Elemental enteral nutrition preserves the mucosal barrier and improves the trophism of the villi after small bowel transplantation in piglets

Nutrition support considerations in pediatric small bowel transplantation

Enteral autonomy is the primary goal of intestinal failure therapy. Intestinal transplantation (ITx) is an option when enteral autonomy cannot be achieved and management complications become life-threatening. The purpose of this review is to summarize existing medical literature related to nutrition requirements, nutrition status, and nutrition support after pediatric ITx. Achieving or maintaining adequate growth after intestinal transplant in children can be challenging because of episodes of rejection that require the use of corticosteroids, occurrences of infection that require a reduction or discontinuation of enteral or parenteral support, and fat malabsorption caused by impaired lymphatic circulation. Nutrient requirements should be assessed and modified regularly based on nutrition status, growth, ventilatory status, wound healing, and the presence of complications. Parenteral nutrition (PN) should be initiated as a continuous infusion early postoperatively. Enteral support should be initiated after evidence of graft bowel function and in the absence of clinical complications. Foods high in simple carbohydrates should be limited, as consumption may result in osmotic diarrhea. Short-term use of a fat-free diet followed by a low-fat diet may reduce the risk of the development of chylous ascites. Micronutrient deficiencies and food allergies are common occurrences after pediatric ITx. Enteral/oral vitamin and mineral supplementation may be required after PN is weaned. Nutrition management of children after ITx can be challenging for all members of the healthcare team. Anthropometric parameters and micronutrient status should be monitored regularly so that interventions to promote growth and prevent or reverse nutrient deficiencies can be implemented promptly.

Puerarin enhances intestinal function in piglets infected with porcine epidemic diarrhea virus

Puerarin has been reported to be an excellent antioxidant, anti-inflammatory and antimicrobial agent, but the potential effect of puerarin on porcine epidemic diarrhea virus (PEDV) is unclear. This study aimed to determine whether puerarin could alleviate intestinal injury in piglets infected with PEDV. A PEDV (Yunnan province strain) infection model was applied to 7-day-old piglets at 10^4.5 TCID₅₀ (50% tissue culture infectious dose). Piglets were orally administered with puerarin at the dosage of 0.5 mg/kg body weight from day 5 to day 9. On day 9 of the trial, piglets were inoculated orally with PEDV. Three days later, jugular vein blood and intestinal samples were collected. Results showed puerarin reduced morbidity of piglets infected with PEDV. In addition, puerarin reduced the activities of aspartate aminotransferase and alkaline phosphatase, the ratio of serum aspartate aminotransferase to serum alanine aminotransferase, the number of white blood cells and neutrophils, and the plasma concentrations of interleukin-6, interleukin-8 and tumor necrosis factor-α, as well as protein abundances of heat shock protein-70 in PEDV-infected piglets. Moreover, puerarin increased D-xylose concentration but decreased intestinal fatty acid-binding protein concentration and diamine oxidase activity in the plasma of piglets infected with PEDV. Puerarin increased the activities of total superoxide dismutase, glutathione peroxidase and catalase, while decreasing the activities of myeloperoxidase and concentration of hydrogen peroxide in both the intestine and plasma of PEDV-infected piglets. Puerarin decreased mRNA levels of glutathione S-transferase omega 2 but increased the levels of nuclear factor erythroid 2-related factor 2. Furthermore, puerarin increased the abundance of total eubacteria (16S rRNA), Enterococcus genus, Lactobacillus genus and Enterobacteriaceae family in the intestine, but reduced the abundance of Clostridium coccoides in the caecum. These data indicate puerarin improved intestinal function in piglets infected by PEDV and may be a promising supplement for the prevention of PEDV infection.

Nutritional and health benefits of semi-elemental diets: A comprehensive summary of the literature

AIM: To critically review and summarize the literature on nutritional and health outcomes of semi-elemental formulations on various nutritionally vulnerable patient populations who are unable to achieve adequate nutrition from standard oral diets.

METHODS: We conducted a comprehensive literature search of Pubmed and Embase databases. We manually screened articles that examined nutritional and health outcomes (e.g., growth, disease activity, gastrointestinal impairment, mortality, and economic impact) among various patient groups receiving semi-elemental diets. This review focused on full-text articles of randomized controlled clinical trials and other intervention studies, but pertinent abstracts and case studies were also included. Results pertaining primarily to tolerance, digestion, and absorption were summarized for each patient population in this systematic review.

RESULTS: Results pertaining primarily to tolerance, digestion, and absorption were summarized for each patient population. The efficacy of semi-elemental whey hydrolyzed protein (WHP) diet have been reported in various nutritionally high risk patient populations including - Crohn’s disease, short bowel syndrome, acute and chronic pancreatitis, cerebral palsy, cystic fibrosis, cerebrovascular accidents, human immunodeficiency virus, critically ill, and geriatrics. Collectively, the evidence from the medical literature indicates that feeding with a semi-elemental diet performs as well or better than parenteral or amino acid based diets in terms of tolerance, digestion, and nutrient assimilation measures across various disease conditions.

CONCLUSION: Based on this comprehensive review of the literature, patient populations who have difficulty digesting or absorbing standard diets may be able to achieve improved health and nutritional outcomes through the use of semi-elemental WHP diets.

The Surgical Approach to Short Bowel Syndrome - Autologous Reconstruction versus Transplantation

BACKGROUND

Short bowel syndrome (SBS) is a state of malabsorption resulting from massive small bowel resection leading to parenteral nutrition (PN) dependency. Considerable advances have been achieved in the medical and surgical management of SBS over the last few decades.

METHODS

This review discusses in detail the surgical approach to SBS.

RESULTS

Widespread use of PN enables long-term survival in patients with intestinal failure but at the cost of PN-associated life-threatening complications including catheter-associated blood stream infection, venous thrombosis, and liver disease. The goal of management of intestinal failure due to SBS is to enable enteral autonomy and wean PN by means of a multi-disciplinary approach. Availability of modified enteral feeding formulas have simplified nutrition supplementation in SBS patients. Similarly, advances in the medical field have made medications like growth hormone and glucagon-like peptide (GLP2) available to improve water and nutrient absorption as well as to enable achieving enteral autonomy. Autologous gastrointestinal reconstruction (AGIR) includes various techniques which manipulate the bowel surgically to facilitate the bowel adaptation process and restoration of enteral nutrition. Ultimately, intestinal transplantation can serve as the last option for the cure of intestinal failure when selectively applied.

CONCLUSION

SBS continues to be a challenging medical problem. Best patient outcomes can be achieved through an individualized plan, using various AGIR techniques to complement each other, and intestinal transplantation as a last resort for cure. Maximum benefit and improved outcomes can be achieved by caring for SBS patients at highly specialized intestinal rehabilitation centers.

The Protective Effects of Exclusive Enteral Nutrition Formulas on Growth Factor Expression and the Proximal Tibial Epiphyseal Growth Plate in a TNBS-Induced IBD Rat Model

OBJECTIVE

This study aimed to evaluate the effectiveness of different types of nutritional formulas in a rat model of TNBS-induced IBD.

METHODS

IBD was induced with TNBS in 4-week-old rats that were then fed different exclusive enteral nutrition diets for 7 days. The length of the tibia and the number of chondrocytes in the proximal tibias were analyzed at 7 days after supplementation. Immunohistochemical analysis, ELISA and real-time PCR were performed to evaluate the levels of growth hormone receptor (GHR) and insulin-like growth factor-I receptor (IGF-IR), the growth factors IGF-I and insulin-like growth factor-binding protein-3 (IGFBP3) , bone morphogenetic protein (BMP)-2 and BMP-6 respectively.

RESULTS

The results demonstrated that the tibia length of the peptide formula group was longer than that of the IBD-Modulen(®) formula and normal diet groups (P < 0.05). Furthermore, the number of chondrocytes of the proximal tibial was more pronounced in the peptide formula group compared to the other groups (P < 0.05). The peptide formula was also more effective in increasing the expression of GHR compared to the other groups (P < 0.05), while the expression of IGF-IR was not significantly different (P > 0.05). In addition, the IGF-I and IGFBP3 levels were more pronounced in the peptide formula supplement group (P < 0.05), and the expression of BMP-2 and BMP-6 mRNA in the proximal tibia growth plate from the peptide formula group was higher than that in the ordinary formula and normal diet groups (P < 0.05).

CONCLUSIONS

EEN, and particularly a peptide formula, exerted protective effects on the proximal tibial epiphyseal growth plate in a TNBS-induced IBD model.

Cost-effectiveness analysis of an enteral nutrition protocol for children with common gastrointestinal diseases in China: good start but still a long way to go

BACKGROUND

A standard nutrition screening and enteral nutrition (EN) protocol was implemented in January 2012 in a tertiary children's center in China. The aims of the present study were to evaluate the cost-effectiveness of a standard EN protocol in hospitalized patients.

METHODS

A retrospective chart review was performed in the gastroenterology inpatient unit. We included all inpatient children requiring EN from January 1, 2010, to December 31, 2013, with common gastrointestinal (GI) diseases. Children from January 1, 2012, to December 31, 2013, served as the standard EN treatment group, and those from January 1, 2010, to December 31, 2011, were the control EN group. Pertinent patient information was collected. We also analyzed the length of hospital stay, cost of care, and in-hospital infection rates.

RESULTS

The standard EN treatment group received more nasojejunal tube feedings. There was a tendency for the standard EN treatment group to receive more elemental and hydrolyzed protein formulas. Implementation of a standard EN protocol significantly reduced the time to initiate EN (32.38 ± 24.50 hours vs 18.76 ± 13.53 hours; P = .011) and the time to reach a targeted calorie goal (7.42 ± 3.98 days vs 5.06 ± 3.55 days; P = .023); length of hospital stay was shortened by 3.2 days after implementation of the standard EN protocol but did not reach statistical significance. However, the shortened length of hospital stay contributed to a significant reduction in the total cost of hospital care (13,164.12 ± 6722.95 Chinese yuan [CNY] vs 9814.96 ± 4592.91 CNY; P < .032).

CONCLUSIONS

Implementation of a standard EN protocol resulted in early initiation of EN, shortened length of stay, and significantly reduced total cost of care in hospitalized children with common GI diseases.

Immunohistochemical study of jejunal graft mucosa cell populations during the initial adaptation phase in the host body in rats

The character of the changes in cell populations within the jejunal graft mucosa during the initial adaptation phase in the host body was investigated. 24 adult male Wistar rats underwent intestinal heterotopic allotransplantation. Aorto-aortal and porto-caval anastomoses were performed using the end-to-side microsurgery technique. Graft tissues were compared to the intestinal tissues of the recipients. This study demonstrates that: (1) Distinct injury to the graft mucosa 1h after transplantation was accompanied by significant reduction in numbers of epithelial secretory cell populations. The injury was more intense in the mesenteric portion. Six hours after transplantation the graft mucosa was covered by a continuous epithelium, but the number of goblet and Paneth cells was found to be less than 30% of that in the recipient epithelium. (2) In comparison with recipients, myeloperoxidase-positive cell numbers increased significantly in the graft mucosa 1 h after transplantation. In the epithelial layer, denudation and destruction of villi was associated with a significant reduction in intraepithelial lymphocyte numbers. A significant decrease in mucosal mast cell numbers was detected 6 h after transplantation. They attained only 10% of the number found in the recipients. (3) Time-dependent changes in the graft mucosa revealed that CD163-positive cells increased significantly in the graft mucosa during 6 h after transplantation and reached the level found in the recipients. In contrast, the myeloperoxidase-positive cell population significantly decreased in the graft mucosa within the initial 6 h.

The immediate response of jejunal mucosa to small bowel heterotopic allotransplatation in rats

The course of histopathological alterations within jejunal graft architecture during the initial adaptation phase in the host body was investigated. Graft tissues were compared to the intestinal tissues of the recipients. This study demonstrates: (1) renewal of intestinal epithelial lining in the graft biopsies during initial hours after transplantation is more likely caused by migration and extension of remaining epithelial cells than by their increased mitotic division. (2) Distinct decrease in histopathological injury was observed in transplanted grafts after 6h, but the morphometrical parameters, particularly villus height and wall thickness, remained altered. (3) Significant decrease in apoptotic cell death in the epithelial lining within 6h of graft recirculation was accompanied by no effect on apoptosis levels of the cells in lamina propria connective tissue. (4) Although the apoptosis level in the connective tissue cells was not modulated in the grafts within the first hour after transplantation, caspase-3 dependent apoptosis was decreased significantly.

Intestinal absorption rate in children after small intestinal transplantation

BACKGROUND

Small bowel transplantation has now become a recognized treatment of irreversible, permanent, and subtotal intestinal failure.

OBJECTIVE

The aim of this study was to assess intestinal absorption at the time of weaning from parenteral nutrition in a series of children after intestinal transplantation.

DESIGN

Twenty-four children (age range: 14-115 mo) received intestinal transplantation, together with the liver in 6 children and the colon in 16 children. Parenteral nutrition was slowly tapered while increasing enteral tube feeding. The absorption rate was measured from a 3-d stool balance analysis performed a few days after the child had weaned from parenteral nutrition to exclusive enteral tube feeding. Results were analyzed according to the resting energy expenditure (REE; Schofield formula).

RESULTS

All children were weaned from parenteral nutrition between 31 and 85 d posttransplantation. Median intakes were as follows: energy, 107 kcal · kg(-1) · d(-1) (range: 79-168 kcal · kg(-1) · d(-1)); lipids, 39 kcal · kg(-1) · d(-1) (range: 20-70 kcal · kg(-1) · d(-1)); and nitrogen, 17 kcal · kg(-1) · d(-1) (range: 11-27 kcal · kg(-1) · d(-1)). Median daily stool output was 998 mL/d (range: 220-2025 mL/d). Median absorption rates were 88% (range: 75-96%) for energy, 82% (range: 55-98%) for lipids, and 77% (range: 61-88%) for nitrogen. The ratios for ingested energy to REE and absorbed energy to REE were 2.2 (range: 1.6-3.6) and 1.8 (range: 1.3-3.3), respectively.

CONCLUSION

These data indicate a suboptimal intestinal graft absorption capacity with fat malabsorption, which necessitates energy intakes of at least twice the REE.

Non-occlusive small bowel necrosis in association with feeding jejunostomy after elective upper gastrointestinal surgery

INTRODUCTION

Non-occlusive small bowel necrosis (NOSBN) has been associated with early postoperative enteral feeding. The purpose of this study was to determine the incidence of this complication in an elective upper gastrointestinal (GI) surgical patient population and the influence of both patient selection and type of feeding jejunostomy (FJ) inserted, based on the experience of two surgical units in affiliated hospitals.

PATIENTS AND METHODS

The records were reviewed of 524 consecutive patients who underwent elective upper GI operations with insertion of a FJ for benign or malignant disease between 1997 and 2006. One unit routinely inserted needle catheter jejunostomies (NCJ), whilst the other selectively inserted tube jejunostomies (TJ).

RESULTS

Six cases of NOSBN were identified over 120 months in 524 patients (1.15%), with no difference in incidence between routine NCJ (n = 5; 1.16%) and selective TJ (n = 1; 1.06%). Median rate of feeding at time of diagnosis was 105 ml/h (range, 75-125 ml/h), and diagnosis was made at a median of 6 days (range, 4-18 days) postoperatively. All patients developed abdominal distension, hypotension and tachycardia in the 24 h before re-exploratory laparotomy. Five patients died and one patient survived.

CONCLUSIONS

The understanding of the pathophysiology of NOSBN is still rudimentary; nevertheless, its 1% incidence in the present study does call into question its routine postoperative use especially in those at high risk with an open abdomen, planned repeat laparotomies or marked bowel oedema. Patients should be fully resuscitated before initiating any enteral feeding, and feeding should be interrupted if there is any evidence of feed intolerance.

Nutrition support after intestinal transplantation: how important is enteral feeding?

PURPOSE OF REVIEW

Intestinal transplantation is the alternative treatment in patients with irreversible intestinal failure, who depend on long-term parenteral nutrition. Nutrition management after intestinal transplantation should contribute to reducing the risk of graft rejection, to improving gut trophicity and should optimize nutrient absorption, the main goal being to achieve full intestinal autonomy.

RECENT FINDINGS

Enteral feeding can be administered into the stomach, or directly into the jejunum. Semi-elemental diets are usually used with the aim of improving nutrient absorption and limiting food antigen overload, which might trigger immune stimulation with subsequent increased risk of acute graft rejection. There is no evidence-based reason to use amino acid-based formula. The feeding usually starts with a dilute semi-elemental formula and with a low rate of delivery. The rate and strength of the formula are slowly increased thereafter, according to the individual tolerance. Chylous ascitis and fat malabsorption impair both short-term and long-term nutritional results and are likely to be due to an insufficient reestablishment of the lymphatic circulation of the graft. After an intestinal transplant, patients usually achieve linear growth. However, catch-up growth is rarely observed in stunted patients.

SUMMARY

Nutritional management after intestinal transplantation is challenging and requires a trained, specialized multidisciplinary team.