Total Parenteral Nutrition Requirements Research Articles

Systemic sclerosis gastrointestinal dysmotility: risk factors, pathophysiology, diagnosis and management.

Nearly all patients with systemic sclerosis (SSc) are negatively affected by dysfunction in the gastrointestinal tract, and the severity of gastrointestinal disease in SSc correlates with high mortality. The clinical complications of this dysfunction are heterogeneous and include gastro-oesophageal reflux disease, gastroparesis, small intestinal bacterial overgrowth, intestinal pseudo-obstruction, malabsorption and the requirement for total parenteral nutrition. The abnormal gastrointestinal physiology that promotes the clinical manifestations of SSc gastrointestinal disease throughout the gastrointestinal tract are diverse and present a range of therapeutic targets. Furthermore, the armamentarium of medications and non-pharmacological interventions that can benefit affected patients has substantially expanded in the past 10 years, and research is increasingly focused in this area. Here, we review the details of the gastrointestinal complications in SSc, tie physiological abnormalities to clinical manifestations, detail the roles of standard and novel therapies and lay a foundation for future investigative work.

Sarcopenia Predicts Inferior Progression-Free Survival in Lymphoma Patients Treated with Autologous Hematopoietic Stem Cell Transplantation

Autologous hematopoietic stem cell transplantation (ASCT) improves survival for patients with chemotherapy-sensitive lymphoma. Validated scoring systems are used in the clinical setting to predict treatment toxicity and survival. However, complications related to disease and treatment still occur, highlighting challenges in optimal patient selection and the necessity of novel predictors. Analysis of body composition and muscle mass can offer an objective assessment to identify vulnerable populations as sarcopenia and frailty have been reported to predict outcomes in other tumor types. This is a retrospective cohort study investigating associations of sarcopenia in patients undergoing ASCT for lymphoma with clinically significant outcomes including overall survival (OS) and progression-free survival (PFS). Computed tomography (CT) images obtained routinely pretransplant of 78 patients were used to assess skeletal muscle mass and reported as skeletal muscle index (SMI). OS, PFS, and clinical outcomes of interest were reported and compared between groups. There were 27 patients (34.6%) in the cohort who met the criteria of sarcopenia. Patients with sarcopenia had a significantly shorter 3-year PFS [59% (95% CI 38% - 75%) versus 84% (95% CI 71% - 92%); p = 0.02] after 3 years of follow up while there was no difference in OS [78% (95% CI 57% - 89%) versus 88% (95% CI 76% - 95%); p = 0.25]. Interestingly, no difference in survival was found with stratification based on Karnofsky performance scale (KPS) or hematopoietic cell transplantation-specific comorbidity index (HCT-CI). There was no significant difference in length of hospital stay and the incidences of other clinical outcomes of interest including febrile neutropenia, mucositis, total parenteral nutrition requirement, acute kidney injury, rate of readmission, or intensive care unit admission observed in our study. This is the first study to our knowledge to correlate sarcopenia with disease control and PFS after ASCT in lymphoma. Possible explanations include higher rate of chemotherapy-related toxicity leading to disruptions of treatment as well as dysfunction of antitumor immunity secondary to impaired regulations from myokines from the loss of muscle mass or an unknown cause that is yet to be elucidated. Physical therapy programs and personalized regimens for treatment based on the analysis of body composition indices can be further studied and implemented to mitigate treatment-related toxicity and to optimize survival in patients with sarcopenia.

The Efficacy and Safety of Methylnaltrexone for the Treatment of Postoperative Ileus.

Postoperative ileus (POI) is a surgical complication resulting in increased morbidity and length of stay (LOS). Usual care for POI includes bowel rest and gastric decompression. It has been questioned if methylnaltrexone (MNTX), a peripheral opioid antagonist, could be used as treatment for POI. The purpose of this study was to determine if MNTX is effective and safe for POI treatment. This single-center, retrospective cohort study included patients ⩾ 18years with a POI. Patients with acute colonic pseudo-obstruction, small bowel obstruction, and gastrointestinal malignancy were excluded. The intervention was MNTX administration. The primary outcome was time to ileus resolution. Secondary outcomes included LOS, duration of nasogastric tube, total parenteral nutrition requirement, and incidence of gastrointestinal perforations. 110 patients were included in the analysis; 28 received MNTX. Time to ileus resolution was 9.9days for the MNTX group and 11.4days for the control group (P = .38). Duration of gastric decompression was 4.6days for the MNTX group and 4.2days for the control group (P = .71). Length of stay was 19.9days for the MNTX group and 19.7days for the control group (P = .96). The percentage of TPN requirement was 17.9% in the MNTX group and 22.0% in the control group (P = .65). No gastrointestinal perforations were observed in either group. For the treatment of POI, MNTX did not significantly reduce time to resolution of ileus, LOS, duration of gastric decompression, or TPN requirements. However, no gastrointestinal perforations were seen, indicating that MNTX may be safely used in these patients.

Hospital Burdens of Patients With Cerebral Palsy Undergoing Posterior Spinal Fusion for Scoliosis.

Study Design:Retrospective cohort study.Objectives:Many patients undergoing posterior spinal fusion (PSF) for scoliosis have concurrent cerebral palsy (CP), which is associated with many medical comorbidities and inherent operative risk. We aimed to quantify the contribution of CP to increased cost, length of stay (LOS), and complication rates in patients with scoliosis undergoing PSF.Methods:Using the National Inpatient Sample database, we collected data regarding patient demographics, hospital characteristics, comorbidities, in-hospital complications, and mortality. Primary outcomes included complications, hospital LOS, and total hospital costs. Multivariate regression models assessed the contribution of CP to in-hospital complications, discharge status, and mortality. Linear regression identified the contribution of a diagnosis of CP on hospital LOS and inflation-adjusted cost.Results:Cerebral palsy was an independent predictor of several complications. The most striking differences were seen for mortality (odds ratio [OR]: 3.40, P < .001), a postoperative requirement for total parenteral nutrition (OR: 3.16, P < .001), urinary tract infection (OR: 2.75, P < .001), surgical site infection (OR: 2.67, P < .001), and pneumonia (2.21, P < .001). Patients with CP ultimately cost an additional $13 482 (P < .001) with a 2.07-day greater LOS (P < .001) than patients without CP.Conclusion:Most complications were seen in higher rates in the CP cohort, with higher cost and LOS in patients with CP versus those with idiopathic scoliosis (IS). Our findings represent important areas of emphasis during preoperative consultations with patients with CP and their families. Extra care in patient selection and multifaceted treatment protocols should continue to be implemented with further investigation on how to mitigate common complications.

Management of Five Hundred Patients With Gut Failure at a Single Center: Surgical Innovation Versus Transplantation With a Novel Predictive Model.

To define the evolving role of integrative surgical management including transplantation for patients gut failure (GF). A total of 500 patients with total parenteral nutrition-dependent catastrophic and chronic GF were referred for surgical intervention particularly transplantation and comprised the study population. With a mean age of 45 ± 17 years, 477 (95%) were adults and 23 (5%) were children. Management strategy was guided by clinical status, splanchnic organ functions, anatomy of residual gut, and cause of GF. Surgery was performed in 462 (92%) patients and 38 (8%) continued medical treatment. Definitive autologous gut reconstruction (AGR) was achievable in 378 (82%), primary transplant in 42 (9%), and AGR followed by transplant in 42 (9%). The 84 transplant recipients received 94 allografts; 67 (71%) liver-free and 27 (29%) liver-contained. The 420 AGR patients received a total of 790 reconstructive and remodeling procedures including primary reconstruction, interposition alimentary-conduits, intestinal/colonic lengthening, and reductive/decompressive surgery. Glucagon-like peptide-2 was used in 17 patients. Overall patient survival was 86% at 1-year and 68% at 5-years with restored nutritional autonomy (RNA) in 63% and 78%, respectively. Surgery achieved a 5-year survival of 70% with 82% RNA. AGR achieved better long-term survival and transplantation better (P = 0.03) re-established nutritional autonomy. Both AGR and transplant were cost effective and quality of life better improved after AGR. A model to predict RNA after AGR was developed computing anatomy of reconstructed gut, total parenteral nutrition requirements, cause of GF, and serum bilirubin. Surgical integration is an effective management strategy for GF. Further progress is foreseen with the herein-described novel techniques and established RNA predictive model.

2608 Teduglutide Therapy for a Patient With Chronic Intestinal Failure Following Multi-Visceral Transplantation

INTRODUCTION: The use of glucagon-like peptide-2 (GLP-2) agonists, such as Teduglutide, and recombinant human growth hormones (HGH), remain important for making advances in Short Bowel Syndrome and intestinal failure to reduce parenteral nutrition requirements. The efficacy of these agents have yet to be studied in the intestinal transplant population who experience decreased absorption with no evidence of acute rejection. We present a case of Teduglutide therapy for chronic intestinal failure following a multi-visceral transplant including stomach, pancreas and small bowel. CASE DESCRIPTION/METHODS: A 47-year-old Caucasian female presented with a history of corrected, congenital duodenal atresia, complicated by recurrent obstructions, requiring a Whipple procedure with bowel to bowel bypass and anastomosis. She developed short bowel syndrome and began to lose weight. She was placed on long-term total parenteral nutrition (TPN), with consequent hospital admissions for fungemia. She underwent a multi-visceral transplant including stomach, pancreas, and small intestine and placed on immunosuppressive therapy. Years later, she developed ongoing, severe watery diarrhea with recurrent need for TPN. She was placed on Pancrelipase and lipids, without any improvement. Intestinal biopsies repeatedly showed no signs of acute rejection or cytomegalovirus (CMV). Loperamide and Diphenoxylate were also trialed. Given a lack of progress, she was placed on Teduglutide. The patient experienced significant symptomatic improvement after 10 days of therapy. She was able to decrease her intravenous fluids (IVF) needs by 50%. After one month she again experienced worsening symptoms. She was placed on Linaclotide in addition to Teduglutide with the need to maximize TPN requirements. Repeat intestinal biopsies did not show evidence of infection or acute rejection. Teduglutide was discontinued after 10 months as it did not improve symptoms. DISCUSSION: Intestinal absorption can remain an issue in short bowel syndrome until transplant can be achieved. It remains problematic when multi-visceral transplant is performed and patients continue to experience malabsorption. Unfortunately, although our patient had a good initial response, this response did not persist and therefore therapy was discontinued. Research is ongoing to discover pharmacologic treatment options that significantly decrease the necessity of TPN and IVF. HGH and GLP-2 agonists are options at this time, however remain in question if they are effective long term.

200.4: Serial Transverse Enteroplasty (STEP) for the Short Gut Syndrome (SGS) Patients with Gut Failure (GF)

Introduction: With recent evolution of gut rehabilitation, bowel lengthening is increasingly utilized to restore nutritional autonomy in patients with GF. This is the first largest single center experience with STEP particularly among adults with different causes of SGS including Crohn’s and allograft rejection. Methods: Over 7 years, 65 SGS-GF-patients received a total of 79 STEP procedures. Sixty one(94%) patients were adults and 4(6%) were children with an age ranging from 2 to 79 years. All patients suffered loss of nutritional autonomy with the requirement for total parenteral nutrition (TPN), or IVF-micronutrient replacement. The leading causes were vascular occlusion (n=22), surgical adhesions (n=13), and Crohn’s disease (n=12). Interestingly, the procedure was performed in an isolated intestinal allograft after partial recovery from acute rejection. The mean pre-STEP length of the residual bowel was 71 ± 13 cm with partially or fully preserved colon in 54(83%) and intact ileo-cecal valve in 14(22%) Reestablishment of gut continuity was accomplished preoperatively in 24(37%) and simultaneously performed in 41(63%). The procedure was reproducible in a total of 13(20%) patients. GLP2 was used as an adjunct therapy before and/or after the STEP procedure in 11(17%) patients. Results: With a total of 79 STEP-procedures and overall total number of 2 to 36 cuts, there was an increment in the bowel length ranging from 2 cm to 50 cm. The increase in the bowel length was influenced by length of the residual bowel, intestine diameter and the cumulative number of the transverse cuts. With a mean follow up of 19 ± 7 months, a total of 28(43%) patients achieved full nutritional autonomy with discontinuation of TPN therapy. The remaining 37(57%) experienced partial reduction in the TPN and IVF support. Length of residual bowel, volume/caloric contents of initial TPN therapy, and presence of the ileo-cecal valve were significant predictors of successful outcome. Conclusions: STEP along with autologous gut reconstruction is an effective bowel lengthening procedure for the management of SGS –GF patients. The operation is also technically feasible in Crohn’s disease patients and recipients of intestinal allografts.

Non-Cryopreserved Autologous Hematopoietic Transplantation Has Less Short Term Complications, Faster Engraftment and Similar Transplant Outcomes Than Cryopreserved Modality in Multiple Myeloma and Lymphoma Patients. a Comparative Analysis of Two Centers

Abstract Introduction Autologous hematopoietic transplantation (AHT) is an established therapy in multiple myeloma (MM) and lymphoma. Standard mode (CRYO) consists on collection of autologous precursors, freezing with dimethyl sulfoxide (DMSO) and subsequent thawing and reinfusion. However, this process is toxic and increases transplantation costs. Non-Cryopreserved (Non-CRYO) mode is a less expensive mode of AHT that has shown same transplantation outcomes in several single-center experiences. The Pontificia Universidad Católica de Chile transplant program began Non-CRYO AHT in 2015. In this study, we have compared patients who had Non-CRYO AHT in Chile with patients who had standard CRYO AHT in Spain at the same period of time. Aims: Our main objective was to compare short-term complications between both modes of AHT in terms of severe mucositis measured by use of morphine, total parenteral nutrition requirements, febrile neutropenia, engraftment and length of hospitalization. Other objectives were overall response, non-relapse mortality and overall survival. Methods. This is a prospective analysis of all consecutive adult patients treated with AHT in both centers from January 2015 to May 2016. CRYO mode procedure consisted of the stimulation of hematopoietic progenitors with filgrastim +/- plerixafor in both MM and lymphoma patients, CD34-apheresis on day 5, freezing of product with DMSO, subsequent thawing and reinfusion post conditioning. In Non-CRYO mode, once patients achieved the best response, they received the same filgrastim +/- plerixafor treatment followed by CD34-apheresis without DMSO freezing. Apheresis product was kept at 5°C during conditioning and then re-infused. Conditioning regimen for MM patients was high dose melphalan and for lymphoma patients BEC or BEAM protocols. All patients were hospitalized during the period of pancytopenia and received transfusions, antibiotics and symptomatic measures as usual. Patients were discharged when they reached &gt;500 neutrophils/uL and 25.000 platelets/uL without the need of transfusions, and did not have active infections. Results. Since 2015, 29 Non-CRYO and 58 CRYO AHT were performed in both centers. General characteristics are detailed in table 1. No significant differences were observed regarding demographic characteristics, basal disease and status, and CD34 cellularity. 7AAD FACS viability at infusion day was greater than 92% in Non-CRYO and all patients engrafted in both groups. As we show in table 2, neutrophil and platelet engraftments were significantly earlier in Non-CRYO group vs CRYO group (p = 0.003). Less gastrointestinal toxicity was seen in Non-CRYO group in terms of morphine use (11% vs 55%, p= 0.001) and total parenteral nutrition requirements (11% vs 14%, p= 0.06). The incidence of febrile neutropenia was lower in Non-CRYO group (28% vs 85% respectively, p=0.0001). Finally, lengh of hospitalization was shorter in Non-CRYO (p=0.008). Overall response obtained after transplant was similar in both groups. Non relapse mortality was low and similar in both groups (0 vs 0.5%). We found no differences in relapse nor overall survival. Conclusions. This analysis demonstrates a clear advantage of Non-CRYO AHT over CRYO AHT in terms of short term complications, in particular, faster engraftment, shorter hospital stay and lower incidence of febrile neutropenia and severe pain manifested by morphine use. These data are especially relevant to transplant centers with high flow of patients or limited resources. The savings in costs of freezing process and shorter hospitalizations should be evaluated in further investigations. Disclosures No relevant conflicts of interest to declare.

Alveolar Rhabdomyosarcoma in a 69-Year-Old Woman Receiving Glucagon-Like Peptide-2 Therapy.

A 69-year-old woman was diagnosed with alveolar rhabdomyosarcoma (ARMS) of the nasopharynx. She has a history of catastrophic thromboembolic event in the abdomen that caused short-gut syndrome and dependence on total parenteral nutrition (TPN) twelve hours per day. She was treated for short-gut syndrome with teduglutide, a glucagon-like peptide-2 (GLP-2) analog, which led to reduction of TPN requirements. However, a few months later, she developed metastatic alveolar rhabdomyosarcoma. Though a causative relationship is unlikely between the peptide and ARMS due to the brief time course between teduglutide therapy and sarcoma diagnosis, neoplastic growth may have been accelerated by the GLP-2 analog, causing release of IGF-1. The transmembrane receptor for IGF-1 is frequently overexpressed in ARMS and is implicated in cell proliferation and metastatic behavior. This case describes a rare incidence of metastatic alveolar rhabdomyosarcoma in a sexagenarian and possibly the first case reported associated with the use of teduglutide. Teduglutide was discontinued due to a potential theoretical risk of acceleration of sarcoma growth, and the patient's rhabdomyosarcoma is in remission following sarcoma chemotherapy.

A Single Nucleotide Polymorphism in SLC7A5 Is Associated with Gastrointestinal Toxicity after High-Dose Melphalan and Autologous Stem Cell Transplantation for Multiple Myeloma

Multiple myeloma is the most frequent indication for high-dose melphalan (HDM) chemotherapy with autologous stem cell transplantation (ASCT). Gastrointestinal symptoms represent the most significant nonhematological toxicity of HDM. However, specific, especially genetic, predictors of their incidence or clinical severity are lacking. The amino acid transporters LAT1 and LAT2 encoded by the SLC7A5 and SLC7A8 genes, respectively, are the principal mediators of melphalan uptake into cells. To determine whether genetic variability at these loci contributed to interindividual differences in the development of gastrointestinal complications of HDM, we analyzed single nucleotide polymorphisms (SNPs) in these genes in 135 patients with multiple myeloma treated with HDM and ASCT and correlated these with the need for total parenteral nutrition (TPN). Seven SNPs in SLC7A5 and 20 in SLC7A8 were genotyped. Multiple analyses indicated that 1 SNP in the first intron of SLC7A5, rs4240803, was significantly associated with TPN use (odds ratio = .45, 95% confidence interval, .25 to .79; P = .007). Further, every haplotype that correlated with TPN requirement included this SNP. These results suggest that variability in melphalan transport affects mucosal injury after HDM. This finding could help in individualizing the dose of this effective and widely used chemotherapeutic agent for multiple myeloma.

Oesophageal Doppler monitoring: a misguided editorial

Ghosh and colleagues raise a series of concerns regarding the guidelines from the National Institute for Health and Clinical Excellence (NICE) on the use of the oesophageal Doppler monitor (ODM) [1]. Firstly, they state the current evidence base is insufficient to justify publication of the guideline, although it has recently been added to regarding major urology surgery [2]. No guideline is perfect, and many treatments in current practice have an imperfect evidence base – one estimate is that 50% of clinical practice guidelines are opinion- rather than evidence-based [3]. The question that Ghosh et al. should address, therefore, is ‘how much evidence is enough?’ The level of evidence for the use of the ODM is greater than for high frequency oscillatory ventilation, extracorporeal membrane oxygenation, and inotropes in heart failure, not to mention other common interventions in anaesthesia and critical care. We live in an imperfect, uncertain world, and waiting for ‘perfect evidence’ risks decision-making stasis. Their second concern relates to links between industry and experts. In general, this is a valid concern, but the apparently dichotomous view that ‘industry link = bad, non-industry link = good’ is, we feel, naive. Most commentators are biased in one way or another [4, 5]. Thirdly, their view appears to be that guidelines should not be produced for specific technologies unless a similar level of information is available for competitor devices. In this case, the comparator is generally ‘current accepted practice’ rather than other cardiac output monitors. The lack of evidence from other devices is not relevant in this instance; indeed, it is consistently the case that despite NICE guidance, use of ODM or similar technologies remains low (personal observation). Such studies of other monitors against ODM are certainly valid, but we doubt that ethics committees would allow a control arm where stroke volume was not estimated and managed; equivalence studies are probably all that would be allowed. Ghosh et al. also suggest that one result of NICE guidance is an inappropriate pressure on managers and clinicians to adopt technologies and treatments. The NICE guidance documents do not state that clinicians are obliged to use ODM technology and many such innovations are routinely debated within departments. In many cases, they will choose not to follow specific recommendations for a variety of reasons. Ghosh et al. also express disbelief that a short-lived intervention can save the NHS £1100 per patient. Nevertheless, an unpublished cost analysis of our study [2] demonstrated a saving in excess of £1900 per patient. This came predominantly from a reduction in bed-days and requirement for total parenteral nutrition, due to a reduction in gastrointestinal complications and the number of long-stay patients. It does not come from a reduction in stay in every treated patient. Finally, Ghosh et al. suggest that one should simply dispense with the ODM and give all patients an extra 500 ml colloid bolus. We presume this is a deliberately tongue-in-cheek remark, rather than their belief after reading the available clinical evidence.

Audit of pharmacy TPN services on the neonatal intensive care unit (NICU)

<h3>Objective</h3> At The Whittington Hospital, pharmacy is responsible for providing a total parenteral nutrition (TPN) service to neonatal intensive care unit (NICU). The aims are to deliver a safe and beneficial service to patients, which is also cost-effective to the Trust. Neonatal TPN bags are manufactured off-site, and there are two main types of bag procured: Standard Stock Bags and Tailor-Made Bags. This audit was designed to investigate the management and delivery of TPN to NICU in the Trust over a 12-week period, focusing on the type of bag prescribed, usage and the expenditure. This in turn helped to determine new local standards of management with the aim of optimising the TPN service, with reduced costs and wastage. <h3>Methods</h3> Data was collected over 12-weeks (19 October 2009 to 8 January 2010) and expenditure calculated with pricing adapted from JAC and the Service Level Agreement held with external suppliers. <h3>Results</h3> Table 1 summarises the types and cost of bag used over the audit period and the number of which incurred wastage. Where there were differences in the TPN prescription compared to the standard formula, tailor-made bags were ordered. Table 2 summarises the main changes made. <h3>Conclusion</h3> Findings from the audit showed a high usage of tailor-made TPN compared to stock TPN, most of which were bespoke bags (bags with additions made to the standard stock formula). Since conducting the audit practice has been reviewed: a new stock order level has been put in place, in addition a new TPN prescription has been developed, which helps distinguish between the different bags available. Although TPN requirements are based on the individual patient, the audit suggests that the stock bag may need to be reviewed for a more favourable alternative (and in-line with the latest ESPGHAN recommendations). A re-audit is intended, where it is hoped that optimised management of the pharmacy TPN service to NICU will be demonstrated.

Zinc: An Essential Trace Element for Parenteral Nutrition

Zinc is an essential trace element for human nutrition that is an integral part of many enzyme systems, including DNA polymerase complex. Zinc deficiency has been associated with stunting of growth and sexual immaturity. In children, deficiency causes a fatal condition called acrodermatitis enteropathica. The same syndrome has been observed in patients on total parenteral nutrition (TPN) who do not receive zinc. In TPN the requirements have been estimated by balance studies to be 3 mg/d in patients without gastrointestinal losses and a mean of 12 mg/d in patients with diarrhea and fistula losses.

Living-Related Small Bowel Transplantation for Three Patients With Short Gut Syndrome

We summarized our experience of living-related small bowel transplantation and postoperative management of 3 patients with short gut syndrome. Patient #1, an 18-year-old boy, received a 150-cm segment of distal ileum with a vascular pedicle of distal superior mesenteric artery and vein, which was donated by his father. Patient #2, a 15-year-old boy, received a 160-cm graft of distal ileum from his mother. Patient #3, a 17-year-old boy, received a 170-cm graft of distal ileum from his father. The graft artery and vein were anastomosed to the recipient infrarenal aorta and vena cava, respectively, in end-to-side fashion using 7/0 Prolene suture. Intestinal continuity was restored by anastomosis of proximal end of the graft to the recipients' own proximal jejunum, the distal end was left open as a stoma. The recipient distal gut was anastomosed to the distal end of the graft. All 3 recipients were given FK506 (tacrolimus) regularly combined with periodic mycophenolate mofetil. In cases of acute rejection, large doses of steroids were administered to the recipients. The recipients and donors had fairly unremarkable postoperative courses. So far, patient #1 has survived for 7 years and 6 months with a well-functioning graft and without requirement for total parenteral nutrition (TPN) support. His body weight increased 20 kg and of his life quality has dramatically improved. Patient #2, however, died of acute rejection with fatal sepsis at 5 months after transplantation. Patient #3 has survived for 3 years and 8 months enjoying a normal life. Postoperative recovery of all 3 donors was unremarkable. They were discharged 12 days after surgery without complications. Outcomes of the implantation using the distal ileum as a graft in living-related small bowel transplantation have been satisfactory for both recipients and donors. It is feasible to anastomose the graft artery and vein to the recipient infrarenal aorta and vena cava. The intestinal continuity can be restored by a 1-stage strategy with minimal risk to the recipient. Appropriate application and adjustment of immune suppressors are crucial for the recipients to experience high-quality lives.

Use of a personal digital assistant to estimate refeeding syndrome risk and total parenteral nutrition requirements by untrained personnel

Use of a personal digital assistant to estimate refeeding syndrome risk and total parenteral nutrition requirements by untrained personnel

Use of a personal digital assistant to estimate refeeding syndrome risk and total parenteral nutrition requirements by untrained personnel

Use of a personal digital assistant to estimate refeeding syndrome risk and total parenteral nutrition requirements by untrained personnel

Threonine Requirement in Neonates Receiving Total Parenteral Nutrition (TPN)

Current neonatal threonine (THR) enteral requirement is 87 mg·kg‐1·d‐1. The THR requirement of the parenterally (TPN) fed human neonate has never been experimentally determined. Concentrations of THR in commercially available TPN solutions are derived from concentrations in cord blood, plasma amino acid profile during TPN feeding, or human milk, and are 30 to 80% higher than the enteral requirement. We showed in piglets that the neonatal TPN requirement for THR was 55% lower than the enteral requirement.Our objective was to determine the human neonatal TPN requirement for THR in post‐surgical neonates using the indicator amino acid oxidation technique with L[1–13C]phenylalanine. Neonates were randomized to receive one of twelve THR intakes ranging from 10 to 100 mg· kg‐1·d‐1. Preliminary data indicate a mean THR requirement between 30 and 40 mg·kg‐1·d‐1, only 30% of the THR concentration in the lowest THR containing TPN solution. We conclude that the THR requirement for TPN fed human neonates is significantly lower than the THR present in current TPN solutions and the recommended intake for orally fed infants. High THR intakes are a concern; THR is potentially neurotoxic and neonates are unable to oxidize excess

EFFECT OF KEPIVANCE ON THE INCIDENCE OF MUCOSITIS, HOSPITAL STAY, AND TOTAL PARENTERAL NUTRITION IN PATIENTS UNDERGOING STEM CELL TRANSPLANTATION.

Kepivance is a keratinocyte growth factor (KGF) that stimulates the growth of cells in the skin, mouth, stomach, and colon. It has been suggested that Kepivance may reduce the incidence and severity of oral mucositis in patients receiving a total body irradiation (TBI) conditioning regimen followed by autologous stem cell rescue. Very few studies have shown the effect of Kepivance on chemotherapy-induced mucositis in patients receiving allogeneic/autologous stem cell transplantation. We analyzed retrospectively the charts of all patients who underwent stem cell transplantation in 2005-2006 at Texas Tech University Health Science Center. The charts of 36 patients were reviewed, of which 21 received Kepivance. The decision to receive Kepivance was judged by the treating physician. Patients with a high risk of developing mucositis from intensive chemotherapy, older patients, type of conditioning regimen, and type of transplant dictated which patient should receive Kepivance. Conditioning regimens in the Kepivance group were as follows: high-dose melphalan (10); TBI, VP-16, and cyclophosphamide (1); BCNU, VP-16, and cyclophosphamide (2); fludarabine and melphalan (1); melphalan and VP-16 (1); busulfan and fludarabine (6). Conditioning regimens in the non-Kepivance group were as follows: melphalan and busulfan (1); melphalan and fuldarabine (2); BCNU, VP-16, and cyclophosphamide (4); high-dose melphalan (8). Of 21 patients who received Kepivance, 12 patients received autologous transplant and 9 patients received allogeneic transplants. Of the 21 patients who received Kepivance, 8 experienced grade II-III mucositis compared with 3 of 15 patients in the non-Kepivance group. No patients in both groups experienced grade IV mucositis. In both groups, 50% of the patients required total parenteral nutrition (TPN). The average length of stay in patients who received kepivance was 31 days versus 36 days in patients who did not receive Kepivance. Day 100 mortality in the Kepivance group was five, all of whom received allogeneic transplant, whereas there was only one death (who received allogeneic transplantation) in the non-Kepivance group. We concluded that Kepivance reduces the hospital stay in patients undergoing stem cell transplantation; however, there were no noted benefits of Kepivance in TPN requirement or the incidence of mucositis. This may be due to physician bias in selecting patients who should receive Kepivance. High-risk patients received Kepivance. A randomized clinical trial is needed to confirm these results.

Etiology and Initial Management of Short Bowel Syndrome

o he normal human small intestine ranges between 3 and 8 m in length, depending on whether measureent is made by radiologic or surgical techniques or at utopsy when the intestine may be desicated.1–5 Short owel syndrome is defined in adults as 200 cm of small ntestine. Although usually acquired because of one or ore enterectomies, short bowel syndrome may also be ongenitally acquired. Nutrient, electrolyte, and fluid bsorption is proportional to the amount of residual ntestine. The degree of intestinal function is better escribed in terms of energy absorption/loss rather than ength of residual intestine.6 Intestinal failure may be efined as the inability to sustain adequate nutritional, lectrolyte, or hydrational status in the absence of speialized nutritional support. This requires an increase in ral intake because absorption is compromised. Clinially, nutrient assimilation is a function of intake and bsorption. As such, some patients with short bowel yndrome will not have sufficient loss of functional caacity as to develop intestinal failure. Significant indiidual variability in jejunal absorption efficiency may be ncountered.7 The patients with the greatest risk for development of ehydration, generalized protein-calorie malnutrition, nd multiple nutrient deficiencies are those with a duoenostomy or jejunoileal anastomosis and 35 cm of esidual small intestine; jejunocolic or ileocoloic anastoosis, and 60 cm of residual small intestine; or end ejunostomy with 115 cm of residual small intesine.6,8–11 Those patients with residual colon in continuty will have enhanced energy and fluid absorption. ence, such patients can tolerate greater loss of small ntestine and retain their nutritional autonomy.

Innovative Approaches to Improving Organ Availability for Small Bowel Transplant Candidates

Small bowel transplant candidates have unique features that create special challenges for providing them with organs in a timely manner. More than half of intestinal transplant candidates also need livers. Because there is a greater overall demand for livers than for small bowels, organ allocation in this candidate subset is dictated by the liver allocation policies. However, the extremely high mortality rate associated with patients on the waiting list for combined liver-intestinal transplantation (LIT) attests to the inadequacies of the liver allocation system in recognizing the unique risk factors in patients with intestinal failure who develop end-stage liver disease (ESLD). This report addresses some of the organ allocation issues underlying the discrepancies in waiting list outcomes seen in LIT candidates and discusses possible contributory factors and potential solutions to this problem. The use of living donor and segmental grafts from deceased donors are discussed specifically as potential surgical solutions to the problem, and the potential utility, limitations, and ethical concerns associated with these innovative strategies are discussed.