Artificial nutrition for the treatment of short bowel syndrome

BACKGROUND: In the short bowel syndromes (SBS) it is often difficult to grant a correct and sufficient alimentary supply only by ordinary natural nutrition. In the present research, we will study the prospective possibilities of integrating the nutritional supply making resort to artificial nutrition techniques in patients with SBS. METHODS: We have treated 7 patients with SBS, 6 males and 1 female, whose age was ranging from 29 and 70 years. They all underwent wide intestinal resection, 2 of them for massive infarct, 4 for Crohn's disease, 1 for bowel volvolus. An evaluation of nutritional and immunological conditions was performed on all of them, determining: albumin, transferrin, C-reactive protein, prealbumin, leukocyte count, skin test. In a second time, a protocol was implemented, based on total parenteral nutrition for the first 5 days, with scalar calorie supply up to a total of 35 kcal/kg/die; on day 6 after the operation, the parenteral caloric supply was reduced of 500 kcal/die, being compensated by the introduction of an equal caloric ration by nasointestinal tube with peristaltic pump having a flow of 20 mL/h. In the following days, the parenteral caloric supply was reduced of 500 cal each 48 hours, being substituted with an equal enteral supply in order to progressively reach a complete abandonment of parenteral nutrition. RESULTS: All the patients have a follow-up of 2 to 5 years; today they follow a high-calorie hyperglycidic, hypolipidic diet; no signs of malnutrition are shown by clinical and laboratory analysis. CONCLUSIONS: In the light of the data in our possession, it can be understood that nutritional therapy is the main treatment for SBS; parenteral subministration has to be abandoned during the postoperatory course to give way to enteral nutrition, in order to create a physiological stimulus able to make the digestive system rapidly adapt to the new situation.     

我国烧伤代谢营养研究

The achievements of burn metabolism and nutrition in China are briefly presented. Advance a new theory "Enterogenous Hypermetabolism". Develop a formula to calculate calorie needs in Chinese burn adults. Put forward new ideas on glucose absorption, neoglycogenesis, insulin resistance, and the use of hypoglycemic agent after burn inury. Observe the variation of plasma level of free aminoacids, investigate the changes and mechanisms of 26S proteasome and 19S regulator in skeletal muscle of burn trauma, and the clinical application and its mechanism of glutamine and arginine. Introduce the approach of 13 C NMR spectroscopy to investigate the alterations of hepatic anabolism functions in severely burned rats. Offer supplying the suitable dosage of vitamin A,C,E and microeiement of zinc, copper, ferrum for burn patients. Carry out serial studies of early enteral and parenteral nutrition, and compare enteral nutrition with parenteral nutrition. Early ehteral nutrition with synbiotics might be beneficial to the controlling of burn infection. Both glucagon like peptide-2(GLP-2) and intestinal trefoil factor(ITF) exhibit protective effect on intestinal mucosa in minimizing injury and protecting barrier function. The choice of suitable opportunity to use rhGH (growth hormone) is investigated. In addition, advance the view points of isehemia and anoxia in metabolism, anti-inflammatory immune and nutrition.     

术后早期肠内营养对食管癌患者肠黏膜屏障功能的影响

目的 探讨食管癌患者术后早期施行肠内营养支持对胃肠道黏膜屏障的保护作用. 方法术前3个月内体重下降超过患病前体重20%的食管癌患者56例,按所给营养方法不同分为肠内营养组(n=30)和肠外营养组(n=26),观察两组患者的临床结果,分别于术后第1、4和8天测定两组患者尿乳果糖与甘露醇的比值、血浆内毒素、肿瘤坏死因子(TNF)、胃泌素和谷氨酰胺水平. 结果肠内营养组患者术后体重减轻较少,感染性并发症发生较少(P<0.01,0.05).术后第4天和8天,肠内营养组尿乳果糖与甘露醇比值、血浆内毒素和TNF较肠外营养组低(P<0.01),胃泌素、谷氨酰胺较肠外营养组高(P<0.01). 结论食管癌患者术后早期肠内营养对肠道黏膜屏障功能具有一定的保护作用,有可能减少术后感染性并发症的发生.     

围手术期补充性肠外营养支持治疗

外科病人营养不良的发生率常较高,摄入不足和胃肠功能减退是主要原因,可导致术后并发症增加和住院时间延长,规范的营养支持治疗可改善临床结局。围手术期营养支持首选肠内营养（EN）,以维护肠屏障和免疫功能,耐受性问题是导致EN难以实施或供给不足的主要原因,较长时间能量和蛋白质供给不足可导致病死率和并发症发生率升高,补充性肠外营养（PN）的核心是在EN的基础上联合PN,既维护肠屏障功能,又能较快到达目标喂养量,满足机体代谢需求,进而达到改善临床结局的目标。围手术期补充性PN的对象是EN不能满足60%以上能量需求的病人,低营养风险筛查2002（NRS2002）评分≤３分或危重症病人营养风险（NUTRIC）评分≤５分病人建议术后7 d启动;对于术前高营养风险（NRS2002评分≥5分或NUTRIC评分≥6分）,术后48~72 h开始。补充性PN处方中添加谷氨酰胺和ω-3脂肪酸可优化外科病人临床结局,多腔袋的应用可减少血流感染,适合外科术后短期补充性PN病人。     

Immunonutritive enteral feeding in the critically ill

Since imbalances in the immune system of the critically ill patient have been demonstrated, the role of the gastrointestinal tract for the pathogenesis of multiple organ failure has been a focus of research in intensive care medicine. Particularly, the integrity of the intestinal barrier function has been studied experimentally and clinically. The enormous number of gram-negative bacteria up to 10(11)/ml intestinal liquid inducing the release of significant amounts of endotoxin, is considered to be a vital threat to the intensive care unit (ICU) patient. Acute failure of the intestinal barrier following various types of severe shock or following parenteral nutrition inducing atrophy of intestinal mucosa may lead to multiple organ dysfunction. Maintenance of hemodynamic stability is a mainstay of therapy of the critically ill. In addition, the intestinal integrity can be preserved by the early onset of enteral nutrition. Moreover, recent concepts of enteral nutrition using immunomodulating nutrients like omega-3-fatty acids, glutamine, arginine, and nucleotides are under clinical evaluation.     

营养支持治疗在外科危重病人中的应用

目的 探讨外科危重病人给予营养支持的效果。方法 对22例外科危重病人实施肠外营养（PN）,早期总热量不超过20Kcal/kg.d,供氮量不超过0.12g/kg.d,脂肪供热不超过40%;应激消退期,相应增加供热、氮量,总热量不超过25Kcal/kg.d,供氮量为0.20g/kg.d,以满足机体全盛代谢的需要,一旦肠道功能恢复逐渐转为肠内营养。结果 本组治愈17例,死亡5例;治疗过程中未出现明显的糖、脂代谢异常和肝酶谱变化的代谢性并发症,EN期间无严重腹泻、腹胀等并发症,使用呼吸机支持者均一次脱机成功。结论 循序渐进、阶段性的肠外营养支持,并适时过渡到EN,可提高危重病人的抢救成功率,降低并发症和死亡率。     

营养不良的胃肠道肿瘤患者术后营养支持的随机对照研究

目的评价术后营养支持对营养不良的胃肠道肿瘤患者预后的影响。方法646例营养不良的胃肠道肿瘤患者随机分为肠外营养组(215例)和肠内营养组(215例)及对照组(216例),术后营养支持7d,采用等热卡[125.5kJ(30kcal)·kg-1·d-1]和等氮(0.25g·kg-1·d-1);对照组术后常规补液直至恢复正常饮食。观察比较术后死亡率、并发症发生率及住院时间。结果入选的3组患者资料具有可比性。术后总死亡率为1.5%,3组间差异无统计学意义。术后并发症发生率:肠外营养组33.5%(72例),肠内营养组28.4%(61例),对照组44.9%(97例);对照组与肠外营养组比较,P=0.001;与肠内营养组比较,P=0.000。肠内营养组感染性并发症发生率10.2%,明显低于肠外营养组的15.3%,P=0.002;而两组非感染性并发症发生率差异无统计学意义(21.9%vs.23.7%,P=0.06)。住院时间:肠外营养组(11.2±5.0)d,肠内营养组(9.8±3.4)d,对照组(14.5±7.1)d;肠内营养组住院时间短于肠外营养组,P=0.002;对照组与肠外营养组比较,P=0.003;与肠内营养组比较,P=0.001。结论术后营养支持可改善营养不良的胃肠道肿瘤患者的预后,术后早期肠内营养较肠外营养能降低术后感染性并发症发生率,并缩短住院时间。     

Nutrition and anabolic agents in burned patients

PURPOSE OF REVIEW: Much of the morbidity and mortality of severely burned patients is connected with hypermetabolism and catabolism with its accompanying impairment of wound healing and increased infection risks. In order to prevent the erosion of body mass, nutritional support and other strategies to prevent catabolism have become a major focus in the care of severely burned patients. RECENT FINDINGS: Major themes discussed in recent literature are dealing with enteral versus parenteral nutrition and gastric versus duodenal feeding. The possibility of overfeeding is another important aspect of high calorie nutrition as commonly used in burned patients. Specific formulas for enteral nutrition for specific metabolic abnormalities are under evaluation as well as the role of anabolic and anticatabolic agents. SUMMARY: From the clinical literature, total enteral nutrition starting as early as possible without any supplemental parenteral nutrition is the preferred feeding method for burned patients. Using a duodenal approach, especially in the early postburn phase, seems to be superior to gastric feeding. Administration of high calorie total enteral nutrition in any later septic phase should be critically reviewed due to possible impairment of splanchnic oxygen balance. Therefore, measurement of CO(2)-gap should be considered as a monitoring method during small bowel nutrition. The impact on the course of disease of supplements such as arginine, glutamine and vitamins as well as the impact of the use of anabolic and anticatabolic agents is not yet evident. Furthermore, the effect of insulin administration and low blood sugar regimes on wound healing and outcome in burned patients should be evaluated in future studies.     

早期肠内营养在胃癌术后应用的疗效观察

目的：观察胃癌术后患者早期肠内营养支持的近期疗效。 方法：将117例患者随机分为肠内营养组与肠外营养组,于术后24h开始分别给予肠内与肠外营养,比较两组患者术后营养状况、免疫水平和临床恢复情况的差异。 结果：在供能基本相同的情况下,肠内营养组在术后短期内免疫水平和临床恢复及住院时间方面都优于肠外营养组（均P<0.05）。 结论：术后早期肠内营养能够有效改善胃癌术后患者的免疫功能,加快胃肠道功能的恢复。     

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??Perioperative supplementary parenteral nutrition support therapy ZHU Ming-wei.Department of General Surgery, Beijing Hospital, National Center for Geriatrics, Beijing 100730??China
Abstract The incidence of malnutrition is high in surgical patients. Inadequate intake and gastrointestinal dysfunction are the main causes, which can lead to increased postoperative complications and prolonged hospitalization. Standardized nutritional support can improve the clinical outcome. Enteral nutrition is preferred as perioperative support to protect the intestinal barrier and immune function. Intolerance is the main reason of enteral nutrition which is difficult to implement. The insufficient supply of energy and protein for longer periods of time can lead to increased mortality and complications. The combined with PN on the basis of EN is the core of parenteral nutrition which is to maintain intestinal barrier function, quickly reach the target amount to meet the metabolic needs and improve the clinical outcome. The target patient of perioperative parenteral nutrition is that enteral nutrition can not provide more than 60% energy needs. The start of enteral nutrition in patients with low nutrition risk (NRS2002 ≤??or Nutric score ≤ 5 ) will start after 7 days; and start at 48-72 hours after operation for high preoperative nutritional risk (NRS2002 ≥5 or Nutric score≥6). Supplement of parenteral nutrition with glutamine and ω-3 fatty acids can optimize the clinical outcomes of surgical patients. The application of multichamber bags can reduce bloodstream infections and is suitable for short-term supplementary parenteral nutrition after surgery.     

Current trends of artificial enteral nutrition in acute pancreatitis

During recent years, there has been considerable debate as to the nutritional supply that needs to be established for a patient with acute pancreatitis. The main problem is still infection of the pancreatic necrosis, which has a decisive bearing on the indication for surgery and is the main cause of mortality. Infection stems from bacterial translocation from the patient's gut. Enteral nutrition with its known potential for reducing this type of infection constitutes an attempt to prevent it by preserving the enteric mucosal barrier. Today, the concept of pancreatic rest is no longer considered mandatory in the guidelines of many Surgical and Nutritional Societies, whilst enteral nutrition is the gold standard for acute pancreatitis. Assuring an integrated parenteral and enteral supply before reaching the full regimen of enteral nutrition is the most reliable policy during the early days of the disease. Moreover, outcomes being equal, enteral nutrition is cheaper than parenteral nutrition, as has been extensively demonstrated in many clinical trials in severe acute pancreatitis.     

Short bowel syndrome in infancy and childhood. Analysis of survival in 60 patients

This report concerns 60 infants and children with short bowel syndrome, most commonly caused by necrotizing enterocolitis in this study. Resection of atretic or gangrenous bowel was performed in 53 patients, tapering enteroplasty and primary anastomosis was performed in 13 patients, and temporary enterostomies were performed in 40 patients. Second-look laparotomy was useful in two of four cases of questionable bowel viability. The ileocecal valve was resected in 33 patients and remained intact in 27. The mean length of remaining bowel was 58.4 cm (range 13 to 150 cm). Seven patients with total aganglionosis and mid to proximal small bowel extension were managed with an initial enterostomy, whereas three had a pull-through procedure with an aganglionic patch enteroplasty. All patients received total parenteral nutrition and early enteral feedings. Home hyperalimentation was attempted when 50 percent of the calorie intake was enteral. Intestinal adaptation required from 3 to 14 months. Frequent setbacks were related to catheter sepsis, rotavirus infection, carbohydrate intolerance, and liver dysfunction. The overall survival rate was 85 percent, with mortality due to liver failure and sepsis associated with total parenteral nutrition.     

Influence of enteral nutrition on cytokine response in resective liver surgery

Postoperative infectious complications are nowadays a major problem in liver surgery. Better surgical outcomes with a consequent reduction in treatment and hospitalisation costs are a primary objective. The aim of this prospective, randomised study was to evaluate the cytokine response during and after portal clamping in patients undergoing liver resection and continuously fed with enteral nutrition as compared to patients receiving parenteral nutritional support. Forty patients with liver tumours were divided into two groups of 20 on the basis of the presence or absence of chronic liver disease. Furthermore, the latter group of 20 were randomised to two subgroups A and B of 10 patients on the basis of the different perioperative nutrition modalities. Group A patients were fed by so-called uninterrupted enteral nutrition, which means without interruption from the day before surgery with a nutritional solution delivered via a nasojejunal tube. The patients in group B were submitted to hepatic resection with parenteral nutritional support. Liver resection had to consist in resection of at least 30% of the parenchyma in non-cirrhotic patients or in segmental resection in cirrhotic ones. Ten milliliter blood samples were harvested before operation, and 10, 30 and 60 min after declamping and at 24 h. Interleukin 6 and a-tumour necrosis factor values were detected in blood samples. The values of C reactive protein and of prealbumin were recorded at 72 h postoperatively. We also evaluated postoperative complications, resumption of bowel movements, oral intake of nourishment, and patient discharge. Values in blood samples in the two groups showed a statistically significant difference in interleukin 6 values only after 24 h (10 min: group A 121 +/- 25.3, group B 156 +/- 31.4; after 24 h: group A 31.5 +/- 12, group B 105.1 +/- 24.1), while the a-tumour necrosis factor assay showed no significant difference between the two groups. However, there was an appreciably longer hospital stay (group A 10.9 +/- 3.1 days (range: 7-21 days), group B 13.2 +/- 2.7 days (range: 8-19 days) (P < 0.02) and a quicker resumption of bowel movements in group A. The data available show that uninterrupted enteral nutrition produces a modulation of the cytokine response following portal clamping. A lower cytokine activation cascade reduces the impact of the action of cytokines on the hepatic parenchyma with consequent enhancement of the hepatic Kupffer cell component. These factors thus substantially reduce the length of the patient's hospital stay and consequently the cost of medical care.     

Importance of Ileum and Colon in Children with Short Bowel Syndrome

BackgroundIt is well known that small bowel length is a dominant prognostic indicator in patients with short bowel syndrome (SBS). The relative importance of jejunum, ileum, and colon is less well defined in children with SBS. Here we review the outcome of children with SBS with respect to the type of remnant intestine.MethodsA retrospective review of 51 children with SBS was conducted at a single institution. The duration of parenteral nutrition use was the main outcome variable. The length of the remaining intestine as well as the type of intestine were recorded for each patient. Kaplan–Meier analyses were conducted to compare the subgroups.ResultsChildren with greater than 10% expected small bowel length or more than 30 cm of small bowel achieved enteral autonomy faster than those with less. The presence of ileocecal valve enhanced the ability to wean from parenteral nutrition. The presence of ileum significantly enhanced the ability to wean from parenteral nutrition. Patients with the entire colon also achieved enteral autonomy sooner than those with partial colon.ConclusionsThe preservation of ileum and colon is important in patients with SBS. Approaches to preserve or lengthen ileum and colon may be beneficial for these patients.Level of evidenceIV.     

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??Nutritional support in mesenteric ischemia FU Qi-ning, ZHAO Yu. Department of General Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
Corresponding author??ZHAO Yu??E-mail??820994765@qq.com
Abstract Mesenteric ischemia is always accompanied by bowel dysfunction??thus appropriate way for nutritional is important. Parenteral nutrition solves the nutritional problem and greatly improves the prognosis of mesenteric ischemia. Intestine is not only a place for digestion??but also an important barrier. For enteral nutrition can maintain intestinal barrier function??more and more attentions are paid on an earlier start for enteral nutrition. But feeding intolerance which is secondary to the mesenteric ischemia makes early enteral nutrition not widely applied in clinic. A personalized nutrition support plan based on the clinical situation and a combination of parenteral nutrition and enteral nutrition as early as possible should be the basic strategy of nutrition support for mesenteric ischemia     

The gut: a central organ after surgical stress

The intestinal tract plays a central role in the protein catabolic response after injury and infection. The mucosa utilizes glutamine and thus spares glucose--presumably sparing this essential fuel source for tissues with an obligate glucose requirement. With inadequate nutritional support or prolonged stress, glutamine levels decrease in both the plasma and the tissue pools, which suggests that glutamine deficiency occurs. This is associated in time with atrophy of the gastrointestinal mucosa. This provision of dietary glutamine results in correction of the abnormally low glutamine concentrations and increased cellularity of the gut mucosa. The derangements in the intestinal mucosa associated with starvation, injury, infection, immunosuppression, chemotherapy, lack of enteral feedings, and other stresses are associated with a breakdown in the barrier function of the gut. Both bacteria and their toxins may enter the host from the intestinal lumen. Through interaction with the reticuloendothelial system, cytokines are produced, which stimulate the pituitary-adrenal axis and thus contribute to the stress response. The elaboration of glucocorticoids facilitates proteolysis, thus increasing glutamine release from skeletal muscle for gut repair. Although this homeostatic mechanism appears to aid mucosal repair and support immunologic responses, severe injury or prolonged glutamine deficits do not adequately support intestinal recovery and allow this cycle to become self-perpetuating (Fig 3). Adequate enteral feedings initiated early in the course of a disease appear to maintain adequate gut barrier function. In the frequent circumstance when feeding by this route is inadequate or impossible, glutamine-containing parenteral feedings offer an appropriate alternative therapy for bowel and immunologic support. Glutamine-containing parenteral feedings are associated with increased mucosal cellularity and improved survival after gut injury. Specific hormones also stimulate mucosal growth, and it is anticipated that a combination of hormones and specific nutrients will provide optimal support of the gut mucosa in the severely ill patient.     

Short bowel syndrome]

Short bowel syndrome (SBS) is defined in adults as a malabsorption disorder as a result of shortening the bowel to <200 cm. The severity of symptoms is less dependent on the amount of residual intestine than on the anatomical position of the resected bowel, the type of operative reconstruction, and the type and quality of nutritional, medical, and surgical treatment. Numerous complications and deficiency symptoms are associated with SBS. The extent of deficient nutrition should be determined. The need to create accesses for enteral and parenteral delivery, to supply supplementation as needed, perform pharmacological therapy, and in individual cases surgical treatment all necessitate a broad knowledge of nutritional medicine. The goals of therapy are correction and prevention of malnourishment, restoration of a normal nutritional status, and the normal thriving of children. Complications should be avoided, particularly those problems associated with parenteral nutrition. The frequency of diarrhea should be reduced. Overall, the aim is to achieve an optimized quality of life.     

Kurzdarmsyndrom

Short bowel syndrome (SBS) is defined in adults as a malabsorption disorder as a result of shortening the bowel to <200 cm. The severity of symptoms is less dependent on the amount of residual intestine than on the anatomical position of the resected bowel, the type of operative reconstruction, and the type and quality of nutritional, medical, and surgical treatment. Numerous complications and deficiency symptoms are associated with SBS. The extent of deficient nutrition should be determined. The need to create accesses for enteral and parenteral delivery, to supply supplementation as needed, perform pharmacological therapy, and in individual cases surgical treatment all necessitate a broad knowledge of nutritional medicine. The goals of therapy are correction and prevention of malnourishment, restoration of a normal nutritional status, and the normal thriving of children. Complications should be avoided, particularly those problems associated with parenteral nutrition. The frequency of diarrhea should be reduced. Overall, the aim is to achieve an optimized quality of life.     

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??How to maximize efficacy of nutrition support in the adult critically ill patients WU Guo-hao. Department of Surgery, Zhongshan Hospital, Fudan University, Shanghai200032??China
Abstract Critically ill patients are hypermetabolic and have increased nutrient requirements. Nutritional support is now considered as a standard of care for the critically ill patients. However, many questions about the appropriate substrate, timing, route and amount of nutritional support in critically ill patients remain understudied. Enteral nutrition is favored over parenteral nutrition when the gastrointestinal tract is functional. Early enteral nutrition is recommended for critically ill patients. Parenteral nutrition is indicated for patients who cannot tolerate enteral feedings. Supplemental parenteral nutrition combined with enteral nutrition can be considered to cover the energy and protein targets when enteral nutrition alone fails to achieve the caloric goal. Clinical studies have demonstrated that new formulae enriched with specific nutrients improves the outcomes of critically ill surgical patients.     

Effect of time to surgical evaluation on the outcomes of infants with gastroschisis

PurposeOur goal is to identify the impact of time to surgical intervention on the outcomes of infants with gastroschisis.MethodsAfter institutional review board approval, we performed a retrospective review of the medical records of all infants admitted to our institution from 2001 to 2010. Transport, bowel stabilization, and closure times were defined as the time from birth to admission, admission to the first-documented operative intervention, and first operative intervention to abdominal closure, respectively. Outcomes included age at full enteral feeds, total parental nutrition days, ventilator days, and hospital length of stay. Multivariate analysis was used to identify independent predictors of the outcomes.ResultsOne hundred eighteen infants with gastroschisis were included in our study. Transport and bowel stabilization times were not predictive of any outcome. However, the time to abdominal wall closure and postnatal gastrointestinal complications were independently predictive of age at full enteral feeds, total parenteral nutrition days, and hospital length of stay.ConclusionTime to surgical evaluation/bowel stabilization was not predictive of any clinically relevant outcomes in infants with gastroschisis. These data demonstrate that potential benefits from prenatal regionalization of infants with gastroschisis are not supported by decreased time to operative intervention.