Management of acute intestinal failure: A position paper from the European Society for Clinical Nutrition and Metabolism (ESPEN) Special Interest Group

Approximately 50% of acute intestinal failure (AIF) patients on short-term parenteral nutrition (PN) have intestinal failure-associated liver disease (IFALD) without effect on hospital length of stay and mortality

INTRODUCTION

Patients with intestinal failure (IF) are often dependent on PN for provision of calories and nutrients for survival. Similar to chronic intestinal failure (CIF) patients, those who have AIF are also at risk of IFALD, which is a poorly understood but potentially fatal condition. The local incidence of IFALD amongst AIF patients is not known.

OBJECTIVES

The primary objective of this study was to determine the incidence of IFALD in AIF patients on short-term PN. Secondary objectives were to analyse patient and PN risk factors of IFALD, and clinical outcomes of length of stay (LOS) and inpatient mortality.

DESIGN

This was a retrospective cross-sectional cohort study of hospitalised adult patients with AIF prescribed with short-term PN. All adult patients aged 21 years and above who received PN for at least 5 consecutive days and had normal liver function tests (LFTs) at the time of PN initiation were included in this study.

RESULTS

A total of 171 patients were enrolled in this study, with 77 (45%) having deranged LFTs at the end of PN therapy and categorised under the IFLAD group. The patient cohort was predominantly male (92 [54%]) and had a median age of 68 years (IQR 59-76). Patients with IFALD at the end of PN therapy had higher diabetes prevalence (36% vs 26%, p = 0.2) and were on PN for a longer duration (median [IQR]: 12 [8-17] vs 8 [6-15] days, p = 0.003) than those without IFALD. There were no significant differences in patient and PN characteristics between the IFLAD and non-IFALD group. The multivariable models showed that the IFALD cohort had longer hospital stays (HR 0.90, 95% CI 0.65-1.23) and lower odds of inpatient death (OR 0.75, 95% CI 0.12-4.60), though both findings are not statistically significant (p = 0.5, 0.7).

CONCLUSION

In this study, IFALD is a common phenomenon in AIF and the incidence was found to be an estimated 50% amongst patients on short-term PN with similar clinical outcomes between the two groups.

LLL 44-4 : Micronutrients in acute disease and critical illness

Micronutrients (MN), i.e. trace elements and vitamins, are essential components of the diet in relatively small amounts in any form of nutrition, with special needs in critically ill patients. Critical illness is characterised by the presence of inflammation and oxidative stress. MNs are tightly involved in antioxidant and immune defences. In addition, some conditions, and treatments result in large losses of biological fluids containing MNs: therefore, acute renal injury requiring renal replacement therapy, acute intestinal failure, and major burns and trauma are at high risk of acute depletion of body stores, and of deficiency. MN requirements are increased above standard DRI. Blood level interpretation is complicated by inflammation: some biomarkers assist the status determination. Due to the acute challenges of critical illness, it of utmost importance to cover the needs to maintain the organism's endogenous immune and antioxidant defences, and capacity to repair tissues. Practical strategies are proposed.

Entero-Cutaneous and Entero-Atmospheric Fistulas: Insights into Management Using Negative Pressure Wound Therapy

Enteric fistulas are a common problem in gastrointestinal tract surgery and remain associated with significant mortality rates, due to complications such as sepsis, malnutrition, and electrolyte imbalance. The increasingly widespread use of open abdomen techniques for the initial treatment of abdominal sepsis and trauma has led to the observation of so-called entero-atmospheric fistulas. Because of their clinical complexity, the proper management of enteric fistula requires a multidisciplinary team. The main goal of the treatment is the closure of enteric fistula, but also mortality reduction and improvement of patients' quality of life are fundamental. Successful management of patients with enteric fistula requires the establishment of controlled drainage, management of sepsis, prevention of fluid and electrolyte depletion, protection of the skin, and provision of adequate nutrition. Many of these fistulas will heal spontaneously within 4 to 6 weeks of conservative management. If closure is not accomplished after this time point, surgery is indicated. Despite advances in perioperative care and nutritional support, the mortality remains in the range of 15 to 30%. In more recent years, the use of negative pressure wound therapy for the resolution of enteric fistulas improved the outcomes, so patients can be successfully treated with a non-operative approach. In this review, our intent is to highlight the most important aspects of negative pressure wound therapy in the treatment of patients with enterocutaneous or entero-atmospheric fistulas.

Parenteral nutrition-related complications in older patients with acute intestinal failure: A descriptive cohort study

INTRODUCTION

Reported outcomes for parenteral nutrition (PN)-related complications in older adult patients with acute intestinal failure who are receiving PN in the acute hospital setting are limited. Our study aims to compare PN-related complications between older and younger adult patients.

METHODS

A retrospective descriptive study of inpatients who were administered PN from January 1, 2019, to December 31, 2019, was performed. Patients were categorized into older (≥65 years old) and younger (<65 years old) adult groups.

RESULTS

Two hundred thirty-five patients were included. There were 103 patients in the older adult group (mean age: 73.9 [SD: 6.9] years) and 132 patients in the younger adult group (mean age: 52.4 [SD: 12.5] years). There was a significantly higher Charlson Comorbidity Index score and lower Karnofsky score in the older adult group. The older adult group received significantly lower total energy (20.8 [SD: 7.8] vs 22.8 [SD: 6.3] kcal/kg/day), dextrose (3.1 [SD: 1.4] vs 3.6 [SD: 1.4] g/kg/day), and protein (1.1 [SD: 0.4] vs 1.2 [SD: 0.3] g/kg/day) than the younger group received. The mean length of stay was significantly shorter in the older adult group (35.9 [SD: 21.3] vs 59.8 [SD: 55.3]; P < 0.05). There was no significant difference in PN-related complications and clinical outcomes (catheter-related bloodstream infections, hypoglycemia or hyperglycemia, fluid overload, or inpatient mortality) between the two groups.

CONCLUSION

Despite more comorbidities in the older adult, the usage of PN in older adult patients with acute intestinal failure was associated with neither an increased rate of PN-related complications nor worse clinical outcomes when compared with that of younger patients.

[Clinical experience in patients with intestinal failure: a cohort study in a third referral hospital]

INTRODUCTION

intestinal failure (IF) is an organic failure classified into three types (I-III); it conditions inability to absorb nutrients and water, so parenteral nutrition (PN) is required.

OBJECTIVE

to evaluate the characteristics of hospitalized patients with IF, and their association with clinical and nutritional outcomes.

METHODS

historical cohort of hospitalized adults with IF and PN. Variables of the nutritional care process (screening, anthropometric, biochemical, clinical, nutritional), mortality and hospital stay were recorded.

RESULTS

six hundred and ninety-seven patients aged 56 (41-68) years, 327 women (46.8 %), with body mass index (BMI) 22.4 (18.3-25.9), were included.

DIAGNOSIS

577 patients with IF-I, 96 patients with IF-II, and 24 patients with IF-III. The most frequent causes were malignant neoplasms, IF-I (26.7 %) and surgical complications in IF-II (21.9 %) and IF-III (37.5 %). The most common pathophysiology in all types of IF was motility disorders (40.6 % in IF-I; 43.8 % in IF-II; 33.8 % in IF-III). The majority of patients had high nutritional risk (92.4 %) and refeeding syndrome (65.6 % high and very high). In acute IF (FI-I) compared to prolonged IF (If-II/IF-III) there is a higher BMI (p = 0.039), visceral fat (p = 0.041) and over-hydration (p = 0.014), but they have a smaller phase angle (p = 0.004), with a lower adequacy percentage than what is prescribed in relation to their energy expenditure (p < 0.001).

CONCLUSIONS

during the nutritional care process there are differences between the types of IF, which are relevant to optimize their multidisciplinary management and avoid related complications.

The gut microbiome and intestinal failure-associated liver disease

Intestinal failure-associated liver disease (IFALD) is a common hepatobiliary complication resulting from long-term parenteral nutrition (PN) in patients with intestinal failure. The spectrum of IFALD ranges from cholestasis, steatosis, portal fibrosis, to cirrhosis. Development of IFALD is a multifactorial process, in which gut dysbiosis plays a critical role in its initiation and progression in conjunction with increased intestinal permeability, activation of hepatic immune responses, and administration of lipid emulsion. Gut microbiota manipulation including pre/probiotics, fecal microbiota transplantation, and antibiotics has been studied in IFALD with varying success. In this review, we summarize current knowledge on the taxonomic and functional changes of gut microbiota in preclinical and clinical studies of IFALD. We also review the function of microbial metabolites and associated signalings in the context of IFALD. By providing microbiota-targeted interventions aiming to optimize PN-induced liver injury, our review provides perspectives for future basic and translational investigations in the field.

ESPEN guideline on chronic intestinal failure in adults - Update 2023

BACKGROUND & AIMS

In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines.

METHODS

The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly.

RESULTS

The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%).

CONCLUSIONS

It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.

Implementation of the ESPEN guideline on clinical nutrition in the intensive care unit (ICU): It is time to move forward!: A position paper from the 'nutrition in the ICU' ESPEN special interest group

Nutritional assessment and provision of nutritional therapy are a core part of intensive care unit (ICU) patient treatment. The ESPEN guideline on clinical nutrition in the ICU was published in 2019. However, uncertainty and difficulties remain regarding its full implementation in daily practice. This position paper is intended to help ICU healthcare professionals facilitate the implementation of ESPEN nutrition guidelines to ensure the best care for their patients. We have aimed to emphasize the guideline recommendations that need to be implemented in the ICU, are advised, or are optional, and to give practical directives to improve the guideline recommendations in daily practice. These statements were written by the members of the ICU nutrition ESPEN special interest group (SIG), based on a survey aimed at identifying current practices relating to key issues in ICU nutrition. The ultimate goal is to improve the ICU patients quality of care.

Perioperative nutritional assessment and support in visceral surgery

Malnutrition in visceral surgery is frequent; it calls for screening prior to an operation, and its postoperative occurrence should be sought out and prevented, if possible. Organization of an individualized nutritional support strategy is based on systematic nutritional assessment and adapted to the type of surgery, the objectives being to forestall malnutrition and to reduce induced morbidity (immunosuppression, delayed wound healing, anastomotic fistulas…). Nutritional support is part and parcel of enhanced recovery after surgery (ERAS), and has shown effectiveness in the field of visceral surgery. Oral feeding should always be privileged to the greatest possible extent, complemented if necessary by nutritional supplements. If nutritional support is required, enteral nutrition should be favored over parenteral nutrition. As for the role of pharmaco-nutrition or immuno-nutrition, it remains ill-defined. Lastly, each type of visceral surgery entails specific modifications of the anatomy of the digestive system and is liable to have specific functional consequences, which should be known and taken into account in view of effectively tailoring nutritional support.

Emerging uses of glucagon-like peptide 1 (GLP-1) receptor agonists following ileal resection: literature review and case examples

Following ileal resection, the combination of severe bile acid (BA) malabsorption, rapid small bowel transit and unrestricted upper gastrointestinal (GI) secretion results in severe diarrhoea that can prove refractory to pharmacological therapies. While established therapies, including BA sequestrants and antidiarrhoeal drugs seek to ameliorate symptoms, they do not target the underlying pathophysiological mechanisms in this patient group. Their use can also be limited by both intolerance and adverse effects. The novel use of glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) in these patients may allow restoration of the physiological negative feedback mechanisms lost in ileal resection and reduce diarrhoea by prolonging small bowel transit time, limiting upper GI secretions and perhaps by inhibiting hepatic BA synthesis. While recent evidence supports the use of GLP-1 RAs as a safe and effective therapy for bile acid diarrhoea (BAD), it remains uncertain whether those with severe BAD and subsequent short bowel syndrome secondary to extensive ileal resection will benefit. Here, we present three cases of severe diarrhoea secondary to extensive ileal resection in which the use of the GLP-1 RA, liraglutide, was well tolerated and resulted in an objective improvement in diarrhoeal symptoms. We further provide a narrative review of the emerging evidence base supporting the use of GLP therapies in this challenging condition.

Gut Microbiota Modulation of Short Bowel Syndrome and the Gut-Brain Axis

Short bowel syndrome (SBS) is a condition that results from a reduction in the length of the intestine or its functional capacity. SBS patients can have significant side effects and complications, the etiology of which remains ill-defined. Thus, facilitating intestinal adaptation in SBS remains a major research focus. Emerging data supports the role of the gut microbiome in modulating disease progression. There has been ongoing debate on defining a "healthy" gut microbiome, which has led to many studies analyzing the bacterial composition and shifts that occur in gastrointestinal disease states such as SBS and the resulting systemic effects. In SBS, it has also been found that microbial shifts are highly variable and dependent on many factors, including the anatomical location of bowel resection, length, and structure of the remnant bowel, as well as associated small intestinal bacterial overgrowth (SIBO). Recent data also notes a bidirectional communication that occurs between enteric and central nervous systems called the gut-brain axis (GBA), which is regulated by the gut microbes. Ultimately, the role of the microbiome in disease states such as SBS have many clinical implications and warrant further investigation. The focus of this review is to characterize the role of the gut microbiota in short bowel syndrome and its impact on the GBA, as well as the therapeutic potential of altering the microbiome.

Definition, classification, and causes of short bowel syndrome

The term "short bowel syndrome (SBS)" defines "the clinical feature associated with a remaining small bowel in continuity of less than 200 cm from the ligament of Treitz" and is characterized by malabsorption, diarrhea, fatty stools, malnutrition, and dehydration. SBS is the primary pathophysiological mechanism of chronic intestinal failure (CIF), defined as the "reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation (IVS) is required to maintain health and/or growth" in a metabolically stable patient. By contrast, the reduction of gut absorptive function that does not require IVS has been termed "intestinal insufficiency or deficiency" (II/ID). The classification of SBS can be categorized as follows: anatomical (anatomy and length of the residual bowel), evolutional (early, rehabilitative, and maintenance phases), pathophysiological (SBS with or without a colon in continuity), clinical (with II/ID or CIF), and severity of CIF (type and volume of the required IVS). Appropriate and homogeneous patient categorization is the mainstay of facilitating communication in clinical practice and in research.

ESPEN guideline on Clinical Nutrition in inflammatory bowel disease

The present guideline is an update and extension of the ESPEN scientific guideline on Clinical Nutrition in Inflammatory Bowel Disease published first in 2017. The guideline has been rearranged according to the ESPEN practical guideline on Clinical Nutrition in Inflammatory Bowel Disease published in 2020. All recommendations have been checked and, if needed, revised based on new literature, before they underwent the ESPEN consensus procedure. Moreover, a new chapter on microbiota modulation as a new option in IBD treatment has been added. The number of recommendations has been increased to 71 recommendations in the guideline update. The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. General aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.

Serum Citrulline and Ornithine: Potential Markers of Coeliac Disease Activity

INTRODUCTION

To date, there is not generally accepted and universal indicator of activity, and functional integrity of the small intestine in patients with coeliac disease. The aim of our study was to investigate whether serum concentrations of the non-essential amino acids citrulline and ornithine might have this function.

METHODS

We examined serum citrulline and ornithine concentrations in a subgroup of patients with proven coeliac disease and healthy controls (blood donors).

RESULTS

A total of 94 patients with coeliac disease (29 men, mean age 53 ± 18 years; 65 women, mean age 44 ± 14 years) and 35 healthy controls (blood donors) in whom coeliac disease was serologically excluded (10 men, mean age 51 ± 14 years; 25 women, mean age 46 ± 12 years) were included in the study. Significantly lower concentrations of serum ornithine were found in patients with coeliac disease (mean 65 ± 3 μmol/L; median 63 μmol/L, IQR 34 μmol/L, p < 0.001). No statistically nor clinically significant differences were found in the citrulline concentrations between the study and control group.

CONCLUSIONS

Serum ornithine (but not citrulline) may be useful for assessing the functional status of the small intestine in uncomplicated coeliac disease. Further studies involving more detailed analysis of dietary and metabolic changes in patients will be needed to reach definitive conclusions.

Are we underusing peripheral parenteral nutrition? A 5-year retrospective review of inpatient parenteral nutrition practices

BACKGROUND

Peripheral parenteral nutrition (PPN) represents an alternative option to central parenteral nutrition (CPN) for patients requiring short-term parenteral nutrition (PN). We hypothesized that the use of PPN could be increased in certain patient cohorts referred for PN in our facility.

METHODS

A retrospective observational study investigating the clinical characteristics of patients receiving PN under the nutrition support team over a 5-year period was undertaken. Patients who received PPN were reviewed descriptively. Of the patients who received CPN, representative samples were grouped into those who received PN for ≤7 or >7-28 days (n = 100 each, randomly assigned). Clinical characteristics considered included indication, duration and referring team for PN, and nutrition status. Descriptive statistics and binary logistic regression model for predictors of PN duration of ≤7 or >7-28 days were derived.

RESULTS

Only four patients received PPN for a median of 4 days, most of whom required this route because of loss of central venous access for CPN. A high proportion of patients with no enteral access received CPN for ≤7 days, whereas the majority of patients with malabsorption required >7-28 days of CPN. Being referred for PN following upper gastrointestinal surgery increased the likelihood of CPN use for >7 days (relative risk, 5.7; 95% CI, 1.7-18.9; P = 0.004).

CONCLUSION

Within our service, PN referrals for no enteral access may represent a group in whom PPN could be used in the first instance; those referred with an indication of malabsorption or following upper gastrointestinal surgery may benefit from early commencement of CPN.

Investigating the Relationship between Home Parenteral Support and Needs-Based Quality of Life in Patients with Chronic Intestinal Failure: A National Multi-Centre Longitudinal Cohort Study

Home parenteral support (HPS) is an essential but potentially burdensome treatment that can affect quality of life (QoL). The aims of this longitudinal study were to understand whether any changes in HPS over time were associated with QoL. The Parenteral Nutrition Impact Questionnaire (PNIQ) was used, and data were collected on HPS prescribed at three time points. Data were analysed using multi-level mixed regression models presented as effect size and were adjusted for confounders. Study recruited 572 participants from 15 sites. Of these, 201 and 145 completed surveys at second and third time-points, respectively. PNIQ score was out of 20 with a higher score indicating poorer QoL. Any reduction in HPS infusions per week was associated with an improved PNIQ score of -1.10 (95% CI -2.17, -0.02) unadjusted and -1.34 (95% CI -2.45, -0.24) adjusted. Per day change to the number of infusions per week was associated with a change in the PNIQ score of 0.32 (95% CI -0.15, 0.80) unadjusted and 0.34 (95% CI -0.17, 0.85) adjusted. This is the largest national study to demonstrate improvements in QoL associated with HPS reduction over time using an HPS-specific and patient-centric tool, adding unique data for use of therapies in intestinal failure.

Surgical Treatment of Short Bowel Syndrome—The Past, the Present and the Future, a Descriptive Review of the Literature

Short bowel syndrome (SBS) is a devastating disorder with both short- and long-term implications for patients. Unfortunately, the prevalence of SBS has doubled over the past 40 years. Broadly speaking, the etiology of SBS can be categorized as congenital or secondary, the latter typically due to extensive small bowel resection following diseases of the small intestine, e.g., necrotizing enterocolitis, Hirschsprung’s disease or intestinal atresia. As of yet, no cure exists, thus, conservative treatment, primarily parenteral nutrition (PN), is the first-line therapy. In some cases, weaning from PN is not possible and operative therapy is required. The invention of the longitudinal intestinal lengthening and tailoring (LILT or Bianchi) procedure in 1980 was a major step forward in patient care and spawned further techniques that continue to improve lives for patients with severe SBS (e.g., double barrel enteroplasty, serial transverse enteroplasty, etc.). With this review, we aim to provide an overview of the clinical implications of SBS, common conservative therapies and the development of operative techniques over the past six decades. We also provide a short outlook on the future of operative techniques, specifically with respect to regenerative medicine.

A Descriptive Analysis of Macronutrient, Fatty Acid Profile, and Some Immunomodulatory Nutrients in Standard and Disease-Specific Enteral Formulae in Europe

Foods for special medical purposes (FSMPs) are commercially available formulations used as a source of nutrition when administered orally or by tube feeding. This study examines, for the first time, the nutritional composition of enteral formulae (EFs) according to European nutritional guidelines. We developed a descriptive study on 118 EFs from 2020 to 2021. Formulae were classified as standard (SFs) and disease-specific (DSF). According to the protein-energy content, SFs were classified into G1, normoprotein-normocaloric; G2, normoprotein-hypercaloric; G3, hyperproteic-normocaloric; and G4, hyperproteic-hypercaloric. Disease-related formulae for metabolic stress, renal, cancer, pulmonary, diabetes, malabsorption, and surgery were studied. Macronutrient distribution, fatty acid profile (monounsaturated [MUFA], polyunsaturated [PUFA], saturated [SFA]), derived fat quality indexes, and immuno-modulatory nutrients (omega-3, eicosapentaenoic acid [EPA], docosahexaenoic acid [DHA], arginine and nucleotides) per 1,500 kcal infused were calculated. In total, 53% were SFs, mainly normoproteic (G1, G2) with higher carbohydrate contents in normocaloric vs. hypercaloric SFs. The most balanced fatty acid profiles (MUFA: 17.7%; PUFA: 6.8%; SFA: 9.5%) belonged to G1. The PUFA/MUFA ratio: ≥0.5 was in 85.7% with a higher proportion of EPA+DHA (46%) vs. omega-3 (15.8%) in SFs. In DSFs (46.9%), higher carbohydrate content (>50%) was in malabsorption and surgery, whereas high-fat content (>50%) was in pulmonary and renal formulae. DSFs had higher SFA vs. MUFA content, except for diabetes. EPA and DHA were added in 45.5% (cancer, malabsorption, and surgery). Only 12.7% of DSFs had arginine and nucleotides. A higher proportion of SFs was found, in line with current European guidelines. Results highlighted a wide intra-group variability of nutrients among the formula selected. These findings are useful to evaluate the nutritional composition of EFs from a preventive and/or therapeutic perspective in clinical settings.

Standardized documentation and synoptic reporting of complex intestinal anatomy in enteric fistulation and intestinal failure

AIM

In intestinal failure, delineation of both structure and function are key to controlling symptoms and planning further intervention. We have developed a template for developing an 'anatomy at a glance' patient-specific map to aid decision making and counselling.

METHOD

A core dataset was developed and used to create an editable template to demonstrate the gastrointestinal tract, its relationship to the genitourinary tract, and specific anterior abdominal wall features. This was then used to create an anatomical template, specific to each patient, and stored in the electronic patient record and imaging archive.

RESULTS

We have developed a technique for integration of multi-modal information into one diagram, easily referenced by the multidisciplinary team. Radiology, endoscopy and previous operation notes can be used to fill out a core dataset, which is then transposed into a standardized template. A worked example is shown.

CONCLUSION

The mapping template has been successfully integrated into practice and aided decision making at all stages of the patient's therapeutic journey. It has been found helpful in planning routes of nutrition, preoperative optimization, surgical planning, interpreting postoperative imaging and managing patient expectations.

Long-Term Outcomes in Patients with Intestinal Failure Due to Short Bowel Syndrome and Intestinal Fistula

Short bowel syndrome (SBS) and enterocutaneous or enteroatmospheric fistulas are common indications for home parenteral nutrition (HPN). However, there are few data describing factors influencing surgical decision-making or outcomes particularly following fistula development. We aimed to compare outcomes between patients with SBS and fistulas and explore surgical decision-making. HPN-dependent adults from 2001−2018 at a national reference centre were included in this study. HPN cessation was analysed using death as competing risk. In total, 465 patients (SBS (62%), fistula (38%)) were included, with median HPN dependency of 2.6 years. In total, 203 patients underwent reconstructive surgery; while frailty was the commonest reason for not undergoing surgery (49.2%), 22.7% declined surgery. Overall, 170 ceased HPN, with a probability of 13.8%, 34.1% and 38.3% at 1, 5 and 10 years, respectively. Patients undergoing surgery had higher nutritional autonomy rates (109.8 incidences/1000 patient years) compared to those not undergoing surgery (18.1 incidences/1000 patient years; p < 0.001). A total of 295 patients (63.4%) were predicted to cease HPN based on gastrointestinal anatomy but only 162/295 (54.9%) achieved this; those unable to do so were older with a higher comorbidity index. There were no differences in long-term nutritional and survival outcomes or surgical decisions between patients with SBS and fistulas, or between enterocutaneous and enteroatmospheric fistulas. This study represents one of the largest datasets describing the ability of HPN-dependent patients with SBS or fistulas to achieve nutritional autonomy. While reconstructive surgery facilitates HPN cessation, approximately one-fifth of patients declined surgery despite HPN dependency. These data will better inform patient expectation and help plan alternative therapies.

Electrolyte and Acid-Base Disturbances in Emergency High-Risk Abdominal Surgery, a Retrospective Study

BACKGROUND

Patients undergoing emergency high-risk abdominal surgery potentially suffer from both systemic dehydration and hypovolaemia. Data on the prevalence and clinical impact of electrolyte disturbances in this patient group, specifically the differences in patients with intestinal obstruction (IO) versus perforated viscus (PV) are lacking.

METHODS

Adult patients undergoing emergency high-risk abdominal surgery in a standardized perioperative pathway were included in this retrospective single-center cohort study. Electrolytes and arterial blood gas analysis were measured during the early perioperative period. Prevalence and clinical impact of electrolyte disturbances were assessed.

RESULTS

A total of 354 patients were included in the study. Preoperative alkalemia dominated preoperatively, significantly more prevalent in IO (45 vs. 32%, p < .001), while acidosis was most pronounced postoperatively in PV (49 vs. 28%, p < .0001). Preoperative hypochloraemia and hypokalemia were more frequent in the IO (34 vs. 20% and 37 vs. 25%, respectively). Hyponatremia was highly prevalent in both IO and PV. Pre- and postoperative hypochloremia were independently associated with 30-day postoperative morbidity and mortality in patients with IO (OR 2.87 (1.35, 6.23) p = 0.006, OR 6.86 (1.71, 32.2) p = 0.009, respectively). Hypochloremic patients presented with reduced long-term survival as compared with the normo- and hyperchloremic patients (p < 0.05). Neither plasma sodium nor potassium showed a significant association with outcome.

CONCLUSION

These observations suggest that acute high-risk abdominal patients have frequent preoperative alkalosis shifting to postoperative acidosis. Both pre- and postoperative hypochloremia were independently associated with both impaired short- and long-term outcome in patients with intestinal obstruction, with potential implications for the choice of resuscitations fluids.

Enterocutaneous Fistula: Open Repair after Unsuccessful Stenting—A Case Report

Enterocutaneous fistula (ECF) is an abnormal connection between the gastrointestinal tract and the skin; by some estimates, it represents 88.2% of all fistulae. It can either develop spontaneously due to underlying malignancy, inflammatory bowel disease, radiation exposure, or, more commonly, as a complication of gastrointestinal surgery. A 75-year-old woman was treated for a small bowel enterocutaneous fistula that developed after laparoscopic cholecystectomy using a HANAROSTENT self-expanding metal stent (SEMS) to cover the fistula. Seven months later, the patient was discharged. For the following 2 years, the patient refused the reconstructive surgery until stent obstruction occurred. After optimizing the patient’s nutritional status, laparotomy and small bowel resection were performed successfully. The use of SEMS in fistulas of the lower gastrointestinal tract is a heavily debated and fairly under-researched topic, especially in the context of enterocutaneous fistulas. No international guidelines officially recommend using SEMS in the small bowel ECF.

Evidence-based recommendations of the Andalusian Group for Nutrition Reflection and Investigation (GARIN) for the management of adult patients with short bowel syndrome

Introduction

In order to develop evidence-based recommendations and expert consensus for the nutritional management of patients with short bowel syndrome (SBS), we conducted a systematic literature search using the PRISMA methodology plus a critical appraisal following the GRADE scale procedures. Pharmacological treatment with antisecretory drugs, antidiarrheal drugs, and somatostatin contributes to reducing intestinal losses. Nutritional support is based on parenteral nutrition; however, oral intake and/or enteral nutrition should be introduced as soon as possible. In the chronic phase, the diet should have as few restrictions as possible, and be adapted to the SBS type. Home parenteral nutrition (HPN) should be individualized. Single-lumen catheters are recommended and taurolidine should be used for locking the catheter. The HPN's lipid content must be greater than 1 g/kg per week but not exceed 1 g/kg per day, and omega-6 fatty acids (ω6 FAs) should be reduced. Trace element vials with low doses of manganese should be used. Patients with chronic SBS who require long-term HPN/fluid therapy despite optimized treatment should be considered for teduglutide treatment. All patients require a multidisciplinary approach and specialized follow-up. These recommendations and suggestions regarding nutritional management in SBS patients have direct clinical applicability.

Nueva técnica para control de contaminación de fístulas enteroatmosféricas en abdomen abierto Björck 4. Método de Capilaridad (MECA)

Introducción. La fístula enteroatmosférica es una patología compleja que puede ser el resultado de múltiples intervenciones quirúrgicas de la cavidad abdominal. Describimos una nueva técnica para el control de la contaminación en pacientes con fístulas enteroatmosféricas en abdomen abierto Björck 4. Métodos. Se realizó un análisis retrospectivo de cuatro pacientes con fístulas enteroatmosféricas desarrolladas como complicación de procedimientos quirúrgicos abdominales. Se trataron integralmente por un grupo multidisciplinario de Cuidados Intensivos, Cirugía general, Soporte nutricional y Cuidado de heridas y ostomías. Se utilizó una novedosa técnica quirúrgica basada en el principio de capilaridad para mantener limpios los tejidos periostomales. Resultados. Con esta técnica se logró el control de la contaminación abdominal en todos los pacientes y una evolución clínica satisfactoria. Posteriormente se programaron para cierre quirúrgico definitivo con éxito. Conclusiones. El manejo de la fístula enteroatmosférica representa un reto para el cirujano y el grupo multidisciplinario que trata al paciente. Esta nueva técnica utilizada en pacientes con fístula enteroatmosférica con abdomen abierto Björck 4 se basa en el principio de capilaridad, y es eficaz en el control de la contaminación, infección y de la sepsis asociada.

[Nasointestinal intubation in surgery of acute intestinal obstruction and peritonitis: past, present and future]

The authors analyze history of development nasointestinal intubation for abdominal decompression in patients acute intestinal obstruction and widespread peritonitis, contribution of Russian and foreign surgical schools to improvement and popularization of this technique. Advisability, clinical efficacy, advantages and disadvantages of this method are stated. The prospects of nasointestinal intubation in the foreseeable future are considered in these patients. Certain technical features of nasointestinal intubation and complications are described. The causes of negative attitude of foreign surgeons to nasointestinal intubation and motivation for refusing of this technique are discussed. Considering the arguments of supporters and opponents, the authors conclude that complete rejection of this technique is premature. A differentiated approach to nasointestinal intubation according to strict indications seems to be more legitimate than categorical rejection.

Hydration by colonic enteroclysis: An alternative to parenteral hydration in patients with high-output double enterostomy

BACKGROUND

High-output double enterostomies (DESs) result in sodium and fluid loss responsible for frequent episodes of dehydration and hospitalizations. Hydration by enteroclysis (HE) is an alternative to parenteral hydration when the small bowel, or the downstream colon, is accessible and functional.

METHODS

A retrospective analysis was conducted on all consecutive patients admitted in our institution with high-output (≥1200 ml per 24 h) DES and access to downstream intestine (including colon), who were treated by enteroclysis between 2015 and 2019. A sodium chloride and bicarbonate solution was instilled through a tube inserted in the colon. The objectives were diuresis >1 L, natriuresis >40 mmol/24 h, and urinary sodium-to-potassium ratio >1.

RESULTS

HE was conducted in 52 patients (24 female, 28 male). Initially, 30 patients received intravenous support. Fifteen patients (50%) were weaned from all parenteral support, of whom 11 of 12 (92%) received fluid and electrolyte support and 4 of 18 (22%) received parenteral nutrition (PN). When intravenous fluids were still required, daily volumes decreased from 2714 ± 1424 to 1578 ± 1000 ml per 24 h (P = .001), as did the energetic intake (NS), from 1439 ± 556 to 1230 ± 362 kcal per 24 h (P = .096).

CONCLUSION

HE through the efferent intestine limits the requirement for parenteral hydration in patients with high-output DES. For patients with intestinal failure dependent on PN, it reduces daily infused volumes.

Systematic review with meta-analysis: effects of implementing a nutrition support team for in-hospital parenteral nutrition

BACKGROUND

Nutrition support teams (NST) may improve parenteral nutrition (PN) outcomes. No previous systematic review has provided conclusive data on catheter-related infection (CRI) occurrence after NST introduction, nor have previous studies performed meta-analysis or graded the evidence.

AIMS

To systematically evaluate the effects of implementing an NST for hospitalised adults on PN and compare these with standard care.

METHODS

This was a systematic review and meta-analysis, pre-registered in PROSPERO (CRD42020218094). On November 24, 2020, PubMed, Web of science, Scopus, Embase, Cochrane Library, and Clinical Key were searched. Clinical trials and observational studies with a standard care comparator were included. Primary outcome was relative reduction in CRI rate. A random-effects meta-analysis was used to estimate effects, and evidence was rated using Cochrane and GRADE methodologies.

RESULTS

Twenty-seven studies with 8166 patients were included. Across 10 studies, NST introduction reduced the CRI rate (IRR = 0.32, 95% CI: 0.19-0.53) with -8 (95% CI: -12 to -5) episodes per 1000 catheter days compared with standard care. Hypophosphataemia occurred less frequently (IRD = -12%, 95% CI: -24% to -1%) and 30-day mortality decreased (IRD = -6%, 95% CI: -11% to -1%). Inappropriate PN use decreased, both judged by indication (IRD = -18%, 95% CI: -28% to -9%) and duration (IRD = -21%, 95% CI: -33% to -9%). Evidence was rated very low to moderate.

CONCLUSIONS

This study documents the clinical impact of introducing an NST, with moderate-grade evidence for the reduction of CRI occurrence compared with standard care. Further, NST introduction significantly reduced metabolic complications, mortality, and inappropriate PN use.

Clinical guidelines for the management of gastrointestinal fistula – developed by experts of the Polish Surgical Society

Introduction: Gastrointestinal fistula is one of the most difficult problems in gastrointestinal surgery. It is associated with high morbidity and mortality, numerous complications, prolonged hospitalization, and high cost of treatment. </br>Aim: This project aimed to develop recommendations for the treatment of gastrointestinal fistulas, based on evidence-based medicine and best clinical practice to reduce treatment-related mortality and morbidity. </br>Material and methods: The preparation of these recommendations is based on a review of the literature from the PubMed, Medline, and Cochrane Library databases from 1.01.2010 to 31.12.2020, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. Recommendations in the form of a directive were formulated and assessed using the Delphi method. </br>Results and conclusions: Nine recommendations were presented along with a discussion and comments of experts. Treatment should be managed by a multidisciplinary team (surgeon, anesthetist, clinical nutritionist/dietician, nurse, pharmacist, endoscopist).

Body composition in patients with type 2 intestinal failure

BACKGROUND

Measurement of body composition is a valuable clinical tool for nutrition assessments, but there are no data on the merits of assessment modalities in type 2 intestinal failure (IF). The aim of this study was to evaluate the prevalence of low muscle mass and quality in type 2 IF, comparing bioelectric impedance analysis (BIA) and computed tomography (CT) at the third lumbar vertebra level.

METHODS

Patients admitted with acute severe (type 2) IF to a national UK IF center who had BIA measurement and CT scan as part of routine care within 40 days of anthropometric measurement were included in this cross-sectional study. Data were also collected on patient demographics and clinical characteristics.

RESULTS

Forty-four patients meeting inclusion criteria were included. Low muscle mass was detected in 37 out of 44 (84.1%) patients by CT scan and in 30 of out 44 (68.2%) by BIA. Low muscle quality was detected in 22 out of 44 (50%) patients by CT scan and in 40 out of 44 (90.1%) by BIA. Comparison of CT and BIA measurements showed a moderate correlation of muscle, Spearman ρ 0.65 (95% CI, 0.42-0.81; P < 0.001), and a strong correlation of body fat mass measurements, Spearman ρ 0.79 (95% CI, 0.62-0.89; P < 0.001).

CONCLUSION

This is the first study to demonstrate that low muscle mass is common in patients with type 2 IF, regardless of body composition assessment modality. A larger cohort study is required to validate the impact of low muscle mass and quality on clinical outcomes and the role of targeted interventions to improve the care of patients with type 2 IF.

Enhanced Recovery after Surgery (ERAS) Protocol Is a Safe and Effective Approach in Patients with Gastrointestinal Fistulas Undergoing Reconstruction: Results from a Prospective Study

BACKGROUND AND AIMS

An enterocutaneous fistula (ECF) poses a major surgical problem. The definitive surgical repair of persistent fistulas remains a surgical challenge with a high rate of re-fistulation and mortality, and the reasons for that is not the surgical technique alone. Enhanced Recovery after Surgery (ERAS®) is an evidence-based multimodal perioperative protocol proven to reduce postoperative complications. The aim of the study was to assess the clinical value of the ERAS protocol in surgical patients with ECF.

METHODS

ERAS protocol was used in all patients scheduled for surgery for ECF at the Stanley Dudrick's Memorial Hospital in Skawina between 2011 and 2020. A multidisciplinary team (MDT) was in charge of the program and performed annual audits. A consecutive series of 100 ECF patients (44 females, 56 males, mean age 54.1 years) were evaluated. Postoperative complications rate, readmission rate, length of hospital stay, prevalence of postoperative nausea and vomiting were assessed. Registered under ClinicalTrials.gov Identifier no. NCT04771832.

RESULTS

ERAS protocol was successfully introduced for ECF surgeries; however, eight modifications to the ERAS program was performed in 2015. They led to improvement of surgical outcomes: reduction of postoperative nausea and vomiting (15 vs. 17% patients, p = 0.025), overall complication rate (11 vs. 10, p = 0.021), median length of hospital stay (overall and after surgery, p = 0.022 and 0.002, respectively).

CONCLUSIONS

ERAS protocol can be successfully used for ECF patients. Prescheduled audits can contribute to the improvement of care.

Oligomeric Formulas in Surgery: A Delphi and Consensus Study

Nutritional management of patients with intestinal failure often includes the use of oligomeric formulas. Implementing the use of oligomeric formulas in surgical patients with maldigestion or malabsorption could be a nutritional strategy to be included in clinical protocols. We aim to generate knowledge from a survey focused on the effectiveness of nutritional therapy with oligomeric formulas with Delphi methodology. Each statement that reached an agreement consensus among participants was defined as a median consensus score ≥7 and as an interquartile range ≤3. The use of oligomeric formulas in surgical patients, starting enteral nutrition in the post-operative phase in short bowel syndrome and in nonspecific diarrhea after surgical procedures, could improve nutritional therapy implementation. Stakeholders agreed that early jejunal enteral nutrition with oligomeric formula is more effective compared to intravenous fluid therapy and it is useful in patients undergoing upper gastro-intestinal tract major surgery when malabsorption or maldigestion is suspected. Finally, oligomeric formulas may be useful when a feeding tube is placed distally to the duodenum. This study shows a practical approach to the use of oligomeric formulas in surgical patients with intestinal disorders and malabsorption, and it helps clinicians in the decision-making process.

Nutritional Treatment in Crohn's Disease

Crohn's disease (CD) is a chronic inflammatory bowel disease (IBD) which can affect any part of the whole gastrointestinal tract (from mouth to anus). Malnutrition affects 65-75% of CD patients, and it is now well acknowledged that diet is of paramount importance in the management of the disease. In this review, we would like to highlight the most recent findings in the field of nutrition for the treatment of CD. Our analysis will cover a wide range of topics, from the well-established diets to the new nutritional theories, along with the recent progress in emerging research fields, such as nutrigenomics.

Different GLIM criteria combinations change prevalence of malnutrition in patients with intestinal insufficiency or intestinal failure

BACKGROUND & AIM

Due to lack of global consensus in diagnosing malnutrition, Global Leadership Initiative on Malnutrition (GLIM) has suggested the GLIM criteria based on etiological and phenotypical criteria. The aim of this study was to investigate the prevalence of malnutrition in patients with intestinal insufficiency (INS) or intestinal failure (IF) based on the different GLIM criteria combinations to diagnose malnutrition. Furthermore, the aim was to investigate the severity of malnutrition in the two patient groups.

METHODS

A cross-sectional study with INS patients on enteral nutrition and IF patients on home parenteral nutrition. We recorded age, gender, weight, height, fat free mass index (FFMI) by bioelectrical impedance analysis, handgrip strength (HGS), arm muscle circumference (AMC) and biochemical parameters: plasma albumin (p-alb) and plasma C-reactive protein (p-CRP). Further, we calculated Glasgow prognostic score (GPS) and body mass index (BMI).

STATISTICS

T-test, Chi-square test and simple logistic regression analysis. Significance level: p < 0.05.

RESULTS

In total 277 INS and IF patients were included (age 59.5 ± 15.2 years, male 43,7%, BMI 22.1 ± 4.3 kg/m2). Groups were comparable according to number, age and gender but more IF patients had decreased BMI, p-alb, HGS and FFMI and increased CRP and GPS 1 or 2. Prevalence of malnutrition using GPS 1 or 2 combined with BMI, FFMI or HGS was 22.6%, 23.4%, 26.3% for INS, respectively (p = 0.756) and 40.7%, 40.0%, 59.3% for IF, respectively (p = 0.001). Agreement between the criteria combinations were: 8.0% for INS and 25.7% for IF. Significantly more with IF was diagnosed with severe malnutrition as compared to no malnutrition (43 vs. 26, p = 0.012, OR 2.1 [CI95% 1.2-3.8]), but only a tendency in the group with moderate malnutrition as compared to no malnutrition (27 vs. 22, p = 0.180, OR 1.6 [CI95% 0.8-3.0]) CONCLUSION: We found both prevalence and severity of malnutrition to be higher in IF than INS patients. GLIM-criteria were able to identify approximately same prevalence of malnutrition in INS but not in IF, when combining GPS 1 or 2 with BMI, FFMI and HGS. However, the agreement was poor in both groups. Consequently, further validation of GLIM is needed - including association to clinical outcome in lack of a gold standard.

Olive oil-based lipid emulsion is noninferior to soybean oil-based lipid emulsion in the acute care setting: A double-blind randomized controlled trial

OBJECTIVES

Olive oil (OO)-based intravenous lipid emulsion (IVLE) may have biological advantages for nutrition and inflammation status compared with soybean oil (SO)-based IVLE. We aimed to compare prealbumin levels during infusion of OO- or SO-based IVLE in patients receiving parenteral nutrition in the acute-care setting.

METHODS

In this prospective, noninferiority, double blind randomized controlled efficacy trial, patients received either OO-based or SO-based IVLE after providing consent. Biochemical and nutrition parameters were collected at baseline and at 7 to 10 d after initiation of parenteral nutrition. Results are expressed as means (standard deviations).

RESULTS

A total of 210 patients completed the study: 102 patients in the SO-based IVLE group and 108 patients in the OO-based IVLE group. Both groups had a significant increase in prealbumin levels from baseline (SO: 0.10 [0.06] versus 0.15 [0.08] g/L; P < 0.0001; OO: 0.11 [0.06] versus 0.16 [0.08] g/L; P < 0.0001), but mean changes between groups were not different (P = 0.53). OO-based IVLE was noninferior to SO-based IVLE in maintaining or increasing serum prealbumin levels, with 20% as the noninferiority margin at follow-up (least square geometric mean ratio [95% CI], 1.10 [0.83,1.47]; P = 0.50). There was a significant improvement in C-reactive protein levels from baseline within each group (SO: 83.24 [69.72] versus 53.4 [59.78] mg/dL; P < 0.0001; OO: 85.13 [68.14] versus 58.75 [60.11] mg/dL; P = 0.004), but mean changes between the groups were not different (P = 0.836). Mortality, length of stay, and infection rates were not different for both groups.

CONCLUSIONS

In this study, OO-based IVLE was not inferior to SO-based IVLE in maintaining or increasing the prealbumin level. The improvement of C-reactive protein levels and other clinical outcomes were not different for both groups.

Modified minimal-contact COVID-19 workflow allows for safe, remote parenteral nutrition prescribing in non-critically ill patients

Background

In line with recent guidance from the American Society for Parenteral and Enteral Nutrition (ASPEN) and the European Society for Clinical Nutrition and Metabolism (ESPEN) to minimize healthcare team exposure by clustering care and relying on other providers or telehealth to collect relevant nutrition assessments, our nutrition support team has adopted a modified workflow using information technology to provide parenteral nutrition (PN) remotely in a safe and timely manner. We aim to compare our prescribing adequacy and PN‐related complications before and during the coronavirus disease 2019 (COVID‐19) outbreak using the modified workflow in non–critically ill patients.

Methods

This study reviewed a prospectively recruited cohort of adults receiving PN in the general wards or high‐dependency units from December 5, 2019, to April 15, 2020. Demographic data, nutrition assessment, PN prescriptions, blood results, electronic notes, capillary blood glucose monitoring, and catheter‐related bloodstream infection rates were reviewed for patients who received PN.

Results

We found that patients who started PN during COVID‐19 were more malnourished with lower body mass index and higher proportion of Subjective Global Assessment B/C scores (52 [92.9%] vs 36 [73.5%], P < .005). The proportion of patients who achieved target energy amounts within 5 days was similar in both groups. Protein prescription was >1 g/kg/day in both groups, though there was a trend of higher protein prescription during COVID‐19. Complications were similar in both groups.

Conclusion

Our study demonstrates that minimal contact with effective multidisciplinary communication using the modified workflow can allow for safe and timely PN administration.

Parenteral nutrition in adults during acute illness: a clinical perspective for clinicians

Parenteral nutrition (PN) is the administration of a nutritional formula by means other than the gastrointestinal (GI) tract. The formula may include carbohydrates, amino acids, lipids, electrolytes and/or micronutrients. The primary indications for PN are intestinal failure (IF) due to an underlying disease or treatment, or if the GI tract is not accessible. The goals of PN should be to ensure adequate nutrition provision to meet patient needs while minimising the risk of complications. PN should be commenced in <48 h in patients who are malnourished or otherwise within 7 days if oral or enteral nutrition is not possible or insufficient. There has been evolution in PN techniques and technology, and the risks associated with PN administration have been reduced. Monitoring clinical, laboratory and metabolic parameters in acute IF is essential to provision of safe nutritional support. When provided to appropriate patients with IF in a timely and considered manner, PN has been shown to be safe, improve nutritional parameters and reduce complications associated with malnutrition. This review aims to provide clinicians a practical guide for the management of PN in adult patients within the acute setting.

Use of Lipids in Adult Patients Requiring Parenteral Nutrition in the Home Setting

It is estimated that over 25,000 Americans receive home parenteral nutrition (HPN), mostly because of intestinal failure (IF). Although there is significant variability in the fluid and energy needs of patients receiving HPN, intravenous lipid emulsions (ILEs) are an essential part of the macronutrient composition, serving as an excellent source of non-protein energy, as well as supplying essential fatty acids. However, the long-term use of ILEs in particular may be associated with some detrimental health effects, such as intestinal failure associated liver disease (IFALD). Although there is lack of unifying diagnosis, IFALD can present as cholestasis, steatosis, or fibrosis, with a prevalence that ranges between 5% and 43%. The development of IFALD tends to be multifactorial. Risk factors of IFALD can include those related to IF, inflammation/infection, and long-term parenteral nutrition. Some studies have shown a link between development of IFALD and ILE dose, especially if the dose is >1 g/kg/d, with high ω-6:ω-3 polyunsaturated fatty acid (PUFA) ratio and phytosterol content being theorized as some contributing factors. Thus, efforts have been made to use alternative oils (olive oil, medium-chain triglycerides, and fish oil) to reduce the soybean-oil content of ILE, which tends to be high in ω-6 PUFA and phytosterols. Although additional long-term clinical data are emerging, this strategy, as reviewed in the current manuscript, has shown to provide some benefit in both prevention and treatment of IFALD and other sequelae of HPN.

Association of Changes in Acute Gastrointestinal Injury Grade with Prognosis in Critically Ill Patients: A Prospective, Single-Center, Observational Study

Purpose

To investigate the association between the change of acute gastrointestinal injury (AGI) grade and the outcome in critically ill patients.

Methods

This was a prospectively observational study. All patients admitted in the ICU from October 2013 to June 2015, with the duration of ICU > 72 h and age >18 years, were enrolled in this study. The AGI grade and gastrointestinal symptoms were evaluated during ICU stay following the 2012 ESICM recommendation. The ICU mortality, duration of ICU stay, mechanical ventilation (MV) use, vasoactive drug use, and continuous renal replacement therapy of patients were recorded accordingly.

Results

A total of 320 patients were included, and 265 of them were diagnosed with AGI. The overall ICU mortality was 11.88%, while it was 13.58% in patients with AGI. In logistic regression analyses, the decreasing trend of AGI grade was identified as a protective factor for ICU death (odds ratio (OR), 0.484; 95% confidence interval (CI), 0.26–0.90), while the max AGI grade was a risk factor (OR, 3.464; 95% CI, 2.71–8.47) for ICU death.

Conclusion

The changes of AGI grades in critically ill patients were associated with their clinical outcomes. The ICU-acquired AGI patients associated with longer ICU stay days.

Multidisciplinary intestinal rehabilitation in acute type II intestinal failure: Results from an intestinal rehabilitation team

BACKGROUND

Type II (acute) intestinal failure (IF) is usually caused by complications of abdominal surgery resulting in enteric fistulas or proximal stomas and requires parenteral nutrition (PN) for several months. This study aimed to evaluate clinical management and outcome of type II IF patients in a single center.

METHODS

Medical records of patients referred to the Intestinal Rehabilitation Team (IRT) at Samsung Medical Center (Seoul, Korea) were retrospectively analyzed.

RESULTS

From 2014 to 2019, 34 patients with IF were referred. 28 patients were type II IF and were included in the analysis. There were 17 males and 11 females. Mean age of patients was 56.7 years. Pathophysiology of IF were high-output stoma in 16 cases, extensive bowel resection (with bowel in continuity) in 7 cases, and enterocutaneous fistula in 5 cases. The catastrophic events necessitating abdominal surgery in the patients were adhesive ileus in 9 cases, superior mesenteric artery thrombosis in 8 cases, internal herniation of bowel in 5 cases, traumatic bowel injury in 3 cases, and ischemic enteritis in 3 cases. Following medical and surgical rehabilitation, 10 patients (35.7%) were weaned off PN and overall mortality was 28.5%. Deaths were related to progression of underlying malignancies in 4 cases, liver failure in 3 cases, and sepsis in 1 case. Thirteen patients underwent surgery to restore bowel continuity. Six postoperative complications occurred in 4 patients (30.7%) and there were no postoperative mortalities.

CONCLUSION

Standardized care including restorative surgery resulted in successful outcomes in type II IF patients in this cohort.

Nutritional Management of Patients With Enterocutaneous Fistulas: Practice and Progression

The management of enterocutaneous fistulas (ECF) can be challenging because of massive fluid loss, which can lead to electrolyte imbalance, severe dehydration, malnutrition and sepsis. Nutritional support plays a key role in the management and successful closure of ECF. The principle of nutritional support for patients with ECF should be giving enteral nutrition (EN) priority, supplemented by parenteral nutrition if necessary. Although total parenteral nutrition (TPN) may be indicated, use of enteral feeding should be advocated as early as possible if patients are tolerant to it, which can protect gut mucosal barrier and prevent bacterial translocation. A variety of methods of enteral nutrition have been developed such as fistuloclysis and relay perfusion. ECF can also be occluded by special devices and then EN can be implemented, including fibrin glue application, Over-The-Scope Clip placement and three-dimensional (3D)-printed patient-personalized fistula stent implantation. However, those above should not be conducted in acute fistulas, because tissues are edematous and perforation could easily occur.

Intravenous lipid emulsions and liver function in adult chronic intestinal failure patients: Results after 5 y of home parenteral nutrition

OBJECTIVES

Intravenous lipid emulsions (ILE) are an essential component of parenteral nutrition (PN); however, pure soybean oil emulsion is considered a risk factor for intestinal failure-associated liver disease (IFALD). Limited data are available on the effect of different ILEs on the liver during long-term PN, and to our knowledge, no study has evaluated outcomes beyond 12 mo. Therefore, the aim of the present study was to assess the influence of mixed ILEs on liver function during long-term PN.

METHODS

A randomized, open-label clinical trial was performed at the Intestinal Failure Center in Skawina, Poland. Sixty-seven patients (35 F, 32 M; mean age, 53.2 years) receiving home parenteral nutrition (HPN) due to stable chronic intestinal failure (CIF) were randomized to receive one of the following three ILEs: medium/long-chain triacylglycerides (MCT/LCT), olive oil/soybean oil (OO/SO), or a combination of SO/MCT/OO/fish oil (FO) (SMOFlipid). Patients were followed for 5 y. Liver function was assessed clinically and with biochemical parameters (total bilirubin, serum glutamyl oxalate transaminase, serum glutamyl pyruvate transaminase, γ-glutamyl transpeptidase, and alkaline phosphatase) at baseline and after 24 and 60 mo.

RESULTS

The most common etiology for CIF was vascular, followed by Crohn's disease, surgical complications, and radiation enteritis. HPN was effective in improving nutritional status and was associated with low rates of catheter infections and clinical complications. No significant differences were observed between groups in median concentrations serum glutamyl oxalate transaminase, serum glutamyl pyruvate transaminase, γ-glutamyl transpeptidase, or alkaline phosphatase at 24 or 60 mo. A significant reduction in median bilirubin concentration was observed in the SMOFlipid group at 60 mo compared with baseline (6.8 umol/L; interquartile range, 5.2-8.5 versus 7.7 umol/L; interquartile range, 4.9-12.4; P = 0.0138).

CONCLUSIONS

Mixed ILEs are safe and effective for use in patients on long-term HPN. A multicomponent ILE with FO can provide additional benefits in terms of liver function during long-term HPN.

The novel use of the Haemodialysis reliable outflow graft (HeRo®) in intestinal failure patients with end-stage vascular access

Intestinal failure (IF) patients are dependent on central venous access to receive parenteral nutrition. Longstanding central venous catheters are associated with life-threatening complications including infections and thromboses resulting in multiple line exchanges and the development ofprogressive central venous stenosis or occlusion. The Haemodialysis Reliable Outflow (HeRO) graft is an arterio-venous device that has been successfully used in haemodialysis patients with ‘end-stage vascular access’. We describe a case series of HeRO graft use in patients with IF and end-stage vascular access. Four HeRO grafts were inserted into IF patients with end-stage vascular access to facilitate or support intestinal transplantation. In all patients the HeRO facilitated immediate vascular access, supporting different combinations of parenteral nutrition, intravenous medications, fluids or renal replacement therapy with no bloodstream infections. In a highly complex group of IF patients with central venous stenosis/occlusion limiting conventional venous access or at risk of life-threatening catheter-related complications, a HeRO^® graft can be a feasible alternative.

Clinical application of fish-oil intravenous lipid emulsion in adult home parenteral nutrition patients

BACKGROUND

High-ω-6 polyunsaturated fatty acids (PUFAs) are noted to contribute to development of intestinal failure-associated liver disease (IFALD) in home parenteral nutrition (HPN). Fish oil (FO) has been added to latest generation of lipid injectable emulsion (ILE) to increase ω-3:ω-6 PUFA ratio; however, appropriate dose of FO to treat IFALD is unknown.

METHODS

After approval of exclusive FO ILE in the US for pediatric patients, we noted 2 adult patients with ongoing IFALD despite transition to mixed-oil (MO) ILE. They were transitioned to off-label FO ILE after review of literature regarding use of FO ILE in adult HPN patients was conducted to guide management.

RESULTS

The first case involves a 40-year-old female receiving HPN with IFALD refractory to MO ILE. MO ILE (with 15% FO) was provided at 50 g/d for 3 d/wk and combined with FO ILE at 50 g/d for 4 d/wk. This combination resulted in improvement in liver studies and allowed for decrease in dextrose calories. The second case involves a 49-year-old male receiving HPN (secondary to complications of necrotizing pancreatitis) who developed IFALD. FO ILE was used as the sole source of lipids and led to improvement in liver function tests. No evidence of essential fatty acid deficiency was found in either case.

CONCLUSIONS

Current case presentations and review of literature support the use of FO ILE to increase ω-3 PUFAs in patients with IFALD refractory to MO ILE. Additional research is necessary to delineate the dose of FO ILE necessary to achieve benefit.

A modern multidisciplinary approach to the treatment of enterocutaneous fistulas in Crohn's disease patients

INTRODUCTION

Enterocutaneous fistulas (ECFs) is a manifestation of penetrating Crohn's disease (CD) that is challenging to treat and has considerable morbidity and mortality rates.

AREAS COVERED

This review aims to explore the practical and updated principles for the optimal treatment of ECFs in CD patients.

EXPERT OPINION

Optimal ECF management requires a multidisciplinary approach. Treatment first includes fluid resuscitation and electrolyte rebalancing with control of sepsis by means of antibiotics and, when indicated, drainage of infected collections. Subsequent therapeutic steps include nutritional support, control of the fistula output and treatment of peristomal skin. Anti-TNF-α therapy seems to have limited utility only after sepsis is resolved and intestinal stenosis excluded. However, ECFs heal in only approximately one-third of cases without surgical intervention. Thus, correct surgical timing combined with adequate nutritional support, sepsis resolution and skin care is considered the appropriate preoperative setting.

Effects of Sexual Function, Social Media Use, and Self-Efficacy on Quality of Life Among Home Parenteral Nutrition Patients

BACKGROUND

Quality of life (QOL) of home parenteral nutrition (HPN) patients is a critical issue for functioning and survival. This study evaluates the roles of sexual function (SF), self-efficacy (SE), and the use of social media (USM) in the QOL of HPN patients.

MATERIALS AND METHODS

The study model investigates the independent variables USM and SF and the dependent variable QOL, and SE is a mediator variable between SF and USM.

RESULTS

We included 203 participants with HPN who completed self-administered, validated questionnaires for QOL, SF, SE, and USM. Statistical analysis included a t-test, Sobel test, bootstrapping method, and Pearson correlations between variances. The mean HPN duration was 10.5 ± 8 years. Results show a significant correlation between QOL scores and SF (P = .001). USM was positively correlated with SE (P = .001). SE as a mediator between USM and SF was supported by significant results in the Sobel test. Patients with a stoma were significantly less sexually active and had lower SE ratings than those without a stoma.

CONCLUSION

Physical changes that affect SE and boost social relationships by allowing emotional support through social networks are important factors for QOL improvement. These findings may guide health professionals in the management of HPN patients.

Combined surgical and negative pressure therapy to treat multiple enterocutaneous fistulas and abdominal abscesses: A case report

Introduction

We report the case of a successful management with combined aggressive surgery and negative pressure therapy, to treat a severely ill-septic patient, affected by multiple chronic enterocutaneous fistulas.

Presentation of case

A 26-year-old female patient presented with multiple pelvic and intra-abdominal abscesses, enterocutaneous fistulas and central venous catheter-related bacteraemia in extremely poor general conditions.The patient underwent both an abdominal CT which showed multiple digestive loops stuck and apparently fistulised and an abdominal-pelvic MRI, confirming the CT findings, and demonstrating a third fistula involving the Pouch and responsible for a pelvic and retroperitoneal chronic abscess.Given the patient's septic condition, despite several attempts of conservative therapies, an aggressive surgical approach was adopted.After temporary abdominal wall closure, the patient underwent Vacuum Assisted Closure therapy in order to close the abdominal wall and drain the residual abscess. The patient was discharged at the 35th post-operative day in good general conditions.

Discussion

This case is about a complex, long-lasting clinical scenario, progressively leading a young woman to death despite several attempts of conservative therapy, sometimes allowed to treat enterocutaneous fistulas. The use of negative pressure therapy to manage open abdomen is still controversial. Patients affected by enterocutaneous fistulas are in need of adequate nutritional support due to their hypercatabolic state, secondary both to the fluid loss and the concomitant inflammatory status.

Conclusion

When conservative management fails and the patient shows septic complications, a multidisciplinary aggressive approach, including surgery, negative-pressure therapy and hyperbaric oxygen therapy is required to treat this life-threatening condition.