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Gombošová L, Suchanský M, Krivuš J, Hornová J, Havlíčeková Z, Fojtová A, Norek B, Valachová I, Šprláková J, Gazda J, Ondrušová M. Evaluation of the Effectiveness of Teduglutide Treatment in Patients with Short Bowel Syndrome in Slovakia-Multicenter Real-World Study. J Clin Med 2024; 13:1238. [PMID: 38592065 PMCID: PMC10931580 DOI: 10.3390/jcm13051238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/16/2024] [Accepted: 02/20/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: We present the first real-world-data study on teduglutide-treated SBS patients in the Slovak Republic and the first study to enable the comparison of the effects of teduglutide treatment between the adult and pediatric populations. (2) Methods: This was a non-interventional retrospective cohort study of adult and pediatric SBS patients treated with teduglutide. Primary and secondary endpoints were the results of teduglutide use at 12 weeks and 6 months after the initiation of treatment, compared to baseline. (3) Results: Teduglutide treatment led to a statistically significant reduction in the volume of intravenous hydration, HPN caloric intake, HPN and intravenous hydration applications per week and to increased urine output in adult patients. The results in the pediatric population were similar, but not statistically significant. A complete weaning off HPN was achieved in 57.14% of all patients (50.00% of children; 62.50% of adults) after a median of 0.99 years of teduglutide treatment (1.07 and 0.98 years for children and adults, respectively). (4) Conclusions: Teduglutide treatment in SBS patients leads to considerable reduction in or even weaning off PN in both pediatric and adult patients.
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Affiliation(s)
- Laura Gombošová
- 2nd Internal Clinic, University Hospital of L. Pasteur and Faculty of Medicine University of Pavol Jozef Šafárik Košice, Tr. SNP 1, 04011 Košice, Slovakia;
| | | | - Juraj Krivuš
- 1st Internal Clinic, University Hospital and Jessenius Faculty of Medicine Comenius University, Kollárova 2, 03659 Martin, Slovakia;
| | - Jarmila Hornová
- Department of Pediatrics, Faculty of Medicine Comenius University and National Institute of Children’s Diseases, Limbová 1, 83340 Bratislava, Slovakia;
| | - Zuzana Havlíčeková
- Department of Paediatrics, University Hospital Martin and Jessenius Faculty of Medicine Comenius University, Kollárova 2, 03601 Martin, Slovakia;
| | - Andrea Fojtová
- Gastroenterology Clinic, Slovak Medical University and Bratislava University Hospital, Antolská 11, 85107 Bratislava, Slovakia; (A.F.); (B.N.)
| | - Barbora Norek
- Gastroenterology Clinic, Slovak Medical University and Bratislava University Hospital, Antolská 11, 85107 Bratislava, Slovakia; (A.F.); (B.N.)
| | - Iveta Valachová
- 2nd Children Clinic, Slovak Medical University and Children's Faculty Hospital, Nám L. Svobodu 4, 97409 Banská Bystrica, Slovakia;
| | - Jana Šprláková
- Gastroenterology and Hepatology Department, Children’s Faculty Hospital, Tr. SNP 1, 04011 Košice, Slovakia;
| | - Jakub Gazda
- 2nd Internal Clinic, University Hospital of L. Pasteur and Faculty of Medicine University of Pavol Jozef Šafárik Košice, Tr. SNP 1, 04011 Košice, Slovakia;
| | - Martina Ondrušová
- PharmIn Ltd., Karadžičova 16, 82108 Bratislava, Slovakia;
- Faculty of Public Health, Slovak Medical University, 83303 Bratislava, Slovakia
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2
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Klepper CM, Moore J, Gabel ME, Fleet SE, Kassel R. Pediatric formulas: Categories, composition, and considerations. Nutr Clin Pract 2023; 38:302-317. [PMID: 36815542 DOI: 10.1002/ncp.10954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/29/2022] [Accepted: 12/31/2022] [Indexed: 02/24/2023] Open
Abstract
Formulas, liquid nutrition, may be consumed orally or via a feeding tube to provide partial or complete nutrition that a given individual could not obtain using natural food stuffs in their native form. A wide range of commercially available formulas exist, which may be used as sole-source nutrition or in conjunction with other foods. Physicians and dietitians must understand the nature of and indications for specific formulas to treat diseases, provide complete nutrition to patients, and avoid harm. Products vary in macronutrient and micronutrient content and calorie concentration among many other factors. They are formulated specifically for patients of specific ages, correlating to nutritional needs and medical diagnoses. Additionally, formula availability, insurance coverage, mode of consumption, physiologic tolerance, and caregiver preference influence formula selection. Caregivers may also make their own pediatric formulas. We review commercial and homemade pediatric formulas.
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Affiliation(s)
- Corie M Klepper
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Joseph Moore
- Department of Clinical Nutrition and Lactation, Children's of Alabama, Birmingham, Alabama, USA
| | - Megan E Gabel
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA.,Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Rochester Medical Center, Rochester, New York, USA
| | - Sarah E Fleet
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachel Kassel
- Department of Pediatrics, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA.,Division of Gastroenterology, Hepatology and Nutrition, Birmingham, Alabama, USA
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3
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Puoti MG, Köglmeier J. Nutritional Management of Intestinal Failure due to Short Bowel Syndrome in Children. Nutrients 2022; 15. [PMID: 36615720 DOI: 10.3390/nu15010062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The most common cause of intestinal failure (IF) in childhood remains short bowel syndrome (SBS), where bowel mass is significantly reduced due to a congenital atresia or resection and parenteral nutrition (PN) needed. Home PN has improved outcome and quality of life, but the long-term therapeutic goal is to achieve enteral autonomy whilst avoiding long term complications. This paper is aimed at discussing nutritional strategies available to clinicians caring for these patients. METHODS A literature search was performed from 1992 to 2022 using Pubmed, MEDLINE and Cochrane Database of Systematic Reviews, and recent guidelines were reviewed. In the absence of evidence, recommendations reflect the authors' expert opinion. RESULTS Consensus on the best possible way of feeding children with IF-SBS is lacking and practice varies widely between centres. Feeding should commence as soon as possible following surgery. Oral feeding is the preferred route and breast milk (BM) the first milk of choice in infants. Donor BM, standard preterm or term formula are alternatives in the absence of maternal BM. Extensively hydrolysed or amino acid-based feeds are used when these are not tolerated. Solids should be introduced as soon as clinically appropriate. Children are encouraged to eat by mouth and experience different tastes and textures to avoid oral aversion. Aggressive weaning of PN and tube (over-) feeding are now discouraged. CONCLUSIONS To date, uniform agreement on the optimal type of feed, timing of food introduction and feeding regime used is lacking and great difference in practice remains. There is need for more research to establish common treatment protocols.
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Lakkasani S, Seth D, Khokhar I, Touza M, Dacosta TJ. Concise review on short bowel syndrome: Etiology, pathophysiology, and management. World J Clin Cases 2022; 10:11273-11282. [PMID: 36387822 PMCID: PMC9649563 DOI: 10.12998/wjcc.v10.i31.11273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/12/2022] [Accepted: 09/20/2022] [Indexed: 02/05/2023] Open
Abstract
Adults have approximately 20 feet of small intestine, which is the primary site for absorbing essential nutrients and water. Resection of the intestine for any medical reason may result in short bowel syndrome (SBS), leading to loss of major absorptive surface area and resulting in various malabsorption and motility disorders. The mainstay of treatment is personalized close dietary management. Here we present SBS with its pathophysiology and different nutritional management options available. The central perspective of this paper is to provide a concise review of SBS and the treatment options available, along with how proper nutrition can solve major dietary issues in SBS and help patients recover faster.
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Affiliation(s)
- Saraswathi Lakkasani
- Gastroenterology and Hepatology, Saint Michael’s Medical Center in Affiliation with New York Medical College, Newark, NJ 07102, United States
| | - Deeksha Seth
- Gastroenterology, Chandan Institute of Liver and Biliary Sciences, Lucknow 226001, India
| | - Imran Khokhar
- Medicine, Suburban Medical Center, Norristown, PA 19401, United States
| | - Masara Touza
- Medicine, Saint Michael’s Medical Center in Affiliation with New York Medical College, Newark, NJ 07102, United States
| | - Theodore Jr Dacosta
- Gastroenterology and Hepatology, Saint Michael’s Medical Center in Affiliation with New York Medical College, Newark, NJ 07102, United States
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Pulvirenti G, Sortino V, Manti S, Parisi GF, Papale M, Giallongo A, Leonardi S. Pathogenesis, diagnosis, dietary management, and prevention of gastrointestinal disorders in the paediatric population. Ital J Pediatr 2022; 48:172. [PMID: 36089576 PMCID: PMC9465927 DOI: 10.1186/s13052-022-01366-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 09/04/2022] [Indexed: 11/13/2022] Open
Abstract
Nutrition has a central role in child growth with long-term effects, and nutrition management in gastrointestinal disorders has great importance for child health and disease outcomes. Breast milk is the first choice for infant nutrition. When it is not available, special milk formulas are adopted in specific conditions, as a medical treatment. Moving from the strong guidelines, recommendations and the new possibilities of special diet treatment, this review will analyse the current diet treatment in different gastrointestinal disorders, including food allergy, cystic fibrosis, inflammatory bowel diseases, short-bowel syndrome, gastroesophageal reflux, and eosinophilic esophagitis. The review also aimed at understanding the role of diet and its effects on these diseases. The growth monitoring can prevent malnutrition and improve disease outcomes, particularly in children, and an appropriate dietary management targeted to specific disorders is the best therapeutic choice alone or in combination with pharmacological therapy.
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Hong WB, Tan WK, Law LS, Ong DE, Lo EA. Changes of Drug Pharmacokinetics in Patients with Short Bowel Syndrome: A Systematic Review. Eur J Drug Metab Pharmacokinet 2021; 46:465-78. [PMID: 34196913 DOI: 10.1007/s13318-021-00696-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Short bowel syndrome is a clinical condition defined by malabsorption of nutrients and micronutrients, most commonly following extensive intestinal resection. Due to a loss of absorptive surfaces, the absorption of orally administered drugs is also often affected. The purpose of this study was to systematically review the published literature and examine the effects of short bowel syndrome on drug pharmacokinetics and clinical outcomes. METHODS Studies were identified through searches of databases MEDLINE, EMBASE, Web of Science, and SCOPUS, in addition to hand searches of studies' reference lists. Two reviewers independently assessed studies for inclusion, yielding 50 studies involving 37 different drugs in patients with short bowel syndrome. RESULTS Evidence of decreased drug absorption was observed in 29 out of 37 drugs, 6 of which lost therapeutic effect, and 14 of which continued to demonstrate clinical benefit through drug monitoring. CONCLUSIONS The influence of short bowel syndrome on drug absorption appears to be drug-specific and dependent on the location and extent of resection. The presence of a colon in continuity may also influence drug bioavailability as it can contribute significantly to the absorption of drugs (e.g., metoprolol); likewise, drugs that have a wide absorption window or are known to be absorbed in the colon are least likely to be malabsorbed. Individualized dosing may be necessary to achieve therapeutic efficacy, and therapeutic drug monitoring, where available, should be considered in short bowel syndrome patients, especially for drugs with narrow therapeutic indices.
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Abstract
Abstract
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.
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Affiliation(s)
- Rosário Eça
- Universidade do Porto, Faculdade de Medicina, Porto, Portugal
| | - Elisabete Barbosa
- Universidade do Porto, Faculdade de Medicina, Porto, Portugal
- Centro Hospitalar de São João, Serviço de Cirurgia Geral, Porto, Portugal
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8
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Muto M, Kaji T, Onishi S, Yano K, Yamada W, Ieiri S. An overview of the current management of short-bowel syndrome in pediatric patients. Surg Today 2021; 52:12-21. [PMID: 33464414 DOI: 10.1007/s00595-020-02207-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 11/29/2020] [Indexed: 12/13/2022]
Abstract
Short-bowel syndrome (SBS) is defined as a state of malabsorption after resection or loss of a major portion of the bowel due to congenital or acquired factors. This article presents an overview on the recent management of pediatric SBS. The pediatric SBS population is very heterogeneous. The incidence of SBS is estimated to be 24.5 per 100,000 live births. The nutritional, medical, and surgical therapies available require a comprehensive evaluation. Thus, multidisciplinary intestinal rehabilitation programs (IRPs) are necessary for the management of these complex patients. The key points of focus in IRP management are hepato-protective strategies to minimize intestinal failure-associated liver disease; the aggressive prevention of catheter-related bloodstream infections; strategic nutritional supply to optimize the absorption of enteral calories; and the management and prevention of small bowel bacterial overgrowth, nephrocalcinosis, and metabolic bone disease. As the survival rate of children with SBS currently exceeds 90%, the application of small bowel transplantation has been evolving. The introduction of innovative treatments, such as combined therapy of intestinotrophic hormones, including glucagon-like peptide-2, may lead to further improvements in patients' quality of life.
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Affiliation(s)
- Mitsuru Muto
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Tatsuru Kaji
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima city, Kagoshima, 890-8520, Japan
| | - Shun Onishi
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Keisuke Yano
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima city, Kagoshima, 890-8520, Japan
| | - Waka Yamada
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.,Clinical Training Center, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima city, Kagoshima, 890-8520, Japan
| | - Satoshi Ieiri
- Department of Pediatric Surgery, Research Field Medicine and Health Sciences, Medical and Dental Sciences Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan.
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Abstract
Pediatric intestinal failure (IF) is the critical reduction of intestinal mass or function below the amount necessary for normal growth in children. Short-bowel syndrome (SBS) is the most common cause of IF in infants and children and is caused by intestinal resection. Enteral autonomy and freedom from parenteral nutrition is the mainstay of nutrition management in SBS. The goal is to achieve intestinal adaptation while maintaining proper growth and development. Treatment is variable, and there remains a paucity of evidence to draw well-informed conclusions for the care of individuals in this complex population. Physiological principles of enteral nutrition and practical recommendations for advancing the diet of patients with pediatric SBS are presented. Emerging trends in nutrition management, such as the growing interest in blending diets and the impact on SBS, are reviewed. Finally, the influence of the microbiome on enteral tolerance and small bowel bacterial overgrowth are considered.
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Affiliation(s)
- Nandini Channabasappa
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sara Girouard
- Department of Clinical Nutrition, Children's Health of Dallas, Dallas, Texas, USA
| | - Van Nguyen
- Department of Gastroenterology, Children's Health of Dallas, Dallas, Texas, USA
| | - Hannah Piper
- Division of Pediatric Surgery, Unversity of British Columbia, Vancouver, British Columbia, Canada
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10
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Abstract
Intestinal failure is defined as a critical reduction of the gut mass or function, below the minimum needed to absorb nutrients and fluids. The ultimate goal in intestinal failure is to promote bowel adaptation and reach enteral autonomy while a healthy growth and development is maintained. The condition is heterogeneous and complex. Therefore, recommendations for the type and duration of parenteral, enteral, and oral nutrition are variable, with the child's age as an additional key factor. The aim of this review is to provide an overview of nutritional feeding strategies in this heterogeneous population. Different perspectives on nutritional management, nutrition and adaptation, and microbiome and nutrition will be discussed.
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Affiliation(s)
- Joanne Olieman
- Department of Internal Medicine, Division of Dietetics, Erasmus MC, University Medical Center Rotterdam, Wytemaweg 40, 3015 GD Rotterdam, The Netherlands;
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Shah AA, Petrosyan M, Franklin AL, Chahine AA, Torres C, Sandler AD. Autologous intestinal reconstruction: a single institution study of the serial transverse enteroplasty (STEP) and the longitudinal intestinal lengthening and tailoring (LILT). Pediatr Surg Int 2019; 35:649-655. [PMID: 30868210 DOI: 10.1007/s00383-019-04468-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE To review the effectiveness of the longitudinal intestinal lengthening and tailoring (LILT) and serial transverse enteroplasty (STEP) operations in a cohort of patients with short bowel syndrome (SBS). METHODS We conducted a retrospective analysis of children with SBS treated at our institution from 2004 until 2014. Children aged 0 days to 18 years with SBS who underwent autologous intestinal reconstruction were included in the study. RESULTS Twenty-two SBS patients underwent 31 different lengthening procedures (LP). Seventeen patients underwent their primary lengthening procedures at our institution: 9 (53%) patients underwent a LILT, 7 (41%) underwent a STEP and 1 (6%) had a simultaneous LILT and STEP procedure. 12/22 patients had a second STEP, two had a third STEP and one patient had an intestinal transplantation after the LP. Median intestinal length at the time of surgery was 25 cm (range 12-90 cm). There was no difference in gain of intestinal length after LILT vs. STEP (p = 0.74). Length of stay and initiation of feeds were similar. Serum albumin increased after autologous bowel lengthening (p < 0.001). 50% were weaned off parenteral nutrition (PN) (5/9 of the LILT, 1/7 of the STEP, 1/1 of the combined LILT/STEP). There were no surgical complications or deaths. CONCLUSION In patients with SBS, LILT and STEP procedures are effective for autologous intestinal reconstruction and enable intestinal rehabilitation.
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Affiliation(s)
- Adil A Shah
- Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA
- Department of Surgery, Howard University Hospital and College of Medicine, Washington, DC, USA
| | - Mikael Petrosyan
- Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA.
| | - Ashanti L Franklin
- Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA
| | - Alfred A Chahine
- Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA
| | - Clarivet Torres
- Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA
- Department of Gastroenterology, Hepatology, and Nutrition, Children's National Health System, Washington, DC, USA
| | - Anthony D Sandler
- Department of General and Thoracic Surgery, Children's National Health System, Washington, DC, USA
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12
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Puntis J, Hojsak I, Ksiazyk J, Braegger C, Bronsky J, Cai W, Campoy C, Carnielli V, Darmaun D, Decsi T, Domellöf M, Embleton N, Fewtrell M, Fidler Mis N, Franz A, Goulet O, Hartman C, Hill S, Hojsak I, Iacobelli S, Jochum F, Joosten K, Kolaček S, Koletzko B, Ksiazyk J, Lapillonne A, Lohner S, Mesotten D, Mihályi K, Mihatsch WA, Mimouni F, Mølgaard C, Moltu SJ, Nomayo A, Picaud JC, Prell C, Puntis J, Riskin A, Saenz De Pipaon M, Senterre T, Shamir R, Simchowitz V, Szitanyi P, Tabbers MM, Van Den Akker CH, Van Goudoever JB, Van Kempen A, Verbruggen S, Wu J, Yan W. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Organisational aspects. Clin Nutr 2018; 37:2392-400. [DOI: 10.1016/j.clnu.2018.06.953] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 12/18/2022]
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13
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Tannuri ACA, Rotondo ÍG, Barros GG, Van Vaisberg V, Mendes-Neto C, Paes VR, Coelho MCM, Gonçalves J, Serafini S, Tannuri U. Are there differences in the growth adaptation processes of growing and mature organism models of short bowel syndrome? Clinics (Sao Paulo) 2018; 73:e499. [PMID: 30365828 PMCID: PMC6178875 DOI: 10.6061/clinics/2018/e499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 05/17/2018] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The purpose of this study was to present an experimental model of short bowel syndrome (SBS) in weaning rats and to compare the adaptative mechanisms of the remaining bowel in weaning rats and adult animals by means of morphometric, histologic and molecular methods. METHODS Twenty-four weaning rats were divided into 3 groups of 8 animals, one control group and two short bowel groups (euthanasia after 4 and 21 days), and were compared with similar adult groups. Morphometric evaluations of the animals and histopathological and molecular studies of the remaining bowel were performed. RESULTS The weight of young rats increased after enterectomy, whereas that of adult rats decreased after enterectomy (p<0.0001). The ratio of intestinal length/body weight was significantly higher in weaning rats than in adults (p<0.002), showing that intestinal growth was more intense in weaning rats. Intestinal resection promoted increased thickness of the small bowel lamina propria (p=0.001) and reduced thickness of the colon lamina propria (p=0.04) in weaning rats relative to those in adults. In addition, intestinal resection promoted increased expression of the Bcl-xl gene (antiapoptotic) in adult animals compared with that in weaning rats (p=0.001). CONCLUSION Morphometric, histological and molecular differences were shown in the adaptation processes of growing and mature organisms.
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Affiliation(s)
- Ana Cristina Aoun Tannuri
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Ítalo Geraldo Rotondo
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Guilherme Garcia Barros
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Victor Van Vaisberg
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Cícero Mendes-Neto
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Vitor Ribeiro Paes
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Maria Cecilia Mendonça Coelho
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Josiane Gonçalves
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Suellen Serafini
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Uenis Tannuri
- Divisao de Cirurgia Pediatrica, Unidade Pediatrica de Transplante de Figado e Laboratorio de Pesquisa em Cirurgia Pediatrica (LIM 30), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
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14
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Kaji T, Nakame K, Machigashira S, Kawano T, Masuya R, Yamada W, Yamada K, Onishi S, Moriguchi T, Sugita K, Mukai M, Ieiri S. Predictors of a successful outcome for infants with short bowel syndrome: a 30-year single-institution experience. Surg Today 2017; 47:1391-6. [DOI: 10.1007/s00595-017-1534-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 03/20/2017] [Indexed: 12/21/2022]
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Stoll B, Price PT, Reeds PJ, Chang X, Henry JF, van Goudoever JB, Holst JJ, Burrin DG. Feeding an Elemental Dietvsa Milk-Based Formula Does Not Decrease Intestinal Mucosal Growth in Infant Pigs. JPEN J Parenter Enteral Nutr 2017; 30:32-9. [PMID: 16387897 DOI: 10.1177/014860710603000132] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND We previously showed that the level of enteral nutrient intake determines the rate of intestinal growth in piglets. Our objective was to determine whether providing enteral nutrition in the form of elemental nutrients (glucose, amino acids, lipid [ED]) rather than cow's milk formula (lactose, protein, lipid [FORM]) reduces small intestinal growth and lactase activity. METHODS Three-week-old piglets were fed either ED (n = 7) intragastrically or FORM (n = 6) orally for 6 days. RESULTS Intestinal protein and DNA masses, villus height, and crypt depth were not different in ED and FORM pigs. Crypt cell proliferation, measured by in vivo bromodeoxyuridine labeling, was significantly (p < .05) higher (+37%) in ED than in FORM pigs. Rates of mucosal protein synthesis (%/d), measured by in vivo 2H-leucine incorporation, were higher (p < .05) in ED than FORM (147 vs 89) pigs. Circulating concentrations (pmol/L) of the intestinotrophic peptide, glucagon-like peptide-2 (GLP-2), were also higher (p < .05) in ED than in FORM (148 vs 87) pigs. The mean lactase-specific activity (micromol/min/g) in proximal and distal segments was higher (p < .05) in FORM than in ED (124 vs 58) pigs. CONCLUSIONS We conclude that intestinal mucosal growth and villus morphology are similar in pigs fed ED and FORM, despite higher cell proliferation and protein synthesis rates and lower lactase activity with ED. This implies that elemental diets may be as trophic as polymeric formulas to simultaneously provide nutrition and a stimulus for intestinal growth during bowel rest.
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Affiliation(s)
- Barbara Stoll
- USDA/ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas 77030, USA.
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Barrett M, Demehri FR, Ives GC, Schaedig K, Arnold MA, Teitelbaum DH. Taking a STEP back: Assessing the outcomes of multiple STEP procedures. J Pediatr Surg 2017; 52:69-73. [PMID: 27865472 DOI: 10.1016/j.jpedsurg.2016.10.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 10/20/2016] [Indexed: 12/12/2022]
Abstract
PURPOSE Short bowel syndrome (SBS) is a highly morbid condition primarily because of parenteral nutrition (PN)-associated complications. Bowel lengthening via serial transverse enteroplasty (STEP) has become standard of care. While initial STEPs have resulted in weaning from PN, outcomes of repeated STEPs (ReSTEPs) are not well described. We investigated outcomes of initial STEP compared to ReSTEP procedures. METHODS This retrospective review of STEPs included 17 children and a total of 24 procedures. Demographics, complications, hospital readmission rates, postoperative costs, and PN weaning were analyzed. RESULTS Neither patient-specific data nor the etiology of SBS was predictive of requiring a ReSTEP. PN weaning was more likely in the year following a first STEP (18% wean rate vs. 0% for ReSTEP, p>.05). No ReSTEP patients reached enteral autonomy. Enteral nutrition (%EN) increases were greater after first STEP compared to ReSTEP (26.0% vs. 4.7%, p=0.03). This trend was true for bowel length as well, where first STEPs resulted in a 51% increase in bowel length compared to a 20% increase after in ReSTEP (p=0.02). CONCLUSIONS ReSTEPs failed to result in significant PN weaning, with no ReSTEP patients achieving enteral autonomy during follow-up. Given its higher costs, smaller bowel length gains, and limited ability to produce enteral autonomy, surgeons should carefully consider performing ReSTEP procedures. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Meredith Barrett
- Division of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan; Ann Arbor, MI.
| | - Farokh R Demehri
- Division of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan; Ann Arbor, MI
| | - Graham C Ives
- Division of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan; Ann Arbor, MI
| | - Kristen Schaedig
- University of Michigan Clinical Financial Planning and Analysis Center, University of Michigan Health System; Ann Arbor, MI
| | - Meghan A Arnold
- Division of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan; Ann Arbor, MI
| | - Daniel H Teitelbaum
- Division of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan; Ann Arbor, MI
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Gause CD, Hayashi M, Haney C, Rhee D, Karim O, Weir BW, Stewart D, Lukish J, Lau H, Abdullah F, Gauda E, Pryor HI. Mucous fistula refeeding decreases parenteral nutrition exposure in postsurgical premature neonates. J Pediatr Surg 2016; 51:1759-1765. [PMID: 27614807 DOI: 10.1016/j.jpedsurg.2016.06.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 06/06/2016] [Accepted: 06/28/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND/PURPOSE Premature neonates can develop intraabdominal conditions requiring emergent bowel resection and enterostomy. Parenteral nutrition (PN) is often required, but results in cholestasis. Mucous fistula refeeding allows for functional restoration of continuity. We sought to determine the effect of refeeding on nutrition intake, PN dependence, and PN associated hepatotoxicity while evaluating the safety of this practice. METHODS A retrospective review of neonates who underwent bowel resection and small bowel enterostomy with or without mucous fistula over 2years was undertaken. Patients who underwent mucous fistula refeeding (RF) were compared to those who did not (OST). Primary outcomes included days from surgery to discontinuation of PN and goal enteral feeds, and total days on PN. Secondary outcomes were related to PN hepatotoxicity. RESULTS Thirteen RF and eleven OST were identified. There were no significant differences among markers of critical illness (p>0.20). In the interoperative period, RF patients reached goal enteral feeds earlier than OST patients (median 28 versus 43days; p=0.03) and were able to have PN discontinued earlier (median 25 versus 41days; p=0.04). Following anastomosis, the magnitude of effect was more pronounced, with RF patients reaching goal enteral feeds earlier than OST patients (median 7.5 versus 20days; p≤0.001) and having PN discontinued sooner (30.5 versus 48days; p=0.001). CONCLUSIONS RF neonates reached goal feeds and were able to be weaned from PN sooner than OST patients. A prospective multicenter trial of refeeding is needed to define the benefits and potential side effects of refeeding in a larger patient population in varied care environments.
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Affiliation(s)
- Colin D Gause
- Department of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Madoka Hayashi
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Courtney Haney
- Department of Pediatric Nutrition, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Daniel Rhee
- Department of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Omar Karim
- Department of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Brian W Weir
- Biostatistics, Epidemiology and Data Management Core, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Dylan Stewart
- Department of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jeffrey Lukish
- Department of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Henry Lau
- Department of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Fizan Abdullah
- Department of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Estelle Gauda
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Howard I Pryor
- Department of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Neelis EG, Olieman JF, Hulst JM, de Koning BA, Wijnen RM, Rings EH. Promoting intestinal adaptation by nutrition and medication. Best Pract Res Clin Gastroenterol 2016; 30:249-61. [PMID: 27086889 DOI: 10.1016/j.bpg.2016.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/01/2016] [Indexed: 01/31/2023]
Abstract
The ultimate goal in the treatment of short bowel syndrome is to wean patients off parenteral nutrition, by promoting intestinal adaptation. Intestinal adaptation is the natural compensatory process that occurs after small bowel resection. Stimulating the remaining bowel with enteral nutrition can enhance this process. Additionally, medication can be used to either reduce factors that complicate the adaptation process or to stimulate intestinal adaptation, such as antisecretory drugs and several growth factors. The aim of this review was to provide an overview of the best nutritional strategies and medication that best promote intestinal adaptation.
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Rossouw L, van der Merwe E. The nutritional management of short bowel syndrome in a very low-birthweight neonate. South African Journal of Clinical Nutrition 2016. [DOI: 10.1080/16070658.2016.1215870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Lacaille F, Gupte G, Colomb V, D'Antiga L, Hartman C, Hojsak I, Kolacek S, Puntis J, Shamir R; ESPGHAN Working Group of Intestinal Failure and Intestinal Transplantation. Intestinal failure-associated liver disease: a position paper of the ESPGHAN Working Group of Intestinal Failure and Intestinal Transplantation. J Pediatr Gastroenterol Nutr 2015; 60:272-83. [PMID: 25272324 DOI: 10.1097/MPG.0000000000000586] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Intestinal failure-associated liver disease is the most prevalent complication affecting children with intestinal failure receiving long-term parenteral nutrition. This paper reviews the definition, diagnostic criteria, pathogenesis, and risk factors. The authors discuss the role of enteral nutrition, parenteral nutrition, and its components, especially lipid emulsions. The authors also discuss the surgical treatment, including intestinal transplantation, its indications, technique, and results, and emphasise the importance of specialised intestinal failure centres.
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Demehri FR, Stephens L, Herrman E, West B, Mehringer A, Arnold MA, Brown PI, Teitelbaum DH. Enteral autonomy in pediatric short bowel syndrome: predictive factors one year after diagnosis. J Pediatr Surg 2015; 50:131-5. [PMID: 25598109 DOI: 10.1016/j.jpedsurg.2014.10.011] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 10/06/2014] [Indexed: 12/12/2022]
Abstract
PURPOSE This study examined predictors of achieving enteral autonomy among pediatric short bowel syndrome (SBS) patients remaining on parenteral nutrition (PN) beyond one year. METHODS A retrospective single-institution study of 171 pediatric SBS patients (defined as ≥50% small bowel (SB) loss or ≥60 days of PN with onset before 6 weeks of age) was performed. Multivariate Cox proportional hazards analysis was conducted, with subgroup analysis of patients on PN for ≥1 year (n=59). Primary outcome was successful wean from PN. RESULTS Over a follow-up of 4.1±4.8 years, 64.3% of children weaned from PN. Mortality was 15.2%. Presence of ≥10% expected SB length (hazard ratio [HR] 6.48, p=0.002) or an ileocecal valve (ICV; HR, 2.86, p<0.001) predicted PN weaning. Of those on PN ≥1 year, the wean rate was 50.8%, and ICV no longer predicted weaning (p=0.153). Predictors among those on PN ≥1 year were: ≥10% expected SB length (HR, 8.27, p=0.010), intestinal atresia (HR, 4.26, p=0.011), and necrotizing enterocolitis (NEC, HR, 2.84, p=0.025). CONCLUSIONS SBS children on PN ≥1 year continue to wean from PN, and those with ≥10% of predicted SB length, NEC, or atresia are more likely to do so. These findings may help direct management and advice for these challenging patients.
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Affiliation(s)
- Farokh R Demehri
- Department of Surgery, Section of Pediatric Surgery, University of MI Health System, Ann Arbor, USA
| | - Lauren Stephens
- Department of Surgery, Section of Pediatric Surgery, University of MI Health System, Ann Arbor, USA
| | - Emma Herrman
- Department of Surgery, Section of Pediatric Surgery, University of MI Health System, Ann Arbor, USA
| | - Brady West
- Center for Statistical Consultation and Research, University of MI, Ann Arbor, USA
| | - Ann Mehringer
- Department of Surgery, Section of Pediatric Surgery, University of MI Health System, Ann Arbor, USA
| | - Meghan A Arnold
- Department of Surgery, Section of Pediatric Surgery, University of MI Health System, Ann Arbor, USA
| | - Pamela I Brown
- Department of Pediatrics, Division of Pediatric Gastroenterology, University of MI Health System, Ann Arbor, USA
| | - Daniel H Teitelbaum
- Department of Surgery, Section of Pediatric Surgery, University of MI Health System, Ann Arbor, USA.
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Gosselin KB, Duggan C. Enteral nutrition in the management of pediatric intestinal failure. J Pediatr 2014; 165:1085-90. [PMID: 25242686 DOI: 10.1016/j.jpeds.2014.08.012] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 07/16/2014] [Accepted: 08/07/2014] [Indexed: 12/28/2022]
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Abstract
The neonatal intestine is a complex organ that regulates the absorption of nutrients essential for growth and development. Intestinal failure results from insufficient or functionally inadequate bowel and can lead to failure of neonatal growth and development. Current literature on neonatal intestinal physiology and failure was reviewed and summarized. A homeostatic interplay of electrolytes, enzymes, and hormonal regulators is essential to achieve the physiologic balance needed for adequate intestinal performance. Physiologic consequences of intestinal failure are dependent on the length and anatomic location of the diseased or surgically resected bowel. Intestinal failure leads to disruption of normal intestinal physiology and may have long-term consequences for growth and development if inadequately treated. Parenteral nutrition remains the mainstay of treatment for neonatal intestinal failure.
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Affiliation(s)
- Sarah J Carlson
- Department of Surgery and the Vascular Biology Program, Boston Children's Hospital, 300 Longwood Ave, Fegan 3, Boston, Massachusetts 02115
| | - Melissa I Chang
- Department of Surgery and the Vascular Biology Program, Boston Children's Hospital, 300 Longwood Ave, Fegan 3, Boston, Massachusetts 02115
| | - Prathima Nandivada
- Department of Surgery and the Vascular Biology Program, Boston Children's Hospital, 300 Longwood Ave, Fegan 3, Boston, Massachusetts 02115
| | - Eileen Cowan
- Department of Surgery and the Vascular Biology Program, Boston Children's Hospital, 300 Longwood Ave, Fegan 3, Boston, Massachusetts 02115
| | - Mark Puder
- Department of Surgery and the Vascular Biology Program, Boston Children's Hospital, 300 Longwood Ave, Fegan 3, Boston, Massachusetts 02115.
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Buccigrossi V, Armellino C, Tozzi A, Nicastro E, Esposito C, Alicchio F, Cozzolino S, Guarino A. Time- and segment-related changes of postresected intestine: a 4-dimensional model of intestinal adaptation. J Pediatr Gastroenterol Nutr 2013; 56:40-5. [PMID: 22820122 DOI: 10.1097/MPG.0b013e318268a9a4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The aim of the present study was to investigate the segment- and time-related changes in rat short bowel syndrome and construct a 4-dimensional (4D) geometrical model of intestinal adaptation. METHODS Sprague-Dawley rats were divided into 3 groups: 2-day, 7-day, and 15-day postresection groups in which 75% of the jejunoileum was removed. Histological and morphometrical parameters in the remaining proximal to distal intestinal segments, from the jejunum to the distal colon, were comparatively evaluated in the groups. The data were used to construct a 4D geometric model in which villi were considered as cylinders, and their surface area was expressed as cylinder lateral area. RESULTS Major adaptive changes were observed in the ileum consisting of an increase in both the diameter of base and the height of villi. A parallel reduction in their number/mm was observed. The resulting ileal architecture was characterized by a limited number of large villi. An opposite pattern was observed in the jejunum whose postresection structure consisted of an increased number of villi. No changes were observed in the colon. Postresection restructuring was early and faster in the ileum than in the jejunum resulting in an increase in absorptive area of 81.5% and 22.5% in the ileum and jejunum, respectively. CONCLUSIONS Postresection adaptation is intestinal segment-specific because all of the major changes occur in the ileum rather than in the jejunum. Sparing ileal segments during resection may improve the outcome of patients undergoing extensive intestinal resection. Our 4D model can be used to test interventions aimed at optimizing postresection intestinal adaptation.
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Abstract
Short bowel syndrome (SBS) reflects a state of malabsorption that occurs due to loss of a significant portion of the small bowel. The pathophysiology of SBS is determined largely by the process of adaptation, which is the innate attempt by the remnant portions of the intestine to increase fluid and nutrient reabsorption. In recent years, emphasis has been placed on intestinal rehabilitation with multidisciplinary teams as a comprehensive approach to the management of patients with SBS. In our institution, the multidisciplinary team members include pediatric gastroenterologists, pediatric surgeons, pediatric dieticians, physical therapists, occupational therapists, neonatologists (especially for patients still under their care), transplant surgeons, transplant coordinators and social workers. Parenteral nutrition plays a significant role in the management of SBS, but its use is associated with many potential complications, including cholestatic liver disease. Fish oil-based lipid emulsions have shown promise in their ability to reverse and also prevent the development of cholestasis in these patients. Clinical trials have shown that growth factors and other trophic hormones facilitate the process of adaptation. The most significant impact has been shown with the use of glucagon-like peptide-2 and its analog (teduglutide). Surgical interventions remain an important part of the management of SBS to facilitate adaptation and treat complications. Intestinal transplantation is a last resort option when the process of adaptation is unsuccessful. This review article is intended to provide an overview of the conventional and emerging therapies for pediatric SBS.
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Affiliation(s)
- Victor Uko
- Department of Pediatric Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, USA
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Olieman JF, Penning C, Spoel M, Ijsselstijn H, van den Hoonaard TL, Escher JC, Bax NMA, Tibboel D. Long-term impact of infantile short bowel syndrome on nutritional status and growth. Br J Nutr 2012; 107:1489-97. [DOI: 10.1017/s0007114511004582] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Short-term bowel adaptation has been documented, but data on long-term effects are scarce. The aim of the present study was to evaluate the long-term consequences of infantile short bowel syndrome (SBS). A cross-sectional assessment (2005–7) of growth, nutritional status, defecation pattern and health status in individuals with a history of infantile SBS, born between 1975 and 2002, were performed. Data were compared with reference values of healthy controls and presented as means and standard deviations or median and ranges. A total of forty subjects (sixteen male and twenty-four female; mean age 14·8 (sd 6·8) years) had received parenteral nutrition during a median of 110 (range 43–2345) d, following small bowel resection. The mean standard deviation scores (SDS) for weight for height and target height (TH) of the children were normal; mean SDS for height for age was − 0·9 (sd 1·3). The median BMI adults was 19·9 (range 17–26) kg/m2; mean SDS for height for age was − 1·0 (range − 2·5 to 1·5). Height in general was significantly shorter than TH, and 53 % of children and 78 % of adults were below TH range. Most subjects had normal body fat percentage (%BF). SDS for total body bone mineral density were generally normal. The SDS for bone mineral content (BMC) of the children were − 1·0 (sd 1·1). Mean energy intake was 91 % of the estimated average requirements. The frequencies of defecation and bowel complaints of the subjects were significantly higher than in healthy controls. In conclusion, infantile SBS results in shorter stature than was expected from their calculated TH. BMC was lower than reference values, but the subjects had normal weight for height and %BF.
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Abstract
Short bowel syndrome (SBS) is the main cause of intestinal failure especially in children. The colon is a crucial partner for small intestine adaptation and function in patients who have undergone extensive small bowel resection. However, SBS predisposes the patient to small intestine bacterial overgrowth (SIBO), explaining its high prevalence in patients with this disorder. SIBO may significantly compromise digestive and absorptive functions and may delay or prevent weaning from total parenteral nutrition (TPN). Moreover, SIBO may be one of the causes of intestinal failure-associated liver disease, requiring liver transplantation in some cases. Traditional tests for assessing SIBO may be unreliable in SBS patients. Management of SIBO with antibiotic therapy as a first-line approach remains a matter of debate, while other approaches, including probiotics, offer potential based on experimental evidence, though only few data from human studies are available.
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Healey KL, Bines JE, Thomas SL, Wilson G, Taylor RG, Sourial M, Pereira-Fantini PM. Morphological and functional changes in the colon after massive small bowel resection. J Pediatr Surg 2010; 45:1581-90. [PMID: 20713204 DOI: 10.1016/j.jpedsurg.2010.02.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Revised: 02/03/2010] [Accepted: 02/03/2010] [Indexed: 12/17/2022]
Abstract
PURPOSE Anecdotal evidence suggests that the colon plays an important role after small bowel resection (SBR). However, colonic changes have not previously been studied. The aim of this study was to characterize morphological and functional changes within the colon after SBR and elucidate the influence of diet complexity on adaptation. METHOD In study 1, 4-week-old piglets underwent a 75% SBR or sham operation and were studied at 2, 4, and 6 weeks postoperation to allow analysis of early and late adaptation responses. Piglets received a polymeric infant formula (PIF). In study 2, SBR piglets received an elemental diet and were studied at 6 weeks postoperation and compared with SBR + PIF piglets from study 1. For both studies, immunohistochemistry was used to quantitate intestinal cell types. Changes in functional proteins were measured by Western blot, enteroendocrine/peptide YY (PYY), enterocyte/liver fatty acid binding protein (L-FABP), and goblet cells/trefoil factor 3 (TFF3). RESULTS In study 1, early and late adaptation-related changes were observed after SBR. Early adaptation included increased numbers of enterocytes (P = .0001), whereas late adaptation included increased proliferative cell numbers (P = .02). Enteroendocrine, goblet, and apoptotic cells numbers were significantly elevated in the resected group at all time-points studied (P < .05). Functional changes included increased levels of L-FABP (P = .04) and PYY (P = .03). There was no change in TFF3 expression. In study 2, feeding with an elemental diet resulted in suboptimal adaptation as evidenced by reduced rate of weight gain and significant reductions in total cell numbers (P = .0001), proliferative (P = .0001) and apoptotic cells (P = .04), enteroendocrine cells (P = .001), and PYY expression (P .004). CONCLUSION These findings indicate that significant morphological and functional changes occur in the colon after massive SBR and that these occur as early and late adaptation responses. Elemental diet was associated with suboptimal adaptation suggesting an effect of diet complexity on colonic adaptation.
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Olieman JF, Penning C, IJsselstijn H, Escher JC, Joosten KF, Hulst JM, Tibboel D. Enteral Nutrition in Children with Short-Bowel Syndrome: Current Evidence and Recommendations for the Clinician. ACTA ACUST UNITED AC 2010; 110:420-6. [DOI: 10.1016/j.jada.2009.12.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Accepted: 07/31/2009] [Indexed: 01/27/2023]
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Abstract
Intestinal failure (IF) is the ultimate malabsorption state, with multiple causes, requiring long-term therapy with enteral or intravenous fluids and nutrient supplements. The primary goal during management of children with potentially reversible IF is to promote intestinal autonomy while supporting normal growth, nutrient status, and preventing complications from parenteral nutrition therapy. This article presents how an improved understanding of digestive pathophysiology is essential for diagnosis, successful management, and prevention of nutrient deficiencies in children with IF.
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Spagnuolo MI, Ruberto E, Guarino A. Isolated liver transplantation for treatment of liver failure secondary to intestinal failure. Ital J Pediatr 2009; 35:28. [PMID: 19754937 PMCID: PMC2758889 DOI: 10.1186/1824-7288-35-28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Accepted: 09/15/2009] [Indexed: 11/10/2022] Open
Abstract
Intestinal Failure is a permanent loss of digestive and absorptive functions as a consequence of short bowel syndrome and/or other primary intestinal conditions. Patients with intestinal failure (IF) require long term parenteral nutrition to survive. The only alternative to parenteral nutrition is intestinal transplantation which still entails high mortality. Children with intestinal failure on parenteral nutrition may develop liver failure (LF), as a consequence of central line infections and other conditions. In children with both irreversible IF and LF a combined transplantation is generally considered. Despite low survival rate, combined liver/intestine transplantation is associated to better intestinal graft survival and lower incidence and severity of rejection compared to isolated small bowel transplantation. Recently, isolated liver transplantation was proposed in children with IF and LF. This procedure may have a higher survival probability compared to isolated intestinal transplant, it may allow progressive weaning from PN in children in whom the remnant intestine has the potential for adaptation and offer a timely solution in children for whom intestinal graft is not immediately available. This innovative approach may prove a better option compared to combined transplantation in both the short and long term.
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Abstract
Malnutrition is a major contributor to mortality and is increasingly recognized as a cause of potentially lifelong functional disability. Yet, a rate-limiting step in achieving normal nutrition may be impaired absorptive function due to multiple repeated enteric infections. This is especially problematic in children whose diets are marginal. In malnourished individuals, the infections are even more devastating. This review documents the evidence that intestinal infections lead to malnutrition and that malnutrition worsens intestinal infections. The clinical data presented here derive largely from long-term cohort studies that are supported by controlled animal studies. Also reviewed are the mechanisms by which enteric infections lead to undernutrition and by which malnutrition worsens enteric infections, with implications for potential novel interventions. Further intervention studies are needed to document the relevance of these mechanisms and, most importantly, to interrupt the vicious diarrhea-malnutrition cycle so children may develop their full potential.
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Affiliation(s)
- Richard L Guerrant
- Department of Medicine, University of Virginia, Charlottesville 22901, USA.
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Olieman JF, Tibboel D, Penning C. Growth and nutritional aspects of infantile short bowel syndrome for the past 2 decades. J Pediatr Surg 2008; 43:2061-9. [PMID: 18970941 DOI: 10.1016/j.jpedsurg.2008.04.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2008] [Accepted: 04/09/2008] [Indexed: 11/18/2022]
Abstract
PURPOSE The aim of this retrospective study is to describe characteristics of the first year of infantile short bowel syndrome (SBS), with regard to nutritional correlates and growth. Differences in outcome between decade 1980 (1980 to 1990) and decade 1990 (1990 to 2000) were studied. METHODS Children with infantile SBS, who had been admitted in their first year of life between January 1975 and January 2002, were included. Patient characteristics, duration of parenteral nutrition (PN), type of enteral nutrition, and every quarterly term weight and height for age were collected. Data of decade 1980 and decade 1990 were compared, using appropriate statistical analysis. RESULTS Twenty-eight patients were identified for decade 1980 vs 62 patients in decade 1990. Length of stay was significantly shorter in decade 1990 (116 vs 182 days; P = .018). Residual bowel length was not significantly longer in the latter decade (74 cm vs 60 cm; not significant [ns]). Mean weight for age (SD score [SDS]) in the first year of SBS in decade 1980 was significantly lower than in decade 1990 (0.9 SDS; P = .035). CONCLUSIONS Improved care of patients with SBS and the slightly longer residual bowel length (ns) in decade 1990 resulted in shorter length of stay, shorter duration of PN, and significantly higher SDS for weight for age compared with decade 1980.
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Affiliation(s)
- Joanne F Olieman
- Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, The Netherlands.
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Masumoto K, Esumi G, Teshiba R, Nagata K, Hayashida M, Nakatsuji T, Takahashi Y, Nishimoto Y, Taguchi T. Cow's milk allergy in extremely short bowel syndrome: Report of two infants. ACTA ACUST UNITED AC 2008; 3:e217-9. [DOI: 10.1016/j.eclnm.2008.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Theyskens C, Dams A. Enteral nutrition regimen for neonates with short bowel syndrome. Nutrition 2008; 24:1045-7. [DOI: 10.1016/j.nut.2008.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Revised: 04/23/2008] [Accepted: 04/25/2008] [Indexed: 11/23/2022]
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Petri WA, Miller M, Binder HJ, Levine MM, Dillingham R, Guerrant RL. Enteric infections, diarrhea, and their impact on function and development. J Clin Invest 2008; 118:1277-90. [PMID: 18382740 DOI: 10.1172/jci34005] [Citation(s) in RCA: 277] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Enteric infections, with or without overt diarrhea, have profound effects on intestinal absorption, nutrition, and childhood development as well as on global mortality. Oral rehydration therapy has reduced the number of deaths from dehydration caused by infection with an enteric pathogen, but it has not changed the morbidity caused by such infections. This Review focuses on the interactions between enteric pathogens and human genetic determinants that alter intestinal function and inflammation and profoundly impair human health and development. We also discuss specific implications for novel approaches to interventions that are now opened by our rapidly growing molecular understanding.
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Affiliation(s)
- William A Petri
- Center for Global Health, Division of Infectious Diseases and International Health, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA
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Schaart MW, de Bruijn ACJM, Tibboel D, Renes IB, van Goudoever JB. Dietary protein absorption of the small intestine in human neonates. JPEN J Parenter Enteral Nutr 2008; 31:482-6. [PMID: 17947603 DOI: 10.1177/0148607107031006482] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The intestine plays a key role in the absorption of dietary proteins, which determines growth of human neonates. Bowel resection in the neonatal period brings loss of absorptive and protective surface and may consequently lead to malabsorption of dietary nutrients. However, there are no data on net dietary protein absorption of the small intestine in the period after intestinal surgery in human neonates. We therefore evaluated dietary feeding tolerance and quantified net dietary protein absorption capacity of the small intestine in human neonates in whom a temporary jejunostomy or ileostomy was created. METHODS Seventeen patients were included in the study. We collected small intestinal outflow fluid at the level of the enterostomy weekly for 24-48 hours during weeks 3 through 6 postoperatively. Protein levels in the intestinal outflow fluid were determined by bicinchoninic acid (BCA) assay. RESULTS In 14 patients, an enteral intake of >100 mL/kg/d was reached at a median of 17 days (range, 8-32 days) postoperatively. Three patients did not reach this level within the study period. Overall, the net dietary protein absorption capacity was 70%-90% of the total enteral protein intake. CONCLUSIONS This study demonstrates that the dietary protein absorption capacity of the small intestine is intact in most human neonates after intestinal surgery in a very critical period of their lives. Furthermore, our results do not support the use of hydrolyzed or elemental formula in newborns with an enterostomy to improve amino acid uptake.
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Affiliation(s)
- Maaike W Schaart
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Abstract
BACKGROUND Serial transverse enteroplasty (STEP) lengthens and tapers dilated bowel. Redilation of the STEP segment occurs in some patients with intestinal failure. The feasibility of a repeat STEP procedure in a pig model is evaluated. METHODS Six pigs underwent reversal of an intestinal segment distal to the ligament of Treitz. At 6-week intervals after reversal, each animal had 2 STEP procedures on the bowel proximal to the reversed segment. Necropsy was performed up to 6 weeks after repeat STEP. RESULTS Bowel length increased by 11.3 +/- 3.9 cm and bowel diameter decreased from a mean of 5.3 +/- 0.8 to 1.8 +/- 0.4 cm (P < .0001) after the first STEP. After repeat STEP, bowel length increased by 16.7 +/- 13.3 cm (P < .01), and the bowel was tapered from a mean of 5.4 +/- 0.9 to 2.2 +/- 0.4 cm (P < .01). Five pigs did well after repeat STEP, and 1 pig had early necropsy for bowel obstruction. None had histologic evidence of bowel ischemia in the repeat STEP segment. CONCLUSIONS A second STEP operation is feasible in a pig model and may be considered to optimize bowel length and function in select patients with intestinal failure.
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Affiliation(s)
- Hannah Piper
- Department of Surgery, Children's Hospital Boston and the Harvard Center for Minimally Invasive Surgery, Harvard Medical School, Boston, MA 02115, USA
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Abstract
PURPOSE OF REVIEW This review summarizes recent knowledge and clinical practice for pediatric patients suffering extensive intestinal resection causing short bowel syndrome. This condition requires the use of parenteral nutrition, as long as intestinal failure persists, and may be, in some selected cases, an indication for intestinal transplantation. RECENT FINDINGS Biological evaluation of intestinal failure is becoming possible with the use of plasma citrulline as a marker of intestinal mass. Few epidemiological data are available; some indicate an increased incidence of short bowel syndrome-related gastroschisis and persistent high incidence of necrotizing enterocolitis. Morbidity and mortality data in pediatric patients with short bowel syndrome are limited, while long-term outcome is better documented from recently reported cohorts. Non-transplant surgery is one of the best options for patients with unadapted short bowel syndrome. Isolated liver transplantation may be avoided. The use of trophic factors for enhancing mucosal hyperplasia still remains disappointing. SUMMARY The management should include therapies adapted to each stage of intestinal failure, based on a multidisciplinary approach in centers involving pediatric surgery, pediatric gastroenterology, parenteral nutrition expertise, home-parenteral nutrition program, and liver-intestinal transplantation experience. If managed appropriately, the prognosis of short bowel syndrome is excellent, with limited indications for intestinal and/or liver transplantation. Timing for patient referral in specialized centers remains an issue.
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Affiliation(s)
- Olivier Goulet
- Integrated Program of Intestinal Failure, Home Parenteral Nutrition, and Intestinal Transplantation, National Reference Center for Rare Digestive Diseases, Necker Hospital for Sick Children, University of Paris, France.
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Lochs H, Dejong C, Hammarqvist F, Hebuterne X, Leon-Sanz M, Schütz T, van Gemert W, van Gossum A, Valentini L, Lübke H, Bischoff S, Engelmann N, Thul P. ESPEN Guidelines on Enteral Nutrition: Gastroenterology. Clin Nutr 2006; 25:260-74. [PMID: 16698129 DOI: 10.1016/j.clnu.2006.01.007] [Citation(s) in RCA: 233] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2006] [Accepted: 01/13/2006] [Indexed: 12/18/2022]
Abstract
Undernutrition as well as specific nutrient deficiencies have been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome (SBS). The present guideline gives evidence-based recommendations for the indication, application and type of formula of enteral nutrition (EN) (oral nutritional supplements (ONS) or tube feeding (TF)) in these patients. It was developed in an interdisciplinary consensus-based process in accordance with officially accepted standards and is based on all relevant publications since 1985. ONS and/or TF in addition to normal food is indicated in undernourished patients with CD or CU to improve nutritional status. In active CD EN is the first line therapy in children and should be used as sole therapy in adults mainly when treatment with corticosteroids is not feasible. No significant differences have been shown in the effects of free amino acid, peptide-based and whole protein formulae for TF. In remission ONS is recommended only in steroid dependent patients in CD. In patients with SBS TF should be introduced in the adaptation phase and should be changed with progressing adaptation to ONS in addition to normal food.
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Affiliation(s)
- H Lochs
- Department of Gastroenterology, Charité-Universitätsmedizin, CCM, Berlin, Germany.
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Abstract
Intestinal failure is a condition requiring the use of parenteral nutrition as long as it persists. Causes of severe protracted intestinal failure include short bowel syndrome, congenital diseases of enterocyte development, and severe motility disorders (total or subtotal aganglionosis or chronic intestinal pseudo-obstruction syndrome). Intestinal failure may be irreversible in some patients, thus requiring permanent parenteral nutrition. Liver disease may develop with subsequent end-stage liver cirrhosis in patients with intestinal failure as a consequence of both underlying digestive disease and unadapted parenteral nutrition. Death will occur if combined liver-intestine transplantation is not performed. Catheter-related sepsis and/or extensive vascular thrombosis may impede the continuation of a safe and efficient parenteral nutrition and may also require intestinal transplantation in some selected cases. Thus management of patients with intestinal failure requires an early recognition of the condition and the analysis of its risk of irreversibility. Timing of referral for intestinal transplantation remains a crucial issue. As a consequence, management should include therapies adapted to each stage of intestinal failure based on a multidisciplinary approach in centers involving pediatric gastroenterology, parenteral nutrition expertise, home parenteral nutrition program, pediatric surgery, and liver intestinal transplantation program.
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Affiliation(s)
- Olivier Goulet
- Integrated Program of Intestinal Failure, Home Parenteral Nutrition and Intestinal Transplantation, National Reference Center for Rare Digestive Disease, Hôpital Necker-Enfants Malades, Université Reni Descartes, Paris, France.
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Abstract
Protein-energy malnutrition and specific nutrient deficiencies are common in inflammatory bowel diseases (IBD), more particularly in Crohn's disease. In adults, the use of artificial nutrition is indicated in the event of malnutrition, short bowel syndrome, or IBD refractory to all other treatments. In children, enteral nutrition has a place as first-line treatment to avoid side effects of corticosteroids on growth. The use, as a therapeutic tool, of specific nutrients (n-3 fatty acids, glutamine, antioxydant vitamins and minerals, TGF-beta, probiotics...) seems interesting at the pathophysiological level. Nevertheless, these nutrients are still under evaluation and there are not enough available studies to recommend them in clinical routine. A very promising solution is the use of probiotics for the treatment of refractory pouchitis.
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Affiliation(s)
- Marie-Astrid Piquet
- Service d'Hépato-Gastroentérologie et Nutrition, Centre Hospitalier Universitaire de Caen, Avenue de la Côte de Nacre, 14033 Caen Cedex
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Abstract
Short bowel syndrome (SBS) is the predominant cause of intestinal failure and is thus associated with a high degree of morbidity and mortality. One of the reasons this occurs is the dramatic reduction in nutrient absorptive capacity. Of the many causes of SBS, the most common cause is extensive surgical resection. The impressive ability of the bowel to adapt functionally and morphologically is critical for decreasing morbidity and mortality in these patients. The degree of adaptation is vital in decreasing the dependence on parenteral nutrition (PN) and for improving patient quality of life and long-term outcome. Provision of appropriate and sufficient nutritional and fluid support is essential for the management of these patients. The primary goal is to prevent or eliminate the need for PN. Recent developments have promoted a greater understanding of the process of intestinal adaptation. Various intestinal trophic factors have been recognized. These efforts have led to the early development of hormonal therapy to stimulate intestinal adaptation and enhance intestinal absorption. Intestinal transplantation remains an option for those who have developed life-threatening complications from PN and cannot be managed using more conservative techniques.
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Affiliation(s)
- Christian Jackson
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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Abstract
Intestinal failure (IF) can be defined as the reduction of functional gut mass below the minimal amount necessary for digestion and absorption adequate to satisfy the nutrient and fluid requirements for maintenance in adults or growth in children. In developed countries, IF mainly includes individuals with the congenital or early onset of conditions requiring protracted or indefinite parenteral nutrition (PN). Short bowel syndrome was the first commonly recognized cause of protracted IF. The normal physiologic process of intestinal adaptation after extensive resection usually allows for recovery of sufficient intestinal function within weeks to months. During this time, patients can be sustained on parenteral nutrition. Only a few children have permanent intestinal insufficiency and life-long dependency on PN. Non-transplant surgery including small bowel tapering and lengthening may allow weaning from PN in some cases. Hormonal therapy with recombinant human growth hormone has produced poor results while therapy with glucagon-like peptide-2 holds promise. Congenital diseases of enterocyte development such as microvillus inclusion disease or intestinal epithelial dysplasia cause permanent IF for which no curative medical treatment is currently available. Severe and extensive motility disorders such as total or subtotal intestinal aganglionosis (long segment Hirschsprung disease) or chronic intestinal pseudo-obstruction syndrome may also cause permanent IF. PN and home-PN remain are the mainstays of therapy regardless of the cause of IF. Some patients develop complications while receiving long-term PN for IF especially catheter related complications (thrombosis, sepsis) and liver disease. These patients may be candidates for intestinal transplantation. This review discusses the causes of irreversible IF and emphasizes the specific medico-surgical strategies for prevention and treatment of these conditions at several stages of IF.
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Affiliation(s)
- Olivier Goulet
- Département de Gastroentérologie, Hépatologie et Nutrition Pédiatriques, Hôpital Necker- Infants Malades and INSERM, Faculté de Necker, Paris, France.
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Abstract
Drug therapy may become difficult when a significant amount of the small intestine is resected, as happens in patients with a short small bowel. Drug absorption from the gastrointestinal tract is altered in these patients; however, this effect is variable in patients and differs with each drug. Literature regarding clinical outcomes of normal or alternative administration routes in patients with a short small bowel is limited. We explored what is written about the normal absorption of commonly used drugs and what difference the resection of different but substantial parts of the small intestine makes. Changes in the gastrointestinal tract after resection of >50% of the small intestine causes malabsorption of macronutrients and micronutrients, and may alter the drug absorption process. The metabolic activity of the abundantly present intestinal lactobacilli can also affect the enteral drug absorption in patients with short small bowel as this results in the production of lactic acid, gaseous CO(2), ethanol and an increased bile acid deconjugation. Accelerated intestinal luminal transit time causes a reduction in absorption of certain antimicrobial agents, digoxin, hydrochlorothiazide, ciclosporin, cimetidine, mesalazine (5-aminosalicylic acid), oral contraceptives and levothyroxine. Gastric hypersecretion and lack of sufficient contact time with the intestinal mucosa in patients with short small bowel leads to insufficient absorption of drugs such as omeprazole. Successful treatment with warfarin, tricyclic antidepressants, metronidazole, fluconazole, procainamide, sotalol and pindolol are reported in several studies. Many different factors cause this variability in drug absorption in such patients. Monitoring the serum drug concentration in these patients may ease dealing with the management problems.
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Affiliation(s)
- René Severijnen
- Department of Paediatric Surgery, Radboud University Nijmegen Medical Centre, 6500 HB Nijmegen, The Netherlands.
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