Remnant Small Bowel Length Research Articles

213.7: A Data-driven Predictive Analytics Framework for the Analysis of Prognostic Factors and Health Outcomes in Paediatric Intestinal Failure Patients

Introduction: Machine learning (ML) involves computational methods and learning mechanisms that can help generate new knowledge from large databases. These techniques are uniquely suited to analyses of paediatric intestinal failure (IF) where classification, prognostication, identification of risk factors, and knowledge extraction can be challenging. Heterogeneous patient populations, small sample sizes, and variations in treatments may complicate our ability to manually identify trends in data. Factors that predict enteral autonomy (EA) and patient management (optimal intravenous lipid emulsion [ILE] solutions; central venous catheter [CVC] complications) have been described, yet a systematic approach that may be prospectively applied to large datasets has never been performed in this patient population. Our study aims to identify predictors of EA through machine learning (ML) and assess their impact on TPN duration. For patients on TPN, assessments of lipid emulsion (ILE) and central venous catheter (CVC) type were also performed. Methods: Demographics, procedures, and outcomes for patients (N=17) from McMaster Children’s Hospital’s (MCH) Intestinal Rehabilitation Program (1999-2021) were collected for a retrospective chart review. Predictors of EA status were obtained using a decision tree ML model. Performance was evaluated as area under the receiver operator characteristics (AUC) and precision-recall (PR) curves. These predictors were assessed for ability to impact TPN duration with Kaplan-Meier (KM) estimates and Cox proportional-hazards (CPH) models. ILE treatments were compared using the Mann-Whitney U test, and CVC types were compared with KM, CPH, and analysis of variance (ANOVA). Results: The model retrieved 10 predictors of EA status. AUC and PR curves were 91% and 71% respectively. Of these 10 predictors: sex, serial transverse enteroplasty (STEP) procedure, ileocecal valve (ICV) presence, and remnant small bowel length were significant for predicting EA status under KM, but not CPH. For ILE treatment, patients on SMOF Lipid® had lower total bilirubin values compared to Intralipid® at six months (4.0 versus 10.0 uMol/L). Longevity of peripherally inserted central catheters (PICC) was 847 days versus 268 days for tunnelled CVCs, and 181 days for ports (95% CI: 0-2044, 93-443, 144-218). Types of complications were not significantly different across CVC. Conclusions: Our study supports the role for ML frameworks in advanced pattern recognition, and promoting adaptive clinical management. Validation of this model using our single-centre dataset supports similar conclusions derived from larger, multi-center registries. Ongoing use of our ML framework offers a novel contribution to intestinal failure analyses by helping identify unique risk factors and protective factors for EA, and approaches to clinical management in the paediatric IF population.

Remnant Small Bowel Length in Pediatric Short Bowel Syndrome and the Correlation with Intestinal Dysbiosis and Linear Growth

Pediatric short bowel syndrome (SBS) is a malabsorptive state placing patients at risk for malnutrition, dehydration, and bacterial overgrowth. These patients are often dependent on parenteral nutrition (PN) while intestinal adaptation is underway. The aim of this study was to characterize the effect of remnant small bowel length on the gut microbiome. Further, we sought to examine the contribution of clinical and nutritional variables to the gut microbiota and anthropometric growth. Clinical data, anthropometrics, and fecal samples were collected from 14 SBS patients and 10 age- and sex-matched controls. Fecal bacterial DNA composition was analyzed using 16s ribosomal RNA gene sequencing. Statistical analysis was completed using the Mann-Whitney or Fisher's exact tests when applicable and linear mixed effect modeling. Distinct microbiota changes were found among those with the least remaining small bowel (<35 cm) compared with those with longer remaining bowel and controls. Those with <35 cm small bowel displayed an increased relative abundance of Proteobacteria, while those with longer remaining small bowel had a higher proportion of Firmicutes. Further, patients with less remaining bowel required more PN (p < 0.01), with a tendency to be shorter in height (p= 0.05) and with a higher BMI (p= 0.05). Remnant small bowel length appears to be a predictor of stunting with diminished linear growth, parenteral nutrition dependency, and a greater relative abundance of Proteobacteria in the gut. These findings suggest an integrated adaptive response predicted by remnant intestinal length. Further research is necessary to examine the effects of intestinal dysbiosis on clinical outcomes.

Establishing Short Bowel Syndrome in Nigerian Dogs

Determining the relationship between percentage resection and development of short bowel syndrome is important as it provides information on the expected outcome of the resection carried out which will enable the surgeon to prepare adequately to manage such patients. Ten adult Nigerian indigenous dogs with mean body weight 11.2 kg were used in this study. The animals were premedicated with atropine (0.04mg/kg) and xylazine (1mg/kg) intramuscularly. Anaesthesia was induced with thiopentone sodium (10mg/kg) intravenously. The abdominal cavity was entered through the ventral midline incision. Three animals each were subjected to 50% and 60% small intestinal resection while four animals were subjected to 70% small intestinal resection. The animals subjected to 50% and 60% intestinal resection did not manifest signs of short bowel syndrome. However, the animals subjected to 70% small intestinal resection manifested clinical signs attributable to short bowel syndrome. The animals subjected to 50% and 60% small intestinal resection had remnant small intestinal tract of up to 100cm while dogs that underwent 70% resection had remnant small intestinal bowel length of less than 100 cm. It is therefore, concluded that 70% small intestinal length resection is the minimum that can produce short bowel syndrome in Nigerian dogs and animals with remnant small bowel length of less than 100 cm after undergoing resection will come down with short bowel syndrome.

Factors affecting poor nutritional status after small bowel resection in patients with Crohn disease.

In Crohn disease, bowel-preserving surgery is necessary to prevent short bowel syndrome due to repeated operations. This study aimed to determine the remnant small bowel length cut-off and to evaluate the clinical factors related to nutritional status after small bowel resection in Crohn disease.We included 394 patients (69.3% male) who underwent small bowel resection for Crohn disease between 1991 and 2012. Patients who were classified as underweight (body mass index < 17.5) or at high risk of nutrition-related problems (modified nutritional risk index < 83.5) were regarded as having a poor nutritional status. Preliminary remnant small bowel length cut-offs were determined using receiver operating characteristic curves. Variables associated with poor nutritional status were assessed retrospectively using Student t tests, chi-squared tests, Fisher exact tests, and logistic regression analyses.The mean follow-up period was 52.9 months and the mean patient ages at the time of the last bowel surgery and last follow-up were 31.2 and 35.7 years, respectively. The mean remnant small bowel length was 331.8 cm. Forty-three patients (10.9%) underwent ileostomy, 309 (78.4%) underwent combined small bowel and colon resection, 111 (28.2%) had currently active disease, and 105 (26.6%) underwent at least 2 operations for recurrent disease. The mean body mass index and modified nutritional risk index were 20.6 and 100.8, respectively. The independent factors affecting underweight status were remnant small bowel length ≤240 cm (odds ratio: 4.84, P < 0.001), ileostomy (odds ratio: 4.70, P < 0.001), and currently active disease (odds ratio: 4.16, P < 0.001). The independent factors affecting high nutritional risk were remnant small bowel length ≤230 cm (odds ratio: 2.84, P = 0.012), presence of ileostomy (odds ratio: 3.36, P = 0.025), and currently active disease (odds ratio: 4.90, P < 0.001).Currently active disease, ileostomy, and remnant small bowel length ≤230 cm are risk factors affecting the poor nutritional status of patients with Crohn disease after small bowel resection.

Valor de la citrulina plasmática como biomarcador de función intestinal en el síndrome de intestino corto y en el trasplante intestinal

IntroductionCitrulline is a non-essential amino acid produced solely in the enterocyte. The aim of this study was to analyse the role of serum citrulline as a biomarker of enterocyte load in children with intestinal failure due to short bowel syndrome (SBS) and its relationship to enteral adaptation. Material and methodsPlasma citrulline concentration was determined by chromatography (normal value>15μmol/L) in 57 patients (age 0.5-18 years) admitted to our Intestinal Rehabilitation Unit with intestinal failure. Those who were dehydrated, with renal insufficiency, or other conditions able to modify the results were excluded. Patients were divided into 4 groups: group i: SBS totally dependent on parenteral nutrition (PN); group ii: SBS under mixed enteral-parenteral nutrition; group iii: IF weaned from PN after a rehabilitation period; group iv: small bowel transplanted patients weaned from PN and taking a normal diet. ResultsThe mean±SD plasma citrulline values were: group i (n=15): 7.1±4.1; group ii (n=11): 15.8±8.9; group iii (n=13): 20.6±7.5; group iv (n=25): 28.8±10.1. Values were significantly lower in group i in comparison with groups ii-iii-iv (P<.001), and in group ii in comparison with groups iii-iv (P<.001). A low citrulline was associated with remnant small bowel length (P<.001, r=0.85). In group iv citrulline levels decreased >50% in 3 patients who developed moderate-severe rejection, and in one patient who developed viral enteritis. Conclusions1. Plasma citrulline could be a sensitive and specific biomarker of the residual functional enterocyte load. 2. It is related to enteral feeding tolerance. 3. Its prognostic value in the process of intestinal adaptation and as a rejection marker in small bowel transplanted patients needs to be confirmed.

Determinants of home parenteral nutrition dependence and survival of 268 patients with non-malignant short bowel syndrome

Short bowel syndrome (SBS) is a rare and severe condition where home parenteral nutrition (HPN) dependence can be either permanent or transient. The timing of HPN discontinuation and the survival, according to SBS characteristics, need to be further reported to help plan pre-emptive intestinal transplantation and reconstructive surgery. 268 Non-malignant SBS patients have been followed in our institution since 1980. HPN dependence and survival rate were studied with univariate and multivariate analysis. Median follow-up was 4.4 (0.3-24) years. Actuarial HPN dependence probabilities were 74%, 64%and 48% at 1, 2 and 5 years, respectively. In multivariate analysis, HPN dependence was significantlydecreased with an early (<6mo) plasma citrulline concentration >20μmol/l, a remaining colon >57% (4/7) and a remnant small bowel length >75cm. Among the 124 patients who became HPN independent, 26.5% did so more than 2 years after SBS constitution. This study indicates that long-term HPN is required in 47% of SBS patients started on this therapy. HPN independence is significantly associated with the remnant small bowel length, remaining colon and early plasma citrulline concentration. Noteworthy, HPN dependence could be reversed until 5 years after SBS constitution.

The experience of a regional pediatric intestinal failure program: Successful outcomes from intestinal rehabilitation

Background The aim of this study was to evaluate the clinical experience of a regional multidisciplinary intestinal failure program for children established in 2005. Methods Data were collected from a prospective internal database. Univariate analyses were performed to compare pre- and post-treatment outcomes. Median values are reported. Results Forty-nine children were referred at an age of 7 months. Remnant small bowel length was 29 cm. With follow-up of 14 months, overall patient survival was 88%. Thirteen bowel-lengthening procedures were performed, thereby increasing small bowel length from 83 to 132 cm ( P < .05). Enteral autonomy was achieved in 22 patients (45%), and the caloric requirement for parenteral nutrition was decreased from 100% to 41% ( P < .01). Conjugated bilirubin was reduced from 4.1 to 0 mg/dL ( P < .05). Conclusion A multidisciplinary approach to pediatric intestinal failure that prioritizes intestinal rehabilitation can achieve successful enteral feeding advancement, improved liver function, and excellent survival in intermediate-range follow-up.

S1346 Operative and Long Term Results After Large Intestinal Resection, Leading to Short Bowel Syndrome, in a Cohort of 108 Chronic Radiation Enteritis Patients

G A A b st ra ct s 108 (96%) of cases. Median HPN duration was 1.2 (0.1-19) years. Actuarial HPN dependence (53/104) probabilities were 65%, 55% and 42% percent at 1, 2 and 3 years, respectively. In multivariate analysis, HPN dependencewas significantly decreased with adaptive hyperphagia (RR=0.39 (0.17-0.86), p=0.02), remnant small bowel length > 100 cm (RR=0.35 (0.180.67), p<0.01) and absence of end enterostomy (RR=0.47 (0.27-0.83), p=0.01). Conclusion: Survival of patients with diffuse CRE after large intestinal resection is good and mainly influenced by underlying comorbidities. Even if HPN is almost always required, it appears a safe therapy with a low related mortality and more than 50% of weaning rate at 3 years.

Parenteral Nutrition Independence in a Patient Left with 25 cm of Ileum and Jejunum: A Case Report

A 44-year-old woman with a history of Roux-en-Y gastric bypass (RYGBP) suffered small bowel volvulus. She was left post-operatively with an intact duodenum, 25 cm of jejunum and ileum, and a colon in continuity, a situation synonymous to short bowel syndrome. This report describes her surgical, medical and nutritional follow-up until complete weaning of parenteral nutrition despite of her very short remnant small bowel and persistently low citrullinemia. The discussion aims at demonstrating the rarity of these complications after RYGBP according to the literature. Furthermore, it challenges the validity of the present markers of parenteral nutrition independence (remnant small bowel length, citrullinemia) in case of short bowel syndrome.

Drastic changes in fecal and mucosa-associated microbiota in adult patients with short bowel syndrome

Short bowel syndrome (SBS) is observed in Humans after a large resection of gut. Since the remnant colon and its associated microbiota play a major role in the outcome of patients with SBS, we studied the overall qualitative and quantitative microbiota composition of SBS adult patients compared to controls. The population was composed of 11 SBS type II patients (with a jejuno-colonic anastomosis) and 8 controls without intestinal pathology. SBS patients had 38 ± 30 cm remnant small bowel length and 66 ± 19% of residual colon. The repartition of proteins, lipids, carbohydrates and fibres was expressed as % of total oral intake in patients and controls. The microbiota was profiled from stool and biopsy samples with temporal temperature gradient gel electrophoresis and quantitative PCR. We show here that microbiota of SBS patients is unbalanced with a high prevalence of Lactobacillus along with a sub-dominant presence and poor diversity of Clostridium leptum, Clostridium coccoides and Bacteroidetes. In addition, Lactobacillus mucosae was detected within the fecal and mucosa-associated microbiota of SBS patients, whereas it remained undetectable in controls. Thus, in SBS the microbial composition was deeply altered in fecal and mucosal samples, with a shift between dominant and sub-dominant microbial groups and the prevalence of L. mucosae.

Damage control surgery for acute mesenteric ischemia

To examine the outcome of damage control surgery (DCS) in patients with acute mesenteric ischemia (AMI). Clinical data of 15 consecutive AMI cases treated with DCS from May 2001 to March 2009 at the Research Institute of General Surgery, Jinling Hospital were retrospectively analyzed. Eleven patients had acute superior mesenteric vein thrombosis (MVT) on admission, and 4 suffered from acute mesenteric arterial embolism/thrombosis (MAE/MAT). The staged damage control approach included immediate resection of the involved bowel (but no attempts to restore gastrointestinal continuity), open thrombectomy, transfer of the patients to ICU for resuscitation, and thrombolysis prior to the planned definitive reconstructive procedure. Of 15 patients, 10 (66.7%) survived. The mean remnant small bowel length was (209.0+/-53.8) cm (120 to 280 cm). None of the survived patients was parenteral nutrition-dependent. Of the 5 deaths, 2 died of recurrence of thrombosis and necrosis of the remaining bowel,1 of massive gastrointestinal bleeding. One patient abandoned treatment intra-operatively, and another with total small bowel resection abandoned treatment postoperatively. Damage control approach improves the survival of patients with AMI. Thrombectomy and thrombolysis are necessary for AMI management to prevent progression or further development of the thrombosis.

Serum citrulline: a potential marker for intestinal epithelial mass and absorption capacity in short bowel syndrome patients

To investigate the potential role of serum citrulline level in evaluating the intestinal absorptive area and capacity in patients with short bowel syndrome (SBS). Serum citrulline concentration was determined using high performance liquid chromatography (HPLC) in SBS patients (n=22) and healthy controls (n=33). In SBS patients, the remnant small bowel lengths and diameters were measured by radiography, and their 5- hour urine D- xylose excretion and intestinal protein absorption were also determined. The correlationship of serum citrulline level with remnant small bowel length, surface area, protein and D- xylose absorption was analyzed. The 6 patients receiving intestinal rehabilitative therapy, serum citrulline level, protein and D- xylose absorption after therapy were also measured. Serum citrulline level of SBS patients was significantly lower than that of healthy controls [(5.94+/- 2.65) vs [(16.87 +/- 5.97) micromol/L, P < 0.01]. In SBS patients, serum citrulline was positively correlated with remnant small bowel length and surface area (r=0.82 and r=0.86 respectively). There was also a significant correlationship of serum citrulline level with 5- hour D- xylose excretion (r=0.56) and intestinal protein absorption (r=0.48). Serum citrulline, 5- hour D- xylose excretion and intestinal protein absorption were all significantly raised in patients after rehabilitative therapy, although no correlation of increasing percentage was found among above three parameters. Serum citrulline concentration is positively correlated with intestinal absorptive area and capacity in SBS patients. It is a potential marker for evaluating the severity of intestinal failure and the efficacy of rehabilitative therapy in short bowel patients.

Plasma Citrulline Concentration

Postabsorptive plasma citrulline concentration has been proposed as a reliable marker of small bowel absorptive capacity in short bowel patients. The aim of this study was to address the potentially confounding impact of intestinal inflammation. Fifty-five patients were selected according to diagnosis, small bowel length, and degree of bowel inflammation. (a) Crohn's disease (CD) with massive small bowel resection leaving </=50 cm (N = 6), (b) CD with 50-150 cm remaining (N = 9), (c) CD with no resection but active inflammation (high C-reactive protein [CRP] and Crohn's Disease Activity Index [CDAI] >220) (N = 7), (d) CD without resection or active inflammation (normal CRP and CDAI <150) (N = 9), (e) mesenteric infarction (MI) with resection leaving </=50 cm (N = 6), (f) MI leaving 50-150 cm (N = 6), (g) active celiac disease (N = 6), (h) healthy volunteers (N = 6). Postabsorptive fasting plasma citrulline was measured using reverse-phase, high performance liquid chromatography. Absorptive capacity and permeability were also measured after oral sugar-mix ingestion (5 g lactulose, 1 g L-rhamnose, 0.5 g D-xylose). The plasma citrulline strongly correlated with small bowel length (P < 0.0001) and xylose absorption (P < 0.001). No correlation was found with CDAI, permeability, CRP, albumin, sedimentation rate, white cell count, or platelet count. Citrulline was significantly higher (P < 0.0004) in CD and MI patients with a remnant small bowel length of 50-150 cm (mean 21.0 micromol/L) than in those with length </=50 cm (mean 9.2 micromol/L). Plasma citrulline concentration is a simple and reliable surrogate for small bowel absorptive capacity and is not influenced by intestinal inflammation.

Serum Citrulline Is A Simple Quantitative Marker for Small Intestinal Enterocytes Mass and Absorption Function in Short Bowel Patients

To investigate the clinical significance of serum citrulline in evaluating the remnant small bowel enterocytes mass and absorptive function in short bowel (SB) patients. Serum citrulline concentrations were determined using high-performance liquid chromatography (HPLC) in 22 SBS patients and 33 healthy controls. Five-hour urine D-xylose excretion and digestive protein absorption were measured using HPLC and micro-Kjeldahl method, respectively. Small bowel length and surface area were assessed on X-ray radiograph. Correlations between serum citrulline levels and small bowel length, small bowel surface, and nutritional substrate digestive absorption percentage were analyzed. For six patients receiving bowel rehabilitation therapy, serum citrulline, D-xylose excretion, and intestinal protein absorption were measured pre- and immediately postmanagement, and their correlations were analyzed. Serum citrulline levels were significantly lower in SB patients compared with healthy controls. In SB patients, they correlated well with remnant small bowel length (r = 0.82, P < 0.001), surface area (r = 0.86, P < 0.001), 5-h urine D-xylose excretion (r = 0.56, P = 0.007), and digestive protein absorption (r = 0.48, P = 0.046). The increased percentage of serum citrulline level in six patients receiving rehabilitation therapy followed a trend of correlating with that of intestinal protein absorption (r = 0.79, P = 0.063) and urine D-xylose excretion (r = 0.81, P = 0.053). In patients with short bowel syndrome, serum citrulline is a simple and accurate biomarker for the severity of intestinal failure and may be a candidate marker for the gut-trophic effects of bowel rehabilitation therapies.