritionally and as a bridge to revision surgery.
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Affiliation(s)
- Manpreet S Mundi
- 1 Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Nishanth Vallumsetla
- 1 Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Jacob B Davidson
- 2 Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Megan T McMahon
- 2 Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara L Bonnes
- 2 Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan T Hurt
- 1 Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA.,2 Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.,3 Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.,4 Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Kentucky, USA
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Allan PJ, Stevens P, Abraham A, Paine P, Farrer K, Teubner A, Carlson G, Lal S. Outcome of intestinal failure after bariatric surgery: experience from a national UK referral centre. Eur J Clin Nutr 2016; 70:772-8. [DOI: 10.1038/ejcn.2016.37] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 10/08/2015] [Accepted: 10/17/2015] [Indexed: 12/27/2022]
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Extracorporeal Hypothermic Perfusion Device for Intestinal Graft Preservation to Decrease Ischemic Injury During Transportation. J Gastrointest Surg 2016; 20:313-21. [PMID: 26487331 DOI: 10.1007/s11605-015-2986-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 10/10/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The small intestine is one of the most ischemia-sensitive organs used in transplantation. To better preserve the intestinal graft viability and decrease ischemia-reperfusion injury, a device for extracorporeal perfusion was developed. We present the results for the first series of perfused human intestine with an intestinal perfusion unit (IPU). METHODS Five human intestines were procured for the protocol. (1) An experimental segment was perfused by the IPU delivering cold preservation solution to the vascular and luminal side continually at 4 ºC for 8 h. (2) Control (jejunum and ileum) segments were preserved in static cold preservation. Tissue samples were obtained for histopathologic grading according to the Park/Chiu scoring system (0 = normal, 8 = transmural infarction). RESULTS Jejunal experimental segments scored 2.2 with the Park/Chiu system compared to the control segments, which averaged 3.2. Overall scoring for ileum experimental and control segments was equal with 1.6. CONCLUSION This data presents proof of concept that extracorporeal intestinal perfusion is feasible. The evidence shows that the IPU can preserve the viability of human intestine, and histopathologic evaluation of perfused intestine is favorable. Our early results can eventually lead to expanding the possibilities of intestinal preservation.
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Autologous Reconstruction and Visceral Transplantation for Management of Patients With Gut Failure After Bariatric Surgery. Ann Surg 2015; 262:586-601. [DOI: 10.1097/sla.0000000000001440] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Veeramootoo D, Wan A, Vasilikostas G. An innovative endoluminal rendezvous technique to restore gastrogastric continuity following extensive gastrointestinal loss from internal herniation after gastric bypass. Surg Obes Relat Dis 2015; 11:e47-50. [PMID: 25733003 DOI: 10.1016/j.soard.2015.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 01/16/2015] [Accepted: 01/16/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Darmarajah Veeramootoo
- Department of Upper Gastrointestinal and Bariatric Surgery, Regional Bariatric Centre, St George's Healthcare NHS Trust, London, United Kingdom.
| | - Andrew Wan
- Department of Upper Gastrointestinal and Bariatric Surgery, Regional Bariatric Centre, St George's Healthcare NHS Trust, London, United Kingdom
| | - Georgios Vasilikostas
- Department of Upper Gastrointestinal and Bariatric Surgery, Regional Bariatric Centre, St George's Healthcare NHS Trust, London, United Kingdom
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Isom KA, Andromalos L, Ariagno M, Hartman K, Mogensen KM, Stephanides K, Shikora S. Nutrition and metabolic support recommendations for the bariatric patient. Nutr Clin Pract 2014; 29:718-39. [PMID: 25288251 DOI: 10.1177/0884533614552850] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Managing the metabolic needs of the patient with obesity is a challenge unto itself without the added demands of accounting for an altered gastrointestinal tract. Nevertheless, with about 200,000 bariatric procedures being performed annually in the United States, clinicians must be prepared to manage the critically ill bariatric surgery patient. This article reviews the recent literature relating to nutrient needs and metabolic support for the bariatric patient. Bariatric patients are at risk for several micronutrient deficiencies, including vitamins D and B₁₂, calcium, and iron; some bariatric procedures affect macronutrient needs as well. Literature on nutrition support guidelines for the bariatric population is limited. However, with an understanding of the anatomical and physiological effects of bariatric surgery, recent guidelines for critically ill patients with obesity can be applied to the bariatric surgery population. The unique needs of the bariatric population, such as susceptibility to micronutrient deficiencies and specialized access routes, must be considered to provide safe and efficacious nutrition support. Further research is necessary to develop specific nutrition support recommendations for the bariatric population.
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Affiliation(s)
- Kellene A Isom
- Brigham and Women's Hospital Center for Metabolic and Bariatric Surgery Boston, Massachusetts
| | - Laura Andromalos
- Brigham and Women's Hospital Center for Metabolic and Bariatric Surgery Boston, Massachusetts
| | - Meghan Ariagno
- Brigham and Women's Hospital Center for Metabolic and Bariatric Surgery Boston, Massachusetts
| | - Katy Hartman
- Brigham and Women's Hospital Center for Metabolic and Bariatric Surgery Boston, Massachusetts
| | - Kris M Mogensen
- Brigham and Women's Hospital Department of Nutrition, Boston, Massachusetts
| | - Katrina Stephanides
- Brigham and Women's Hospital Center for Metabolic and Bariatric Surgery Boston, Massachusetts
| | - Scott Shikora
- Brigham and Women's Hospital Center for Metabolic and Bariatric Surgery Boston, Massachusetts
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