A. Teubner

Review article: intestinal failure

Intestinal failure is a specific disease entity resulting from intestinal resection or disease‐associated malabsorption and characterized by the inability to maintain protein‐energy, fluid, electrolyte or micronutrient balance. We performed a MEDLINE search (1966–2006) to identify relevant articles, using keywords intestinal failure, parenteral or enteral nutrition, intestinal fistula and short bowel syndrome.

Fistuloclysis can successfully replace parenteral feeding in the nutritional support of patients with enterocutaneous fistula

Use of total parenteral nutrition (TPN) in patients with acute intestinal failure due to enteric fistulation might be avoided if a simpler means of nutritional support was available. The aim of this study was to determine whether feeding via an intestinal fistula (fistuloclysis) would obviate the need for TPN.

Outcome of reconstructive surgery for intestinal fistula in the open abdomen.

Objective:To determine factors which influence the outcome of surgical techniques to close enterocutaneous fistulas within the open abdomen. Summary Background Data:Enterocutaneous fistulation within an open abdominal wound is associated with considerable morbidity and mortality. The factors that influence the outcome of reconstructive surgery are unclear. Methods:Sixty-one patients undergoing 63 operations to close enterocutaneous fistulas associated with open abdominal wounds were referred to a national center for further management. Once sepsis had been eradicated, nutritional status restored and local conditions in the abdomen judged to be suitable, fistulas were resected and the abdominal wall reconstructed by suture repair with and without component separation, or by suture repair in combination with absorbable or nonabsorbable prosthetic mesh. Patients were followed up for 16 to 84 months postoperatively. Results:There were 3 postoperative deaths (4.8%). Major complications, including postoperative respiratory and surgical site infection occurred in 52 of 63 (82.5%) procedures. Refistulation occurred in 7 cases (11.1%) but was more common when the abdominal wall was reconstructed with prosthetic mesh (7 of 29, 24.1%) than with sutures (0 of 34, 0%). Porcine collagen mesh was associated with a particularly high rate of refistulation (5 of 12, 41.7%). Conclusions:Simultaneous reconstruction of the intestinal tract and abdominal wall remains associated with a high complication rate, justifying the management of such patients in specialized units. Simultaneous reconstruction of the abdominal wall with prosthetic mesh is associated with a particularly high incidence of recurrent postoperative fistulation and should be avoided if possible.

Review article: the management of long‐term parenteral nutrition

Home parenteral nutrition (HPN) is currently the management of choice for patients with chronic intestinal failure.

Central Venous Catheter Salvage in Home Parenteral Nutrition Catheter-Related Bloodstream Infections Long-Term Safety and Efficacy Data

BACKGROUND Catheter-related bloodstream infections (CRBSIs) are a serious complication in the provision of home parenteral nutrition (HPN). Antibiotic salvage of central venous catheters (CVCs) in CRBSI is recommended; however, this is based on limited reports. We assessed the efficacy of antibiotic salvage of CRBSIs in HPN patients. MATERIALS AND METHODS All confirmed CRBSIs occurring in patients receiving HPN in a national intestinal failure unit (IFU), between 1993 and 2011, were analyzed. A standardized protocol involving antibiotic and urokinase CVC locks and systemic antibiotics was used. RESULTS In total, 588 patients were identified with a total of 2134 HPN years, and 297 CRBSIs occurred in 137 patients (65 single and 72 multiple CRBSIs). The overall rate of CRBSI in all patients was 0.38 per 1000 catheter days. Most (87.9%) infections were attributable to a single microorganism. In total, 72.5% (180/248) of CRBSIs were salvaged when attempted (coagulase-negative staphylococcus, 79.8% [103/129], Staphylococcus aureus, 56.7% [17/30]; polymicrobial infections, 67.7% [21/30]; and miscellaneous, 66.1% [39/59]). CVC salvage was not attempted in 49 episodes because of life-threatening sepsis (n = 18), fungal infection (n = 7), catheter problems (n = 20), and CVC tunnel infection (n = 4). Overall, the CVC was removed in 33.7% (100/297) of cases. There were 5 deaths in patients admitted to the IFU for management of the CRBSI (2 severe sepsis at presentation, 3 metastatic infection). CONCLUSIONS This is the largest reported series of catheter salvage in CRBSIs and demonstrates successful catheter salvage in most cases when using a standardized protocol.

What information should lead to a suspicion of catheter sepsis in HPN

BACKGROUND & AIMS The diagnosis of catheter sepsis in patients on home parenteral nutrition can be difficult and patients often do not present with classical symptoms of pyrexia whilst feeding. This study reviews the clinical and diagnostic criteria needed to diagnose catheter sepsis. METHODS A retrospective consecutive notes review of 2 years of patients presenting with catheter infections assessed symptoms, inflammatory markers and some liver function tests. The same data was also collected on those same patients who had successfully under gone line salvage. The two sets were compared using the Mann-Whitney U-test and predictive calculations were carried out using receiver operated characteristic curves. RESULTS Over the two year period there were 37 episodes of CRBSI in 31 patients recorded. Successful catheter salvage was achieved in 30 episodes (in 24 patients) which is an 81% salvage rate. The most significant abnormality seen was a raised C-reactive protein, but less than a third of patients had a raised white cell count. However, there were significant changes in the bilirubin (p=0.0007) and albumin (p=0.0013) in these patients. Almost a third of patients who feel unwell do not present with a raised temperature. CONCLUSIONS The diagnosis of CRBSI remains difficult, but it should be suspected in patients with newly abnormal CRP, albumin or bilirubin and in the non-specifically unwell patient a clinician should not be misled by a normal white cell count and apyrexia.

OC-034 Salvage of central venous catheters in HPN catheter-related blood stream infections is safe and effective: 18 years experience from a national centre

Introduction Catheter-related blood stream infections (CRBSI) are a serious and life-threatening complication in the provision of HPN. European guidelines recommend antibiotic salvage of central venous catheters (CVCs) with CRBSI, wherever possible, to minimise repeated catheter replacement and preserve venous access, but this is based on limited reported evidence.1 Methods Data were analysed from a prospectively-maintained register of all confirmed CRBSIs occurring in patients on HPN since January 1993 to December 2011, managed in a National Intestinal Failure Unit (IFU). Diagnosis of a CRBSI was based on quantitative and qualitative assessment of central and peripheral blood cultures and pour plates. Treatment was commenced according a standardised protocol involving antibiotic and urokinase CVC locks and systemic antibiotic administration. Results A total of 299 CRBSIs occurred in 138 patients (66 single CRBSI, 72 multiple CRBSI) with 377 patients having no catheter infections. The mean number of catheter days prior to developing an infection was 712 (range 5–6128). This represents an overall rate of infection in all patients of 0.39 per 1000 catheter days. A single microorganism caused 87.9% of infections, most commonly coagulase negative staphylococcus (CNS; 49.5% cases). Overall catheter salvage was achieved in 62.2% (intention to treat) of all patients presenting with CRBSIs (Coagulase negative staphylococcus 70.5% (105/149), MRSA 36.4% (4/11), polymicrobial infections 58.3% (21/36), other Staphylococcus aureus 48.3% (14/29) and miscellaneous 56.8% (42/74)). Line salvage was not attempted in 46 patients because of life-threatening sepsis (n=18), fungal line infection (n=7), mechanical catheter problems (eg, co-existing line fracture; n=18) and tunnel line infection (n=3). The catheter was removed in 37.7% (95/299) of cases. There were five deaths in patients admitted to the IFU for management of the CRBSI. Conclusion This is the largest reported series of catheter salvage in CRBSIs and demonstrates that catheter salvage according to a standardised protocol is a safe and effective strategy to preserve essential venous access in patients dependent on HPN. Competing interests None declared. Reference 1. Pittiruti M, Hamilton H, Biffi R, et al. ESPEN guidelines on parenteral nutrition: central venous catheters (access, care, diagnosis, and therapy of complications). Clin Nutr 2009;28:365–77.

Proximal loop jejunostomy is a useful adjunct in the management of multiple intestinal suture lines in the septic abdomen

Bowel repair in the septic abdomen can be problematic. This study investigated the use of a proximal loop jejunostomy to protect injured or fistulated bowel that had been returned to the abdomen after repair and/or anastomosis.

Radiation enteritis leading to intestinal failure: 1994 patient-years of experience in a national referral centre

Background/Objectives:Chronic radiation enteritis (RE) has been reported in up to 20% of patients receiving pelvic radiotherapy and can lead to intestinal failure (IF), accounting for 3.9% of new registrants for home parenteral nutrition (HPN) in the UK annually. Our aim is to report nutritional and survival outcomes for patients with RE referred to a national IF unit.Subjects/Methods:A retrospective study of all new admissions over a 13-year period at the Intestinal Failure Centre, Manchester, UK. Data are presented as median (range).Results:Twenty-three (3.8%) of 611 patients were admitted with IF secondary to RE. The primary site of malignancy was genitourinary in 17 (74%) patients. Radiotherapy was administered 9.5 (1–42) years previously. Patients underwent 2 (1–5) laparotomies prior to intestinal failure unit (IFU) admission. Twelve (52%) patients were admitted with intestinal obstruction and 11 (48%) with intractable weight loss and/or high output fistulae/stomas. Additional conditions contributing to IF were noted in 11 (48%) patients. Twenty-two (96%) patients had 2 (1–5) laparotomies prior to IFU referral. At discharge, 5 (22%) patients resumed oral diet without the need for artificial nutrition support, 3 (13%) required enteral feeding and 13 (56%) commenced HPN. The 10-year survival of the patient cohort was 48.2%.Conclusions:Surgical intervention is infrequently required, whereas the majority of patients with IF secondary to RE require long-term HPN. The judicious use of surgery in selected patients, coupled with an aggressive medical strategy to detect and treat contributing factors, and optimal enteral feeding may allow a modest proportion of patients with IF secondary to RE to achieve independence from PN.

Unexplained gastrointestinal dysmotility: the clue may lie in the brain

A 23-year-old male was referred to our tertiary intestinal failure unit for evaluation and nutritional support. He had presented to a neighbouring hospital with a 2 year history of episodic vomiting, abdominal pain and progressive weight loss. Evaluation at that hospital had suggested an annular pancreas causing duodenal narrowing, and he underwent a surgical resection and gastrojejunostomy. Symptoms persisted for >3 months postsurgery and a working diagnosis of severe gastrointestinal dysmotility was made following further endoscopic and radiological investigation (figure 1). Following further nutritional decline, parenteral nutrition was commenced and he was referred to our hospital for …