O'Keefe Stephen J D
Division of Gastroenterology, University of Pittsburgh, Pittsburgh, PA, USA.
Nestle Nutr Inst Workshop Ser. 2015;82:75-90. doi: 10.1159/000382005. Epub 2015 Oct 20.
In this review, I focus on the extreme of the short bowel syndrome where the loss of intestine is so great that patients cannot survive without intravenous feeding. This condition is termed short bowel intestinal failure. The review outlines the principles behind diagnosis, assessing prognosis and management. The advent of intravenous feeding (parenteral nutrition) in the 1970s enabled patients with massive (>90%) bowel resection to survive for the first time and to be rehabilitated back into normal life. To achieve this, central venous catheters were inserted preferably into the superior vena cava and intravenous infusions were given overnight so that the catheter could be sealed by day in order to maximize ambulation and social integration. However, quality of life has suffered by the association of serious complications related to permanent catheterization - mostly in the form of septicemias, thrombosis, metabolic intolerance and liver failure - from the unphysiological route of nutrient delivery. This has led to intense research into restoring gut function. In addition to dietary modifications and therapeutic suppression of motility, novel approaches have been aimed at enhancing the natural adaptation process, first with recombinant growth hormone and more recently with gut-specific glucagon-like peptide-2 analogues, e.g. teduglutide. These approaches have met with some success, reducing the intravenous caloric needs by approximately 500 kcal/day. In controlled clinical trials, teduglutide has been shown to permit >20% reductions in intravenous requirements in over 60% of patients after 6 months of treatment. Some patients have been weaned, but more have been able to drop infusion days. The only approach that predictably can get patients with massive intestinal loss completely off parenteral nutrition is small bowel transplantation, which, if successful (1-year survival for graft and host >90%) is accompanied by dramatic improvements in quality of life.
在本综述中，我聚焦于短肠综合征的极端情况，即肠道丧失极为严重，患者若无静脉营养支持便无法存活。这种情况被称为短肠型肠衰竭。本综述概述了诊断、评估预后及管理背后的原则。20世纪70年代静脉营养（肠外营养）的出现，使接受大量（>90%）肠切除的患者首次得以存活，并恢复正常生活。为实现这一点，中心静脉导管最好插入上腔静脉，夜间进行静脉输注，以便白天封住导管，从而最大限度地增加患者活动及融入社会的机会。然而，由于与长期置管相关的严重并发症——主要表现为败血症、血栓形成、代谢不耐受和肝功能衰竭——通过非生理性的营养输送途径出现，患者的生活质量受到了影响。这促使人们对恢复肠道功能展开深入研究。除了饮食调整和对肠道动力进行治疗性抑制外，新方法旨在增强自然适应过程，最初是使用重组生长激素，最近则是使用肠道特异性胰高血糖素样肽-2类似物，如替度鲁肽。这些方法已取得一定成功，使静脉热量需求减少约500千卡/天。在对照临床试验中，替度鲁肽已被证明，治疗6个月后，超过60%的患者静脉营养需求减少>20%。一些患者已成功停用静脉营养，但更多患者能够减少输注天数。唯一可预期能让大量肠道丧失的患者完全摆脱肠外营养的方法是小肠移植，如果成功（移植物和宿主1年生存率>90%），患者生活质量会有显著改善。
