Functional Liver Recovery Parallels Autologous Gut Salvage in Short Bowel Syndrome

Kishore R. Iyer, S. Horslen, C. Torres, J. A. Vanderhoof, A. N. Langnas, Thomas Tracy

Research output: Contribution to journalArticle

24 Citations (Scopus)

Abstract

Background/Purpose: Parenteral nutrition (PN) is life saving in short bowel syndrome. However, long-term parenteral nutrition is frequently complicated by a syndrome of progressive cholestatic liver disease that is considered to be irreversible beyond the early stages of cholestasis, particularly in the presence of any degree of fibrosis in the liver. The purpose of this study was to examine apparent improvement in PN-associated liver dysfunction in a cohort of children with short bowel syndrome. Methods: A retrospective case-record review of all patients managed within a dedicated Intestinal Rehabilitation Program (IRP) identified 13 patients with short bowel who had PN-associated liver dysfunction, defined for this purpose as hyperbilirubinemia or an abnormal liver biopsy. Results: At referral, 12 of the 13 patients were exclusively on PN, and one was on 50% PN. At current follow-up, 3 patients have achieved complete enteral autonomy from PN, and 7 patients have had smaller decrements in PN requirements. Specific operative procedures to improve intestinal function were undertaken in 11 patients; 4 patients also underwent cholecystectomies with biliary irrigation at the time of intestinal reconstruction. The median highest bilirubin level in these 13 patients was 10. 7 mg% (range, 3.2 to 24.5 mg%). Liver biopsy results indicated that 5 patients were cirrhotic, 3 had bridging fibrosis, and 4 had severe cholestasis or lesser degrees of fibrosis. Of 10 survivors in this series, 9 patients currently have a serum bilirubin less than 1 mg% with a median bilirubin in the group of 0.6 mg% (range, 0.3 to 6.4 mg%). Twelve of the 13 patients in this series were initially referred for liver-small bowel transplantation. Conclusions: This preliminary experience suggests that PN-dependent patients with advanced liver dysfunction in the setting of the short bowel syndrome may, in some instances, experience functional and biochemical liver recovery. The latter appears to parallel autologous gut salvage in most cases. As a corollary, the authors believe that even advanced degrees of liver dysfunction should not preclude attempts at autologous gut salvage in very carefully selected patients. Such a policy of "aggressive conservatism" may help avoid the need for liver/intestinal transplantation in some patients who appear to be not responding to PN.

Original languageEnglish (US)
Pages (from-to)340-344
Number of pages5
JournalJournal of Pediatric Surgery
Volume39
Issue number3
DOIs
StatePublished - Jan 1 2004

Fingerprint

Short Bowel Syndrome
Parenteral Nutrition
Liver
Liver Diseases
Bilirubin
Cholestasis
Fibrosis
Biopsy
Nutritional Requirements
Hyperbilirubinemia
Operative Surgical Procedures
Cholecystectomy
Politics
Liver Cirrhosis
Liver Transplantation

All Science Journal Classification (ASJC) codes

  • Surgery
  • Pediatrics, Perinatology, and Child Health

Cite this

Iyer, Kishore R. ; Horslen, S. ; Torres, C. ; Vanderhoof, J. A. ; Langnas, A. N. ; Tracy, Thomas. / Functional Liver Recovery Parallels Autologous Gut Salvage in Short Bowel Syndrome. In: Journal of Pediatric Surgery. 2004 ; Vol. 39, No. 3. pp. 340-344.
@article{b76a55c12b344705b4d8c11b72611309,
title = "Functional Liver Recovery Parallels Autologous Gut Salvage in Short Bowel Syndrome",
abstract = "Background/Purpose: Parenteral nutrition (PN) is life saving in short bowel syndrome. However, long-term parenteral nutrition is frequently complicated by a syndrome of progressive cholestatic liver disease that is considered to be irreversible beyond the early stages of cholestasis, particularly in the presence of any degree of fibrosis in the liver. The purpose of this study was to examine apparent improvement in PN-associated liver dysfunction in a cohort of children with short bowel syndrome. Methods: A retrospective case-record review of all patients managed within a dedicated Intestinal Rehabilitation Program (IRP) identified 13 patients with short bowel who had PN-associated liver dysfunction, defined for this purpose as hyperbilirubinemia or an abnormal liver biopsy. Results: At referral, 12 of the 13 patients were exclusively on PN, and one was on 50{\%} PN. At current follow-up, 3 patients have achieved complete enteral autonomy from PN, and 7 patients have had smaller decrements in PN requirements. Specific operative procedures to improve intestinal function were undertaken in 11 patients; 4 patients also underwent cholecystectomies with biliary irrigation at the time of intestinal reconstruction. The median highest bilirubin level in these 13 patients was 10. 7 mg{\%} (range, 3.2 to 24.5 mg{\%}). Liver biopsy results indicated that 5 patients were cirrhotic, 3 had bridging fibrosis, and 4 had severe cholestasis or lesser degrees of fibrosis. Of 10 survivors in this series, 9 patients currently have a serum bilirubin less than 1 mg{\%} with a median bilirubin in the group of 0.6 mg{\%} (range, 0.3 to 6.4 mg{\%}). Twelve of the 13 patients in this series were initially referred for liver-small bowel transplantation. Conclusions: This preliminary experience suggests that PN-dependent patients with advanced liver dysfunction in the setting of the short bowel syndrome may, in some instances, experience functional and biochemical liver recovery. The latter appears to parallel autologous gut salvage in most cases. As a corollary, the authors believe that even advanced degrees of liver dysfunction should not preclude attempts at autologous gut salvage in very carefully selected patients. Such a policy of {"}aggressive conservatism{"} may help avoid the need for liver/intestinal transplantation in some patients who appear to be not responding to PN.",
author = "Iyer, {Kishore R.} and S. Horslen and C. Torres and Vanderhoof, {J. A.} and Langnas, {A. N.} and Thomas Tracy",
year = "2004",
month = "1",
day = "1",
doi = "10.1016/j.jpedsurg.2003.11.023",
language = "English (US)",
volume = "39",
pages = "340--344",
journal = "Journal of Pediatric Surgery",
issn = "0022-3468",
publisher = "W.B. Saunders Ltd",
number = "3",

}

Functional Liver Recovery Parallels Autologous Gut Salvage in Short Bowel Syndrome. / Iyer, Kishore R.; Horslen, S.; Torres, C.; Vanderhoof, J. A.; Langnas, A. N.; Tracy, Thomas.

In: Journal of Pediatric Surgery, Vol. 39, No. 3, 01.01.2004, p. 340-344.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Functional Liver Recovery Parallels Autologous Gut Salvage in Short Bowel Syndrome

AU - Iyer, Kishore R.

AU - Horslen, S.

AU - Torres, C.

AU - Vanderhoof, J. A.

AU - Langnas, A. N.

AU - Tracy, Thomas

PY - 2004/1/1

Y1 - 2004/1/1

N2 - Background/Purpose: Parenteral nutrition (PN) is life saving in short bowel syndrome. However, long-term parenteral nutrition is frequently complicated by a syndrome of progressive cholestatic liver disease that is considered to be irreversible beyond the early stages of cholestasis, particularly in the presence of any degree of fibrosis in the liver. The purpose of this study was to examine apparent improvement in PN-associated liver dysfunction in a cohort of children with short bowel syndrome. Methods: A retrospective case-record review of all patients managed within a dedicated Intestinal Rehabilitation Program (IRP) identified 13 patients with short bowel who had PN-associated liver dysfunction, defined for this purpose as hyperbilirubinemia or an abnormal liver biopsy. Results: At referral, 12 of the 13 patients were exclusively on PN, and one was on 50% PN. At current follow-up, 3 patients have achieved complete enteral autonomy from PN, and 7 patients have had smaller decrements in PN requirements. Specific operative procedures to improve intestinal function were undertaken in 11 patients; 4 patients also underwent cholecystectomies with biliary irrigation at the time of intestinal reconstruction. The median highest bilirubin level in these 13 patients was 10. 7 mg% (range, 3.2 to 24.5 mg%). Liver biopsy results indicated that 5 patients were cirrhotic, 3 had bridging fibrosis, and 4 had severe cholestasis or lesser degrees of fibrosis. Of 10 survivors in this series, 9 patients currently have a serum bilirubin less than 1 mg% with a median bilirubin in the group of 0.6 mg% (range, 0.3 to 6.4 mg%). Twelve of the 13 patients in this series were initially referred for liver-small bowel transplantation. Conclusions: This preliminary experience suggests that PN-dependent patients with advanced liver dysfunction in the setting of the short bowel syndrome may, in some instances, experience functional and biochemical liver recovery. The latter appears to parallel autologous gut salvage in most cases. As a corollary, the authors believe that even advanced degrees of liver dysfunction should not preclude attempts at autologous gut salvage in very carefully selected patients. Such a policy of "aggressive conservatism" may help avoid the need for liver/intestinal transplantation in some patients who appear to be not responding to PN.

AB - Background/Purpose: Parenteral nutrition (PN) is life saving in short bowel syndrome. However, long-term parenteral nutrition is frequently complicated by a syndrome of progressive cholestatic liver disease that is considered to be irreversible beyond the early stages of cholestasis, particularly in the presence of any degree of fibrosis in the liver. The purpose of this study was to examine apparent improvement in PN-associated liver dysfunction in a cohort of children with short bowel syndrome. Methods: A retrospective case-record review of all patients managed within a dedicated Intestinal Rehabilitation Program (IRP) identified 13 patients with short bowel who had PN-associated liver dysfunction, defined for this purpose as hyperbilirubinemia or an abnormal liver biopsy. Results: At referral, 12 of the 13 patients were exclusively on PN, and one was on 50% PN. At current follow-up, 3 patients have achieved complete enteral autonomy from PN, and 7 patients have had smaller decrements in PN requirements. Specific operative procedures to improve intestinal function were undertaken in 11 patients; 4 patients also underwent cholecystectomies with biliary irrigation at the time of intestinal reconstruction. The median highest bilirubin level in these 13 patients was 10. 7 mg% (range, 3.2 to 24.5 mg%). Liver biopsy results indicated that 5 patients were cirrhotic, 3 had bridging fibrosis, and 4 had severe cholestasis or lesser degrees of fibrosis. Of 10 survivors in this series, 9 patients currently have a serum bilirubin less than 1 mg% with a median bilirubin in the group of 0.6 mg% (range, 0.3 to 6.4 mg%). Twelve of the 13 patients in this series were initially referred for liver-small bowel transplantation. Conclusions: This preliminary experience suggests that PN-dependent patients with advanced liver dysfunction in the setting of the short bowel syndrome may, in some instances, experience functional and biochemical liver recovery. The latter appears to parallel autologous gut salvage in most cases. As a corollary, the authors believe that even advanced degrees of liver dysfunction should not preclude attempts at autologous gut salvage in very carefully selected patients. Such a policy of "aggressive conservatism" may help avoid the need for liver/intestinal transplantation in some patients who appear to be not responding to PN.

UR - http://www.scopus.com/inward/record.url?scp=1542408746&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=1542408746&partnerID=8YFLogxK

U2 - 10.1016/j.jpedsurg.2003.11.023

DO - 10.1016/j.jpedsurg.2003.11.023

M3 - Article

C2 - 15017549

AN - SCOPUS:1542408746

VL - 39

SP - 340

EP - 344

JO - Journal of Pediatric Surgery

JF - Journal of Pediatric Surgery

SN - 0022-3468

IS - 3

ER -