Enteral Feeding as a Part of Combination Treatment in a Patient after Small Intestine Transplantation

Objective: to describe the first experience with an enteral feeding regimen used as part of combination therapy in a patient after small intestine transplantation (SIT).

Materials and methods. The results of treatment in a 48year-old male after heterotopic SIT for short bowel syndrome were given. The extent of the graft was 250 cm. The combination treatment aimed  to  restore  graft  functions  and  included  immunosuppressive,  infusion,  transfusion,  antibacterial,  antiviral,  and detoxification therapies and parenteral and enteral feeding (EF). Our elaborated EF regimen was divided into 3 steps: 1) early enteral therapy (on day 1) using a monomeric saline enteral solution and a specialized formula containing pharmaconutrients (glutamine, antioxidants, and tributyrine); 2) incorporation of a semielemental formula (on day 5); 3) use of polymeric  formulas  and  clinical  nutrition.  Laboratory,  ultrasound,  radiological,  and  endoscopic  monitoring  and  biopsy were performed.

Results. The combination treatment using stepwise EF could satisfy a patient's protein-energy needs. Restoration of histological structures in the graft mucosa was observed during morphological examination on day 7. At enteroscopy, the intestinal mucosa was pink with prominent villi, motility, and bile-colored chyme. On day 7, there was a 150-ml self-colored stool. Data confirmed that the intestinal graft restored absorption and parietal digestion. On day 30, the patient was switched to polymeric formulas and curative diet. By the discharge from hospital, on day 86, his body mass index was 23.1 kg/m².

Conclusion. The positive treatment results in the patient became possible after SIT due to improvement of surgical techniques, current immunosuppression, and a comprehensive approach to treating him in the postoperative period. Our elaborated stepwise EF regiment is an important component of combination therapy after SIT and facilitates  the  restoration  of  the  major  functions  of  the  transplanted  intestine  and  its  preparation  for  the  assimilation  of polysubstrate formulas and natural foods. 

1. Braun F., Broering D., Faendrich F. Small intestine transplantation today. Langenbecks Arch. Surg. 2007; 392 (3): 227—238. http://dx.doi.org/10.1007/s00423-006-0134-5.PMID: 17252235

2. Ueno T., Fukuzawa M. Current status of intestinal transplantation. Surg. Today. 2010; 40 (12): 1112—1122. http://dx.doi.org/10.1007/s00595-010-4324-y. PMID: 21110153

3. Петухов А.Б., Лященко Ю.Н. Питание больных с синдромом короткой кишки. В кн.: Лященко Ю.Н., Петухов А.Б. Основы энтерального питания. М.: Вега-Интел; 2001: 195—237.

4. Парфёнов А.И. Синдром короткой тонкой кишки. В кн.: Парфёнов А.И. Энтерология. Руководство для врачей. 2-е изд. М.: МИА; 2009: 646—653.

5. Савилов П.Н., Молчанов Д.В., Яковлев В.Н. Влияние гипербарической оксигенации на кинетику глутамина в организме при печёночной недостаточности. Общая реаниматология. 2012; 8 (2): 20—27.

6. Ломиворотов В.В., Ефремов С.М., Бобошко В.А., Ведерников П.Е., Николаев Д.А. Скрининг нутриционного статуса в кардиохирургии. Общая реаниматология. 2013; 9 (1): 43—50.

7. Баклыкова Н.М. Состав и приготовление сред для внутрикишечного введения при перитоните. Методические рекомендации. М.; 1986: 19.

8. Баклыкова Н.М., Курапов Е.П., Костюченко Л.Н. Смеси для энтерального зондового питания и корригирующей терапии в послеоперационном периоде при хирургической патологии желудочно-кишечного тракта. В кн.: Парентеральное и энтеральное зондовое питание в экстренной и плановой хирургии органов брюшной полости. Труды НИИ скорой помощи им. Н.В.Склифосовского. т.24. М.; 1976: 59—68.

9. Лященко Ю.Н., Рык А.А. Энтеральное питание: история, современное состояние и перспективы развития. Часть 2. История создания и современная классификация смесей и растворов для энтерального введения. Клиническое питание. 2006; 1/2: 5—12.

10. Kreymann K.G., Berger M.M., Deutz N.E., Hiesmayr M., Jolliet P., Kazandjiev G., Nitenberg G., van den Berghe G., Wernerman J.; DGEM (German Society for Nutritional Medicine), Ebner C., Hartl W., Heymann C., Spies C.; ESPEN (European Society for Parenteral and Enteral Nutrition). ESPEN Guidelines on Enteral Nutrition: Intensive care. Clin. Nutr. 2006; 25 (2): 210—223. http://dx.doi.org/10.1016/j.clnu. 2006.01.021. PMID: 16697087

11. Singer P., Berger M.M., van den Berghe G., Biolo G., Calder P., Forbes A., Griffiths R., Kreyman G., Leverve X., Pichard C., ESPEN. ESPEN Guidelineson Parenteral Nutrition: Intensive care. Clin. Nutr. 2009; 28 (4): 387—400. http://dx.doi.org/10.1016/j.clnu.2009.04.024. PMID: 19505748

12. Conejero R., Bonet A., Grau T., Esteban A., Mesejo A., Montejo J.C., López J., Acosta J.A. Effect of a glutamine-enriched enteral diet on intestinal permeability and infectious morbidity at 28 days in critically ill patients with systemic inflammatory response syndrome: a randomized, single-blind, prospective, multicenter study. Nutrition. 2002; 18 (9): 716—721. PMID: 12297203

13. Falcão de Arruda I.S., de Aguilar Nascimento J.E. Benefits of early enteral nutrition with glutamine and probiotics in brain injury patients. Clin. Sci. (Lond). 2004; 106 (3): 287—292. http://dx.doi.org/10.1042/CS20030251. PMID: 14558885

14. McQuiggan M., Kozar R., Sailors R.M., Ahn C., McKinley B., Moore F. Enteral glutamine during active shock resuscitation is safe and enhances tolerance of enteral feeding. JPEN J. Parenter. Enteral. Nutr. 2008; 32 (1): 28—35. http://dx.doi.org/10.1177/014860710803200128. PMID: 18165444

15. Venhuizen A.M., Bell L., Garrard C.S., Castell L.M. Enteral glutamine feeding and some aspects of immune function in intensive care patients. Crit. Care. 2001; 5 (Suppl 1): 123. http://dx.doi.org/10.1186/cc1190.

16. Beale R.J., Sherry T., Lei K., Campbell-Stephen L., McCook J., Smith J., Venetz W., Alteheld B., Stehle P., Schneider H. Early enteral supplementation with key pharmaconutrients improves Sequential Organ Failure Assessment score in critically ill patients with sepsis: Outcome of a randomized, controlled, double-blind trial. Crit. Care Med. 2008; 36 (1): 131—144. http://dx.doi.org/10. 1097/01.CCM.0000297954.45251.A9. PMID: 18007263

17. Журавель С.В., Никулина В.П., Рык А.А., Киселев В.В., Чжао А.В. Применение глютамина после трансплантации печени. Вестн.службы крови России. 2009; 1: 31—35.

18. Петриков С.С., Зинкин В.Ю., Солодов А.А., Рык А.А., Крылов В.В. Использование энтерального глутамина в составе искусственного питания у больных с внутричерепными кровоизлияниями. Вестн. интенс. терапии. 2010; 4: 59—64.

19. Рык А.А., Лященко Ю.Н. Современные представления о роли внутривенного введения глутамина как стандарта лечения пациентов в критических состояниях. Медицина крит. состояний. 2010; 4 (4): 43—50.

20. McClave S.A., Martindale R.G., Vanek V.W., McCarthy M., Roberts P., Taylor B., Ochoa J.B., Napolitano L., Cresci G.; A.S.P.E.N. Board of Directors; American College of Critical Care Medicine; Society of Critical Care Medicine. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J. Parenter. Enteral. Nutr. 2009; 33 (3): 277—316. http://dx.doi.org/10.1177/0148607109335234. PMID: 19398613

21. Wernerman J. Clinical use of glutamine supplementation. J. Nutr. 2008; 138 (10): 2040S–2044S. PMID: 18806121

22. Newsholme P., Procopio J., Lima M.M., Pithon-Curi T.C., Curi R. Glutamine and glutamate-their central role in cell metabolism and function. Cell Biochem. Funct. 2003; 21 (1): 1—9. http://dx.doi.org/10.1002/cbf.1003. PMID: 12579515

23. Conjard A., Brun V., Martin M., Baverel G., Ferrier B. Effect of starvation on glutamine ammoniagenesis and gluconeogenesis in isolated mouse kidney tubules. Biochem. J. 2002; 368 (Pt 1): 301—308. http://dx.doi.org/10.1042/BJ20020331. PMID: 12164789

24. Ramos Lima M.M., de Mello M.A., Curi R. Walker 256 tumour growth causes marked changes of glutamine metabolism in rat small intestine. Cell Biochem. Funct. 2002; 20 (2): 107—113. PMID: 11979506

25. de Souza H.M., Borba Murad G.R., Ceddia R.B., Curi R., Vardanega-Peicher M., Bazotte R.B. Rat liver responsiveness to gluconeogenic substrates during insulin induced hypoglycemia. Braz. J. Med. Biol. Res. 2001; 34 (6): 771—777. http://dx.doi.org/10.1590/S0100879X2001000600012. PMID: 11378667

26. Khogali S.E., Pringle S.D., Weryk B.V., Rennie M.J. Is glutamine beneficial in ischemic heart disease? Nutrition. 2002; 18 (2): 123—126. http://dx.doi.org/10. 1016/S0899-9007(01)00768-7. PMID: 11844641

27. Matés J.M., Pérez-Gómez C., Núñez de Castro I., Asenjo M., Márquez J. Glutamine and its relationship with intracellular redox status, oxidative stress and cell proliferation/death. Int. J. Biochem. Cell Biol. 2002; 34 (5): 439—458. http://dx.doi.org/10.1016/S1357-2725(01)00143-1. PMID: 11906817

28. Pithon-Curi T.C., Levada A.C., Lopes L.R., Doi S.Q., Curi R. Glutamine plays a role in superoxide production and the expression of p47phox, p22 phox and gp91 phox in rat neutrophils. Clin. Sci. (Lond). 2002; 103 (4): 403—408. PMID: 12241540

29. Pithon-Curi T.C., Schumacher R.I., Freitas J.J., Lagranha C., Newsholme P., Palanch A.C., Doi S.Q., Curi R. Glutamine delays spontaneous apoptosis in neutrophils. Am. J. Physiol. Cell Physiol. 2003; 284 (6): 1355—1361. http://dx.doi.org/10.1152/ajpcell.00224.2002. PMID: 12529242

30. Boza J.J., Moënnoz D., Bournot C.E., Blum S., Zbinden I., Finot P.A., Ballèvre O. Role of glutamine on the de novo purine nucleotide synthesis in Caco-2 cells. Eur. J. Nutr. 2000; 39 (1): 38—46. http://dx.doi.org/10.1007/s003940050074. PMID: 10900556