Jejunocolic Anastomosis Research Articles

Dietary and nursing management of calcium oxalate renal stones in patients with a jejunocolic anastomosis: a narrative review

Jejunocolic anastomosis (JCA) is a surgical procedure that can result in various complications. Depending on how much of the jejunum remains, these patients are often defined as having intestinal failure (IF) because of short bowel syndrome (SBS). One of the significant complications among these patients is the formation of calcium oxalate renal stones. It has been estimated that 24% of patients with a JCA develop symptomatic renal stones. This narrative review aims to explore the nursing and dietary management strategies for individuals with oxalate stones following JCA. This includes providing adequate hydration, limiting dietary intakes of fat and oxalate, and optimising dietary intake of fluid and calcium whilst discussing the evidence for dietary magnesium, vitamin C and citric acid.

Circulating Apolipoprotein B-48 as a Biomarker of Parenteral Nutrition Dependence in Adult Patients with Short Bowel Syndrome.

Short bowel syndrome (SBS) is a rare but serious condition that may lead to chronic intestinal failure. Citrulline concentrations are currently used to reflect the residual intestinal mass in patients with SBS, although this method has several limitations. In a cohort of patients with SBS, we quantified apolipoprotein B-48 (ApoB-48), which is exclusively synthesized by enterocytes and secreted associated with dietary lipids and investigated the relationship between ApoB-48 and clinical and biological data as well as PN dependence. A total of 51 adult patients were included, 36 of whom were PN-dependent. We found a robust positive correlation between circulating ApoB-48 and residual small bowel length, which was also found in the subgroup of patients with jejunocolic anastomosis. Fasting ApoB-48 levels were significantly lower in PN-dependent patients than in PN-weaned patients and negatively correlated with parenteral nutrition dependence. Our results suggest that ApoB-48 could be proposed as a marker of intestinal absorptive function and could be an interesting follow-up marker in patients with SBS.

Towards a standardized initial training program in experimental microsurgery for pediatric surgeons.

To describe a basic training program in microsurgery and to analyze the learning curve through the process, including improvement in operating times and functional outcome. Our learning program included basic, transitional, and experimental models. The experimental model included tail vein cannulation, intestinal resection and anastomosis, dissection, division and anastomosis of the cava and aorta. Wistar rats (66.7% male; 406.9 ± 38.9 grams) were used. The program adhered to the 3R principle and obtained animal welfare committee approval. Mean tail vein cannulation time was 2.4 ± 1.2 minutes. Mean intestinal resection and jejunocolic anastomosis time was 14.8 ± 2.7 minutes and 10.4 ± 3 minutes, respectively. All anastomoses were functionally valid. Mean vessel dissection time was 22.9 ± 7.7 minutes, aortic artery anastomosis was 17.2 ± 7.1 minutes, and vena cava anastomosis was 25.9 ± 7.3 minutes. 66.7% of vena cava anastomoses were functionally valid vs. 88.9% for the aorta. The time required for all procedures decreased after the third attempt, except for vena cava anastomoses, which remained similar in all 9 procedures. Our model demonstrated that the procedures were suitable for trainer progression in terms of surgical time and functional outcome. Microsurgical training would benefit from standardized programs to optimize results.

Partial jejunal diversion (PJD) with jejunocolic anastomosis preliminary results of a pilot study.

Bariatric-metabolic surgery is an effective tool in the treatment of severe obesity and related diseases. Its importance has increased even more in the era of the type II diabetes mellitus and COVID 19 pandemics. The aim of our study is to present the initial results of a new operation that minimizes surgical trauma. In the prospective study, laparoscopic side-to-side anisoperistaltic jejunocolic anastomosis was constructed in order to derive part of the chyme by the anastomosis. Patients were operated in the period of IV/2018VII/2019; their mean age was 48.43±10.36 years, mean weight 112.3±16.6 kg and mean BMI 41.9±5.2. Patients were examined one month before surgery and then followed at 3, 6 and 12 months after surgery. We evaluated weight loss and changes in carbohydrate metabolism. We did not record any perioperative or postoperative surgical complications. There was a statistically significant weight loss during the study period. There was a significant decrease in absolute weight in kilograms (p.

Characteristics of adult patients with chronic intestinal failure due to short bowel syndrome: An international multicenter survey.

The case-mix of patients with intestinal failure due to short bowel syndrome (SBS-IF) can differ among centres and may also be affected by the timeframe of data collection. Therefore, the ESPEN international multicenter cross-sectional survey was analyzed to compare the characteristics of SBS-IF cohorts collected within the same timeframe in different countries. The study included 1880 adult SBS-IF patients collected in 2015 by 65 centres from 22 countries. The demographic, nutritional, SBS type (end jejunostomy, SBS-J; jejuno-colic anastomosis, SBS-JC; jejunoileal anastomosis with an intact colon and ileocecal valve, SBS-JIC), underlying disease and intravenous supplementation (IVS) characteristics were analyzed. IVS was classified as fluid and electrolyte alone (FE) or parenteral nutrition admixture (PN). The mean daily IVS volume, calculated on a weekly basis, was categorized as <1, 1-2, 2-3 and >3L/day. In the entire group: 60.7% were females and SBS-J comprised 60% of cases, while mesenteric ischaemia (MI) and Crohn' disease (CD) were the main underlying diseases. IVS dependency was longer than 3 years in around 50% of cases; IVS was infused ≥5 days/week in 75% and FE in 10% of cases. Within the SBS-IF cohort: CD was twice and thrice more frequent in SBS-J than SBS-JC and SBS-JIC, respectively, while MI was more frequent in SBS-JC and SBS-JIC. Within countries: SBS-J represented 75% or more of patients in UK and Denmark and 50-60% in the other countries, except Poland where SBS-JC prevailed. CD was the main underlying disease in UK, USA, Denmark and The Netherlands, while MI prevailed in France, Italy and Poland. SBS-IF type is primarily determined by the underlying disease, with significant variation between countries. These novel data will be useful for planning and managing both clinical activity and research studies on SBS.

Variation of plasma citrulline as a predictive factor for weaning off long-term parenteral nutrition in children with neonatal short bowel syndrome

Long-term parenteral nutrition (PN) is the mainstay of the therapeutic strategy in intestinal failure (IF) due to neonatal short bowel syndrome (SBS). Our aim was to identify prognostic factors for PN weaning and to assess if measuring plasma citrulline concentrations over time could account for the intestinal adaptation in progress. This retrospective study included children with neonatal SBS with surgical measurement of the residual bowel length and repeated plasma citrulline assessments during a 4-year follow-up. The degree of IF was assessed by the PN dependency index (PN caloric intake/Resting energy expenditure). The analysis was carried out according to SBS anatomical groups: end-jejunostomy (type 1), jejuno-colic (type 2) and jejuno-ileal anastomosis (type 3). Fifty-five patients (8 type 1, 27 type 2, 20 type 3) were included. None of the patients with SBS type 1, 11 (41%) with type 2 and 11 (55%) with type 3 were weaned off during the follow-up period. Plasma citrulline levels significantly increased with time in patients who were finally weaned off PN; conversely, the levels did not consistently increase in patients who were still on PN at the end of the study period. There was an inverse relationship between plasma citrulline levels and the PN dependency index. The increasing citrulline levels had a positive effect on the probability of weaning, 2.7 times higher for each point increase in citrulline. No significant effect of age and residual bowel length at baseline was found. The increased plasma citrulline level over time in addition to the SBS anatomical type is a reliable marker for subsequent PN weaning. The prediction of PN weaning assessed solely by the residual bowel length or a single measurement of citrulline is insufficient and should also take into account the anatomical type of SBS and repeated measurements of plasma citrulline levels.

Intrauterine intestinal volvulus prompting emergency delivery and surgery in a 32wk fetus

Abstract Fetal intestinal volvulus is a medical emergency with potentially fatal consequences thus requires a high index of suspicion and prompt intervention. Echogenic dilated bowels, Whirlpool/Coffee bean signs, polyhydramnios, fetal anemia, fetal ascites with aperistalsis, nonreaasuring CTG are few important diagnostic signs. Mostly it has been described without associated malrotation,as segmental volvulus due to malfixation of gut with or without associated anaomalies such as meconium ileus, CDH, abdominal wall defects. We describe for the first time a case of 1.9kg female fetus detected to have intestinal volvulus associated with multiple ileal atresias and mesenteric defect. The fetus had classical Whirlpool sign, polyhydramnios and anemia, was delivered by emergency Ceasarian Section, post natally detected to have tense abdomen, confirmed Whirlpool sign on post natal USG, underwent emergency laparotomy, resection of necrotic ileal loops & I-C junction and Jejuno-Colic anastomosis. Child adapted to elemental feeding with 50cm of Jejunum without Ileo-cecal valve without shortbowel syndrome. Importance of multidisciplinary perinatal care, possible intrauterine vascular accident in pathogenesis of atresia and fetal volvulus has been emphasized in the case report.

Predictors of Leak After Colorectal Anastomoses: a Case Series Analysis

Anastomotic leak (AL) is a major morbid complication after colorectal surgery. There are only few articles to find the predictors of leak after colorectal anastomoses that have been published in the literature. The aim of this study is to identify different predictors for colorectal AL in Indian set up. Historical data were collected from the hospital record of patients from June 2005 to April 2014. In prospective period, from May 2014 to February 2016, colorectal surgery patients were recruited to collect the data. Various preoperative, intraoperative, and postoperative factors for AL were analyzed using Student’s t test and Chi square test. The p value less than 0.05 was considered statistically significant for all results. The AL rate was 9.1%. The predictors for AL were comorbidities like cerebrovascular accident (CVA) (p < 0.05), alcohol intake and smoking habit (p = 0.006), preoperative low albumin (AL in 21.2%), emergency surgery (AL in 25% with p = 0.016), jejuno-colic anastomosis − 1/1 (100%), and maximum AL in ligation of ileocolic artery (p = 0.019). History of CVA, smoking, alcohol, hypoalbuminemia, emergency surgery, type of surgery, and high artery ligation have significant role in causing AL in a patient of colorectal surgery. Raised temperature and tachycardia are the significant clinical signs to diagnose AL after colorectal surgery.

Severe Intestinal Dysbiosis in Rat Models of Short Bowel Syndrome with Ileocecal Resection.

Short bowel syndrome (SBS) resulting from extensive intestinal resection is thought to significantly affect gut microbiota. Data are limited on the signatures of the intestinal microbiome in SBS with different anatomical types. The aim of our investigation was to characterize the composition and function of gut microbiota in SBS with or without ileocecal resection (ICR). Six-week-old male Sprague-Dawley rats underwent 75% small bowel resection (SBR) with the ileocecal junction intact (SBR group, jejunoileal anastomosis, n = 10) or removed (ICR group, jejunocolic anastomosis, n = 10), or sham surgery (sham group, n = 10). Colonic contents of the rats were collected 28days after operation, and 16S rRNA gene sequencing was performed on the MiSeq Illumina platform to analyze bacterial composition. Overall structures of the gut microbiome differed significantly among the three groups. The bacterial α-diversity of the ICR group was remarkably lower than that of the sham group. ICR rats were enriched with Lactobacillus and opportunistic pathogens from Proteobacteria but depleted of commensal genera belonging to the Lachnospiraceae, Ruminococcaceae and Erysipelotrichaceae families. Genera from the Bacteroidales S24-7 group, Porphyromonadaceae, Prevotellaceae, Rikenellaceae and Christensenellaceae were prevalent in SBR rats. Functional pathways of branched-chain and aromatic amino acid biosynthesis, lipopolysaccharide biosynthesis and infectious diseases were abundant in the ICR group, while SBR rats featured pathways of C5 branched dibasic acid metabolism, biotin metabolism and one carbon pool folate. ICR causes dramatically more severe intestinal dysbiosis than SBR only in SBS rat models, resulting in altered functional profiles of the gut microbiome.

Plasma citrulline is not a biomarker for intestinal adaptation in short bowel syndrome, studied in piglets: a model for human neonates.

There are no in vivo methods to measure adaptation in neonatal short bowel syndrome (SBS). We evaluated citrulline (Cit)levels in neonatal piglet surgical models of SBS. Piglets underwent 75% mid-intestinal resection with jejunoileal anastomosis (JI), 75% distal resection of ileum with jejunocolic anastomosis (JC) or sham surgery. Jugular and gastric catheters were inserted for parenteral and enteral nutrition. On D7, small intestine length and weight were measured, jejunum collected for histopathology and Cit level determined. JI (n = 5) compared to JC (n = 5) had increased small intestinal length (JC - 17.5cm; JI +22.0cm; p = 0.02) and mass (JC 43.1mg/cm/kg; JI 51.3mg/cm/kg; p = 0.02), while Cit did not differ (JI 801.0µM; JC 677.7µM; p = 0.90). Including non-resected shams (n = 4), Cit correlated with length (R2 = 0.48; p = 0.006), but not for SBS alone (R2 = 0.11; p = 0.4), mass (R2 = 0.05; p = 0.5). A second experiment compared change in Cit levels from baseline to D7. Levels declined in sham (n = 8) and JC (n = 10) (sham - 110.1µM; JC - 56.6µM; p = 0.17), regardless of intestinal lengthening (sham 29.9cm; JC - 10.4cm; p = 0.002). Citrulline levels predict large differences in intestinal length and 'identify' SBS. However, citrulline cannot discriminate between adaptation in JI and JC, nor predict intestinal lengthening.

Novel Long‐Acting GLP‐2 Analogue, FE 203799 (Apraglutide), Enhances Adaptation and Linear Intestinal Growth in a Neonatal Piglet Model of Short Bowel Syndrome with Total Resection of the Ileum

Glucagon-like peptide-2 (GLP-2) is an intestinotrophic factor released from L-cells in the ileum, a segment commonly resected or atretic in neonatal short bowel syndrome (SBS). In piglets, ileal resection decreases intestinal adaptation and endogenous GLP-2 production, whereas exogenous replacement promotes adaptation. In this study, we determined the effect of a novel long-acting GLP-2 analogue, FE 203799 (FE; apraglutide), upon intestinal growth, adaptation, and function in neonatal SBS piglets without ileum. Neonatal piglets were randomized to saline (n = 10) vs FE treatment (n = 8). All piglets underwent 75% intestinal resection with jejunocolic anastomosis and were pair-fed parenteral and enteral nutrition. Saline and FE (5mg/kg) treatments were administered subcutaneously on days 0 and 4. On day 6, 24-hour fecal samples were collected for subsequent nutrient analysis. On day 7, small-intestinal length and weight were measured and tissue collected for analyses. On day 7, saline and FE-treated piglets were healthy and gained equivalent weight (P = 0.12). Compared with saline piglets, FE-treated piglets had lower fecal fat (P = 0.043) and energy (P = 0.043) losses and exhibited intestinal lengthening (P = 0.001), greater small-intestinal weight (P = 0.004), longer villus height (P = 0.027), and greater crypt depth (P = 0.054). The subcutaneous GLP-2 analogue, FE, enhanced intestinal adaptation in a neonatal model of SBS without ileum. The observed intestinal lengthening with FE treatment was unique compared with our prior experience with native GLP-2 in this same model and has important clinical implications for treating neonatal SBS. At this developmental stage, growth in the intestine, if augmented, could accelerate weaning from parenteral nutrition.

Surgical Anatomy Does Not Affect the Progression of Intestinal Failure-Associated Liver Disease in Neonatal Piglets.

Intestinal failure-associated liver disease (IFALD) causes significant morbidity in neonates with short bowel syndrome (SBS) dependent on parenteral nutrition (PN). Resected ileum, with loss of the ileocecal valve (ICV), is the most common anatomy in SBS, yet its impact on IFALD has not been adequately studied. Neonatal piglets were randomized to 75% intestinal resection with jejunocolic anastomosis (JC, n=12), 75% resection with jejunoileal anastomosis and intact ICV (JI, n=13), PN-fed sham (sham, n=14), or sow-fed control (SF, n=8). Surgical and sham piglets received 100% PN for 14 days before bile flow was measured and blood chemistry, liver pathology, jejunal permeability, and bacterial translocation were assessed. Bile flow was lower for PN-fed compared with SF (P=.002) but not different between the PN-fed groups. Total bilirubin (P=.03) and liver pathology (P < .001) were greater in PN-fed than SF groups but not different between PN-fed groups. Serum bile acids were increased in sham (P=.01) but not different between SBS groups. PN-fed piglets with sepsis had lower bile flow (P=.001) and increased bilirubin (P=.04). Neither jejunal permeability nor bacterial translocation were different between JC, JI, or sham groups. Contrary to our hypothesis, the remnant anatomy does not appear to worsen the progression of IFALD. However, the role of sepsis in IFALD should be further explored, in addition to other mechanisms, including PN factors, host immune responses, and intestinal bacterial dysbiosis.

Effects of exogenous glucagon-like peptide-2 and distal bowel resection on intestinal and systemic adaptive responses in rats.

ObjectiveTo determine the effects of exogenous glucagon-like peptide-2 (GLP-2), with or without massive distal bowel resection, on adaptation of jejunal mucosa, enteric neurons, gut hormones and tissue reserves in rats.BackgroundGLP-2 is a gut hormone known to be trophic for small bowel mucosa, and to mimic intestinal adaptation in short bowel syndrome (SBS). However, the effects of exogenous GLP-2 and SBS on enteric neurons are unclear.MethodsSprague Dawley rats were randomized to four treatments: Transected Bowel (TB) (n = 8), TB + GLP-2 (2.5 nmol/kg/h, n = 8), SBS (n = 5), or SBS + GLP-2 (2.5 nmol/kg/h, n = 9). SBS groups underwent a 60% jejunoileal resection with cecectomy and jejunocolic anastomosis. All rats were maintained on parenteral nutrition for 7 d. Parameters measured included gut morphometry, qPCR for hexose transporter (SGLT-1, GLUT-2, GLUT-5) and GLP-2 receptor mRNA, whole mount immunohistochemistry for neurons (HuC/D, VIP, nNOS), plasma glucose, gut hormones, and body composition.ResultsResection increased the proportion of nNOS immunopositive myenteric neurons, intestinal muscularis propria thickness and crypt cell proliferation, which were not recapitulated by GLP-2 therapy. Exogenous GLP-2 increased jejunal mucosal surface area without affecting enteric VIP or nNOS neuronal immunopositivity, attenuated resection-induced reductions in jejunal hexose transporter abundance (SGLT-1, GLUT-2), increased plasma amylin and decreased peptide YY concentrations. Exogenous GLP-2 attenuated resection-induced increases in blood glucose and body fat loss.ConclusionsExogenous GLP-2 stimulates jejunal adaptation independent of enteric neuronal VIP or nNOS changes, and has divergent effects on plasma amylin and peptide YY concentrations. The novel ability of exogenous GLP-2 to modulate resection-induced changes in peripheral glucose and lipid reserves may be important in understanding the whole-body response following intestinal resection, and is worthy of further study.

Short Bowel Syndrome

Objective: Short Bowel Syndrome (SBS) is the leading cause of Intestinal Failure (IF) in children requiring Home Parenteral Nutrition (HPN). This 16-year study evaluates the complications and prognosis factors of SBS patients managed by a single expert center. Study design: SBS pediatric patients referred to HPN between January 1st 2000 and December 31st 2015 were classified into 3 groups: type 1: end jejunostomy, type 2: jejuno-colic anastomosis and type 3: jejuno-ileal anastomosis. The level of PN dependency [by using the index Non Protein Energy Intake (NPEI)/Resting Energy Expenditure (REE) by Schofield formula], outcomes, complications, growth, pubertal onset were analyzed. Results: For the 156 children, the underlying diseases were necrotizing enterocolitis (NEC) (22.40%), midgut volvulus (21.80%), gastroschisis (20.50%), extensive Hirschsprung’s disease (EHD) (16.00%), intestinal atresia (15.40%), or other events (3.90%). Weaning off was achieved in 79 patients (50.70%), after 2.20 ± 1.70 years of PN. Intestinal Transplantation (ITx) was performed in 13 patients (8.30%) after 4.20 ± 1.30 years of PN. At the end of the study period, 63 patients (40.40%) were still on HPN for 5.3 ± 3.7 years. Only one patient with cystic fibrosis and liver cirrhosis deceased. By Cox regression analysis, the following anatomical characteristics are independent prognosis factors of PN duration: length of remnant bowel, presence of an ostomy, ileo-caecal valve (ICV) resection, colon resection. Citrulline plasma levels correlate with the ratio NPEI/REE. Overall rate of catheter related sepsis was 1.2 CRS/1000 days of PN. Bilirubin > 30 μmole/l was observed in 16% of patients still dependent on PN after 5.30 ± 3.70 years. No statistical differences on growth were found between the groups, proving that sufficient nutritional intake was provided to achieve optimal growth. The puberty occurred in 8 girls at 12.1 ± 1.0 years and 8 boys at 13.8 ± 0.7 years. Conclusion: SBS has a very good outcome despite long term PN. HPN is a safe and efficient therapeutic option for long term management of SBS pediatric patients. Such data might be very helpful in addressing criteria for GLP-2 (teduglutide).

Intestinal failure due to short bowel syndrome: impact of a multidisciplinary intestinal rehabilitation program

In patients suffering intestinal failure due to short bowel, the goal of an Intestinal Rehabilitation Program is to optimize and tailor all aspects of clinical management, and eventually, wean patients off lifelong parenteral nutrition. To report the results of our program in patients suffering intestinal failure. A registry of all patients referred to the Intestinal Failure unit between January 2009 and December 2015 was constructed. Initial work up included prior intestinal surgery, blood tests, endoscopic and imaging studies. Also demographic data, medical and surgical management as well as clinical follow-up, were registered. Data from 14 consecutive patients aged 26 to 84 years (13 women) was reviewed. Mean length of remnant small bowel was 100 cm and they were on parenteral nutrition for a median of eight months. Seven of 14 patients had short bowel secondary to mesenteric vascular events (embolism/thrombosis). Medical management and autologous reconstruction of the bowel included jejuno-colic anastomosis in six, enterorraphies in three, entero-rectal anastomosis in two, lengthening procedures in two, ileo-colic anastomosis in one and reversal Roux-Y gastric bypass in one. Thirteen of 14 patients were weaned off parenteral nutrition. Our Multidisciplinary Intestinal Rehabilitation Program, allowed weaning most of the studied patients off parenteral nutrition.

Gangrenous Adult Midgut Volvulus from Midgut Malrotation: A Case Report

Malrotation of the midgut is mainly a childhood congenital anomaly. Adult Midgut malrotation is rare with the clinical symptomatology varied and non-specific making pre-operative diagnosis difficult. Midgut volvulus from malrotation is a true surgical emergency requiring early intervention to prevent bowel necrosis and death.We report a 27yr old male who was referred to our centre with paralytic ileus post appendectomy. He underwent emergency laparotomy with findings of gangrenous volvulus involving almost the entire midgut from malrotation. He had bowel resection with jejunocolic anastomosis. Post-operatively he was referred on account of short bowel.A high index of suspicion is needed in acute abdomen with atypical features to allow for early diagnosis and prompt intervention to avert this catastrophic event.

Managing high-output stomas: module 2 of 3

All patients with short bowel should be provided with some lumenal source of nutrition if it is safe to do so. Dietary needs are very complex, and support and education through a dedicated dietetics team is pivotal and will improve clinical outcome (Culkin et al, 2009). Energy requirements are higher than in normal people if patients are to be maintained on enteral nutrition alone. These requirements can be met by eating highenergy food, having oral sip feeds, or high-energy enteral feeds at night via a naso-gastric or gastrostomy tube. If increasing the enteral intake fails to meet the requirements or leads to an unacceptable amount of diarrhoea/stoma output, parental nutrition (PN) is indicated (Nightingale and Woodward, 2006). Enteroclysis or fistuloclysis, which is the infusion of enteral feed into the distal limb of a loop stoma or enterocutaneous fistula, might be a viable alternative in some cases (Levy et al, 1988; Teubner et al, 2004). Dietary advice will differ according to the intestinal anatomy that the patient has. There are three main categories of patients with short bowel syndrome: mid-ileal resection, jejunocolic anastomosis and jejunostomy (or high-output enterocutaneous fistula) (Figure 1). Patients with a mid-ileal resection rarely run into nutritional or fluid balance problems. Vitamin B12 is absorbed in the terminal ileum and this will need to be supplemented in these patients. Bile acid malabsorption can also be a cause of Simon Gabe

Effects of Polymeric Formula vs Elemental Formula in Neonatal Piglets With Short Bowel Syndrome

Intestinal adaptation is important for recovery in short bowel syndrome (SBS). This process is dependent on the presence of enteral nutrition (EN) and trophic factors, such as glucagon-like peptide-2 (GLP-2). In clinical practice, elemental formula is often used to feed neonates with SBS, whereas animal studies suggest polymeric formula promotes better intestinal adaptation. In neonatal piglet models of SBS, with or without ileum, we compared the elemental with the polymeric formula, including the effect on endogenous GLP-2. Forty-eight piglets underwent 75% mid-intestinal resection with jejunoileal anastomosis, 75% distal-intestinal resection with jejunocolic anastomosis (JC), or sham without resection. Parenteral nutrition (PN) started postoperatively, tapering as EN was increased, according to clinical criteria, based on diarrhea and weight. Within groups, piglets were randomized to an isocaloric/isonitrogenous elemental (amino acid) or polymeric (intact protein) diet. Plasma GLP-2 and histology for adaptation were measured at 14 days. Within both SBS and control groups, no difference in adaptation was observed according to diet. A difference was observed only within the JC piglet group with regard to clinical outcomes. In these piglets, compared with elemental formula, the polymeric formula was associated with more diarrhea ( P = .023) and longer duration of PN support (P = .047). An overall benefit of the polymeric formula over the elemental formula on gut adaptation was not observed. Furthermore, SBS piglets without ileum had less ability to tolerate polymeric formula, contributing to more days of PN support.

Enteral nutrients potentiate glucagon-like peptide-2 action and reduce dependence on parenteral nutrition in a rat model of human intestinal failure

Glucagon-like peptide-2 (GLP-2) is a nutrient-dependent, proglucagon-derived gut hormone that shows promise for the treatment of short bowel syndrome (SBS). Our objective was to investigate how combination GLP-2 + enteral nutrients (EN) affects intestinal adaption in a rat model that mimics severe human SBS and requires parenteral nutrition (PN). Male Sprague-Dawley rats were assigned to one of five groups and maintained with PN for 18 days: total parenteral nutrition (TPN) alone, TPN + GLP-2 (100 μg·kg(-1)·day(-1)), PN + EN + GLP-2(7 days), PN + EN + GLP-2(18 days), and a nonsurgical oral reference group. Animals underwent massive distal bowel resection followed by jejunocolic anastomosis and placement of jugular catheters. Starting on postoperative day 4, rats in the EN groups were allowed ad libitum access to EN. Groups provided PN + EN + GLP-2 had their rate of PN reduced by 0.25 ml/day starting on postoperative day 6. Groups provided PN + EN + GLP-2 demonstrated significantly greater body weight gain with similar energy intake and a safe 80% reduction in PN compared with TPN ± GLP-2. Groups provided PN + EN + GLP-2 for 7 or 18 days showed similar body weight gain, residual jejunal length, and digestive capacity. Groups provided PN + EN + GLP-2 showed increased jejunal GLP-2 receptor (GLP-2R), insulin-like growth factor-I (IGF-I), and IGF-binding protein-5 (IGFBP-5) expression. Treatment with TPN + GLP-2 demonstrated increased jejunal expression of epidermal growth factor. Cessation of GLP-2 after 7 days with continued EN sustained the majority of intestinal adaption and significantly increased expression of colonic proglucagon compared with PN + EN + GLP-2 for 18 days, and increased plasma GLP-2 concentrations compared with TPN alone. In summary, EN potentiate the intestinotrophic actions of GLP-2 by improving body weight gain allowing for a safe 80% reduction in PN with increased jejunal expression of GLP-2R, IGF-I, and IGFBP-5 following distal bowel resection in the rat.

Novel Neonatal Piglet Models of Surgical Short Bowel Syndrome With Intestinal Failure

Short bowel syndrome occurring after surgery for acquired or congenital intestinal abnormalities causes considerable neonatal morbidity and mortality. Animal models are a valuable research tool for this problem; however, few successful neonatal models have been developed and most do not include distal intestinal resection as seen commonly in human babies. We report novel piglet models addressing these gaps. Neonatal piglets (1-6 days) underwent venous and gastric catheter insertion and 75% intestinal resection. Group 1 (n = 6) had midintestinal resection with jejunoileal anastomosis; group 2 (n = 5) had distal intestinal resection with jejunocolic anastomosis; group 3 (n = 5) were sham controls; and group 4 (n = 5) were sow reared. Postoperatively, groups 1 to 3 piglets commenced parenteral nutrition (PN), and enteral nutrition was introduced and advanced using a standard regimen. Data collection included days on PN, weight gain, fat absorption, small intestine lengthening, and bowel/liver histology. Group 2 piglets had more days on PN (P = 0.008), less weight gain (P = 0.027), and greater malabsorption (P = 0.012). They did not show small intestine lengthening and had more cholestatic liver disease. Group 1 piglets had histological evident intestinal adaptation and 1.5-fold intestinal lengthening (P = 0.001). These novel piglet models of short bowel syndrome are the first to represent the full clinical spectrum of intestinal failure as observed in human neonates. By considering the impact of different short bowel anatomy on potential for adaptation and growth, these animal models are a significant advance. They permit evaluation of new therapies to promote intestinal adaptation and reduce complications, such as cholestasis.