Lethal short-bowel syndrome

Multidisciplinary Management in Pediatric Ultrashort Bowel Syndrome

Pediatric intestinal failure (IF) remains a complex and devastating condition resulting in the inability of the gastrointestinal tract to absorb adequate fluids and nutrients to sustain life. The goal in the management of IF is to achieve enteral autonomy and when not possible to avoid and minimize the development of long-term complications. Survival rates for children with IF have continued to improve resulting in an increased population of children with more altered anatomy. While IF remains a rare disease, children with IF secondary to ultrashort bowel syndrome comprise an even smaller patient population. The goal of this article is to review the recent literature related to the impact of multidisciplinary intestinal rehabilitation programs (IRPs) on the management and outcomes of intestinal failure in children with ultrashort bowel syndrome and potential avenues to further improve the long-term outcomes of this patient population.

[Short bowel syndrome in children: a diagnosis and management update]

Short bowel syndrome (SBS) refers to the sum of the functional alterations that are the result of a critical reduction in the length of the intestine, which in the absence of adequate treatment, presents as chronic diarrhea, chronic dehydration, malnutrition, weight loss, nutriment and electrolyte deficiency, along with a failure to grow that is present with greater frequency during the neonatal period. The aim was to carry out a review of the literature encompassing the definition and the most frequent causes of SBS, together with an understanding of its physiopathology, prognostic factors, and treatment. An Internet search of PubMed articles was carried out for the existing information published over the last 20 years on SBS in children, using the keywords "short bowel syndrome". From a total of 784 potential articles, 82 articles were chosen for the literature review. The treatment of patients presenting with SBS is quite a challenge and therefore it is necessary to establish multidisciplinary management with a focus on maintaining optimal nutritional support that covers the necessities of growth and development and at the same time provides a maximum reduction of short, medium, and long-term complications. The diagnosis and treatment of a child with SBS require a team of professionals that are experts in gastroenterologic, pediatric, and nutritional management. The outcome for the child will be directly related to opportune management, as well as to the length of the intestinal resection and the presence or absence of the ileocecal valve.

Factors affecting survival to intestinal transplantation in the very young pediatric patient

BACKGROUND

Very young pediatric patients awaiting intestinal transplantation have a high mortality rate due to long waiting times, scarcity of appropriate size donor organs, and mortality due to sepsis and liver failure. To investigate specific risk factors impacting survival to intestinal transplantation, we performed a 4-year institutional retrospective study comparing children who received grafts by age 18 months with children 18 months or younger who died while on the waiting list.

PATIENTS AND METHODS

Twelve children comprised the transplanted group and had the underlying diagnoses: necrotizing enterocolitis, gastroschisis, Hirschsprung's disease, and omphalocele. Ten children comprised the deceased group and had the underlying diagnoses: intestinal atresia, necrotizing enterocolitis, gastroschisis, and midgut volvulus. Multiple risk factors were assessed in these groups.

RESULTS

No differences in residual small bowel length, presence of the colon, number of line infections, or number of central lines were found. The average body weight of the transplanted group trended higher, whereas the deceased group had more impairment of hepatic function. Intestinal atresia was the most common diagnosis in the deceased group while none of the transplanted group carried this diagnosis. Ileocecal valve was retained in 80% of the deceased group and in none of the transplanted group.

CONCLUSIONS

In children younger than 18 months, risk factors affecting survival to intestinal transplantation include small body size and advanced liver disease. A primary diagnosis of intestinal atresia and the presence of the ileocecal valve may confer additional risk to these very young children.

Pediatric short bowel syndrome: adaptation after massive small bowel resection

BACKGROUND

Short bowel syndrome (SBS) develops after massive small bowel resections. Patients with less than 12 cm of jejunoileum have a slim possibility of being weaned from parenteral nutrition (PN).

PATIENTS AND METHODS

In a retrospective review of records of consecutive patients with SBS, 8 patients were evaluated for treatment by adaptation and weaning from PN. These included 4 patients with class I SBS (0-10 cm of small bowel), one with class II SBS (>10-25 cm), one with class III SBS (>25-50 cm), and 2 with class IV SBS (>50-75 cm). Adaptation was assessed by measuring growth in the small bowel and the ability to be weaned from PN.

RESULTS

Adaptation was achieved primarily by extending the length of jejunoileum by approximately 450% over the first 2.5 years after resection and by increasing the degree of colonic fermentation and absorption of nutrients. As of July 1, 2005, all of the patients were off PN, with the exception of 2 patients with class I-A SBS: patient 3 had a remaining jejunoileum of only 2.5 cm and patient 4 had a remaining jejunoileum of 9 cm but developed eosinophilic enterocolitis. These 2 patients continued with PN on alternate months.

CONCLUSIONS

Bowel growth after massive small bowel resection provides an objective parameter of adaptation and a means of predicting ability to be weaned from PN. Aggressive nutritional support makes even patients with class I SBS, whose disease was previously considered hopeless, likely candidates to achieve freedom from PN.

Atresia of the colon

BACKGROUND/PURPOSE

Colonic atresia (CA) is one of the rarest causes of neonatal intestinal obstructions, and no large series can be reported. Therefore, we did perform a retrospective clinical trial to delineate our CA cases and carry out a literature survey.

METHODS

We reviewed the charts of CA cases treated in our center between 1992 and 2002. We aimed to collect all reported cases in Medline, and personal communications with the authors of published series were used to reach the missing data.

RESULTS

The chart review revealed 9 newborns with CA treated in our center (6 cases of type III, 2 cases of type II, and 1 case of type IV). These accounted for 3.7% of all gastrointestinal atresias managed in our center. Of the CA cases, 3 were isolated and 6 had at least one or more associated congenital anomalies. The preferred surgical technique at the initial treatment of CA was performing a proximal stoma and distal mucous fistula in an average of postnatal 59.4 hours. The literature survey enabled us to reach 224 cases of CA, including our cases.

CONCLUSIONS

Because of the low incidence of CA, delay in diagnosis and treatment may occur. The mortality is statistically higher when the surgical management is performed after 72 hours of age. However, the prognosis of CA is satisfactory if diagnosis and surgical management could be made promptly and properly.

Classification, epidemiology and aetiology

Intestinal failure and its most important cause, short-bowel syndrome (SBS), are rare clinical entities leading to a vast complex of symptoms and complications with significant morbidity and mortality. Both conditions occur as the result of a massive reduction in enteral nutrient absorptive capacity. Disease manifestation is based on aetiological and anatomical characteristics such as remaining intestinal length and the presence of a functionally intact colon. Congenital and perinatal conditions, for example, intestinal atresia, necrotizing enterocolitis (NEC) and intestinal volvulus are the most important causes in children. The aetiology in adults is based on diseases inducing loss of intestinal function or loss of intestinal surface area after extensive surgical resections. The most frequent causes are mesenteric infarction, radiation enteritis and Crohn's disease. Knowledge of the epidemiology of intestinal failure and SBS is limited, being mainly based on the extrapolated figures of home parenteral nutrition centres and single-centre studies. At present, the incidence of SBS is estimated to be 2-5 per million.

Mortality and economics in short bowel syndrome

The incidence of patients with short-bowel syndrome (SBS) has increased over the years due to progress of intensive care medicine and parenteral nutrition techniques. These techniques have significantly improved the prognosis of neonates, children and adults who have lost major parts of their intestinal tract. Long-term survival is possible and does not depend primarily on the length of the remaining bowel but on complications such as parenteral nutrition-associated cholestasis, recurrent septicaemia, central venous catheter infections, and the motility of the remaining intestine. Thus, the overall related mortality in infants with SBS ranges from 15 to 25%, and in adults from 15 to 47%, depending on the age of the patients, the underlying disease, and the duration on total parenteral nutrition. Home parenteral nutrition (HPN) significantly decreases the complication rate and improves the psychological situation of the patient. Additionally, HPN reduces in-hospital cost significantly. Nevertheless, the annual costs/patient are between $100000 and $150000. The mortality rate of SBS patients on HPN is about 30% after 5 years, which is still lower than the 5-year survival rate of intestinal grafts, and it is about equal to patients' survival after intestinal transplantation. However, the overall costs of a successful intestinal transplantation are already lower after 2 years when compared with the cost of a prolonged HPN programme.

Current status of small bowel transplantation in children: update 2003

This article reviews the current indications for intestinal transplantation and advances in immunosuppression and postoperative care, which help to improve the outcome results of intestinal transplantation. Major current controversies and future trends are discussed briefly.

Acute loss of the small bowel in a school-age boy. Difficult choices: to sustain life or to stop treatment?

A 9-year-old boy lost almost all his small bowel after an acute volvulus due to a congenital, but previously unsuspected malrotation. Survival using total parenteral nutrition is possible in these cases, but the medical burden is heavy. Small intestinal transplantation was performed for the first time in the Netherlands in 2001 and this patient was treated 3 years earlier. The results of bowel transplantation are not as good as in kidney or liver transplantation. A method of Ethical Case Deliberation helped to elucidate the importance of each contribution in the discussion and provided space and a broad basis for decision-making. The parents refused to allow parenteral nutrition to be started because of the bad prospects for quality of life in the future and the medical team, after thorough deliberation with specialists throughout the country, and consultation of the literature, agreed.

CONCLUSION

Despite the many different opinions, the parents felt accepted in their refusal of treatment for their son and the team accepted the decision.

Indications for pediatric intestinal transplantation: a position paper of the American Society of Transplantation

Parenteral nutrition represents standard therapy for children with short bowel syndrome and other causes of intestinal failure. Most infants with short bowel syndrome eventually wean from parenteral nutrition, and most of those who do not wean tolerate parenteral nutrition for protracted periods. However, a subset of children with intestinal failure remaining dependent on parenteral nutrition will develop life-threatening complications arising from therapy. Intestinal transplantation (Tx) can now be recommended for this select group. Life-threatening complications warranting consideration of intestinal Tx include parenteral nutrition-associated liver disease, recurrent sepsis, and threatened loss of central venous access. Because a critical shortage of donor organs exists, waiting times for intestinal Tx are prolonged. Therefore, it is essential that children with life-threatening complications of intestinal failure and parenteral nutrition therapy be identified comparatively early, i.e. in time to receive suitable donor organs before they become critically ill. Children with liver dysfunction should be considered for isolated intestinal Tx before irreversible, advanced bridging fibrosis or cirrhosis supervenes, for which a combined liver and intestinal transplant is necessary. Irreversible liver disease is suggested by hyperbilirubinemia persisting beyond 3-4 months of age combined with features of portal hypertension such as splenomegaly, thrombocytopenia, or prominent superficial abdominal veins; esophageal varices, ascites, and impaired synthetic function are not always present. Death resulting from complications of liver failure is especially common during the wait for a combined liver and intestinal transplant, and survival following combined liver and intestinal Tx is probably lower than following an isolated intestinal transplant. The incidence of morbidity and mortality following intestinal Tx is greater than that following liver or kidney Tx, but long-term survival following intestinal Tx is now at least 50-60%. It is probable that outcomes shall improve in the future with continued refinements in operative technique and post-operative management, including immunosuppression.

Hereditary multiple atresias of the gastrointestinal tract: report of a case and review of the literature

Hereditary multiple atresia of the gastrointestinal tract is an extremely rare subgroup of intestinal atresia. The aim of this study was to report a new case, to review the literature, and to describe the unique features of this malformation. A computer-generated list of articles on this subject was obtained, and all articles relative to this malformation were reviewed. Thirty-five other well-documented cases were found in the literature. Hereditary multiple atresias have several unique features: (1) the abdominal x-ray shows signs of gastric or duodenal atresia combined with typical large rounded or oval homogeneous calcifications in the abdominal cavity, (2) intraoperatively widespread atresias (exclusively type I and II) extending mostly from stomach to rectum are found, (3) cystic dilatation of the bile ducts can be present in cases with both complete pyloric and duodenal or proximal jejunal atresia, (4) the pathogenesis is still speculative; a combined immunodeficiency should be excluded, and (5) a fatal outcome is the rule.

Surgical approach to short-bowel syndrome. Experience in a population of 160 patients

OBJECTIVE

The authors reviewed their experience with short-bowel syndrome to define the surgical approach to this problem in 160 patients.

METHODS

Forty-eight adults and 112 children were evaluated over a 15-year period.

RESULTS

Seventy-one patients (44%) adapted to resection and took enteral nutrition alone. Forty-four patients (28%) were supported by parenteral nutrition (PN). Forty-five patients (28%) have had 49 surgical procedures. Fifteen patients with adequate intestinal length (> 120 cm in adults) but dilated dysfunctional bowel underwent stricturoplasty (n = 4) or tapering (n = 11). Thirteen patients (87%) demonstrated clinical improvement. Fourteen patients with shorter remnants (90-120 cm) and rapid transit time received an artificial valve (n = 2) or a reversed segment (n = 1). All patients' conditions improved initially, but the reversed segment was revised or taken down. Fourteen patients with short remnants and dilated bowel underwent intestinal lengthening. Twelve patients' conditions improved (86%), one underwent transplantation, and one died. Sixteen patients with very short remnants (< 60 cm) and complications of PN underwent solitary intestine (n = 4) or combined liver-intestinal transplantation (n = 13). One-year graft survival was 65%. There have been five deaths.

CONCLUSIONS

The surgical approach to short-bowel syndrome depends on the patient's age, remnant length and caliber, intestinal function, and PN-related complications. Nontransplant procedures have a role in the treatment of selected patients. Intestinal transplantation is emerging as a potential therapy for patients with significant PN-related complications.

Gut failure in pediatric and adult patients. Candidates for small-bowel transplantation in southern Finland

BACKGROUND

This study investigated the need for small-bowel transplantation (SBT) in southern Finland. In addition, we evaluated the effect of colon resection on the time required for intestinal adaptation in patients with gut failure.

METHODS

Mortality, morbidity, intestinal adaptation time, and surgical management were evaluated retrospectively in 24 patients (12 adults and 12 children) with jejunoileal exculsion. Of the 24 patients 19 had undergone accompanying colon resection.

RESULTS

Intestinal adaptation had occurred in 12 of 18 survivors (67%). Two unadapted survivors were considered to be currently suitable candidates for SBT. The length of the remaining colon was inversely correlated (correlation coefficient r = -0.789; p < 0.0001) with the duration of intestinal adaptation.

CONCLUSIONS

Each year one to two patients per 1.27 million people could benefit from SBT in southern Finland. The length of the remaining colon is a major determinant of the duration of intestinal adaptation in patients with massive jejunoileal resection.

Construction of a new intestinal valve

PURPOSE

A surgical technique is presented which creates an intestinal valve.

METHODS

In six dogs, the terminal ileum and the ascending colon were removed and the valve was made. The valve has been constructed in eight humans, three of them were cases of short bowel syndrome with resection of the ileocecal valve and five cases were right hemicolectomies attributable to a carcinoma of the cecum and ascending colon.

RESULTS

The dogs were observed for a period of four to six months, during which time the animals stayed healthy. In the cases of short bowel syndrome in humans, the valve reduced the number of evacuations, in the five cases of right hemicolectomies the evolution was without complications.

CONCLUSION

This surgical technique can be useful in the management of patients with morbidity by resection of the ileocecal valve.

Short bowel syndrome: metabolic and surgical management

The management of short bowel syndrome requires long-term nutritional support and monitoring, medication, and occasionally additional surgical procedures. Constant attention is required to ensure adequate adaptation of the gut. This article reviews the normal function of the small bowel, adaptation following resection, total parenteral and enteral nutrition, and the role of adjunctive surgical procedures in the management of short bowel syndrome.

Adaptation in short-bowel syndrome: reassessing old limits

The improving survival of patients with severe short-bowel syndrome along with the advent of successful intestinal transplantation have accentuated the need to answer two questions. (1) Is there an intestinal length below which adaptation to full enteral nutrition can not be expected to occur? (2) How much time is necessary to complete intestinal adaptation? We reviewed the outcome of 21 infants with less than 50 cm of small intestine to answer these questions. Patients were divided into three groups based on intestinal length, regardless of ileocecal valve status: group I, < 10 cm (n = 3); group II, 10 to 30 cm (n = 11); and group III, 30 to 50 cm (n = 7). Data were collected to assess survival, incidence of adaptation, time to adaptation, and causes of mortality. Infants in group I did not achieve intestinal adaptation to full enteral nutrition. One survived and 2 died, one from varicella pneumonia and the other after intestinal transplantation. Eight of the 11 (73%) patients in group II survived and 5 of 8 (63%) survivors achieved full intestinal adaptation after a mean interval of 320 days (range, 148 to 506 days) on parenteral nutrition. Six of the seven patients (86%) in group III survived and all survivors (100%) achieved complete enteral adaptation after an average of 376 days (range, 58 to 727 days). The overall survival was 71% (15/21), but survival in patients with > 10 cm was 78%.(ABSTRACT TRUNCATED AT 250 WORDS)

A new bowel elongation technique for the short-bowel syndrome using the isolated bowel segment Iowa models

For the management of infants with the short-bowel syndrome, we developed a two-stage bowel elongation procedure based on experimental studies of what we term as an isolated bowel segment. The procedure consists of: (1) initial coaptation of the antimesenteric surface of a segment of bowel to host organs such as liver and abdominal wall, and (2) after collaterals have developed from these host organs, secondary longitudinal split of the bowel to provide two bowel loops, one from its antimesenteric half and the other from its mesenteric half. These are arranged in series by end-to-end anastomosis to double the original bowel length. The antimesenteric loop is totally free of its original mesenteric attachment but viable by vascular collaterals formed across the coaptation site. This procedure was successfully used for an infant who was born with 17 cm of duodenum and 17 cm of the distal colon from first trimester intrauterine midgut volvulus. At completion of the multistaged procedures at the age of 1 year when we reentered the abdomen for duodenoplasty, his small bowel measured 90 cm in length. He is currently taking 50% to 60% of required calories via the enteric route at 18 months of age. This procedure is suitable for elongating the duodenum of infants when other alternatives such as the Bianci procedure are not feasible because of mesenteric absence.