Intestinal failure: a review

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Abstract

Intestinal failure (IF) is the inability of the gut to absorb necessary water, macronutrients (carbohydrate, protein, and fat), micronutrients, and electrolytes sufficient to sustain life and requiring intravenous supplementation or replacement. Acute IF (types 1 and 2) is the initial phase of the illness and may last for weeks to a few months, and chronic IF (type 3) from months to years. The challenge of caring for patients with IF is not merely the management of the underlying condition leading to IF or the correct provision of appropriate nutrition or both but also the prevention of complications, whether thromboembolic phenomenon (for example, venous occlusion), central venous catheter-related bloodstream infection, IF-associated liver disease, or metabolic bone disease. This review looks at recent questions regarding chronic IF (type 3), its diagnosis and management, the role of the multidisciplinary team, and novel therapies, including hormonal treatment for short bowel syndrome but also surgical options for intestinal lengthening and intestinal transplant.

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Randomised placebo-controlled trial of teduglutide in reducing parenteral nutrition and/or intravenous fluid requirements in patients with short bowel syndrome

Palle Bekker Jeppesen, R Gilroy, M. Pertkiewicz … (2011)

Background and aims Teduglutide, a GLP-2 analogue, may restore intestinal structural and functional integrity by promoting repair and growth of the mucosa and reducing gastric emptying and secretion, thereby increasing fluid and nutrient absorption in patients with short bowel syndrome (SBS). This 24-week placebo-controlled study evaluated the ability of teduglutide to reduce parenteral support in patients with SBS with intestinal failure. Methods In 83 patients randomised to receive subcutaneous teduglutide 0.10 mg/kg/day (n=32), 0.05 mg/kg/day (n=35) or placebo (n=16) once daily, parenteral fluids were reduced at 4-week intervals if intestinal fluid absorption (48 h urine volumes) increased ≥10%. Responders were subjects who demonstrated reductions of ≥20% in parenteral volumes from baseline at weeks 20 and 24. The primary efficacy end point, a graded response score (GRS), took into account higher levels and earlier onset of response, leading to longer duration of response. The intensity of the response was defined as a reduction from baseline in parenteral volume (from 20% to 100%), and the duration of the response was considered the response at weeks 16, 20 and 24. The results were tested according to a step-down procedure starting with the 0.10 mg/kg/day dose. Results Using the GRS criteria, teduglutide in a dose of 0.10 mg/kg/day did not have a statistically significant effect compared with placebo (8/32 vs 1/16, p=0.16), while teduglutide in a dose of 0.05 mg/kg/day had a significant effect (16/35, p=0.007). Since parenteral volume reductions were equal (353±475 and 354±334 ml/day), the trend towards higher baseline parenteral volume (1816±1008 vs 1374±639 ml/day, p=0.11) in the 0.10 mg/kg/day group compared with the 0.05 mg/kg/day group may have accounted for this discrepancy. Three teduglutide-treated patients were completely weaned off parenteral support. Serious adverse events were distributed similarly between active treatment groups and placebo. Villus height, plasma citrulline concentration and lean body mass were significantly increased with teduglutide compared with placebo. Conclusions Teduglutide was safe, well tolerated, intestinotrophic and suggested pro-absorptive effects facilitating reductions in parenteral support in patients with SBS with intestinal failure. ClinicalTrials.gov number NCT00172185.

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Intestinal transplant registry report: global activity and trends.

Gary D. Grant, K Abu-Elmagd, G Mazariegos … (2015)

The Registry has gathered information on intestine transplantation (IT) since 1985. During this time, individual centers have reported progress but small case volumes potentially limit the generalizability of this information. The present study was undertaken to examine recent global IT activity. Activity was assessed with descriptive statistics, Kaplan-Meier survival curves and a multiple variable analysis. Eighty-two programs reported 2887 transplants in 2699 patients. Regional practices and outcomes are now similar worldwide. Current actuarial patient survival rates are 76%, 56% and 43% at 1, 5 and 10 years, respectively. Rates of graft loss beyond 1 year have not improved. Grafts that included a colon segment had better function. Waiting at home for IT, the use of induction immune-suppression therapy, inclusion of a liver component and maintenance therapy with rapamycin were associated with better graft survival. Outcomes of IT have modestly improved over the past decade. Case volumes have recently declined. Identifying the root reasons for late graft loss is difficult due to the low case volumes at most centers. The high participation rate in the Registry provides unique opportunities to study these issues.

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Serial transverse enteroplasty (STEP): a novel bowel lengthening procedure.

Heung Bae Kim, Dario Fauza, Jennifer Garza … (2003)

Bowel lengthening may be beneficial for children with short bowel syndrome. However, current techniques require at least one intestinal anastomosis and place the mesenteric blood supply at risk. This study seeks to establish the technical principles of a new, simple, and potentially safer bowel lengthening procedure. Young pigs (n = 6) underwent interposition of a reversed intestinal segment to produce proximal small bowel dilation. Five weeks later the reversed segment was resected. Lengthening of the dilated bowel then was performed by serial transverse applications of a GIA stapler, from opposite directions, to create a zig zag channel. A distal segment of equal length served as an in situ morphometric control. Contrast radiologic studies were performed 6 weeks later, and the animals were killed. Statistical comparisons were made by paired t test with P less than.05 considered significant. After bowel lengthening, all animals gained weight (66.7 +/- 3.0 [SD] kg v 42.5 +/- 3.5 kg; P <.001) and showed no clinical or radiologic evidence of intestinal obstruction. Intraoperatively, immediately after serial transverse enteroplasty, the intestine was substantially elongated (82.8 +/- 6.7 cm v 49.2 +/- 2 cm; P <.01). Six weeks after surgery, the lengthened intestinal segment became practically straight and, compared with the in situ control, remained significantly longer (80.7 +/- 13.1 cm v 57.2 +/- 10.4 cm; P <.01). There was no difference in diameter between these segments (4.3 +/- 0.7 cm v 3.8 +/- 0.4 cm; P value, not significant). Serial transverse enteroplasty (STEP) significantly increases intestinal length without any evidence of obstruction. This procedure may be a safe and facile alternative for intestinal lengthening in children with short bowel syndrome. Copyright 2003, Elsevier Science (USA). All rights reserved.

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Author and article information

Contributors

Philip Allan: Role: Writing – Original Draft Preparation

Simon Lal: Role: ConceptualizationRole: Writing – Review & Editing

ORCID: https://orcid.org/0000-0002-6245-8864

Journal

Journal ID (nlm-ta): F1000Res

Journal ID (iso-abbrev): F1000Res

Journal ID (pmc): F1000Research

Title: F1000Research

Publisher: F1000 Research Limited (London, UK )

ISSN (Electronic): 2046-1402

Publication date (Electronic): 18 January 2018

Publication date Collection: 2018

Volume: 7

Electronic Location Identifier: 85

Affiliations

[1 ]Translational Gastroenterology Department, University Hospitals Oxford NHS Foundation Trust, Oxford, UK

[2 ]Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK

Author notes

[a ] Simon.Lal@ 123456srft.nhs.uk

Phillip Allan wrote the manuscript. Simon Lal conceived the work and reviewed and edited the manuscript.

No competing interests were disclosed.

Author information

Simon Lal https://orcid.org/0000-0002-6245-8864

Article

DOI: 10.12688/f1000research.12493.1

PMC ID: 5773925

PubMed ID: 29399329

SO-VID: 79273a21-7419-40f7-9197-e2fe969ba59c

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This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date accepted : 15 January 2018

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The author(s) declared that no grants were involved in supporting this work.

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Intestinal failure: a review

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Most cited references 84

Randomised placebo-controlled trial of teduglutide in reducing parenteral nutrition and/or intravenous fluid requirements in patients with short bowel syndrome

Intestinal transplant registry report: global activity and trends.

Serial transverse enteroplasty (STEP): a novel bowel lengthening procedure.

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