[Practical guideline for short bowel syndrome]

Short bowel syndrome is a rare complex disease that mainly develops due to extensive bowel resections and can lead to chronic intestinal failure. Due to the decreased intestinal surface absorption of macronutrient, micronutrient and/or fluids is reduced. Correspondingly manifold symptoms arise as diarrhoea, weight loss, vitamin deficiencies, chronic kidney disease, hepatopathy and others with great impact on quality of life of patients. Therapy is complex and needs interdisciplinary collaboration between dieticians, gastroenterologists, surgeons and also a dense monitoring of general practitioners. Commonly patients need permanent home-parenteral support. Therapies have to be decided individually and have to be reviewed regularly for effectivity and side effects. Furthermore, periodic monitoring of several clinical and laboratory tests should be performed. Morbidity and mortality of this disease complex is high and lead by appearance and management of complications. This practical guide should give an overview about the disease, diagnostics and management and should enable the best possible care of these complex patients.

The Natural History of Crohn's Disease Leading to Intestinal Failure: A Longitudinal Cohort Study from 1973 to 2018

BACKGROUND AND AIMS

The natural history of Crohn's disease leading to intestinal failure is not well characterised. This study aims to describe the clinical course of Crohn's disease preceding intestinal failure and to compare disease course and burden between Crohn's disease patients with and without intestinal failure.

METHODS

Patients with Crohn's disease complicated by intestinal failure from Rigshospitalet, Copenhagen [n = 182] and a nationwide Danish Crohn's disease cohort without intestinal failure [n = 22,845] were included. Using nationwide registries in Denmark, disease course was determined from hospitalisations, surgeries, and outpatient medications, and disease burden was determined from employment and mortality data.

RESULTS

The 10-year cumulative incidence of intestinal failure following Crohn's disease diagnosis declined from 2.7% prior to 1980 to 0.2% after 2000. Compared with Crohn's disease patients without intestinal failure, those with intestinal failure experienced significantly longer duration of severe disease [50 vs 19 years per 100 patient-years, p < 0.01], secondary to greater corticosteroid use [71% vs 60%, p = 0.02], inpatient contacts [98% vs 55%, p < 0.01], and abdominal surgeries [99% vs 48%, p < 0.01]. However, exposure to biologics was not different between the two groups [20.4% vs 21%, p = 0.95], and duration on biologics was shorter in Crohn's disease patients with intestinal failure [2068 vs 4126 days per 100 patient-years, p = 0.02]. Standard mortality ratio in Crohn's disease patients with intestinal failure was 3.66 (97.5% confidence interval [CI] 2.79, 4.72].

CONCLUSION

Patients with Crohn's disease complicated by intestinal failure experienced a more persistently severe preceding course of Crohn's disease but were not more likely to be treated with biological therapy.

Gut instinct: Navigating the landscape of parenteral support in short bowel syndrome

Depending on the remaining bowel anatomy and the degree of bowel adaptation, patients with short bowel syndrome (SBS) may require parenteral nutrition (PN) and/or intravenous fluid support, sometimes temporarily and sometimes permanently. Although the use of parenteral support in SBS is often lifesaving, it is not without its limitations. Herein, we undertake a focused review of several issues related to use of parenteral support in patients with SBS, including initiation of parenteral support, considerations when formulating PN, select complications, short-term and long-term nutrition monitoring, and weaning strategies.

Funding and resource availability for home parenteral nutrition in Australia: A national cross-sectional survey

BACKGROUND

Home parenteral nutrition (HPN) is a life-saving therapy required for the management of type III intestinal failure, one of the rarest organ failures. It requires a multidisciplinary approach to manage the complexity of the underlying medical, surgical, and nutrition issues, but the current levels of healthcare funding in Australia are unknown. This study aimed to quantify the caseload, staffing, and capacity of existing HPN centers nationally.

METHODS

This was a cross-sectional survey inviting centers known to provide HPN care. The survey was designed to capture metrics related to the national framework for the delivery of HPN. These centered on staffing levels, patient load, capacity to audit key outcomes, and service challenges.

RESULTS

A total of 24 (89%) of 27 invited centers responded to the survey. There were 17 (71%) adult centers and 7 (29%) pediatric centers. Adult centers managed a median of 12 (interquartile range [IQR]: 6-25) patients vs 16 (IQR: 9-17) in pediatric centers. Several centers did not have dedicated funding for core team members. The total funded clinician time each week per patient was 7 min (IQR: 0-12 min) in adult centers and 14 min (IQR: 10-21 min) in pediatric centers. Fewer than half of centers reported having sufficient resources to regularly audit key metrics.

CONCLUSION

The availability of dedicated expertise to manage the highly complex needs of people living with type III intestinal failure is lacking in Australia. Current funding of HPN services falls well short of being sufficient to meet the requirements outlined in the national quality framework.

A Systematic Review of Quality of Life in Patients with Short Bowel Syndrome and Their Caregivers

Purpose

Understanding the quality of life and the factors that influence it for patients with short bowel syndrome (SBS) and their caregivers is of utmost importance in order to enhance their well-being. Therefore, This study aimed to provide a comprehensive understanding of the impact of SBS on patients and their caregivers, as well as its associated factors, by synthesizing the available evidence.

Methods

A systematic review of the literature was done using PubMed, Embase databases, CNKI, and ISPOR conference papers. Included articles were manually searched to identify any other relevant studies. Quality was assessed using appropriate Joanna Briggs Institute critical appraisal tools.

Results

This review included 16 studies, comprising 15 observational studies and 1 randomized controlled trial. The findings revealed that the QoL of patients with SBS was lower than that of the general population regarding physical functioning and psychological domain. Meanwhile, caregivers experienced challenges in maintaining their QoL. The QoL of SBS patients was found to be influenced by various factors such as treatment, age, sex, stoma, and small intestine length. Among them, the treatment is the most noteworthy factor that can be effectively improved through external interventions.

Conclusion

While numerous studies have provided insights into the compromised QoL experienced by individuals with SBS and their caregivers, there remains a scarcity of large-sample quantitative investigations examining the determinants of QoL. The existing body of literature on caregivers is also notably deficient.

Use of teduglutide in adults with short bowel syndrome-associated intestinal failure

Short bowel syndrome (SBS) is a rare gastrointestinal disorder associated with intestinal failure (SBS-IF) and poor health-related outcomes. Patients with SBS-IF are unable to absorb sufficient nutrients or fluids to maintain significantly metabolic homeostasis via oral or enteral intake alone and require long-term intravenous supplementation (IVS), consisting of partial or total parenteral nutrition, fluids, electrolytes, or a combination of these. The goal of medical and surgical treatment for patients with SBS-IF is to maximize intestinal remnant absorptive capacity so that the need for IVS support may eventually be reduced or eliminated. Daily subcutaneous administration of the glucagon-like peptide 2 analog, teduglutide, has been shown to be clinically effective in reducing IVS dependence and potentially improving the health-related quality of life of patients with SBS-IF. The management of patients with SBS-IF is complex and requires close monitoring. This narrative review discusses the use of teduglutide for patients with SBS-IF in clinical practice. The screening of patient eligibility for teduglutide treatment, initiation, monitoring of efficacy and safety of treatment, adapting or weaning off IVS, and the healthcare setting needed for SBS-IF management are described, taking into consideration data from clinical trials, observational studies, and clinical experience.

Metabolic and Nutritional Issues after Lower Digestive Tract Surgery: The Important Role of the Dietitian in a Multidisciplinary Setting

Many patients undergo small bowel and colon surgery for reasons related to malignancy, inflammatory bowel disease (IBD), mesenteric ischemia, and other benign conditions, including post-operative adhesions, hernias, trauma, volvulus, or diverticula. Some patients arrive in the operating theatre severely malnourished due to an underlying disease, while others develop complications (e.g., anastomotic leaks, abscesses, or strictures) that induce a systemic inflammatory response that can increase their energy and protein requirements. Finally, anatomical and functional changes resulting from surgery can affect either nutritional status due to malabsorption or nutritional support (NS) pathways. The dietitian providing NS to these patients needs to understand the pathophysiology underlying these sequelae and collaborate with other professionals, including surgeons, internists, nurses, and pharmacists. The aim of this review is to provide an overview of the nutritional and metabolic consequences of different types of lower gastrointestinal surgery and the role of the dietitian in providing comprehensive patient care. This article reviews the effects of small bowel resection on macronutrient and micronutrient absorption, the effects of colectomies (e.g., ileocolectomy, low anterior resection, abdominoperineal resection, and proctocolectomy) that require special dietary considerations, nutritional considerations specific to ostomized patients, and clinical practice guidelines for caregivers of patients who have undergone a surgery for local and systemic complications of IBD. Finally, we highlight the valuable contribution of the dietitian in the challenging management of short bowel syndrome and intestinal failure.

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.

Management of short-bowel syndrome: A survey of unmet educational needs among healthcare providers

BACKGROUND

Management of short-bowel syndrome with intestinal failure (SBS-IF) is complex and requires a multidisciplinary approach. Because of the rarity of SBS-IF, healthcare professionals (HCPs) often lack clinical experience with the disease and may benefit from education regarding SBS-IF and its management. This study identified unmet educational needs related to the management of patients with SBS-IF.

METHODS

This was a prospective, web-based survey (December 2019-January 2020) in which a series of clinical questions were posed to US HCPs after presenting three standardized SBS-IF cases to assess current practice patterns. HCPs were then asked a series of questions to identify potential knowledge gaps and unmet educational needs relating to SBS-IF management.

RESULTS

Overall, 558 HCPs completed the survey, with 12%-38% having a formal SBS-IF multidisciplinary team currently available to make treatment decisions within their institution. Clinicians involved in care included gastroenterologists (93%), registered dietitians (79%), gastroenterology nurse practitioners and physician assistants (37%), registered nurses (43%), social workers (45%), and psychologists/psychiatrists (27%). There was underuse of published guidelines and limited understanding of the course of intestinal adaptation. Responses to the clinical scenarios highlighted disparities in SBS-IF care delivery, including diagnosis, management goals, medications prescribed, and nutrition practices.

CONCLUSIONS

Future SBS-IF educational interventions for HCPs should aim to improve awareness and understanding of the disease, facilitate timely diagnosis, and standardize management practices to ensure patients receive optimal interdisciplinary care as widely as possible.

First Registry of Adult Patients with Chronic Intestinal Failure due to Short Bowel Syndrome in Argentina, the RESTORE Project

BACKGROUND

Short-bowel syndrome (SBS) is considered a low prevalence disease. In Argentina, no registries are available on chronic intestinal failure (CIF) and SBS. This project was designed as the first national registry to report adult patients with this disease.

METHODS

A prospective multicenter observational registry was created including adult patients with CIF/SBS from 8/12 approved centers. Demographics, clinical characteristics, nutritional assessment, home-parenteral-nutrition (HPN) management plus complications, surgeries performed, medical treatment, overall survival, and freedom from HPN survival were analyzed.

RESULTS

Of the 61 enrolled patients, 56 with available follow up data were analyzed. At enrollment, the mean intestinal length was 59.5±47.3cms; the anatomy was: type 1 (n=41), type 2 (n=10), and type 3 (n=5). At the end of the interim analysis, anatomy changed to type 1 in 31, type 2 in 17, and type 3 in 8 patients. The overall mean time on HPN before enrollment was 33.5±56.2 months. Autologous gastrointestinal-reconstruction surgery was performed before enrollment on 21 patients, and afterward on 11. Nine patients (16.1%) were weaned-off HPN with standard medical-nutritional treatment; 12 patients received enterohormones, and 2 of them suspended HPN; 1 was considered a transplant candidate. In 23.7±14.5 months, 11 out of 56 patients discontinued HPN; Kaplan-Meier freedom from HPN survival was 28.9%. The number of cases collected represented 19.6 new adult CIF/SBS patients/year.

CONCLUSIONS

The RESTORE project allowed us to know the incidence, the current medical and surgical management of this pathology, as well as its outcome and complications related with the therapeutic approach currently available.

CLINICAL RELEVANCY STATEMENT

RESTORE is the first ongoing prospective, observational, epidemiological, multicenter registry of adult patients with chronic intestinal failure (CIF) due to short bowel syndrome (SBS) in Argentina. The interim analysis enabled an estimate of the incidence of adult CIF/SBS of 19.6 new adult CIF/SBS patients/year in our country and would serve for a better understanding of the current care provided, the manner to continue improving that condition, the current treatment outcomes, and a more accurate definition of the national needs. This article is protected by copyright. All rights reserved.

Severe Short Bowel Syndrome: Prognosis for Nutritional Independence Through Management by a Multidisciplinary Nutrition Service and Surgery

INTRODUCTION

Short bowel syndrome (SBS) is a debilitating condition associated with significant morbidity and mortality. Historically, SBS patients require indefinite parenteral nutrition (PN) and endure lifelong nutritional challenges. The purpose of this study was to review the outcomes, specifically nutritional independence, of a multidisciplinary nutrition service.

METHODS

A retrospective analysis of SBS patients followed by our surgical nutrition service was performed. Patients without 1-year follow-up were excluded. Demographics and nutritional parameters were collected at 4 intervals: initial presentation, 1-year, 2-year, and 5-year follow-up. Short bowel syndrome anatomical subtypes identified through operative reports were characterized as end jejunostomy, jejunocolonic, or jejuno-ileocolonic with ileo-cecal valve intact. Intestinal failure was defined by the requirement of PN, while intestinal insufficiency was defined by enteral support requirement. Clinical outcomes examined included mortality, fistula closure, and nutritional independence.

RESULTS

The study cohort comprised 89 patients, 50 of whom had ≤ 100 cm intestinal length. Mean age was 57 ± 17y, 55 (62%) were female, and median initial intestinal length was 77 [60-120] cm. Short bowel syndrome was complicated by fistulas in 47 (53%) of patients. Overall mortality was 13%, and 67 (75%) were liberated from PN. A total of 58 (65%) underwent operative intervention and fistula closure was achieved in 37 of 47 (79%) patients.

CONCLUSIONS

Short bowel syndrome patients can experience significant benefit under treatment by a multidisciplinary nutrition service. By incorporating surgical intervention, the majority of patients previously relegated to lifelong PN have the opportunity to become nutritionally independent within 5 years.

Learn Intestinal Failure Tele-ECHO Project: An innovative online telementoring and case-based learning clinic

Intestinal failure (IF) is a rare chronic disease requiring intravenous (IV) fluids or parenteral nutrition (PN) dependency for optimal patient health and sustenance. The complex care is best managed by specialized multidisciplinary teams. Patients who have limited access to intestinal rehabilitation centers often receive IV/PN care from clinicians lacking specialty expertise. An innovative videoconferencing project was launched in May 2019 to provide online telementoring and case-based learning in IF. The Extension for Community Healthcare Outcomes (ECHO) model was adopted to provide education and virtual support via the Learn Intestinal Failure Tele-ECHO (LIFT-ECHO) project. Online clinics include patient case presentations, moderated discussion, best-practice recommendations, and didactic continuing education lectures on IF- and PN-related topics. Participation is interprofessional and international. Via knowledge dissemination and specialty mentorship, LIFT-ECHO is expected to improve healthcare for patients with IF and transform care delivery by overcoming the limitations in access to expertise.

Short bowel syndrome: treatment options

Introduction Short bowel syndrome (SBS) refers to the malabsorptive state that occurs following extensive intestinal resection and is associated with several complications.

Methods The research for this review was conducted in the Pubmed database. Relevant scientific articles dated between 1991 and 2015 and written in Portuguese, Spanish or English were selected.

Results Several therapies, including nutritional support, pharmacological options and surgical procedures have been used in these patients.

Conclusions Over the last decades new surgical and pharmacological approaches emerged, increasing survival and quality of life (QoL) in patients with SBS. All SBS patients ought to have an individualized and multidisciplinary care that promotes intestinal rehabilitation.

Adaptation of the medical-nutrition therapy for patients with intestinal failure in a developing country: A modified Delphi survey

BACKGROUND & AIMS

Intestinal Failure (IF) is a complex disease with huge impacts on our society due to complications. Therefore, in a developing country like Mexico without specialized IF clinics, health care professionals must provide evidence-based interventions for the IF patient. This study aims to achieve consensus on how to adapt the existing guidelines for IF to the local practices considering the available resources and local practices.

METHODS

A three-round modified Delphi process was used to build consensus on the most important interventions for our IF patients. For each round, data was collected and consensus was defined as ≥80% of agreement for each item. Descriptive statistics were used to determine whether a consensus was achieved.

RESULTS

Ten content experts completed the three-round modified Delphi survey. Consensus was achieved for 98% of the items related to the hospitalized patient, ambulatory care management, and drug therapy. Some of these items are not included in the ESPEN guidelines for IF, but we considered that they are relevant in our clinical practice, like the calculation of fluids for patients with very low body weight, screening for refeeding syndrome and the use of some conventional drugs to promote intestinal rehabilitation.

CONCLUSIONS

Using a three-round modified Delphi process, consensus was achieved for nearly all items. This represents a starting point for the improvement of our local practices towards this complex disease, leading to better outcomes and the implementation of evidence-based protocolized interventions which can have an important impact due to the lack of access to some of the most novel pharmacological therapies like the glucagon-like-peptide (GLP-2) analog.

Teduglutide for the treatment of adults with intestinal failure associated with short bowel syndrome: pooled safety data from four clinical trials

BACKGROUND

In multiple clinical studies, teduglutide reduced parenteral support (PS) with a consistent safety profile in adults with short bowel syndrome-associated intestinal failure (SBS-IF). The objective of this study was to assess adverse events (AEs) from a pooled data set.

METHODS

Safety data from four prospective clinical trials of teduglutide in patients with SBS-IF were assimilated. AEs were evaluated in patient groups based on treatment received in each study and in populations stratified to create distinct subgroups based on aetiology, bowel anatomy and baseline PS volume requirements.

RESULTS

Safety data are reported for up to 2.5 years, totalling 222 person-years exposure to teduglutide. In most patients, AEs were reported as mild or moderate in severity in all patient groups and occurred at comparable rates between patients who received teduglutide or placebo. Several common gastrointestinal AEs, including abdominal pain, nausea and abdominal distension, were reported more frequently earlier in the course of treatment, with their frequency declining over time. Fewer gastrointestinal AEs were reported in patients with vascular causes of SBS-IF and patients with most of their colon-in-continuity than in other patient subgroups. Across the patient stratification subgroups, the predominant treatment-emergent AEs for which patients receiving teduglutide had a significantly increased relative risk were abdominal distension and gastrointestinal stoma complication compared with patients receiving placebo.

CONCLUSIONS

Teduglutide had a safety profile consistent with prior adult data and no new safety concerns were identified. The most frequently reported AEs were gastrointestinal in origin, consistent with the underlying disease condition and intestinotrophic actions of teduglutide.

CLINICAL TRIAL REGISTRY INFORMATION

NCT00081458/EudraCT, 2004-000438-35; NCT00798967/EudraCT, 2008-006193-15; NCT00172185/EudraCT, 2004-000439-27; NCT00930644/EudraCT, 2009-011679-65.

A Single Urine Sodium Measurement May Validly Estimate 24-hour Urine Sodium Excretion in Patients With an Ileostomy

BACKGROUND

Sodium deficiency in patients with an ileostomy is associated with chronic dehydration and may be difficult to detect. We aimed to investigate if the sodium concentration in a single spot urine sample may be used as a proxy for 24-hour urine sodium excretion.

METHODS

In a prospective observational study with 8 patients with an ileostomy and 8 volunteers with intact intestines, we investigated the correlations and agreements between spot urine sodium concentrations and 24-hour urine sodium excretions. Spot urine samples were drawn from every micturition during 24 hours, and relevant blood samples were drawn. All participants documented their food and fluid intakes.

RESULTS

There was a high and statistically significant correlation between 24-hour natriuresis and urine sodium concentrations in both morning spot samples (n = 8, Spearman's rho [ρ] = 0.78, P = 0.03) and midday spot samples (n = 8, ρ = 0.82, P = 0.02) in the patients with an ileostomy. The agreement between methods was fair (bias = -1.5, limits of agreement = -32.3 to 29.4). There were no statistically significant associations for evening samples or for samples from volunteers with intact intestines independently of time of day.

CONCLUSION

A single spot urine sodium sample obtained in the morning or midday may estimate 24-hour urine sodium excretion in patients with an ileostomy and thus help to identify sodium depletion.

Nontransplant Surgery for Intestinal Failure

Insufficient absorptive mucosal surface is the fundamental problem in the short bowel state. Intestinal adaptation has been well studied, and it is well recognized that it may lead to dilatation of the bowel with increased thickness of the bowel wall, resulting from both mucosal hypertrophy and hyperplasia. Autologous reconstructive surgery exploits bowel dilatation in short bowel syndrome and maximizes the absorptive potential of the available mucosal surface. Indeed, autologous gastrointestinal reconstructive procedures may be better viewed as optimizing bowel diameter rather than focusing on length, thus allowing better prograde peristalsis and improved contact between luminal nutrients and mucosa, ultimately enhancing absorption.

Nutritional Management of a Patient with a High-Output Stoma after Extensive Small Bowel Resection to Treat Crohn's Disease

For patients with short bowel syndrome who undergo ileostomy, nutritional management is essential to prevent complications associated with a high-output stoma (HOS). We report a practical example of ostomic, medical nutrition therapy provided by an intensive nutritional support team (NST). A 42-year-old male with a history of Crohn's disease visited Seoul National University Hospital for treatment of mechanical ileus. He underwent loop ileostomy after extensive small bowel resection. As his remaining small bowel was only 160 cm in length, the stomal output was about 3,000 mL/day and his body weight fell from 52.4 to 40.3 kg. Given his clinical condition, continuous tube feeding for 24 h was used to promote adaptation of the remnant bowel. Thereafter, an oral diet was initiated and multiple, nutritional educational sessions were offered by dietitians. Constant infusion therapy was prescribed and included in the discharge plan. Two months after discharge, his body weight had increased to 46.6 kg and his hydration status was appropriately maintained. This case suggests that the critical features of medical nutritional therapy for ostomy management are frequent assessments of fluid balance, weight history, and laboratory data and after nutritional interventions.

Short article: Frequency, pathophysiology, and clinical classification of intestinal failure type II and III at a tertiary referral center

OBJECTIVE

Intestinal failure (IF) is a complex disease that is gaining significance and attention throughout the world. In Mexico, there are no available data on this condition. The aim of this study was to determine the frequency and characteristics of patients with IF type II and III hospitalized at a tertiary referral center in our country.

PATIENTS AND METHODS

A cross-sectional study was carried out from August 2016 to July 2017. Adult patients hospitalized in noncritical areas with a recent diagnosis of IF type II or III according to the European Society for Clinical Nutrition and Metabolism classification were included. Demographic, anthropometric, nutritional therapy, biochemical, and clinical characteristics were registered. Nutritional risk was determined by the Nutritional Risk Score 2002.

RESULTS

During the study, 4144 patients were admitted to noncritical areas; 21 (5/1000) of these patients were included. The mean age of the patients was 51±18.8 years, and the mean BMI was 17.6±5.5 kg/m. Fifteen (71.5%) patients were diagnosed with IF type II and six (28.5%) with IF type III. The primary diagnosis was surgical complications in seven (33.3%) of the cases and the principal pathophysiological mechanism was short bowel syndrome in nine (42.8%) patients. The most frequent (37%) clinical classification was D2: more than 20 kcal/kg/day and 1001-2000 ml/day and parenteral nutrition and PN2: 1001-2000 ml/day (52.3%) based on the modified European Society for Clinical Nutrition and Metabolism clinical classification.

CONCLUSION

In this study, a high frequency of IF was found; surgical complications and short bowel syndrome were the main mechanisms involved, and D2 was the most frequent clinical category.

Research Gaps in Diet and Nutrition in Inflammatory Bowel Disease. A Topical Review by D-ECCO Working Group [Dietitians of ECCO]

Although the current doctrine of IBD pathogenesis proposes an interaction between environmental factors and gut microbiota in genetically susceptible individuals, dietary exposures have attracted recent interest and are, at least in part, likely to explain the rapid rise in disease incidence and prevalence. The D-ECCO working group along with other ECCO experts with expertise in nutrition, microbiology, physiology, and medicine reviewed the evidence investigating the role of diet and nutritional therapy in the onset, perpetuation, and management of IBD. A narrative topical review is presented where evidence pertinent to the topic is summarised collectively under three main thematic domains: i] the role of diet as an environmental factor in IBD aetiology; ii] the role of diet as induction and maintenance therapy in IBD; and iii] assessment of nutritional status and supportive nutritional therapy in IBD. A summary of research gaps for each of these thematic domains is proposed, which is anticipated to be agenda-setting for future research in the area of diet and nutrition in IBD.

Intestinal Failure and Transplant: The Australian Experience (2009 to 2014)

BACKGROUND

A joint adult and pediatric intestinal transplant (ITx) program for Australia was developed in 2009 to provide life-saving ITx to patients with irreversible intestinal failure (IF). We aimed to analyze the outcomes of patients treated by our service over the past 5 years.

METHODS

A retrospective medical record review was conducted on all IF patients referred to our service. Patient demographics, underlying disease, nutrition support, TPN complications, and current transplant program status were evaluated.

RESULTS

Fifty-seven patients (35 adults, 40.4 ± 12.4 years; 22 children, 6.3 ± 4.3 years) throughout Australia and New Zealand have been referred. Leading causes of IF were short bowel syndrome followed by pseudo-obstruction. Forty patients (70%) exhibited at least 1 life-threatening complication of PN at referral: liver failure, impending loss of venous access, and/or recurrent line sepsis. Three patients have undergone ITx with 100% survival (median follow-up, 1161 days). Four patients (8%) are listed for transplant, 6 patients (12%) are awaiting transplant assessment, and 4 patients (8%) have died (2 while awaiting transplantation, 2 during assessment period). Causes of death included sepsis and intracranial bleed. Two-thirds of all referred patients (n = 40) were deferred or rejected from wait-listing.

CONCLUSIONS

After 5 years of establishing the first dedicated ITx program in Australia and New Zealand, early results indicate that ITx is an available and life-saving option for IF patients in these countries. Current barriers to ITx in Australia include a shortage of appropriate donors and a high rate of donor-specific antibodies among potential recipients. Growing awareness of the service and early referral to assist appropriate patient selection will aid in the program's success.

Vaizey CJ, Maeda Y, Barbosa E, Bozzetti F, Calvo J, Irtun Ø, Jeppesen PB, Klek S, Panisic-Sekeljic M, Papaconstantinou I, Pascher A, Panis Y, Wallace WD, Carlson G, Boermeester M. European Society of Coloproctology consensus on the surgical management of intestinal failure in adults

Intestinal failure (IF) is a debilitating condition of inadequate nutrition due to an anatomical and/or physiological deficit of the intestine. Surgical management of patients with acute and chronic IF requires expertise to deal with technical challenges and make correct decisions. Dedicated IF units have expertise in patient selection, operative risk assessment and multidisciplinary support such as nutritional input and interventional radiology, which dramatically improve the morbidity and mortality of this complex condition and can beneficially affect the continuing dependence on parenteral nutritional support. Currently there is little guidance to bridge the gap between general surgeons and specialist IF surgeons. Fifteen European experts took part in a consensus process to develop guidance to support surgeons in the management of patients with IF. Based on a systematic literature review, statements were prepared for a modified Delphi process. The evidence for each statement was graded using Oxford Centre for Evidence-Based Medicine Levels of Evidence. The current paper contains the statements reflecting the position and practice of leading European experts in IF encompassing the general definition of IF surgery and organization of an IF unit, strategies to prevent IF, management of acute IF, management of wound, fistula and stoma, rehabilitation, intestinal and abdominal reconstruction, criteria for referral to a specialist unit and intestinal transplantation.

Definitions of intestinal failure and the short bowel syndrome

The European Society for Clinical Nutrition and Metabolism defined intestinal failure (IF) as "the reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth". IF is classified as type 1-acute, type 2-prolonged acute and type 3-chronic IF. A short bowel syndrome (SBS) due to the intestinal malabsorption associated with a functional small intestine length of less than 200 cm is the most frequent mechanism of IF. SBS is a difficult and multifaced disease. Complications due to SBS itself and to treatments, such as long term home parenteral nutrition, can adversely affect the patient outcome. The care of SBS requires complex technologies and multidisciplinary and multiprofessional activity and expertise. Patient outcome is strongly dependent on care and support from an expert specialist team. This paper focuses on the aspects of the pathophysiology and on the complications of SBS, which are most relevant in the clinical practice, such as intestinal failure associated liver disease, renal failure, biliary and renal stones, dehydration and electrolyte depletion, magnesium deficiency and D-lactic acidosis.

Long-Term Teduglutide for the Treatment of Patients With Intestinal Failure Associated With Short Bowel Syndrome

OBJECTIVES:

In the pivotal 24-week, phase III, placebo-controlled trial, teduglutide significantly reduced parenteral support (PS) requirements in patients with short bowel syndrome (SBS). STEPS-2 was a 2-year, open-label extension of that study designed to evaluate long-term safety and efficacy of teduglutide.

METHODS:

Enrolled patients had completed 24 weeks of either teduglutide (TED/TED) or placebo (PBO/TED) in the initial placebo-controlled study or qualified for that study, but were not treated (NT/TED) because of full enrollment. Patients received subcutaneous teduglutide 0.05 mg/kg/day for up to 24 months (NT/TED and PBO/TED) or up to 30 months (TED/TED). Clinical response was defined as 20–100% reduction from baseline in weekly PS volume; baseline was considered the beginning of teduglutide treatment in the initial placebo-controlled study (TED/TED) or STEPS-2 (NT/TED and PBO/TED). Descriptive statistics summarized changes in efficacy and safety variables.

RESULTS:

Of 88 enrolled patients, 65 (74%) completed STEPS-2. The most common treatment-emergent adverse events were abdominal pain (34%), catheter sepsis (28%), and decreased weight (25%). Mean weight, body mass index, and serum albumin remained stable. In patients who completed the study, clinical response was achieved in 28/30 (93%) TED/TED, 16/29 (55%) PBO/TED, and 4/6 (67%) NT/TED patients. Mean PS volume reductions from baseline were 7.6 (66%), 3.1 (28%), and 4.0 (39%) l/week in the TED/TED, PBO/TED, and NT/TED groups, respectively. Thirteen patients achieved full enteral autonomy.

CONCLUSIONS:

In patients with SBS, long-term teduglutide treatment resulted in sustained, continued reductions in PS requirements. Overall health and nutritional status was maintained despite PS reductions.

[Parenteral Nutritional Support in Gastrointestinal and Liver Diseases]

Protein-calorie malnutrition and deficiencies of specific nutrients could commonly occur in various types of gastrointestinal diseases. These nutritional problems could delay recovery from diseases, resulting in increased morbidity and mortality, and impairment of quality of life. Parenteral nutrition (PN) is one of the methods of nutritional support through which macronutrients (glucose, amino acids, and triglycerides), micronutrients (vitamins and trace elements), water, and electrolytes are administered via peripheral or central venous route. PN could play an important role for patients for whom enteral/oral feeding is contraindicated or cannot meet the patients' requirement for adequate nutrition due to anatomical and/or functional problems. Since insufficient and excessive PN supplement could both be harmful for patients, it is very important to adhere to correct indication, optimal timing, and dosage/composition of PN. In this article, the current role of PN for various gastrointestinal diseases will be reviewed and discussed.

[Clinical nutrition therapy in patients with short bowel syndrome in line with principles of personalized medicine]

Home parenteral nutrition administered in selected care centres has been financed in Hungary since January, 2013. The authors discuss diagnostic issues, treatment and nutrition therapy of short bowel syndrome patients in line with the principles of personalised medicine. The most severe form of short bowel syndrome occurs in patients having jejunostomy, whose treatment is discussed separately. The authors give a detailed overview of home parenteral feeding, its possible complications, outcomes and adaptation of the remaining bowel. They describe how their own care centre operates where they administer home parenteral nutrition to 12 patients with short bowel syndrome (5 females and 7 males aged 51.25±14.4 years). The body mass index was 19.07±5.08 kg/m2 and 20.87±3.3 kg/m2, skeletal muscle mass was 25.7±6.3 kg and 26.45±5.38 kg, and body fat mass was 14.25±8.55 kg and 11.77±2.71 kg at the start of home parenteral nutrition and presently, respectively. The underlying conditions of short bowel syndrome were tumours in 4 patients, bowel ischaemia in four patients, surgical complications in three patients, Crohn's disease in one patient, and Crohn's disease plus tumour in one patient.

Targeted therapy of short-bowel syndrome with teduglutide: the new kid on the block

Extensive intestinal resection impairs the absorptive capacity and results in short-bowel syndrome-associated intestinal failure (SBS-IF), when fluid, electrolyte, acid-base, micro-, and macronutrient homeostasis cannot be maintained on a conventional oral diet. Several factors, including the length and site of the resected intestine, anatomical conformation of the remnant bowel, and the degree of postresection intestinal adaptation determine the disease severity. While mild SBS patients achieve nutritional autonomy with dietary modification (eg, hyperphagia, small frequent meals, and oral rehydration fluids), those with moderate-to-severe disease may develop SBS-IF and become dependent on parenteral support (PS) in the form of intravenous fluids and/or nutrition for sustenance of life. SBS-IF is a chronic debilitating disease associated with a poor quality of life, and carries significant morbidity and health care costs. Medical management of SBS-IF is primarily focused on individually tailored symptomatic treatment strategies, such as antisecretory and antidiarrheal agents to mitigate fluid losses, and PS. However, PS administration is associated with potentially life-threatening complications, such as central venous thromboses, bloodstream infections, and liver disease. In pursuit of a targeted therapy to augment intestinal adaptation, research over the past 2 decades has identified glucagon-like peptide, an intestinotrophic gut peptide that has been shown to enhance intestinal absorptive capacity by causing an increase in the villus length, crypt depth, and mesenteric blood flow and by decreasing gastrointestinal motility and secretions. Teduglutide, a recombinant analog of glucagon-like peptide-2, is the first targeted therapeutic agent to gain approval for use in adult SBS-IF. Teduglutide was shown to result in significant (20%–100%) reduction in PS-volume requirement and have a satisfactory safety profile in three randomized control trials. Further research is warranted to see if reduction in PS dependency translates to improved quality of life and reduced PS-associated complications.