Initiation Of Total Parenteral Nutrition Research Articles

Association between dextrose-containing maintenance fluids and phosphorus supplementation during total parenteral nutrition initiation in adult patients who were hospitalized: A retrospective cohort study.

Use of dextrose-containing maintenance fluids prior to parenteral nutrition (PN) initiation is speculated to reduce the risk for refeeding syndrome. We aimed to assess if the use of dextrose vs nondextrose maintenance fluids before PN initiation changes electrolyte supplementation requirements and shifts during initiation. This retrospective cohort study included patients who received nothing by mouth but received maintenance fluids ≥72 h before PN. The major end point was phosphorus supplementation over 48 h following nutrition initiation. Minor end point included other electrolyte supplementation, changes in electrolyte levels, time to discharge, and goal kilocalories per day. Fifty-three patients between August 1, 2019, and August 26, 2020, met criteria for analysis; 60% (n = 32) used a dextrose and 40% (n = 21) used a nondextrose maintenance fluid. Baseline characteristics were similar between fluid groups except for body mass index (25.1 dextrose vs 27.5 kg/m2 nondextrose), sex (43.8% female vs 52.4% male), and severe malnutrition (46.9% vs 28.6%), respectively. Phosphorus (52.5 vs 50 mmol; P = 0.33) and magnesium (24 vs 22 g; P = 0.63) supplementation 48 h following nutrition initiation were similar between groups; however, potassium supplementation was lower in the dextrose group (165.0 vs 208.7 mEq; P = 0.01). No difference was observed between groups for time to discharge following nutrition initiation or time to goal kilocalories per day. After controlling for patients who were malnourished between fluid groups using linear regression, phosphorus repletion differences remained nonsignificant. This study did not detect a difference in phosphorus supplementation between groups, even after controlling for patients who were malnourished.

Total parenteral nutrition for patients with gastrointestinal cancers: a clinical practice review.

The use of total parenteral nutrition (TPN) in patients with gastrointestinal cancers is a well-established practice, yet there is substantial variability in its use across institutions. Decision-making around the initiation of TPN is complex. An interdisciplinary team can help identify patient factors and clinical situations that influence whether a patient is likely to benefit from parenteral nutrition. We present the case of a woman with a gastrointestinal cancer who benefited from the initiation of TPN as a bridge therapy to further cancer treatment. This case highlights the importance of establishing a plan for nutrition with specific goals in mind, such as optimizing patients for more cancer-directed therapy. Although patients with gastrointestinal cancers may be candidates for TPN, many patient-specific factors, such as functional status and opportunities for future treatments, must be considered prior to the initiation of parenteral nutrition. An interdisciplinary approach should be used to make recommendations based on patient goals, with a focus on patient and cancer characteristics that are associated with positive outcomes after initiation of TPN. These characteristics include functional status, nutritional status, degree of symptom control, and ability to safely administer nutrition. It is important to continually assess whether parenteral nutrition is beneficial in respect to a patient's preferences and prognosis.

S2186 A Case of Abdominal Cocooning From Appendiceal Carcinomatosis

Introduction: Abdominal cocooning is a rare radiologic finding where thickened peritoneal membrane surrounds the intestines causing bowel to become trapped and adhered to each other. This is usually a result of chronic inflammation and can be associated with infections like tuberculosis (TB) or chronic processes like sarcoidosis, peritoneal dialysis, VP shunts, or carcinomatosis. Patients typically present with intractable nausea, vomiting, abdominal pain and distension. Here, we present a case of abdominal cocooning with recurrent ascites secondary to appendiceal carcinomatosis. Case Description/Methods: 41-year-old male with history of remote polysubstance use (IV and alcohol) and incarceration who presented to the ED with progressively worsening abdominal distension and intractable nonbloody, nonbilious emesis. This patient had been hospitalized for a similar presentation weeks prior. At that time, he was found to have large volume ascites (SAAG 1.1, 774 nucleated cells, 3% segs) and was diagnosed with alcoholic cirrhosis though RUQ ultrasound with liver doppler and lab work were normal. CT abdomen and pelvis showed “peritoneal thickening concerning for peritonitis” (Figure) and the patient was treated for presumed spontaneous bacterial peritonitis. He presented to our facility weeks later with recurrent ascites (SAAG 1.2, 795 nucleated cells, 1% segs). Triphasic liver CT showed findings that were “highly suspicious for encapsulating peritoneal sclerosis/abdominal cocoon”. Ultimately, a peritoneal biopsy was performed given concerns for carcinomatosis vs. TB infection. Final pathology showed goblet cell adenocarcinoma with presumed appendiceal origin. Colonoscopy was unsuccessful due to cementing of the peritoneum. Patient was not a candidate for chemotherapy due to having severe malnutrition requiring the initiation of total parenteral nutrition. He was discharged with outpatient GI oncology follow up. Discussion: Although cirrhotic ascites is commonly diagnosed and treated by physicians, it is vital that clinicians are also aware of the diagnostic findings of noncirrhotic ascites. In this case, the degree of WBC count elevation with low segmented cells likely indicated TB or carcinomatosis at the initial presentation. Familiarity with imaging findings of abdominal cocooning may have also contributed to an expedited diagnosis. This case reiterates the importance of questioning and further exploring symptom etiologies when routine workup is not consistent with common causes of an everyday complaint.Figure 1.: Peritoneal thickening consistent with abdominal cocooning with large-volume ascites.

Disparities in uptake of cholecystectomy for idiopathic pancreatitis: A nationwide retrospective cohort study

BackgroundThe majority of cases of idiopathic acute pancreatitis (IAP) are thought to result from occult biliary disease. A growing body of evidence suggests that cholecystectomy for IAP reduces the risk of recurrence by up to two thirds. This study examined nationwide uptake and disparities in adoption of cholecystectomy for IAP. MethodsThe National Inpatient Sample was queried to identify admissions for IAP between October 2015 and December 2018. Patients who underwent cholecystectomy before discharge and those that did not were compared using Wald χ2 tests for categorical variables and Student’s t test for continuous variables. Patient- and hospital-level predictors of cholecystectomy were identified using weighted multivariable logistic regression. ResultsOf 62,305 estimated admissions for IAP, only 665 (1.1%) underwent cholecystectomy before discharge. Female sex, initiation of total parenteral nutrition (TPN), insurance status, and hospital type were associated with cholecystectomy on univariable analysis. On multivariable analysis, Hispanic patients (odds ration [OR] 1.60, 95% confidence interval [CI] 1.01–2.56), patients on TPN (OR 2.70, 95% CI 1.17–6.24), and those with private insurance (OR 2.18, 95% CI 1.48–3.21 versus Medicare/Medicaid) were more likely to receive operations. Small hospitals and hospitals in rural areas were least likely to perform empiric cholecystectomies. ConclusionDespite increasing evidence supporting cholecystectomy after IAP, the practice remains rare in the United States. Educational efforts and active implementation efforts are needed to promote adoption. Particular attention should be focused on small, rural centers and those that disproportionately care for uninsured patients and patients with public insurance.

Aetiological diagnosis of hyponatraemia in non-critical patients on total parenteral nutrition: A prospective multicentre study

BackgroundIn patients receiving total parenteral nutrition (TPN), the frequency of hyponatraemia is high. However, the causes of hyponatraemia in TPN have not been elucidated, although diagnosis is required for appropriate therapy. The aim of this study is to describe the aetiology of hyponatraemia in non-critical hospitalised patients receiving TPN. MethodsProspective multicentre study in 19 Spanish hospitals. Non-critically hyponatraemic patients receiving TPN and presenting hyponatraemia over a 9-month period were studied. Data collected included sex, age, previous comorbidities, and serum sodium levels (SNa) before and following TPN initiation. Parameters for study of hyponatraemia were also included: clinical volaemia, the presence of pain, nausea, gastrointestinal losses, diuretic use, oedema, renal function, plasma and urine osmolality, urinary electrolytes, cortisolaemia, and thyroid stimulating hormone. Results162 patients were included, 53.7% males, age 66.4 (SD13.8) years. Volume status was evaluated in 142 (88%): 21 (14.8%) were hypovolaemic, 96 (67.6%) euvolaemic and 25 (17.6%) hypervolaemic. In 111/142 patients the analytical assessment of hyponatraemia was completed. Hypovolaemic hyponatraemia was secondary to GI losses in 10/111 (9%), and to diuretics in 3/111 (2.7%). Euvolaemic hyponatraemia was due to Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH) in 47/111 (42.4%), and to physiological stimuli of Arginine Vasopressin (AVP) secretion in 28/111 (25.2%). Hypervolaemic hyponatraemia was induced by heart failure in 19/111 (17.1%), cirrhosis of the liver in 4/111 (3.6%). ConclusionsSIADH was the most frequent cause of hyponatraemia in patients receiving TPN. The second most frequent cause was physiological stimuli of AVP secretion induced by pain/nausea.

Defining Persistent Total Parenteral Nutrition Use in Patients with Neurologic Impairment.

Background: Patients with neurologic impairment (NI) experience gastrointestinal symptoms as one of three common problems associated with NI, including occasional persistent total parenteral nutrition (TPN) use. Objective: To describe the incidence of persistent TPN use in patients with NI. Design: Retrospective chart review on patients 0-38 years old enrolled in the Complex Health Care Program from January 2011 to October 2015. Setting/Subjects: This study occurred in a United States pediatric tertiary care hospital. Two hundred and eight participants were included based on NI, utilizing a surgical feeding tube, and having encounters with a dietitian. Measurements: The primary outcome was incidence of persistent TPN use in patients with NI. Secondary outcomes included mortality rate, hospitalization frequency, time-to-TPN initiation, and describing symptoms preceding persistent TPN use. Results: Median number of admissions was 4 for 168 hospitalized patients (59% male, 58% White). One hundred twenty-five patients required admission for unplanned bowel rest with average length-of-stay of 7.3 days. Twenty-six patients required TPN initiation. Average time-to-TPN was two years since enrollment. Mortality rate was 14% (n = 28). TPN initiation (odds ratio [OR]: 3.99; 95% confidence interval [CI]: 1.16-13.8) was significantly associated with increased OR of mortality. Conclusions: Our study demonstrates a substantial population of patients with NI and surgical feeding tube are affected by persistent feeding intolerance. We propose that persistent TPN use may be a risk factor for mortality. Additional research is needed to delineate relationships between persistent TPN use, hospitalizations, and mortality.

69-Year Old Man With Dysphagia and Nasal Regurgitation

69-Year Old Man With Dysphagia and Nasal Regurgitation

Aetiological diagnosis of hyponatraemia in non-critical patients on total parenteral nutrition: A prospective multicentre study

BackgroundIn patients receiving total parenteral nutrition (TPN), the frequency of hyponatraemia is high. However, the causes of hyponatraemia in TPN have not been elucidated, although diagnosis is required for appropriate therapy. The aim of this study is to describe the aetiology of hyponatraemia in non-critical hospitalised patients receiving TPN. MethodsProspective multicentre study in 19 Spanish hospitals. Non-critically hyponatraemic patients receiving TPN and presenting hyponatraemia over a 9-month period were studied. Data collected included sex, age, previous comorbidities, and serum sodium levels (SNa) before and following TPN initiation. Parameters for study of hyponatraemia were also included: clinical volaemia, the presence of pain, nausea, gastrointestinal losses, diuretic use, oedema, renal function, plasma and urine osmolality, urinary electrolytes, cortisolaemia, and thyroid stimulating hormone. Results162 patients were included, 53.7% males, age 66.4 (SD13.8) years. Volume status was evaluated in 142 (88%): 21 (14.8%) were hypovolaemic, 96 (67.6%) euvolaemic and 25 (17.6%) hypervolaemic. In 111/142 patients the analytical assessment of hyponatraemia was completed. Hypovolaemic hyponatraemia was secondary to GI losses in 10/111 (9%), and to diuretics in 3/111 (2.7%). Euvolaemic hyponatraemia was due to Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH) in 47/111 (42.4%), and to physiological stimuli of Arginine Vasopressin (AVP) secretion in 28/111 (25.2%). Hypervolaemic hyponatraemia was induced by heart failure in 19/111 (17.1%), cirrhosis of the liver in 4/111 (3.6%). ConclusionsSIADH was the most frequent cause of hyponatraemia in patients receiving TPN. The second most frequent cause was physiological stimuli of AVP secretion induced by pain/nausea.

P-29: Rapid Progression of Parenteral Nutrition-associated Liver Disease on Liver Biopsies of Pediatric Patients with Short-gut Syndrome: a Case Series

Introduction: The rate of parenteral nutrition-associated liver disease (PNALD) development in short-bowel syndrome (SBS) children on total parenteral nutrition (TPN) is unknown. We present the first case series of pediatric SBS patients on TPN with rapid progression of their PNALD on liver biopsies (LB) obtained <12 months (m) after TPN initiation. Methods: Charts of 81 children with a history of TPN use at a single institution between 2009-2019 were reviewed for inclusion criteria: 1) SBS diagnosis 2) LB obtained <12 m after TPN initiation and 3) No underlying liver disease. Clinical history, nutritional support, and liver function markers (direct bilirubin [Dbili], aspartate aminotransferase [AST], alanine aminotransferase, international normalized ratio, AST to Platelets Ratio Index, ultrasound elastography and LB) were collected via retrospective chart review approved by our institutional review board. Liver pathology was graded by one pathologist. Results: 10 patients fulfilled criteria; the mean duration on TPN prior to LB was 4m (range 1-10.8m) with half on Intralipid, and the other half on an alternative lipid emulsion. Seventy percent also received enteral feeds. Forty percent patients had elevated Dbili. All LBs showed moderate to marked bile ductular reaction associated with a mixed, portal-predominant inflammatory infiltrate of lymphocytes, neutrophils, and occasional eosinophils of mild to moderate severity. Inflammatory infiltration of interlobular bile ducts was a rare finding in a subset of cases; plasma cells were not a prominent feature. Most samples showed some degree of cholestasis, usually canalicular. Lobular inflammation and hepatocyte necrosis were typically mild and nonzonal/spotty though some showed diffuse ballooning hepatocellular injury. No significant steatosis was observed. Fibrosis on trichrome stain was variable, typically portal-predominant; few cases demonstrated pericellular fibrosis. Based on the LB pathology, 70% had a change in medical care such as changing the lipid emulsion. Conclusion: The progression of PNALD in SBS children on LBs <12 months from TPN initiation was more rapid than previously hypothesized. LBs taken at the time of another surgical procedure may be warranted for SBS pediatric patients on TPN.

The Utility of Preoperative Nutrition Screenings and Postoperative Nutrition Protocols in Patients with Ventricular Assist Devices and Heart Transplantation

<h3>Purpose</h3> Malnutrition can result in worse clinical outcomes following ventricular assist device (VAD) and heart transplantation (HT). Hemodynamic instability often leads to delays in optimal nutrition and increases the risk of iatrogenic malnutrition. In these settings, the exclusive or supplemental use of total parenteral nutrition (TPN) may enhance nutrition provision and avoid enteral nutrition (EN)-related complications. Nutrition screening and protocols may serve as a solution to address these issues by improving safety and delivery of EN/TPN in ICU settings. <h3>Methods</h3> Data were extracted from electronic medical records pre (2014-2016) and post (2017-2019) protocol implementation. The high-risk enteral nutrition guidelines (HRENG) were introduced in the setting of hemodynamic instability after VAD or HT: cardiogenic shock, need for ECMO, balloon pump, temporary mechanical support. Preoperative nutrition screenings were implemented to strengthen HRENG adherence. We assessed calorie/protein delivery POD 1-14, % of nutrition needs met, TPN start/end day, central line associated blood infection (CLABSI), ICU and total length of stay (LOS) and mortality rate. <h3>Results</h3> A total of 113 patients who met criteria of the HRENG were included. We compared 62 patients prior to the protocol to 51 managed after protocol implementation. Average 14 day calorie/protein deficits decreased (<i>P</i> <0.01), patients met a larger proportion of goal calorie/protein needs (P < 0.05) with earlier start of TPN (<i>P</i> < 0.01). ICU LOS decreased (<i>P</i> = 0.01) and when stratifying patients by overall TPN usage and developing a CLABSI, there were higher rates of CLABSI without TPN versus with TPN use (<i>P</i> = 0.04) (Figure 1). <h3>Conclusion</h3> The implementation of preoperative nutrition screenings in conjunction with HRENG may not only facilitate earlier TPN initiation and decrease nutrient deficits, but decrease ICU LOS. Enhanced TPN use was not associated with higher CLABSI rates.

Revisiting Infectious Complications Following Total Parenteral Nutrition Use During Hematopoietic Stem Cell Transplantation

BackgroundTotal parenteral nutrition (TPN) is frequently used to manage caloric needs during hematopoietic stem cell transplantation (HSCT). Previous studies in transplant patients who received TPN have reported widely discordant results with regard to infection and mortality, and risk factors for TPN-related infection remain unclear.MethodWe conducted a retrospective study of all HSCT recipients treated with TPN between 2005 to 2014 at Northwestern Memorial Hospital to determine the incidence and epidemiology of infections. Electronic records were used to identify patients treated with TPN for at least 2 days who developed infection.ResultsAmong 198 patients treated with TPN, 30% developed documented infection. Total parenteral nutrition treatment duration (13 vs. 7 days; p < .0001) and the timing of TPN initiation (> day 9 post HSCT; p < .0001) were significantly higher in patients who received TPN and developed infection. Receipt of an allogeneic transplant was associated with increased risk for infection (p < .0138), and day 60 mortality was significantly higher in TPN-treated patients with infection (p < .0001).ConclusionStem cell recipients who receive TPN, especially from an allogeneic donor, have high rates of infection and mortality. Minimizing TPN exposure may reduce the chance for infection.

Home Total Parenteral Nutrition for Intestinal Failure in Patients with Advanced Small Intestinal Neuroendocrine Neoplasms

The role of total parenteral nutrition (TPN) in cancer patients is controversial, but it may be a treatment option for some patients with indolent but advanced small intestinal neuroendocrine neoplasms (SI-NENs). The aim of this study is to investigate whether home TPN was associated with long-term survival and to assess the indications, duration and complications of TPN in patients with advanced SI-NENs. Patients with advanced SI-NENs who received home TPN were retrospectively included. Electronic records were reviewed for clinical information. Five patients receiving home TPN were identified out of 1011 patients with SI-NENs in our center. The median duration of TPN administration was 12 mo. Small bowel obstruction was the most common reason for TPN initiation. TPN-related complications included two catheter infections, one thrombosis and one episode of TPN-related transaminitis. At the last follow-up, three patients had died and two were alive. The median survival was 12 mo. Overall estimated 1-yr probability of survival on home TPN by Kaplan–Meier analysis was 40%. In conclusion, home TPN may be a treatment option in highly selected advanced SI-NEN patients with severe gastrointestinal tract dysfunction. The initiation of home TPN is associated with long-term survival (≥1 yr), and complication rates appear acceptable.

Lysinuric protein intolerance: Pearls to detect this otherwise easily missed diagnosis.

BACKGROUND:Lysinuric protein intolerance (LPI) is a rare autosomal recessive disorder characterized by deficient membrane transport of cationic amino acids. It is caused by pathogenic variants in SLC7A7, resulting in impairment of intestinal import and renal proximal tubule loss of the affected amino acids. LPI typically presents with gastrointestinal symptoms, such as vomiting, diarrhea, and failure to thrive.CASE REPORT:A 4-year-old African-American boy presented with multiple respiratory tract infections, weight loss in the setting of chronic diarrhea and worsening abdominal distention, and multiple episodes of rectal prolapse. Development was unaffected. Laboratory examination demonstrated mild anemia, hypokalemia and hypoalbuminemia, transaminitis, and normal ammonia. Initial urine amino acid analysis did not show major elevations of lysine and ornithine, often lower than expected in the setting of malnutrition. Upon initiation of total parenteral nutrition (TPN), his urine amino acids showed a characteristic profile of dibasic aminoaciduria.CONCLUSIONS:Failure to thrive, chronic diarrhea, and hepatomegaly should raise suspicion for LPI. Urine amino acids can be normal in this condition in the setting of malnutrition, a common complication of the disease. Additionally, it has been previously shown that the plasma arginine and ornithine concentration is higher in LPI subjects.

Distal Superior Mesenteric Artery Endarterectomy Remains an Excellent Option for Mesenteric Revascularization in the Endovascular Era

Endovascular treatment of mesenteric lesions has become increasingly prevalent. Mesenteric bypass, however, remains the optimal treatment in the cases of chronic mesenteric ischemia (CMI) in young, medically fit patients given its durability. Endarterectomy has gone by the wayside, but in certain situations, this technique remains surgically relevant and should still be used. Herein, we present 2 cases of distal superior mesenteric artery (SMA) endarterectomy for mesenteric revascularization. Case 1 is a 40-year-old male with history of antithrombin III deficiency, myocardial infarction, bilateral pulmonary embolism, acute aortic thrombus, and mesenteric ischemia status after placement of a proximal SMA stent and was transferred to our institution because of concern for ischemic bowel. Intraoperative angiography showed mid to distal SMA chronic thromboembolism with narrow lumen of recanalization and distal flow. No intervention was performed at that time. He developed worsening abdominal pain and weight loss over several months which required initiation of total parenteral nutrition, complicated by line-associated sepsis. Subsequent distal SMA endarterectomy was performed. He recovered well and had improved enteral intake at 1-month follow-up, and radiographic imaging at 2 months showed patent vessels. Case 2 is a 50-year-old female with extensive smoking history and hyperlipidemia and gastroesophageal reflux who presented with postprandial abdominal pain and a forty-pound weight loss over the past year. Attempted angiographic cannulation with a stent was not successful because of flush occlusion of the SMA approximately 1centimeter distal to the ostium that was unable to be crossed. Computed tomography angiography confirmed that the SMA origin was free of atherosclerotic disease with a distal focal segment of occlusion. She underwent successful endarterectomy of this occlusion. The postoperative course was uneventful, and at 1-month follow-up, she reported continued improvement in pain and appetite. SMA endarterectomy can be successfully performed on mid to distal lesions of the SMA. This operation should remain a viable option in the management of CMI.

Prevalence and Risk Factors of Total Parenteral Nutrition Induced Hyperglycemia at a Single Institution: Retrospective Study.

Background: Total parenteral nutrition (TPN) provides full nutrition support to critically ill patients with an impaired digestive tract. Patients who receive TPN support are at higher risk for complications such as hyperglycemia. In our study, we aim to assess the prevalence of hyperglycemia induced by TPN and identify its risk factors in hospitalized adult patients.Methods: Patients who received TPN between January 2012 and December 2017 at University of Pittsburgh Medical Center—St. Margaret hospital were retrospectively screened. TPN-induced hyperglycemia was confirmed whether blood glucose was ≥180 mg/dL at any point, from the time of TPN initiation until 1-day post TPN termination. Characteristics of the hyperglycemia and the nonhyperglycemia groups were analyzed to predict potential risk factors.Results: A total of 197 patients were screened, 55 were excluded (1 died, 37 diabetic, and 17 had elevated blood glucose before TPN), and 142 patients were included, 42 of them (29.6%) developed hyperglycemia following TPN administration. Duration of TPN, surgical indications, and obesity were significantly higher in the hyperglycemia group. Additionally, age and steroids use were independent predictors of hyperglycemia in TPN patients after applying multivariable logistic regression model on our sample.Conclusions: Hyperglycemia is common after TPN. Risk factors assessment may help optimizing glycemic control in higher risk individuals to improve their outcomes. These include patients with obesity, surgical indication of TPN, and longer duration of TPN.

Depression Predicts Prolonged Length of Hospital Stay in Pediatric Inflammatory Bowel Disease.

Few studies report the impact of depression on inflammatory bowel disease (IBD)-related hospitalizations. We evaluated the association between depression and pediatric IBD-related hospitalizations. Our primary aim was to test the hypothesis that depression is associated with hospital length of stay (LOS); our secondary goal was to evaluate if patients with depression are at higher risk for undergoing additional imaging and procedures. Data were extracted from the 2012 Kids Inpatient Database (KID), the largest nationally representative publicly available all-payer pediatric inpatient cross-sectional database in the United States. Hospitalizations for patients less than 21 years with a primary diagnosis Crohn disease (CD) or ulcerative colitis (UC) by ICD-9 code were included. Multivariable logistic regression was used to predict long LOS controlling for patient- and hospital-level variables and for potential disease confounders. For primary IBD-related hospitalizations (N = 8222), depression was associated with prolonged LOS (odds ratio [OR] 1.50; 95% confidence interval [CI] 1.19-1.90) and total parenteral nutrition use (OR 1.54; 95% CI 1.04-2.27). Depression was not associated with increased likelihood of surgery (OR 0.97; 95% CI 0.72-1.30), endoscopy (OR 0.91; 95% CI 0.74-1.14), blood transfusion (OR 0.85; 95% CI 0.58-1.23), or abdominal imaging (OR 1.15; 95% CI 0.53-2.53). Depression is associated with prolonged LOS in pediatric patients with IBD, even when controlling for gastrointestinal disease severity. Future research evaluating the efficacy of standardized depression screening and early intervention may be beneficial to improving inpatient outcomes in this population.

2116 Salvage Therapy for Recurrent Gastrojejunal Anastomotic Stricture Using a Lumen-Apposing Metal Stent

INTRODUCTION: Gastrojejunal (GJ) anastomotic stricture following Roux-en-Y gastric bypass is a well-known complication of the surgery with reported ranges varying from 2.9-23%.1 Unfortunately, prior endoscopic interventions for these strictures have had limited durability of treatment response. CASE DESCRIPTION/METHODS: A 71-year-old male with previous Roux-en-Y gastric bypass presented to our hospital with 2 weeks of nausea, vomiting, weight loss, and severe hypoglycemia. Initial imaging with CT abdomen showed a fluid-filled and distended gastric pouch with likely stenosis of the GJ anastomosis. An upper GI series was performed which confirmed significant stenosis at the GJ anastomosis (Figure 1a). An EGD was performed at which time the stricture was successfully dilated using a through-the-scope (TTS) 6-7-8 mm and then an 8-9-10 mm balloon dilator (Figure 2). Unfortunately, the patient did not clinically respond to dilation and was unable to advance diet beyond liquids, requiring initiation of total parenteral nutrition. Subsequently, the patient underwent a repeat EGD with placement of a 20 mm × 10 mm lumen apposing metal stent (LAMS) (Axios, Boston Scientific) under fluoroscopic guidance. The stent was successfully dilated with a TTS 12-13.5-15 mm balloon dilator to a maximal size of 13.5 mm with obliteration of the waist. The LAMS was then sutured into place with the endoscopic suturing device (OverStitch, Apollo Endosurgery, Inc) using 2.0 polypropylene suture and placing 2 interrupted sutures with cinches on both ends (Figure 3). An upper GI series was repeated 24 hours after LAMS, which showed excellent functioning of the stent without leak or obstruction (Figure 1b). Over the next five days, the patient’s symptoms abated, diet was gradually advanced to low residue diet, TPN was discontinued, and the patient was discharged home. DISCUSSION: Management of these strictures has primarily been pneumatic balloon dilation or fully covered self-expanding stents; however, dilation is unlikely to achieve durable response and other stents are associated with complications of stent migration and recurrence of symptoms after removal. Previous case reports have documented successful treatment of GJ anastomotic strictures using LAMS with excellent response given its novel shape and anchoring phalanges. 1 We further show the successful endoscopic suturing of the LAMS, which will allow for prolonged time for stent placement with enhanced risk-mitigation for stent migration.

Pancreaticoduodenectomy and placement of operative enteral access: Better or worse?

BackgroundIt is unclear whether placement of operative enteral access (OEA) during pancreaticoduodenectomy (PD) correlates with decreased morbidity. MethodsA retrospective chart review of patients undergoing PD with and without OEA placement between January 2016 and May 2018 was undertaken. Outcomes included length of stay (LOS), 30- and 90-day readmission, initiation of total parenteral nutrition (TPN), postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), and surgical site infection (SSI). Results69 patients were evaluated; there was a trend toward decreased LOS for patients without OEA (9 vs. 7.5 days, p = 0.07). There were no significant differences in initiation of TPN (9.1% vs 19.4%, p = 0.311), POPF (21.2% vs 11.1%, p = 0.999), DGE (24.2% vs 22.2%, p = 0.999), organ/space SSI (12.1% vs 8.3%, p = 0.702). ConclusionOEA placement at the time of PD is not necessarily associated with improved perioperative morbidity and outcomes, suggesting that OEA may not be necessary and should be considered on a case by case basis. SummaryIt is unclear whether placement of operative enteral access (OEA) during pancreaticoduodenectomy (PD) correlates with decreased morbidity. A retrospective review of patients undergoing PD with and without OEA placement between January 2016 and May 2018 was performed, demonstrating that there were no overall significant differences in postoperative complications and outcomes.

Preoperative nutritional status and use of total parenteral nutrition in pediatric and adolescent patients undergoing continent urinary tract reconstruction

A nutritional assessment is a critical but often neglected aspect of a preoperative evaluation. Malnutrition is clearly associated with worse surgical outcomes in adults undergoing major abdominal surgery, whereas a paucity of evidence is available in the pediatric population. The objectives were to describe the preoperative nutritional status of pediatric and adolescent patients undergoing continent urinary tract reconstruction and to determine the association among malnutrition, use of total parenteral nutrition (TPN), and surgical outcomes. A retrospective cohort study was performed for patients aged up to 20 years who underwent continent urinary tract reconstruction between January 2012 and November 2016. Malnutrition was classified with body mass index and height for age z-scores on admission as well as change in z-scores and weight over the 3-6 months before surgery. Primary outcomes included the duration of intensive care and hospitalization as well as readmissions and complications within 30 days. A total of 123 patients who underwent 130 continent urinary tract reconstructions were identified during the study period. Demographic and perioperative data are provided in the Table. Anthropometric and biochemical measurements as well as the early initiation of TPN (≤2 days) were not associated with any primary outcomes. In a subgroup analysis of patients with a bowel anastomosis, the early initiation of TPN was an independent predictor for duration of hospitalization (P<0.0001) and 30-day complications (odds ratio 9.51, P=0.005) after adjusting for other statistically significant and clinically relevant variables. The few available studies on surgical nutrition have primarily focused on infants and young children undergoing cardiac surgery and provided no consensus on a preoperative nutritional assessment. The findings on TPN from the present study favorably compare with a growing body of evidence in adult and pediatric critically ill and surgical patients. The limitations of the present study include its retrospective design at a single institution, potential misclassification of nutritional status, and selection bias from the initiation of TPN at the discretion of the primary surgeon. Malnutrition was identified in greater than 20% of pediatric and adolescent patients undergoing continent urinary tract reconstruction. Anthropometric and biochemical parameters were not associated with surgical outcomes, although the early initiation of TPN did not offer any benefit for nutritional support. In a subset of patients with a bowel anastomosis, TPN was associated with worse surgical outcomes, including a longer duration of hospitalization and development of 30-day complications.

Case 4: A Preterm Infant with a Necrotic Ulcer Over the Perianal Area

A 1.07-kg male infant with severe growth restriction is born at 30 weeks’ gestational age to a 36-year-old gravida 3, para 2 mother by emergency cesarean delivery for nonreassuring heart tracing. The parents are of low socioeconomic status and are first-degree consanguineous relatives. The mother received steroids and her membranes ruptured at delivery. At birth, the infant’s cord clamping was delayed, and after an initial weak cry he underwent intubation for poor respiratory efforts. Apgar scores were 4 and 7 at 1 and 5 minutes, respectively. His initial stabilization included surfactant administration, mechanical ventilation with volume guarantee, catheter line placement (umbilical venous and arterial catheters), initiation of total parenteral nutrition, antibiotics, and inotropic support. On day 3, he underwent extubation and received noninvasive intermittent positive pressure ventilation (NIPPV), inotropic support was discontinued, and antibiotics were stopped, because his blood culture was sterile. He demonstrated steady clinical improvement in the next 3 days, was weaned from NIPPV to nasal continuous positive pressure, and nasogastric feeds progressed gradually. On day 6, the bedside nurse noticed a small macule and blister with surrounding erythema over the lateral aspect of his right thigh, which progressed rapidly in hours to blackish-gray discoloration of skin in an area 4 × 1 cm in size with a small hemorrhagic lesion in the center (Fig 1). The infant’s clinical condition worsened rapidly in the next 24 hours; he became lethargic, hypothermic, tachycardic, hypotensive with poor perfusion, and apneic with increased oxygen requirement. He underwent elective reintubation for recurrent apnea and mixed respiratory and metabolic acidosis. A limited sepsis screening (complete blood cell count and cultures from blood, skin wound, and urine) was performed. Empiric antibiotic treatment with piperacillin-tazobactam was commenced. The infant received a bolus of normal saline, and dopamine treatment was commenced for low mean blood pressure. …