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Solar H, Ortega ML, Gondolesi G. Current Status of Chronic Intestinal Failure Management in Adults. Nutrients 2024; 16:2648. [PMID: 39203785 PMCID: PMC11356806 DOI: 10.3390/nu16162648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 06/25/2024] [Accepted: 07/02/2024] [Indexed: 09/03/2024] Open
Abstract
BACKGROUND Chronic intestinal failure (CIF) is a heterogeneous disease that affects pediatric and adult populations worldwide and requires complex multidisciplinary management. In recent years, many advances in intravenous supplementation support, surgical techniques, pharmacological management, and intestinal transplants have been published. Based on these advances, international societies have published multiple recommendations and guidelines for the management of these patients. The purpose of this paper is to show the differences that currently exist between the recommendations (ideal life) and the experiences published by different programs around the world. METHODS A review of the literature in PubMed from 1980 to 2024 was carried out using the following terms: intestinal failure, CIF, home parenteral nutrition, short bowel syndrome, chronic intestinal pseudo-obstruction, intestinal transplant, enterohormones, and glucagon-like peptide-2. CONCLUSIONS There is a difference between what is recommended in the guidelines and consensus and what is applied in real life. Most of the world's countries are not able to offer all of the steps needed to treat this pathology. The development of cooperative networks between countries is necessary to ensure access to comprehensive treatment for most patients on all continents, but especially in low-income countries.
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Affiliation(s)
- Héctor Solar
- Nutritional Support, Intestinal Rehabilitation and Intestinal Transplant Unit, Hospital Universitario Fundación Favaloro, Buenos Aires C1093AAS, Argentina; (M.L.O.); (G.G.)
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2
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Walter E, Dawoud C, Hütterer E, Stift A, Harpain F. Cost-effectiveness of teduglutide in adult patients with short bowel syndrome - a European socioeconomic perspective. Am J Clin Nutr 2024; 119:1187-1199. [PMID: 38431119 PMCID: PMC11130673 DOI: 10.1016/j.ajcnut.2024.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 02/22/2024] [Accepted: 02/28/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Short bowel syndrome with intestinal failure (SBS-IF) is a rare but devastating medical condition. An absolute loss of bowel length forces the patients into parenteral support dependency and a variety of medical sequelae, resulting in increased morbidity and mortality. Interdisciplinary treatment may include therapy with the effective but expensive intestinotrophic peptide teduglutide. OBJECTIVES A time-discrete Markov model was developed to simulate the treatment effect [lifetime costs, quality-adjusted life years (QALYs), and life years (LYs)] of teduglutide plus best supportive care compared with best supportive care alone in patients with SBS-IF. METHODS The health status of the model was structured around the number of days on PS. Clinical data from 3 data sets were used: 1) an Austrian observational study (base case), 2) pooled observational cohort studies, and 3) a prospective study of teduglutide effectiveness in parenteral nutrition-dependent short bowel syndrome subjects. Direct and indirect costs were derived from published sources. QALYs, LYs, and costs were discounted (3% per annum). RESULTS Under the base case assumption, teduglutide is associated with costs of 2,296,311 € per patient and 10.78 QALYs (13.74 LYs) over a lifetime horizon. No teduglutide is associated with 1,236,816 € and 2.24 QALYs (8.57 LYs). The incremental cost-utility ratio (ICUR) amounts to 123,945 €. In case of the pooled clinical data set, the ICUR increases to 184,961 €. If clinical data based on the study of teduglutide effectiveness in parenteral nutrition-dependent short bowel syndrome subjects were used, the ICUR increased to 235,612 €. CONCLUSIONS Teduglutide in treating patients with SBS-IF meets the traditional cost-effectiveness criteria from a European societal perspective. Nevertheless, the varying concentrations of teduglutide efficacy leave a degree of uncertainty in the calculations.
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Affiliation(s)
- Evelyn Walter
- IPF Institute for Pharmaeconomic Research, Vienna, Austria
| | - Christopher Dawoud
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Hütterer
- Division of Oncology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Anton Stift
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Felix Harpain
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria.
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3
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Ukkola-Vuoti L, Tuominen S, Pohju A, Kovac B, Lassenius MI, Merras-Salmio L, Pakarinen MP, Sallinen V, Pikkarainen S. Expenditure and survival of adult patients with intestinal failure due to short bowel syndrome: real-world evidence from Southern Finland. Scand J Gastroenterol 2024; 59:401-410. [PMID: 38217349 DOI: 10.1080/00365521.2024.2303063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/03/2024] [Indexed: 01/15/2024]
Abstract
OBJECTIVES Comprehensive follow-up data from the largest hospital district in Finland was used to assess hospital-based healthcare resource utilization (HCRU) and expenses, incidence and prevalence, survival, and effect of comorbidities/complications on survival of adult patients with intestinal failure due to short bowel syndrome (SBS-IF). METHODS This study utilized electronic healthcare data covering all ≥18-year-old patients with SBS-IF at the Hospital District of Helsinki and Uusimaa in Finland between 2010 and 2019. Patients were followed from SBS-IF onset until the end of 2020 or death and compared to birth year and sex-matched control patients without SBS-IF. RESULTS The study included 77 patients with SBS-IF (cases) and 363 controls. Cases had high HCRU; the cumulative expenses were about tenfold compared to the controls, at the end of the study (€123,000 vs. €14,000 per patient). The expenses were highest during the first year after SBS-IF onset (€53,000 per patient). Of the cases with a median age 62.5 years, 51.9% died during study time. The median survival was 4.4 years from SBS-IF onset and cases died 13.5 times more likely during the follow-up compared to controls. Mortality risk was lower in female cases (hazard ratio (HR) 0.46; 95% confidence intervals (CI) 0.24, 0.9) and higher with presence of comorbidities (Charlson comorbidity index HR 1.55; 95% CI 1.2, 2.0) and mesenteric infarction (HR 4.5; 95% CI 1.95, 10.36). The incidence of adult SBS-IF was 0.6 per 100,000 adults. CONCLUSION Our study demonstrates a high demand for healthcare support and elevated mortality in adult SBS-IF-patients. Our results suggest that the presence of comorbidities is a key driver for mortality.
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Affiliation(s)
| | | | - Anne Pohju
- Clinical Nutrition Unit, Internal Medicine and Rehabilitation, Helsinki University Hospital, Helsinki, Finland
| | - Bianca Kovac
- Gastroenterolgy Department, Takeda Oy, Helsinki, Finland
| | | | - Laura Merras-Salmio
- Helsinki University Hospital, Pediatric Gastroenterology Unit, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikko P Pakarinen
- Section of Pediatric Surgery, Pediatric Liver and Gut Research Group, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Women's Health, Karolinska Institute, Solna, Sweden
| | - Ville Sallinen
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sampsa Pikkarainen
- Abdomen Center, Gastroenterology Unit, Helsinki University Hospital, Helsinki, Finland
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4
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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: 29] [Impact Index Per Article: 29.0] [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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5
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Luhn C, Agis H, Hütterer E, Simonitsch‐Klupp I, Dawoud C, Stift A, Harpain F. Teduglutide in amyloidosis-associated intestinal failure. Clin Case Rep 2023; 11:e7653. [PMID: 37601424 PMCID: PMC10433832 DOI: 10.1002/ccr3.7653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/19/2023] [Indexed: 08/22/2023] Open
Abstract
Amyloidosis is a heterogeneous disease characterized by tissue deposition of abnormally folded fibrillary proteins that can manifest itself by a wide variety of symptoms depending on the affected organs. GI involvement among amyloidosis patients is common. Its clinical manifestation often presents with nonspecific symptoms such as weight loss, diarrhea, and malabsorption. With no specific treatment existing for GI amyloidosis, therapy focuses on impeding amyloid deposition and managing the patients' symptoms with supportive measures. Here, we present an AL-amyloidosis patient with GI involvement and intestinal failure (IF) who was successfully treated with the glucagon-like peptide-2 (GLP-2) analogue teduglutide. Over the course of treatment with teduglutide, the patient was able to achieve independence from parenteral nutrition and experienced a significant improvement in quality of life (QoL) as stool frequency and consistency improved, urinary output was stabilized and body weight as well as body composition improved over the course of teduglutide therapy. With no longer being exposed to the burden and associated risks of parenteral nutrition, we were able to reduce the potential morbidity and mortality rate as well as to improve the patient's overall QoL. Intestinal tissue biopsy workup revealed a histopathological correlate for the clinical response; Congo-Red-positive intestinal depositions almost completely disappeared within 6 months of teduglutide therapy. Implementing intestinotrophic GLP-2 analogue teduglutide may enrich the spectrum of treatment options for amyloidosis patients with IF who are dependent on parenteral support.
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Affiliation(s)
- Clara Luhn
- Division of Visceral Surgery, Department of General SurgeryMedical University ViennaViennaAustria
| | - Hermine Agis
- Division of Hematology and Hemostaseology, Department of Internal Medicine IMedical University of ViennaViennaAustria
| | - Elisabeth Hütterer
- Division of Oncology, Department of Internal Medicine IMedical University of ViennaViennaAustria
| | | | - Christopher Dawoud
- Division of Visceral Surgery, Department of General SurgeryMedical University ViennaViennaAustria
| | - Anton Stift
- Division of Visceral Surgery, Department of General SurgeryMedical University ViennaViennaAustria
| | - Felix Harpain
- Division of Visceral Surgery, Department of General SurgeryMedical University ViennaViennaAustria
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D'Eusebio C, Merlo FD, Ossola M, Bioletto F, Ippolito M, Locatelli M, De Francesco A, Anrò M, Romagnoli R, Strignano P, Bo S, Aimasso U. Mortality and parenteral nutrition weaning in patients with chronic intestinal failure on home parenteral nutrition: A 30-year retrospective cohort study. Nutrition 2023; 107:111915. [PMID: 36566610 DOI: 10.1016/j.nut.2022.111915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/06/2022] [Accepted: 11/13/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Home parenteral nutrition (HPN) is the standard treatment for patients with chronic intestinal failure (CIF). Mortality and weaning rates of these patients differ widely among cohorts; however, these outcomes were often considered independent-rather than competing-events, leading to an upward bias of the retrieved estimates. OBJECTIVES The aim of this retrospective cohort study was to evaluate, evaluating through a competing risk analysis, the rates and predictors of mortality and weaning in CIF patients from an Italian referral center. METHODS All adult patients with CIF receiving > 3 mo HPN from 1985 until 2016 were enrolled. Clinical information was collected from the database of the Intestinal Failure Unit of Torino, Italy. Patients were stratified according to the presence or not of short bowel syndrome (SBS). RESULTS The cumulative incidences of death and weaning were 27.3% and 32.3% and 39.0% and 33.7% at 5 and 10 y from HPN initiation, respectively. At multivariable competing risk analyses, mortality was predicted by age (sub-distribution hazard ratio [SHR] = 1.65 per 10-y increase; 95% CI, 1.35-2.01), type 3 SBS (SHR = 0.38; 0.15-0.94), small bowel length ≥ 100 cm (SHR = 0.42; 0.22-0.83), and reconstructive surgery (SHR = 0.11; 0.02-0.64) in SBS patients, and by age (SHR = 1.38 per 10-y increase; 1.16-1.64) and presence of stoma (SHR = 0.30; 0.12-0.78) in non-SBS patients. In the same model, weaning was predicted by type 3 SBS (SHR = 6.86; 3.10-15.16), small bowel length ≥ 100 cm (SHR = 3.54; 1.99-6.30), and reconstructive surgery (SHR = 2.86; 1.44-5.71) in SBS patients, and by age (SHR = 0.79 per 10-y increase; 0.66-0.94) and presence of stoma (SHR = 2.64; 1.38-5.07) in non-SBS patients. CONCLUSIONS Surgical procedures strongly affected mortality and weaning risk in CIF patients.
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Affiliation(s)
- Chiara D'Eusebio
- Department of Medical Science, University of Torino, 10124 Torino, Italy
| | - Fabio Dario Merlo
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy.
| | - Marta Ossola
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Fabio Bioletto
- Department of Medical Science, University of Torino, 10124 Torino, Italy
| | - Mirko Ippolito
- Department of Medical Science, University of Torino, 10124 Torino, Italy
| | - Monica Locatelli
- Food Chemistry, Biotechnology and Nutrition Unit, University of Piemonte Orientale, 28100 Novara, Italy
| | - Antonella De Francesco
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Marta Anrò
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Renato Romagnoli
- General Surgery 2U, Liver Transplantation Unit, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Paolo Strignano
- General Surgery 2U, Liver Transplantation Unit, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Simona Bo
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy.
| | - Umberto Aimasso
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
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Nelson AD, Elkins JR, Stocchi L, Farraye FA, Hashash JG. Use and Misuse of Parenteral Nutrition in Patients with Inflammatory Bowel Disease. Inflamm Bowel Dis 2022; 28:1592-1602. [PMID: 35472221 DOI: 10.1093/ibd/izac085] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Indexed: 12/09/2022]
Abstract
Malnutrition is a very common and often underrecognized condition among patients with inflammatory bowel diseases (IBD). This is most commonly due to increased nutritional requirements and gastrointestinal losses, along with reduced oral intake. Screening for malnutrition is an essential component of managing both inpatients and outpatients with IBD. Although enteral nutrition is the preferred route of supplementation, parenteral nutrition (PN) remains an important strategy and should be considered in certain situations, such as cases with short-bowel syndrome, high-output intestinal fistula, prolonged ileus, or small-bowel obstruction. Appropriate use of PN is critical in order to prevent associated complications. This review addresses the common indications for use of PN, the composition of PN, and the possible complications encountered with PN use, as well as scenarios of inappropriate PN use among patients with IBD. A clinical management algorithm for utilizing PN among patients with IBD is proposed in this review.
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Affiliation(s)
- Alfred D Nelson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Luca Stocchi
- Division of Colorectal Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Jana G Hashash
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
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8
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Fuglsang KA, Brandt CF, Jeppesen PB. Survival In Patients Initiating Home Parenteral Support Due To Nonmalignant Short Bowel Syndrome Compared With Background Population. Clin Nutr ESPEN 2022; 50:170-177. [DOI: 10.1016/j.clnesp.2022.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 05/09/2022] [Accepted: 05/25/2022] [Indexed: 12/25/2022]
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9
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Complications After Implantation of Subcutaneous Central Venous Ports: Focus on Infection and Catheter Pinch-off. Int Surg 2022. [DOI: 10.9738/intsurg-d-15-00316.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective
The objective of this study was to determine the causes of postoperative complications associated with subcutaneous central venous ports.
Summary of Background Data
Central venous ports were subcutaneously implanted in 523 patients between January 2005 and December 2013.
Methods
The purpose of port implantation was administration of chemotherapy in 439 patients and home central venous nutrition in 84 patients. The underlying disease was malignant in 481 patients and benign in 42.
Results
The median follow-up was 12 months (range, 1–99 months), and postoperative complications developed in 69 patients (13%). Infection occurred in 40 patients (7.6%) and catheter pinch-off in 11 patients (3%). Significant risk factors for infection were nutritional port placement (P < 0.001) and use of a femoral vein approach (P = 0.001). A left subclavian approach was a significant risk factor for catheter pinch-off (P = 0.003).
Conclusions
Postoperative complications, mainly infections and catheter pinch-off, developed in 13% of the patients. As for measures against complications, a femoral vein approach should be avoided to prevent infection. Moreover, because ports for parenteral nutrition require multiple punctures, methods to reduce the number of punctures and techniques for disinfection and management should be reevaluated. To prevent catheter pinch-off, an internal jugular vein approach should be used instead of a left subclavian approach.
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10
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Oke SM, Nightingale JM, Donnelly SC, Naghibi M, Willsmore J, Lloyd DAJ, Gabe SM. Outcome of adult patients receiving parenteral support at home: 36 years' experience at a tertiary referral centre. Clin Nutr 2021; 40:5639-5647. [PMID: 34662849 DOI: 10.1016/j.clnu.2021.08.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 08/27/2021] [Accepted: 08/28/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Patients with intestinal failure often need long-term home parenteral support (PS). We aimed to determine how the underlying diagnosis, complications and survival had changed over the last 36 years in the UK's largest IF centre. METHODS 978 adult home PS patient records were analysed from January 1979 until October 2016. The age, sex, underlying aetiology, complications and survival was compared over 5-year periods. RESULTS Pre-1990 to 2011-2016, numbers increased from 29 to 451, the mean age of patients increased from 31 ± 16.5 to 52 ± 17.6 years. The percentage of patients with IF due to surgical complications increased (3.4%-28.8%, p < 0.001)), while those with inflammatory bowel disease decreased (37.9%-22.6%, p < 0.001). Complication of home PS reduced: catheter related blood stream infections (CRBSI) 71.4% to 42,2%, CVC thrombosis 34.5%-5.3%. Intestinal failure associated liver disease (IFLAD) 10.3%-1.8%. Patients with dysmotility, scleroderma and a congenital aetiology had the highest incidence of CRBSI and CVC Thrombosis. Overall survival was greater pre-1995 [HR 0.2-0.4 (p = 0.02)] most likely associated with an increase in mean age. Survival for patients without malignancy was 90%, 66%, 55%, 45%, 33% and 25% at 1,5, 10, 15, 20 and 30 years respectively. Multivariate analysis demonstrated a relationship between survival and age of starting home PS; type of home PS; presence or absence of the colon in continuity; and underlying aetiology. CONCLUSION Demand for home PS is increasing in particular for advanced malignancy, post-surgical complications and older more co-morbid patients. Complications of home PS are reducing over the last 30 years and 10-year survival for non-malignant aetiologies improving. Survival and changes in aetiology in intestinal failure.
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Affiliation(s)
- Siddhartha M Oke
- St. Mark's Hospital, Harrow, United Kingdom; Department of Metabolism, Digestion and Reproduction Imperial College London, United Kingdom.
| | | | | | | | - James Willsmore
- St. Mark's Hospital, Harrow, United Kingdom; Department of Metabolism, Digestion and Reproduction Imperial College London, United Kingdom
| | | | - Simon M Gabe
- St. Mark's Hospital, Harrow, United Kingdom; Department of Metabolism, Digestion and Reproduction Imperial College London, United Kingdom
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11
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Harpain F, Schlager L, Hütterer E, Dawoud C, Kirchnawy S, Stift J, Krotka P, Stift A. Teduglutide in short bowel syndrome patients: A way back to normal life? JPEN J Parenter Enteral Nutr 2021; 46:300-309. [PMID: 34614239 PMCID: PMC9298195 DOI: 10.1002/jpen.2272] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background The glucagon‐like peptide 2 analogue teduglutide is an effective drug for the treatment of short bowel syndrome patients with intestinal failure (SBS‐IF). This intestinotrophic peptide improves intestinal capacity for fluid and nutrient absorption through induction of mucosal growth and reduction of gastrointestinal motility. Clinical trials demonstrated the efficacy of teduglutide in reducing the need for parenteral support (PS). This study describes an SBS‐IF patient population receiving teduglutide therapy in a specialized medical care setting. Method A retrospective analysis was performed using data of patients experiencing nonmalignant SBS‐IF. They were treated with teduglutide in a multidisciplinary SBS‐IF program at a single university medical center between June 2016 and June 2020. Results Thirteen patients under teduglutide treatment were included in the final analysis. Mean small bowel length was 82 ± 31 cm, with 77% of patients having their colon in continuity. Over a median follow‐up of 107 weeks, all patients (13 of 13, 100%) responded to the therapy with a clinically significant reduction of PS volume. Mean PS reduction increased with therapy duration and ranged from −82.5% at week 24 (n = 13) to −100% in patients (n = 5) who were treated for 144 weeks. Enteral autonomy was achieved in 12 of 13 (92%) patients. Teduglutide therapy improved stool frequency and consistency, changed dietary habits, and reduced disease‐associated sleep disruptions. Conclusion Integrating SBS‐IF patients treated with teduglutide in a proactive and tight‐meshed patient care program significantly improves the clinical outcome, leading to an increased proportion of patients reaching enteral autonomy.
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Affiliation(s)
- Felix Harpain
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Lukas Schlager
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Hütterer
- Department of Internal Medicine I, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Christopher Dawoud
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Sabine Kirchnawy
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Judith Stift
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Pavla Krotka
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Anton Stift
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
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Abstract
PURPOSE OF REVIEW Intestinal transplantation has evolved to be a viable treatment option for patients with intestinal failure. This review shows the most current tendencies and practices of intestinal transplant centers and an overall comparison to intestinal rehabilitation. RECENT FINDINGS This review outlines that timing for referral and advances in preoperative and postoperative care of intestinal and multivisceral transplant candidates are crucial to achieve results comparable to intestinal rehabilitation. SUMMARY Current practices have shown that intestinal transplantation continues to improve overall results and could be considered in patients with permanent home parenteral nutrition. Timing for referral and preoperative and postoperative management are crucial to optimize long-term results.
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Affiliation(s)
| | - Gennaro Selvaggi
- Departmetn of Surgery, Liver and Gastrointestinal Transplantation, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
| | - Akin Tekin
- Departmetn of Surgery, Liver and Gastrointestinal Transplantation, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
| | - Rodrigo Vianna
- Departmetn of Surgery, Liver and Gastrointestinal Transplantation, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
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Twenty Years of Gut Transplantation for Chronic Intestinal Pseudo-obstruction: Technical Innovation, Long-term Outcome, Quality of Life, and Disease Recurrence. Ann Surg 2021; 273:325-333. [PMID: 31274659 DOI: 10.1097/sla.0000000000003265] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To define long-term outcome, predictors of survival, and risk of disease recurrence after gut transplantation (GT) in patients with chronic intestinal pseudo-obstruction (CIPO). BACKGROUND GT has been increasingly used to rescue patients with CIPO with end-stage disease and home parenteral nutrition (HPN)-associated complications. However, long-term outcome including quality of life and risk of disease recurrence has yet to be fully defined. METHODS Fifty-five patients with CIPO, 23 (42%) children and 32 (58%) adults, underwent GT and were prospectively studied. All patients suffered gut failure, received HPN, and experienced life-threatening complications. The 55 patients received 62 allografts; 43 (67%) liver-free and 19 (33%) liver-contained with 7 (13%) retransplants. Hindgut reconstruction was adopted in 1993 and preservation of native spleen was introduced in 1999. Immunosuppression was tacrolimus-based with antilymphocyte recipient pretreatment in 41 (75%). RESULTS Patient survival was 89% at 1 year and 69% at 5 years with respective graft survival of 87% and 56%. Retransplantation was successful in 86%. Adults experienced better patient (P = 0.23) and graft (P = 0.08) survival with lower incidence of post-transplant lymphoproliferative disorder (P = 0.09) and graft versus host disease (P = 0.002). Antilymphocyte pretreatment improved overall patient (P = 0.005) and graft (P = 0.069) survival. The initially restored nutritional autonomy was sustainable in 23 (70%) of 33 long-term survivors with improved quality of life. The remaining 10 recipients required reinstitution of HPN due to allograft enterectomy (n = 3) or gut dysfunction (n = 7). Disease recurrence was highly suspected in 4 (7%) recipients. CONCLUSIONS GT is life-saving for patients with end-stage CIPO and HPN-associated complications. Long-term survival is achievable with better quality of life and low risk of disease recurrence.
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Noelting J, Gramlich L, Whittaker S, Armstrong D, Marliss E, Jurewitsch B, Raman M, Duerksen DR, Stevenson D, Lou W, Saha S, Allard JP. Survival of Patients With Short‐Bowel Syndrome on Home Parenteral Nutrition: A Prospective Cohort Study. JPEN J Parenter Enteral Nutr 2020; 45:1083-1088. [DOI: 10.1002/jpen.1984] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/23/2020] [Accepted: 07/27/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Jessica Noelting
- Department of Medicine Toronto General Hospital University of Toronto Toronto Canada
| | - Leah Gramlich
- Department of Medicine University of Alberta Edmonton Alberta Canada
| | - Scott Whittaker
- Department of Medicine University of British Columbia Vancouver British Columbia Canada
| | - David Armstrong
- Division of Gastroenterology & Farncombe Family Digestive Health Research Institute McMaster University Hamilton Ontario Canada
| | - Errol Marliss
- Department of Medicine McGill University Montréal Québec Canada
| | - Brian Jurewitsch
- Department of Pharmacy St Michael's Hospital University of Toronto Toronto Ontario Canada
| | | | | | | | - Wendy Lou
- Dalla Lana Public Health Department University of Toronto Toronto Ontario Canada
| | - Sudipta Saha
- Dalla Lana Public Health Department University of Toronto Toronto Ontario Canada
| | - Johane P. Allard
- Department of Medicine Toronto General Hospital University of Toronto Toronto Canada
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Salazar E, Clermont‐Dejean NM, Schwenger KJP, Noelting J, Lu Z, Lou W, Allard JP. Patients With Severe Gastrointestinal Dysmotility Disorders Receiving Home Parenteral Nutrition Have Similar Survival As Those With Short‐Bowel Syndrome: A Prospective Cohort Study. JPEN J Parenter Enteral Nutr 2020; 45:530-537. [DOI: 10.1002/jpen.1866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/29/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Ennaliza Salazar
- Toronto General Hospital University of Toronto Toronto Canada
- Singapore General Hospital Singapore
| | | | | | | | - Zihang Lu
- Dalla Lana Public Health Department University of Toronto Toronto Ontario Canada
| | - Wendy Lou
- Dalla Lana Public Health Department University of Toronto Toronto Ontario Canada
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Zittan E, Gralnek IM, Hatoum OA, Sakran N, Kolonimos N. Preoperative Exclusive Total Parental Nutrition is Associated with Clinical and Laboratory Remission in Severe Active Crohn's Disease-A Pilot Study. Nutrients 2020; 12:nu12051244. [PMID: 32353942 PMCID: PMC7281989 DOI: 10.3390/nu12051244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The effect of 1-3 months of preoperative exclusive total parental nutrition (TPN) in active Crohn's disease (CD) patients is not well established. We investigated the efficacy of exclusive TPN in active CD patients. METHODS In a retrospective multi-visit study with data according to our standard care therapy, we assessed clinical and laboratory remission to refractory CD with exclusive preoperative TPN. Inclusion required exclusive preoperative home TPN without additional oral intake for 1-3 months prior to planning surgery. RESULTS Twenty preoperative CD patients (65% male; 35% female) were on exclusive TPN. The mean age of the cohort was 30.8 ± 11.6 years. Mean duration of preoperative TPN treatment was 73 days (range: 24-142 days). Most patients had terminal ileal (35%) or ileocolonic CD (30%), and with stricturing (B2) phenotype. All 20 patients had significant clinical improvement in all disease activity indices at the end of preoperative TPN (baseline vs. post TPN): HBI 14.5 vs. 4.0 (p = 0.001); BMI 19.2 vs. 19.7 kg/m2 (p = 0.017); CRP 57.2 vs. 10.3 mg/L (p = 0.001); Fecal calprotectin (FC) 672 vs. 200 (μg/g); albumin 2.7 vs. 3.6 g/dL (p = 0.001). Two patients (10%) no longer required surgery after completion of exclusive TPN. CONCLUSION Exclusive preoperative TPN was found to provide significant improvement in nutritional status, and clinical and laboratory remission in severe active Crohn's patients.
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Affiliation(s)
- Eran Zittan
- Ellen and Pinchas Mamber Institute of Gastroenterology and Liver Diseases and the Center for IBD, HaEmek Medical Center, Afula 1834111, Israel; (I.M.G.); (N.K.)
- Correspondence:
| | - Ian M. Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Liver Diseases and the Center for IBD, HaEmek Medical Center, Afula 1834111, Israel; (I.M.G.); (N.K.)
- Rappaport Faculty of Medicine Technion-Israel Institute of Technology, Haifa 31096, Israel; (O.A.H.); (N.S.)
| | - Ossama A. Hatoum
- Rappaport Faculty of Medicine Technion-Israel Institute of Technology, Haifa 31096, Israel; (O.A.H.); (N.S.)
- Department of Surgery B, HaEmek Medical Center, Afula 1834111, Israel
| | - Nasser Sakran
- Rappaport Faculty of Medicine Technion-Israel Institute of Technology, Haifa 31096, Israel; (O.A.H.); (N.S.)
- Department of Surgery A, HaEmek Medical Center, Afula 1834111, Israel
| | - Nitzan Kolonimos
- Ellen and Pinchas Mamber Institute of Gastroenterology and Liver Diseases and the Center for IBD, HaEmek Medical Center, Afula 1834111, Israel; (I.M.G.); (N.K.)
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Saqui O, Fernandes G, Allard J. Central venous catheter infection in Canadian home parenteral nutrition patients: a 5-year multicenter retrospective study. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2020; 29:S34-S42. [PMID: 32324464 DOI: 10.12968/bjon.2020.29.8.s34] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
HIGHLIGHTS A lower central venous catheter (CVC) infection rate suggests an improvement in practice and education. CVC infection remains a complication that often requires significant health care resources. Use of tunneled CVC and patient education on catheter care reduces CVC infection rates. OBJECTIVES CVC infection is one of the most frequent, life-threatening complications in home parenteral nutrition (HPN) patients. Our objective was to conduct a 5-year retrospective chart review regarding CVC infections in 3 adult HPN programs. METHODS Data were collected from the Canadian HPN Registry and patient charts that include demography, infection diagnosis, blood cultures, and treatments. RESULTS Results are reported as median (range) ± standard error of mean or population frequency. Eighty-one charts were reviewed. Mean age was 51.98 ± 1.71 years. Short bowel syndrome (54.3%) was the primary diagnosis, with 36 months (range, 1324 months) median length of HPN therapy. Forty-seven subjects (58%) had infections over a 5-year period. Of these, there were 144 sepsis events. There was positive correlation (r=0.423; P<0.001) between number of infections and HPN duration. The median length of time the CVC was in place was 281 (range, 14-4380) days. There were 66.7% tunneled CVCs; 25.9% peripherally inserted central catheters (PICCs), and 7.4% implanted venous port. In this sample, there was no association between line infection and catheter type. Most patients presented with fever (58.3%) and chills (38.2%). Blood cultures were done (89.6%), and coagulase negative Staphylococcus was the resulting pathogen present in 25.7%. Patients with bloodstream infection were treated for 17.9 ± 1.2 days with combination antibiotics (22.2%). Overall, the CVC infection rate was 0.97 per 1000 catheter days. CONCLUSION We found the standard approach to infection prevention is comparable to reports in literature. However, a subset of patients with multiple CVC infections require education with an emphasis on preventive techniques in order to reduce the incidence of infection.
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Affiliation(s)
- Olivia Saqui
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - G Fernandes
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - J Allard
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Fuglsang KA, Brandt CF, Scheike T, Jeppesen PB. Differences in methodology impact estimates of survival and dependence on home parenteral support of patients with nonmalignant short bowel syndrome. Am J Clin Nutr 2020; 111:161-169. [PMID: 31562502 DOI: 10.1093/ajcn/nqz242] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/29/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In patients with intestinal failure (IF), who are receiving home parenteral support (HPS), variations between centers in estimates of survival and HPS dependency often reflect differences in population characteristics. However, variations in methodology and adherence to model assumptions may further contribute. OBJECTIVES We investigated how differences in methodology affect estimates of outcomes in IF patients. METHODS We applied different model assumptions and statistical methods to real-life outcome data from a well-characterized cohort of nonmalignant short bowel syndrome (SBS) patients. This retrospective study was based on extracts from the Copenhagen IF database and from the Danish death registry. RESULTS Estimates of mortality varied substantially, depending on the study design and statistical method. The 5-y mortality rate obtained with the Kaplan-Meier (KM) method was estimated to be 10.1% higher if patients were only followed during HPS treatment, compared with follow-up regardless of HPS treatment. The 5-y cumulative incidence of weaning off HPS was overestimated by 4.4% when inappropriately using the KM method, instead of the cumulative incidence function. The 5-y survival rates in nonmalignant SBS-IF patients who initiated HPS were 89.1% for those aged younger than 40 y, 74.8% for patients aged 40-60 y, and 52.1% for those older than 60 y. A Cox regression analysis identified age and diagnoses other than inflammatory bowel disease as significant risk factors for mortality. For HPS dependency, bowel anatomy was significantly associated with the ability to wean off, and no patients without a colon and less than 100 cm remnant of the small bowel remained continuously weaned off and alive for one year. CONCLUSIONS The large variations in outcomes illustrated in this study emphasize the importance of the appropriate selection of statistical methods. A comparison between studies is problematic, due to differences in the methods employed.
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Affiliation(s)
- Kristian Asp Fuglsang
- Department of Medical Gastroenterology and Hepatology, Rigshospitalet, Copenhagen, Denmark
| | | | - Thomas Scheike
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Palle Bekker Jeppesen
- Department of Medical Gastroenterology and Hepatology, Rigshospitalet, Copenhagen, Denmark
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19
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An international study of the quality of life of adult patients treated with home parenteral nutrition. Clin Nutr 2019; 38:1788-1796. [DOI: 10.1016/j.clnu.2018.07.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 07/01/2018] [Accepted: 07/20/2018] [Indexed: 11/18/2022]
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20
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Oke SM, Rye B, Malietzis G, Baldwin-Cleland R, Bottle A, Gabe SM, Lung PFC. Survival and CT defined sarcopenia in patients with intestinal failure on home parenteral support. Clin Nutr 2019; 39:829-836. [PMID: 30962104 DOI: 10.1016/j.clnu.2019.03.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 11/21/2018] [Accepted: 03/12/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Sarcopenia occurs in patients with intestinal failure (IF) and has been associated with poorer survival in several chronic diseases. CT can measure sarcopenia through a L3 skeletal muscle index (LSMI). We aim to describe the prevalence of sarcopenia in a section of our IF population using LSMI, & evaluate the effect of home parenteral support (PS) on LSMI & survival. Additionally, we aim to assess any association between LSMI, BMI & other anthropometric measurements. METHODS IF patients on PS treated at St Mark's Hospital between 1/1/2006-1/10/2016 were identified from a prospectively maintained database. Patients were included if they were on PS & had 2 CTs: the first ≤30 days before start of HPN (pre-PS); the second ≥100 days from PS start (post-PS). Patient records were reviewed to obtain clinical & demographic information & date of death. Anthropometric measurements & BMI contemporaneous to CT scans were recorded. RESULTS 64 patients met inclusion criteria (M:F 1:1). 83% of our cohort had LSMI below previously published thresholds for sarcopenia. Mean (SD) pre-PS LSMI was 36.5 (6.8)cm2/m2. Mean BMI pre-PS was 22.1 (4.8) kg/m2. Both BMI (22.1 kg/m2 to 23.5 kg/m2) p < 0.001) & LSMI (36.5 cm2/m2 to 38.4 cm2/m2) (p = 0.003) increased post-PS. A positive correlation was seen between BMI & LSMI pre (r = 0.47 p < 0.001) & post-PS (r = 0.37 p = 0.003). No correlation was seen between LSMI & anthropometric measurements pre-PS (p = 0.78) or post-PS (p = 0.96). 11 (17%) patients died during the study period; a low LSMI pre-PS was not a risk factor for mortality (HR 0.97 p = 0.55). CONCLUSIONS This study is the first to look at sarcopenia & survival using CT defined LSMI (CT-LSMI) in the IF population. 83% of our cohort had a pre-PS LSMI below previously published thresholds, yet we found no relationship between lower baseline LSMI & survival. This may reflect the heterogeneity of the prognoses of the IF population, or that parenteral nutrition itself affects survival. Our study showed that LSMI & BMI improved following PS but demonstrated that other anthropometric measurements had poor correlation with LSMI & showed no significant improvement overall after PS, confirming the known problems of inter-operator & patient variability of these measurements. Whilst we found significant correlation between LSMI & BMI, BMI significantly underestimated the presence & degree of sarcopenia. LSMI has the potential to provide an objective & reproducible measure of sarcopenia in IF. Future larger studies should be performed to evaluate associations with patient outcomes & utility in clinical decision making.
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Affiliation(s)
- Siddhartha M Oke
- St. Mark's Hospital, Harrow, United Kingdom; Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Beth Rye
- St. Mark's Hospital, Harrow, United Kingdom
| | - George Malietzis
- St. Mark's Hospital, Harrow, United Kingdom; Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | | | - Alex Bottle
- Department of Primary Care and Public Health, United Kingdom
| | - Simon M Gabe
- St. Mark's Hospital, Harrow, United Kingdom; Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Phillip F C Lung
- St. Mark's Hospital, Harrow, United Kingdom; Department of Surgery and Cancer, Imperial College, London, United Kingdom.
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21
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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: 18] [Impact Index Per Article: 3.6] [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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22
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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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23
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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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Hon K, Bihari S, Holt A, Bersten A, Kulkarni H. Rate of Catheter-Related Bloodstream Infections Between Tunneled Central Venous Catheters Versus Peripherally Inserted Central Catheters in Adult Home Parenteral Nutrition: A Meta-analysis. JPEN J Parenter Enteral Nutr 2018; 43:41-53. [PMID: 30035806 DOI: 10.1002/jpen.1421] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 06/05/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Tunneled central venous catheters (TCVCs) and peripherally inserted central catheters (PICC) are often used for the provision of home parenteral nutrition (HPN). There is no formal comparison being made to study the rate of catheter-related bloodstream infection (CRBSI) between TCVCs and PICC in HPN to recommend the use of 1 over the other. METHODS An online MEDLINE, PubMed, and Scopus search was conducted. Studies reporting the rate of CRBSI in HPN patients were included. DerSimonian and Laird random effects meta-analyses were used to analyze comparative studies, whereas Begg and Pilote's random effects meta-analysis was used to pool and analyze single-arm studies. RESULTS Seventeen studies (12 single-arm studies and 5 comparative studies) were included for analysis. Meta-analysis of comparative studies showed that PICC use was associated with a significantly lower rate of CRBSI (relative risk (RR) 0.40, 95% CI 0.19-0.83), whereas meta-analysis of single-arm studies revealed that the relative risk for CRBSI was not statistically significantly different from unity. CONCLUSION TCVC is more commonly used in long-term HPN. Our analysis of comparative studies showed a lower rate of CRBSI in HPN patients using PICC compared with TCVC; however, analysis of single-arm studies showed that the rate of CRBSI was comparable in PICC and TCVC use. The decision to which type of catheter is most suited for HPN patients should hence be based on the duration of treatment, level of care, patients' dexterity, as well patients' underlying comorbidities that may potentially contribute to other catheter-related complications.
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Affiliation(s)
- Kay Hon
- College of Medicine, Flinders University, South Australia, Australia
| | - Shailesh Bihari
- College of Medicine, Flinders University, South Australia, Australia.,Department of Intensive and Critical Care Unit, Flinders Medical Centre, South Australia, Australia
| | - Andrew Holt
- College of Medicine, Flinders University, South Australia, Australia.,Department of Intensive and Critical Care Unit, Flinders Medical Centre, South Australia, Australia.,South Australia Home Parenteral Nutrition Unit, Flinders Medical Centre, South Australia, Australia
| | - Andrew Bersten
- College of Medicine, Flinders University, South Australia, Australia.,Department of Intensive and Critical Care Unit, Flinders Medical Centre, South Australia, Australia
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Hawksworth JS, Desai CS, Khan KM, Kaufman SS, Yazigi N, Girlanda R, Kroemer A, Fishbein TM, Matsumoto CS. Visceral transplantation in patients with intestinal-failure associated liver disease: Evolving indications, graft selection, and outcomes. Am J Transplant 2018; 18:1312-1320. [PMID: 29498797 PMCID: PMC5992069 DOI: 10.1111/ajt.14715] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 12/11/2017] [Accepted: 02/04/2018] [Indexed: 01/25/2023]
Abstract
Intestinal failure (IF)-associated liver disease (IFALD) is widely recognized as a lethal complication of long-term parenteral nutrition. The pathophysiology of IFALD is poorly understood but appears to be multifactorial and related to the inflammatory state in the patient with IF. Visceral transplant for IFALD includes variants of intestine, liver, or combined liver-intestine allografts. Graft selection for an individual patient depends on the etiology of IF, abdominal and vascular anatomy, severity of IFALD, and potential for intestinal rehabilitation. The past decade has witnessed dramatic improvement in the management of IFALD, principally due to improved lipid emulsion formulations and the multidisciplinary care of the patient with IF. As the recognition and treatment of IFALD continue to improve, the requirement of liver-inclusive visceral grafts appears to be decreasing, representing a paradigm shift in the care of the patient with IF. This review highlights the current indications, graft selection, and outcomes of visceral transplantation for IFALD.
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Affiliation(s)
- Jason S. Hawksworth
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA,Walter Reed National Military Medical Center, Department of Surgery, Organ Transplant Service, Bethesda, MD USA
| | - Chirag S. Desai
- University of North Carolina, Department of Surgery, Division of Abdominal Transplant, Chapel Hill, NC USA
| | - Khalid M. Khan
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Stuart S. Kaufman
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Nada Yazigi
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Raffaele Girlanda
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Alexander Kroemer
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Thomas M. Fishbein
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Cal S. Matsumoto
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
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McNeice A, Scott R, Rafferty GP, Cash WJ, Turner GB. The hepatobiliary complications of malnutrition and nutritional support in adults. Ir J Med Sci 2018; 188:109-117. [DOI: 10.1007/s11845-018-1836-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 05/22/2018] [Indexed: 01/08/2023]
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Home parenteral nutrition and employment in patients with intestinal failure: Factors associated with return to employment. Clin Nutr 2018; 38:1211-1214. [PMID: 30449605 DOI: 10.1016/j.clnu.2018.04.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 04/25/2018] [Accepted: 04/30/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND & AIMS Home parenteral nutrition (HPN) is provided to patients with intestinal failure (IF). HPN can however affect the patients' quality of life and ability to remain in employment. The aim of this study was to determine the effect of HPN on employment and factors associated with the likelihood of maintaining or returning to employment while on HPN. METHODS Patients with chronic IF were identified from a prospectively maintained IF Unit database. A structured questionnaire was designed to probe employment both before and after starting HPN, intention to work and social welfare status (benefits & pensions). RESULTS A total of 196 (62.8% females, median age 53 years) patients participated in the study of which 184 (94%) patients were in full or part time employment before their illness. At the time of starting HPN, 102 (52%) patients had the desire to return to work with 19 (18%) and 48 (47%) patients returning to full time or part time employment respectively. Multivariate analysis demonstrated that the frequency of the HPN infusion per week (p = 0.045) and intention to work after starting HPN (p = 0.001) were significantly associated with returning to work. CONCLUSIONS Patients on HPN can have their employment status affected. The number of days per week on HPN and the desire of the patient to return to employment are significantly associated with employment.
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Keane N, Fragkos KC, Patel PS, Bertsch F, Mehta SJ, Di Caro S, Rahman F. Performance Status, Prognostic Scoring, and Parenteral Nutrition Requirements Predict Survival in Patients with Advanced Cancer Receiving Home Parenteral Nutrition. Nutr Cancer 2017; 70:73-82. [PMID: 29111787 DOI: 10.1080/01635581.2018.1380206] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We describe a cohort of Home Parenteral Nutrition (HPN) patients with advanced cancer in order to identify factors affecting prognosis. Demographic, anthropometric, biochemical and medical factors, Karnofsky Performance Status (KPS), Glasgow Prognostic Score (GPS), and PN requirements were recorded. Univariate and multivariate analyses were performed including Kaplan-Meier curves, Cox Regression, and correlation analyses. In total, 107 HPN patients (68 women, 39 men, mean age 57 yr) with advanced cancer were identified. The main indications for HPN were bowel obstruction (74.3%) and high output ostomies (14.3%). Cancer cachexia was present in 87.1% of patients. The hazard ratio (HR) for upper gastrointestinal and "other" cancers vs. gynaecological malignancy was 1.75 (p = 0.077) and 2.11 (p = 0.05), respectively. KPS score, GPS, PN volume, and PN potassium levels significantly predicted survival (HRKPS ≥50 vs <50 = 0.47; HRGPS = 2 vs. GPS = 0 = 3.19). In multivariate analysis, KPS and GPS remained significant predictors (p < 0.05), whilst PN volume reached borderline significance (p = 0.094). Survival was not significantly affected by the presence of metastatic disease, previous or concurrent surgery, chemo-radiotherapy, or indication for HPN (p > 0.05). Most patients passed away in their homes or hospice (77.9%). Performance status, prognostic scoring, and PN requirements may predict survival in patients with advanced cancer receiving HPN.
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Affiliation(s)
- Niamh Keane
- a Intestinal Failure Service, Gastrointestinal (GI) Services , University College London Hospitals NHS Foundation Trust , London , UK
| | - Konstantinos C Fragkos
- a Intestinal Failure Service, Gastrointestinal (GI) Services , University College London Hospitals NHS Foundation Trust , London , UK
| | - Pinal S Patel
- a Intestinal Failure Service, Gastrointestinal (GI) Services , University College London Hospitals NHS Foundation Trust , London , UK
| | - Friderike Bertsch
- a Intestinal Failure Service, Gastrointestinal (GI) Services , University College London Hospitals NHS Foundation Trust , London , UK
| | - Shameer J Mehta
- a Intestinal Failure Service, Gastrointestinal (GI) Services , University College London Hospitals NHS Foundation Trust , London , UK
| | - Simona Di Caro
- a Intestinal Failure Service, Gastrointestinal (GI) Services , University College London Hospitals NHS Foundation Trust , London , UK
| | - Farooq Rahman
- a Intestinal Failure Service, Gastrointestinal (GI) Services , University College London Hospitals NHS Foundation Trust , London , UK
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Bonnes SL, Salonen BR, Hurt RT, McMahon MT, Mundi MS. Parenteral and Enteral Nutrition—From Hospital to Home: Will It Be Covered? Nutr Clin Pract 2017; 32:730-738. [DOI: 10.1177/0884533617734491] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Sara L. Bonnes
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Bradley R. Salonen
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan T. Hurt
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Megan T. McMahon
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Manpreet S. Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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30
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Jin T, Li KX, Li PJ, Huang S, Chen XZ, Chen M, Hu QY, Shi L, Chen YY. An evaluation of nutrition intervention during radiation therapy in patients with locoregionally advanced nasopharyngeal carcinoma. Oncotarget 2017; 8:83723-83733. [PMID: 29137377 PMCID: PMC5663549 DOI: 10.18632/oncotarget.19381] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 07/12/2017] [Indexed: 11/25/2022] Open
Abstract
Purpose To evaluate the effectiveness of nutrition intervention during radiation for patients with locoregionally advanced (III-IVa) nasopharyngeal carcinoma (NPC). Materials and Methods We retrospectively reviewed 117 patients with locoregionally advanced (III-IVa) NPC treated between December 2015 and March 2016 in Zhejiang Cancer Hospital. All the patients underwent radical chemo-radiotherapy. First, all the patients were divided into the nutrition intervention group and the control group, depending on whether they accepted nutrition intervention. Repeated measures were used to analyze the change of nutritional indicators before, during, and after radiation therapy and to simultaneously compare the difference in nutritional status between the two groups at the same time point. Subsequently, the 117 patients were divided into the malnourished group (weight loss > 5%) and the non-malnourished group (weight loss ≤ 5%) according to whether their weight loss was over 5% of their body weight during radiotherapy. Chi-square tests and logistic regression analysis were used to explore the influence factors for the weight loss. Results The repeated measures showed that all indicators including weight, body mass index (BMI), albumin, pre-albumin(PA), and prognostic nutritional index (PNI) dramatically declined in both groups compared with their levels before radiation therapy (All p < 0.001). However, there was no significant difference between the intervention and non-intervention groups regarding the mean values of nutritional indicators at the same time point, that before, during, and after radiation therapy, except BMI (All p > 0.05). Logistic regression analysis revealed grade ≥ 3 radiation-induced oral mucositis as the prognostic factor for a poor nutrition status (odds ratio, OR = 3.232, p = 0.021, confidence interval, CI [1.198, 8.820]). Besides this, patients with a decrease of >15% in pre-albumin level were more likely to be malnourished (OR = 2.442, p = 0.041, CI [1.036, 5.757]). Similar to that observed in our former analysis, we did not find that existing nutrition intervention can significantly improve nutritional status (OR = 1.217, p = 0.704, CI [0.042, 3.348]). Conclusions Our study shows that the nutritional status of the patients gradually declined during treatment. We concluded that grade ≥ 3 radiation-induced oral mucositis would aggravate the extent of malnutrition during radiation therapy in patients with locoregionally advanced NPC. Pre-albumin level was a predictive marker for weight loss in patients with NPC. However, current nutrition intervention during radiation therapy can't significantly reverse nutritional status.
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Affiliation(s)
- Ting Jin
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, Zhejiang 310022, People's Republic of China.,Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, Zhejiang 310022, People's Republic of China
| | - Kai-Xin Li
- Department of Radiation Oncology, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, Fujian 362000, People's Republic of China
| | - Pei-Jing Li
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, Zhejiang 310022, People's Republic of China.,Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, Zhejiang 310022, People's Republic of China
| | - Shuang Huang
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, Zhejiang 310022, People's Republic of China.,Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, Zhejiang 310022, People's Republic of China
| | - Xiao-Zhong Chen
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, Zhejiang 310022, People's Republic of China.,Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, Zhejiang 310022, People's Republic of China
| | - Ming Chen
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, Zhejiang 310022, People's Republic of China.,Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, Zhejiang 310022, People's Republic of China
| | - Qiao-Ying Hu
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, Zhejiang 310022, People's Republic of China.,Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, Zhejiang 310022, People's Republic of China
| | - Lei Shi
- Department of Radiology, Zhejiang Cancer Hospital, Hangzhou, Zhejiang 310022, People's Republic of China.,Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, Zhejiang 310022, People's Republic of China
| | - Yuan-Yuan Chen
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hangzhou, Zhejiang 310022, People's Republic of China.,Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, Zhejiang 310022, People's Republic of China
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Parenteral Nutrition and Intestinal Failure. Nutrients 2017; 9:nu9050466. [PMID: 28481229 PMCID: PMC5452196 DOI: 10.3390/nu9050466] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/11/2017] [Accepted: 04/19/2017] [Indexed: 12/27/2022] Open
Abstract
Severe short bowel syndrome (SBS) is a major cause of chronic (Type 3) intestinal failure (IF) where structural and functional changes contribute to malabsorption and risk of micronutrient deficiencies. Chronic IF may be reversible, depending on anatomy and intestinal adaptation, but most patients require long-term nutritional support, generally in the form of parenteral nutrition (PN). SBS management begins with dietary changes and pharmacologic therapies taking into account individual anatomy and physiology, but these are rarely sufficient to avoid PN. New hormonal therapies targeting intestinal adaptation hold promise. Surgical options for SBS including intestinal transplant are available, but have significant limitations. Home PN (HPN) is therefore the mainstay of treatment for severe SBS. HPN involves chronic administration of macronutrients, micronutrients, fluid, and electrolytes via central venous access in the patient's home. HPN requires careful clinical and biochemical monitoring. Main complications of HPN are related to venous access (infection, thrombosis) and metabolic complications including intestinal failure associated liver disease (IFALD). Although HPN significantly impacts quality of life, outcomes are generally good and survival is mostly determined by the underlying disease. As chronic intestinal failure is a rare disease, registries are a promising strategy for studying HPN patients to improve outcomes.
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Prophylaxis of Venous Thromboembolism in Home Care: An Integrative Review. Home Healthc Now 2017; 35:268-276. [PMID: 28471794 DOI: 10.1097/nhh.0000000000000534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Venous thromboembolism (VTE) is a set of diseases that carries both the risk of sudden death and long-term morbidity. Several studies conducted in Brazilian hospitals have identified that most patients considered at high risk for VTE do not receive prophylactic anticoagulant prescription properly. Risk of VTE in patients under home care is unknown. The objective of this integrative review is to identify evidence regarding prophylaxis of VTE in home care. The databases PubMed/Medline, LILACS, and National Guideline Clearinghouse were searched for articles published between January 1985 and June 2015. Although there is an extensive literature and clear guidelines for the prophylaxis and treatment of VTE in the hospital environment, studies on the same subject in home care are scarce, sometimes small, and almost exclusively based on retrospective collection of chart data. Additional research on VTE prophylaxis in the home care setting is needed in order to develop evidence-based practice guidelines.
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Fuyuki A, Ohkubo H, Higurashi T, Iida H, Inoh Y, Inamori M, Nakajima A. Clinical importance of cine-MRI assessment of small bowel motility in patients with chronic intestinal pseudo-obstruction: a retrospective study of 33 patients. J Gastroenterol 2017; 52:577-584. [PMID: 27549243 DOI: 10.1007/s00535-016-1251-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/06/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although chronic intestinal pseudo-obstruction (CIPO) is a rare and extremely severe functional digestive disorder, its clinical course and severity show various patterns. We assessed small bowel peristalsis in CIPO patients using cine-MRI (video-motion MRI) and their clinical characteristics to evaluate the clinical importance of performing cine-MRI in patients with this intractable disease. METHODS The medical records of 131 patients referred to our institution with a suspected diagnosis of CIPO between 2010 and 2015 were retrospectively evaluated. Thirty-three patients (22 female/11 male; age range 16-79 years) who met the criteria for CIPO and underwent cine-MRI were enrolled. Mean luminal diameter (MLD), contraction ratio (CR), and contraction cycle (CC) were determined and compared with these parameters in healthy volunteers. Clinical outcomes in patients with CIPO were also evaluated. RESULTS The median follow-up time was 25.2 months (range, 1-65 months). Of the 33 patients with CIPO, 23 (70 %) showed apparently disturbed small intestinal peristalsis, whereas 10 (30 %) did not. The percentage of patients requiring intravenous alimentation was significantly higher (p = 0.03), and the mean serum albumin level was significantly lower (p = 0.04), in patients with than without impaired small intestinal peristalsis. Although both cine-MRI and CT findings in the latter ten cases were within the normal range, MLD and CR differed significantly from healthy volunteers. CONCLUSIONS Cine-MRI is useful in predicting severe clinical features in patients with CIPO, and in detecting slightly impaired small contractility that cannot be detected on CT.
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Affiliation(s)
- Akiko Fuyuki
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Hidenori Ohkubo
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Takuma Higurashi
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Hiroshi Iida
- Department of Medical Education, Yokohama City University School of Medicine, Yokohama, Japan
| | - Yumi Inoh
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Masahiko Inamori
- Department of Medical Education, Yokohama City University School of Medicine, Yokohama, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fuku-ura, Kanazawa-ku, Yokohama, 236-0004, Japan.
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34
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Pironi L, Konrad D, Brandt C, Joly F, Wanten G, Agostini F, Chambrier C, Aimasso U, Zeraschi S, Kelly D, Szczepanek K, Jukes A, Di Caro S, Theilla M, Kunecki M, Daniels J, Serlie M, Poullenot F, Wu J, Cooper SC, Rasmussen HH, Compher C, Seguy D, Crivelli A, Pagano MC, Hughes SJ, Guglielmi FW, Kozjek NR, Schneider SM, Gillanders L, Ellegard L, Thibault R, Matras P, Zmarzly A, Matysiak K, Van Gossum A, Forbes A, Wyer N, Taus M, Virgili NM, O'Callaghan M, Chapman B, Osland E, Cuerda C, Sahin P, Jones L, Lee ADW, Bertasi V, Orlandoni P, Izbéki F, Spaggiari C, Díez MB, Doitchinova-Simeonova M, Garde C, Serralde-Zúñiga AE, Olveira G, Krznaric Z, Czako L, Kekstas G, Sanz-Paris A, Jáuregui EP, Murillo AZ, Schafer E, Arends J, Suárez-Llanos JP, Shaffer J, Lal S. Clinical classification of adult patients with chronic intestinal failure due to benign disease: An international multicenter cross-sectional survey. Clin Nutr 2017; 37:728-738. [PMID: 28483328 DOI: 10.1016/j.clnu.2017.04.013] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/19/2017] [Accepted: 04/11/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS The aim of the study was to evaluate the applicability of the ESPEN 16-category clinical classification of chronic intestinal failure, based on patients' intravenous supplementation (IVS) requirements for energy and fluids, and to evaluate factors associated with those requirements. METHODS ESPEN members were invited to participate through ESPEN Council representatives. Participating centers enrolled adult patients requiring home parenteral nutrition for chronic intestinal failure on March 1st 2015. The following patient data were recorded though a structured database: sex, age, body weight and height, intestinal failure mechanism, underlying disease, IVS volume and energy need. RESULTS Sixty-five centers from 22 countries enrolled 2919 patients with benign disease. One half of the patients were distributed in 3 categories of the ESPEN clinical classification. 9% of patients required only fluid and electrolyte supplementation. IVS requirement varied considerably according to the pathophysiological mechanism of intestinal failure. Notably, IVS volume requirement represented loss of intestinal function better than IVS energy requirement. A simplified 8 category classification of chronic intestinal failure was devised, based on two types of IVS (either fluid and electrolyte alone or parenteral nutrition admixture containing energy) and four categories of volume. CONCLUSIONS Patients' IVS requirements varied widely, supporting the need for a tool to homogenize patient categorization. This study has devised a novel, simplified eight category IVS classification for chronic intestinal failure that will prove useful in both the clinical and research setting when applied together with the underlying pathophysiological mechanism of the patient's intestinal failure.
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Affiliation(s)
- Loris Pironi
- Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Denise Konrad
- Home Nutrition Support, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Francisca Joly
- Centre for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Federica Agostini
- Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Cecile Chambrier
- Unité de Nutrition Clinique Intensive, Hospices Civils de Lyon, Hôpital de la Croix Rousse, Lyon, France
| | | | - Sarah Zeraschi
- Nutrition Team Office, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Darlene Kelly
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - Amelia Jukes
- University Hospital of Wales, Cardiff, United Kingdom
| | | | | | | | - Joanne Daniels
- Nottingham University Hospital NHS Trust, Nottingham, United Kingdom
| | | | - Florian Poullenot
- Service de Gastroentérologie, Hôpital Haut-Lévêque, CHU de Bordeaux, Pessac, France
| | - Jian Wu
- Intestinal Failure Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Sheldon C Cooper
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Henrik H Rasmussen
- Centre for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Charlene Compher
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - David Seguy
- Service de Nutrition, CHRU de Lille, Lille, France
| | - Adriana Crivelli
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante de Intestino, Hospital Universitario Fundacion Favaloro, Buenos Aires, Argentina
| | | | - Sarah-Jane Hughes
- Belfast Health and Social Care Trust, Belfast, Northern Ireland, United Kingdom
| | | | | | - Stéphane M Schneider
- Gastroenterology and Clinical Nutrition, CHU of Nice, University of Nice Sophia Antipolis, Nice, France
| | - Lyn Gillanders
- National Intestinal Failure Service, Auckland City Hospital, Auckland, New Zealand
| | - Lars Ellegard
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Ronan Thibault
- Gastrointestinal and Nutritional Rehabilitation Medicine, Clinique Saint Yves, Rennes Cedex, France
| | - Przemysław Matras
- Department of General and Transplant Surgery and Clinical Nutrition, Medical University of Lublin, Lublin, Poland
| | - Anna Zmarzly
- Department of Clinical Nutrition, J. Gromkowski City Hospital, Wroclaw, Poland
| | - Konrad Matysiak
- Centre for Intestinal Failure, Department of General, Endocrinological and Gastroenterological Surgery, Poznan University of Medical Science, Poznań, Poland
| | - Andrè Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - Alastair Forbes
- Norfolk and Norwich University Hospital, University of East Anglia, Norwich, United Kingdom
| | - Nicola Wyer
- University Hospital, Coventry, United Kingdom
| | - Marina Taus
- Centro di Riferimento Regionale NAD Ospedali Riuniti Ancona, Ancona, Italy
| | - Nuria M Virgili
- Unitat Nutrició i Dietética, Servei Endocrinologia i Nutrició, Hospital Universitari de Bellvitge, Barcelona, Spain
| | | | | | - Emma Osland
- Royal Brisbane and Women's Hospital, Herston, Australia
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | | | - Lynn Jones
- Royal Prince Alfred Hospital, Camperdown, Australia
| | - Andre D W Lee
- Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Paolo Orlandoni
- Centro di Riferimento Regionale NAD, INRCA -IRCCS, Ancona, Italy
| | - Ferenc Izbéki
- Szent György Teaching Hospital of County Fejér, Székesfehérvár, Hungary
| | | | - Marta Bueno Díez
- Servei d'Endocrinologia i Nutrició, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | | | - Carmen Garde
- Hospital Universitario Donostia, San Sebastian, Spain
| | | | | | - Zeljko Krznaric
- Centre of Clinical Nutrition, Department of Medicine, University Hospital Centre, Zagreb, Croatia
| | - Laszlo Czako
- First Department of Internal Medicine, Szeged, Hungary
| | | | | | | | | | - Eszter Schafer
- Magyar Honvedseg Egészségügyi Központ (MHEK), Budapest, Hungary
| | - Jann Arends
- Department of Medicine, Oncology and Hematology, University of Freiburg, Germany
| | - José P Suárez-Llanos
- Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Jon Shaffer
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
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Nakamura T, Sasaki J, Asari Y, Sato T, Torii S, Watanabe M. Complications after implantation of subcutaneous central venous ports (PowerPort Ⓡ). Ann Med Surg (Lond) 2017; 17:1-6. [PMID: 28348733 PMCID: PMC5358939 DOI: 10.1016/j.amsu.2017.03.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 03/08/2017] [Accepted: 03/08/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The aim of our study was revised as follows: to clarify the postoperative complications of multifunctional central venous ports and the risk factors for such complications to promote the safe use of the PowerPort system in the hospital. METHODS The study group comprised 132 patients in whom implantable central venous access ports (PowerPortⓇ) were placed in our hospital from March 2014 through December 2015. The approach used for port placement was the subclavian vein in 43 patients (33%), the internal jugular vein in 87 patients (66%), and the femoral vein in 2 patients (1%). RESULTS Postoperative complications occurred in 8 patients (6%). The catheter was removed because of infection in 4 patients and catheter kinking in 1 patient. Port extravasation occurred in 3 patients. No patient had catheter pinch-off. The mean operation time was 74 min (range, 32 to 171). No patients had intraoperative bleeding or pneumothorax. Benign disease was a risk factor for postoperative complications (p = 0.009). CONCLUSION PowerPort is a multifunctional port. Benign disease was a risk factor for postoperative complications. Because many types of subcutaneously implanted ports are used in our hospital, we had to inform the hospital staff about the functions of PowerPort.
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Affiliation(s)
| | - Jiichiro Sasaki
- Division of Clinical Oncology, Department of Comprehensive Medicine, Research and Development Center for New Medical Frontiers, Kitasato University School of Medicine, Japan
| | - Yasushi Asari
- Department of Emergency and Disaster Medicine, Kitasato University School of Medicine, Japan
| | - Takeo Sato
- Department of Surgery, Kitasato University School of Medicine, Japan
| | - Shinzo Torii
- Department of Clinical Skills Education, Kitasato University School of Medicine, Japan
| | - Masahiko Watanabe
- Department of Surgery, Kitasato University School of Medicine, Japan
- Corresponding author. Kitasato University School of Medicine, Department of Surgery, 1-15-1 Kitasato, Sagamihara, Kanagawa 252-0374, Japan.Kitasato University School of MedicineDepartment of Surgery1-15-1 KitasatoSagamiharaKanagawa252-0374Japan
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DeLegge MH, Borak G, Moore N. Central Venous Access in the Home Parenteral Nutrition Population–You PICC. JPEN J Parenter Enteral Nutr 2017; 29:425-8. [PMID: 16224035 DOI: 10.1177/0148607105029006425] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Central venous access is imperative for the delivery of home parenteral nutrition (HPN). Peripherally inserted central catheters (PICC) are being used more frequently for the delivery of HPN. There is an abundance of short-term information on the use of PICC in the hospitalized patient. However, there are no data comparing the use of PICC to other central venous access devices (OCVAD; Hickman, port) for the delivery of HPN. Catheter-related infections (CRI) are the most common cause of hospital readmission for the HPN patients. METHODS A retrospective analysis was performed from the Digestive Disease Center HPN database at the Medical University of South Carolina and the open architecture clinical information system (OACIS) hospital and clinic reporting system. All CRI were analyzed and compared between patients with PICC and OCVAD. The PICC group and the OCVAD group were further broken down into diabetic patients and nondiabetic patients, and the incidence of CRI was compared within those groups. RESULTS HPN patients with PICC had a statistically significant increase (p < .01) of CRI as compared with OCVAD within our HPN patients. There was no statistically significant increase in CRI between diabetic and nondiabetic patients. CONCLUSIONS The use of PICC for HPN may be associated with an increase in CRI. A prospective, randomized trial in the HPN population between PICC and OCVAD must be performed.
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Affiliation(s)
- Mark H DeLegge
- Section of Nutrition, Digestive Disease Center, Medical University of South Carolina, Charleston, 29425, USA.
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Brown CR, DiBaise JK. Intestinal Rehabilitation: A Management Program for Short-Bowel Syndrome. Prog Transplant 2016; 14:290-6; quiz 297-8. [PMID: 15663014 DOI: 10.1177/152692480401400404] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Over the last 3 decades, there has been significant improvement in the survival and quality of life of patients who require home parenteral nutrition; however, parenteral nutrition remains costly, is associated with multiple complications, and does not promote the function of the remaining bowel. Intestinal rehabilitation refers to the process of restoring enteral autonomy and decreasing dependence on parenteral nutrition by utilizing dietary, pharmacological, and, occasionally, surgical interventions. A major focus of research has been to identify a trophic factor that will enhance adaptation of the remaining gastrointestinal tract following massive gut resection and allow enteral autonomy. Whether intestinal rehabilitation occurs as the result of increased intestinal adaptation or as the result of a comprehensive approach to care has yet to be determined. This article reviews intestinal failure as the result of short-bowel syndrome and the management strategy of an intestinal rehabilitation program in the care of these patients.
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Affiliation(s)
- Cindy R Brown
- Department of Surgery, University of Nebraska Medical Center, Omaha, Neb., USA
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Walthers CM, Lyall CJ, Nazemi AK, Rana PV, Dunn JCY. Collagen and heparan sulfate coatings differentially alter cell proliferation and attachment in vitro and in vivo. TECHNOLOGY 2016; 4:159-169. [PMID: 28713850 PMCID: PMC5507618 DOI: 10.1142/s2339547816400033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Tissue engineering is an innovative field of research applied to treat intestinal diseases. Engineered smooth muscle requires dense smooth muscle tissue and robust vascularization to support contraction. The purpose of this study was to use heparan sulfate (HS) and collagen coatings to increase the attachment of smooth muscle cells (SMCs) to scaffolds and improve their survival after implantation. SMCs grown on biologically coated scaffolds were evaluated for maturity and cell numbers after 2, 4 and 6 weeks in vitro and both 2 and 6 weeks in vivo. Implants were also assessed for vascularization. Collagen-coated scaffolds increased attachment, growth and maturity of SMCs in culture. HS-coated implants increased angiogenesis after 2 weeks, contributing to an increase in SMC survival and growth compared to HS-coated scaffolds grown in vitro. The angiogenic effects of HS may be useful for engineering intestinal smooth muscle.
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Affiliation(s)
- Christopher M Walthers
- Department of Bioengineering and Department of Surgery, University of California, Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Chase J Lyall
- Department of Bioengineering and Department of Surgery, University of California, Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Alireza K Nazemi
- Department of Bioengineering and Department of Surgery, University of California, Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Puneet V Rana
- Department of Bioengineering and Department of Surgery, University of California, Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - James C Y Dunn
- Department of Bioengineering and Department of Surgery, University of California, Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
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Abstract
Despite recent therapeutic advances, patients with Crohn's disease (CD) continue to experience high recurrence with cumulative structural damage and ultimate loss of nutritional autonomy. With short bowel syndrome, strictures, and enteric fistulae being the underlying pathology, CD is the second common indication for home parenteral nutrition (HPN). With development of intestinal failure, nutritional management including HPN is required as a rescue therapy. Unfortunately, some patients do not escape the HPN-associated complications. Therefore, the concept of gut rehabilitation has evolved as part of the algorithmic management of these patients, with transplantation being the ultimate life-saving therapy. With type 2 intestinal failure, comprehensive rehabilitative measures including nutritional care, pharmacologic manipulation, autologous reconstruction, and bowel lengthening is often successful, particularly in patients with quiescent disease. With type 3 intestinal failure, transplantation is the only life-saving treatment for patients with HPN failure and intractable disease. With CD being the second common indication for transplantation in adults, survival outcome continues to improve because of surgical innovation, novel immunosuppression, and better postoperative care. Despite being a rescue therapy, the procedure has achieved survival rates similar to other solid organs, and comparable to those who continue to receive HPN therapy. With similar technical, immunologic, and infectious complications, survival is similar in the CD and non-CD recipients. Full nutritional autonomy is achievable in most survivors with better quality of life and long-term cost-effectiveness. CD recurrence is rare with no impact on graft function. Further progress is anticipated with new insights into the pathogenesis of CD and mechanisms of transplant tolerance.
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Steiger E, Ireton-Jones C. The Evolution of Home Parenteral Nutrition in the United States. Nutr Clin Pract 2016. [DOI: 10.1177/088453360101600407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Brandt CF, Hvistendahl M, Naimi RM, Tribler S, Staun M, Brøbech P, Jeppesen PB. Home Parenteral Nutrition in Adult Patients With Chronic Intestinal Failure: The Evolution Over 4 Decades in a Tertiary Referral Center. JPEN J Parenter Enteral Nutr 2016; 41:1178-1187. [DOI: 10.1177/0148607116655449] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Christopher Filtenborg Brandt
- Department of Medical Gastroenterology CA 2-12-1, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mark Hvistendahl
- Department of Medical Gastroenterology CA 2-12-1, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Rahim M. Naimi
- Department of Medical Gastroenterology CA 2-12-1, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Siri Tribler
- Department of Medical Gastroenterology CA 2-12-1, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Michael Staun
- Department of Medical Gastroenterology CA 2-12-1, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Per Brøbech
- Department of Medical Gastroenterology CA 2-12-1, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Palle Bekker Jeppesen
- Department of Medical Gastroenterology CA 2-12-1, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Dibb M, Soop M, Teubner A, Shaffer J, Abraham A, Carlson G, Lal S. Survival and nutritional dependence on home parenteral nutrition: Three decades of experience from a single referral centre. Clin Nutr 2016; 36:570-576. [PMID: 26972088 DOI: 10.1016/j.clnu.2016.01.028] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 01/14/2016] [Accepted: 01/30/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Home parenteral nutrition (HPN) is the mainstay of treatment for patients with Type 3 intestinal failure (IF), however long term data on mortality and nutritional outcomes are limited. OBJECTIVES To assess the long-term survival and requirements for ongoing HPN in patients receiving treatment at a UK national referral centre for intestinal failure. METHODS Patients with IF who received HPN for more than 3 months at this Intestinal Failure Unit between 1978 and 2011 had their clinical records reviewed. SPSS 20 was utilised to perform Cox regression analysis and generate Kaplan Meier curves, with the aim of identifying factors associated with death and the continued need for HPN. RESULTS Case notes from 545 patients were reviewed. Overall survival (OS) in patients without malignancy at commencement of IF was 93%, 71%, 59% and 28% at 1, 5, 10 and 20 years after starting treatment. Crohn's disease, mesenteric ischaemia and chronic intestinal pseudo-obstruction were associated with a better OS than scleroderma and radiation enteritis on multivariate analysis. Older age at onset of IF was associated with poor OS, while shorter small bowel length or central line sepsis was not. 15% (25/170) of deaths were due to complications of HPN (central line sepsis = 10, IF-associated liver disease = 15). Continued HPN dependence in survivors was 83%, 63%, 59% and 53% at 1, 5, 10 and 15 years, respectively. Among the 153 patients without malignancy who achieved nutritional independence from HPN, 77 (50.3%) did so after surgical reconstruction of the alimentary tract (HPN duration mean 19 months, range 3-126 months). 76 patients (49.7%) weaned from HPN without undergoing surgical reconstruction. CONCLUSION This is the largest reported data set on long-term survival and dependence on HPN and will inform the indications, benefits and risks of treatment in disease specific groups. A significant proportion of patients achieved nutritional autonomy without surgical intervention.
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Affiliation(s)
- Martyn Dibb
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, United Kingdom.
| | - Mattias Soop
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, United Kingdom
| | - Antje Teubner
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, United Kingdom
| | - Jon Shaffer
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, United Kingdom
| | - Arun Abraham
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, United Kingdom
| | - Gordon Carlson
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, United Kingdom
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, United Kingdom
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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: 461] [Impact Index Per Article: 57.6] [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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Evidence of Absorptive Function in vivo in a Neo-Formed Bio-Artificial Intestinal Segment Using a Rodent Model. J Gastrointest Surg 2016; 20:34-42; discussion 42. [PMID: 26464017 DOI: 10.1007/s11605-015-2974-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 09/28/2015] [Indexed: 02/06/2023]
Abstract
A promising therapeutic approach for intestinal failure consists in elongating the intestine with a bio-engineered segment of neo-formed autologous intestine. Using an acellular biologic scaffold (ABS), we, and others, have previously developed an autologous bio-artificial intestinal segment (BIS) that is morphologically similar to normal bowel in rodents. This neo-formed BIS is constructed with the intervention of naïve stem cells that repopulate the scaffold in vivo, and over a period of time, are transformed in different cell populations typical of normal intestinal mucosa. However, no studies are available to demonstrate that such BIS possesses functional absorptive characteristics necessary to render this strategy a possible therapeutic application. The aim of this study was to demonstrate that the BIS generated has functional absorptive capacity. Twenty male August × Copenhagen-Irish (ACI) rats were used for the study. Two-centimeter sections of ABS were transplanted in the anti-mesenteric border of the small bowel. Animals were studied at 4, 8, and 12 weeks post-engraftment. Segments of intestine with preserved vascular supply and containing the BIS were isolated and compared to intestinal segments of same length in sham control animals (n = 10). D-Xylose solution was introduced in the lumen of the intestinal segments and after 2 h, urine and blood were collected to evaluate D-Xylose levels. Quantitative analysis was performed using ELISA. Morphologic, ultrastructural, and indirect functional absorption analyses were also performed. We observed neo-formed intestinal tissue with near-normal mucosa post-implantation as expected from our previously developed model. Functional characteristics such as morphologically normal enterocytes (and other cell types) with presence of brush borders and preserved microvilli by electron microscopy, preserved water, and ion transporters/channels (by aquaporin and cystic fibrosis transmembrane conductance regulator (CFTR)) were also observed. The capacity of BIS containing neo-formed mucosa to increase absorption of d-Xylose in the blood compared to normal intestine was also confirmed. With this study, we demonstrated for the first time that BIS obtained from ABS has functional characteristics of absorption confirming its potential for therapeutic interventions.
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Edakkanambeth Varayil J, Yadav S, Miles JM, Okano A, Kelly DG, Hurt RT, Mundi MS. Hyperglycemia During Home Parenteral Nutrition Administration in Patients Without Diabetes. JPEN J Parenter Enteral Nutr 2015; 41:672-677. [DOI: 10.1177/0148607115606116] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Jithinraj Edakkanambeth Varayil
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
- Second Department of Internal Medicine, Charles University Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Siddhant Yadav
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - John M. Miles
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Akiko Okano
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Darlene G. Kelly
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Ryan T. Hurt
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
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Adaba F, Uppara M, Iqbal F, Mallappa S, Vaizey CJ, Gabe SM, Warusavitarne J, Nightingale JMD. Chronic cholestasis in patients on parenteral nutrition: the influence of restoring bowel continuity after mesenteric infarction. Eur J Clin Nutr 2015; 70:189-93. [DOI: 10.1038/ejcn.2015.147] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 07/18/2015] [Accepted: 07/25/2015] [Indexed: 01/03/2023]
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DiMarco RL, Dewi RE, Bernal G, Kuo C, Heilshorn SC. Protein-engineered scaffolds for in vitro 3D culture of primary adult intestinal organoids. Biomater Sci 2015; 3:1376-85. [PMID: 26371971 DOI: 10.1039/c5bm00108k] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Though in vitro culture of primary intestinal organoids has gained significant momentum in recent years, little has been done to investigate the impact of microenvironmental cues provided by the encapsulating matrix on the growth and development of these fragile cultures. In this work, the impact of various in vitro culture parameters on primary adult murine organoid formation and growth are analyzed with a focus on matrix properties and geometric culture configuration. The air-liquid interface culture configuration was found to result in enhanced organoid formation relative to a traditional submerged configuration. Additionally, through use of a recombinantly engineered extracellular matrix (eECM), the effects of biochemical and biomechanical cues were independently studied. Decreasing mechanical stiffness and increasing cell adhesivity were found to increase organoid yield. Tuning of eECM properties was used to obtain organoid formation efficiency values identical to those observed in naturally harvested collagen I matrices but within a stiffer construct with improved ease of physical manipulation. Increased ability to remodel the surrounding matrix through mechanical or enzymatic means was also shown to enhance organoid formation. As the engineering and tunability of recombinant matrices is essentially limitless, continued property optimization may result in further improved matrix performance and may help to identify additional microenvironmental cues that directly impact organoid formation, development, differentiation, and functional behavior. Continued culture of primary organoids in recombinant matrices could therefore prove to be largely advantageous in the field of intestinal tissue engineering for applications in regenerative medicine and in vitro tissue mimics.
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Catheter-related complications in long-term home parenteral nutrition patients with chronic intestinal failure. J Vasc Access 2015; 13:490-7. [PMID: 23258588 DOI: 10.5301/jva.5000133] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2012] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Home Parenteral Nutrition is a therapeutic option to improve quality of life in chronic intestinal failure. AIMS To describe frequency of complications both in cancer and noncancer patients. METHODS This study was performed on 270 adult patients (52% with cancer, 48% without cancer) followed for a total of 371 years of treatment. Mean duration of therapy was 191±181 for cancer and 830±1168 days/patient for noncancer. The treatment was administered by a competent, dedicated provider. Patients received our prescribed "all-in-one admixtures" at their homes. RESULTS Catheter-related complications/1000-days-catheter was 1.40; mechanical complications were comparable in cancer (0.82) and noncancer (0.91) patients while a statistically significant difference was observed between cancer (0.71) and noncancer (0.46) patients for sepsis. Bacterial infections were more frequent in noncancer, mycotic infections primarily affected cancer patients. In our experience 49% of the patients were readmitted, with a low incidence rate of 0.89/1000 days-catheter. The incidence of hepatobiliary complications in our population was 65%. The degree of liver damage was related to short bowel syndrome and to length of treatment. CONCLUSIONS This study indicated that cancer patients are more vulnerable to CVC-related infections during Home Parenteral Nutrition and that a safer Home Parenteral Nutrition protocol should be adopted in order to contain CVC-related complications.
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Barone M, Viggiani MT, Amoruso A, Licinio R, Iannone A, Montenegro L, Scavo MP, Addante I, Di Leo A. Influence of age and type of underlying disease on complications related to home enteral nutrition: a single Italian center experience. JPEN J Parenter Enteral Nutr 2014; 38:991-5. [PMID: 23934935 DOI: 10.1177/0148607113498422] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND No data about the influence of age and underlying diseases on home enteral nutrition (HEN)-related complications are reported in the literature. Herein, we retrospectively investigated this issue by analyzing HEN-related complications in a cohort of consecutive patients grouped according to the underlying disease and age. MATERIAL AND METHODS We reviewed the medical records of 101 patients referring to our team in 2007-2010 to obtain patients' demographic data, age, nutrition status, duration of HEN treatment, and type of HEN-related complications. They were divided in cancer and neurologic patients and subgrouped on the basis of their age. HEN-related complications were expressed as complication rates. RESULTS Patients with neurological diseases suffered a significantly higher number of complications as compared with cancer patients (P = .04). Age did not significantly influence complication rates. The mechanical complications were the most frequent. The majority of HEN-related complications were resolved at home. CONCLUSION Our data strongly suggest that HEN-related complications are influenced by underlying diseases and not by age. In neurologic patients, dementia, loss of autonomy, and the different therapies administered by PEG probably play an important role in increasing the number of HEN-related complications as compared with cancer patients. The most frequent complications can be managed at home, reducing the costs of hospitalizations and discomfort for the patient.
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Affiliation(s)
- Michele Barone
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Maria Teresa Viggiani
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Annabianca Amoruso
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Raffaele Licinio
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Andrea Iannone
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Lucia Montenegro
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Maria Principia Scavo
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Irene Addante
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Alfredo Di Leo
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
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