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Chronisches DarmversagenChronic intestinal failure
Abstract
The term intestinal failure (IF) is understood as the transient or irreversible loss of the resorptive capacity of the bowels. This includes a multitude of diseases, some of which have anatomical causes and others functional causes. The functional capacity (absorption and motility) of the remaining digestive tract and the bacterial overgrowth and false colonization of the small bowel are of prognostic importance. After exclusion of pathological intestinal findings, such as stenosis and dilatation, initially conservative treatment is employed with the aim of intestinal adaptation. Before failure or complications, initially conservative surgery and then organ replacement by transplantation should be considered. The IF is a temporary or permanent condition. For adults a length of 100cm small bowel without the colon, 60cm still with continuity to the colon and 35cm small bowel with complete preservation of the colon including the ileocecal valve are potentially sufficient for intestinal autonomy.
Background
Intestinal failure (IF) describes a condition of insufficient absorption capacity and general function of the gastrointestinal tract and may necessitate long‐term intravenous fluid and nutrient supplementation. Quality of life (QoL) may be reduced in these patients. The aim of the study was to analyze QoL by two tools (SBS‐QoL and SF‐12) to elucidate which parameters impact QoL in patients with IF.
Methods
QoL was assessed in a cohort of 105 patients with IF at a tertiary referral center for intestinal rehabilitation. Complete data for SBS‐QoL and SF‐12 were available in 44 of 81 surviving patients at a single time point for a cross‐sectional analysis. Medical data, outcome parameters, and comorbidities (Charlson comorbidity index [CCI]) were extracted and entered in a prospective database for analysis and correlation with QoL assessment.
Results
Subscales of SBS‐QoL and SF‐12 highly correlated with each other (P = −0.64 for physical subscales; P = −0.75 for mental subscales). Significant differences in QoL were detected in patients with Messing Type I (end‐jejunostomy) and Type III anatomy (ileocolonic anastomosis) (one‐way ANOVA: P < 0.05). Performance of autologous gut reconstruction (AGR) was associated with significantly better physical QoL. CCI correlated significantly with QoL scores. Longer duration of illness resulted in higher QoL in SBS‐QoL (reduction of 0.15 per month; P = 0.045).
Conclusion
Both SBS‐QoL and SF‐12 are useful to determine QoL in patients with IF. AGR was associated with improved QoL by changing SBS‐related anatomy and function. Thus, AGR surgery should be included in the treatment plan whenever possible. Comorbidities should be addressed interdisciplinarily to improve QoL.
Intestinal transplantation (ITx) is indicated in patients with irreversible intestinal failure (IF) and life-threatening complications related to total parenteral nutrition (TPN). ITx can be classified into three main types. Isolated intestinal transplantation (IITx), that is, transplantation of the jejunoileum, is indicated in patients with preserved liver function. Combined liver-intestine transplantation (L-ITx), that is, transplantation of the liver and the jejunoileum, is indicated in patients with liver failure related to TPN. Thus, patients with cirrhosis or advanced fibrosis should receive a combined allograft, while patients with lower grades of liver fibrosis can usually safely undergo ITx. Reflecting their degree of sickness, the waitlist mortality rate and the early posttransplant outcomes of patients receiving L-ITx are worse than IITx. However, L-ITx is associated with better long-term graft and patient survival. Multivisceral transplantation (MVTx), that is, transplantation of the organs dependent on the celiac axis and superior mesenteric artery, can be classified into full MVTx if it includes the liver and modified MVTx if it does not. The most common indications for MVTx are extensive portomesenteric thrombosis and diffuse gastrointestinal pathology such as motility disorders and polyposis syndrome. Every patient with IF should undergo a multidisciplinary evaluation by an experienced ITx team.
Clinical-nutritional autonomy is the ultimate goal of patients with intestinal failure (IF). Traditionally, patients with IF have been relegated to lifelong parenteral nutrition (PN) once surgical and medical rehabilitation attempts at intestinal adaptation have failed. Over the past two decades, however, outcome improvements in intestinal transplantation have added another dimension to the therapeutic armamentarium in the field of gut rehabilitation. This has become possible through relentless efforts in the standardization of surgical techniques, advancements in immunosuppressive therapies and induction protocols and improvement in postoperative patient care. Four types of intestinal transplants include isolated small bowel transplant, liver-small bowel transplant, multivisceral transplant and modified multivisceral transplant. Current guidelines restrict intestinal transplantation to patients who have had significant complications from PN including liver failure and repeated infections. From an experimental stage to the currently established therapeutic modality for patients with advanced IF, outcome improvements have also been possible due to the introduction of tacrolimus in the early 1990s. Studies have shown that intestinal transplant is cost-effective within 1-3 years of graft survival compared with PN. Improved survival and quality of life as well as resumption of an oral diet should enable intestinal transplantation to be an important option for patients with IF in addition to continued rehabilitation. Future research should focus on detecting biomarkers of early rejection, enhanced immunosuppression protocols, improved postoperative care and early referral to transplant centers.
Einleitung: Beim Kurzdarmsyndrom und beim Darmversagen sind enterale und parenterale Ernährung die Basis der Therapie. Die rekonstruktive Chirurgie vermag die anatomische Situation zu verbessern. Die Darmtransplantation stellt gegenwärtig eine Therapieoption beim drohenden Scheitern der parenteralen Ernährung dar.
Methodik: Es wurde eine systematische Literatursuche zum Kurzdarmsyndrom und zum Darmversagen, gekoppelt mit einer Literatursuche zur enteralen und parenteralen Ernährung, zur rekonstruktiven Chirurgie und zur Darmtransplantation durchgeführt. In der Arbeitsgruppe wurden auf dieser Basis Empfehlungen formuliert und hinsichtlich der Empfehlungsstärke bewertet. Sie wurden anschließend in einem Delphi-Verfahren und einer Konsensuskonferenz vorgestellt, diskutiert und verabschiedet.
Ergebnisse: Die Leitlinie bezieht sich spezifisch auf das Kurzdarmsyndrom bei Erwachsenen. Sie enthält einen allgemeinen Teil mit Definitionen sowie Empfehlungen zur Dokumentation der anatomischen Situation und des Ernährungszustands, zur Indikation, Zusammensetzung und Durchführung einer parenteralen Ernährung (unter besonderer Berücksichtigung der meist im Vordergrund stehenden Flüssigkeits- und Elektrolytverluste), zu den Prinzipien der spezifischen Diät, zu den Kathetern und deren Infektionsmanagement, zur spezifischen und symptomatischen Pharmakotherapie, zur rekonstruktiven Chirurgie und zur Darmtransplantation.
Schlussfolgerung: Kontrollierte Studien sind beim Darmversagen spärlich wegen der Seltenheit des Krankheitsbilds und der großen individuellen Unterschiede. Die prognostizierte Kurzdarmsituation auf der Basis einer möglichst detailliert beschriebenen anatomischen Ausgangssituation stellt die Indikation zur Ernährungsintervention dar. Die ergänzend intendierte, individualisierte parenterale Ernährung, die Prophylaxe und Therapie der Komplikationen und die rekonstruktiv-operativen Ansätze sollen konsequent umgesetzt werden. Spezifische und symptomatische pharmakologische Ansätze können ebenfalls genutzt werden. Die Darmtransplantation stellt eine Option beim drohenden Scheitern der parenteralen Ernährung dar.
Background & aims
Intestinal failure (IF) is not included in the list of PubMed Mesh terms, as failure is the term describing a state of non functioning of other organs, and as such is not well recognized. No scientific society has yet devised a formal definition and classification of IF. The European Society for Clinical Nutrition and Metabolism guideline committee endorsed its “home artificial nutrition and chronic IF” and “acute IF” special interest groups to write recommendations on these issues..
Methods
Using a Medline Search, in December 2013, for "intestinal failure" and "review"[Publication Type], the project was developed using the Delphi round methodology. The final consensus was reached on March 2014, after 5 Delphi rounds and two live meetings.
Results
The recommendations comprise the definition of IF, a functional and a pathophysiological classification for both acute and chronic IF and a clinical classification of chronic IF. IF was 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 is required to maintain health and/or growth”.
Conclusions
This formal definition and classification of IF, will facilitate communication and cooperation among professionals in clinical practice, organization and management, and research.
Purpose: Nutritional support in the homecare and outpatient sector comprises home parenteral nutrition (HPN) and home enteral nutrition (HEN) as well as oral nutritional supplements (ONS), being administered in the patientʼs home or in nursing homes. In most cases the HPN/HEN starts following an in-patient treatment in hospital. The present guideline offers evidence-based recommendations for nutritional support in the outpa-
tient or homecare sector.
Methods: A systematic literature search about HEN, HPN, and ONS in the homecare sector was conducted. The results were discussed in an inter-disciplinary working group that consisted of physicians, pharmacists, nutrition scientists and dietitians. Based on this discussion and the literature, the working group developed recommendations, which were presented, discussed, partly modified and finally passed at the consensus conference on December 1st, 2012.
Results: The guideline includes 54 recommendations for nutritional support in the outpatient sector. The indication for nutritional support in the outpatient sector does not differ basically from the indication for the in-patient treatment. Criteria like prognosis, quality of life and ethical considerations play a more important role in the outpatient sector. The appropriate way of administration nutritional support in the homecare setting depends on the functional integrity of the gastrointestinal tract. In case of a long-term HEE a percutaneous endoscopic gastrostomy (PEG) tube should be preferred towards surgical gastrostomy procedures, because of lower complication rates. In case of relevant disorders of transport and absorptive capacity of the small intestine intravenous nutrition should be chosen. The nursing care of the tubes and catheters for HEN and HPN should be carried out by professional care attendants according to evidence-based guidlines andnursing standards in order to achieve a high hygiene quality. For the exclusive and long-term HEN via gastrointestinal tube and for nutritional support by ONS nutritionally complete formula (“balanced diets”) should be used because they meet the D-A-CH recommendations and EU guidelines. For HPE, all-in-one bags/three-chamber-bags should be used because these are considered as safe, effective and risk-reducing standards for HPN. Conclusion: HEN and HPN are accepted as safe procedures, if they are performed following standardized routines according to up-to-date scientific evidence, and if they are coordinated preferably by an interdisciplinary nutrition support team (NST). The NST can enhance the quality of treatment and reduce complication rates. Nutritional support in the homecare and outpatient sector can contribute substantially to an improvement of the patientʼs quality of life and of cost efficiency of medical procedures.
Short bowel syndrome (SBS) is characterized by nutrient malabsorption and occurs following surgical resection, congenital defect, or disease of the bowel. The severity of SBS depends on the length and anatomy of the bowel resected and the health of the remaining tissue. During the 2 years following resection, the remnant bowel undergoes an adaptation process that increases its absorptive capacity. Oral diet and enteral nutrition (EN) enhance intestinal adaptation; although patients require parenteral nutrition (PN) and/or intravenous (IV) fluids in the immediate postresection period, diet and EN should be reintroduced as soon as possible. The SBS diet should include complex carbohydrates; simple sugars should be avoided. Optimal fat intake varies based on patient anatomy; patients with end-jejunostomies can tolerate a higher proportion of calories from dietary fat than patients with a remnant colon. Patients with SBS are prone to deficiencies in vitamins, minerals, and essential fatty acids; serum levels should be periodically monitored and supplements provided as needed. Prebiotic or probiotic therapy may be beneficial for patients with SBS, although further research is needed to determine optimal protocols. Patients with SBS, particularly those without a colon, are at high risk of dehydration; oral rehydration solutions sipped throughout the day can help maintain hydration. One of the primary goals of SBS therapy is to reduce or eliminate dependence on PN/IV; optimization of EN and hydration substantially increases the probability of successful PN/IV weaning.
Previous studies demonstrate improvement in IBS after antibiotic therapy, with the greatest efficacy seen with the antibiotic, rifaximin. The purpose of this study was to compare the efficacy of rifaximin in both the treatment and retreatment of IBS.
A retrospective chart review was conducted on Rome I-positive IBS patients. Charts were reviewed to evaluate all antibiotic treatments (rifaximin, neomycin, doxycycline, amoxicillin/clavulanate, and ciprofloxacin), even those predating 1 July 2004. Data collection included symptoms, breath test results (pre- and post-treatment), antibiotics used, and clinical response to individual antibiotic treatments before and after rifaximin availability in the USA.
Out of 98 eligible charts, 84 patients received one course of rifaximin. Fifty of these (60%) had a follow-up breath test. Among these, 31 (62%) were clinical responders and 19 (38%) were nonresponders. Of 31 responders, 25 (81%) had a normal follow-up breath test compared with only 3 of the 19 nonresponders (16%) (P < 0.001). Of participants given rifaximin, 69% (58 out of 84) had a clinical response compared with only 38% (9 out of 24) with neomycin (P < 0.01) and 44% (27 out of 61) with all non-rifaximin antibiotics (P < 0.01). Rifaximin was used as retreatment on 16 occasions, and all patients improved.
Rifaximin is more effective than other antibiotics in the treatment and retreatment of IBS.
Es existiert eine Vielzahl teils ähnlicher, teils sehr unterschiedlicher viszeralchirurgischer Operationstechniken am Darm. Immer komplexere Eingriffe machen es für Allgemeinmediziner und Ärzte anderer Disziplinen unerlässlich, sich Grundzüge spezifischer Anforderungen von Patienten nach Darmoperationen anzueignen. Einerseits spielen direkt postoperativ-chirurgische Faktoren eine Rolle, wie das Verständnis um Wundheilung, Kostaufbau und Schmerztherapie. Zum anderen ist es für den ambulant weiterbehandelnden Arzt wichtig, über stuhlregulierende Maßnahmen und Besonderheiten einer Stomaversorgung Bescheid zu wissen. Diese Übersichtsarbeit gibt allgemeine Hinweise für die postoperative Betreuung und Nachsorge von Patienten nach Darmoperationen. Darüber hinaus werden wichtige betreuungsspezifische Besonderheiten der häufigsten Darmoperationen aufgeführt.© Sebastian Kaulitzki / stock.adobe.com © Sebastian Kaulitzki / stock.adobe.com
Purpose of review:
The purpose of this article is to review the existing literature on the current indications, surgical techniques, immunosuppressive therapy and outcomes following intestinal transplantation (ITx).
Recent findings:
Over recent years, ITx has become a more common operation with approximately 2500 procedures carried out worldwide by 2014. It is reserved for patients with intestinal failure and who have developed complications of home parenteral nutrition or who have a high risk of dying from their underlying disease. Recent advances such as the improvement in survival rates, not only for isolated small bowel transplants but also following inclusion of a liver graft in combined liver-small bowel transplant, and the utility of citrulline as a noninvasive biomarker to appreciate acute rejection herald an exciting shift in the field of ITx.
Summary:
With advancements in immunosuppressive drugs, induction regimens, standardization of surgical techniques and improved postoperative care, survival is increasing. In due course, it will most likely become as good as remaining on home parenteral nutrition and as such could become a viable first-line option.
Subcutaneous teduglutide (Revestive(®)), a glucagon-like peptide-2 analogue that increases intestinal absorption, is approved in the EU for the treatment of short bowel syndrome (SBS) in patients aged ≥1 year who are stable following a period of postsurgical intestinal adaptation. In a phase III trial in adults with SBS intestinal failure (IF) dependent on parenteral support (PS), a significantly greater proportion of teduglutide 0.05 mg/kg/day than placebo recipients achieved a ≥20% reduction in weekly PS volume from baseline to week 20 and maintained it to week 24. The proportion of patients who had a reduction in one or more days on PS was also significant with teduglutide compared with placebo. Improved intestinal absorption and reduced PS requirements were generally maintained in the longer term. Results from a phase III trial in paediatric patients with SBS-IF dependent on PS were consistent with those in adults. Adverse events were mostly of mild to moderate severity and generally consistent with the underlying condition or known mechanism of the drug (e.g. central line-related issues, gastrointestinal events). Teduglutide is therefore a useful treatment option in children (aged ≥1 year), adolescents and adults with SBS.
Quality of life (QoL) gains importance in intestinal transplantation (ITx). This systematic review aimed to summarize all evidence on self-reported QoL in adult ITx. Pubmed, EMBASE, CCTR, CINAHL, PsycINFO were searched until October 2014. Structured data abstraction was performed and methodological quality was assessed using a standardized checklist. Nine eligible studies were identified addressing one or more study-aims: (i) QoL comparison pre- and post-ITx (n = 4); (ii) QoL follow-up post-ITx (n = 1); (iii) QoL comparison between ITx and home parenteral nutrition (HPN) patients (n = 6), healthy subjects (n = 1), general population (n = 1). Assessments indicated sub-optimal methodology throughout, e.g., retrospective (n = 2) and cross-sectional (n = 7) study designs, non-probabilistic sampling with inadequate matching of ITx subjects, non-standard terminology, lack of operational definitions and variety in assessment instruments. Still, despite these inconsistencies, this review produced three encouraging findings: (i) post-ITx QoL improved versus pre-ITx (anxiety, sleep, social support, leisure); (ii) post-ITx QoL improved with longer follow-up (anxiety, impulsiveness/control); and (iii) QoL between ITx and HPN patients was similar for most domains yet ITx patients excelled for energy, social functioning and travel ability. Although results are encouraging, QoL research in adult ITx is scarce and needs methodological improvement by implementing prospective multicenter studies, adequate QoL conceptualization and appropriate measurements.
The Registry has gathered information on intestine transplantation (IT) since 1985. During this time, individual centers have reported progress but small case volumes potentially limit the generalizability of this information. The present study was undertaken to examine recent global IT activity. Activity was assessed with descriptive statistics, Kaplan–Meier survival curves and a multiple variable analysis. Eighty-two programs reported 2887 transplants in 2699 patients. Regional practices and outcomes are now similar worldwide. Current actuarial patient survival rates are 76%, 56% and 43% at 1, 5 and 10 years, respectively. Rates of graft loss beyond 1 year have not improved. Grafts that included a colon segment had better function. Waiting at home for IT, the use of induction immune-suppression therapy, inclusion of a liver component and maintenance therapy with rapamycin were associated with better graft survival. Outcomes of IT have modestly improved over the past decade. Case volumes have recently declined. Identifying the root reasons for late graft loss is difficult due to the low case volumes at most centers. The high participation rate in the Registry provides unique opportunities to study these issues.
As data about prevalence and standard of care in short bowel syndrome (SBS) are not available for Germany, this study estimated the prevalence and assessed the medical infrastructure to potentially improve care of SBS patients.
In a validated approach for prevalence estimation in rare diseases, a randomized census of 478 size-stratified hospitals with surgical, internal medicine and pediatric departments was conducted to estimate SBS prevalence. The number of SBS patients, specialized outpatient clinics and caregiver expertise were assessed.
The response rate was 85 % of randomized hospitals (405/478). Strata-derived estimation yielded a total of 2,808 SBS patients in Germany for 2011/2012 (95 % CI: 1750.3865), translating into a prevalence estimation for 34/million inhabitants (95 % CI: 21.47). Overall expertise in SBS treatment was only rated "satisfactory" by most caregivers. While 86 specialized outpatient clinics were identified, there was no central registry to access these resources.
Short bowel syndrome, with a newly estimated prevalence of 34/million inhabitants is not a very rare medical condition in Germany. The interdisciplinary approach needed for optimal care for SBS patients would be greatly facilitated by a central registry.
Small intestinal bacterial overgrowth (SIBO) is an under-recognised diagnosis with important clinical implications when untreated. However, the optimal treatment regimen remains unclear.
To perform a systematic review and meta-analysis comparing the clinical effectiveness of antibiotic therapies in the treatment of symptomatic patients with documented SIBO.
Four databases were searched to identify clinical trials comparing effectiveness of: (i) different antibiotics, (ii) different doses of the same antibiotic and (iii) antibiotics compared with placebo. Data were independently extracted according to predetermined inclusion and exclusion criteria. Study quality was independently assessed. The primary outcome was normalisation of post-treatment breath testing. The secondary outcome was post-treatment clinical response.
Of 1356 articles identified, 10 met inclusion criteria. Rifaximin was the most commonly studied antibiotic (eight studies) with overall breath test normalisation rate of 49.5% (95% confidence interval, CI 44.0-55.1) (44.0%-55.1%) then (46.7%-55.5%), then (4.6%-17.8%). Antibiotic efficacy varied by antibiotic regimen and dose. Antibiotics were more effective than placebo, with a combined breath test normalisation rate of 51.1% (95% CI 46.7-55.5) for antibiotics compared with 9.8% (95% CI 4.6-17.8) for placebo. Meta-analysis of four studies favoured antibiotics over placebo for breath test normalisation with an odds ratio of 2.55 (95% CI 1.29-5.04). Clinical response was heterogeneously evaluated among six studies, but tended to correlate with breath test normalisation.
Antibiotics appear to be more effective than placebo for breath test normalisation in patients with symptoms attributable to SIBO, and breath test normalisation may correlate with clinical response. Studies were limited by modest quality, small sample size and heterogeneous design. Additional higher quality clinical trials of SIBO therapy are warranted.
Despite the current increase in interest in the role of the microbiota in health and disease and the recognition, for over 50 years, that an excess of colonic-type flora in the small intestine could lead to a malabsorption syndrome, small intestinal overgrowth remains poorly defined. This lack of clarity owes much to the difficulties that arise in attempting to arrive at consensus with regard to the diagnosis of this condition: there is currently no gold standard and the commonly available methodologies (the culture of jejunal aspirates and a variety of breath tests) suffer from considerable variations in their performance and interpretation, leading to variations in the prevalence of overgrowth in a variety of clinical contexts. Treatment is similarly supported by a scant evidence base and the most commonly used antibiotic regimens owe more to custom than clinical trials.
To point new insights in the cholestasis that is a complication of both intestinal failure and parenteral nutrition. View on liver disease has recently evolved with the onset of fish oil-based intravenous lipid emulsions (ILE).
Focused on the role of ILE in causing liver disease. Reversal of cholestasis was recently achieved in infants with short bowel syndrome, by replacing the 'reference' soybean oil-based ILE by fish oil-based ILE.
It is likely that this reversal involves several factors such as the change in n-6: n-3 ratio, the reduction in phytosterol load, the increased provision of alpha-tocopherol as antioxidant agent. Alternative issue might be based on the use of a new generation of ILE aiming to provide n-3 and to reduce n-6 fatty acids load while enhancing alpha-tocopherol intake. New data are based on the use of an ILE containing a balanced proportion of four types of oil as a physical mixture of 30% soybean oil, 30% medium-chain triglycerides, 25% olive oil and 15% fish oil with amounts of alpha-tocopherol calculated according to the number of double bonds. This new emulsion was reported to be beneficial in reversing or preventing liver disease.
A reproducible technique is described for doubling the length of a loop of small intestine, while simultaneously reducing its luminal diameter, and preserving the maximum amount of small bowel mucosa for intestinal adaptation. In pig experiments, 7 loops have been increased in length by the "intestinal loop lengthening" procedure, with survival of 5 of the 7 animals for a period of 16-26 wk. Leakage from the lengthened intestinal segment led to the death of one animal. At a second operation, or at termination of the experiment, all seven lengthened loops had a good blood supply and were patent along their full length. Histologic examination of 3 of the 4 specimens from the first phase of the study confirmed their viability. The potential application of intestinal loop lengthening in the management of the short gut syndrome is discussed.
The short bowel syndrome (SBS) may be associated with either transient or permanent intestinal failure, presently treated by parenteral nutrition (PN). Survival and PN-dependence probabilities, taking into account both small bowel remnant length and the type of the digestive circuit of anastomosis, are not known in adult SBS patients. The aim of this study was to assess such prognostic factors.
A total of 124 consecutive adults with nonmalignant SBS were enrolled from 1980 to 1992 at 2 home PN centers. They were analyzed for survival and PN-dependence probabilities using the Cox model and for PN dependence using linear discriminant analysis. Data were updated in April 1996.
Survival and PN-dependence probabilities were 86% and 49% and 75% and 45% at 2 and 5 years, respectively. In multivariate analysis, survival was related negatively to end-enterostomy, to small bowel length of <50 cm, and to arterial infarction as a cause of SBS, but not to PN dependence. The latter was related negatively to postduodenal small bowel lengths of <50 and 50-99 cm and to absence of terminal ileum and/or colon in continuity. Cutoff values of small bowel lengths separating transient and permanent intestinal failure were 100, 65, and 30 cm in end-enterostomy, jejunocolic, and jejunoileocolic type of anastomosis, respectively.
In adult SBS patients, small bowel length of <100 cm is highly predictive of permanent intestinal failure. Presence of terminal ileum and/or colon in continuity enhances both weaning off PN and survival probabilities. After 2 years of PN, probability of permanent intestinal failure is 94%. These rates may lead to selection of other treatments, especially intestinal transplantation, instead of PN, for permanent intestinal failure caused by SBS.
Bowel lengthening may be beneficial for children with short bowel syndrome. However, current techniques require at least one intestinal anastomosis and place the mesenteric blood supply at risk. This study seeks to establish the technical principles of a new, simple, and potentially safer bowel lengthening procedure.
Young pigs (n = 6) underwent interposition of a reversed intestinal segment to produce proximal small bowel dilation. Five weeks later the reversed segment was resected. Lengthening of the dilated bowel then was performed by serial transverse applications of a GIA stapler, from opposite directions, to create a zig zag channel. A distal segment of equal length served as an in situ morphometric control. Contrast radiologic studies were performed 6 weeks later, and the animals were killed. Statistical comparisons were made by paired t test with P less than.05 considered significant.
After bowel lengthening, all animals gained weight (66.7 +/- 3.0 [SD] kg v 42.5 +/- 3.5 kg; P <.001) and showed no clinical or radiologic evidence of intestinal obstruction. Intraoperatively, immediately after serial transverse enteroplasty, the intestine was substantially elongated (82.8 +/- 6.7 cm v 49.2 +/- 2 cm; P <.01). Six weeks after surgery, the lengthened intestinal segment became practically straight and, compared with the in situ control, remained significantly longer (80.7 +/- 13.1 cm v 57.2 +/- 10.4 cm; P <.01). There was no difference in diameter between these segments (4.3 +/- 0.7 cm v 3.8 +/- 0.4 cm; P value, not significant).
Serial transverse enteroplasty (STEP) significantly increases intestinal length without any evidence of obstruction. This procedure may be a safe and facile alternative for intestinal lengthening in children with short bowel syndrome.
Nosocomial infections are a leading cause of morbidity and mortality among hospitalized patients. These infections have made newspaper headlines recently in many countries, and both patients and their relatives are now perfectly aware of their existence and of the risks which are inherent to any medical activity. However, significant improvements in the knowledge of the pathophysiology and epidemiology of nosocomial infections allow us to prevent them efficiently. Accordingly, they should no longer be considered as an inevitable tribute to pay to the continuous progress of medicine, but as a real challenge in the process of improving the quality of patient care. This is particularly the case for bloodstream infections, of which at least 80% are considered to be catheter associated. This paper reviews the epidemiology and impact of infections associated with the use of intravenous catheters. Principles of therapy are reviewed, as well as major aspects of prevention.
Conventional management of dialysis catheter-related bacteremia involves administration of systemic antibiotics, as well as removal of the infected catheter. This approach adds burdensome and expensive procedures, and creates short-term problems for dialysis access. Recent research has shown that bacterial biofilms form routinely in the catheter lumen, and act as the nidus for bacteremic episodes. Instillation of a concentrated antibiotic-anticoagulant solution into the catheter lumen ('antibiotic lock') may permit successful treatment of the infection, while salvaging the patient's catheter. A number of recent studies have reported the success of an antibiotic lock protocol in about two thirds of cases of catheter-related bacteremia. Catheter replacement is only performed in those patients with protocol failures (persistent fever or positive surveillance blood cultures). In conclusion, routine application of an antibiotic lock protocol may reduce substantially the need for routine catheter replacement in hemodialysis patients with catheter-related bacteremia.
Rifaximin is a broad spectrum non-absorbable antibiotic used for treatment of small intestinal bacterial overgrowth. Doses of 1200 mg/day showed a decontamination rate of 60% with low side-effects incidence.
To assess efficacy, safety and tolerability of rifaximin 1600 mg with respect to 1200 mg/day for small intestinal bacterial overgrowth treatment.
Eighty consecutive small intestinal bacterial overgrowth patients were enrolled. Diagnosis of small intestinal bacterial overgrowth based the clinical history and positivity to H(2)/CH(4) glucose breath test. Patients were randomized in two 7-day treatment groups: rifaximin 1600 mg (group 1); rifaximin 1200 mg (group 2). Glucose breath test was reassessed 1 month after. Compliance and side-effect incidence were also evaluated.
One drop-out was observed in group 1 and two in group 2. Glucose breath test normalization rate was significantly higher in group 1 with respect to group 2 both in intention-to-treat (80% vs. 58%; P < 0.05) and per protocol analysis (82% vs. 61%; P < 0.05). No significant differences in patient compliance and incidence of side effects were found between groups.
Rifaximin 1600 mg/day showed a significantly higher efficacy for small intestinal bacterial overgrowth treatment with respect to 1200 mg with similar compliance and side-effect profile.
Short bowel syndrome in Germany. Estimated prevalence and standard of care
- Von Websky
- M M Liermann
- U Buchholz
- MM Von Websky
American Gastroenterological Association medical position statement: short bowel syndrome and intestinal transplantation
Parenterale Ernährung. Arzneiverordnung in der Praxis
- U Zech
Parenterale Substitution und parenterale Ernährung bei Darmversagen
- G Lamprecht