This document discusses intestinal failure and its management via parenteral nutrition or intestinal transplantation. Intestinal failure results from inadequate intestinal absorption and can be caused by short bowel syndrome or other conditions. Parenteral nutrition is first-line therapy but is associated with serious complications like infections, liver disease, and catheter issues. Intestinal transplantation can cure intestinal failure by replacing the diseased intestine but carries risks of rejection, infection, and lifelong immunosuppression. Outcomes have improved in recent decades with 1-year survival rates over 80% for most age groups.
Dear Viewers,
Greetings from “ Surgical Educator”
Today I have uploaded a video on one of the congenital causes for obstructive jaundice- Biliary Atresia. In this episode, I am discussing about the etiology, types, clinical features, investigations, treatment and surgical outcome of Biliary Atresia. I hope you will enjoy the video. You can watch all my surgical teaching video casts in the following link: surgicaleducator.blogspot.com.
Short bowel syndrome in infants... Dr Sunil DeshmukhSunil Deshmukh
Management of Short bowel syndrome in neonates & infants.........................by
Dr Sunil B Deshmukh, MBBS MD Paediatrics, Fellow in Neonatology(KEM Hospital ,Pune)
Biliary atresia is a condition in which the normal hepatic biliary system is disrupted. Progressive damage of extrahepatic and intrahepatic bile ducts occurs secondary to inflammation, leading to fibrosis, biliary cirrhosis, and eventual liver failure.
explaining the presently available criteria to define futility in liver transplantation and prposing future trends in the definition of futility in liver transplantation
This file offers information regarding the chronic pancreatitis disease, as well as a case study of a chronic pancreatitis patient in a soap format. Please go over all of the slides to get a complete picture of the situation.
If any queries or suggestions please drop down in the comment section.
Thank you!
Dear Viewers,
Greetings from “ Surgical Educator”
Today I have uploaded a video on one of the congenital causes for obstructive jaundice- Biliary Atresia. In this episode, I am discussing about the etiology, types, clinical features, investigations, treatment and surgical outcome of Biliary Atresia. I hope you will enjoy the video. You can watch all my surgical teaching video casts in the following link: surgicaleducator.blogspot.com.
Short bowel syndrome in infants... Dr Sunil DeshmukhSunil Deshmukh
Management of Short bowel syndrome in neonates & infants.........................by
Dr Sunil B Deshmukh, MBBS MD Paediatrics, Fellow in Neonatology(KEM Hospital ,Pune)
Biliary atresia is a condition in which the normal hepatic biliary system is disrupted. Progressive damage of extrahepatic and intrahepatic bile ducts occurs secondary to inflammation, leading to fibrosis, biliary cirrhosis, and eventual liver failure.
explaining the presently available criteria to define futility in liver transplantation and prposing future trends in the definition of futility in liver transplantation
This file offers information regarding the chronic pancreatitis disease, as well as a case study of a chronic pancreatitis patient in a soap format. Please go over all of the slides to get a complete picture of the situation.
If any queries or suggestions please drop down in the comment section.
Thank you!
Short bowel syndrome (SBS) is a devastating condition in which small intestinal length is inadequate and characterized clinically by inability to absorb adequate enteral nutrition to sustain normal growth and development.
3. Intestinal Failure - Definition
• Failure of digestion and absorption
• Inability of the intestinal tract to maintain adequate
nutritional status and fluid / electrolyte balance
• Results from a loss or absence of sufficient
functional intestinal area
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4. Intestinal Failure - Etiology
Children
• Short gut (necrotizing enterocolitis, others)
• Intestinal atresia
• Midgut volvulus
• Gastroschisis
• Hirschprung’s disease
• Microvillus inclusion disease
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7. Intestinal Failure - Management
• Medically or surgically alter the remaining
intestine to compensate for inadequate
absorptive surface area
• Meet caloric and nutritional requirements via
an alternate route (parenteral nutrition (PN))
• Intestinal transplantation
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8. Parenteral nutrition (PN)
• First line therapy
• Requires long term central venous access
• Labor intensive
• Expensive (total costs up to $1000/day)
• Associated with serious and frequent
complications
– Infections
– Loss of vascular access
– Electrolyte abnormalities
– Nutritional deficiencies (trace metals, other)
– Liver disease
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9. Parenteral nutrition – complications
• Catheter related sepsis:
– Standard site infection
– Seeding from compromised intestine
• Bacterial translocation
• Avoiding catheter infections
– Meticulous site care
– 70% alcohol dwell
– Antibiotic dwell
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10. Parenteral nutrition – complications
• Loss of vascular access
– 6 primary sites for vascular access
• Jugular, subclavian, femoral
– Thrombus formation
• May require anticoagulation
• Heparin dwell
– Vein sclerosis / narrowing
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11. Parenteral nutrition – complications
• Cholestatic liver disease
– Progressive cholestasis and cirrhosis
– Rate of progression may be associated with
length of remaining intestine
• Full intestinal length – liver failure slow onset
• Short intestinal length – more rapid
progression
– Low lipid strategies
• <1g/kg per day
• Every other day or 3x/week lipids
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12. Parenteral nutrition – complications
• Cholestatic liver disease (continued)
– Liver function tests in short gut patients are
altered after 6 months in 15% to 40% of
adults and 95% of children
– Chronic cholestasis related to short gut,
bacterial overgrowth, lipid infusion > 1g/kg,
overfeeding , lack of oral feedings, infections
– Liver dysfunction is the ultimate cause of
death in 30 to 40% of PN patients
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13. Parenteral nutrition – FAILURE
• Medicare approved criteria for PN failure:
– Impending/overt liver failure due to PN-induced liver
injury
– Thrombosis of 2 or more central venous access sites
– The development of 2 or more episodes of systemic
sepsis secondary to line infection, in one year, that
requires hospitalization indicates failure of PN therapy
– A single episode of line-related fungemia, septic shock,
and/or acute respiratory distress syndrome is
considered an indicator of TPN failure
– Frequent episodes of severe dehydration despite
intravenous fluid supplementation in addition to TPN.
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15. Intestinal transplantation
• Advantages:
– Replace normal intestinal anatomy, continuity
– Patient able to eat and drink
– Chance for definitive cure of disease
– Able to stop PN
• Remove central venous catheters
– Decrease infection risk
– Decrease risk of loss of vascular access
• Reversal of liver injury
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16. Intestinal transplantation
• Disadvantages:
– Risks of major surgery
– Risk of rejection
– Risks of life-long immunosuppression
• Infections
• Cancers
• Renal failure
• Graft versus host disease
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17. Intestinal Transplantation - surgery
• Intestinal transplant options:
– Isolated intestinal transplant
• Small intestine only
– Modified multivisceral transplant
• Small intestine + pancreas + stomach
– Full multivisceral transplant
• Small intestine + pancreas + stomach + liver
– Can add in other organs, as indicated
• +/- kidney
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18. Intestinal Transplantation - surgery
• Surgical considerations:
– Organs to include
– Composite or separate
– Whole or reduced size
– Arterial inflow
– Venous outflow
– Enteric connection
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20. Intestinal Transplantation
• Isolated intestinal transplant
– Indication: Intestinal failure in the absence of
any other organ failure
• Normal function of liver, stomach, pancreas
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24. Intestinal Transplantation
• Modified multivisceral transplant
– Indication: Intestinal failure in the absence of
liver failure
• Normal function of liver
• Dysfunction of stomach, intestine, +/- pancreas
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39. Intestinal Transplantation - Volume
• World Intestinal Transplant Registry (ITR)
– Worldwide database of all intestinal
transplants
– Between 2005 and 2007, 28 centers
wordwide reporting to the ITR performed 389
intestinal transplants on 377 patients
• In U.S. (Year 2010):
– 151 transplants (-16% from previous year)
– 17 centers with at least one transplant
– 6 centers with 10 or more transplants
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40. Intestinal Transplantation - Outcomes
• U.S. Adult intestinal transplant outcomes
Patient Survival
Age group 1-year 5-years
18 to 34 years 81% 70%
35 to 49 years 80% 63%
50 to 64 years 93% 38%
65+ years 100% N/A
From the Organ Procurement and Transplant Network (U.S.), 2002-2007
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41. Intestinal Transplantation – Costs
• Cost to maintain a patient on PN ranges from $75,000-$200,000 per
year
– Added costs of home nursing, support, equipment
• PN related complications result in an average of 1 major
hospitalization per year, and catheter related complications are
common and costly
• Intestinal transplantation has been shown to be a cost effective
therapy and is superior to continued PN in appropriately selected
patients
• Costs for intestinal transplantion, including the initial hospitalization
for the transplant range from $200,000-$500,000
• There are frequent hospital readmissions post-transplant, but these
admissions decrease markedly after the second year post-transplant
• The cost-benefit of transplantation reaches parity with PN after 2-3
years post-transplant and is more cost-effective thereafter
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