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Pironi L, Cuerda C, Jeppesen PB, Joly F, Jonkers C, Krznarić Ž, Lal S, Lamprecht G, Lichota M, Mundi MS, Schneider SM, Szczepanek K, Van Gossum A, Wanten G, Wheatley C, Weimann A. ESPEN guideline on chronic intestinal failure in adults - Update 2023. Clin Nutr 2023; 42:1940-2021. [PMID: 37639741 DOI: 10.1016/j.clnu.2023.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND & AIMS In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines. METHODS The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly. RESULTS The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%). CONCLUSIONS It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.
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Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Center for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy.
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Francisca Joly
- Center for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Cora Jonkers
- Nutrition Support Team, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Željko Krznarić
- Center of Clinical Nutrition, Department of Medicine, University Hospital Center, Zagreb, Croatia
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, United Kingdom
| | | | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), United Kingdom
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany
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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.
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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
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Schmidt LH, Aa JS, Hartmann B, Madsen GI, Qvist N, Ellebæk MB. Segmental reversal of the distal small intestine in a short bowel syndrome model in piglets showed detrimental effect on weight gain. BMC Gastroenterol 2022; 22:349. [PMID: 35858830 PMCID: PMC9297615 DOI: 10.1186/s12876-022-02418-3] [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: 09/23/2021] [Accepted: 07/06/2022] [Indexed: 11/15/2022] Open
Abstract
Background To investigate the effects of a reversed segment of the distal small intestine to improve weight gain in an experimental short bowel syndrome (SBS) model in piglets. Methods Twenty-four piglets underwent resection of 70% of the distal small intestine. In half of the animals a conventional anastomosis was performed, and in the other half, the distal 25 cm of the remnant jejunum was reversed before the intestinal continuity was recreated. Weight was measured daily until day 28, where the animals were euthanized. Glucagon-Like Peptide-2 (GLP-2) and Glucose-dependent Insulinotropic Peptide (GIP) was measured pre- and postoperatively at day 28. Results The group with reversal of small intestine had a significant lower weight gain at 5.26 ± 3.39 kg (mean ± SD) compared to the control group with 11.14 ± 3.83 kg (p < 0.05). In the control group greater villus height and crypt depth was found distally, and greater muscular thickness was found proximally in the intervention group. GLP-2 and GIP levels increased significantly in the control group. Conclusions Treatment of short bowel syndrome with a reversed jejunal segment of 25 cm had a detrimental effect on the weight gain.
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Affiliation(s)
- Lasse Hartmann Schmidt
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, J. B. Winsløws Vej 4, 5000, Odense C, Denmark.
| | - Jesper Stensig Aa
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, J. B. Winsløws Vej 4, 5000, Odense C, Denmark
| | - Bolette Hartmann
- Department of Medical Sciences, NNF Center for Basic Metabolic Research, Faculty of Health Science, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen N, Denmark
| | - Gunvor Iben Madsen
- Research Unit for Pathology, Odense University Hospital, University of Southern Denmark, J. B. Winsløws Vej 4, 5000, Odense C, Denmark
| | - Niels Qvist
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, J. B. Winsløws Vej 4, 5000, Odense C, Denmark
| | - Mark Bremholm Ellebæk
- Research Unit for Surgery, Odense University Hospital, University of Southern Denmark, J. B. Winsløws Vej 4, 5000, Odense C, Denmark
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Boroni G, Parolini F, Stern MV, Moglia C, Alberti D. Autologous Intestinal Reconstruction Surgery in Short Bowel Syndrome: Which, When, and Why. Front Nutr 2022; 9:861093. [PMID: 35463997 PMCID: PMC9023091 DOI: 10.3389/fnut.2022.861093] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
Short bowel syndrome (SBS), secondary to any natural loss or after any extensive bowel resection for congenital malformations or acquired disease, is the most common cause of intestinal failure in children. Extensive introduction of parenteral nutrition (PN) has dramatically changed the outcome of these patients, allowing for long-term survival. The main goal in children with SBS remains to be increasing enteral tolerance and weaning from PN support. Post resection intestinal adaptation allows for achievement of enteral autonomy in a subset of these patients, but the inability to progress in enteral tolerance exposes others to long-term complications of PN. Autologous intestinal reconstruction surgery (AIRS) can facilitate the fulfilment of enteral autonomy, maximizing the absorptive potential of the remaining gut. All the different intestinal reconstruction techniques, from simple procedures like tapering, reversed segments, and colon interposition, to more complex lengthening procedures (LILT: longitudinal intestinal lengthening and tailoring, STEP: serial transverse enteroplasty, and SILT: spiral intestinal lengthening and tailoring) and techniques designed for peculiar problems like controlled intestinal tissue expansion or duodenal lengthening are presented. AIRS indications, clinical applications, and results reported in the literature are reviewed.
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Affiliation(s)
- Giovanni Boroni
- Department of Paediatric Surgery, ASST Spedali Civili di Brescia, Brescia, Italy
- *Correspondence: Giovanni Boroni,
| | - Filippo Parolini
- Department of Paediatric Surgery, ASST Spedali Civili di Brescia, Brescia, Italy
| | | | - Cristina Moglia
- Department of Paediatric Surgery, University of Brescia, Brescia, Italy
| | - Daniele Alberti
- Department of Paediatric Surgery, ASST Spedali Civili di Brescia, Brescia, Italy
- Department of Paediatric Surgery, University of Brescia, Brescia, Italy
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State-of-the-art colorectal disease: conservative surgical management of intestinal failure in adults. Int J Colorectal Dis 2021; 36:1597-1607. [PMID: 33629118 DOI: 10.1007/s00384-021-03863-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Intestinal failure (IF) is defined by the reduction of gut function under the minimum necessary for adequate absorption of macronutrients and/or electrolytes, requiring home parenteral nutrition (HPN) to maintain health and/or growth. Among the different causes of IF, short bowel syndrome (SBS) is one of the main causes of IF in adults. Management of IF and SBS is complex and requires a multidisciplinary approach. The aim of this study was to review the place and the modalities of conservative surgical procedures performed for IF in adults. RESULTS-CONCLUSION HPN has drastically modified the poor prognosis of these patients, leading to an overall survival around 70-75% at 5 years in patients without cancer. However, HPN is associated with life-threatening long-term complications, including liver failure and catheter-related complications, main causes of deaths for these patients. Surgery can be proposed, in order to try to reduce SBS consequences with either conservative or non-conservative procedures. Simple bowel continuity restoration should be performed as often as possible in order to wean or at least to reduce HPN. Lengthening procedures are proposed to increase the absorption surface of the remnant bowel. These procedures can be only performed on a dilated small bowel. The slowing transit time procedure is represented by segmental reversal of the small bowel. Intestinal transplantation is the last surgical option for patients with IF but is still today associated with high mortality and failure rates. Thus, conservative procedures have a major role in the surgical armentarium for patients with IF.
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Fousekis FS, Mitselos IV, Christodoulou DK. New insights into intestinal failure-associated liver disease in adults: A comprehensive review of the literature. Saudi J Gastroenterol 2021; 27:3-12. [PMID: 33642350 PMCID: PMC8083246 DOI: 10.4103/sjg.sjg_551_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Intestinal failure-associated liver disease (IFALD) remains one of the most common and serious complications of parenteral nutrition (PN), causing a wide spectrum of hepatic manifestations from steatosis and mild cholestasis to portal hypertension and end-stage liver failure. The prevalence of IFALD depends on the diagnostic criteria and ranges from 4.3% to 65%. Moreover, many factors are shown to contribute to its development, including nutrient deficiencies, toxicity of PN, infections, and alterations of bile acid metabolism and gut microbiota. Prevention and management of IFALD aim at ameliorating or eliminating the risk factors associated with IFALD. The use of PN formulations with a lower ratio omega-6-to-omega-3 polyunsaturated fatty acids, cycle PN, optimization of enteral stimulation and prevention and early treatment of infections constitute the main therapeutic targets. However, failure of improvement and severe IFALD with end-stage liver failure should be considered as the indications of intestinal transplantation. The aim of this review is to provide an update of the epidemiology, pathophysiology, and diagnosis of IFALD in the adult population as well as to present a clinical approach of the therapeutic strategies of IFALD and present novel therapeutic targets.
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Affiliation(s)
- Fotios S. Fousekis
- Department of Gastroenterology and Hepatology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Ioannis V. Mitselos
- Department of Gastroenterology and Hepatology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Dimitrios K. Christodoulou
- Department of Gastroenterology and Hepatology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, Ioannina, Greece,Address for correspondence: Prof. Dimitrios K. Christodoulou, Professor of Gastroenterology, Department of Gastroenterology and Hepatology, School of Health Sciences, University Hospital of Ioannina, Faculty of Medicine, University of Ioannina, POBox 1186, Ioannina 45110, Greece. E-mail:
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Lauro A, Cirocchi R, Cautero N, Dazzi A, Pironi D, Di Matteo FM, Santoro A, Pironi L, Pinna AD. Reconnection surgery in adult post-operative short bowel syndrome < 100 cm: is colonic continuity sufficient to achieve enteral autonomy without autologous gastrointestinal reconstruction? Report from a single center and systematic review of literature. G Chir 2019; 38:163-175. [PMID: 29182898 DOI: 10.11138/gchir/2017.38.4.163] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A systematic bibliographic research concerning patients operated on for SBS was performed: inclusion criteria were adult age, reconnection surgery and SBS < 100 cm. Autologous gastrointestinal reconstruction represented an exclusion criteria. The outcomes of interest were the rate of total parenteral nutrition (TPN) independence and the length of follow-up (minimum 1 year) after surgery. We reviewed our experience from 2003 to 2013 with minimum 1-year follow-up, dealing with reconnection surgery in 13 adults affected by < 100 cm SBS after massive small bowel resection: autologous gastrointestinal reconstruction was not feasible. Three (out of 5168 screened papers) non randomized controlled trials with 116 adult patients were analysed showing weaning from TPN (40%, 50% and 90% respectively) after reconnection surgery without autologous gastrointestinal reconstruction. Among our 13 adults, mean age was 54.1 years (53.8 % ASA III): 69.2 % had a high stomal output (> 500 cc/day) and TPN dependence was 100%. We performed a jejuno-colonic anastomosis (SBS type II) in 53.8%, in 46.1% of cases without ileo-cecal valve, leaving a mean residual small bowel length of 75.7 cm. In-hospital mortality was 0%. After a minimum period of 1 year of intestinal rehabilitation, all our patients (100%) went back to oral intake and 69.2% were off TPN (9 patients). No one was listed for transplantation. A residual small bowel length of minimum 75 cm, even if reconnected to part of the colon, seems able to produce a TPN independence without autologous gastrointestinal reconstruction after a minimum period of 1 year of intestinal rehabilitation.
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8
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Lauro A, Lacaille F. Short bowel syndrome in children and adults: from rehabilitation to transplantation. Expert Rev Gastroenterol Hepatol 2019; 13:55-70. [PMID: 30791840 DOI: 10.1080/17474124.2019.1541736] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Short bowel syndrome (SBS) is a dramatic clinical condition in both children and adults; the residual bowel length is not sufficient to avoid intestinal failure, with subsequent malnutrition and growth retardation, and intravenous support is required to provide the nutrients normally coming from the intestine. Apart from the primary disease, the medical status can be worsened by complications of intestinal failure: if there are irreversible, the prognosis is poor unless a successful intestinal rehabilitation is achieved. Areas covered: The rescue of the remnant small bowel requires a multidisciplinary expertise to achieve digestive autonomy. The use of intestinal trophic factors has shown encouraging results in improving the intestinal adaptation process. Whenever the residual bowel length is inadequate, in a well-selected population weaning parenteral nutrition (PN) off could be attempted by surgery through lengthening procedures. A further subset of patients, with total and irreversible intestinal failure and severe complications on PN, may have an indication to intestinal transplantation. This procedure is still affected by poor long-term results. Expert commentary: Novel approaches developed through a multidisciplinary team work, such as manipulation of microbiota or tissue bioengineering, should be added to current therapies to treat successfully SBS.
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Affiliation(s)
- Augusto Lauro
- a Emergency Surgery Department , St. Orsola University Hospital , Bologna , Italy
| | - Florence Lacaille
- b Gastroenterology Hepatology Nutrition Unit , Hôpital Necker-Enfants Malades , Paris , France
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Pironi L, Corcos O, Forbes A, Holst M, Joly F, Jonkers C, Klek S, Lal S, Blaser AR, Rollins KE, Sasdelli AS, Shaffer J, Van Gossum A, Wanten G, Zanfi C, Lobo DN. Intestinal failure in adults: Recommendations from the ESPEN expert groups. Clin Nutr 2018; 37:1798-1809. [PMID: 30172658 DOI: 10.1016/j.clnu.2018.07.036] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 07/30/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Intestinal failure (IF) is defined as "the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth". Functionally, it may be classified as type I acute intestinal failure (AIF), type II prolonged AIF and type III chronic intestinal failure (CIF) The ESPEN Workshop on IF was held in Bologna, Italy, on 15-16 October 2017 and the aims of this document were to highlight the current state of the art and future directions for research in IF. METHODS This paper represents the opinion of experts in the field, based on current evidence. It is not a formal review, but encompasses the current evidence, with emphasis on epidemiology, classification, diagnosis and management. RESULTS IF is the rarest form of organ failure and can result from a variety of conditions that affect gastrointestinal anatomy and function adversely. Assessment, diagnosis, and short and long-term management involves a multidisciplinary team with diverse expertise in the field that aims to reduce complications, increase life expectancy and improve quality of life in patients. CONCLUSIONS Both AIF and CIF are relatively rare conditions and most of the published work presents evidence from small, single-centre studies. Much remains to be investigated to improve the diagnosis and management of IF and future studies should rely on multidisciplinary, multicentre and multinational collaborations that gather data from large cohorts of patients. Emphasis should also be placed on partnership with patients, carers and government agencies in order to improve the quality of research that focuses on patient-centred outcomes that will help to improve both outcomes and quality of life in patients with this devastating condition.
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Affiliation(s)
- Loris Pironi
- Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola Hospital, University of Bologna, Italy.
| | - Olivier Corcos
- Intestinal Stroke Center (SURVI)/ Gastroenterology, IBD and Nutrition Support Department, Beaujon Hospital, and Laboratory for Vascular Translational Science UMR 1148, University Paris VII, France
| | - Alastair Forbes
- Norwich Medical School, University of East Anglia, Bob Champion Building, Norwich Research Park, Norwich, NR4 7UQ, UK
| | - Mette Holst
- Center for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital and Department of Clinical Medicine, Aalborg University, Denmark
| | - Francisca Joly
- Gastroenterology, IBD and Nutrition Support Department, Beaujon Hospital, and Gastrointestinal and Metabolic Dysfunctions in Nutritional Pathologies UMR 1149, University Paris VII, France
| | - Cora Jonkers
- Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Stanislaw Klek
- Stanley Dudrick's Memorial Hospital, General Surgery Unit with Intestinal Failure Center, Skawina, Poland
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal & Manchester University, Manchester, UK
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia; Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Katie E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - Anna S Sasdelli
- Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola Hospital, University of Bologna, Italy
| | - Jon Shaffer
- Intestinal Failure Unit, Salford Royal & Manchester University, Manchester, UK
| | - Andre Van Gossum
- Clinic of Intestinal Diseases and Nutritional Support, Hopital Erasme, Free University of Brussels, Brussels, Belgium
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chiara Zanfi
- Department of Organ Failure and Transplantation, Sant'Orsola Hospital, University of Bologna, Italy
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
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Marino IR, Lauro A. Surgeon's perspective on short bowel syndrome: Where are we? World J Transplant 2018; 8:198-202. [PMID: 30370230 PMCID: PMC6201325 DOI: 10.5500/wjt.v8.i6.198] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/25/2018] [Accepted: 10/08/2018] [Indexed: 02/05/2023] Open
Abstract
Short bowel syndrome (SBS) is due to a massive loss of small bowel: the reduction of gut function is below the minimum necessary to maintain health (in adults) and growth (in children) so intravenous supplementation is required. Parenteral nutrition represents the milestone of treatment and surgical attempts should be limited only when the residual bowel is sufficient to increase absorption, reducing diarrhea and slowing the transit time of nutrients, water and electrolytes. The surgical techniques lengthen the bowel (tapering it) or reverse a segment of it: developed in children, nowadays are popular also among adults. The issue is mainly represented by the residual length of the small bowel where ileum has shown increased adaptive function than jejunum, but colon should be considered because of its importance in the digestive process. These concepts have been translated also in intestinal transplantation, where a colonic graft is nowadays widely used and the terminal ileum is the selected segment for a living-related donation. The whole replacement by a bowel or multivisceral transplant is still affected by poor long term outcome and must be reserved to a select population of SBS patients, affected by intestinal failure associated with irreversible complications of parenteral nutrition.
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Affiliation(s)
- Ignazio R Marino
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia PA 19107, United States
| | - Augusto Lauro
- Liver and Multiorgan Transplant Unit, St. Orsola-Malpighi University Hospital, Bologna 40138, Italy
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Billiauws L, Maggiori L, Joly F, Panis Y. Medical and surgical management of short bowel syndrome. J Visc Surg 2018; 155:283-291. [DOI: 10.1016/j.jviscsurg.2017.12.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Five-year survival and causes of death in patients on home parenteral nutrition for severe chronic and benign intestinal failure. Clin Nutr 2018; 37:1415-1422. [DOI: 10.1016/j.clnu.2017.06.016] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/14/2017] [Accepted: 06/13/2017] [Indexed: 11/18/2022]
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Abstract
PURPOSE OF REVIEW Short bowel syndrome (SBS) is a rare disease but with many complications due to intestinal failure, parenteral nutrition and underlying disease. A better prevention, comprehension and treatment could improve the outcome of these patients. RECENT FINDINGS Recent studies have been published on acute intestinal failure, first cause of SBS, and gives us strategy to avoid extended intestinal resection and thus SBS. There has been progress in the comprehension of intestinal adaptation, characterized by improvements in intestinal absorption, changes on hormonal secretion, development of a hyperphagia and dysbiosis of the gut microbiota. Hormonal treatment focusing on intestinal rehabilitation by promoting intestinal hyperadaptation has been proposed in patients with SBS, who require parenteral nutrition and intravenous fluids, such as glucagon-like peptide-2 (GLP-2) analog which is now recommended by the latest European Society for Clinical Nutrition and Metabolism Guidelines. SUMMARY Multimodal treatment of acute meseteric ischemia may avoid intestinal resection and is an effective prevention strategy for SBS. New understandings in intestinal adaptation can help us to optimize this adaptation, including with hormonal therapy. GLP-2 analog is now the treatment of reference in SBS patients with chronic intestinal failure.
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Affiliation(s)
- Lore Billiauws
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital
- Gastrointestinal and Metabolic Dysfunctions in Nutritional Pathologies, Inserm UMR 1149, Centre de Recherche sur l'Inflammation Paris Montmartre, UFR de Médecine Paris Diderot, Paris, France
| | - Olivier Corcos
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital
| | - Francisca Joly
- Department of Gastroenterology and Nutrition Support, APHP Beaujon Hospital
- Gastrointestinal and Metabolic Dysfunctions in Nutritional Pathologies, Inserm UMR 1149, Centre de Recherche sur l'Inflammation Paris Montmartre, UFR de Médecine Paris Diderot, Paris, France
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14
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Grave PK, Thomsen SV, Clark PS, Madsen GI, Qvist N, Ellebæk MB. Segmental reversal of distal small intestine in short bowel syndrome: a study on the influence on postoperative weight and intestinal topography in piglets. Pediatr Surg Int 2018; 34:671-677. [PMID: 29666926 DOI: 10.1007/s00383-018-4269-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2018] [Indexed: 12/30/2022]
Abstract
PURPOSE The objective of the present study was to investigate the effect of segmental reversal of the distal 20 cm of the small intestine in piglets with induced SBS compared to controls with SBS alone. Primary endpoint was postoperative weight change over a period of 1 month. Secondary endpoints were the influence on cell proliferation and mucosal architecture shown by histological analysis. METHODS Sixteen piglets underwent a 60% resection of the distal small intestine and were randomized into two groups. Group 1 short bowel syndrome alone (SBS) (n = 8) and group 2 with reversal of a distal small intestinal segment (SBS-RS) (n = 8). Body weight was measured daily and the pigs were euthanized after 1 month. Crypt depths, villus heights and muscle layers thicknesses were measured. For the evaluation of microvilli of the brush border of the epithelium and cell proliferation, immunohistochemical staining with Villin and Ki-67 was performed. RESULTS No statistically significant differences were observed concerning weight gain. Mean ± SD weight gain was 2.31 ± 2.85 kg for SBS-RS and 2.03 ± 1.27 kg for SBS (p = 0.8). In the proximal jejunal segment a significant increase in villus heights was found in the SBS group and increase in the thickness of the circular and longitudinal muscle layers in the SBS-RS group. In the distal ileal segment the longitudinal muscle layer thicknesses were increased in the SBS group. Otherwise, no significant changes were found. CONCLUSION Reversal of a 20-cm distal segment showed no effect on weight gain, but there were some significant histological changes of unknown clinical significance.
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Affiliation(s)
- Pernille Kock Grave
- Surgical Department A, Odense University Hospital, JB Winsløwsvej 4, 5000, Odense C, Denmark
| | | | - Pia Susanne Clark
- Department of Pathology, Odense University Hospital, JB Winsløwsvej 7, 5000, Odense C, Denmark
| | - Gunvor Iben Madsen
- Department of Pathology, Odense University Hospital, JB Winsløwsvej 7, 5000, Odense C, Denmark
| | - Niels Qvist
- Surgical Department A, Odense University Hospital, JB Winsløwsvej 4, 5000, Odense C, Denmark. .,Danish Centre for Regenerative Medicine, Odense University Hospital, JB Winsløwsvej 4, 5000, Odense C, Denmark.
| | - Mark Bremholm Ellebæk
- Surgical Department A, Odense University Hospital, JB Winsløwsvej 4, 5000, Odense C, Denmark
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Pre-emptive Intestinal Transplant: The Surgeon's Point of View. Dig Dis Sci 2017; 62:2966-2976. [PMID: 28918445 DOI: 10.1007/s10620-017-4752-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 09/06/2017] [Indexed: 12/13/2022]
Abstract
Pre-emptive transplantation is a well-established practice for certain types of end-organ failure such as in the use of kidney transplantation. For irreversible intestinal failure, total parenteral nutrition (TPN) remains the gold standard, due to the suboptimal long-term results of intestinal transplantation. As such, the only role for pre-emptive transplantation, if at all, will be for patients identified to be at high risk of complications and mortality while on definitive long-term TPN. In these patients, the timing of early listing and transplantation could become life-saving, taking into account that mortality on the waiting list is still the highest for intestinal candidates. The development of simulation models or pre-transplant scoring systems could help in selecting patients based on potential outcome on TPN or with transplantation, and recent reports from high-volume centers identify few underlying pathologic conditions and some TPN complications as at higher risk of increased morbidity and mortality. A pre-emptive transplant could be used as a rehabilitative procedure in a well-selected case-by-case scenario, among TPN patients at risk of liver failure, repeated central line infections, mesenteric infarction, short bowel syndrome (SBS) <50 cm or with end stoma, congenital mucosal disease, desmoid tumors: These conditions must be carefully evaluated, not to underestimate the clinical stage nor to over-estimate the impact of a temporary situation. At the present time, diseases with a variable and unpredictable course, such as intestinal dysmotility disorders, or quality of life and financial issues are still far from being considered as indications for a pre-emptive transplant.
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16
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Chyme reinfusion in patients with intestinal failure due to temporary double enterostomy: A 15-year prospective cohort in a referral centre. Clin Nutr 2017; 36:593-600. [DOI: 10.1016/j.clnu.2016.04.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 04/10/2016] [Accepted: 04/11/2016] [Indexed: 01/22/2023]
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Abstract
Extensive loss of small bowel in all age groups has significant morbidity and mortality consequences. Despite the astonishing ability of the small bowel to compensate for an extensive loss, long-term parenteral nutrition and enteral nutrition, tailored to the need of the patients in relation to the missing intestinal regions is needed. Organ-preserving surgical intervention becomes necessary in patients with a very short intestinal transit time and in an other group of patients with impaired propulsive peristalsis. Intestinal transplantation is indicated in recurrent septical infections or if nearly all of the small bowel is missing. This review discusses indications and risks of the organ-preserving surgical therapies in children with short bowel syndrome.
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Affiliation(s)
- Michael E Höllwarth
- University Clinic for Pediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz 36, 8034, Graz, Austria.
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18
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Thompson JS. Reversed Intestinal Segment Revisited. Transplant Proc 2017; 48:453-6. [PMID: 27109977 DOI: 10.1016/j.transproceed.2015.09.072] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 08/19/2015] [Accepted: 09/15/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Reversed segments (RS) designed to slow intestinal transit and improve absorption in patients with short bowel syndrome (SBS) are performed infrequently, and patient selection remains controversial. Our aim was to evaluate patient selection and outcome for RS in SBS patients. METHODS Sixteen adult patients underwent RS among 520 SBS patients. All patients had remnant length >80 cm and rapid intestinal transit. Ten patients had a colon remnant and 12 had an ostomy. SBS was present for 8 to 150 months prior to RS. RESULTS RS was performed either alone (n = 9) or concurrently with ostomy closure (n = 5) or creation (n = 2). There were 3 postoperative complications and no deaths. Three patients had bacterial overgrowth. One required repair of an ileocolonic stricture. Two reversed segments were taken down 12 months and 96 months later. Two patients subsequently underwent serial transverse enteroplasty (STEP) procedures, and 1 had isolated intestinal transplant. Fourteen (88%) required parenteral nutrition (PN) pre-operatively and 2 (12%) had intractable diarrhea. Nine (56%) patients improved and 7 (44%) remained on PN or had persistent intractable diarrhea. Patients with a successful outcome were similar to those without improvement with respect to ostomy takedown, duration of SBS, Crohn's disease, intestinal length, a colon remnant, anatomy, and transit time. CONCLUSIONS Reversed segments significantly benefit one half of selected SBS patients who have rapid transit but adequate remnant length. Outcome in individual patients remains difficult to predict. Subsequent operation is frequently required. This procedure is applicable to a small proportion of SBS patients.
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Affiliation(s)
- J S Thompson
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska.
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Parcours de soins du patient adulte souffrant de syndrome de grêle court avec insuffisance intestinale. NUTR CLIN METAB 2016. [DOI: 10.1016/j.nupar.2016.10.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Thompson JS, Langenfeld SJ, Hewlett A, Chiruvella A, Crawford C, Armijo P, Oleynikov D. Surgical treatment of gastrointestinal motility disorders. Curr Probl Surg 2016; 53:503-549. [PMID: 27765162 DOI: 10.1067/j.cpsurg.2016.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 08/22/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Jon S Thompson
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE.
| | - Sean J Langenfeld
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Alexander Hewlett
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | | | | | | | - Dmitry Oleynikov
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
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Hommel MJ, van Baren R, Haveman JW. Surgical management and autologous intestinal reconstruction in short bowel syndrome. Best Pract Res Clin Gastroenterol 2016; 30:263-80. [PMID: 27086890 DOI: 10.1016/j.bpg.2016.03.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/05/2016] [Indexed: 01/31/2023]
Abstract
Short bowel syndrome (SBS) is a serious condition with considerable morbidity and mortality. When treatment with parenteral nutrition fails and life-threatening complications occur, autologous intestinal reconstruction (AIR) should be considered before intestinal transplantation (ITx). Single or combined ITx should be reserved for patients with severe liver disease and as last resort in the treatment of SBS. Longitudinal intestinal lengthening and tailoring (LILT) has proven its value in AIR, but its availability depends on the expertise of the surgeons. Serial transverse enteroplasty (STEP) has similar success rates as LILT and fewer patients progress to ITx. STEP is also applicable at small bowel dilatation in ultra-short bowel syndrome. The scope may be widened when duodenal dilatation can be treated as well. Spiral intestinal lengthening and tailoring (SILT) is a promising alternative. More research is needed to confirm these findings. Therefore we suggest an international data registry for all intestinal lengthening procedures.
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Affiliation(s)
- Matthijs J Hommel
- Department of Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
| | - Robertine van Baren
- Department of Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
| | - Jan Willem Haveman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
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Pironi L, Arends J, Bozzetti F, Cuerda C, Gillanders L, Jeppesen PB, Joly F, Kelly D, Lal S, Staun M, Szczepanek K, Van Gossum A, Wanten G, Schneider SM. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr 2016; 35:247-307. [PMID: 26944585 DOI: 10.1016/j.clnu.2016.01.020] [Citation(s) in RCA: 457] [Impact Index Per Article: 57.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 01/27/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Chronic Intestinal Failure (CIF) is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF. METHODS The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members. RESULTS The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%. CONCLUSIONS CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.
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Affiliation(s)
- Loris Pironi
- Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola-Malpighi University Hospital, Bologna, Italy.
| | - Jann Arends
- Department of Medicine, Oncology and Hematology, University of Freiburg, Germany
| | | | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Lyn Gillanders
- Nutrition Support Team, Auckland City Hospital, (AuSPEN) Auckland, New Zealand
| | | | - Francisca Joly
- Centre for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Darlene Kelly
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA; Oley Foundation for Home Parenteral and Enteral Nutrition, Albany, NY, USA
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Michael Staun
- Rigshospitalet, Department of Gastroenterology, Copenhagen, Denmark
| | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - André Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Stéphane Michel Schneider
- Gastroenterology and Clinical Nutrition, CHU of Nice, University of Nice Sophia Antipolis, Nice, France
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Rege A. The Surgical Approach to Short Bowel Syndrome - Autologous Reconstruction versus Transplantation. VISZERALMEDIZIN 2015; 30:179-89. [PMID: 26288592 PMCID: PMC4513826 DOI: 10.1159/000363589] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Short bowel syndrome (SBS) is a state of malabsorption resulting from massive small bowel resection leading to parenteral nutrition (PN) dependency. Considerable advances have been achieved in the medical and surgical management of SBS over the last few decades. METHODS This review discusses in detail the surgical approach to SBS. RESULTS Widespread use of PN enables long-term survival in patients with intestinal failure but at the cost of PN-associated life-threatening complications including catheter-associated blood stream infection, venous thrombosis, and liver disease. The goal of management of intestinal failure due to SBS is to enable enteral autonomy and wean PN by means of a multi-disciplinary approach. Availability of modified enteral feeding formulas have simplified nutrition supplementation in SBS patients. Similarly, advances in the medical field have made medications like growth hormone and glucagon-like peptide (GLP2) available to improve water and nutrient absorption as well as to enable achieving enteral autonomy. Autologous gastrointestinal reconstruction (AGIR) includes various techniques which manipulate the bowel surgically to facilitate the bowel adaptation process and restoration of enteral nutrition. Ultimately, intestinal transplantation can serve as the last option for the cure of intestinal failure when selectively applied. CONCLUSION SBS continues to be a challenging medical problem. Best patient outcomes can be achieved through an individualized plan, using various AGIR techniques to complement each other, and intestinal transplantation as a last resort for cure. Maximum benefit and improved outcomes can be achieved by caring for SBS patients at highly specialized intestinal rehabilitation centers.
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Affiliation(s)
- Aparna Rege
- Division of Transplantation, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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24
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Reply to letter: "segmental reversal of the small bowel can end permanent parenteral nutrition dependency". Ann Surg 2015; 261:e96-7. [PMID: 24263320 DOI: 10.1097/sla.0000000000000359] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Pakarinen MP. Autologous intestinal reconstruction surgery as part of comprehensive management of intestinal failure. Pediatr Surg Int 2015; 31:453-64. [PMID: 25820764 DOI: 10.1007/s00383-015-3696-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2015] [Indexed: 12/21/2022]
Abstract
Pediatric intestinal failure (IF) remains to be associated with significant morbidity and mortality, the most frequent underlying etiologies being short bowel syndrome (SBS), and primary motility disorders. Management aims to assure growth and development, while preventing complications and facilitating weaning off parenteral support (PS) by fully utilizing adaptation potential of the remaining gut. Probability of survival and weaning off PS is improved by coordinated multidisciplinary intestinal rehabilitation combining individualized physiological enteral and parenteral nutrition (PN), meticulous central line care and medical management with carefully planned surgical care. Increasing evidence suggests that autologous intestinal reconstruction (AIR) surgery is effective treatment for selected short bowel patients. Bowel lengthening procedures normalize pathological adaptation-associated short bowel dilatation with potential to support intestinal absorption and liver function by various mechanisms. Although reversed small intestinal segment, designed to prolong accelerated intestinal transit, improves absorption in adult SBS, its feasibility in children remains unclear. Controlled bowel obstruction to induce dilatation followed by bowel lengthening aims to gain extra length in patients with the shortest duodenojejunal remnant. Reduced PS requirement limits the extent of complications, improving prognosis and quality of life. The great majority of children with SBS can be weaned from PS while prognosis of intractable primary motility disorders remains poor without intestinal transplantation, which serves as a salvage therapy for life-threatening complications such as liver failure, central vein thrombosis or recurrent bloodstream infections.
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Affiliation(s)
- Mikko P Pakarinen
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group Helsinki, Children's Hospital, University of Helsinki and Helsinki University Hospital, Stenbackinkatu 11, Po Box 281, 00029 HUS, Helsinki, Finland,
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Tavernier A, Cavin JB, Le Gall M, Ducroc R, Denis RGP, Cluzeaud F, Guilmeau S, Sakar Y, Barbot L, Kapel N, Le Beyec J, Joly F, Chua S, Luquet S, Bado A. Intestinal deletion of leptin signaling alters activity of nutrient transporters and delayed the onset of obesity in mice. FASEB J 2014; 28:4100-10. [PMID: 24928195 DOI: 10.1096/fj.14-255158] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 05/27/2014] [Indexed: 11/11/2022]
Abstract
The importance of B-isoform of leptin receptor (LEPR-B) signaling in the hypothalamus, pancreas, or liver has been well characterized, but in the intestine, a unique site of entry for dietary nutrition into the body, it has been relatively ignored. To address this question, we characterized a mouse model deficient for LEPR-B specifically in intestinal epithelial cells (IECs). (IEC)LEPR-B-knockout (KO) and wild-type (WT) mice were generated by Cre-Lox strategy and fed a normal or high-fat diet (HFD). The analyses of the animals involved histology and immunohistochemistry of intestinal mucosa, indirect calorimetric measurements, whole-body composition, and expression and activities of nutrient transporters. (IEC)LEPR-B-KO mice exhibited a 2-fold increase in length of jejunal villi and have normal growth on a normal diet but were less susceptible (P<0.01) to HFD-induced obesity. No differences occurred in energy intake and expenditure between (IEC)LEPR-B-WT and -KO mice, but (IEC)LEPR-B-KO mice fed an HFD showed increased excreted fats (P<0.05). Activities of the Na(+)/glucose cotransporter SGLT-1 and GLUT2 were unaffected in LEPR-B-KO jejunum, while GLUT5-mediated fructose transport and PepT1-mediated peptide transport were substantially reduced (P<0.01). These data demonstrate that intestinal LEPR-B signaling is important for the onset of diet-induced obesity. They suggest that intestinal LEPR-B could be a potential per os target for prevention against obesity.
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Affiliation(s)
- Annabelle Tavernier
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixte de Recherche en Santé (UMRS) 1149, Unité de Formation et de Recherche (UFR) de Médecine Paris Diderot, Sorbonne Paris Cite, Paris, France
| | - Jean-Baptiste Cavin
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixte de Recherche en Santé (UMRS) 1149, Unité de Formation et de Recherche (UFR) de Médecine Paris Diderot, Sorbonne Paris Cite, Paris, France
| | - Maude Le Gall
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixte de Recherche en Santé (UMRS) 1149, Unité de Formation et de Recherche (UFR) de Médecine Paris Diderot, Sorbonne Paris Cite, Paris, France
| | - Robert Ducroc
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixte de Recherche en Santé (UMRS) 1149, Unité de Formation et de Recherche (UFR) de Médecine Paris Diderot, Sorbonne Paris Cite, Paris, France
| | - Raphaël G P Denis
- Université Paris Diderot, Sorbonne Paris Cité, Unité de Biologie Fonctionnelle et Adaptative, Centre National de la Recherche Scientifique (CNRS) Unité Mixte de Recherche (UMR) 8251, Paris, France
| | - Françoise Cluzeaud
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixte de Recherche en Santé (UMRS) 1149, Unité de Formation et de Recherche (UFR) de Médecine Paris Diderot, Sorbonne Paris Cite, Paris, France
| | - Sandra Guilmeau
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixte de Recherche en Santé (UMRS) 1149, Unité de Formation et de Recherche (UFR) de Médecine Paris Diderot, Sorbonne Paris Cite, Paris, France
| | - Yassine Sakar
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixte de Recherche en Santé (UMRS) 1149, Unité de Formation et de Recherche (UFR) de Médecine Paris Diderot, Sorbonne Paris Cite, Paris, France
| | - Laurence Barbot
- Service de Coprologie Fonctionnelle, Hopital La Pitié Salpêtrière, Paris, France
| | - Nathalie Kapel
- Service de Coprologie Fonctionnelle, Hopital La Pitié Salpêtrière, Paris, France
| | - Johanne Le Beyec
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixte de Recherche en Santé (UMRS) 1149, Unité de Formation et de Recherche (UFR) de Médecine Paris Diderot, Sorbonne Paris Cite, Paris, France; Université Pierre et Marie Curie, Paris, France
| | - Francisca Joly
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixte de Recherche en Santé (UMRS) 1149, Unité de Formation et de Recherche (UFR) de Médecine Paris Diderot, Sorbonne Paris Cite, Paris, France; Service de Gastroenterologie et d'Assistance Nutritive, Hopital Beaujon, Clichy, France; and
| | - Streamson Chua
- Department of Medicine and Neuroscience, Albert Einstein College of Medicine, New York, New York, USA
| | - Serge Luquet
- Université Paris Diderot, Sorbonne Paris Cité, Unité de Biologie Fonctionnelle et Adaptative, Centre National de la Recherche Scientifique (CNRS) Unité Mixte de Recherche (UMR) 8251, Paris, France
| | - Andre Bado
- Institut National de la Santé et de la Recherche Médicale (INSERM) Unité Mixte de Recherche en Santé (UMRS) 1149, Unité de Formation et de Recherche (UFR) de Médecine Paris Diderot, Sorbonne Paris Cite, Paris, France;
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an update of recent advances in the areas of short bowel syndrome (SBS) and small bowel transplantation (SBT). RECENT FINDINGS Recent reports from two of the largest multicenter randomized, controlled trials in patients with SBS support the safety and efficacy of teduglutide as an aid to parenteral nutrition weaning. In well selected SBS patients, outcomes as diverse as survival, macronutrient absorption and parenteral nutrition weaning are improved after autologous gastrointestinal reconstructive surgery. SBT is no longer considered investigational and given improved outcomes noted in recent reports, indications for transplantation are expanding. Although SBT early survival rates are approaching those of other organ allografts, long-term graft survival remains suboptimal. SUMMARY Recently available trophic factors hold promise as aids in restoring freedom from parenteral nutrition support; however, their long-term benefits, preferred timing of administration in relation to the onset of SBS, optimal patient selection for use, duration of treatment and cost effectiveness require further study. Despite recent evidence of improved early survival after SBT, more dedicated research is needed to design more effective strategies to better tolerize small bowel grafts, prevent rejection and, ultimately, improve long-term outcomes. Reserved for well selected patients, autologous gastrointestinal reconstruction should be considered complementary and not antagonistic to SBT.
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