Claire Guedon

Prognosis of patients with nonmalignant chronic intestinal failure receiving long-term home parenteral nutrition

BACKGROUND/AIMS Long-term survival of patients with intestinal failure requiring home parenteral nutrition (HPN) has been only partly shown. Therefore, we described the survival of these patients and explored prognosis factors. METHODS Two hundred seventeen noncancer non-acquired immunodeficiency syndrome adult patients presenting with chronic intestinal failure enrolled from January 1980 to December 1989 in approved HPN programs in Belgium and France; prognosis factors of survival were explored using multivariate analysis. Data were updated in March 1991; not one of the patients was lost to follow-up. RESULTS Seventy-three patients died during the survey, and the mortality rate related to HPN complications accounted for 11% of deaths. Probabilities of survival at 1, 3, and 5 years were 91%, 70%, and 62%, respectively. Three independent variables were associated with a decreased risk of death: age of patients younger than 40 years, start of HPN after 1987, and absence of chronic intestinal obstruction. In patients younger than 60 years of age included after 1983 with a very short bowel, who could represent suitable candidates for small bowel transplantation, the 2-year survival rate was 90%, a prognosis that compared favorably with recent reports of survival after small bowel transplantation. CONCLUSIONS HPN prognosis compares favorably with recent reports of survival after small bowel transplantation.

Efficacy of antibiotic-lock technique with teicoplanin in staphylococcus epidermidis catheter-related sepsis during long-term parenteral nutrition

BACKGROUND The antibiotic-lock technique has been suggested to treat catheter-related sepsis in parenteral nutrition and to avoid catheter removal. METHODS To determine the incidence of catheter-related sepsis, the bacteria involved, and the efficacy of the antibiotic-lock technique with teicoplanin, all patients (n = 263) undergoing parenteral nutrition from January 1997 to December 1999 in one center, with patients at the hospital (n = 209) and at home (54) were retrospectively studied. The antibiotic-lock technique with teicoplanin was systematically used in all suspected infections and maintained in staphylococcus epidermidis (SE) infections. RESULTS A total of 21 of 263 patients had 34 infections (0.11/patient per year): 12 of 209 hospitalized and 9 of 54 home patients. A total of 10 of 34 infections were due to non-SE, and the catheter was immediately removed. The other 24 of 34 infections were due to SE; in 5 of 24, the catheter was removed after 48 hours of the antibiotic-lock technique because of persistent fever or thrombosis. A total of 5 of 12 patients had 2 or more infections on the same catheter. The antibiotic-lock technique prevented short-term catheter removal in these cases, but a second infection occurred within a median of 50 days. In 4 of 5 cases, a third infection occurred in a mean delay of 90 days so that the catheter was removed. In 3 of 5 patients, bacteria was analyzed with pulsed field gel electrophoresis, which showed that recurrent infections were due to the same strain in all cases. CONCLUSIONS In this study, the incidence of catheter-related sepsis was low and mostly related to SE. Our results do not support the use of the teicoplanin antibiotic-lock technique in SE infections.

Duodenojejunal motility after oral and enteral nutrition in humans: a comparative study.

BACKGROUND Small bowel motility during enteral nutrition (EN) remains poorly known. Our aim was to compare, in six healthy volunteers, the duodenojejunal motor patterns after a 750-kcal meal either ingested or infused intraduodenally at two different infusion rates: 2 kcal/min for 6 hours (6-hour EN) or 1 kcal/min for 12 hours (12-hour EN). METHODS In each volunteer, the three manometric studies were carried out in a random order with an interval of > or = 1 week between each recording. Number of phase III (PIIIs), their characteristics, number of waves (NW), and area under the curve (AUC) were determined. RESULTS PIIIs were interrupted by each type of nutrition in every volunteer. In five of six during 6-hour EN and in six of six during 12-hour EN, the first PIII returned before the end of EN. The mean duration of the fed pattern was similar in the three studies. During the interruption of PIIIs after oral meal, duodenojejunal motility was characterized by uninterrupted random contractions. By contrast, in four of six during the 6-hour EN and in five of six during 12-hour EN, it was organized as regular short bursts of contractions separated by motor quiescence. In all studies during the disruption of PIIIs, NW and AUC values decreased progressively with time and were higher at the jejunum level than in the duodenum (p < .001). However, at each level of recording, NW and AUC values were similar in the three types of feeding. After the return of PIIIs, the number, duration, and propagation velocity of PIIIs, NW, and AUC values were similar in the three studies. CONCLUSIONS EN interrupts PIIIs, but, in most cases, PIIIs reappear before the end of EN. During the interruption of PIIIs, the organization of the contractions is qualitatively different from the fed pattern observed after oral feeding. For the same caloric value of the meal, the quantitative duodenojejunal motor response is not affected by the infusion rate, and the more important jejunal, rather than duodenal motor response found after an oral meal, is observed during EN. During EN, after the return of PIIIs, despite the persistence of a nutrient infusion into the duodenum, the small bowel motor patterns are not qualitatively or quantitatively different from those recorded in fasting subjects.

Prise en charge d’un malade opéré

C’est une éventualité fréquente lors du premier mois [1, 2, 5]. Elle est le principal facteur d’échec tardif (35-80 %) [6-8] (niveau 2). Les causes les plus souvent invoquées sont la tension excessive, des facteurs généraux (poussée aiguë sévère, dénutrition, corticothérapie prolongée) et des facteurs anatomiques (étroitesse du bassin, surcharge pondérale) [5, 9, 10] (niveau 3). L’âge (plus de 60 70 ans), n’est pas, en soi, un facteur de ris(1) Service de chirurgie digestive et transplantation, Hôpital Claude Huriez, 59034 Lille ; (2) Service d’hépato-gastroentérologie et nutrition, Hôpital Saint Antoine, 75012 Paris ; (3) Département d’hépato-gastroentérologie, Hôpital Charles Nicolle, 76041 Rouen ; (4) Service de chirurgie, Hôpital Sainte Marguerite, 13274 Marseille ; (5) Service de chirurgie digestive, Hôpital Lariboisière Louis, 75010 Paris.

Effect of chemotherapy on resting energy expenditure in patients with non-Hodgkin's lymphoma. Results of a sequential study.

This study compared the resting energy expenditure (REE) modifications observed during successive intensive identical chemotherapy courses in non‐Hodgkins lymphoma patients to assess indirectly the metabolic changes induced by the cytotoxic effect of drugs on the tumor. With this therapeutic regimen, reduction of tumor mass is mostly achieved during the first course of chemotherapy. The study included 10 non‐Hodgkins lymphoma adult patients receiving three intensive 5‐day courses of Adriamycin (doxorubicin Adria Laboratories, Columbus, OH), cyclophosphamide, vindesine, and bleomycin. Resting energy expenditure was evaluated by indirect calorimetry during each course, first within the first 2 days before chemotherapy and then on days 2, 3 and 5. Initial REE (day 0) on entry into the study (21.8 ± 1.2 kcal/kg.d−1) represented 99 ± 6.7% of theoretical REE. Resting energy expenditure on day 0 was lower during course 2 and 3 (19.1 ± 0.7 and 18.4 ± 1.8 kcal/kg/d) than during course 1 (21.8 ± 1.2 kcal/kg/d). The REE profile was different among the 3 courses: course 1 induced a significant REE decrease on days 3 and 5 (P < 0.01); during course 2, REE remained stable and was lower than during course 1; during course 3, REE increased on days 2, 3, and 5 (P < 0.05). Energy balance was positive during the three courses and nutritional status remained stable. The REE decrease observed during course 1 may be regarded as the metabolic effect of chemotherapy on the tumor metabolism.

Increase in cyclooxygenase-2 and nitric oxide–synthase-2 mRNAs in pouchitis without modification of inducible isoenzyme heme-oxygenase-1

OBJECTIVES:The pathophysiology of pouchitis occurring after ileal pouch–anal anastomosis remains controversial. Prostaglandins and nitric oxide synthesized in excess by cyclooxygenase-2 and nitric oxide synthase-2 are thought to be involved in the inflammatory process. Because heme oxygenase-1, by its antioxidant properties, could modulate inflammatory reaction, we analyzed mRNAs of the three enzymes (cyclooxygenase-2, nitric oxide synthase-2, and heme oxygenase-1) in patients with ileal pouch–anal anastomosis.METHODS:Endoscopic biopsies were obtained in eight patients with normal ileal pouch–anal anastomosis, in eight patients with pouchitis, and in normal ileum of six healthy subjects. A relative quantitative RT-PCR was performed to determine the levels of cyclooxygenase-2, nitric oxide synthase-2, and heme oxygenase-1 mRNAs.RESULTS:Cyclooxygenase-2 and nitric oxide synthase-2 mRNAs were increased both in normal ileal pouch–anal anastomosis and in pouchitis, compared with healthy subjects. Pouchitis disease activity index was correlated with mRNA levels of cyclooxygenase-2 (r = 0.71; p < 0.01) and nitric oxide synthase-2 (r = 0.51; p < 0.05). Heme oxygenase-1 mRNA levels were not significantly different in patients versus healthy subjects.CONCLUSIONS:The increase in cyclooxygenase-2 and nitric oxide synthase-2 mRNA levels both in pouchitis and normal ileal pouch–anal anastomosis demonstrates that a latent inflammatory process occurs in the ileal pouch mucosa. This inflammatory process was not found to be associated with an induction of heme oxygenase mRNA, a possible regulator of the inflammatory response.

Does chronic supplementation of the diet with dietary fibre extracted from pea or carrot affect colonic motility in man

The aim of the present study was to assess, in healthy volunteers and under physiological conditions, the acceptability, clinical tolerance and effects on colonic motility of chronic supplementation of the usual diet with new dietary fibre sources. Three studies were carried out, one after a period of habitual diet, and two after randomized 3-week periods of supplementation with fibre extracted either from pea hulls or carrots, added to the meals as a fine powder. The 24 h motility was recorded on an unprepared colon at five levels to determine the initiation site and the number of high amplitude propagated contractions (HAPC) and to quantify motor activity every 30 min, particularly in the two periods following lunch and breakfast. With the habitual diet the motility pattern was an irregular alternation of quiescence and sporadic non-propagated contractions. HAPC always started from the ascending colon and occurred mainly after breakfast. With either type of fibre the 24 h motor profiles, the 24 h variations and the number of HAPC were not significantly modified but a more distal initiation of HAPC was found. The colonic postprandial motor response was more diffuse after dietary enrichment with carrot fibre than after enrichment with pea-hull fibre. In healthy volunteers the long-term addition of fibre extracted from pea hulls and carrots to the usual diet was easy and well-tolerated without clinical side-effects, but with limited colonic motor effects. However, the more distal initiation of HAPC observed could be deleterious.

Effects of intraduodenal and intravenous fat infusion on small bowel motility in humans: a comparative study of medium- and long-chain triglycerides

Objective: To test the effects of medium-chain triglycerides (MCT) and long-chain triglycerides (LCT), given intraduodenally or intravenously to healthy volunteers, on small bowel motility. Design: Two groups comprized of eight volunteers were studied. The 5-h fat infusion always began 30 min after a phase III. In study 1, volunteers received at random either 50 g LCT or MCT intraduodenally. In study 2, they received 500 ml of an emulsion of either LCT only or 50% LCT/50% MCT intravenously. Manometric recording continued from the beginning of fat delivery until the recurrence of a phase III after fat administration ceased. Results: In study 1, LCTs reduced phases III and I, while intraduodenal MCTs did not effect the fasting motor pattern of the small bowel. In study 2, phase III was recorded in all volunteers with both intravenous infusions. The percentage of time in phase III was greater with MCT than with the LCT infusion but the percentage of time in phases I and II remained the same with both types of intravenous fat. Conclusions: The effects of lipids on small bowel motor activity in humans depends on two parameters: the type of lipid and the route of administration.