Neonates With Short Bowel Syndrome An Optimistic Future for Parenteral Nutrition Independence
Neonates With Short Bowel Syndrome An Optimistic Future for Parenteral Nutrition Independence
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DOI：
10.1001/jamasurg.2013.4332
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发表时间：
2014-07-01
期刊：
影响因子：
16.9
通讯作者：
Puder, Mark
中科院分区：
文献类型：
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作者：
Fallon, Erica M.;Mitchell, Paul D.;Puder, Mark
重要性：肝保护策略和多学科管理的引入显著改善了需要肠外营养（PN）的短肠综合征（SBS）新生儿的预后。
目的：在肝保护策略和多学科管理的新时代，根据肠道长度确定SBS新生儿从PN断奶的概率。
设计、地点和参与者：在一家单中心学术机构进行回顾性病历审查。纳入矫正胎龄不超过30天且小肠不超过100 cm、被诊断患有胃肠外科疾病且依赖PN至少2周的新生儿。数据收集时间为2004年1月1日至2012年6月1日。
暴露因素：需要PN的SBS新生儿。
主要结局和指标：通过逻辑回归确定至少1年未重新开始PN的断奶概率。使用精确条件逻辑回归评估断奶的预测因素。通过Cox比例风险回归确定断奶时间的预测因素。
结果：63例患者进行了分析，其中位（第25百分位数，第75百分位数[四分位间距（IQR）]）胎龄为31（27，35）周，出生体重为1423（895，2445）g，小肠长度为41.0（24.0，65.0）cm，预测长度为29.0%（17.1%，45.5%）。51例患者（81%）接受了基于鱼油的脂质乳剂（1 g/kg/d），40例（63%）断奶，11例（17%）仍依赖PN，4例（6%）接受了移植，8例（13%）在使用PN期间死亡。排除接受移植或死亡的患者，断奶患者的中位（IQR）小肠长度为55.0（28.0，75.0）cm，PN依赖患者为26.0（14.0，41.0）cm（P = 0.006），51例中有40例（78%）在研究结束时断奶。小肠至少50 cm的患者在12个月后的断奶累积概率为88%，24个月后为96%。小肠小于50 cm的患者在12个月后的断奶累积概率为23%，24个月后为38%，57个月后为71%。小肠长度是断奶的主要预测因素。断奶时间的显著预测因素包括剩余小肠量（风险比，每20 cm肠道为1.94[95%置信区间，1.45 - 2.58]；P < 0.001）、在本机构内的全程护理（3.27[1.59 - 6.72]；P = 0.001）以及肠道延长手术（0.19[0.04 - 0.84]；P = 0.03）。
结论和相关性：尽管肠道长度较短，但大多数患者仍可从PN断奶，这可能是新的管理策略与多学科团队方法相结合的结果。
IMPORTANCE The introduction of hepatoprotective strategies and multidisciplinary management has significantly improved the outcome of neonates with short bowel syndrome (SBS) who require parenteral nutrition (PN).OBJECTIVE To determine the probability of weaning from PN based on intestinal length in neonates with SBS amidst the new era of hepatoprotective strategies and multidisciplinary management.DESIGN, SETTING, AND PARTICIPANTS Retrospective medical record review at a single-center academic institution. Neonates with no more than 100 cm of small intestine at a corrected gestational age of no more than 30 days who were diagnosed with a surgical gastrointestinal disease and PN dependent for at least 2 weeks were included. Data were collected from January 1, 2004, through June 1, 2012.EXPOSURE Neonates with SBS requiring PN.MAIN OUTCOMES AND MEASURES The probability of wean from PN without reinitiation for at least 1 year, as determined by logistic regression. Predictors of wean were evaluated using exact conditional logistic regression. Predictors of time to wean were determined by Cox proportional hazards regression.RESULTS Sixty-three patients with a median (25th percentile, 75th percentile [interquartile range (IQR)]) gestational age of 31 (27, 35) weeks, birth weight of 1423 (895, 2445) g, small intestinal length of 41.0 (24.0, 65.0) cm, and predicted length of 29.0% (17.1%, 45.5%) underwent analysis. Fifty-one patients (81%) received a fish oil-based lipid emulsion (1 g/kg/d), 40 (63%) were weaned, 11 (17%) remained PN dependent, 4 (6%) underwent transplant, and 8 (13%) died while on PN. Excluding patients who underwent transplant or died, the median (IQR) small intestinal length was 55.0 (28.0, 75.0) cm in weaned and 26.0 (14.0, 41.0) cm in PN-dependent patients (P = .006), with 40 of 51 (78%) weaned by study end. The cumulative probability of wean for patients with at least 50 cm of small intestine was 88% after 12 and 96% after 24 months. Patients with less than 50 cm of small intestine had a cumulative probability of wean of 23% after 12, 38% after 24, and 71% after 57 months. Small intestinal length was found to be the primary predictor of wean. Notable predictors of time to wean included the amount of small intestine remaining (hazard ratio, 1.94 [95% CI, 1.45-2.58] per 20 cm of intestine; P < .001), entirety of care within our institution (3.27 [1.59-6.72]; P = .001), and intestinal lengthening procedure (0.19 [0.04-0.84]; P = .03).CONCLUSIONS AND RELEVANCE The majority of patients will wean from PN despite short intestinal length, likely as a result of new management strategies combined with a multidisciplinary team approach.