RESUMEN
OBJECTIVE(S): To define the evolving role of integrative surgical management including transplantation for patients gut failure (GF). METHODS: A total of 500 patients with total parenteral nutrition-dependent catastrophic and chronic GF were referred for surgical intervention particularly transplantation and comprised the study population. With a mean age of 45â±â17 years, 477 (95%) were adults and 23 (5%) were children. Management strategy was guided by clinical status, splanchnic organ functions, anatomy of residual gut, and cause of GF. Surgery was performed in 462 (92%) patients and 38 (8%) continued medical treatment. Definitive autologous gut reconstruction (AGR) was achievable in 378 (82%), primary transplant in 42 (9%), and AGR followed by transplant in 42 (9%). The 84 transplant recipients received 94 allografts; 67 (71%) liver-free and 27 (29%) liver-contained. The 420 AGR patients received a total of 790 reconstructive and remodeling procedures including primary reconstruction, interposition alimentary-conduits, intestinal/colonic lengthening, and reductive/decompressive surgery. Glucagon-like peptide-2 was used in 17 patients. RESULTS: Overall patient survival was 86% at 1-year and 68% at 5-years with restored nutritional autonomy (RNA) in 63% and 78%, respectively. Surgery achieved a 5-year survival of 70% with 82% RNA. AGR achieved better long-term survival and transplantation better (P = 0.03) re-established nutritional autonomy. Both AGR and transplant were cost effective and quality of life better improved after AGR. A model to predict RNA after AGR was developed computing anatomy of reconstructed gut, total parenteral nutrition requirements, cause of GF, and serum bilirubin. CONCLUSIONS: Surgical integration is an effective management strategy for GF. Further progress is foreseen with the herein-described novel techniques and established RNA predictive model.
Asunto(s)
Reglas de Decisión Clínica , Enfermedades Intestinales/cirugía , Intestinos/trasplante , Terapias en Investigación/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Lactante , Enfermedades Intestinales/diagnóstico , Enfermedades Intestinales/mortalidad , Trasplante de Hígado , Masculino , Persona de Mediana Edad , Calidad de Vida , Resultado del Tratamiento , Adulto JovenRESUMEN
The Cleveland Clinic institutional guidelines for the management of intestinal failure, including long-term or home parenteral nutrition and related complications, intestinal rehabilitation, and small bowel transplantation, were reviewed. PubMed was searched for relevant articles. The search was performed in November 2008; keywords used were home parenteral nutrition, short bowel syndrome, intestinal rehabilitation, and small-bowel transplantation. Randomized, prospective, observational, retrospective reviews and case report articles that contained relevant data for long-term parenteral nutrition, intestinal rehabilitation, and intestinal transplantation were selected. Researchers reviewed 67 selected articles that met our inclusion criteria. Our institution data registries for intestinal rehabilitation and home parenteral nutrition were also reviewed for relevant data. The survival of tens of thousands of children and adults with complicated gastrointestinal problems has been possible because of parenteral nutrition. In selected patients, a program of intestinal rehabilitation may avoid the need for long-term parenteral nutrition.
Asunto(s)
Enfermedades Intestinales/diagnóstico , Enfermedades Intestinales/terapia , Nutrición Parenteral Total/métodos , Síndrome del Intestino Corto/terapia , Centros Médicos Académicos , Continuidad de la Atención al Paciente , Femenino , Estudios de Seguimiento , Humanos , Enfermedades Intestinales/mortalidad , Enfermedades Intestinales/cirugía , Intestinos/trasplante , Cuidados a Largo Plazo , Masculino , Necesidades Nutricionales , Estado Nutricional , Nutrición Parenteral en el Domicilio/efectos adversos , Nutrición Parenteral en el Domicilio/métodos , Nutrición Parenteral Total/efectos adversos , Alta del Paciente , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudios Retrospectivos , Medición de Riesgo , Síndrome del Intestino Corto/diagnóstico , Síndrome del Intestino Corto/mortalidad , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
Intestinal failure is a complex disease state for which extensive therapy is often required. Parenteral nutrition is one of these therapies, but with its long-term use, life-threatening complications may develop. Intestinal rehabilitation to enhance intestinal absorption and function through diet and medication is another therapy that can be used in hopes of weaning parenteral nutrition and preventing malnutrition. For patients who develop complications from parenteral nutrition and fail intestinal rehabilitation interventions, intestinal transplantation may be the best option. In this review, therapies available for intestinal failure and the use of a multidisciplinary approach to the patient with intestinal failure will be reviewed.
Asunto(s)
Enfermedades Intestinales/terapia , Intestinos/trasplante , Nutrición Parenteral , Síndrome del Intestino Corto/terapia , Adaptación Fisiológica , Terapia Combinada , Humanos , Absorción Intestinal , Nutrición Parenteral/efectos adversosRESUMEN
Treatment of short bowel syndrome (SBS) is often a difficult endeavor due to the high variability among patients with SBS in regard to remaining anatomical structure and functional capacity. Research efforts to substantiate the use of existing therapies in the treatment of SBS are ongoing, with newer developments yet to be fully explored. Current therapy for SBS begins with the implementation of a modified diet based on the presence or absence of the colon. Patients with difficulty ingesting enough nutrients and fluids for weight maintenance and fluid balance may benefit from nocturnal enteral nutrition and hydration. Those with inadequate absorptive capacity despite maximization of oral and enteral intake will need parenteral nutrition (PN) or hydration. Medications, including antisecretory agents, antidiarrheals, pancreatic enzymes, bile acid sequestrants, and antibiotics, often are useful in abating symptoms commonly associated with SBS. Growth factors, including recombinant human growth hormone and glucagon-like peptide 2, may be trialed to stimulate intestinal adaptation and enhance absorption in PN-dependent SBS patients. The gradual refinement of surgical procedures for SBS, including small bowel transplantation, has led to improved outcomes, and early referral of SBS patients to centers of excellence will optimize care.
RESUMEN
Extensive resection of the intestinal tract with resulting malabsorption is known as short bowel syndrome (SBS). Adaptation and rehabilitation of the remaining small bowel occurs spontaneously after resection and can be enhanced by diet, medications, and use of intestinal trophic factors such as recombinant human growth hormone (r-hGH). Many trials have been published on the influence of r-hGH therapy in SBS patients, with varying results. Analysis of the trials has produced a set of criteria that can be used to define the patient most likely to benefit from r-hGH therapy.
Asunto(s)
Hormona de Crecimiento Humana/uso terapéutico , Síndrome del Intestino Corto/tratamiento farmacológico , Adaptación Fisiológica/efectos de los fármacos , Humanos , Absorción Intestinal/efectos de los fármacos , Educación del Paciente como Asunto , Selección de Paciente , Proteínas Recombinantes/uso terapéutico , Resultado del TratamientoRESUMEN
Hiram Studley's 1936 article of research was the first publication to present a connection between preoperative weight loss and adverse postoperative outcome. Almost 70 years later, weight loss remains one of the most prominently used tools to assess nutritional status and predict surgical risk. This paper provides an overview of surgical practices at the time of Dr Studley and demonstrates Studley's unique contributions to the field of nutrition support. The search for more accurate methods of preoperative nutrition assessment is traced to show how subsequent research continues to validate the use of weight loss in the assessment of surgical risk. New developments center on techniques of body composition assessment to quantify weight lost as functional weight and clarify the impact of malnutrition on operative outcome.