A regional EUS service using a collaborative network

Endoscopic ultrasound (EUS) is increasingly used in the management of hepatobiliary lesions, allowing staging and tissue acquisition. It is operator-dependent, and fine needle aspiration (FNA) of solid lesions provides an auditable standard; high-volume centres have shown excellent results for solid pancreatic lesion FNA with sensitivities of 92%-97%. The British Society of Gastroenterology guidelines stress that clinical quality should determine service provision, with geographical accessibility a secondary consideration. We set up the Wessex EUS network, working from a single hepatobiliary (HPB) pancreatic multidisciplinary team, with EUS provided in four local centres providing agreed standards and audit. Pancreatic solid lesion FNA results showed a pooled sensitivity of 94%, comparable with high-volume single centres. This demonstrates a network with good clinical governance is a plausible solution to providing a specialist service such as EUS and may be a roadmap that other specialist services under pressure could follow.

Review article: psychological aspects of home parenteral nutrition, abnormal illness behaviour and risk of self-harm in patients with central venous catheters

BACKGROUND

Home parenteral nutrition is established as standard management for patients with chronic severe intestinal failure. Although the treatment is welcomed by many patients, there are psychological consequences of living with a central venous catheter and there are associated restrictions to the lives of patients on home parenteral nutrition. A subgroup of home parenteral nutrition patients may use their central venous catheter for self-harm.

AIMS

To review existing literature relating to abnormal psychological responses to central venous catheters in patients receiving home parenteral nutrition and the psychological meaning of living with a central venous catheter. It also attempts to alert professionals to ways in which patients may self-harm using their central venous catheters.

METHODS

A literature review was performed. Data were obtained both from literature searches and from personal experience at a Psychological Medicine Unit attached to a large home parenteral nutrition centre.

RESULTS

Patients receiving home parenteral nutrition may use their central venous catheter in various ways to self-harm. Motivation may be conscious or unconscious. Sequelae of such self-harm may be life-threatening.

CONCLUSION

This paper concludes with recommendations for best practice with respect to the psychological management of home parenteral nutrition patients in whom central venous catheter abuse is suspected.

Chronic biochemical cholestasis in patients receiving home parenteral nutrition: prevalence and predisposing factors

BACKGROUND

Chronic biochemical cholestasis has been shown to be associated with a fivefold increase in histologically advanced liver disease in patients receiving home parenteral nutrition.

AIMS

To investigate prevalence of chronic biochemical cholestasis in home parenteral nutrition patients and examine factors influencing its occurrence.

METHODS

Records of all patients receiving home parenteral nutrition for >6 months treated at a single centre were reviewed and plasma biochemistry recorded. Logistic regression analysis was employed to identify factors associated with prevalence of chronic biochemical cholestasis.

RESULTS

Records of 113 patients were reviewed. The point prevalence of chronic biochemical cholestasis was 24%, increasing to 28% if patients receiving parenteral fluid and electrolytes only were excluded. In multivariate analysis, presence of colon in continuity was associated with a significantly lower prevalence of chronic biochemical cholestasis, while total parenteral calorie intake was associated with a higher prevalence of chronic biochemical cholestasis. No association was seen between small intestinal lengths or between parenteral lipid intake and chronic biochemical cholestasis in multivariate analysis.

CONCLUSIONS

Chronic biochemical cholestasis is common in patients receiving home parenteral nutrition. High parenteral calorie intake and lack of a colon in continuity with small intestine are independently associated with an increased risk of chronic biochemical cholestasis.

Prolonged Maintenance of Neointestine Using Subcutaneously Implanted Tubular Scaffolds in a Rat Model

Tissue-engineered small intestine offers a possible alternative to long-term parenteral nutrition or intestinal transplantation in patients with short bowel syndrome. The aim of this study was to investigate the prolonged development of neointestine grown on subcutaneously implanted scaffolds. Tubular polylactide-coglycolide (PLGA) scaffolds were implanted into adult Lewis rats. Four weeks after scaffold implantation, a suspension of organoid units was delivered to the lumen of each scaffold. Organoid units were manufactured from small intestine harvested from neonatal Lewis rats by partial digestion using collagenase and dispase. Scaffolds were removed at 4, 8, and 12 weeks after organoid unit implantation, processed to paraffin, and sectioned. Hematoxylin and eosin staining demonstrated well-developed and well-differentiated intestinal mucosa and a vascularised submucosa within the scaffolds at 4, 8, and 12 weeks. Appearances were similar to native small intestine. Immunohistochemistry performed using primary antibody against proliferating cell nuclear antigen, a marker for cellular proliferation, demonstrated positively staining cells within the mucosa and submucosa at all time points. In the mucosal layer these positively staining cells were found primarily in the crypts. These findings show that neointestinal mucosa can be maintained for at least 12 weeks on a subcutaneous PLGA scaffold, and the presence of actively proliferating cells at 12 weeks suggests potential for further development beyond this.

Survival and dependence on home parenteral nutrition: experience over a 25-year period in a UK referral centre

BACKGROUND

Home parenteral nutrition (HPN) is the standard treatment for severe intestinal failure in the United Kingdom.

AIM

To review long-term survival and ongoing HPN dependence of patients receiving HPN treated at a specialist UK referral centre.

METHODS

Medical records of patients commenced on HPN between 1979 and 2003 were reviewed retrospectively. Regression analysis was employed to identify factors associated with poor prognosis.

RESULTS

Case notes of 188 patients were reviewed. Overall probability of survival was 86%, 77%, 73% and 71% at 1, 3, 5 and 10 years after starting treatment. In multivariate analysis, association was seen between mechanism of intestinal failure and survival: short bowel syndrome associated with a favourable prognosis, and intestinal dysfunction, dysmotility and obstruction with poorer prognoses. There was an association between increasing age and poor prognosis, but increased mortality was also seen in the youngest age groups. Only 9% of deaths were due to complications of HPN. Continued HPN dependence was 89%, 87%, 84% and 84% at 1, 3, 5 and 10 years in survivors.

CONCLUSIONS

Long-term survival of patients receiving HPN remains better than that reported after intestinal transplantation. Mortality predominantly relates to underlying disease rather than complications of HPN.

Nutrition and management of enterocutaneous fistula

BACKGROUND

The management of enterocutaneous fistula is challenging, with significant associated morbidity and mortality. This article reviews treatment, with emphasis on the provision and optimal route of nutritional support.

METHODS

Relevant articles were identified using Medline searches. Secondary articles were identified from the reference lists of key papers.

RESULTS AND CONCLUSION

Management of enterocutaneous fistula should initially concentrate on correction of fluid and electrolyte imbalances, drainage of collections, treatment of sepsis and control of fistula output. The routine use of somatostatin infusion and somatostatin analogues remains controversial; although there are data suggesting reduced time to fistula closure, there is little evidence of increased probability of spontaneous closure. Malnutrition is common and adequate nutritional provision is essential, enteral where possible, although supplemental parenteral nutrition is often required for high-output small bowel fistulas. The role of immunonutrition is unknown. Surgical repair should be attempted when spontaneous fistula closure does not occur, but it should be delayed for at least 3 months.

Parenteral nutrition: ethical and legal considerations

Parenteral nutrition is an expensive therapeutic modality that is used to treat patients with intestinal failure. The benefit it offers in terms of life prolongation needs to be weighed against its risks and burdens. Through the use of descriptive clinical vignettes, this article illustrates the ethical and legal principles that underpin decisions to administer and, more importantly, to withhold or withdraw parenteral nutrition.

A pilot study investigating a novel subcutaneously implanted pre-cellularised scaffold for tissue engineering of intestinal mucosa

Tissue engineering of the small intestine offers an alternative to long-term intravenous nutrition and transplantation in patients with intestinal failure. Initial work, although encouraging, is limited by the volume of neonatal tissue required to produce a small neomucosal cyst. Our novel approach is to implant tubular poly-lactide-co-glycolide (PGLA) foam scaffolds subcutaneously. The aim of this study was to investigate whether these scaffolds would support growth of intestinal neomucosa. PGLA scaffolds were implanted subcutaneously into 8 Lewis rats; after 5 weeks, 'organoid units' were injected into the lumens. Tissue was assessed histologically after harvesting and quantitative immunohistochemistry was performed using antibodies against vascular endothelial growth factor (VEGF), vascular endothelial growth factor receptor 2 (VEGF-R2), fibroblast growth factor basic (bFGF) and fibroblast growth factor receptor 2 (FGF-R2). At 4 weeks post organoid unit implantation, clearly recognisable mucosa and submucosa was present on the luminal surface of the scaffold. Densities of VEGF and VEGF-R2 positive cells increased with time post organoid unit implantation. This pilot study demonstrates that it is possible to tissue engineer small intestinal neomucosa using subcutaneously implanted PLGA scaffolds. The yield of the process compares favourably to the published literature. Further work is required to optimise the technique.

Acute and chronic pancreatitis--diseases on the rise: a study of hospital admissions in England 1989/90-1999/2000

BACKGROUND

The number of hospital admissions for acute and chronic pancreatitis increased in Britain from the 1960s to the 1980s.

AIMS

To determine time trends in acute and chronic pancreatitis for hospital admissions from 1989/90 to 1999/2000, mortality from 1979 to 1999, and various indices of alcohol consumption.

METHODS

Hospital Episode Statistics for admissions were obtained from the Department of Health and mortality data from the Office for National Statistics. Alcohol consumption data were obtained from the General Household Survey.

RESULTS

Between 1989/90 and 1999/2000, age-standardized hospital admission rates for acute pancreatitis increased by 43%, whilst those for chronic pancreatitis rose by 100%. The proportions of admissions requiring surgical operations increased for acute pancreatitis, but declined for chronic pancreatitis. Case fatality rates for acute pancreatitis declined, but mortality statistics showed no significant change. The proportion of women who drank more than 14 units of alcohol a week also increased.

CONCLUSIONS

There has been a steady increase in admission rates for both acute and chronic pancreatitis over the study period, and these conditions will become an increasingly important part of the workload of the gastroenterologist.