短肠综合征的营养康复治疗

短肠综合征的治疗主要为营养支持和小肠移植,但两种疗法都有其限制和不足之处。作者总结了３例短肠综合征患者联合应用重组人生长激素、谷氨酰胺、纤维素行营养康复治疗的经验,３例患者残存小肠的长度分别为６５、７５、３０ｃｍ,治疗后患者残存肠管的吸收功能和营养状况均有明显改善。作者认为营养康复疗法为短肠综合征提供了一个新的有效的治疗选择。     

短肠综合征治疗中值得注意的问题

随着对短肠综合征的病理生理过程和残存小肠适应性代偿机制的深入认识以及临床应用营养支持和器官移植技术的进步,短肠综合征的治疗效果取得了长足进步.短肠综合征的治疗包括：针对短肠综合征代谢改变的内科治疗、营养支持、残存小肠康复治疗、非移植的外科手术和小肠移植.然而,除了残存小肠的长度、功能等因素外,治疗是否及时、适当也是影响短肠综合征疗效的重要因素,有许多问题值得注意.     

短肠综合征康复治疗的实验研究和临床应用

目的观察应用重组人生长激素、谷氨酰胺和膳食纤维行康复治疗的实验动物及短肠综合征患者的治疗效果。方法 30只大鼠分为对照组、短肠组和生长激素 (growthhormone ,GH)组 ,短肠组和GH组切除 80 %小肠 ,GH组术后第 1天开始注射GH 1U·kg-1·d-1,共 2 8d ;9例患者残存小肠长度为 (4 4± 2 4)cm ,其中 3例无完整结肠。结果S期细胞比率系数、增殖指数和增殖细胞核抗原表达的增强表明外源性GH可明显促进残存小肠粘膜的增殖 ,GH的作用机理可能与原癌基因C jun表达的改变有关。康复治疗后 9例患者营养状况和残存肠管吸收功能均明显改善 ,8例患者进行了随访 ,75 %的患者完全脱离肠外营养 ,2 5 %的患者需间断肠外营养补充。结论康复治疗为短肠综合征提供了一个新的有效的治疗方法     

短肠综合征患者血清瓜氨酸水平与小肠吸收面积和功能的相关性

目的研究短肠综合征患者血清瓜氨酸水平的变化及其与肠道面积及吸收功能的相关性。方法采用高效液相色谱法测定22例短肠患者（短肠组）和33例健康人（对照组）血清瓜氨酸水平。短肠患者残存小肠长度及直径采用X线造影检测，并测定短肠患者尿D-木糖排泄率和肠道蛋白吸收度。分析短肠患者血清瓜氨酸与残存小肠长度、面积、蛋白及D-木糖吸收的相关性。6例行肠康复治疗的患者测定康复治疗前后瓜氨酸、D-木糖及蛋白吸收水平的变化。结果短肠组血清瓜氨酸水平显著低于健康对照组[（5．94±2．65）比（16．87±5．97）μmol／L，P〈0．01]。短肠组患者血清瓜氨酸水平与残存小肠长度（r=0.82）及表面积（r=0.86）呈正相关，与尿D-木糖排泄（r=0.56）及肠道蛋白吸收（r=0.48）也呈正相关。6例行肠康复治疗的患者治疗后血清瓜氨酸水平、蛋白及D-木糖吸收均显著增加，但3者增加百分比之间并无相关。结论血清瓜氨酸水平与短肠患者的小肠吸收面积和吸收功能呈正相关，能反映短肠患者小肠功能和衰竭程度，是康复疗效的良好指标。     

短肠综合征并肠外瘘的诊治(附32例分析)

目的研究短肠综合征合并肠外瘘的诊断与治疗方法的特点与规律。方法1995~2005年共收治剩余小肠<100 cm的肠外瘘病人32例,就肠外瘘发生原因、部位、治疗方法和肠康复方法进行分析。结果治愈20例,死亡6例,6例好转后中断治疗出院。病人残存的肠管平均(58.03±28.30)cm。28例接受了肠内营养,其中9例未进行肠康复治疗,肠管平均长度为(52.8±31.5)cm,肠内营养平均恢复时间为(129.6±89.8)d;19例接受了肠康复治疗,肠管平均长度(64.1±19.2)cm,肠内营养平均恢复时间为(61.8±54.0)d。结论短肠综合征合并肠外瘘的主要疾病为肠扭转,部位多在吻合口,原因是坏死范围较大,切除界限不易判断。早期使用生长抑素有减少肠液分泌的作用,还可减少短肠综合征急性期的腹泻症状。后期使用生长激素有促进肠外瘘自愈和肠康复的双重作用。     

危重患者急性胃肠损伤与肠康复治疗

急性胃肠损伤(AGI)是指危重患者因为急性疾病导致胃肠道功能不正常.AGI按严重程度可分为4级:Ⅰ级,存在发展至胃肠道功能障碍和衰竭的风险;Ⅱ级,胃肠道功能障碍;Ⅲ级,胃肠道功能衰竭;Ⅳ级,胃肠道功能衰竭伴有远隔器官功能障碍.AGI的症状包括呕吐与反流、胃潴留、腹泻、消化道出血、麻痹性肠梗阻、肠扩张和肠鸣音异常.针对目前国内外诊断和治疗AGI的现状,可应用肠康复治疗AGI.肠康复是早年促进短肠综合征患者残存小肠恢复肠内营养与经口饮食的整套方案.肠康复的步骤包括全肠外营养、肠外+肠内营养、全肠内营养和经口饮食等4个阶段.临床实践中应根据AGI损伤的程度决定肠康复的起始措施,不一定拘泥于前述的4个步骤,同时还应通过肠内或肠外途径提供肠黏膜组织特异营养因子.     

短肠综合征患者健康相关生命质量研究及影响因素调查

目的调查短肠综合征患者健康相关生命质量(HRQOL)状况,并统计健康相关生命质量的影响因素及其主次关系。方法使用生活质量评价量表(SF-36)测量HRQOL总分,并对短肠综合征患者的一般状况进行统计,同时使用单因素方差分析及多元逐步线性回归统计对HRQOL的影响因素进行分析。结果影响HRQOL评分的9个因素依次为:治疗、食欲、小肠吻合方式、锻炼、月收入、饮酒、睡眠时间、年龄、居住地(P0.05)。HRQOL得分与治疗、食欲、锻炼、月收入、睡眠时间呈正相关(P0.05),与小肠吻合方式、饮酒、年龄、居住地呈负相关(P0.05)。结论短肠综合征患者HRQOL不佳,应加大对低收入、农村、中老年以及采用高位空肠造口术的患者的重视。我们应对患者积极营养治疗和肠康复治疗,鼓励患者戒酒和多运动锻炼,保证充沛的睡眠时间,促进食欲。以上措施可显著改善短肠综合征患者HRQOL。     

生长因子及其在短肠综合征中的应用

目的探讨生长因子促进大量肠切除后肠道代偿的作用与机制,并了解其在短肠综合征营养支持治疗中的研究进展。方法对介绍生长因子促进肠切除后肠道代偿以及其在短肠综合征患者的应用的有关文献进行综述。结果不同种类的生长因子对促进肠切除后肠道代偿产生着不同的效应,可根据短肠综合征患者的具体情况合理选择外源性生长因子,以缩短残留小肠代偿时间,改善患者的营养状况。结论生长因子能够在一定意义上促进肠切除后肠道代偿,但不同种类的生长因子有各自的作用效应,将对短肠综合征患者尽早摆脱完全肠外营养有帮助,但仍需进一步的研究。     

短肠综合征的手术治疗进展

近年来随着小肠疾病发病率及诊断率的升高,短肠综合征的发病率也呈逐年上升趋势。手术是治疗短肠综合征的重要方法,其手术治疗方式主要包括治疗短肠综合征并发症、促进肠动力、延长食物停留时间、小肠缩窄与延长以及小肠移植术。     

活体部分小肠移植治疗短肠综合征并肠瘘1例的临床经验

目的 总结活体部分小肠移植在治疗短肠综合征合并肠瘘中的临床经验.方法 1例短肠综合征合并肠瘘患者接受其子的150 cm 回肠,供肠动、静脉分别与受体的腹主动脉和下腔静脉行端侧吻合,受体残余空肠与供体回肠近端行端端吻合,受体结肠与供肠远端行端侧吻合,供肠远端造瘘作为观察窗,术后给予免疫抑制等治疗. 结果患者小肠移植术后恢复顺利,肠道功能恢复,血管吻合口通畅,正常生活110 d后因心脏意外死亡.结论 短肠综合征合并肠瘘患者实施活体部分小肠移植是可行的,植入肠管的血管植入技术对小肠移植成功非常重要.     

Improved survival in a multidisciplinary short bowel syndrome program

Purpose

Pediatric short bowel syndrome (SBS) remains a management challenge with significant mortality. In 1999, we initiated a multidisciplinary pediatric intestinal rehabilitation program. The purpose of this study was to determine if the multidisciplinary approach was associated with improved survival in this patient population.

Methods

The Center for Advanced Intestinal Rehabilitation includes dedicated staff in surgery, gastroenterology, nutrition, pharmacy, nursing, and social work. We reviewed the medical records of all inpatients and outpatients with severe SBS treated from 1999 to 2006. These patients were compared to a historical control group of 30 consecutive patients with severe SBS who were treated between 1986 and 1998.

Results

Fifty-four patients with severe SBS managed by the multidisciplinary program were identified. Median follow-up was 403 days. The mean residual small intestinal length was 70 ± 36 vs 83 ± 67 cm in the historical controls (P = NS). Mean peak direct bilirubin was 8.1 ± 7.9 vs 9.0 ± 7.4 mg/dL in controls (P = NS). Full enteral nutrition was achieved in 36 (67%) of 54 patients with severe SBS vs 20 (67%) of 30 patients in the control group (P = NS). The overall survival rate, however, was 89% (48/54), which is significantly higher than in the historical controls (70%, 21/30; P < .05).

Conclusions

A multidisciplinary approach to intestinal rehabilitation allows for fully integrated care of inpatients and outpatients with SBS by fostering coordination of surgical, medical, and nutritional management. Our experience with 2 comparable cohorts demonstrates that this multidisciplinary approach is associated with improved survival.     

Current management of the short bowel syndrome

Short bowel syndrome is a challenging clinical problem that benefits from a multidisciplinary approach. Much progress has recently been made in all aspects of management. Medical intestinal rehabilitation should be the initial treatment focus, and several new potential pharmacologic agents are being investigated. Surgical rehabilitation using nontransplant procedures in selected patients may further improve intestinal function. Intestinal lengthening procedures are particularly promising. Intestinal transplantation has increasingly been used with improving success in patients with life-threatening complications of intestinal failure.     

Medical management of motility disorders in patients with intestinal failure: a focus on necrotizing enterocolitis, gastroschisis, and intestinal atresia

Background

Intestinal failure (IF) is the dependence upon parenteral nutrition to maintain minimal energy requirements for growth and development. It may occur secondary to a loss of bowel length, disorders of motility, or both. Short bowel syndrome (SBS) is a malabsorptive state resulting from surgical resection, congenital defect, or diseases associated with loss of absorptive surface area. A particularly vexing problem is associated with whole bowel and/or segmental intestinal dysmotility. Motility disorders within the context of SBS and IF may relate to rapid intestinal transit secondary to loss of intestinal length, dysmotility associated with loss or poor antegrade peristalsis, or gastroparesis. Therapy may be classified into medical (prokinetic and antidiarrheal agents) and surgical to deal with the overdistended poorly motile bowel.

Methods

We performed a systematic review of the literature pertaining to IF, SBS, and dysmotility in the pediatric population with gastroschisis, necrotizing enterocolitis, and intestinal atresia. In addition to the available treatment options, we have provided a review of the literature and a summary of the available evidence.

Conclusion

Despite relatively poor level of evidence regarding the application of promotility and antidiarrheal medications in patients with SBS and IF, these agents continue to be used. Herein, we provide a review of the physiology and pathophysiology of intestinal motility/dysmotility and available strategies for the use of promotility and antidiarrheal agents in patients with IF/SBS.     

Bridging intestinal failure with Teduglutide – A case report

Introduction and importanceIntestinal failure (IF) describes the state of a person's gastrointestinal absorption capabilities becoming unable to absorb fluids and nutrients needed to sustain normal physiology, leading to severe comorbidities and if left untreated, to death. IF is most commonly seen as a result of short bowel syndrome (SBS).Teduglutide is a glucagon-like peptide 2 (GLP-2) analogue used in the treatment of patients with SBS and intestinal failure (IF) as a way to reduce the need for parenteral support. Teduglutide leads to the growth of intestinal mucosa by stimulating intestinal crypt cell growth and inhibiting enterocyte apoptosis. It is usually prescribed as a final treatment step after the diagnosis of SBS-IF is made.Case presentationIn this case report we present a novel strategy for using teduglutide as a bridging therapy to intestinal reconstruction. The patient achieved enteral autonomy preoperatively, underwent surgery, and remained in enteral autonomy after intestinal reconstruction.Clinical discussionTeduglutide has been previously exclusively used as continuous therapy in SBS-IF, this is the first reported case of using teduglutide as bridging to intestinal reconstruction. The hypothesis of this approach was to achieve an adequate nutritional status for reconstruction without the disadvantages of parenteral support.ConclusionThe controlled application of teduglutide can provide the benefits of preoperative nutritional optimization without the disadvantages of parenteral support and at the same time facilitate an earlier and easier intestinal reconstruction.     

Short bowel syndrome

The short bowel syndrome (SBS) is a state of malabsorption following intestinal resection where there is less than 200 cm of intestinal length. The management of short bowel syndrome can be challenging and is best managed by a specialised multidisciplinary team. A good understanding of the pathophysiological consequences of resection of different portions of the small intestine is necessary to anticipate and prevent, where possible, consequences of SBS. Nutrient absorption and fluid and electrolyte management in the initial stages are critical to stabilisation of the patient and to facilitate the process of adaptation. Pharmacological adjuncts to promote adaptation are in the early stages of development. Primary restoration of bowel continuity, if possible, is the principle mode of surgical treatment. Surgical procedures to increase the surface area of the small intestine or improve its function may be of benefit in experienced hands, particularly in the paediatric population. Intestinal transplant is indicated at present for patients who have failed to tolerate long-term parenteral nutrition but with increasing experience, there may be a potentially expanded role for its use in the future.     

An integrated approach to intestinal failure: Results of a new program with total parenteral nutrition, bowel rehabilitation, and transplantation

Intestinal failure can be treated with bowel rehabilitation, total parenteral nutrition, or intestinal transplantation. Little has been done to integrate these therapies for patients with intestinal insufficiency or failure and to develop an algorithm for appropriate use and timing. We established a multidisciplinary program using bowel rehabilitation, total parenteral nutrition, or intestinal transplantation as appropriate in a large population. Evaluation included clinical, pathlogic, and psychosocial assessments and assignment to therapy based on the results of this evaluation. Of 59 patients evaluated for life-threatening complications of intestinal failure, 68% were considered appropriate candidates for transplantation, 10% were managed with rehabilitation, and 17% were maintained on optimized long-term parenteral nutrition. Nineteen transplants were performed, with 78% patient survival and 66% graft survival. Patient survival among isolated intestine recipients was 90%. All patients managed with rehabilitation were weaned from parenteral nutrition within 6 months. Long-term management with parenteral nutrition resulted in a significant number of deaths both among patients waiting for a transplant and those who were poor candidates for transplant. Intestinal rehabilitation, when successful, is optimal. For patients with irreversible intestinal failure, isolated intestinal transplantation holds particular promise. Parenteral nutrition is plagued by high failure rates among this population of debilitated patients compared with the general parenteral nutrition population. Integration of these therapies, with individualization of care based on a multidisciplinary approach and perhaps with earlier isolated intestinal transplantation for patients with irreversible intestinal failure, should optimize survival. Presented in part at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, California, May 21–24, 2000 (oral presentation).     

Les nouveaux traitements médicamenteux dans le syndrome de grêle court de l’adulte

The European Society for Clinical Nutrition and Metabolism has recently published recommendations on the “definition and classification of intestinal failure (IF) in adults”. Two criteria must be simultaneously present to diagnose IF: a “decreased absorption of macronutrients and/or water and electrolytes due to a loss of gut function” and the “need for parenteral support”. Home parenteral support (HPS) is the primary treatment for chronic intestinal failure (CIF).The principal cause of CIF is the short bowel syndrome (SBS). The aim of treatments is to maximize intestinal absorption and avoid, reduce or eliminate the need for HPS to achieve the best possible quality of life for the patient. Teduglutide, an analog of glucagon-like peptide 2, improves intestinal rehabilitation by promoting mucosal growth thereby reducing intestinal losses and promoting intestinal absorption. Thus, several studies showed that the GLP2 decreases parenteral calorie and fluid requirements in SBS patients with CIF.     

Postoperative short bowel syndrome

BACKGROUND: Unanticipated massive resection after intraabdominal procedures is an increasing cause of short bowel syndrome (SBS). Our aim was to determine the frequency and potential mechanisms of postoperative SBS. STUDY DESIGN: We reviewed retrospectively the clinical course of 210 adult patients with SBS evaluated over a 20-year period. RESULTS: Fifty-two (25%) patients had postoperative SBS. The initial operations included colectomy (n=20), hysterectomy (n=8), appendectomy (n=5), gastric bypass (n=5), and other (n=14). Intestinal obstruction (n=38) was the most common reason for resection leading to SBS, either from adhesions (n=26) or volvulus (n=12). Postoperative intestinal ischemia led to resection in 14 patients. SBS occurred from 1 day postoperatively to years later, with 16 (30%) intestinal resections occurring within 1 month. Patients undergoing resection for intestinal ischemia were more likely to undergo resection during the first month than were patients with adhesions and volvulus (86% versus 4% and 25%,respectively, p < 0.05): Patients undergoing resection for ischemia and volvulus were more likely to have remnant length<60 cm compared with those with adhesions (57% and 58% versus 23%, respectively, p < 0.05). Patients undergoing resection for adhesive obstruction were more likely to undergo multiple resections. Thirty-five (67%) patients required longterm parenteral nutrition. Seven (13%) patients died, three in the early postoperative period and four from complications of SBS. CONCLUSIONS: SBS is a potential postoperative complication of intraabdominal procedures and accounts for a considerable proportion of tertiary referrals for SBS. Surgical treatment of postoperative obstruction after common surgical procedures is the most frequent cause. Preventing adhesions, avoiding technical errors, diagnosing a potentially ischemic intestine in a timely manner, and approaching the frozen abdomen cautiously are important strategies for preventing this condition.