Intestinal transplantation for short bowel syndrome secondary to gastroschisis

Gastroschisis Outcomes: Presence of Histologic Chorioamnionitis and the Impact on Time to Full Enteral Feeds and Length of Hospital Stay

OBJECTIVE

 Despite improvements in our ability for early diagnosis and providing supportive care for infants with gastroschisis, it continues to be associated with long length of stay and morbidity. Intestinal dysfunction secondary to chronic inflammatory insult to exposed bowel is well known; however, little research has been done on the impact of acute inflammation in the perinatal period on intestinal function. This study's aim was to investigate the impact of acute chorioamnionitis on the time to achieve full enteral feeds and length of hospital stay.

STUDY DESIGN

 Retrospective chart review of 60 mothers and their infants born with gastroschisis at a Level IV NICU from November 2011 to June 2020 was performed. Infants were divided into two groups based on the presence of histologic chorioamnionitis, and outcomes were compared. The primary outcome was delayed full enteral feeds (full enteral feeds after 28 days of life). The secondary outcomes were differences in their time to achieve full enteral feeds and time to hospital discharge, and prolonged length of hospital stay (discharge after 30 days of life). Univariate and multivariate logistic regression analyses were performed to assess the association between the dependent and the predictor variables.

RESULT

 Of the 60 infants enrolled, 23 (38%) had evidence of histologic chorioamnionitis. The median gestational age was 37 weeks. Fifty-four (90%) infants achieved full enteral feeds, with a median time of 24 days. Median length of hospital stay was 31 days. The presence of histologic chorioamnionitis was not associated with delayed full enteral feeds (odds ratio [OR] = 0.79; 95% confidence interval [CI] = 0.14-4.23; p = 0.80) or prolonged length of hospital stay (OR = 0.45; 95% CI = 0.1-0.23; p = 0.32) in the adjusted analysis.

CONCLUSION

 Acute placental inflammation during the perinatal period does not impact the infant's time to achieve full feeds or prolong their hospital stay. Larger studies are needed to confirm these findings.

KEY POINTS

· Chronic inflammatory injury to exposed bowel in utero is well known in fetuses with gastroschisis.. · Acute inflammatory injury during perinatal period may impact enteral feeding outcomes.. · No impact of acute placental inflammation on time to full enteral feeds..

Clinical challenges of short bowel syndrome and the path forward for organoid-based regenerative medicine

Short bowel syndrome (SBS) is a rare condition, the main symptom of which is malabsorption following extensive resection of the small intestine. Treatment for SBS is mainly supportive, consisting of supplementation, prevention and treatment of complications, and promotion of intestinal adaptation. While development of parenteral nutrition and drugs promoting intestinal adaptation has improved clinical outcomes, the prognosis of patients with SBS remains poor. Intestinal transplantation is the only curative therapy but its outcome is unsatisfactory. In the absence of definitive therapy, novel treatment is urgently needed. With the advent of intestinal organoids, research on the intestine has developed remarkably in recent years. Concepts such as the "tissue-engineered small intestine" and "small intestinalized colon," which create a functional small intestine by combining organoids with other technologies, are potentially novel regenerative therapeutic approaches for SBS. Although they are still under development and there are substantial issues to be resolved, the problems that have prevented establishment of the complex function and structure of the small intestine are gradually being overcome. This review discusses the current treatments for SBS, the fundamentals of the intestine and organoids, the current status of these new technologies, and future perspectives.

Outcomes in patients with short bowel syndrome after autologous intestinal reconstruction: Does etiology matter?

BACKGROUND

Short bowel syndrome (SBS) is the most common cause of intestinal failure in children. Many factors have been investigated in an attempt to define which parameters influence most survival and ability to wean off parenteral nutrition (PN). The aim of this study was to investigate if aetiology of SBS affects the outcomes in paediatric patients treated with autologous gastrointestinal reconstructive surgery.

METHODS

All children with SBS who underwent autologous gastrointestinal reconstructive surgery between 2002 and 2012 were retrospectively reviewed and outcome measures were recorded.

RESULTS

Forty-three patients were divided into 4 groups according to aetiology (gastroschisis, volvulus, necrotizing enterocolitis (NEC), intestinal atresia). No significant differences were found among groups regarding survival and median age at surgery. The volvulus group had a lower pre-operative bowel length in comparison with gastroschisis and intestinal atresia and the lowest percentage of patients off PN (30%). Gastroschisis had the lowest rate of preserved ileocaecal valve (10%), while intestinal atresia had the highest (66%). For children who weaned off PN, intestinal atresia had also the longest time to achieve enteral autonomy (14.5months), while NEC had the shortest (3.5months), followed by gastroschisis (8.5months). None of the patients needed transplant.

CONCLUSIONS

In our experience it does not appear that diagnosis is significantly related to outcome and this is consistent with the conclusions of other reviews. However, it should be noted that in our series patients with volvulus had the worse outcome in terms of weaning off PN when compared with intestinal atresia.

TYPE OF STUDY

Retrospective Study.

LEVEL OF EVIDENCE

II.

Spatial variability of gastroschisis in Canada, 2006-2011: An exploratory analysis

OBJECTIVES

Gastroschisis is a serious birth defect of the abdominal wall that is associated with mortality and significant morbidity. Our understanding of the factors causing this defect is limited. The objective of this paper is to describe the geographic variation in incidence of gastroschisis and characterize the spatial pattern of all gastroschisis cases in Canada between 2006 and 2011. Specifically, we aimed to ascertain the differences in spatial patterns between geographic regions and identify significant clusters and their location.

METHODS

The study population included 641 gastroschisis cases from the Canadian Pediatric Surgery Network (CAPSNet) database, a population-based dataset of all gastroschisis cases in Canada. Cases were geocoded based on maternal residence. Using Statistics Canada live-birth data as a denominator, the total prevalence of gastroschisis was calculated at the provincial/territorial levels. Random effects logistic models were used to estimate the rates of gastroschisis in each census division. These rates were then mapped using ArcGIS. Cluster detection was performed using Local Indicators of Spatial Association (LISA).

RESULTS

There is significant spatial heterogeneity of the rate of gastroschisis across Canada at both the provincial/territorial and census-division level. The Yukon, Northwest Territories and Prince Edward Island have higher overall rates of gastroschisis relative to other provinces/territories. Several census divisions in Alberta, Manitoba, Saskatchewan, Ontario, Northwest Territories and British Columbia demonstrated case "clusters", i.e., focally higher rates in discrete areas relative to surrounding areas.

CONCLUSIONS

There is clear evidence of spatial variation in the rates of gastroschisis across Canada. Future research should explore the role of area-based variables in these patterns to improve our understanding of the etiology of gastroschisis.

Diagnosis of abdominal wall defects in the first trimester

PURPOSE OF REVIEW

To review prognostic parameters reported recently in the evaluation of abdominal wall defects in the first trimester.

RECENT FINDINGS

Evaluation of abdominal wall defects in the first trimester is based principally on associated structural or chromosomal anomalies. In the case of gastroschisis, which is rarely associated with other anomalies, evaluation of prenatal or postnatal outcome is based mainly on the course of pregnancy. In the case of isolated omphalocele in the first trimester, recent studies have evaluated parameters that could help predict prenatal or postnatal outcome.

SUMMARY

We review recent studies using new parameters to diagnose abdominal wall defects in the first trimester and to provide early prenatal counselling to parents regarding prenatal and postnatal prognosis.

Race affects outcome among infants with intestinal failure

OBJECTIVE

Intestinal failure (IF) is a rare, devastating condition associated with significant morbidity and mortality. We sought to determine whether ethnic and racial differences were associated with patient survival and likelihood of receiving an intestinal transplant in a contemporary cohort of children with IF.

METHODS

This was an analysis of a multicenter cohort study with data collected from chart review conducted by the Pediatric Intestinal Failure Consortium. Entry criteria included infants ≤ 12 months receiving parenteral nutrition (PN) for ≥ 60 continuous days and studied for at least 2 years. Outcomes included death and intestinal transplantation (ITx). Race and ethnicity were recorded as they were in the medical record. For purposes of statistical comparisons and regression modeling, categories of race were consolidated into "white" and "nonwhite" children.

RESULTS

Of 272 subjects enrolled, 204 white and 46 nonwhite children were available for analysis. The 48-month cumulative incidence probability of death without ITx was 0.40 for nonwhite and 0.16 for white children (P < 0.001); the cumulative incidence probability of ITx was 0.07 for nonwhite versus 0.31 for white children (P = 0.003). The associations between race and outcomes remained after accounting for low birth weight, diagnosis, and being seen at a transplant center.

CONCLUSIONS

Race is associated with death and receiving an ITx in a large cohort of children with IF. This study highlights the need to investigate reasons for this apparent racial disparity in outcome among children with IF.

Intestinal stem cells and stem cell-based therapy for intestinal diseases

Currently, many gastrointestinal diseases are a major reason for the increased mortality rate of children and adults every year. Additionally, these patients may cope with the high cost of the parenteral nutrition (PN), which aids in the long-term survival of the patients. Other treatment options include surgical lengthening, which is not sufficient in many cases, and intestinal transplantation. However, intestinal transplantation is still accompanied by many challenges, including immune rejection and donor availability, which may limit the transplant's success. The development of more safe and promising alternative treatments for intestinal diseases is still ongoing. Stem cell-based therapy (SCT) and tissue engineering (TE) appear to be the next promising choices for the regeneration of the damaged intestine. However, suitable stem cell source is required for the SCT and TE process. Thus, in this review we discuss how intestinal stem cells (ISCs) are a promising cell source for small intestine diseases. We will also discuss the different markers were used to identify ISCs. Moreover, we discuss the dominant Wnt signaling pathway in the ISC niche and its involvement in some intestinal diseases. Additionally, we discuss ISC culture and expansion, which are critical to providing enough cells for SCT and TE. Finally, we conclude and recommend that ISC isolation, culture and expansion should be considered when SCT is a treatment option for intestinal disorders. Therefore, we believe that ISCs should be considered a cell source for SCT for many gastrointestinal diseases and should be highlighted in future clinical applications.

Cholestasis and growth in neonates with gastroschisis

PURPOSE

The aim of this study was to determine the incidence of cholestasis and the correlation between cholestasis and weight-for-age z scores in parenteral nutrition-dependent neonates with gastroschisis.

METHODS

A single-center retrospective review of 59 infants born with gastroschisis from January 2000 to June 2007 was conducted. Demographic and clinical data were collected and analyzed. Subjects were divided into cholestatic and noncholestatic groups. Statistical analyses included the Student t test, Wilcoxon rank sum test, Fisher exact test, and a general linear model.

RESULTS

Fifty-nine neonates with gastroschisis were identified, and 16 (28%) of 58 patients developed cholestasis. Younger gestational age and cholestasis were found to be independently associated with weight-for-age z score in 30 of 58 patients with available long-term follow-up data.

CONCLUSIONS

Parenteral nutrition-dependent neonates with gastroschisis remain at considerable risk for the development of cholestasis. Both gestational age and cholestasis were found to be independent risk factors, predisposing these neonates to poor postnatal growth.

Gastroschisis with intestinal atresia--predictive value of antenatal diagnosis and outcome of postnatal treatment

PURPOSE

The purpose of this study is to evaluate (1) the predictive value of fetal bowel dilatation (FBD) for intestinal atresia in gastroschisis and (2) the postnatal management and outcome of this condition.

METHODS

A retrospective review of all gastroschisis cases diagnosed in our fetal medicine unit between 1992 and 2010 and treated postnatally in our center was performed.

RESULTS

One hundred thirty cases had full postnatal data available. Intestinal atresia was found at surgery in 14 neonates (jejunum, n = 6; ileum, n = 3; ascending colon, n = 3; multiple, n = 2). Polyhydramnios and FBD were more likely in the atresia group compared with infants with no atresia (P = .0003 and P = .005, respectively). Fetal bowel dilatation had 99% negative predictive value (95% confidence interval, 0.9-0.99) and 17% positive predictive value (95% confidence interval, 0.1-0.3) for atresia. Treatment of intestinal atresia included primary anastomosis (n = 5), delayed anastomosis (n = 2), and stoma formation followed by anastomosis (n = 7). Infants with atresia had longer duration of parenteral nutrition, higher incidence of sepsis, and cholestasis compared with infants with no atresia (P = .0003). However, the presence of atresia did not increase mortality.

CONCLUSIONS

Polyhydramnios and FBD are associated with atresia. Absence of FBD in gastroschisis excludes intestinal atresia. In our experience, atresia is associated with a longer duration of parenteral nutrition but does not influence mortality. These findings may be relevant for antenatal counseling.

Early severe hypoalbuminemia is an independent risk factor for intestinal failure in gastroschisis

OBJECTIVE

This study attempted to evaluate the association of early hypoalbuminemia with the risk of intestinal failure in gastroschisis patients.

PATIENTS AND METHODS

Neonates with gastroschisis treated at a tertiary children's hospital over a 10-year period were initially categorized into groups based on the lowest serum albumin measurement during the first 7 days of life. Based on preliminary analysis, patients with serum albumin <1.5 g/dL were considered to have early severe hypoalbuminemia. Intestinal failure was defined as inability of the patient to wean from parenteral nutrition (PN) during the initial hospital admission, thus requiring home PN. Logistic regression modeling was performed to adjust for sex, gestational age, birth weight, and concomitant intestinal complications.

RESULTS

One hundred and thirty-five gastroschisis patients were included, of whom 21% had early severe hypoalbuminemia. Patients with early severe hypoalbuminemia had a significantly higher risk of intestinal failure compared to those with higher albumin levels (26 vs. 8%, p = 0.015). On multivariable logistic regression modeling, early severe hypoalbuminemia was strongly associated with intestinal failure (OR 6.4, 95% CI 1.8-23.3, p = 0.005).

CONCLUSIONS

Early severe hypoalbuminemia appears to be an independent risk factor for long-term intestinal compromise rather than merely an indicator of overall illness. Further interventional studies are needed to determine whether clinical protocols utilizing judicious fluid administration, exogenous albumin, and early enteral feeding can improve clinical outcomes in gastroschisis.

Contemporary postnatal surgical management strategies for congenital abdominal wall defects

Early definitive closure of abdominal wall defects is possible in most cases. Staged reduction does offer distinct advantages, and mortality and morbidity may be better. Risk stratification may produce outcome and tailor management of difficult cases in the form of a clinical pathway. Stem cell technology may, in the future, offer the ideal allogenic prosthesis in complex cases.

Closed gastroschisis: total parenteral nutrition-free survival with aggressive attempts at bowel preservation and intestinal adaptation

BACKGROUND

In infants with gastroschisis antenatal closure of the umbilical defect results in a proximal atresia with ischemia and/or volvulus of the extracorporeal midgut. It has been described as "closed gastroschisis" or "vanishing midgut."

METHODS

A 10-year review of 219 gastroschisis patients identified 10 infants with this rare complication.

RESULTS

In these 10 infants, the extracorporeal midgut was invariably matted and fibrosed. In 3 cases, the midgut had completely "vanished." In the remaining 7 cases, the remnant midgut was surgically reduced into the abdominal cavity with care not to compromise the diminutive vascular pedicle. Abdominal exploration was performed several weeks later to reestablish bowel continuity; 4 required an ostomy and 2 underwent a serial transverse enteroplasty. Mean residual length of salvaged small bowel was 79 cm with retention of the distal half of the colon. Eight infants survived the initial hospitalization, with a mean length of stay of 121 days and mean hospital charge of $287,094. Six of the 7 long-term survivors have been completely weaned off total parenteral nutrition.

CONCLUSION

A nihilistic attitude toward infants with closed gastroschisis may not be uniformly supported because in the majority of these infants' long-term independence from total parenteral nutrition was achieved.

Canadian Pediatric Surgical Network: a population-based pediatric surgery network and database for analyzing surgical birth defects. The first 100 cases of gastroschisis

PURPOSE

Outcomes studies for gastroschisis are constrained by small numbers, prolonged accrual, and nonstandardized data collection. The aim of this study is to create a national pediatric surgical network and database for gastroschisis (GS) that tracks cases from diagnosis to hospital discharge.

METHODS

The 16-center network serves a population of 32 million. Gastroschisis cases are ascertained at prenatal diagnosis. Perinatal data include maternal risk and fetal ultrasound variables, delivery plan and outcome, a postnatal bowel injury score, intended and actual surgical treatment, and neonatal outcomes. Institutional review board-approved data collection conforms to regional privacy legislation. Deidentified data are centralized and accessible for research through the network steering committee.

RESULTS

To date, 114 cases of pre- and/or postnatal gastroschisis have been uploaded. Of 106 live-born infants (40 [38%] by cesarean delivery), 100 had complete records, and overall survival to discharge was 96%, with a mean survivor length of stay (LOS) of 46 days. Infants treated with attempted urgent closure (61%) had significantly shorter LOS (42 vs 57 days; P = .048) but comparable LOS compared with those treated with silos and delayed closure. Fetal bowel dilation 18 mm or greater did not predict a difference in outcome.

CONCLUSION

Population-based databases allow rapid case accrual and enable studies that should aid in the identification of optimal perinatal treatment.