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Ozata IH, Tufekci T, Aksan T, Eren E, Karahan SN, Kalender M, Gulluoglu YB, Uymaz DS, Ozoran E, Karadag A, Rencuzogullari A, Bugra D, Balik E. Reducing dehydration-induced readmissions post-colorectal surgery: the impact of a prevention bundle. Int J Colorectal Dis 2024; 39:138. [PMID: 39243310 PMCID: PMC11380635 DOI: 10.1007/s00384-024-04709-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2024] [Indexed: 09/09/2024]
Abstract
INTRODUCTION Ileostomy, frequently created after colorectal resections, hinders the physiologic function of the colon and can lead to dehydration and acute kidney injury due to high stoma outputs. This study aimed to evaluate the effectiveness of preventive measures on ileostomy-induced dehydration and related readmissions in a high-volume unit. METHODS In this prospective cohort study at a high-volume colorectal surgery department in Turkiye, the Prospective Ileostomy-induced Dehydration Prevention Bundle Project (PIDBP) was assessed from March 2021 to March 2022. The study enrolled patients undergoing colorectal surgery with ileostomy and involved comprehensive inpatient stoma care, education, and a structured post-discharge follow-up. The follow-up included the "Hydration follow-up scale" to monitor ileostomy output and related complications. The primary outcome was the readmission rate due to dehydration-related complications. The patients receiving the bundle intervention were compared with patients treated in the preceding year, focusing on the effectiveness of interventions such as dietary adjustments, fluid therapy, and pharmacological management. RESULTS In the study, 104 patients were analyzed, divided into 54 pre-bundle and 50 bundle group patients, with no significant differences in patient characteristics. While the overall readmission rate due to dehydration was 12.5%, a significant reduction in dehydration-related readmissions was observed in the bundle group compared to the pre-bundle group (2% vs. 22%, p = 0.002). Univariate analysis identified high stoma output (> 800 ml/24 h) (p < 0.001), chronic renal failure (CRF) (p = 0.01), postoperative ileus (p = 0.03), higher ASA status (p = 0.04), extended hospital stays (p = 0.03), and small bowel resections (especially in J-pouch patients) (p < 0.001) as significant predictors of readmission. Multivariate analysis revealed that the mean ileostomy output before discharge was the sole significant predictor of dehydration-related readmission (OR 1.01), with an optimal cutoff of 877.5 ml/day identified with an area under the curve (AUC) of 0.947, demonstrating high sensitivity (92.3%) and specificity (86.8%) in predicting readmission risk. CONCLUSION The Prospective Ileostomy-induced Dehydration Prevention Bundle Project significantly reduced readmission rates after colorectal surgery.
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Affiliation(s)
- Ibrahim H Ozata
- Department of General Surgery, Koc University School of Medicine, Istanbul, Türkiye.
| | - Tutku Tufekci
- Department of General Surgery, Koc University School of Medicine, Istanbul, Türkiye
| | - Tugce Aksan
- Department of General Surgery, Koc University Hospital, Istanbul, Türkiye
| | - Ecem Eren
- Department of General Surgery, Koc University Hospital, Istanbul, Türkiye
| | - Salih Nafiz Karahan
- Department of General Surgery, Koc University School of Medicine, Istanbul, Türkiye
| | - Mekselina Kalender
- Department of General Surgery, Koc University School of Medicine, Istanbul, Türkiye
| | | | - Derya Salim Uymaz
- Department of General Surgery, Koc University School of Medicine, Istanbul, Türkiye
| | - Emre Ozoran
- Department of General Surgery, Koc University School of Medicine, Istanbul, Türkiye
| | | | - Ahmet Rencuzogullari
- Department of General Surgery, Koc University School of Medicine, Istanbul, Türkiye
| | - Dursun Bugra
- Department of General Surgery, Koc University School of Medicine, Istanbul, Türkiye
- VKF American Hospital, Istanbul, Türkiye
| | - Emre Balik
- Department of General Surgery, Koc University School of Medicine, Istanbul, Türkiye
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Choi D, Ben-Horin S. Editorial: Finger in the dam-A clinical trial of long-acting somatostatin for high-output ostomies and fistulas. Aliment Pharmacol Ther 2024. [PMID: 39225453 DOI: 10.1111/apt.18183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
LINKED CONTENTThis article is linked to de Vries et al papers. To view these articles, visit https://doi.org/10.1111/apt.14136 and https://doi.org/10.1111/apt.18166
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Affiliation(s)
- David Choi
- University of Chicago Medicine Inflammatory Bowel Disease Center, Chicago, Illinois, USA
| | - Shomron Ben-Horin
- Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, University of Tel Aviv, Tel Aviv, Israel
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Timmer AS, de Vries F, Gans SL, Zwanenburg PR, Bemelman WA, Dijkgraaf MGW, Dijkstra G, van der Heide F, Haveman JW, Serlie MJ, Boermeester MA. Clinical trial: The effectiveness of long-acting somatostatin analogue for output reduction of high-output intestinal fistula or small bowel enterostomy. A randomised controlled trial. Aliment Pharmacol Ther 2024; 60:727-736. [PMID: 38993030 DOI: 10.1111/apt.18166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 02/13/2024] [Accepted: 07/04/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND High-output intestinal fistulas and small bowel enterostomies are associated with morbidity and mortality. Current standard treatment for output reduction consists of fluid and dietary restrictions and medical therapy. There is conflicting evidence regarding the use of somatostatin analogues for output reduction. AIM The aim of this study is to investigate whether lanreotide, added to current standard treatment, further reduces intestinal output in patients with high-output fistulas and enterostomies. METHODS This was an open-label, multicentre, randomised controlled trial. Adult patients with a high-output intestinal fistula (>500 mL/24 h) or small bowel enterostomy (>1500 mL/24 h) more than 4 weeks post-surgery and receiving standard medical treatment (dietary- and fluid restriction, PPI, loperamide and codeine) for at least 2 weeks were eligible for inclusion. We randomised patients 1:1 between continuing standard treatment (control), and subcutaneous lanreotide 120 mg every 4 weeks with standard treatment. The primary outcome was the number of responders, with response defined as an output reduction of ≥25%, 8 weeks after randomisation. We also investigated the proportional change in output. RESULTS We randomised 40 patients; 17 had a fistula and 23 a small bowel enterostomy. There were 9/20 responders in the intervention group and 2/20 in the control group (p = 0.013). The proportional output reduction was -26% (IQR -4 to -38) in the intervention group, compared to an increase of 4% (IQR 20 to -13) in the control group (p = 0.004). CONCLUSIONS In patients with a high-output fistula or small bowel enterostomy, addition of lanreotide to current standard treatment can provide a clinically relevant output reduction. TRIAL REGISTRATION EudraCT: 2013-003998-10.
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Affiliation(s)
- Allard S Timmer
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - Fleur de Vries
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Sarah L Gans
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter R Zwanenburg
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Marcel G W Dijkgraaf
- Amsterdam UMC Location University of Amsterdam, Epidemiology and Data Science, Amsterdam, The Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, The Netherlands
| | - Gerard Dijkstra
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frans van der Heide
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan Willem Haveman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mireille J Serlie
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam, The Netherlands
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Solar H, Ortega ML, Gondolesi G. Current Status of Chronic Intestinal Failure Management in Adults. Nutrients 2024; 16:2648. [PMID: 39203785 PMCID: PMC11356806 DOI: 10.3390/nu16162648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 06/25/2024] [Accepted: 07/02/2024] [Indexed: 09/03/2024] Open
Abstract
BACKGROUND Chronic intestinal failure (CIF) is a heterogeneous disease that affects pediatric and adult populations worldwide and requires complex multidisciplinary management. In recent years, many advances in intravenous supplementation support, surgical techniques, pharmacological management, and intestinal transplants have been published. Based on these advances, international societies have published multiple recommendations and guidelines for the management of these patients. The purpose of this paper is to show the differences that currently exist between the recommendations (ideal life) and the experiences published by different programs around the world. METHODS A review of the literature in PubMed from 1980 to 2024 was carried out using the following terms: intestinal failure, CIF, home parenteral nutrition, short bowel syndrome, chronic intestinal pseudo-obstruction, intestinal transplant, enterohormones, and glucagon-like peptide-2. CONCLUSIONS There is a difference between what is recommended in the guidelines and consensus and what is applied in real life. Most of the world's countries are not able to offer all of the steps needed to treat this pathology. The development of cooperative networks between countries is necessary to ensure access to comprehensive treatment for most patients on all continents, but especially in low-income countries.
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Affiliation(s)
- Héctor Solar
- Nutritional Support, Intestinal Rehabilitation and Intestinal Transplant Unit, Hospital Universitario Fundación Favaloro, Buenos Aires C1093AAS, Argentina; (M.L.O.); (G.G.)
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Deleenheer B, Lauwers N, Spriet I, Declercq P, Vanuytsel T. Medication use in a cohort of adults with chronic intestinal failure: A prospective cross-sectional study. Nutr Clin Pract 2024; 39:168-176. [PMID: 37604787 DOI: 10.1002/ncp.11065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/20/2023] [Accepted: 07/23/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Oral drug therapy may be compromised in chronic intestinal failure (IF) because of alterations in absorption and transit. Only scarce literature is available on which medication patients with chronic IF take in daily life. The aim was to describe the medication use in these patients. METHODS A medication history was obtained from adults with chronic IF treated in our tertiary care IF center. Degree of polypharmacy, drug classes, Biopharmaceutics Classification System classes, route of administration, and formulation of drugs were analyzed. RESULTS From October 2019 until December 2020, 72 patients (35 patients with short bowel syndrome [SBS] and 37 patients without SBS) were included. Polypharmacy was seen in 85.7% of patients with SBS and 75.7% of patients without SBS. The top three drug classes were proton-pump inhibitors, vitamin D or acetaminophen, and antimotility medication or laxatives/benzodiazepines. Approximately 25% of the drugs were classified as Biopharmaceutics Classification System class I drugs. In patients with SBS (78%) and patients without SBS (74.9%), most medication was taken orally, requiring gastrointestinal absorption of the active substance to be pharmacologically active. Most of these medications (77% in patients with SBS and 80.8% in patients without SBS) were formulated as a capsule or tablet, requiring disintegration and dissolution in the gastrointestinal tract before absorption can take place. CONCLUSION Polypharmacy was observed in most patients with chronic IF. Most medication was taken orally in formulations requiring disintegration, dissolution, and gastrointestinal absorption, which could be compromised in chronic IF.
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Affiliation(s)
- Barbara Deleenheer
- Pharmacy Division, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism-Translational Research in Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
- Leuven Intestinal Failure and Transplantation (LIFT), University Hospitals Leuven, Leuven, Belgium
| | - Nathalie Lauwers
- Leuven Intestinal Failure and Transplantation (LIFT), University Hospitals Leuven, Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Division, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Peter Declercq
- Pharmacy Division, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Department of Chronic Diseases and Metabolism-Translational Research in Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
- Leuven Intestinal Failure and Transplantation (LIFT), University Hospitals Leuven, Leuven, Belgium
- Division of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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Stoop TF, van Bodegraven EA, Ten Haaft BHEA, van Etten-Jamaludin FS, van Zundert SMC, Lambe C, Tabbers MM, Gorter RR. Systematic review on management of high-output enterostomy in children: An urgent call for evidence. J Pediatr Gastroenterol Nutr 2024; 78:188-196. [PMID: 38374570 DOI: 10.1002/jpn3.12043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 10/24/2023] [Accepted: 10/29/2023] [Indexed: 02/21/2024]
Abstract
OBJECTIVES/BACKGROUND High-output stoma is one of the most common major morbidities in young children with an enterostomy that could lead to intestinal failure. Management of high-output enterostomy in children is mostly based on personal experience. This systematic review aims to clarify the evidence-based therapeutic approach of high-output enterostomy in children. METHODS A systematic review was performed using Pubmed, Embase (Ovid), and Cochrane Library to identify studies published until March 20, 2023, following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. The study population comprised children (i.e., age <18 years) with high-output enterostomy (i.e., jejuno-, ileo-, and/or colostomy), regardless of underlying aetiology. Interventions comprised any (non)pharmacological and/or surgical treatment. Interventions were compared with each other, placebos, and/or no interventions. Primary outcome was reduction of enterostomy output. Secondary outcomes were morbidity, mortality, quality of life, associated healthcare costs, and adverse events. RESULTS The literature search identified 4278 original articles of which 366 were screened on full text, revealing that none of the articles met the inclusion criteria. CONCLUSION This first systematic review on management of high-output enterostomy in children revealed that any evidence on the primary and secondary outcomes is lacking. There is an urgent need for evidence on conservative treatment strategies including fluid restrictions, dietary advices, oral rehydration solution, chyme re-infusion, and pharmacological and surgical treatments of high-output enterostomy in children, aiming to reduce the risk for short- and long-term complications. Till more evidence is available, a systematic and multidisciplinary step-up approach is needed. Therefore, a therapeutic work-up is proposed that could guide the care.
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Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, Location University of Amsterdam, Pediatric Surgical Center of Amsterdam, Emma Children's Hospital, Department of Pediatric Surgery, Amsterdam, The Netherlands
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Eduard A van Bodegraven
- Amsterdam UMC, Location University of Amsterdam, Pediatric Surgical Center of Amsterdam, Emma Children's Hospital, Department of Pediatric Surgery, Amsterdam, The Netherlands
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Britte H E A Ten Haaft
- Amsterdam UMC, Location University of Amsterdam, Pediatric Surgical Center of Amsterdam, Emma Children's Hospital, Department of Pediatric Surgery, Amsterdam, The Netherlands
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Suzanne M C van Zundert
- Amsterdam UMC, Location University of Amsterdam, Department of Nutrition and Dietetics, Amsterdam, The Netherlands
| | - Cécile Lambe
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Merit M Tabbers
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ramon R Gorter
- Amsterdam UMC, Location University of Amsterdam, Pediatric Surgical Center of Amsterdam, Emma Children's Hospital, Department of Pediatric Surgery, Amsterdam, The Netherlands
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Pironi L, Cuerda C, Jeppesen PB, Joly F, Jonkers C, Krznarić Ž, Lal S, Lamprecht G, Lichota M, Mundi MS, Schneider SM, Szczepanek K, Van Gossum A, Wanten G, Wheatley C, Weimann A. ESPEN guideline on chronic intestinal failure in adults - Update 2023. Clin Nutr 2023; 42:1940-2021. [PMID: 37639741 DOI: 10.1016/j.clnu.2023.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 08/31/2023]
Abstract
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.
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Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Center for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy.
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Francisca Joly
- Center for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Cora Jonkers
- Nutrition Support Team, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Željko Krznarić
- Center of Clinical Nutrition, Department of Medicine, University Hospital Center, Zagreb, Croatia
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, United Kingdom
| | | | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), United Kingdom
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany
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Lakananurak N, Wall E, Catron H, Delgado A, Greif S, Herlitz J, Moccia L, Mercer D, Vanuytsel T, Kumpf V, Berner-Hansen M, Gramlich L. Real-World Management of High Stool Output in Patients with Short Bowel Syndrome: An International Multicenter Survey. Nutrients 2023; 15:2763. [PMID: 37375667 DOI: 10.3390/nu15122763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/07/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND International practice guidelines for high-stool-output (HSO) management in short bowel syndrome (SBS) are available, but data on implementation are lacking. This study describes the approach used to manage HSO in SBS patients across different global regions. METHODS This is an international multicenter study evaluating medical management of HSO in SBS patients using a questionnaire survey. Thirty-three intestinal-failure centers were invited to complete the survey as one multidisciplinary team. RESULTS Survey response rate was 91%. Dietary recommendations varied based on anatomy and geographic region. For patients without colon-in-continuity (CiC), clinical practices were generally consistent with ESPEN guidelines, including separation of fluid from solid food (90%), a high-sodium diet (90%), and a low-simple-sugar diet (75%). For CiC patients, practices less closely followed guidelines, such as a low-fat diet (35%) or a high-sodium diet (50%). First-line antimotility and antisecretory medications were loperamide and proton-pump inhibitors. Other therapeutic agents (e.g., pancreatic enzymes and bile acid binders) were utilized in real-world practices, and usage varied based on intestinal anatomy. CONCLUSION Expert centers largely followed published HSO-management guidelines for SBS patients without CiC, but clinical practices deviated substantially for CiC patients. Determining the reasons for this discrepancy might inform future development of practice guidelines.
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Affiliation(s)
- Narisorn Lakananurak
- Division of Clinical Nutrition, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Elizabeth Wall
- Clinical Nutrition, University of Chicago Medicine, Chicago, IL 60637, USA
| | - Hilary Catron
- College of Allied Health, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Adela Delgado
- Royal Alexandra Hospital, Alberta Health Services, Edmonton, AB T5H 3V9, Canada
| | - Sophie Greif
- Department of Hepatology and Gastroenterology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, 10117 Berlin, Germany
| | - Jean Herlitz
- Clinical Nutrition, University of Chicago Medicine, Chicago, IL 60637, USA
| | - Lisa Moccia
- Center for Human Nutrition, Cleveland Clinic, Cleveland, OH 44195, USA
| | - David Mercer
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Tim Vanuytsel
- Gastroenterology and Hepatology, Katholieke Universiteit Leuven, 3000 Leuven, Belgium
| | - Vanessa Kumpf
- Center for Human Nutrition, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Mark Berner-Hansen
- Digestive Disease Center K, Bispebjerg University Hospital of Copenhagen, 2400 Copenhagen, Denmark
- Zealand Pharma, 2860 Soeborg, Denmark
| | - Leah Gramlich
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T5B 4E4, Canada
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9
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DiBaise JK. Short bowel syndrome: Recognizing unmet needs. Nutr Clin Pract 2023; 38 Suppl 1:S4-S8. [PMID: 37115035 DOI: 10.1002/ncp.10948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/05/2022] [Indexed: 04/29/2023] Open
Affiliation(s)
- John K DiBaise
- Division of Gastroenterology and Hepatology, Mayo Clinic in Arizona, Scottsdale, Arizona, USA
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10
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Bering J, DiBaise JK. Short bowel syndrome: Complications and management. Nutr Clin Pract 2023; 38 Suppl 1:S46-S58. [PMID: 37115034 DOI: 10.1002/ncp.10978] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 04/29/2023] Open
Abstract
Short bowel syndrome (SBS) occurs when a patient loses bowel length or function significantly enough to cause malabsorption, oftentimes requiring lifelong parenteral support. In adults, this occurs most commonly in the setting of massive intestinal resection, whereas congenital anomalies and necrotizing enterocolitis predominate in children. Many patients with SBS develop long-term clinical complications over time related to their altered intestinal anatomy and physiology or to various treatment interventions such as parenteral nutrition and the central venous catheter through which it is administered. Identifying, preventing, and treating these complications can be challenging. This review will focus on the diagnosis, treatment, and prevention of several complications that can occur in this patient population, including diarrhea, fluid and electrolyte imbalance, vitamin and trace element derangements, metabolic bone disease, biliary disorders, small intestinal bacterial overgrowth, d-lactic acidosis, and complications of central venous catheters.
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Affiliation(s)
- Jamie Bering
- Division of Gastroenterology and Hepatology, Mayo Clinic in Arizona, Scottsdale, Arizona, USA
| | - John K DiBaise
- Division of Gastroenterology and Hepatology, Mayo Clinic in Arizona, Scottsdale, Arizona, USA
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11
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Wauters L, Joly F. Treatment of short bowel syndrome: Breaking the therapeutic ceiling? Nutr Clin Pract 2023; 38 Suppl 1:S76-S87. [PMID: 37115030 DOI: 10.1002/ncp.10974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/26/2023] [Accepted: 02/04/2023] [Indexed: 04/29/2023] Open
Abstract
Short bowel syndrome (SBS) is the most common cause of chronic intestinal failure, requiring home parenteral support (intravenous fluid, parenteral nutrition, or parenteral nutrition with intravenous fluid) to compensate for severe malabsorption. The loss of mucosal absorptive area after extensive intestinal resection is accompanied by an accelerated transit and hypersecretion. Changes in physiology and clinical outcomes differ between patients with SBS with or without the distal ileum and/or colon-in-continuity. This narrative review summarizes the treatments used in SBS, with a focus on novel approaches with intestinotrophic agents. During the early postoperative years, spontaneous adaptation occurs and can be induced or accelerated with conventional therapies, which include dietary and fluid modifications and antidiarrheal and antisecretory drugs. Based on the proadaptive role of enterohormones (eg, glucagon-like peptide [GLP]-2), analogues have been developed to allow enhanced or hyperadaptation after a period of stabilization. Teduglutide is the first GLP-2 analogue developed and commercialized with proadaptive effects resulting in reduced parenteral support needs; however, the potential for weaning of parenteral support is variable. Whether early treatment with enterohormones or accelerated hyperadaptation would further improve absorption and outcomes remains to be shown. Longer-acting GLP-2 analogues are currently being investigated. Encouraging reports with GLP-1 agonists require confirmation in randomized trials, and dual GLP-1 and GLP-2 analogues have yet to be clinically investigated. Future studies will prove whether the timing and/or combinations of different enterohormones will be able to break the ceiling of intestinal rehabilitation in SBS.
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Affiliation(s)
- Lucas Wauters
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Gastroenterology and Nutrition Support, Assistance Publique des Hopitaux de Paris, University of Paris, Clichy, France
| | - Francisca Joly
- Department of Gastroenterology and Nutrition Support, Assistance Publique des Hopitaux de Paris, University of Paris, Clichy, France
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Timmer AS, Claessen JJM, Boermeester MA. Risk Factor-Driven Prehabilitation Prior to Abdominal Wall Reconstruction to Improve Postoperative Outcome. A Narrative Review. JOURNAL OF ABDOMINAL WALL SURGERY : JAWS 2022; 1:10722. [PMID: 38314165 PMCID: PMC10831687 DOI: 10.3389/jaws.2022.10722] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/31/2022] [Indexed: 02/06/2024]
Abstract
All abdominal wall reconstructions find themselves on a scale, varying between simple to highly complex procedures. The level of complexity depends on many factors that are divided into patient comorbidities, hernia characteristics, and wound characteristics. Preoperative identification of modifiable risk factors provides the opportunity for patient optimization. Because this so called prehabilitation greatly improves postoperative outcome, reconstructive surgery should not be scheduled before all modifiable risk factors are optimized to a point where no further improvement can be expected. In this review, we discuss the importance of preoperative risk factor recognition, identify modifiable risk factors, and utilize options for patient prehabilitation, all aiming to improve postoperative outcome and therewith long-term success of the reconstruction.
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Affiliation(s)
- Allard S. Timmer
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam, Netherlands
| | - Jeroen J. M. Claessen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam, Netherlands
| | - Marja A. Boermeester
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam, Netherlands
- Amsterdam Institute for Infection and Immunity, Amsterdam, Netherlands
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Aksan A, Farrag K, Blumenstein I, Schröder O, Dignass AU, Stein J. Chronic intestinal failure and short bowel syndrome in Crohn’s disease. World J Gastroenterol 2021; 27:3440-3465. [PMID: 34239262 PMCID: PMC8240052 DOI: 10.3748/wjg.v27.i24.3440] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 01/24/2021] [Accepted: 03/08/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic intestinal failure (CIF) is a rare but feared complication of Crohn’s disease. Depending on the remaining length of the small intestine, the affected intestinal segment, and the residual bowel function, CIF can result in a wide spectrum of symptoms, from single micronutrient malabsorption to complete intestinal failure. Management of CIF has improved significantly in recent years. Advances in home-based parenteral nutrition, in particular, have translated into increased survival and improved quality of life. Nevertheless, 60% of patients are permanently reliant on parenteral nutrition. Encouraging results with new drugs such as teduglutide have added a new dimension to CIF therapy. The outcomes of patients with CIF could be greatly improved by more effective prevention, understanding, and treatment. In complex cases, the care of patients with CIF requires a multidisciplinary approach involving not only physicians but also dietitians and nurses to provide optimal intestinal rehabilitation, nutritional support, and an improved quality of life. Here, we summarize current literature on CIF and short bowel syndrome, encompassing epidemiology, pathophysiology, and advances in surgical and medical management, and elucidate advances in the understanding and therapy of CIF-related complications such as catheter-related bloodstream infections and intestinal failure-associated liver disease.
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Affiliation(s)
- Aysegül Aksan
- Institute of Nutritional Sciences, Justus-Liebig-Universität, Giessen 35392, Germany
- Department of Clinical Research, Interdisziplinäres Crohn Colitis Centrum Rhein-Main, Frankfurt am Main 60594, Germany
| | - Karima Farrag
- Department of Clinical Research, Interdisziplinäres Crohn Colitis Centrum Rhein-Main, Frankfurt am Main 60594, Germany
- Department of Gastroenterology and Clinical Nutrition, DGD Kliniken Sachsenhausen, Teaching Hospital of the JW Goethe University, Frankfurt am Main 60594, Germany
| | - Irina Blumenstein
- Department of Gastroenterology, Hepatology and Clinical Nutrition, First Medical Clinic, JW Goethe University Hospital, Frankfurt am Main 60529, Germany
| | - Oliver Schröder
- Department of Clinical Research, Interdisziplinäres Crohn Colitis Centrum Rhein-Main, Frankfurt am Main 60594, Germany
- Department of Gastroenterology and Clinical Nutrition, DGD Kliniken Sachsenhausen, Teaching Hospital of the JW Goethe University, Frankfurt am Main 60594, Germany
| | - Axel U Dignass
- Department of Medicine I, Agaplesion Markus Hospital, Goethe-University, Frankfurt am Main 60431, Germany
| | - Jürgen Stein
- Department of Clinical Research, Interdisziplinäres Crohn Colitis Centrum Rhein-Main, Frankfurt am Main 60594, Germany
- Department of Gastroenterology and Clinical Nutrition, DGD Kliniken Sachsenhausen, Teaching Hospital of the JW Goethe University, Frankfurt am Main 60594, Germany
- Institute of Pharmaceutical Chemistry, JW Goethe University, 60438 Frankfurt am Main, Germany
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Abstract
INTRODUCTION Short bowel syndrome (SBS) is a rare, highly disabling, life-threatening condition due to extensive intestinal resections, characterized by diarrhea, malabsorption, and malnutrition. SBS is the main cause of intestinal failure (SBS-IF). The primary therapy for SBS-IF is intravenous supplementation (IVS) of nutrients. The pharmacological therapy aims to improve the remnant bowel function, leading to the decrease of IVS requirement. AREAS COVERED This review provides a safety perspective and discusses unmet clinical needs on pharmacotherapy for SBS, ranging from symptomatic agents traditionally used off-label to manage hypersecretion and diarrhea, to curative drugs with selective intestinotrophic properties. Real-world evidence on symptomatic drugs is lacking. Data on teduglutide - the first-in-class glucagon-like peptide-2 (GLP-2) receptor agonist approved in SBS - are mainly derived from clinical trials, with several unsettled safety issues, including the risk of malignancies. EXPERT OPINION Defining the long-term safety of drugs used for SBS is a priority; a unified list of commonly used drugs with consolidated proof of effectiveness is needed to harmonize the symptomatic pharmacological approach to SBS. GLP-2 receptor agonists are a promising curative pharmaco-therapeutic approach, although long-term safety and effectiveness deserve further real-world assessment. Pharmacovigilance and global data sharing are crucial to support safe prescribing in SBS.
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de Vries FEE, Claessen JJM, van Hasselt-Gooijer EMS, van Ruler O, Jonkers C, Kuin W, van Arum I, van der Werf GM, Serlie MJ, Boermeester MA. Bridging-to-Surgery in Patients with Type 2 Intestinal Failure. J Gastrointest Surg 2021; 25:1545-1555. [PMID: 32700102 PMCID: PMC8203517 DOI: 10.1007/s11605-020-04741-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 07/07/2020] [Indexed: 01/31/2023]
Abstract
AIM Type 2 intestinal failure (IF) is characterized by the need for longer-term parenteral nutrition (PN). During this so-called bridging-to-surgery period, morbidity and mortality rates are high. This study aimed to evaluate to what extent a multidisciplinary IF team is capable to safely guide patients towards reconstructive surgery. METHODS A consecutive series of patients with type 2 IF followed up by a specialized IF team between January 1st, 2011, and March 1st, 2016, was analyzed. Data on their first outpatient clinic visit (T1) and their last visit before reconstructive surgery (T2) was collected. The primary outcome was a combined endpoint of a patient being able to recover at home, have (partial) oral intake, and a normal albumin level (> 35 g/L) before surgery. RESULTS Ninety-three patients were included. The median number of previous abdominal procedures was 4. At T2 (last visit prior to reconstructive surgery), significantly more patients met the combined primary endpoint compared with T1 (first IF team consultation) (66.7% vs. 28.0% (p < 0.0001), respectively); 86% had home PN. During "bridging-to-surgery," acute hospitalization rate was 40.9% and acute surgery was 4.3%. Postoperatively, 44.1% experienced a major complication, 5.4% had a fistula, and in-hospital mortality was 6.5%. Of the cohort, 86% regained enteral autonomy, and when excluding in-hospital mortality and incomplete follow-up, this was 94.1%. An albumin level < 35 g/L at T2 and weight loss of > 10% at T2 compared with preadmission weight were significant risk factors for major complications. CONCLUSION Bridging-to-surgery of type 2 IF patients under the guidance of an IF team resulted in the majority of patients being managed at home, having oral intake, and restored albumin levels prior to reconstructive surgery compared with their first IF consultation.
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Affiliation(s)
- Fleur E. E. de Vries
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam University Medical Centers, location AMC, Postbox 22660, 1100 DD Amsterdam, The Netherlands
| | - Jeroen J. M. Claessen
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam University Medical Centers, location AMC, Postbox 22660, 1100 DD Amsterdam, The Netherlands
| | - Elina M. S. van Hasselt-Gooijer
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam University Medical Centers, location AMC, Postbox 22660, 1100 DD Amsterdam, The Netherlands
| | - Oddeke van Ruler
- grid.414559.80000 0004 0501 4532Department of Surgery, IJsselland Ziekenhuis, Capelle a/d IJssel, The Netherlands
| | - Cora Jonkers
- grid.509540.d0000 0004 6880 3010Nutrition Support Team, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Wanda Kuin
- grid.509540.d0000 0004 6880 3010Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Irene van Arum
- grid.509540.d0000 0004 6880 3010Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - G. Miriam van der Werf
- grid.509540.d0000 0004 6880 3010Nutrition Support Team, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Mireille J. Serlie
- grid.509540.d0000 0004 6880 3010Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Marja A. Boermeester
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam University Medical Centers, location AMC, Postbox 22660, 1100 DD Amsterdam, The Netherlands
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Patient characteristics and clinical outcomes in a specialised intestinal failure unit: An observational cohort study. Clin Nutr ESPEN 2020; 38:253-262. [DOI: 10.1016/j.clnesp.2020.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/07/2020] [Indexed: 12/20/2022]
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Hollanda Martins Da Rocha M, Lee ADW, Marin MLDM, Faintuch S, Mishaly A, Faintuch J. Treating short bowel syndrome with pharmacotherapy. Expert Opin Pharmacother 2020; 21:709-720. [DOI: 10.1080/14656566.2020.1724959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Mariana Hollanda Martins Da Rocha
- Clinical nutrition multidisciplinary team (MDT), Hospital das Clinicas, Sao Paulo, Brazil
- Head, Short bowel syndrome MDT, Hospital das Clinicas, Sao Paulo, Brazil
| | - André Dong Won Lee
- Clinical nutrition multidisciplinary team (MDT), Hospital das Clinicas, Sao Paulo, Brazil
- Liver and Digestive Organs Transplantation Service, Hospital das Clinicas, Department of Gastroenterology, Hospital das Clinicas, Sao Paulo, Brazil
| | - Marcia Lucia De Mario Marin
- Clinical nutrition multidisciplinary team (MDT), Hospital das Clinicas, Sao Paulo, Brazil
- Research Unit, Central Pharmacy, Hospital das Clinicas, Sao Paulo, Brazil
| | - Salomao Faintuch
- Clinical Director, Vascular and Interventional Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Asher Mishaly
- Medical Student, Americas Faculty of Medicine, Sao Paulo, Brazil
| | - Joel Faintuch
- Department of Gastroenterology, Hospital das Clinicas and Sao Paulo University Medical School, Sao Paulo, Brazil
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Carrott P, Pearlman M, Allen K, Suwanabol P. Disease-Specific Diets in Surgical Diseases. CURRENT SURGERY REPORTS 2018. [DOI: 10.1007/s40137-018-0214-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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