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Chiba M, Masumoto K, Kaji T, Matsuura T, Morii M, Fagbemi A, Hill S, Pakarinen MP, Protheroe S, Urs A, Chen ST, Sakui S, Udagawa E, Wada M. Efficacy and Safety of Teduglutide in Infants and Children With Short Bowel Syndrome Dependent on Parenteral Support. J Pediatr Gastroenterol Nutr 2023; 77:339-346. [PMID: 37364133 PMCID: PMC10412081 DOI: 10.1097/mpg.0000000000003867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 06/08/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVES Our objective was to evaluate the short- and long-term safety and efficacy of teduglutide treatment in infants and children with short bowel syndrome with intestinal failure (SBS-IF). METHODS Two open-label phase 3 studies and 1 extension study investigated the short- and long-term safety and efficacy of teduglutide (0.05 mg/kg/day) in infants and children with SBS-IF: NCT03571516, 24-week study of infants who were randomized to receive teduglutide or standard of care (SoC); NCT02980666, 24-week study of infants and children who all received teduglutide; and NCT03268811, 24-week extension study of patients who completed NCT02980666 (patients could receive up to 48 weeks of total treatment). RESULTS Twelve infants and 8 children enrolled in the core studies, and 2 infants and 7 children in the extension study. After 24 weeks of treatment, parenteral support (PS) requirements reduced by ≥20% from baseline for 4 infants (57.1%) and 4 children (66.7%) receiving teduglutide and for 2 infants receiving SoC (50.0%). One infant (50.0%) and 4 children (80.0%) receiving teduglutide maintained the ≥20% reduction in PS at 48 weeks of treatment. Two children receiving teduglutide achieved enteral autonomy, after 12 weeks and 28 weeks of treatment, respectively. All adverse events (AEs) were in line with known impacts of SBS-IF and adverse reactions to teduglutide. Only one serious AE (abdominal pain) was considered related to teduglutide. CONCLUSIONS Short- and long-term treatment with teduglutide resulted in clinically meaningful reductions in PS requirements for infants and children with SBS-IF. Teduglutide was well tolerated, and efficacy improved with longer-term treatment.
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Affiliation(s)
- Masahiro Chiba
- From the Division of Pediatric Surgery, Department of Surgery, Showa University, Tokyo, Japan
| | - Kouji Masumoto
- the Department of Pediatric Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tatsuru Kaji
- the Department of Pediatric Surgery, Research Field in Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Toshiharu Matsuura
- the Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mayako Morii
- the Department of Pediatric Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Andrew Fagbemi
- the Department of Paediatric Gastroenterology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Susan Hill
- the Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children, NHS Foundation Trust and UCL Institute of Child Health, London, UK
| | - Mikko P. Pakarinen
- the Pediatric Research Center, Children’s Hospital, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Susan Protheroe
- the Department of Gastroenterology and Nutrition, Birmingham Women and Children’s Hospital, Birmingham, UK
| | - Arun Urs
- the Department of Paediatric Gastroenterology, Sheffield Children’s Hospital, Sheffield, UK
| | - Szu-Ta Chen
- Takeda Development Center Americas, Inc., Boston, MA, USA
| | - Sho Sakui
- Statistical and Quantitative Sciences, Data Sciences Institute, Takeda Pharmaceutical Company Limited, Osaka, Japan
| | - Eri Udagawa
- Japan Medical Office, Takeda Pharmaceutical Company Limited, Tokyo, Japan
| | - Motoshi Wada
- the Department of Pediatric Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
- the Division of Pediatric Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Japan
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Sukhotnik I, Levi R, Moran-Lev H. Impact of Dietary Protein on the Management of Pediatric Short Bowel Syndrome. Nutrients 2023; 15:2826. [PMID: 37447153 DOI: 10.3390/nu15132826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/15/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Essential amino acids (AAs) play a key role in stimulating intestinal adaptation after massive small gut resection. The nutritional effect of dietary amino acids during intestinal regrowth has received considerable attention in recent years. This review explores the significance of dietary amino acids in the nutritional management of infants and children with intestinal failure and short bowel syndrome (SBS) as reported in the medical literature over the last three decades. A literature search was conducted using electronic databases. Breast milk emerged as the first-line enteral regimen recommended for infants with SBS. Hydrolyzed formulas (HFs) or amino acid formulas (AAFs) are recommended when breast milk is not available or if the infant cannot tolerate whole protein milk. The superiority of AAFs over HFs has never been demonstrated. Although glutamine (GLN) is the main fuel for enterocytes, GLN supplementation in infants with SBS showed no difference in the child's dependence upon parenteral nutrition (PN). Circulating citrulline is considered a major determinant of survival and nutritional prognosis of SBS patients. Early enteral nutrition and dietary supplementation of AAs following bowel resection in children are essential for the development of intestinal adaptation, thereby eliminating the need for PN.
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Affiliation(s)
- Igor Sukhotnik
- Department of Pediatric Surgery, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., Tel Aviv 6423906, Israel
| | - Reut Levi
- Department of Pediatric Gastroenterology, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., Tel Aviv 6423906, Israel
| | - Hadar Moran-Lev
- Department of Pediatric Gastroenterology, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann St., Tel Aviv 6423906, Israel
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3
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Huang Y, Jiao J, Yao D, Guo F, Li Y. Altered fecal microbiome and metabolome profiles in rat models of short bowel syndrome. Front Microbiol 2023; 14:1185463. [PMID: 37362931 PMCID: PMC10289890 DOI: 10.3389/fmicb.2023.1185463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
Introduction Short bowel syndrome (SBS) is featured by impaired nutrients and fluids absorption due to massive small intestine resection. Gut dysbiosis has been implicated in SBS, this study aimed to characterize the metagenomic and metabolomic profiles of SBS and identify potential therapeutic targets. Methods Fecal samples from SBS and Sham rats (n = 8 per group) were collected for high-throughput metagenomic sequencing. Fecal metabolomics was measured by untargeted liquid chromatography-mass spectrometry. Results We found that the species-level α-diversity significantly decreased in SBS rats, accompanied by altered microbiome compositions. The beneficial anaerobes from Firmicutes and Bacteroidetes were depleted while microorganisms from Lactobacillus, Escherichia, Enterococcus, and Streptococcus were enriched in faces from SBS rats. LEfSe analysis identified 17 microbial species and 38 KEGG modules that were remarkably distinct between SBS and Sham rats. In total, 1,577 metabolites with known chemical identity were detected from all samples, among them, 276 metabolites were down-regulated and 224 metabolites were up-regulated in SBS group. The typical signatures of SBS fecal metabolome comprised reduced short-chain fatty acids and products of amino acid metabolism (indole derivatives and p-cresol), as well as altered bile acid spectrum. We revealed 215 robust associations between representative differentially abundant microbial species and metabolites, the species with the same changing trend tended to have a similar correlation with some certain metabolites. Conclusion The fecal microbiome and metabolome significantly altered in SBS. Our findings may lay the foundation for developing new strategies to facilitate intestinal adaptation in SBS patients.
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Affiliation(s)
- Yuhua Huang
- Department of General Surgery, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Jian Jiao
- Department of General Surgery, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Danhua Yao
- Department of General Surgery, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Feilong Guo
- Department of General Surgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Yousheng Li
- Department of General Surgery, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
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Caporilli C, Giannì G, Grassi F, Esposito S. An Overview of Short-Bowel Syndrome in Pediatric Patients: Focus on Clinical Management and Prevention of Complications. Nutrients 2023; 15:nu15102341. [PMID: 37242224 DOI: 10.3390/nu15102341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/26/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
Short-bowel syndrome (SBS) in pediatric age is defined as a malabsorptive state, resulting from congenital malformations, significant small intestine surgical resection or disease-associated loss of absorption. SBS is the leading cause of intestinal failure in children and the underlying cause in 50% of patients on home parental nutrition. It is a life-altering and life-threatening disease due to the inability of the residual intestinal function to maintain nutritional homeostasis of protein, fluid, electrolyte or micronutrient without parenteral or enteral supplementation. The use of parenteral nutrition (PN) has improved medical care in SBS, decreasing mortality and improving the overall prognosis. However, the long-term use of PN is associated with the incidence of many complications, including liver disease and catheter-associated malfunction and bloodstream infections (CRBSIs). This manuscript is a narrative review of the current available evidence on the management of SBS in the pediatric population, focusing on prognostic factors and outcome. The literature review showed that in recent years, the standardization of management has demonstrated to improve the quality of life in these complex patients. Moreover, the development of knowledge in clinical practice has led to a reduction in mortality and morbidity. Diagnostic and therapeutic decisions should be made by a multidisciplinary team that includes neonatologists, pediatric surgeons, gastroenterologists, pediatricians, nutritionists and nurses. A significant improvement in prognosis can occur through the careful monitoring of nutritional status, avoiding dependence on PN and favoring an early introduction of enteral nutrition, and through the prevention, diagnosis and aggressive treatment of CRSBIs and SIBO. Multicenter initiatives, such as research consortium or data registries, are mandatory in order to personalize the management of these patients, improve their quality of life and reduce the cost of care.
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Affiliation(s)
- Chiara Caporilli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Giuliana Giannì
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Federica Grassi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
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Wang W, Wang Y, Lu Y, Tian X, Chen S, Wu B, Du J, Xiao Y, Cai W. Inositol hexaphosphate promotes intestinal adaptation in short bowel syndrome via an HDAC3-mediated epigenetic pathway. Food Nutr Res 2023; 67:8694. [PMID: 36794012 PMCID: PMC9899046 DOI: 10.29219/fnr.v67.8694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 08/29/2022] [Accepted: 11/07/2022] [Indexed: 02/05/2023] Open
Abstract
Background Short bowel syndrome (SBS) has high morbidity and mortality rates, and promoting intestinal adaptation of the residual intestine is a critical treatment. Dietary inositol hexaphosphate (IP6) plays an important role in maintaining intestinal homeostasis, but its effect on SBS remains unclear. This study aimed at investigating the effect of IP6 on SBS and clarified its underlying mechanism. Methods Forty male Sprague-Dawley rats (3-week-old) were randomly assigned into four groups (Sham, Sham + IP6, SBS, and SBS + IP6 groups). Rats were fed standard pelleted rat chow and underwent resection of 75% of the small intestine after 1 week of acclimation. They received 1 mL IP6 treatment (2 mg/g) or sterile water daily for 13 days by gavage. Intestinal length, levels of inositol 1,4,5-trisphosphate (IP3), histone deacetylase 3 (HDAC3) activity, and proliferation of intestinal epithelial cell-6 (IEC-6) were detected. Results IP6 treatment increased the length of the residual intestine in rats with SBS. Furthermore, IP6 treatment caused an increase in body weight, intestinal mucosal weight, and IEC proliferation, and a decrease in intestinal permeability. IP6 treatment led to higher levels of IP3 in feces and serum, and higher HDAC3 activity of the intestine. Interestingly, HDAC3 activity was positively correlated with the levels of IP3 in feces (r = 0.49, P = 0.01) and serum (r = 0.44, P = 0.03). Consistently, IP3 treatment promoted the proliferation of IEC-6 cells by increasing HDAC3 activity in vitro. IP3 regulated the Forkhead box O3 (FOXO3)/Cyclin D1 (CCND1) signaling pathway. Conclusion IP6 treatment promotes intestinal adaptation in rats with SBS. IP6 is metabolized to IP3 to increase HDAC3 activity to regulate the FOXO3/CCND1 signaling pathway and may represent a potential therapeutic approach for patients with SBS.
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Affiliation(s)
- Weipeng Wang
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,Division of Pediatric Gastroenterology and Nutrition, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ying Wang
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,Division of Pediatric Gastroenterology and Nutrition, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,Shanghai Institu of Pediatric Research, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Ying Lu
- Shanghai Institu of Pediatric Research, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Xinbei Tian
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shanshan Chen
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Bo Wu
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jun Du
- Shanghai Institu of Pediatric Research, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Yongtao Xiao
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,Division of Pediatric Gastroenterology and Nutrition, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,Shanghai Institu of Pediatric Research, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China,Yongtao Xiao Division of Pediatric Gastroenterology and Nutrition, Xin Hua Hospital, Shanghai Jiao Tong University, No. 1665, Kong Jiang Road, Shanghai, China.
| | - Wei Cai
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,Division of Pediatric Gastroenterology and Nutrition, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,Shanghai Institu of Pediatric Research, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China,Wei Cai Department of Pediatric Surgery, Xin Hua Hospital, Shanghai Jiao Tong University, No. 1665, Kong Jiang Road, 200092 Shanghai, China.
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Verbiest A, Jeppesen PB, Joly F, Vanuytsel T. The Role of a Colon-in-Continuity in Short Bowel Syndrome. Nutrients 2023; 15. [PMID: 36771335 DOI: 10.3390/nu15030628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/11/2023] [Accepted: 01/20/2023] [Indexed: 01/28/2023] Open
Abstract
Short bowel syndrome (SBS) is a rare gastrointestinal condition that is defined as having less than 200 cm of remaining small intestine. SBS results from extensive surgical resection and is associated with a high risk for intestinal failure (IF) with a need for parenteral support (PS). Depending on the region of intestinal resection, three different main anatomy types can be distinguished from each other. In this review, we synthesize the current knowledge on the role of the colon in the setting of SBS-IF with a colon-in-continuity (SBS-IF-CiC), e.g., by enhancing the degree of intestinal adaptation, energy salvage, and the role of the microbiota. In addition, the effect of the disease-modifying treatment with glucagon-like peptide-2 (GLP-2) analogs in SBS-IF-CiC and how it differs from patients without a colon will be discussed. Overall, the findings explained in this review highlight the importance of preservation of the colon in SBS-IF.
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Puoti MG, Köglmeier J. Nutritional Management of Intestinal Failure due to Short Bowel Syndrome in Children. Nutrients 2022; 15. [PMID: 36615720 DOI: 10.3390/nu15010062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The most common cause of intestinal failure (IF) in childhood remains short bowel syndrome (SBS), where bowel mass is significantly reduced due to a congenital atresia or resection and parenteral nutrition (PN) needed. Home PN has improved outcome and quality of life, but the long-term therapeutic goal is to achieve enteral autonomy whilst avoiding long term complications. This paper is aimed at discussing nutritional strategies available to clinicians caring for these patients. METHODS A literature search was performed from 1992 to 2022 using Pubmed, MEDLINE and Cochrane Database of Systematic Reviews, and recent guidelines were reviewed. In the absence of evidence, recommendations reflect the authors' expert opinion. RESULTS Consensus on the best possible way of feeding children with IF-SBS is lacking and practice varies widely between centres. Feeding should commence as soon as possible following surgery. Oral feeding is the preferred route and breast milk (BM) the first milk of choice in infants. Donor BM, standard preterm or term formula are alternatives in the absence of maternal BM. Extensively hydrolysed or amino acid-based feeds are used when these are not tolerated. Solids should be introduced as soon as clinically appropriate. Children are encouraged to eat by mouth and experience different tastes and textures to avoid oral aversion. Aggressive weaning of PN and tube (over-) feeding are now discouraged. CONCLUSIONS To date, uniform agreement on the optimal type of feed, timing of food introduction and feeding regime used is lacking and great difference in practice remains. There is need for more research to establish common treatment protocols.
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Boutte HJ, Chen J, Wylie TN, Wylie KM, Xie Y, Geisman M, Prabu A, Gazit V, Tarr PI, Levin MS, Warner BW, Davidson NO, Rubin DC. Fecal microbiome and bile acid metabolome in adult short bowel syndrome. Am J Physiol Gastrointest Liver Physiol 2022; 322:G154-G168. [PMID: 34816756 PMCID: PMC8793869 DOI: 10.1152/ajpgi.00091.2021] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Loss of functional small bowel surface area causes short bowel syndrome (SBS), intestinal failure, and parenteral nutrition (PN) dependence. The gut adaptive response following resection may be difficult to predict, and it may take up to 2 yr to determine which patients will wean from PN. Here, we examined features of gut microbiota and bile acid (BA) metabolism in determining adaptation and ability to wean from PN. Stool and sera were collected from healthy controls and from patients with SBS (n = 52) with ileostomy, jejunostomy, ileocolonic, and jejunocolonic anastomoses fed with PN plus enteral nutrition or who were exclusively enterally fed. We undertook 16S rRNA gene sequencing, BA profiling, and 7α-hydroxy-4-cholesten-3-one (C4) quantitation with LC-MS/MS and serum amino acid analyses. Patients with SBS exhibited altered gut microbiota with reduced gut microbial diversity compared with healthy controls. We observed differences in the microbiomes of patients with SBS with ileostomy versus jejunostomy, jejunocolonic versus ileocolonic anastomoses, and PN dependence compared with those who weaned from PN. Stool and serum BA composition and C4 concentrations were also altered in patients with SBS, reflecting adaptive changes in enterohepatic BA cycling. Stools from patients who were weaned from PN were enriched in secondary BAs including deoxycholic acid and lithocholic aicd. Shifts in gut microbiota and BA metabolites may generate a favorable luminal environment in select patients with SBS, promoting the ability to wean from PN. Proadaptive microbial species and select BA may provide novel targets for patient-specific therapies for SBS.NEW & NOTEWORTHY Loss of intestinal surface area causes short bowel syndrome, intestinal failure, and parenteral nutrition dependence. We analyzed the gut microbiota and bile acid metabolome of a large cohort of short bowel syndrome adult patients with different postsurgical anatomies. We report a novel analysis of the microbiome of patients with ileostomy and jejunostomy. Enrichment of specific microbial and bile acid species may be associated with the ability to wean from parenteral nutrition.
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Affiliation(s)
- Harold J. Boutte
- 1Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Jacqueline Chen
- 1Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Todd N. Wylie
- 2Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri,3McDonnell Genome Institute, Washington University School of Medicine, St. Louis, Missouri
| | - Kristine M. Wylie
- 2Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri,3McDonnell Genome Institute, Washington University School of Medicine, St. Louis, Missouri
| | - Yan Xie
- 1Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Mackenzie Geisman
- 1Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Anirudh Prabu
- 1Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Vered Gazit
- 1Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Phillip I. Tarr
- 2Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri,4Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri
| | - Marc S. Levin
- 1Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri,7Veterans Administration Saint Louis Health Care System, St. Louis, Missouri
| | - Brad W. Warner
- 5Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Nicholas O. Davidson
- 1Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri,6Department of Developmental Biology, Washington University School of Medicine, St. Louis, Missouri
| | - Deborah C. Rubin
- 1Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri,6Department of Developmental Biology, Washington University School of Medicine, St. Louis, Missouri
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Eliasson J, Hvistendahl MK, Freund N, Bolognani F, Meyer C, Jeppesen PB. Apraglutide, a novel glucagon-like peptide-2 analog, improves fluid absorption in patients with short bowel syndrome intestinal failure: Findings from a placebo-controlled, randomized phase 2 trial. JPEN J Parenter Enteral Nutr 2021; 46:896-904. [PMID: 34287970 PMCID: PMC9292678 DOI: 10.1002/jpen.2223] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Treatment with glucagon‐like peptide‐2 (GLP‐2) analogs improve intestinal adaptation in patients with short bowel syndrome–associated intestinal failure (SBS‐IF) and may reduce parenteral support requirements. Apraglutide is a novel, long‐acting GLP‐2 analog designed for once‐weekly dosing. This trial investigated the safety and efficacy of apraglutide in patients with SBS‐IF. Methods In this placebo‐controlled, double‐blind, randomized, crossover phase 2 trial, eight adults with SBS‐IF were treated with once‐weekly 5‐mg apraglutide doses and placebo for 4 weeks, followed by once‐weekly 10‐mg apraglutide doses for 4 weeks, with a washout period of 6–10 weeks between treatments. Safety was the primary end point. Secondary end points included changes from baseline in urine volume output compared with placebo, collected for 48 h before and after each treatment period. Results Common treatment‐related adverse events (AEs) were mild to moderate and included polyuria, decreased stoma output, stoma complications, decreased thirst, and edema. No serious AEs were considered to be related to apraglutide treatment. The safety profile was comparable for the lower and higher doses. Treatment with once‐weekly 5‐ and 10‐mg apraglutide doses significantly increased urine volume output by an adjusted mean of 714 ml/day (95% CI, 490–939; P < .05) and 795 ml/day (95% CI, 195–1394; P < .05), respectively, compared with placebo, with no significant differences between doses. Conclusions Once‐weekly apraglutide was well tolerated at both tested doses and significantly increased urine volume output, providing evidence for increased intestinal fluid absorption. A phase 3 trial is underway in adults with SBS‐IF.
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Affiliation(s)
- Johanna Eliasson
- Department of Intestinal Failure and Liver Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mark K Hvistendahl
- Department of Intestinal Failure and Liver Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nanna Freund
- Department of Intestinal Failure and Liver Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Palle B Jeppesen
- Department of Intestinal Failure and Liver Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Vomhof-DeKrey EE, Lansing JT, Darland DC, Umthun J, Stover AD, Brown C, Basson MD. Loss of Slfn3 induces a sex-dependent repair vulnerability after 50% bowel resection. Am J Physiol Gastrointest Liver Physiol 2021; 320:G136-G152. [PMID: 33237796 PMCID: PMC7864235 DOI: 10.1152/ajpgi.00344.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/13/2020] [Accepted: 11/20/2020] [Indexed: 02/07/2023]
Abstract
Bowel resection accelerates enterocyte proliferation in the remaining gut with suboptimal absorptive and digestive capacity because of a proliferation-associated decrease in functional differentiation markers. We hypothesized that although schlafen 3 (Slfn3) is an important regulator of enterocytic differentiation, Slfn3 would have less impact on bowel resection adaptation, where accelerated proliferation takes priority over differentiation. We assessed proliferation, cell shedding, and enterocyte differentiation markers from resected and postoperative bowel of wild-type (WT) and Slfn3-knockout (Slfn3KO) mice. Villus length and crypt depth were increased in WT mice and were even longer in Slfn3KO mice. Mitotic marker, Phh3+, and the proliferation markers Lgr5, FoxL1, and platelet-derived growth factor-α (PDGFRα) were increased after resection in male WT, but this was blunted in male Slfn3KO mice. Cell-shedding regulators Villin1 and TNFα were downregulated in female mice and male WT mice only, whereas Gelsolin and EGFR increased expression in all mice. Slfn3 expression increased after resection in WT mice, whereas other Slfn family members 1, 2, 5, 8, and 9 had varied expressions that were affected also by sex difference and loss of Slfn3. Differentiation markers sucrase isomaltase, Dpp4, Glut2, and SGLT1 were all decreased, suggesting that enterocytic differentiation effort is incompatible with rapid proliferation shift in intestinal adaptation. Slfn3 absence potentiates villus length and crypt depth, suggesting that the differentiating stimulus of Slfn3 signaling may restrain mucosal mass increase through regulating Villin1, Gelsolin, EGFR, TNFα, and proliferation markers. Therefore, Slfn3 may be an important regulator not only of "normal" enterocytic differentiation but also in response to bowel resection.NEW & NOTEWORTHY The differentiating stimulus of Slfn3 signaling restrains an increase in mucosal mass after bowel resection, and there is a Slfn3-sex interaction regulating differentiation gene expression and intestinal adaptation. This current study highlights the combinatory effects of gender and Slfn3 genotype on the gene expression changes that contribute to the adaptation in intestinal cellular milleu (i.e. villus and crypt structure) which are utilized to compensate for the stress-healing response that the animals display in intestinal adaptation.
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Affiliation(s)
- Emilie E Vomhof-DeKrey
- Departments of Surgery, Pathology, and Biomedical Sciences, School of Medicine and the Health Sciences, University of North Dakota, Grand Forks, North Dakota
| | - Jack T Lansing
- Departments of Surgery, Pathology, and Biomedical Sciences, School of Medicine and the Health Sciences, University of North Dakota, Grand Forks, North Dakota
- Department of Biology, University of North Dakota, Grand Forks, North Dakota
| | - Diane C Darland
- Department of Biology, University of North Dakota, Grand Forks, North Dakota
| | - Josey Umthun
- Departments of Surgery, Pathology, and Biomedical Sciences, School of Medicine and the Health Sciences, University of North Dakota, Grand Forks, North Dakota
- Department of Biology, University of North Dakota, Grand Forks, North Dakota
| | - Allie D Stover
- Departments of Surgery, Pathology, and Biomedical Sciences, School of Medicine and the Health Sciences, University of North Dakota, Grand Forks, North Dakota
| | - Christopher Brown
- Departments of Surgery, Pathology, and Biomedical Sciences, School of Medicine and the Health Sciences, University of North Dakota, Grand Forks, North Dakota
| | - Marc D Basson
- Departments of Surgery, Pathology, and Biomedical Sciences, School of Medicine and the Health Sciences, University of North Dakota, Grand Forks, North Dakota
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11
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Abstract
Short bowel syndrome (SBS) is a rare disease that results from extensive resection of the intestine. When the remaining absorption surface of the intestine cannot absorb enough macronutrients, micronutrients, and water, SBS results in intestinal failure (IF). Patients with SBS who suffer from IF require parenteral nutrition for survival, but long-term parenteral nutrition may lead to complications such as catheter sepsis and metabolic diseases. Spontaneous intestinal adaptation occurs weeks to months after resection, resulting in hyperplasia of the remnant gut, modification of gut hormone levels, dysbiosis, and hyperphagia. Oral nutrition and presence of the colon are two major positive drivers for this adaptation. This review aims to summarize the current knowledge of the mechanisms underlying spontaneous intestinal adaptation, particularly in response to modifications of luminal content, including nutrients. In the future, dietary manipulations could be used to treat SBS.
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Affiliation(s)
- Johanne Le Beyec
- Centre de Recherche sur l'Inflammation, INSERM UMRS-1149, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75018 Paris, France; .,Service de Biochimie Endocrinienne et Oncologique, Hôpital Pitié-Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, 75013 Paris, France
| | - Lore Billiauws
- Centre de Recherche sur l'Inflammation, INSERM UMRS-1149, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75018 Paris, France; .,Service de Gastroentérologie, MICI et Assistance Nutritive, Groupe Hospitalier Universitaire Paris Nord Val de Seine (GHUPNVS), Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris, 92110 Clichy, France
| | - André Bado
- Centre de Recherche sur l'Inflammation, INSERM UMRS-1149, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75018 Paris, France;
| | - Francisca Joly
- Centre de Recherche sur l'Inflammation, INSERM UMRS-1149, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75018 Paris, France; .,Service de Gastroentérologie, MICI et Assistance Nutritive, Groupe Hospitalier Universitaire Paris Nord Val de Seine (GHUPNVS), Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Université de Paris, 92110 Clichy, France
| | - Maude Le Gall
- Centre de Recherche sur l'Inflammation, INSERM UMRS-1149, Assistance Publique-Hôpitaux de Paris, Université de Paris, 75018 Paris, France;
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12
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Ou J, Courtney CM, Steinberger AE, Tecos ME, Warner BW. Nutrition in Necrotizing Enterocolitis and Following Intestinal Resection. Nutrients 2020; 12:nu12020520. [PMID: 32085587 PMCID: PMC7071274 DOI: 10.3390/nu12020520] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 12/25/2022] Open
Abstract
This review aims to discuss the role of nutrition and feeding practices in necrotizing enterocolitis (NEC), NEC prevention, and its complications, including surgical treatment. A thorough PubMed search was performed with a focus on meta-analyses and randomized controlled trials when available. There are several variables in nutrition and the feeding of preterm infants with the intention of preventing necrotizing enterocolitis (NEC). Starting feeds later rather than earlier, advancing feeds slowly and continuous feeds have not been shown to prevent NEC and breast milk remains the only effective prevention strategy. The lack of medical treatment options for NEC often leads to disease progression requiring surgical resection. Following resection, intestinal adaptation occurs, during which villi lengthen and crypts deepen to increase the functional capacity of remaining bowel. The effect of macronutrients on intestinal adaptation has been extensively studied in animal models. Clinically, the length and portion of intestine that is resected may lead to patients requiring parenteral nutrition, which is also reviewed here. There remain significant gaps in knowledge surrounding many of the nutritional aspects of NEC and more research is needed to determine optimal feeding approaches to prevent NEC, particularly in infants younger than 28 weeks and <1000 grams. Additional research is also needed to identify biomarkers reflecting intestinal recovery following NEC diagnosis individualize when feedings should be safely resumed for each patient.
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Affiliation(s)
- Jocelyn Ou
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA;
| | - Cathleen M. Courtney
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
| | - Allie E. Steinberger
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
| | - Maria E. Tecos
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
| | - Brad W. Warner
- Department of Surgery, Division of Pediatric Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA; (C.M.C.); (A.E.S.); (M.E.T.)
- Correspondence: ; Tel.: 314-454-6022
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13
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Berlin P, Reiner J, Witte M, Wobar J, Lindemann S, Barrantes I, Kreikemeyer B, Bastian M, Schäffler H, Bannert K, Jaster R, Lamprecht G. Nod2 deficiency functionally impairs adaptation to short bowel syndrome via alterations of the epithelial barrier function. Am J Physiol Gastrointest Liver Physiol 2019; 317:G727-G738. [PMID: 31509436 DOI: 10.1152/ajpgi.00117.2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Nucleotide-binding oligomerization domain-containing protein 2 (NOD2) gene mutations are a risk factor for Crohn's disease and also associated with worse outcome in short bowel syndrome (SBS) patients independent of the underlying disease. The aim of this study was to analyze the effect of Nod2 deficiency on barrier function and stool microbiome after extensive ileocecal resection in mice. Male C57BL6/J wild-type (WT) and Nod2-knockout (KO) mice underwent 40% ileocecal resection. Sham control mice received simple transection of the ileum. Clinical outcome was monitored daily. Barrier function was measured with Ussing chambers using FITC-4-kDa-Dextran flux, transmucosal electrical resistance, and dilution potentials. Immunofluorescence of claudin-2 was studied. Composition of the stool microbiome was assessed by 16S rRNA gene sequencing. Resected Nod2-KO mice had impaired clinical outcome compared with resected WT mice. This was accompanied by increased stool water contents and increased plasma aldosterone. Histomorphological adaptation was independent of Nod2. Barrier function studies revealed impaired sodium to chloride permeability and altered claudin-2 localization in the absence of Nod2. Resection induced decreases of bacterial diversity and a shift of bacteriodetes-to-firmicutes ratios. Ileum and cecum resection-induced increase in proteobacteria was absent in Nod2-deficient mice. Verrucomicrobia were temporarily increased in Nod2-KO mice. Nod2 deficiency functionally impairs adaptation to short bowel syndrome via a lesser increase of epithelial sodium pore permeability, altered epithelial barrier function, and the microbiome.NEW & NOTEWORTHYNOD2 gene mutations are associated with the development of severe short bowel syndrome and intestinal failure. The influence of Nod2 mutations on intestinal adaptation in experimental short bowel syndrome has not been studied yet. Here, we provide data that Nod2 deficiency worsens clinical outcome and functional adaptation under SBS conditions in mice, indicating that NOD2 is required for successful adaptation after ileocecal resection.
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Affiliation(s)
- Peggy Berlin
- Division of Gastroenterology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
| | - Johannes Reiner
- Division of Gastroenterology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
| | - Maria Witte
- Department of General, Thoracic, Vascular, and Transplantation Surgery, Rostock University Medical Center, Rostock, Germany
| | - Jakob Wobar
- Division of Gastroenterology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
| | - Sabeth Lindemann
- Division of Gastroenterology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
| | - Israel Barrantes
- Institute for Biostatistics and Informatics in Medicine and Ageing Research, Rostock University Medical Center, Rostock, Germany
| | - Bernd Kreikemeyer
- Institute for Microbiology, Virology, and Hygiene, University of Medicine Rostock, Rostock, Germany
| | - Manuela Bastian
- Institute for Clinical Chemistry and Laboratory Medicine, Rostock University Medical Center, Rostock, Germany
| | - Holger Schäffler
- Division of Gastroenterology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
| | - Karen Bannert
- Division of Gastroenterology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
| | - Robert Jaster
- Division of Gastroenterology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
| | - Georg Lamprecht
- Division of Gastroenterology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
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14
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Abstract
Purpose of Review Short gut syndrome is life-altering and life-threatening disease resulting most often from massive small bowel resection. Recent advances in understanding of the perturbed physiology in these patients have translated into improved care and outcomes. This paper seeks to review the advances of care in SBS patients. Recent Findings Anatomic considerations still predominate the early care of SBS patients, including aggressive preservation of bowel and documentation of remnant bowel length and quality. Intestinal adaptation is the process by which remnant bowel changes to fit the physiologic needs of the patient. Grossly, the bowel dilates and elongates to increase intestinal weight and protein content. Architectural changes are noted, such as villus lengthening and deepening of crypts. In addition, gene expression changes occur that function to maximize nutrient uptake and fluid preservation. Management is aimed at understanding these physiologic changes and augmenting them whenever possible in an effort to gain enteral autonomy. Complication mitigation is key, including avoidance of catheter complications, bloodstream infections, cholestasis, and nutrient deficiencies. Summary Multidisciplinary teams working together towards intestinal rehabilitation have shown improved outcomes. Today's practioner needs a current understanding of the ever-evolving care of these patients in order to promote enteral autonomy, recognize complications, and counsel patients and families appropriately.
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Affiliation(s)
- Baddr A Shakhsheer
- Division of Pediatric Surgery, Saint Louis Children's Hospital, Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Brad W Warner
- Division of Pediatric Surgery, Saint Louis Children's Hospital, Department of Surgery, Washington University School of Medicine, Saint Louis, MO
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15
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Isani MA, Gee K, Schall K, Schlieve CR, Fode A, Fowler KL, Grikscheit TC. Wnt signaling inhibition by monensin results in a period of Hippo pathway activation during intestinal adaptation in zebrafish. Am J Physiol Gastrointest Liver Physiol 2019; 316:G679-G691. [PMID: 30896968 DOI: 10.1152/ajpgi.00343.2018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Intestinal adaptation (IA) is a critical response to increase epithelial surface area after intestinal loss. Short bowel syndrome (SBS) may follow massive intestinal resection in human patients, particularly without adequate IA. We previously validated a model in zebrafish (ZF) that recapitulates key SBS pathophysiological features. Previous RNA sequencing in this model identified upregulation of genes in the Wnt and Hippo pathways. We therefore sought to identify the timeline of increasing cell proliferation and considered the signaling that might underpin the epithelial remodeling of IA in SBS. SBS was created in a ZF model as previously reported and compared with sham fish with and without exposure to monensin, an ionophore known to inhibit canonical Wnt signaling. Rescue of the monensin effects was attempted with a glycogen synthase kinase 3 inhibitor that activates wnt signaling, CHIR-99021. A timeline was constructed to identify peak cellular proliferation, and the Wnt and Hippo pathways were evaluated. Peak stem cell proliferation and morphological changes of adaptation were identified at 7 days. Wnt inhibition diminished IA at 2 wk and resulted in activation of genes of the Wnt/β-catenin and Yes-associated protein (YAP)/Hippo pathway. Increased cytoplasmic YAP was observed in monensin-treated SBS fish. Genes of the WASP-interacting protein (WIP) pathway were elevated during Wnt blockade. In conclusion, cellular proliferation and morphological changes accompany SBS even in attempted Wnt blockade. Wnt/β-catenin, YAP/Hippo pathway, and WIP pathway genes increase during early Wnt blockade. Further understanding of the effects of Wnt and YAP pathway signaling in proliferating stem cells might enrich our knowledge of targets to assist IA. NEW & NOTEWORTHY Intestinal adaptation is a critical response to increase epithelial surface area after large intestinal losses. Inhibition of Wnt/β-catenin signaling impairs intestinal adaptation in a zebrafish model of short bowel syndrome. There is a subsequent upregulation in genes of the Yes-associated protein/Hippo and WIP pathway. These may be targets for future human therapies, as patients are salvaged by the compensation of increased intestinal epithelial surface area through successful intestinal adaptation.
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Affiliation(s)
- Mubina A Isani
- Division of Pediatric Surgery and Developmental Biology and Regenerative Medicine, Saban Research Institute, Children's Hospital Los Angeles, California
| | - Kristin Gee
- Division of Pediatric Surgery and Developmental Biology and Regenerative Medicine, Saban Research Institute, Children's Hospital Los Angeles, California
| | - Kathy Schall
- Division of Pediatric Surgery and Developmental Biology and Regenerative Medicine, Saban Research Institute, Children's Hospital Los Angeles, California
| | - Christopher R Schlieve
- Division of Pediatric Surgery and Developmental Biology and Regenerative Medicine, Saban Research Institute, Children's Hospital Los Angeles, California
| | - Alexa Fode
- Division of Pediatric Surgery and Developmental Biology and Regenerative Medicine, Saban Research Institute, Children's Hospital Los Angeles, California
| | - Kathryn L Fowler
- Division of Pediatric Surgery and Developmental Biology and Regenerative Medicine, Saban Research Institute, Children's Hospital Los Angeles, California
| | - Tracy C Grikscheit
- Division of Pediatric Surgery and Developmental Biology and Regenerative Medicine, Saban Research Institute, Children's Hospital Los Angeles, California.,Department of Surgery, Keck School of Medicine, University of Southern California , Los Angeles, California
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16
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Dai LN, Yan JK, Zhang T, Cai W, Yan WH. Butyrate promotes the adaptation of intestinal smooth muscle cells through the yes-associated protein (YAP) pathway in a rat model of short bowel syndrome. Am J Transl Res 2019; 11:453-462. [PMID: 30788001 PMCID: PMC6357317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 12/23/2018] [Indexed: 06/09/2023]
Abstract
Our previous study demonstrated that the proliferation of human intestinal smooth muscle (ISM) cells was stimulated by butyrate through the yes-associated protein (YAP) pathway in vitro, suggesting a valuable approach for intestinal adaption of short bowel syndrome (SBS). This study was conducted to confirm these findings in vivo. Three-week-old Sprague-Dawley rats were randomly divided into the following groups: Sham group (bowel transection and reanastomosis), SB W group (80% small bowel resection/water ad libitum), and SB Bu group (80% small bowel resection/50 mM sodium butyrate ad libitum). Morphological changes were determined by hematoxylin and eosin staining; the proliferation rate of ISM cells was examined by Ki67 staining, and apoptosis was determined in the TUNEL assay. Changes in the expression of YAP and its downstream genes were evaluated by quantitative-polymerase chain reaction and western blotting. Fourteen days post-operation, a significant increase in ISM thickness was observed in the SB Bu group compared to the SB W group, accompanied by enhanced proliferation of ISM cells and suppression of apoptosis. Notably, YAP expression was also significantly increased in the SB Bu group, with a 6.5-fold increase in the proportion of YAP-positive ISM cells, 2.2-fold increase in YAP mRNA expression, and 3.4-fold increase in protein expression. In conclusion, our results suggest that butyrate promotes ISM adaption through YAP in vivo, which may be a potential therapeutic approach for SBS patients.
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Affiliation(s)
- Li-Na Dai
- Department of Pediatric Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of MedicineNo. 1665, Kongjiang Road, Shanghai 200092, China
| | - Jun-Kai Yan
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai Institute for Pediatric ResearchShanghai 200092, China
| | - Tian Zhang
- Department of Pediatric Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of MedicineNo. 1665, Kongjiang Road, Shanghai 200092, China
| | - Wei Cai
- Department of Pediatric Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of MedicineNo. 1665, Kongjiang Road, Shanghai 200092, China
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai Institute for Pediatric ResearchShanghai 200092, China
| | - Wei-Hui Yan
- Department of Pediatric Surgery, Xinhua Hospital, Shanghai Jiao Tong University School of MedicineNo. 1665, Kongjiang Road, Shanghai 200092, China
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17
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Tannuri ACA, Rotondo ÍG, Barros GG, Van Vaisberg V, Mendes-Neto C, Paes VR, Coelho MCM, Gonçalves J, Serafini S, Tannuri U. Are there differences in the growth adaptation processes of growing and mature organism models of short bowel syndrome? Clinics (Sao Paulo) 2018; 73:e499. [PMID: 30365828 PMCID: PMC6178875 DOI: 10.6061/clinics/2018/e499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 05/17/2018] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The purpose of this study was to present an experimental model of short bowel syndrome (SBS) in weaning rats and to compare the adaptative mechanisms of the remaining bowel in weaning rats and adult animals by means of morphometric, histologic and molecular methods. METHODS Twenty-four weaning rats were divided into 3 groups of 8 animals, one control group and two short bowel groups (euthanasia after 4 and 21 days), and were compared with similar adult groups. Morphometric evaluations of the animals and histopathological and molecular studies of the remaining bowel were performed. RESULTS The weight of young rats increased after enterectomy, whereas that of adult rats decreased after enterectomy (p<0.0001). The ratio of intestinal length/body weight was significantly higher in weaning rats than in adults (p<0.002), showing that intestinal growth was more intense in weaning rats. Intestinal resection promoted increased thickness of the small bowel lamina propria (p=0.001) and reduced thickness of the colon lamina propria (p=0.04) in weaning rats relative to those in adults. In addition, intestinal resection promoted increased expression of the Bcl-xl gene (antiapoptotic) in adult animals compared with that in weaning rats (p=0.001). CONCLUSION Morphometric, histological and molecular differences were shown in the adaptation processes of growing and mature organisms.
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Affiliation(s)
- Ana Cristina Aoun Tannuri
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Ítalo Geraldo Rotondo
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Guilherme Garcia Barros
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Victor Van Vaisberg
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Cícero Mendes-Neto
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Vitor Ribeiro Paes
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Maria Cecilia Mendonça Coelho
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Josiane Gonçalves
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Suellen Serafini
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Uenis Tannuri
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
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18
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Yang Y, Zheng T, Zhou J, Song H, Cai W, Qian L. Bile salt dependent lipase promotes intestinal adaptation in rats with massive small bowel resection. Biosci Rep 2018; 38:BSR20180077. [PMID: 29669842 DOI: 10.1042/BSR20180077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/09/2018] [Accepted: 04/18/2018] [Indexed: 01/14/2023] Open
Abstract
Intestinal adaptation is important for the short bowel syndrome (SBS) patients. Growing evidence has suggested that bile salt dependent lipase (BSDL) not only has the lipolytic activity, but also the immune-modulating and pro-proliferative activities. The purpose of the present study was to investigate the effects of BSDL on intestinal adaptive growth and gut barrier function in a rat model of SBS. Twenty-four male Sprague-Dawley rats were randomly divided into three experimental groups: sham group (rats underwent bowel transection and re-anastomosis), SBS group (rats underwent 80% bowel resection), SBS-BSDL group (SBS rats orally administered BSDL). The animals were weighed daily. The intestinal morpho-histochemical changes and intestinal barrier function were determined 14 days after the operations. Meanwhile, the expressions of Wnt signaling molecules in enterocytes were also analyzed by immunohistochemistry and Western blot. The postoperative weight gain was faster in the SBS rats treated with BSDL than in the SBS/untreated group. The SBS rats treated with BSDL had significantly greater villus height, crypt depth, and enterocyte proliferation in their residual intestines, as compared with the SBS/untreated group. The recovery of intestinal barrier function was promoted and the expressions of tight-junction proteins were increased in the SBS rats treated with BSDL. Additionally, the data indicated that the proadaptive activities of BSDL might be mediated by Wnt signaling activation in the enterocytes. These observations suggested that enteral BSDL administration promoted intestinal adaptive growth and barrier repairing by activating Wnt signaling pathway in SBS rats.
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19
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Capriati T, Nobili V, Stronati L, Cucchiara S, Laureti F, Liguori A, Tyndall E, Diamanti A. Enteral nutrition in pediatric intestinal failure: does initial feeding impact on intestinal adaptation? Expert Rev Gastroenterol Hepatol 2017; 11:741-748. [PMID: 28562106 DOI: 10.1080/17474124.2017.1335196] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Primary IF can be due to impaired gut length or impaired gut function; short bowel syndrome (SBS) is the leading cause of IF. In IF patients complete enteral starvation should be avoided whenever possible and enteral/oral nutrition (EN/ON) should be employed at the maximum tolerated amount in each phase of the clinical evolution of IF. Intraluminal nutrients have stimulatory effects on epithelial cells and on trophism that enhance intestinal adaptation. Areas covered: Evidence for nutritional interventions in pediatric IF is limited and of poor quality. Clinical practice in SBS feeding are more 'experience-based' rather than 'evidence-based' and this dearth of clinical evidence is partly due to the rarity of this condition. This review updates knowledge concerning the impact of the initial diet with EN/ON in neonatal onset SBS in the process of bowel adaption. Expert commentary: Human milk resulted the preferred starting diet and it is generally combined with amino-acids (AAs) in Northern America and with hydrolyzed proteins (HFs) in Europe; polymeric diet is rarely employed. HFs were not more effective than AAs in promoting intestinal adaptation.
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Affiliation(s)
- Teresa Capriati
- a Department of Pediatrics , Pediatric Hospital "Bambino Gesù" , Rome , Italy
| | - Valerio Nobili
- b Liver Res Unit , IRCCS, Bambino Gesu Children Hosp , Rome , Italy
| | - Laura Stronati
- c Department of Pediatrics , Universita degli Studi di Roma La Sapienza Facolta di Medicina e Psicologia , Rome , Italy
| | | | - Francesca Laureti
- a Department of Pediatrics , Pediatric Hospital "Bambino Gesù" , Rome , Italy
| | - Alessandra Liguori
- a Department of Pediatrics , Pediatric Hospital "Bambino Gesù" , Rome , Italy
| | - Elaine Tyndall
- a Department of Pediatrics , Pediatric Hospital "Bambino Gesù" , Rome , Italy
| | - Antonella Diamanti
- a Department of Pediatrics , Pediatric Hospital "Bambino Gesù" , Rome , Italy
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Cavin JB, Voitellier E, Cluzeaud F, Kapel N, Marmuse JP, Chevallier JM, Msika S, Bado A, Le Gall M. Malabsorption and intestinal adaptation after one anastomosis gastric bypass compared with Roux-en-Y gastric bypass in rats. Am J Physiol Gastrointest Liver Physiol 2016; 311:G492-500. [PMID: 27418681 DOI: 10.1152/ajpgi.00197.2016] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 07/08/2016] [Indexed: 01/31/2023]
Abstract
The technically easier one-anastomosis (mini) gastric bypass (MGB) is associated with similar metabolic improvements and weight loss as the Roux-en-Y gastric bypass (RYGB). However, MGB is controversial and suspected to result in greater malabsorption than RYGB. In this study, we compared macronutrient absorption and intestinal adaptation after MGB or RYGB in rats. Body weight and food intake were monitored and glucose tolerance tests were performed in rats subjected to MGB, RYGB, or sham surgery. Carbohydrate, protein, and lipid absorption was determined by fecal analyses. Intestinal remodeling was evaluated by histology and immunohistochemistry. Peptide and amino acid transporter mRNA levels were measured in the remodeled intestinal mucosa and those of anorexigenic and orexigenic peptides in the hypothalamus. The MGB and RYGB surgeries both resulted in a reduction of body weight and an improvement of glucose tolerance relative to sham rats. Hypothalamic orexigenic neuropeptide gene expression was higher in MGB rats than in RYGB or sham rats. Fecal losses of calories and proteins were greater after MGB than RYGB or sham surgery. Intestinal hyperplasia occurred after MGB and RYGB with increased jejunum diameter, higher villi, and deeper crypts than in sham rats. Peptidase and peptide or amino acid transporter genes were overexpressed in jejunal mucosa from MGB rats but not RYGB rats. In rats, MGB led to greater protein malabsorption and energy loss than RYGB. This malabsorption was not compensated by intestinal overgrowth and increased expression of peptide transporters in the jejunum.
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Affiliation(s)
- Jean-Baptiste Cavin
- Inserm UMR 1149, Université Paris Diderot, Sorbonne Paris Cité, DHU Unity AP-HP, Paris, France
| | - Eglantine Voitellier
- Inserm UMR 1149, Université Paris Diderot, Sorbonne Paris Cité, DHU Unity AP-HP, Paris, France
| | - Françoise Cluzeaud
- Inserm UMR 1149, Université Paris Diderot, Sorbonne Paris Cité, DHU Unity AP-HP, Paris, France
| | - Nathalie Kapel
- AP-HP, Hôpital Pitié-Salpêtrière-Charles Foix, Département de Coprologie Fonctionnelle, Paris, France
| | - Jean-Pierre Marmuse
- Inserm UMR 1149, Université Paris Diderot, Sorbonne Paris Cité, DHU Unity AP-HP, Paris, France; Service de Chirurgie Générale et Digestive, AP-HP Hôpital Bichat Claude Bernard, Paris, France
| | - Jean-Marc Chevallier
- Service de Chirurgie Digestive, AP-HP Hôpital Européen Georges Pompidou, Paris, et Université Paris Descartes, Sorbonne Paris Cité, France; and
| | - Simon Msika
- Inserm UMR 1149, Université Paris Diderot, Sorbonne Paris Cité, DHU Unity AP-HP, Paris, France; Service de Chirurgie Digestive, AP-HP Hôpital Louis Mourier, Colombes, France
| | - André Bado
- Inserm UMR 1149, Université Paris Diderot, Sorbonne Paris Cité, DHU Unity AP-HP, Paris, France
| | - Maude Le Gall
- Inserm UMR 1149, Université Paris Diderot, Sorbonne Paris Cité, DHU Unity AP-HP, Paris, France;
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21
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Mezoff EA, Hawkins JA, Ollberding NJ, Karns R, Morrow AL, Helmrath MA. The human milk oligosaccharide 2'-fucosyllactose augments the adaptive response to extensive intestinal. Am J Physiol Gastrointest Liver Physiol 2016; 310:G427-38. [PMID: 26702137 PMCID: PMC4796291 DOI: 10.1152/ajpgi.00305.2015] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 12/22/2015] [Indexed: 01/31/2023]
Abstract
Intestinal resection resulting in short bowel syndrome (SBS) carries a heavy burden of long-term morbidity, mortality, and cost of care, which can be attenuated with strategies that improve intestinal adaptation. SBS infants fed human milk, compared with formula, have more rapid intestinal adaptation. We tested the hypothesis that the major noncaloric human milk oligosaccharide 2'-fucosyllactose (2'-FL) contributes to the adaptive response after intestinal resection. Using a previously described murine model of intestinal adaptation, we demonstrated increased weight gain from 21 to 56 days (P < 0.001) and crypt depth at 56 days (P < 0.0095) with 2'-FL supplementation after ileocecal resection. Furthermore, 2'-FL increased small bowel luminal content microbial alpha diversity following resection (P < 0.005) and stimulated a bloom in organisms of the genus Parabacteroides (log2-fold = 4.1, P = 0.035). Finally, transcriptional analysis of the intestine revealed enriched ontologies and pathways related to antimicrobial peptides, metabolism, and energy processing. We conclude that 2'-FL supplementation following ileocecal resection increases weight gain, energy availability through microbial community modulation, and histological changes consistent with improved adaptation.
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Affiliation(s)
- Ethan A. Mezoff
- 1Cincinnati Children's Hospital Medical Center, Division of Gastroenterology, Hepatology, and Nutrition;
| | - Jennifer A. Hawkins
- 2Cincinnati Children's Hospital Medical Center, Division of Pediatric General and Thoracic Surgery;
| | - Nicholas J. Ollberding
- 3Cincinnati Children's Hospital Medical Center, Division of Biostatistics and Epidemiology;
| | - Rebekah Karns
- 4Cincinnati Children's Hospital Medical Center, Division of Biomedical Informatics; and
| | - Ardythe L. Morrow
- 5Cincinnati Children's Hospital Medical Center, Division of Neonatology and Pulmonary Biology
| | - Michael A. Helmrath
- 2Cincinnati Children's Hospital Medical Center, Division of Pediatric General and Thoracic Surgery;
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Sun RC, Choi PM, Diaz-Miron J, Sommovilla J, Guo J, Erwin CR, Warner BW. High-protein diet improves postoperative weight gain after massive small-bowel resection. J Gastrointest Surg 2015; 19:451-7. [PMID: 25519080 DOI: 10.1007/s11605-014-2715-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 11/21/2014] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Short bowel syndrome (SBS) is a morbid clinical condition that results from massive small-bowel resection (SBR). After SBR, there is a dramatic weight loss in the acute postoperative period. Our aim was to determine the impact of a high-protein diet (HPD) on weight gain and body composition in mice after SBR. METHODS C57BL/6 mice underwent 50 % proximal SBR. Postoperatively, mice were randomly selected to receive standard rodent liquid diet (LD) (n = 6) or an isocaloric HPD (n = 9) for 28 days. Mice weights were recorded daily. Body composition analyses were obtained weekly. Student's t test was used for statistical comparisons with p < 0.05 considered significant. RESULTS Mice that were fed HPD after SBR returned to baseline weight on average at postoperative day (POD) 8 versus mice that were fed LD that returned to baseline weight on average at POD 22. Total fat mass and lean mass were significantly greater by POD 14 within the HPD group. Both groups of mice demonstrated normal structural adaptation. CONCLUSION HPD results in greater weight gain and improved body composition in mice after SBR. This finding may be clinically important for patients with SBS since improved weight gain may reduce the time needed for parenteral nutrition.
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23
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Sommovilla J, Zhou Y, Sun RC, Choi PM, Diaz-Miron J, Shaikh N, Sodergren E, Warner BB, Weinstock GM, Tarr PI, Warner BW. Small bowel resection induces long-term changes in the enteric microbiota of mice. J Gastrointest Surg 2015; 19:56-64; discussion 64. [PMID: 25183407 DOI: 10.1007/s11605-014-2631-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 08/11/2014] [Indexed: 01/31/2023]
Abstract
PURPOSE The enteric microbiome is known to play a major role in healthy gut homeostasis and several disease states. It may also contribute to both the intestinal recovery and complications that occur in patients with short bowel syndrome. The extent and nature of alterations to the gut microbiota following intestinal resection, however, are not well studied in a controlled setting. The purpose of this investigation is to characterize the effects of massive small bowel resection on the murine enteric microflora. METHODS Wild-type C57BL6 mice, following a week of acclamation to a liquid rodent diet, underwent either 50% proximal small bowel resection (SBR) or a sham operation. Mice were sacrificed, and enteric contents from the small bowel, cecum, and stool were harvested at 7 and 90 days post-operatively. DNA was isolated, and the V3-V5 regions of the 16s rRNA gene amplified and pyrosequenced on a Roche 454 platform. Sequences were clustered into operation taxonomic units and classified. Communities were then analyzed for diversity and phylogenic composition. RESULTS In the long-term group, the microbes inhabiting the ileum of mice undergoing SBR and sham operation differed significantly at the genus level (p < 0.001). Small bowel contents collected before and after SBR also differed significantly (p = 0.006). This was driven by an increase in Lactobacillus and decrease in Enterobacteriaceae species in mice undergoing SBR. No difference was seen in the long-term stool or in stool, cecal, or ileal contents in the short-term. No difference in microbial community diversity was found in any group. CONCLUSION Bowel resection induces long-term changes in the microbial community of the murine ileum, but not at more distal sites of the gastrointestinal tract. The increase in Lactobacillus encountered small bowel of resected mice correlates with limited previous studies. These changes may reflect an adaptive response of the microbiota to maximize energy extraction, but further studies are needed to establish the role played by this altered community.
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Abstract
Extensive intestinal resection impairs the absorptive capacity and results in short-bowel syndrome-associated intestinal failure (SBS-IF), when fluid, electrolyte, acid-base, micro-, and macronutrient homeostasis cannot be maintained on a conventional oral diet. Several factors, including the length and site of the resected intestine, anatomical conformation of the remnant bowel, and the degree of postresection intestinal adaptation determine the disease severity. While mild SBS patients achieve nutritional autonomy with dietary modification (eg, hyperphagia, small frequent meals, and oral rehydration fluids), those with moderate-to-severe disease may develop SBS-IF and become dependent on parenteral support (PS) in the form of intravenous fluids and/or nutrition for sustenance of life. SBS-IF is a chronic debilitating disease associated with a poor quality of life, and carries significant morbidity and health care costs. Medical management of SBS-IF is primarily focused on individually tailored symptomatic treatment strategies, such as antisecretory and antidiarrheal agents to mitigate fluid losses, and PS. However, PS administration is associated with potentially life-threatening complications, such as central venous thromboses, bloodstream infections, and liver disease. In pursuit of a targeted therapy to augment intestinal adaptation, research over the past 2 decades has identified glucagon-like peptide, an intestinotrophic gut peptide that has been shown to enhance intestinal absorptive capacity by causing an increase in the villus length, crypt depth, and mesenteric blood flow and by decreasing gastrointestinal motility and secretions. Teduglutide, a recombinant analog of glucagon-like peptide-2, is the first targeted therapeutic agent to gain approval for use in adult SBS-IF. Teduglutide was shown to result in significant (20%–100%) reduction in PS-volume requirement and have a satisfactory safety profile in three randomized control trials. Further research is warranted to see if reduction in PS dependency translates to improved quality of life and reduced PS-associated complications.
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Affiliation(s)
- Kishore Vipperla
- Division of General Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Stephen J O'Keefe
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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25
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Garcia AM, Wakeman D, Lu J, Rowley C, Geisman T, Butler C, Bala S, Swietlicki EA, Warner BW, Levin MS, Rubin DC. Tis7 deletion reduces survival and induces intestinal anastomotic inflammation and obstruction in high-fat diet-fed mice with short bowel syndrome. Am J Physiol Gastrointest Liver Physiol 2014; 307:G642-54. [PMID: 25059825 PMCID: PMC4166722 DOI: 10.1152/ajpgi.00374.2013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Effective therapies are limited for patients with parenteral nutrition-dependent short bowel syndrome. We previously showed that intestinal expression of the transcriptional coregulator tetradecanoyl phorbol acetate-induced sequence 7 (tis7) is markedly increased during the adaptive response following massive small bowel resection and tis7 plays a role in normal gut lipid metabolism. Here, we further explore the functional implications of tis7 deletion in intestinal lipid metabolism and the adaptive response following small bowel resection. Intestinal tis7 transgenic (tis7(tg)), tis7(-/-), and wild-type (WT) littermates were subjected to 50% small bowel resection. Mice were fed a control or a high-saturated-fat (42% energy) diet for 21 days. Survival, body weight recovery, lipid absorption, mucosal lipid analysis, and the morphometric adaptive response were analyzed. Quantitative real-time PCR was performed to identify tis7 downstream gene targets. Postresection survival was markedly reduced in high-fat, but not control, diet-fed tis7(-/-) mice. Decreased survival was associated with anastomotic inflammation and intestinal obstruction postresection. High-fat, but not control, diet-fed tis7(-/-) mice had increased intestinal IL-6 expression. Intestinal lipid trafficking was altered in tis7(-/-) compared with WT mice postresection. In contrast, high-fat diet-fed tis7(tg) mice had improved survival postresection compared with WT littermates. High-fat diet feeding in the setting of tis7 deletion resulted in postresection anastomotic inflammation and small bowel obstruction. Tolerance of a calorie-rich, high-fat diet postresection may require tis7 and its target genes. The presence of luminal fat in the setting of tis7 deletion promotes an intestinal inflammatory response postresection.
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Affiliation(s)
- Amy M. Garcia
- 2Division of Pediatric Gastroenterology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri;
| | - Derek Wakeman
- 3Department of Pediatric Surgery, Washington University School of Medicine, St. Louis, Missouri;
| | - Jianyun Lu
- 1Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri;
| | - Christopher Rowley
- 1Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri;
| | - Taylor Geisman
- 1Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri;
| | - Catherine Butler
- 1Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri;
| | - Shashi Bala
- 1Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri;
| | - Elzbieta A. Swietlicki
- 1Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri;
| | - Brad W. Warner
- 3Department of Pediatric Surgery, Washington University School of Medicine, St. Louis, Missouri;
| | - Marc S. Levin
- 1Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri; ,4Department of Medicine, Veterans Affairs St. Louis Health Care System; St. Louis, Missouri; and
| | - Deborah C. Rubin
- 1Division of Gastroenterology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri; ,5Department of Developmental Biology, Washington University School of Medicine, St. Louis, Missouri
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Abstract
PURPOSE OF REVIEW This review will provide the practitioner with an understanding of the spectrum of nontransplant surgical options for managing patients with short bowel syndrome (SBS). RECENT FINDINGS Intestinal lengthening procedures are a promising therapy to allow autonomy from parenteral nutrition. The recently described serial transverse enteroplasty is an effective procedure that is easier to perform and has similar outcomes to the more standard longitudinal lengthening procedure described by Bianchi. SUMMARY There are several surgical options for management of the SBS, including construction of intestinal valves or reversed intestinal segments, interposition of segments of colon, or intestinal lengthening procedures. The choice of technique is dictated by the patient's underlying pathophysiology and includes such factors as intestinal transit time, length of remnant bowel, presence of intact colon, and degree of small bowel dilation. Nontransplant surgical interventions are important adjuncts to the elimination of parenteral nutrition dependence and need for intestinal transplantation.
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Abstract
Intestinal adaptation is a natural compensatory process that occurs following extensive intestinal resection, whereby structural and functional changes in the intestine improve nutrient and fluid absorption in the remnant bowel. In animal studies, postresection structural adaptations include bowel lengthening and thickening and increases in villus height and crypt depth. Functional changes include increased nutrient transporter expression, accelerated crypt cell differentiation, and slowed transit time. In adult humans, data regarding adaptive changes are sparse, and the mechanisms underlying intestinal adaptation remain to be fully elucidated. Several factors influence the degree of intestinal adaptation that occurs post resection, including site and extent of resection, luminal stimulation with enteral nutrients, and intestinotrophic factors. Two intestinotrophic growth factors, the glucagon-like peptide 2 analog teduglutide and recombinant growth hormone (somatropin), are now approved for clinical use in patients with short bowel syndrome (SBS). Both agents enhance fluid absorption and decrease requirements for parenteral nutrition (PN) and/or intravenous fluid. Intestinal adaptation has been thought to be limited to the first 1-2 years following resection in humans. However, recent data suggest that a significant proportion of adult patients with SBS can achieve enteral autonomy, even after many years of PN dependence, particularly with trophic stimulation.
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Affiliation(s)
- Kelly A Tappenden
- Department of Food Science and Human Nutrition, University of Illinois at Urbana-Champaign, Urbana, Illinois
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28
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Abstract
Short bowel syndrome (SBS) is the most common cause of intestinal failure in infants. In neonates and young infants, necrotizing enterocolitis, gastroschisis, intestinal atresia, and intestinal malrotation/volvulus are the leading causes of SBS. Following an acute postsurgical phase, the residual gastrointestinal tract adapts with reorganization of the crypt-villus histoarchitecture and functional changes in nutrient absorption and motility. A cohesive, multidisciplinary approach can allow most neonates with SBS to transition to full enteral feeds and achieve normal growth and development. In this article, the clinical features, management, complications, and prognostic factors in SBS are reviewed.
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Abstract
Adaptation is an important compensatory response to environmental cues resulting in enhanced survival. In the gut, the abrupt loss of intestinal length is characterized by increased rates of enterocyte proliferation and apoptosis and culminates in adaptive villus and crypt growth. In the development of an academic pediatric surgical career, adaptation is also an important compensatory response to survive the ever changing research, clinical, and economic environment. The ability to adapt in both situations is critical for patients and a legacy of pediatric surgical contributions to advance our knowledge of multiple conditions and diseases.
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Brinkman AS, Murali SG, Hitt S, Solverson PM, Holst JJ, Ney DM. Enteral nutrients potentiate glucagon-like peptide-2 action and reduce dependence on parenteral nutrition in a rat model of human intestinal failure. Am J Physiol Gastrointest Liver Physiol 2012; 303:G610-22. [PMID: 22744334 PMCID: PMC3468558 DOI: 10.1152/ajpgi.00184.2012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Glucagon-like peptide-2 (GLP-2) is a nutrient-dependent, proglucagon-derived gut hormone that shows promise for the treatment of short bowel syndrome (SBS). Our objective was to investigate how combination GLP-2 + enteral nutrients (EN) affects intestinal adaption in a rat model that mimics severe human SBS and requires parenteral nutrition (PN). Male Sprague-Dawley rats were assigned to one of five groups and maintained with PN for 18 days: total parenteral nutrition (TPN) alone, TPN + GLP-2 (100 μg·kg(-1)·day(-1)), PN + EN + GLP-2(7 days), PN + EN + GLP-2(18 days), and a nonsurgical oral reference group. Animals underwent massive distal bowel resection followed by jejunocolic anastomosis and placement of jugular catheters. Starting on postoperative day 4, rats in the EN groups were allowed ad libitum access to EN. Groups provided PN + EN + GLP-2 had their rate of PN reduced by 0.25 ml/day starting on postoperative day 6. Groups provided PN + EN + GLP-2 demonstrated significantly greater body weight gain with similar energy intake and a safe 80% reduction in PN compared with TPN ± GLP-2. Groups provided PN + EN + GLP-2 for 7 or 18 days showed similar body weight gain, residual jejunal length, and digestive capacity. Groups provided PN + EN + GLP-2 showed increased jejunal GLP-2 receptor (GLP-2R), insulin-like growth factor-I (IGF-I), and IGF-binding protein-5 (IGFBP-5) expression. Treatment with TPN + GLP-2 demonstrated increased jejunal expression of epidermal growth factor. Cessation of GLP-2 after 7 days with continued EN sustained the majority of intestinal adaption and significantly increased expression of colonic proglucagon compared with PN + EN + GLP-2 for 18 days, and increased plasma GLP-2 concentrations compared with TPN alone. In summary, EN potentiate the intestinotrophic actions of GLP-2 by improving body weight gain allowing for a safe 80% reduction in PN with increased jejunal expression of GLP-2R, IGF-I, and IGFBP-5 following distal bowel resection in the rat.
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Affiliation(s)
- Adam S. Brinkman
- 1Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin; ,2Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin;
| | - Sangita G. Murali
- 2Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin;
| | - Stacy Hitt
- 3Department of Pathology, University of Wisconsin-Madison, Madison, Wisconsin; and
| | - Patrick M. Solverson
- 2Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin;
| | - Jens J. Holst
- 4Department of Medical Physiology, The Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Denise M. Ney
- 2Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin;
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31
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Gutierrez IM, Kang KH, Calvert CE, Johnson VM, Zurakowski D, Kamin D, Jaksic T, Duggan C. Risk factors for small bowel bacterial overgrowth and diagnostic yield of duodenal aspirates in children with intestinal failure: a retrospective review. J Pediatr Surg 2012; 47:1150-4. [PMID: 22703785 PMCID: PMC3377944 DOI: 10.1016/j.jpedsurg.2012.03.019] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 03/06/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Children with intestinal failure (IF) are at risk for small bowel bacterial overgrowth (SBBO) because of anatomical and other factors. We sought to identify risk factors for SBBO confirmed by quantitative duodenal culture. METHODS A single-center retrospective record review of children who had undergone endoscopic evaluation for SBBO (defined as bacterial growth in duodenal fluid of >10(5) colony-forming unit per mL) was performed. RESULTS We reviewed 57 children with median (25th-75th percentile) age 5.0 (2.0-9.2) years. Diagnoses included motility disorders (28%), necrotizing enterocolitis (16%), atresias (16%), gastroschisis (14%), and Hirschsprung disease (10.5%). Forty patients (70%) had confirmed SBBO. Univariate analysis showed no significant differences between patients with and without SBBO for the following variables: age, sex, diagnosis, presence of ileocecal valve, and antacid use. Patients receiving parenteral nutrition (PN) were more likely to have SBBO (70% vs 35%, P = .02). Multiple logistic regression analysis confirmed that PN administration was independently associated with SBBO (adjusted odds ratio, 5.1; adjusted 95% confidence interval, 1.4-18.3; P = .01). SBBO was not related to subsequent risk of catheter-related bloodstream infection (CRBSI). CONCLUSION SBBO is strongly and independently associated with PN use. Larger prospective cohorts and more systematic sampling techniques are needed to better determine the relationship between SBBO and gastrointestinal function.
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Affiliation(s)
- Ivan M. Gutierrez
- Center for Advanced Intestinal Rehabilitation, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA,Department of Surgery, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
| | - Kuang Horng Kang
- Center for Advanced Intestinal Rehabilitation, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA,Department of Surgery, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
| | - Catherine E. Calvert
- Department of Surgery, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
| | - Victor M. Johnson
- Department of Surgery, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
| | - David Zurakowski
- Department of Surgery, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
| | - Daniel Kamin
- Center for Advanced Intestinal Rehabilitation, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA,Division of Gastroenterology and Nutrition, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
| | - Tom Jaksic
- Center for Advanced Intestinal Rehabilitation, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA,Department of Surgery, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
| | - Christopher Duggan
- Center for Advanced Intestinal Rehabilitation, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA,Division of Gastroenterology and Nutrition, Children’s Hospital Boston and Harvard Medical School, Boston, MA 02115, USA,Corresponding Author: Christopher Duggan, Division of Gastroenterology and Nutrition, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, Telephone: 1+ 617 355 7612, Fax: 1+ 617 730 4722,
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Wakeman D, Guo J, Santos JA, Wandu WS, Schneider JE, McMellen ME, Leinicke JA, Erwin CR, Warner BW. p38 MAPK regulates Bax activity and apoptosis in enterocytes at baseline and after intestinal resection. Am J Physiol Gastrointest Liver Physiol 2012; 302:G997-1005. [PMID: 22383494 PMCID: PMC3362074 DOI: 10.1152/ajpgi.00485.2011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Increased apoptosis in crypt enterocytes is a key feature of intestinal adaptation following massive small bowel resection (SBR). Expression of the proapoptotic factor Bax has been shown to be required for resection-induced apoptosis. It has also been demonstrated that p38-α MAPK (p38) is necessary for Bax activation and apoptosis in vitro. The present studies were designed to test the hypothesis that p38 is a key regulator of Bax activation during adaptation after SBR in vivo. Enterocyte expression of p38 was deleted by tamoxifen administration to activate villin-Cre in adult mice with a floxed Mapk14 (p38-α) gene. Proximal 50% SBR or sham operations were performed on wild-type (WT) and p38 intestinal knockout (p38-IKO) mice under isoflurane anesthesia. Mice were killed 3 or 7 days after operation, and adaptation was analyzed by measuring intestinal morphology, proliferation, and apoptosis. Bax activity was quantified by immunoprecipitation, followed by Western blotting. After SBR, p38-IKO mice had deeper crypts, longer villi, and accelerated proliferation compared with WT controls. Rates of crypt apoptosis were significantly lower in p38-IKO mice, both at baseline and after SBR. Levels of activated Bax were twofold higher in WT mice after SBR relative to sham. In contrast, activated Bax levels were reduced by 67% in mice after p38 MAPK deletion. Deleted p38 expression within the intestinal epithelium leads to enhanced adaptation and reduced levels of enterocyte apoptosis after massive intestinal resection. p38-regulated Bax activation appears to be an important mechanism underlying resection-induced apoptosis.
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Affiliation(s)
- Derek Wakeman
- Department of Surgery, Division of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri
| | - Jun Guo
- Department of Surgery, Division of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri
| | - Jethrina A. Santos
- Department of Surgery, Division of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri
| | - Wambui S. Wandu
- Department of Surgery, Division of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri
| | - John E. Schneider
- Department of Surgery, Division of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri
| | - Mark E. McMellen
- Department of Surgery, Division of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri
| | - Jennifer A. Leinicke
- Department of Surgery, Division of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri
| | - Christopher R. Erwin
- Department of Surgery, Division of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri
| | - Brad W. Warner
- Department of Surgery, Division of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri
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Murali SG, Brinkman AS, Solverson P, Pun W, Pintar JE, Ney DM. Exogenous GLP-2 and IGF-I induce a differential intestinal response in IGF binding protein-3 and -5 double knockout mice. Am J Physiol Gastrointest Liver Physiol 2012; 302:G794-804. [PMID: 22281475 PMCID: PMC3355561 DOI: 10.1152/ajpgi.00372.2011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Glucagon-like peptide-2 (GLP-2) action is dependent on intestinal expression of IGF-I, and IGF-I action is modulated by IGF binding proteins (IGFBP). Our objective was to evaluate whether the intestinal response to GLP-2 or IGF-I is dependent on expression of IGFBP-3 and -5. Male, adult mice in six treatment groups, three wild-type (WT) and three double IGFBP-3/-5 knockout (KO), received twice daily intraperitoneal injections of GLP-2 (0.5 μg/g body wt), IGF-I (4 μg/g body wt), or PBS (vehicle) for 7 days. IGFBP-3/-5 KO mice showed a phenotype of lower plasma IGF-I concentration, but greater body weight and relative mass of visceral organs, compared with WT mice (P < 0.001). WT mice showed jejunal growth with either IGF-I or GLP-2 treatment. In KO mice, IGF-I did not stimulate jejunal growth, crypt mitosis, sucrase activity, and IGF-I receptor (IGF-IR) expression, suggesting that the intestinotrophic actions of IGF-I are dependent on expression of IGFBP-3 and -5. In KO mice, GLP-2 induced significant increases in jejunal mucosal cellularity, crypt mitosis, villus height, and crypt depth that was associated with increased expression of the ErbB ligand epiregulin and decreased expression of IGF-I and IGF-IR. This suggests that in KO mice, GLP-2 action in jejunal mucosa is independent of the IGF-I system and linked with ErbB ligands. In summary, the intestinotrophic actions of IGF-I, but not GLP-2, in mucosa are dependent on IGFBP-3 and -5. These findings support the role of multiple downstream mediators for the mucosal growth induced by GLP-2.
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Affiliation(s)
| | - Adam S. Brinkman
- Departments of 1Nutritional Sciences and ,2Surgery, School of Medicine and Public Health, University
of Wisconsin-Madison, Madison, Wisconsin;
| | | | - Wing Pun
- Departments of 1Nutritional Sciences and
| | - John E. Pintar
- 3Department of Neuroscience and Cell Biology, Robert Wood
Johnson Medical School, University of Medicine and Dentistry of New Jersey,
Piscataway, New Jersey
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Abstract
INTRODUCTION Current medical management of short bowel syndrome (SBS) involves the use of lifelong parenteral nutrition (PN). Glucagon-like peptide-2 (GLP-2), an important intestinotrophic growth factor has been shown to increase intestinal absorption in SBS through augmentation of post-resection intestinal adaptation. This may lead to the reduction of PN dependence in patients with SBS. AREAS COVERED IN REVIEW Advancing research of GLP-2 physiology has spurred the growing understanding of the diverse effects of GLP-2. The development of the degradation resistant GLP-2 analog, teduglutide (Gattex(TM), NPS Pharmaceuticals, Bedminster, NJ), has allowed its exploration as a therapeutic agent in a variety of clinical settings. Recent multicenter, placebo-controlled studies of GLP-2 in SBS patients demonstrate meaningful reductions in PN requirements with good safety profiles. The reparative and immunomodulatory effects of teduglutide may also be beneficial in patients with inflammatory bowel disease (IBD). Safety concerns about possible carcinogenic properties during long-term use require ongoing evaluation. SUMMARY GLP-2 appears to offer a novel adjuvant treatment modality for SBS. Promise for its use in other clinical settings like IBD has been shown in small pilot studies.
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Affiliation(s)
- Cheng T Tee
- Lennard-Jones Intestinal Failure Unit, St Mark's Hospital and Academic Institute, Harrow, UK
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Madhavan S, Scow JS, Chaudhry RM, Nagao M, Zheng Y, Duenes JA, Sarr MG. Intestinal adaptation for oligopeptide absorption via PepT1 after massive (70%) mid-small bowel resection. J Gastrointest Surg 2011; 15:240-7; discussion 247-9. [PMID: 21170601 DOI: 10.1007/s11605-010-1320-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Accepted: 08/09/2010] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Proteins are absorbed primarily as short peptides via peptide transporter 1 (PepT1). HYPOTHESIS Intestinal adaptation for peptide absorption after massive mid-small intestinal resection occurs by increased expression of PepT1 in the remnant small intestine and colon. METHODS Peptide uptake was measured in duodenum, jejunum, ileum, and colon using glycyl-sarcosine 1 week (n = 9) and 4 weeks (n = 11) after 70% mid-small bowel resection and in corresponding segments from unoperated rats (n = 12) and after transection and reanastomosis of jejunum and ileum (n = 8). Expression of PepT1 (mRNA, protein) and villus height were measured. RESULTS Intestinal transection/reanastomosis did not alter gene expression. Compared to non-operated controls, 70% mid-small bowel resection increased jejunal peptide uptake (p < 0.05) associated with increased villus height (1.13 vs 1.77 and 1.50 mm, respectively, p < 0.01). In ileum although villus height increased at 1 and 4 weeks (1.03 vs 1.21 and 1.35 mm, respectively; p < 0.01), peptide uptake was not altered. PepT1 mRNA and protein were decreased at 1 week, and PepT1 protein continued low at 4 weeks. Gene expression, peptide uptake, and histomorphology were unchanged in the colon. CONCLUSIONS Jejunal adaptation for peptide absorption occurs by hyperplasia. Distal ileum and colon do not have a substantive role in adaptation for peptide absorption.
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Abstract
Extensive resection of the intestinal tract frequently results in inadequate digestion and/or absorption of nutrients, a condition known as short bowel syndrome (SBS). This challenging condition demands a dedicated multidisciplinary team effort to overcome the morbidity and mortality in these patients. With advances in critical care management, more and more patients survive the immediate morbidity of massive intestinal resection to present with SBS. Several therapies, including parenteral nutrition (PN), bowel rehabilitation and surgical procedures to reconstruct bowel have been used in these patients. Novel dietary approaches, pharmacotherapy and timely surgical interventions have all added to the improved outcome in these patients. However, these treatments only partially correct the underlying problem of reduced bowel function and have limited success resulting in 30% to 50% mortality rates. However, increasing experience and encouraging results of intestinal transplantation has added a new dimension to the management of SBS. Literature available on SBS is exhaustive but inconclusive. We conducted a review of scientific literature and electronic media with search terms 'short bowel syndrome, advances in SBS and SBS' and attempted to give a comprehensive account on this topic with emphasis on the recent advances in its management.
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Affiliation(s)
- Prasad Seetharam
- Department of General Surgery, Kasturba Medical College, Manipal University, Manipal, India
| | - Gabriel Rodrigues
- Department of General Surgery, Kasturba Medical College, Manipal University, Manipal, India,Address for correspondence: Dr. Gabriel Rodrigues, Department of General Surgery, Kasturba Medical College, Manipal University, Manipal, India. E-mail:
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Garrison AP, Dekaney CM, von Allmen DC, Lund PK, Henning SJ, Helmrath MA. Early but not late administration of glucagon-like peptide-2 following ileo-cecal resection augments putative intestinal stem cell expansion. Am J Physiol Gastrointest Liver Physiol 2009; 296:G643-50. [PMID: 19118113 PMCID: PMC2660180 DOI: 10.1152/ajpgi.90588.2008] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Accepted: 12/27/2008] [Indexed: 01/31/2023]
Abstract
Expansion of intestinal progenitors and putative stem cells (pISC) occurs early and transiently following ileo-cecal resection (ICR). The mechanism controlling this process is not defined. We hypothesized that glucagon-like peptide-2 (GLP-2) would augment jejunal pISC expansion only when administered to mice immediately after ICR. Since recent reports demonstrated increases in intestinal insulin-like growth factor (IGF)-I following GLP-2 administration, we further hypothesized that increased intestinal IGF-I expression would correlate with pISC expansion following ICR. To assess this, GLP-2 or vehicle was administered to mice either immediately after resection (early) or before tissue harvest 6 wk following ICR (late). Histological analysis quantified proliferation and intestinal morphometrics. Serum levels of GLP-2 were measured by ELISA and jejunal IGF-I mRNA by qRT-PCR. Expansion of jejunal pISC was assessed by fluorescent-activated cell sorting of side population cells, immunohistochemistry for phosphorylated beta-catenin at serine 552 (a pISC marker), percent of crypt fission, and total numbers of crypts per jejunal circumference. We found that early but not late GLP-2 treatment after ICR significantly augmented pISC expansion. Increases in jejunal IGF-I mRNA correlated temporally with early pISC expansion and effects of GLP-2. Early GLP-2 increased crypt fission and accelerated adaptive increases in crypt number and intestinal caliber. GLP-2 increased proliferation and intestinal morphometrics in all groups. This study shows that, in mice, GLP-2 promotes jejunal pISC expansion only in the period immediately following ICR. This is associated with increased IGF-I and accelerated adaptive increases in mucosal mass. These data provide clinical rationale relevant to the optimal timing of GLP-2 in patients with intestinal failure.
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Affiliation(s)
- Aaron P Garrison
- University of North Carolina at Chapel Hill, Department of Surgery, G140 Physician's Office Bldg., CB #7223, Chapel Hill, NC 27599-7223, USA
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Tian J, Hao L, Chandra P, Jones DP, Willams IR, Gewirtz AT, Ziegler TR. Dietary glutamine and oral antibiotics each improve indexes of gut barrier function in rat short bowel syndrome. Am J Physiol Gastrointest Liver Physiol 2009; 296:G348-55. [PMID: 19095767 PMCID: PMC2643904 DOI: 10.1152/ajpgi.90233.2008] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Short bowel syndrome (SBS) is associated with gut barrier dysfunction. We examined effects of dietary glutamine (GLN) or oral antibiotics (ABX) on indexes of gut barrier function in a rat model of SBS. Adult rats underwent a 60% distal small bowel + proximal colonic resection (RX) or bowel transection (TX; control). Rats were pair fed diets with or without l-GLN for 20 days after operation. Oral ABX (neomycin, metronidazole, and polymyxin B) were given in some RX rats fed control diet. Stool secretory immunoglobulin A (sIgA) was measured serially. On day 21, mesenteric lymph nodes (MLN) were cultured for gram-negative bacteria. IgA-positive plasma cells in jejunum, stool levels of flagellin- and lipopolysaccharide (LPS)-specific sIgA, and serum total, anti-flagellin- and anti-LPS IgG levels were determined. RX caused gram-negative bacterial translocation to MLN, increased serum total and anti-LPS IgG and increased stool total sIgA. After RX, dietary GLN tended to blunt bacterial translocation to MLN (-29%, P = NS) and significantly decreased anti-LPS IgG levels in serum, increased both stool and jejunal mucosal sIgA and increased stool anti-LPS-specific IgA. Oral ABX eliminated RX-induced bacterial translocation, significantly decreased total and anti-LPS IgG levels in serum, significantly decreased stool total IgA and increased stool LPS-specific IgA. Partial small bowel-colonic resection in rats is associated with gram-negative bacterial translocation from the gut and a concomitant adaptive immune response to LPS. These indexes of gut barrier dysfunction are ameliorated or blunted by administration of dietary GLN or oral ABX, respectively. Dietary GLN upregulates small bowel sIgA in this model.
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Affiliation(s)
- Junqiang Tian
- Nutrition and Health Sciences Program, Emory Center for Clinical and Molecular Nutrition, and Departments of Medicine and Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia
| | - Li Hao
- Nutrition and Health Sciences Program, Emory Center for Clinical and Molecular Nutrition, and Departments of Medicine and Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia
| | - Prakash Chandra
- Nutrition and Health Sciences Program, Emory Center for Clinical and Molecular Nutrition, and Departments of Medicine and Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia
| | - Dean P. Jones
- Nutrition and Health Sciences Program, Emory Center for Clinical and Molecular Nutrition, and Departments of Medicine and Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia
| | - Ifor R. Willams
- Nutrition and Health Sciences Program, Emory Center for Clinical and Molecular Nutrition, and Departments of Medicine and Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia
| | - Andrew T. Gewirtz
- Nutrition and Health Sciences Program, Emory Center for Clinical and Molecular Nutrition, and Departments of Medicine and Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia
| | - Thomas R. Ziegler
- Nutrition and Health Sciences Program, Emory Center for Clinical and Molecular Nutrition, and Departments of Medicine and Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia
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Jeppesen PB, Sanguinetti EL, Buchman A, Howard L, Scolapio JS, Ziegler TR, Gregory J, Tappenden KA, Holst J, Mortensen PB. Teduglutide (ALX-0600), a dipeptidyl peptidase IV resistant glucagon-like peptide 2 analogue, improves intestinal function in short bowel syndrome patients. Gut 2005; 54:1224-31. [PMID: 16099790 PMCID: PMC1774653 DOI: 10.1136/gut.2004.061440] [Citation(s) in RCA: 326] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Glucagon-like peptide 2 (GLP-2) may improve intestinal absorption in short bowel syndrome (SBS) patients with an end jejunostomy. Teduglutide (ALX-0600), a dipeptidyl peptidase IV resistant GLP-2 analogue, prolongs the intestinotrophic properties of GLP-2 in animal models. The safety and effect of teduglutide were investigated in SBS patients with and without a colon in continuity. METHODS Teduglutide was given subcutaneously for 21 days once or twice daily to 16 SBS patients in the per protocol investigational group, 10 with end jejunostomy (doses of 0.03 (n = 2), 0.10 (n = 5), or 0.15 (n = 3) mg/kg/day), one with <50% colon in continuity (dose 0.03 mg/kg/day), and five with > or = 50% colon in continuity (dose 0.10 mg/kg/day). Nutrient balance studies, D-xylose tests, and intestinal mucosa biopsies were performed at baseline, on the last three days of treatment, and after three weeks of follow up. Pre-study fasting native GLP-2 levels were determined for the five patients with > or = 50% colon in continuity. RESULTS Pooled across groups and compared with baseline, teduglutide increased absolute (+743 (477) g/day; p<0.001) and relative (+22 (16)%; p<0.001) wet weight absorption, urine weight (+555 (485) g/day; p<0.001), and urine sodium excretion (+53 (40) mmol/day; p<0.001). Teduglutide decreased faecal wet weight (-711 (734) g/day; p = 0.001) and faecal energy excretion (-808 (1453) kJ/day (-193 (347) kcal/day); p = 0.040). In SBS patients with end jejunostomy, teduglutide significantly increased villus height (+38 (45)%; p = 0.030), crypt depth (+22 (18)%; p = 0.010), and mitotic index (+115 (108)%; p = 0.010). Crypt depth and mitotic index did not change in colonic biopsies from SBS patients with colon in continuity. The most common side effects were enlargement of the stoma nipple and mild lower leg oedema. The improvements in intestinal absorption and decreases in faecal excretion noted after treatment had reversed after the drug free follow up period. A controlled study with a more robust design is ongoing in order to determine the optimal dosage of teduglutide for SBS patients to achieve the maximal effect and utility of this drug in clinical practice. CONCLUSION Teduglutide, at three dose levels for 21 days, was safe and well tolerated, intestinotrophic, and significantly increased intestinal wet weight absorption in SBS patients with an end jejunostomy or a colon in continuity.
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Affiliation(s)
- P B Jeppesen
- Department of Medicine CA-2121, Section of Gastroenterology, Rigshospitalet, University Hospital of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
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40
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Abstract
OBJECTIVE Arginine supplementation seems logical in situations where this amino acid becomes essential, for example after massive intestinal resection. Arginine is taken up and metabolised by the liver to a large extent and its supplementation is potentially unsafe. Citrulline is not captured by the liver and passes freely to the kidneys where it is metabolised to arginine, and so is a good candidate to generate arginine and thereby improve nutritional status. METHODS Twenty four rats were assigned to four groups: citrulline, arginine, control, and sham. The sham group underwent transection and the three other groups resection of 80% of the small intestine. All rats were fed by enteral nutrition and its composition was as follows: supplementation with citrulline in the citrulline group, supplementation with arginine in the arginine group, and standard polymeric enteral nutrition in the control and sham groups. All groups received isonitrogenous nutrition and citrulline and arginine intakes were equimolar in their respective groups. After 10 days, the rats were sacrificed. RESULTS Arginine concentration was higher (p<0.05) in plasma and muscle in the citrulline group than in the three other groups. Plasma levels of arginine were 110 (12), 79 (7), 167 (22), and 228 (13) mumol/l in the sham, control, arginine, and citrulline groups respectively. Arginine concentrations in the gastrocnemius were: 0.15 (0.02), 0.16 (0.02), 0.40 (0.05), and 0.94 (0.20) mumol/g, respectively. Citrulline preserved nitrogen balance in resected rats but not in arginine supplemented rats (mean J10: 2.27 (0.29), 1.67 (0.15), 1.98 (0.29), and 2.43 (0.41) g/24 hours in the sham, control, arginine, and citrulline groups, respectively). CONCLUSION Supplementing the diet with citrulline is a very efficient means of increasing arginine levels and improving nitrogen balance after massive intestinal resection. The results of this study form a strong rationale for citrulline supplementation in these patients.
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Affiliation(s)
- S Osowska
- Laboratoire de Biologie de la Nutrition, Faculté de Pharmacie-Université Paris 5, 4 Avenue de l'Observatoire, 75270 Paris Cedex 06, France
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