Enteral Tolerance Research Articles

Ostomy in continuity: A novel approach for the management of children with complex short bowel syndrome

IntroductionDespite medical and surgical management, a subset of children with short bowel syndrome (SBS) who have discrepancy between proximal small bowel and distal colon have persistent feeding intolerance. We propose the use of an Ostomy in Continuity (OIC) (Bishop-Koop or Santulli) as a salvage procedure to decompress the proximal bowel while still maintaining maximal intestinal length, in these patients. MethodsA retrospective chart review of 104 SBS patients identified sixteen patients who underwent an OIC. Measures of reliance on parenteral nutrition (PN), growth, intestinal failure associated liver disease, the rate of central venous catheter infections and enterocolitis were collected. These parameters were compared before and after the placement of OIC in the same patients at a median follow-up period of 24months (range 3–52months). Outcome measures include intestinal autonomy and survival without intestinal and liver transplant. ResultsAll 16 patients showed significant improvement in their enteral tolerance after OIC. The mean PN caloric requirement decreased from 95% to 21% (p=0.0001). The median weight Z score improved from −1.18 to 0.20 (p=0.0006) and the median height Z score improved from −2.74 to −1 (p=0.0001). The mean conjugated bilirubin decreased from 10.3mg/dl to 0.3mg/dl (p=0.0001) in nine patients with hyperbilirubinemia. There was no decrease in central venous catheter infections (CVCI) but there was a decrease in the rate of enterocolitis. None of the patients required intestinal or liver transplant. There was one minor skin excoriation complication in one patient with a Bishop-Koop stoma. ConclusionsThe application of an ostomy in continuity within a comprehensive intestinal rehabilitation program is a novel approach in the treatment of refractory short bowel syndrome that improves intestinal autonomy and decreases the rate of enterocolitis. Type of StudyCase Series. Level of evidenceIV (Cohort Study).

Brain natriuretic peptide as a marker of digestive evolution in the premature newborn

Background and objective: hemodynamically significant patent ductus arteriosus (HS-PDA) is associated with an increased risk of necrotizing enterocolitis (NEC) and worse enteral tolerance in preterm newborns (PN). An association has been demonstrated between brain natriuretic propeptide (proBNP) and HS-PDA. Our objective was to analyze the relationship between proBNP levels and enteral tolerance, NEC risk and weight gain in PN. Material and methods: a retrospective study was performed in neonates born before 32 weeks' gestation or with birth weight below 1500 grams, in whom proBNP determination and echocardiography were performed at 48 to 72 h of life. Results: 117 patients were included. 65.8% had a HS-PDA and 9.4% had an outcome of NEC. HS-PDA was associated with longer duration of parenteral nutrition (p < 0.001), a confirmed NEC (p = 0.006) and worse weight gain during admission (p < 0.001). ProBNP levels were associated to NEC (no NEC 12189.5 pg / mL, range 654-247986; NEC 41445 pg/mL, range 15275-166172, p < 0.001). No association was found with the rest of gastrointestinal outcomes. Multivariate logistic regression analysis showed a significant association of NEC with gestational age and proBNP above 22,400 pg/mL (OR 13,386, 95% CI 1,541-116,262, p = 0.019). Conclusions: proBNP could be an early marker of severe digestive pathology in PN. Increased proBNP levels could be associated with a significant increased risk of NEC in very immature newborns.

The Role of Pyridostigmine in Pediatric Motility Disorders

Background: Gastrointestinal (GI) motility disorders are common in children. Treatment is challenging with limited medical and surgical options. Pyridostigmine, acetyl cholinesterase inhibitor, increases acetylcholine at the neuromuscular junction promoting intestinal contractions. Little is known about pyridostigmine role and dosing in pediatric GI motility disorders. Methods: Case series of children with GI dysmotility managed with oral Pyridostigmine. Patients' diagnoses include chronic intestinal pseudo-obstruction, gastroparesis with delayed small intestinal transit, chronic constipation with failure to thrive, and prolonged ileus after pelvic surgery with chronic opioid use (note attached table for details). Results: Pyridostigmine was effective and safe in all cases. Pyridostigmine decreased abdominal distention, increased bowel movements frequency, and improved enteral feeding tolerance. Effective dosing ranged between 0.25-2.0 mg/kg/day. Conclusion: We found oral pyridostigmine to be helpful in children with different GI motility problems. Pyridostigmine should be considered in such patients when other treatment interventions have not been beneficial.Figure: Upright film in 11 yo with pelvic sarcoma. Air fluid levels suggestive of ileus or partial obstruction.Figure: ADM in 18 years old with CIPO. MMC activity with low amplitude retrograde contractions.Figure: Significant abdominal distention on coronal CT image in a 7 year old patient with failure to thrive, abdominal distention, and constipation.Table: Table. Summary of cases treated with pyridostigmine

Feeding advancement and tolerance in preterm infants receiving an extensively hydrolyzed protein infant formula versus an intact protein premature infant formula: A triple-blind randomized clinical trial

Objectives: To evaluate enteral feeding advancement and tolerance in preterm infants randomly assigned to receive one of two marketed preterm formulas, intact protein (IP) or extensively hydrolysed (EH) formula for the first 14 feeding days.

Early Empiric Antibiotic Use Is Associated With Delayed Feeding Tolerance in Preterm Infants: A Retrospective Analysis.

The causative factors of neonatal feeding intolerance are poorly understood, but potentially related to clinical practices such as empiric antibiotic usage. The objective of this study was to evaluate whether early empiric antibiotic exposure negatively affects preterm infants' enteral feeding tolerance. Data from infants without risk factors for sepsis, 500 to 1499 g birth weight and 24 to 34 weeks gestational age were analyzed. The primary outcomes were the empiric antibiotic exposure effects on the infants' total parenteral nutrition usage duration and prevalence of necrotizing enterocolitis (NEC). Among the 901 infants included, 67 were exposed to early empiric antibiotic. A 50% increase in parenteral nutrition usage duration and a 4-fold greater prevalence of NEC was seen in the early empiric antibiotic-exposed neonates, when compared with control infants (P < 0.01). Early empiric antibiotic exposure appears to negatively influence preterm infant feeding tolerance and possibly contributes to NEC.

Intestinal and Multivisceral Transplantation for Management of Chronic Intestinal Psuedo-Obstruction (CIPO)

Objective(s): Visceral transplantation has been increasingly utilized for management of patients with end-stage chronic intestinal pseudo-obstruction (CIPO). This is the largest single center study to comprehensively address long-term efficacy of transplantation in both children and adults. Methods: Between 1991 and 2011, a total of 536 patients received 593 visceral transplants. Of these, 55 (10%) carried teh CIPO disgnosis, 23 (42%) children and 32 (58%) adults. All patients failed home parenteral nutrition (HPN). With 62 total allografts, 43 (67%) were liver-free and 19 (33%) were liver-contained with 7 (13%) retransplants. Hindgut reconstruction was adopted in 1993 and preservation of native pancreaticoduodenum was introduced in 1999. Immunosuppression was tacrolimus-based with utilization of anti-lymphoctye recipeitn pretreatment since 2001(Era-III). Results: Actuarial patient survival was 89% at 1-year and 69% at 5-years with respective graft survival of 87% and 56%. Retransplantation was successful in 86%. Era-III was associated with better patient (p=0.005) and graft (p=0.069) survival. Adults experienced better patient (p=0.23) and graft (p=0.08) survival compared to children with lower incidences of post-transplant lymphoproliferative disorder (p=0.09) and graft versus host disease (p=0.002). The restored nurtitional autonomy was sustained in 23 (70%) of the 33 long-term survivors. The remaining 10 recipients required reinstitution of HPN due to enterectomy (n=3) or dysfunction (n=7) of the visceral allograft. Disease recurrence or de-novo motility disorder was suspected in 7% of the allografts. Conclusion: Intestinal and multivisceral transplantation is life-saving for patients with refractory CIPO and HPN failure. Long-term survival is achievable with full restoration of enteral tolerance. Further progress is foreseen with early referral and new discoveries in the field of CIPO-pathobiology and gut-alloimmunity.

Effects of Maternal Magnesium Sulfate Treatment on Neonatal Feeding Tolerance.

To determine whether antenatal exposure to magnesium sulfate has an effect on neonatal enteral feeding tolerance. In this single-center, retrospective, observational study, charts of pregnant women who received intravenous magnesium sulfate infusions prior to delivery between July 1, 2012, and July 31, 2013, were reviewed. Neonates born at 24 weeks' gestational age or greater admitted to the neonatal intensive care unit (NICU) whose mothers received magnesium sulfate infusions prior to delivery were included. Neonates with independent factors that could lead to feeding intolerance were excluded. The primary outcome was incidence of neonatal enteral feeding intolerance measured by deviations from the NICU feeding protocol. Secondary outcomes included days on parenteral nutrition, incidence of necrotizing enterocolitis, time to first stool, and urine output in the first 72 hours of life. Cumulative maternal magnesium sulfate dose was significantly higher in the enteral feeding intolerance group than those infants who tolerated enteral feeds (70.4 ± 52.3 vs 47.4 ± 40.1 g; p = 0.04). Infants exposed to more than 80 g of maternal magnesium sulfate therapy were more likely to develop enteral feeding intolerance (44% vs 22%; p = 0.04). Multivariate logistic regression indicated that prematurity and cumulative maternal magnesium sulfate dose were the strongest predictors of neonatal enteral feeding intolerance. Infants of mothers who received more than 80 g of intravenous magnesium sulfate prior to delivery were more likely to develop feeding intolerance. Prematurity also was a significant predictor of intolerance.

Predicting Full Enteral Feeding in the Postoperative Period in Infants with Congenital Diaphragmatic Hernia.

Introduction The objective of the study is to examine the factors associated with time to achieve full enteral feeding after repair of congenital diaphragmatic hernia. Materials and Methods Demographic, clinical, and therapeutic data were retrospectively assessed, and uni- and multivariate Cox regression were performed to examine factors predictive of achieving full enteral feeding that was defined as time to achieve120 mL/kg/d after surgical repair. Results Of 78 infants, 66 underwent intervention before hospital discharge. All infants who survived had reached full enteral feeding at the time of hospital discharge by a median of 22 days (range: 2-119 days) after surgery and 10 days (range: 1-91) after initiation of postoperative enteral feedings. Independent risk factors associated with a longer time to reach full enteral feeding achievement included gastroesophageal reflux and days of antibiotics in the postoperative period. Daily stool passage preoperatively predicted earlier enteral tolerance. Conclusion Infants who survive congenital diaphragmatic hernia generally are able to achieve full enteral feedings after surgical repair. A longer time to full feeding is needed in the most severe cases, but some specific characteristics can be used to help identify patients at higher risk. Although some of these characteristics are unavoidable, others including rational antibiotic usage and active gastroesophageal reflux prevention and treatment are feasible and may improve enteral tolerance.

Protocol. Nutrition therapy of critically ill children

The Protocol isn't seen as directive. The goal of the Protocol is to define theframes ofdiagnostic criteria and therapeutic action, within which a doctor working in an intensive therapy children have freedom of choice. The Protocol takes into account that the critical and postagressive states are characterized by the features of malnutrition, particularly manifested in the period of intensive growth (first life year). The Protocol submitted by: contraindications to artificial nutricion in any form; indications for parenteral nutrition; components ofparenteral nutrition; calculation of water and energy needs; calculation of substrate requirements; the system of "two in one" and "three in one "; monitoring the effectiveness ofparenteral nutrition; the use of adjuvants and active additives to artificial nutrition, indications for early enteral nutrition, time of the beginning of enteral nutricion and tolerance to it: trial feeding; trophic nutricion; the technique ofprobe feeding; selection offormulas for enteral nutrition; monitoring the effectiveness of enteral nutrition. The Protocol does not discuss the issues of planned nutritional preparation for surgery, nutritional support in chronic malabsorption, sipping.

Role of nasogastric tube in children undergoing elective distal bowel surgery.

Nasogastric tubes are being routinely used in children and adults undergoing elective abdominal surgery without much scientific evidence supporting their true usefulness. The aim of our study was to assess the role of nasogastric tube in children undergoing elective distal bowel surgery. All pediatric patients undergoing elective distal bowel surgery were enrolled and randomized into two groups: those with nasogastric tube (NG group) or without nasogastric tube (NNG group). Outcome parameters such as resumption of bowel function, enteral feed tolerance, postoperative complications, hospital stay and patient with their parent satisfaction were compared between the groups. A total of 60 patients were included with equal distribution in the NG and NNG groups. Patient variables were comparable in both the groups. Patients in NNG group progressed to full oral feeds significantly earlier (57±18 vs. 106.07±18.35h, p<0.001) and had shorter duration of hospital stay (91.93±26.03 vs. 114.67±18.83h, p<0.001) as compared to the NG group. Significant number of patients with nasogastric tube reported sore throat (9 vs. 1 p=0.03) and nausea (5 vs. 0 p=0.010). There was no significant difference in return of bowel function (39.43h±15.92 vs. 43.60h±17.77, p=0.171), hiccups, sleep disturbance, complications and nasogastric tube reinsertion rate between the two groups. Routine use of nasogastric tube after elective distal bowel surgery in children is not necessary.

Utility of Octreotide in Advancing Enteral Feeds in Children with Chronic Intestinal Pseudo-Obstruction.

Chronic intestinal pseudo-obstruction (CIPO) is a challenging disorder with high morbidity and mortality due to limited effective therapies that improve enteral tolerance. We aimed to present our experience using octreotide in children with CIPO and evaluate factors predicting therapy response. The study population included total parenteral nutrition (TPN)-dependent children with CIPO receiving octreotide at a tertiary care center. Octreotide response was defined as an enteral feeding increase of ≥10cc/kg/day. A total of 16 children were included (median age 5 years, range 1-18; 88% female). We observed an overall feed increase in 11/16 (69%) subjects and 7/16 (44%) were considered responders: three tolerated >65cc/kg/day (discontinued TPN), one tolerated >30cc/kg/day (decreased TPN) and three patients tolerated 10-12cc/kg/day. We found an association between therapeutic octreotide response and both the presence of octreotide-induced intestinal phase III of the migrating motor complex (MMC) as well as a higher median increase in intestinal motility index after octreotide challenge during the antroduodenal manometry (p=0.03 and <0.01, respectively). We did not find an association between octreotide response and age, presence of ileostomy, and colonic manometry testing parameters. Side effects were observed in four patients: an allergic reaction and hyperglycemia requiring octreotide discontinuation, hypertension that responded to dose reduction, and cholecystitis (gallstones) with octreotide successfully restarted after cholecystectomy. Octreotide is safe and effective in improving enteral tolerance in TPN-dependent children with CIPO and the antroduodenal manometry may be helpful in predicting octreotide response. Prospective studies are needed to evaluate the safety and efficacy of octreotide in children with CIPO.

Beneficial Effects of Probiotic Administration in Extremely Low Birthweight Infants: A Review

The aim of this review was to evaluate the beneficial effects of probiotic supplementation on extremely low birthweight infants (birthweight &lt;1000 g). Extremely low birthweight (ELBW) infants are the most vulnerable population in the neonatal intensive care unit (NICU). They are at the highest risk for necrotizing enterocolitis (NEC), sepsis, and inadequate nutrition due to their immature gastrointestinal (GI) function. Nutrition plays an important role in the future neurodevelopmental outcomes of these infants. Research methods for the review were conducted using PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL). In total, eight research studies evaluated the effect of probiotic use in ELBW infants: three studies assessed GI colonization, five studies assessed enteral feeding and GI tolerance, one study assessed growth, five studies assessed NEC, five studies assessed sepsis, and two studies assessed length of hospital stay. This review found the use of probiotics improved GI tolerance, weight gain and length of hospital stay in ELBW infants, but was unable to make conclusions on the effect of probiotic use on incidences of NEC and sepsis. More research is needed in ELBW infants before making probiotic supplementation a standard of care in this population.

Improved enteral tolerance following step procedure: systematic literature review and meta-analysis.

Surgical management of children with short bowel syndrome (SBS) changed with the introduction of the serial transverse enteroplasty procedure (STEP). We conducted a systematic review and meta-analysis using MEDLINE and SCOPUS to determine if children with SBS had improved enteral tolerance following STEP. Studies were included if information about a child's pre- and post-STEP enteral tolerance was provided. A random effects meta-analysis provided a summary estimate of the proportion of children with enteral tolerance increase following STEP. From 766 abstracts, seven case series involving 86 children were included. Mean percent tolerance of enteral nutrition improved from 35.1 to 69.5. Sixteen children had no enteral improvement following STEP. A summary estimate showed that 87% (95% CI 77-95%) of children who underwent STEP had an increase in enteral tolerance. Compilation of the literature supports the belief that SBS subjects' enteral tolerance improves following STEP. Enteral nutritional tolerance is a measure of efficacy of STEP and should be presented as a primary or secondary outcome. By standardizing data collection on children undergoing STEP procedure, better determination of nutritional benefit from STEP can be ascertained.

Comparison of enteral feeding of preterm infants between two hospitals in China and United States

Aim: To compare the details of preterm infants enteral feeding between the two hospitals in China and in the United States, and to analyze the reason of the differences.Methods: A retrospective cohort study was conducted. Infants < 32 weeks were enrolled from Cincinnati University Hospital (CUH) during January 2011 to January 2012 and Peking Union Medical College Hospital (PUMCH) during January 2011 to May 2012. Basic data and enteral feeding data of the two groups were compared.Results: Eighty-two infants in CUH group and 74 infants in PUMCH group were enrolled, infants in CUH group were much smaller than PUMCH group (gestational age (29.1 ± 2.0) versus (30.6 ± 1.3) weeks, p = 0.000, birth weight (1204 ± 328) versus (1406 ± 320) g, p = 0.000). Significantly more infants in CUH group received human milk as the first enteral feeding (78/82 versus 7/74, p = 0.000). Human milk feeding rate in first 28 days in CUH group was much higher (77/82 versus 7/74, p = 0.000). The initial milk volume, and the milk volume on the 7th, 14th, 21st and 27th day of CUH group were significant larger [(15.9 versus 9.3 ml/kg·d, p = 0.000), (79.8 versus 35.2 ml/kg·d, p = 0.000), (133.2 versus 76.4 ml/kg·d, p = 0.000), (140.6 versus 108.6 ml/kg·d, p = 0.000), (142.2 versus 121.5 ml/kg·d, p = 0.002)]. CUH group achieved full enteral feeding sooner (12.0 versus 22.4 d, p = 0.000).Conclusion: Preterm infants achieved full enteral feeding sooner at CUH compared to PUMCH. Human milk feeding may improve enteral feeding tolerance. We need more aggressive enteral feeding proposal in PUMCH.

Parenteral nutrition in the ICU setting: need for a shift in utilization.

The difficulties to feed the patients adequately with enteral nutrition alone have drawn the attention of the clinicians toward the use of parenteral nutrition, although recommendations by the recent guidelines are conflicting. This review focuses on the intrinsic role of parenteral nutrition, its new indication, and modalities of use for the critically ill patients. A recent trial demonstrated that selecting either parenteral nutrition or enteral nutrition for early nutrition has no impact on clinical outcomes. However, it must be acknowledged that the risk of relative overfeeding is greater when using parenteral nutrition and the risk of underfeeding is greater when using enteral nutrition because of gastrointestinal intolerance. Both overfeeding and underfeeding in the critically ill patients are associated with deleterious outcomes. Thus, early and adequate feeding according to the specific energy needs can be recommended as the optimal feeding strategy. Parenteral nutrition can be used to substitute or supplement enteral nutrition, if adequately prescribed. Testing for enteral nutrition tolerance during 2-3 days after ICU admission provides the perfect timing to start parenteral nutrition, if needed. In case of absolute contraindication for enteral nutrition, consider starting parenteral nutrition carefully to avoid overfeeding.

Preventing the Progression of Intestinal Failure-Associated Liver Disease in Infants Using a Composite Lipid Emulsion: A Pilot Randomized Controlled Trial of SMOFlipid.

To examine whether SMOFlipid prevents progression of intestinal failure-associated liver disease (IFALD) in parenteral nutrition (PN)-dependent infants with early IFALD (conjugated bilirubin 17-50 µmol/L, 1-3 mg/dL). Pilot multicenter blinded randomized controlled trial comparing SMOFlipid with Intralipid. Patients received the trial lipid for up to 12 weeks, unless they achieved full enteral tolerance sooner. The primary clinical outcome was the serum conjugated bilirubin. Twenty-four infants (mean age, 6 weeks) participated in the trial (13 Intralipid and 11 SMOFlipid). At the time of trial enrollment, patients in both groups were receiving 90% of their calories by PN. Mean duration on trial was 8 weeks and did not differ according to treatment ( P = .99). At trial conclusion, patients who received SMOFlipid had a lower conjugated bilirubin than those who received Intralipid (mean difference, -59 µmol/L; P = .03). Patients receiving SMOFlipid were also more likely to have a decrease in serum conjugated bilirubin to 0 µmol/L than those in the Intralipid group over the entire observation period (hazard ratio, 10.6; 95%; P = .03). The time to achievement of full enteral tolerance did not differ statistically (hazard ratio, 1.3; P = .59) between the groups. There was no significant difference in safety outcomes between the groups. Compared with Intralipid, SMOFlipid reduces the risk of progressive IFALD in children with intestinal failure. This trial was registered at clinicaltrials.gov as NCT00793195.

Stepwise Management of Necrotizing Enterocolitis Could Improve Outcome of this Life-Threatening Disease

Objectives: To present various lines of management of infants with necrotizing enterocolitis (NEC) and to outline its outcome. Patients and Methods: This prospective study included 127 neonates met Bell' s criteria for NEC diagnosis. All neonates were managed at NICU. Whenever indicated emergency laparotomy (EL) was performed. Medical management included no oral feeding, gastric suction, parentral nutrition, intravenous antibiotic therapy and cardiorespiratory support till patients start to thrive. Then, enteral feeding tolerance was tested and was started with mothers' milk given gradually. Bedside diagnostic mini-laparoscopy was performed for non-responders to medical intervention and if possible, dealing with pathology was conducted. Postoperative care was provided at NICU and patients were monitored for full recovery, development of additional morbidities or death. Results: Thirty-nine patients required EL, while 88 patients underwent the medical intervention trial. Fifty-four cases responded to medical treatment and tolerated oral feeding within a mean duration of 39.3 ± 8.4 days. Bedside laparoscopy was performed for 34 non-responders and was therapeutic in 10 and preparatory for EL in 6 and reduced the need for EL in 18 cases. Fifty-seven patients tolerated oral feeding and started to thrive uneventfully, while 70 patients developed additional morbidities; 19 after medical and 51 after surgical intervention. Thirty-five patients died; 5 after medical and 30 after surgical intervention with significantly higher success rate and lower morbidity and mortality rates among patients had medical intervention compared to patients had surgical intervention. Conclusion: Medical treatment and early gradual entral feeding with breast milk provided success rate of 61.4%. Bed-side laparoscopy is promising adjuvant diagnostic and therapeutic modality for non-responders to medical intervention. Mortality rate was significantly higher with surgical interference, so could be preserved only whenever indicated.

Severe Obesity Predicts Adverse Outcomes in Acute Pancreatitis

Introduction: Obesity has been associated with an increased risk of pancreatitis and likelihood of systemic inflammatory response syndrome (SIRS) in those who develop pancreatic inflammation. Its impact on the severity of acute pancreatitis based on the revised Atlanta classification (2012) is unknown. This study aims to determine whether a Body Mass Index (BMI) greater than or equal to 35 (severe obesity) is correlated with pancreatitis severity. Methods: Patients presenting with acute pancreatitis were identified as part of an ongoing randomized controlled trial of goal directed fluid therapy for acute pancreatitis (NCT 01761539). Detailed data regarding their clinical course was prospectively collected. Body mass index > 35 was the primary predictor. The primary outcome, severe pancreatitis, was defined as persistent organ failure or systemic complications lasting >48 hours in accordance with the revised Atlanta Classification. Secondary outcomes included SIRS on admission and at 24 hours, length of hospitalization, time to tolerance of enteral diet, ICU admission, intubation/pressor requirements, and mortality. Results: Among 175 patients who presented with acute pancreatitis, 26 patients had a BMI ≥ 35. Patients with a BMI ≥ 35 were more likely to be female and have gallstones as the etiology of their pancreatitis (57.7%). Compared to patients with a BMI ≤ 35, patients with a BMI ≥ 35 were more likely to develop severe (OR 3.73; 95% CI (0.83-16.68)) and fatal (OR 6.34; 95% CI (1.21-33.4)) pancreatitis (Table 1). Though there was no difference in ICU admission or SIRS, patients with BMI ≥ 35 were more likely to require endotracheal intubation and/or pressor support for hypotension than those with a BMI ≤ 35. Additionally, compared to patients with a BMI ≤ 35, patients with a BMI ≥ 35 had a longer hospitalization (8.3 ± 1.1 vs 5.4 ± 0.44, p=0.01) and days to enteral diet tolerance (5.7 ± 0.8 vs 3.2 ± 0.33, p < 0.01).Table 1: Acute Pancreatis Outcomes in those with Severe ObesityConclusion: Severe obesity is associated with severe and fatal pancreatitis. These patients should be vigilantly monitored for systemic complications. Basic and translational research studying the interplay between pancreatitis, visceral adiposity, and systemic inflammation are needed.

Mesenteric near-infrared spectroscopy and risk of gastrointestinal complications in infants undergoing surgery for congenital heart disease.

We hypothesised that lower mesenteric near-infrared spectroscopy values would be associated with a greater incidence of gastrointestinal complications in children weighing <10 kg who were recovering from cardiac surgery. We evaluated mesenteric near-infrared spectroscopy, central venous oxygen saturation, and arterial blood gases for 48 hours post-operatively. Enteral feeding intake, gastrointestinal complications, and markers of organ dysfunction were monitored for 7 days. A total of 50 children, with median age of 16.7 (3.2-31.6) weeks, were studied. On admission, the average mesenteric near-infrared spectroscopy value was 71±18%, and the systemic oxygen saturation was 93±7.5%. Lower admission mesenteric near-infrared spectroscopy correlated with longer time to establish enteral feeds (r=-0.58, p<0.01) and shorter duration of feeds at 7 days (r=0.48, p<0.01). Children with gastrointestinal complications had significantly lower admission mesenteric near-infrared spectroscopy (58±18% versus 73±17%, p=0.01) and higher mesenteric arteriovenous difference of oxygen at admission [39 (23-47) % versus 19 (4-27) %, p=0.02]. Based on multiple logistic regression, admission mesenteric near-infrared spectroscopy was independently associated with gastrointestinal complications (Odds ratio, 0.95; 95% confidence interval, 0.93-0.97; p=0.03). Admission mesenteric near-infrared spectroscopy showed an area under the receiver operating characteristic curve of 0.76 to identify children who developed gastrointestinal complications, with a suggested cut-off value of 72% (78% sensitivity, 68% specificity). In this pilot study, we conclude that admission mesenteric near-infrared spectroscopy is associated with gastrointestinal complications and enteral feeding tolerance in children after cardiac surgery.

Topical treatment of major omphalocoele: Acacia nilotica versus povidone-iodine: A randomised controlled study.

Background:Conservative management for major omphalocoele with topical agents as escharotics therapy is well established in practice. Different agents have been used in the past, including mercurochrome and alcohol, proved later to be unsafe. The aim of this study is to evaluate the efficacy and safety of the application of Acacia nilotica paste compared to povidone-iodine solution as a primary non-surgical treatment of major omphalocoele.Patients and Methods:A double-blind, randomised study was conducted on 24 cases of major omphalocoele where they were randomly divided into two equal groups; Group A treated with topical application of A. nilotica paste and Group B treated with topical application of povidone-iodine solution. Cases with gastroschisis, ruptured major omphalocoele or minor omphalocoele were excluded from the study. The evaluating parameters were size of the fascial defect in cm, period of mechanical ventilation if needed, time required for full oral feeding tolerance, duration of hospital stay and any short- or long-term complications.Results:There was no statistical significant difference between both groups regarding their gestational or post-natal age, weight and the mean umbilical port defect. Patients from Group A tolerated full oral feeding earlier and had shorter total hospital stay duration than those from Group B, but without a statistical significant difference (P = 0.347 and 0.242, respectively). The overall mortality rate was 33.3% without a statistical significant difference between both groups (P = 0.667).Conclusions:Application of A. nilotica is a safe and effective treatment of major omphalocoele as it was associated with rapid full enteral feeding tolerance, short duration of hospital stay and low mortality rate.