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Patients with intestinal failure often need long-term home parenteral support (PS). We aimed to determine how the underlying diagnosis, complications and survival had changed over the last 36 years in the UK's largest IF centre.978 adult home PS patient records were analysed from January 1979 until October 2016. The age, sex, underlying aetiology, complications and survival was compared over 5-year periods.Pre-1990 to 2011-2016, numbers increased from 29 to 451, the mean age of patients increased from 31 ± 16.5 to 52 ± 17.6 years. The percentage of patients with IF due to surgical complications increased (3.4%-28.8%, p 0.001)), while those with inflammatory bowel disease decreased (37.9%-22.6%, p 0.001). Complication of home PS reduced: catheter related blood stream infections (CRBSI) 71.4% to 42,2%, CVC thrombosis 34.5%-5.3%. Intestinal failure associated liver disease (IFLAD) 10.3%-1.8%. Patients with dysmotility, scleroderma and a congenital aetiology had the highest incidence of CRBSI and CVC Thrombosis. Overall survival was greater pre-1995 [HR 0.2-0.4 (p = 0.02)] most likely associated with an increase in mean age. Survival for patients without malignancy was 90%, 66%, 55%, 45%, 33% and 25% at 1,5, 10, 15, 20 and 30 years respectively. Multivariate analysis demonstrated a relationship between survival and age of starting home PS; type of home PS; presence or absence of the colon in continuity; and underlying aetiology.Demand for home PS is increasing in particular for advanced malignancy, post-surgical complications and older more co-morbid patients. Complications of home PS are reducing over the last 30 years and 10-year survival for non-malignant aetiologies improving. Survival and changes in aetiology in intestinal failure.

BACKGROUND & AIMS: Disease-associated factors influence parenteral support (PS) reduction in response to teduglutide in patients with intestinal failure associated-short bowel syndrome (SBS-IF). We sought to determine correlative relationships between plasma citrulline levels, small bowel length, and PS volume.METHODS: A post hoc analysis of plasma citrulline levels from patients in the STEPS 24-week study of teduglutide in patients with SBS-IF. Plasma citrulline was assessed in all patients; patients were stratified 3 times into subgroups based on bowel anatomy, cause of SBS-IF, and baseline PS volumes. Correlation analyses used simple linear regression models. Statistical comparisons between study groups were conducted using 2-sided t tests for 2 independent mean differences.RESULTS: Baseline plasma citrulline correlated with remnant small bowel length (r = 0.355, P = 0.002), but not with baseline PS volume (r = -0.167, P = 0.14), in the overall population. There was a robust correlation between the baseline and Week 24 citrulline (r = 0.705, P < 0.0001), and an inverse correlation between change from baseline in citrulline and PS volume from baseline to Week 24 (r = -0.359, P = 0.001). In all subgroups, patients treated with teduglutide showed numerically greater increases in plasma citrulline at Week 24 compared with placebo.CONCLUSION: Baseline plasma citrulline showed significant correlations with small bowel length in patients with ≥50% colon remaining/no stoma/colon-in-continuity, and patients with SBS-IF causes other than IBD/vascular disease. Citrulline levels may correlate with PS changes in response to teduglutide and more research may reveal a relationship between citrulline levels within the heterogeneous population of patients with SBS-IF. ClinicalTrials.gov NCT00798967, ClinicalTrialsRegister.eu 2008-006193-15.

Summary Background & aims Sarcopenia occurs in patients with intestinal failure (IF) and has been associated with poorer survival in several chronic diseases. CT can measure sarcopenia through a L3 skeletal muscle index (LSMI). We aim to describe the prevalence of sarcopenia in a section of our IF population using LSMI, & evaluate the effect of home parenteral support (PS) on LSMI & survival. Additionally, we aim to assess any association between LSMI, BMI & other anthropometric measurements. Methods IF patients on PS treated at St Mark's Hospital between 1/1/2006-1/10/2016 were identified from a prospectively maintained database. Patients were included if they were on PS & had 2 CTs: the first ≤30 days before start of HPN (pre-PS); the second ≥100 days from PS start (post-PS). Patient records were reviewed to obtain clinical & demographic information & date of death. Anthropometric measurements & BMI contemporaneous to CT scans were recorded. Results 64 patients met inclusion criteria (M:F 1:1). 83% of our cohort had LSMI below previously published thresholds for sarcopenia. Mean (SD) pre-PS LSMI was 36.5 (6.8)cm2/m2. Mean BMI pre-PS was 22.1 (4.8) kg/m2. Both BMI (22.1 kg/m2 to 23.5 kg/m2) p Conclusions This study is the first to look at sarcopenia & survival using CT defined LSMI (CT-LSMI) in the IF population. 83% of our cohort had a pre-PS LSMI below previously published thresholds, yet we found no relationship between lower baseline LSMI & survival. This may reflect the heterogeneity of the prognoses of the IF population, or that parenteral nutrition itself affects survival. Our study showed that LSMI & BMI improved following PS but demonstrated that other anthropometric measurements had poor correlation with LSMI & showed no significant improvement overall after PS, confirming the known problems of inter-operator & patient variability of these measurements. Whilst we found significant correlation between LSMI & BMI, BMI significantly underestimated the presence & degree of sarcopenia. LSMI has the potential to provide an objective & reproducible measure of sarcopenia in IF. Future larger studies should be performed to evaluate associations with patient outcomes & utility in clinical decision making.

AIM In intestinal failure, delineation of both structure and function are key to both controlling symptoms and planning further intervention. We have developed a template for developing an "anatomy at a glance" patient-specific map to aid decision making and counselling. METHOD A core data set was developed and used to create an editable template to demonstrate the gastrointestinal tract, its relationship to the genitourinary tract, and specific anterior abdominal wall features. This was then used to create an anatomical template, specific to each patient, and stored in the electronic patient record and imaging archive. RESULTS We have developed a technique for integration of multi-modal information into one diagram, easily referenced by the multidisciplinary team. Radiology, endoscopy and previous operation notes can be used to fill out a core data set, which is then transposed into a standardised template. A worked example is shown in the main article. CONCLUSION The mapping template has been successfully integrated into practice, and aided decision making at all stages of the patient's therapeutic journey. It has been found helpful in planning routes of nutrition, pre-operative optimisation, surgical planning, interpreting post-operative imaging and managing patient expectations.

Background & aims: Intestinal failure (IF) is defined from a requirement or intravenous supplementation due to failing capacity to absorb nutrients and fluids. Acute IF is an acute, potentially reversible form of IF. We aimed to identify the prevalence, underlying causes and outcomes of acute IF.Methods: This point-of-prevalence study included all adult patients hospitalized in acute care hospitals and receiving parenteral nutrition (PN) on a study day. The reason for PN and the mechanism of IF (if present) were documented by local investigators and reviewed by an expert panel.Results: Twenty-three hospitals (19 university, 4 regional) with a total capacity of 16,356 acute care beds and 1237 intensive care unit (ICU) beds participated in this study. On the study day, 338 patients received PN (21 patients/1000 acute care beds) and 206 (13/1000) were categorized as acute IF. The categorization of reason for PN was revised in 64 cases (18.9% of total) in consensus between the expert panel and investigators. Hospital mortality of all study patients was 21.5%; the median hospital stay was 36 days. Patients with acute IF had a hospital mortality of 20.5% and median hospital stay of 38 days (P > 0.05 for both outcomes). Disordered gut motility (e.g. ileus) was the most common mechanism of acute IF, and 71.5% of patients with acute IF had undergone abdominal surgery. Duration of PN of >= 42 days was identified as being the best cut-off predicting hospital mortality within 90 days. PN >= 42 days, age, sepsis and ICU admission were independently associated with 90-day hospital mortality.Conclusions: Around 2% of adult patients in acute care hospitals received PN, 60% of them due to acute IF. High 90-day hospital mortality and long hospital stay were observed in patients receiving PN, whereas presence of acute IF did not additionally influence these outcomes. Duration of PN was associated with increased 90-day hospital mortality. (C) 2019 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

BACKGROUND: Teduglutide response, in terms of parenteral support (PS) volume reduction, is associated with specific disease characteristics among adults with short bowel syndrome-associated intestinal failure (SBS-IF). Whether these associations apply to PS weaning with teduglutide is unknown.METHODS: Adults with SBS-IF treated with teduglutide in the phase III STEPS study and open-label extensions STEPS-2 and STEPS-3 were included in the analysis. Patients required PS ≥ 3 times weekly for ≥ 12 months at enrollment. The study population was stratified 3 times to create 3 distinct analysis populations based on bowel anatomy, etiology, and baseline PS volume. Outcomes included characteristics of patients who achieved PS independence and total and percentage of patients who had ≥ 1, ≥ 2, and ≥ 3 d/wk off PS at the end of STEPS, STEPS-2, and STEPS-3.RESULTS: Eight of 39 patients who received teduglutide in STEPS obtained PS independence during the STEPS study series. Patients required > 6 months of teduglutide treatment before enteral autonomy was achieved, regardless of underlying disease characteristics. Patients who attained PS independence and greater numbers of days per week off PS tended to have lower baseline PS volumes and noninflammatory bowel disease (non-IBD) etiology. Patients with ≥ 50% colon-in-continuity showed a trend for achieving greater numbers of days per week off PS.CONCLUSION: Although this analysis was limited by low patient numbers, results suggest that SBS-IF characteristics of lower baseline PS volume and non-IBD etiology were associated with PS reduction benefits with teduglutide in terms of days off per week and enteral autonomy.

Summary Background & aims Home parenteral nutrition (HPN) is provided to patients with intestinal failure (IF). HPN can however affect the patients' quality of life and ability to remain in employment. The aim of this study was to determine the effect of HPN on employment and factors associated with the likelihood of maintaining or returning to employment while on HPN. Methods Patients with chronic IF were identified from a prospectively maintained IF Unit database. A structured questionnaire was designed to probe employment both before and after starting HPN, intention to work and social welfare status (benefits & pensions). Results A total of 196 (62.8% females, median age 53 years) patients participated in the study of which 184 (94%) patients were in full or part time employment before their illness. At the time of starting HPN, 102 (52%) patients had the desire to return to work with 19 (18%) and 48 (47%) patients returning to full time or part time employment respectively. Multivariate analysis demonstrated that the frequency of the HPN infusion per week (p = 0.045) and intention to work after starting HPN (p = 0.001) were significantly associated with returning to work. Conclusions Patients on HPN can have their employment status affected. The number of days per week on HPN and the desire of the patient to return to employment are significantly associated with employment.

BACKGROUND Patients with a jejunostomy or high output stoma may need a glucose-sodium oral rehydration solution drink to maintain hydration. These solutions are unpalatable and a new flavoured pre-packaged solution was developed. METHODS After 8 h of fasting, 27 patients took 500 mL of the modified World Health Organization (WHO) cholera solution or Glucodrate® (Vitaflo) on two occasions in a cross-over random order and urine and stomal output was collected for 6 h. RESULTS There was a small but significant difference in net sodium absorption in favour of the modified WHO cholera solution (10 ± 28 mmol modified WHO cholera solution vs. -1 ± 26 mmol Glucodrate®, p = 0.01). However the Glucodrate® was more palatable, with 24 patients (89%) preferring it to the modified WHO cholera solution (p

Introduction Restorative proctocolectomy is a surgical treatment for patients with medically refractory ulcerative colitis and some cases of familial adenomatous polyposis. Intestinal failure, defined as an inability to maintain adequate hydration and micronutrient balances when on a conventionally accepted normal diet, is a rare complication of restorative proctocolectomy. We describe our experience of patients with restorative proctocolectomy who have developed intestinal failure requiring parenteral support. Material and methods This was a retrospective analysis using a database of patients referred to our intestinal failure unit from January 1998 to January 2016. We analysed the records of all those patients who had restorative proctocolectomy who developed intestinal failure. Results 807 patient records analysed, 35 patients were found to have had a restorative proctocolectomy (13 male and 22 female). Ninety-one percent (n = 32) of patients developed IF as a consequence of unpredictable complications which occurred after RPC formation. Potentially predictable complications were noted in 9% (n = 3) of patients. Discussion and conclusions Most cases of intestinal failure in restorative proctocolectomy were unpredictable. In a small number of patients, accurate assessment and measurement of the small intestine may have better predicted the adverse outcome of intestinal failure allowing improved pre-operative counseling of patients.

Summary Background & aims Patients with Type 3 Intestinal Failure (IF) who need Home Parenteral Nutrition (HPN) face several clinical, psychological and social problems. The study was designed to produce and test the first patient-centric measure for HPN (‘PNIQ: Parenteral Nutrition Impact Questionnaire’). The new measure focused on the extent to which patients were able to fulfil their human needs. Methods Questionnaire content was derived from the analysis of transcripts of interviews conducted with UK HPN patients. Cognitive debriefing interviews (CDIs) were performed to ensure patients found the draft scale clear, relevant and accessible. Finally, a test–-retest postal validation survey was conducted to reduce the number of items in the scale and to ensure that; it was unidimensional, reproducible and had construct validity. Results The 30 interview transcripts were analysed to identify issues related to a wide range of needs. Fifteen CDIs showed that patients found the draft scale easy to complete and highly relevant. The postal survey included 233 patients on HPN recruited through two IF units. Items were rejected if they did not fit the Rasch model, had too similar content to other items or displayed differential item functioning related to age, gender or underlying mechanism of IF. A 20-item unidimensional scale was identified with high internal consistency (0.91) and test–retest reliability (0.92). Scores on PNIQ correlated moderately highly with social isolation, emotional reactions and energy level and were related to perceived interference on life of HPN. The underlying cause of IF did not influence the way the scale worked. Conclusions The PNIQ is a scientifically rigorous, unidimensional outcome measure that provides a complete assessment of the effect of HPN on everyday life. It will prove useful for measuring patient value in clinical practice and for determining outcome in clinical trials, audit, economic evaluations and outcomes-based reimbursement.

Summary Introduction Home parenteral nutrition (HPN) is an expensive therapy. Restoring bowel continuity has been shown to wean patients off HPN. The aims of this study were to estimate the economic impact and QALY gained after restoring bowel continuity in adult patients with short bowel and intestinal failure due to mesenteric infarction. Method A Markov cohort model was constructed to simulate patients undergoing bowel restoration following mesenteric infarction. Probabilities associated with restoration of bowel continuity were determined using published data. Costs were estimated using the National Health Service (NHS) reference costs (2013–14). Utilities were determined from literature and opinion of experts. Results The expected QALY at 1 year following restoring bowel was 0.47. This increased to 3.29 at 5 years. The marginal cost per QALY gained calculated for the first year following restoration of bowel continuity was £95959.72 and this decreases to £10797.63 at 5 years. Conclusion Restoring bowel continuity reduces the overall costs associated with HPN and it results in increased QALY over time.

Introduction Candidiasis is associated with significant morbidity & mortality. Central venous catheters (CVC) are commonly used for home parenteral nutrition (HPN) in patients with intestinal failure (IF) & are commonly linked to development of candidaemia. We aim to describe the long-term survival in patients with candidal catheter related blood stream infections (CRBSI) in the IF population & assess factors that may be associated with poorer outcome. Methods Clinical records of patients receiving HPN at our unit were reviewed between 1/1/2007 to 1/5/2018. Candidal CRBSI was defined as either: documented or reported positive cultures from the CVC line with negative peripheral cultures, peripheral cultures with time to positivity faster than CVC cultures, paired positive cultures from CVC & peripheral blood with symptoms of sepsis, or positive CVC tip culture following CVC removal. Demographic data, underlying aetiology, small intestinal length, colonic continuity, long-term survival & cause of death were recorded. Data were also collated on number of candidal CRBSI, candidal species, bacterial co-infection, antifungal resistance together with opiate & immunosuppression use at the time of infection. Differences between groups were analysed using Chi-Squared tests, Kaplan-Meier & Cox’s regression model were used to assess factors affecting survival. Results 66 patients were identified of whom 22 (33.3%) were male. The mean age was 49.4 (SD 16.5). 13 (19.7%) patients had multiple candidal CRBSI. Candida galbrata & albicans accounted for 32 (48.5%) of the index infections. 8 (12%) patients had candidal species that were resistant to ≥1 anti-fungal agent. 48 (72.7%) patients were receiving an opiate at the time of the fungal CRBSI, & 8 (12.1%) were receiving some form of immunosuppression. 25 (38%) patients died during the study period. The 1, 5 & 10 year survival rates were 97%, 67% & 53% respectively. From the time of first fungal CRBSI, the 1, 5 & 10 year survival rates were 85%, 55% & 27%. No difference was seen in survival between patients who had single & multiple candidal infections (log-rank p=0.669). On multivariate analysis increasing age (HR 1.08 p=0.02), increasing time of HPN prior to index infection (HR 0.45 p

Spinal infections are a rare yet serious metastatic complication of bacteremia among patients with long-term central venous catheters (CVCs) for which clinicians must remain vigilant. We performed a retrospective review of all cases of spinal infection occurring in the context of a CVC for long-term parenteral nutrition (PN) managed in our department between January 2010 and October 2013, a cohort of 310 patients over this time period. Six patients were identified (mean age, 65 years; 5 male). One hundred percent of patients presented with spinal pain (5/6 cervical, 1/6 thoracic). Organisms were cultured from the CVC in 5 of 6 patients. In all cases, the white blood cell count was normal, and in 5 of 6, C-reactive protein was normal. All diagnoses were confirmed on magnetic resonance imaging (MRI), and in 3 of 6 cases, an MRI was repeated (on the advice of neurosurgical colleagues) to confirm resolution of changes after a period of antimicrobial therapy. There was no clear correlation between duration of PN or number of days following CVC insertion and onset of infection. The CVC was replaced in 4 of 6 patients at the time of diagnosis, delayed removal in 1 of 6, and salvaged in the remaining case. Although rare, a high index of suspicion is needed in patients receiving long-term PN who present with spinal pain. Peripheral inflammatory markers may not be elevated. MRI should be performed and patients should be treated with antibiotics alongside involvement of local microbiology and neurosurgical teams. Multidisciplinary discussion on CVC salvage in these cases is important, especially in cases of challenging vascular anatomy.

BackgroundHome parenteral nutrition (HPN) is a life-preserving therapy for patients with chronic intestinal failure (CIF) indicated for patients who cannot achieve their nutritional requirements by enteral intake. Intravenously administered lipid emulsions (ILEs) are an essential component of HPN, providing energy and essential fatty acids, but can become a risk factor for intestinal-failure-associated liver disease (IFALD). In HPN patients, major effort is taken in the prevention of IFALD. Novel ILEs containing a proportion of omega-3 polyunsaturated fatty acids (n-3 PUFA) could be of benefit, but the data on the use of n-3 PUFA in HPN patients are still limited.Methods/designThe HOME study is a prospective, randomized, controlled, double-blind, multicenter, international clinical trial conducted in European hospitals that treat HPN patients. A total of 160 patients (80 per group) will be randomly assigned to receive the n-3 PUFA-enriched medium/long-chain triglyceride (MCT/LCT) ILE (Lipidem/Lipoplus® 200 mg/ml, B. Braun Melsungen AG) or the MCT/LCT ILE (Lipofundin® MCT/LCT/Medialipide® 20%, B. Braun Melsungen AG) for a projected period of 8 weeks. The primary endpoint is the combined change of liver function parameters (total bilirubin, aspartate transaminase and alanine transaminase) from baseline to final visit. Secondary objectives are the further evaluation of the safety and tolerability as well as the efficacy of the ILEs.DiscussionCurrently, there are only very few randomized controlled trials (RCTs) investigating the use of ILEs in HPN, and there are very few data at all on the use of n-3 PUFAs. The working hypothesis is that n-3 PUFA-enriched ILE is safe and well-tolerated especially with regard to liver function in patients requiring HPN. The expected outcome is to provide reliable data to support this thesis thanks to a considerable number of CIF patients, consequently to broaden the present evidence on the use of ILEs in HPN.Trial registrationClinicalTrials.gov, ID:NCT03282955. Registered on 14 September 2017.

AIM This study aims to determine the prevalence of incisional hernia (IH) and enterocutaneous fistula (ECF) in patients with intestinal failure (IF) referred to a tertiary centre and to identify factors associated with their development. METHOD A retrospective case note review was undertaken of a prospectively maintained database of all patients on home parenteral nutrition between 2011 and 2016 at a UK tertiary referral centre for IF. Risk factors were identified using binary logistic regression. RESULTS The database search identified 447 patients, of whom 349 (78.1%) had surgery prior to developing IF. Eighty-one (23.2%) patients had an IH and 123 (35.2%) had an ECF at the time of referral. Of these, 51 (14.6%) had both IH and ECF. IH was associated with a high body mass index (P = 0.05), a history of a major surgical complication resulting in IF (P = 0.01), previous emergency surgery (P = 0.04), increasing number of operations (P = 0.02) and surgical site infection (SSI; P = 0.01). ECF was associated with complications relating to earlier surgery. (P ≤ .001), previous treatment with an open abdomen (P = 0.03), SSI (P = 0.001), intra-abdominal collection (P ≤ 0.001) and anastomotic leak (P = 0.02). CONCLUSION In this series, patients with IF had a prevalence of IH which was more than double that expected following elective laparotomy (about 10%) and one in three had an ECF. Risk factors for IH and ECF are discussed.

Introduction Sarcopenia is recognised in patients with intestinal failure (IF) and has been associated with poorer survival in several chronic diseases. CT can measure sarcopenia through a L3 skeletal muscle index (LSMI). We aim to evaluate the prevalence of sarcopenia in our IF population using LSMI, and evaluate the effect of home parenteral support (HPN) on LSMI and survival. Additionally, we aim to assess any association between LSMI, BMI and other anthropometric measurements. Methods IF patients on HPN treated at St Mark’s Hospital between 1/1/2006–1/10/2016 were identified from a prospectively maintained database. Patients were included if they were on HPN and had 2 CTs: the first ≤30 days before start of HPN (pre-HPN); the second ≥100 days from HPN start (post-HPN). Patient records were reviewed to obtain clinical and demographic information and date of death. Anthropometric measurements and BMI contemporaneous to CT scans were recorded. Results 64 patients met inclusion criteria (M:F 1:1). 83% of our cohort had LSMI below previously published thresholds for sarcopenia. Mean pre-HPN LSMI was 36.5±6.8 cm2/m2. Mean BMI pre-HPN was 22.1±4.8 kg/m2. Both BMI (p Conclusions This study is the first to look at sarcopenia and survival using CT defined LSMI in the IF population. 83% of our cohort had a pre-HPN LSMI below previously published thresholds, yet we found no relationship between lower baseline LSMI and survival. This may reflect the heterogeneity of the prognoses of the IF population, or that parenteral nutrition itself affects survival. Our study showed that LSMI and BMI improved following HPN but demonstrated that other anthropometric measurements had poor correlation with LSMI and showed no significant improvement overall after HPN, confirming the known problems of inter-operator and patient variability of these measurements. Whilst we found significant correlation between LSMI and BMI, BMI significantly underestimated the presence and degree of sarcopenia. We have shown LSMI can provide an objective and reproducible measure of sarcopenia in IF. Future larger studies should be performed to evaluate associations with patient outcomes and utility in clinical decision making.

Introduction The importance of presence of a nutrition support team (NST) and a nutrition steering committee (NSC) were recognised in 1994 by BAPEN with the recommendation that all major UK hospitals should appoint a NSC and at least one NST. It was recognised that delivering excellent nutritional care within hospitals required the co-ordination and oversight of a NSC. The NST’s role was to bring together a multi-disciplinary team that could support hospital staff in the provision of nutritional therapy, especially enteral and parenteral nutritional support, at a ward level. A NST should contain at least a doctor, nurse, dietician and pharmacist with specialist skills in nutritional support. NICE guidelines have also made recommendations about the provision of a NSC and NST in all acute trusts. In 2010 the NCEPOD report – A Mixed bag, reported only 60.2% of hospitals in the UK as having a NST of which only 59% had a full MDT provision. We aimed to assess the current provision of NSC’s and NST’s within the UK at this present time. Methods In June 2017 BAPEN sent a freedom of information (FOI) request to all trusts in England, health boards in Scotland and Wales and social care trusts in Northern Ireland. This requested information on the size of the trust, the presence and composition of the NST and their role within the hospital along with information about the trust’s NSC. Those responses received before 18th October were collated. Hospitals with fewer than 100 beds were excluded from the analysis. Results Of the 181 FOI requests made BAPEN received responses from 122 trusts representing 154 hospitals with more than 100 beds. 91% of trusts in the UK had a NSC and only 80% of trusts reported having a NST. Of this only 25% of social care trusts in Northern Ireland and 40% of health boards in Wales reported having an NST. 48% of trusts with an NST had a nutrition nurse, a dietician, a doctor and a pharmacist. 76% of trusts with an NST had a nutrition nurse, 79% had a pharmacist, 86% had a doctor and 88% had a dietician. 57% of NSTs performed a ward round more than once a week with 10% seeing patients as required and 4% providing an advisory role only. Conclusion There has been a clear improvement in the provision of NSC’s and NST’s within the UK over time. Sadly despite this increase in NSC’s and NST’s we have not managed to fulfil the aim of having one in each trust. Furthermore the majority do not have the full multi-disciplinary team provision required to provide the highest level of care. More work needs to be done to promote the importance of the NSC and NST and provide support in developing them in trusts that currently do not have them ensure that all trusts have access to them.

Introduction Faecal Calprotectin (FC) is a marker of neutrophil activity, and is sensitive at detecting gastrointestinal inflammation. FC levels>150 µg/g are considered to be associated with a higher risk of endoscopically active inflammatory bowel disease. Meta-analyses report that the sensitivity and specificity at predicting active Crohn’s disease (CD) using a cut off FC >50 µg/g is 83%–91% and 47%–53% respectively; for FC >150 µg/g, the sensitivity and specificity is 75% and 71% respectively. Whilst the use of FC from stoma effluent has been studied in the context of predicting allograft rejection after small bowel transplant, its use in IBD has not been assessed, even though many CD patients have stomas. The aim of this study is to assess the accuracy of FC from stoma samples. Methods Consecutive patients with a stoma and CD were identified from a prospectively maintained clinical database. The FC from stoma effluent was categorised as: FC 150 µg/g. This was correlated to endoscopic and/or radiologic findings within 3 months of the FC result. An endoscopy was considered abnormal if the Simple Endoscopic Score for Crohn’s Disease (SES-CD) was ≥2 as rated by 2 blinded observers on the basis of the endoscopy report/pictures. An MRI or CT was considered abnormal if any evidence of active inflammation was reported. Results 47 FC results were analysed from 29 CD patients with a stoma (M:F 12:15). 16/29 patients had intestinal failure. 25 samples were from an ileostomy, 18 from a jejunostomy and 4 from a colostomy. 18 patients had one sample, 5 had 2 samples, 3 had 3 samples and 2 patients had 4 samples assessed. The median time between FC and imaging was 40 days (range 2–95); and between FC and endoscopy was 56 days (range 6–91). 29 patients had a CT or MRI, 9 had an endoscopy and 9 had both. Of the 4 colostomy samples: 3 had FC of The sensitivity at FC cut off of 50 µg/g and 150 µg/g was 80% and 73% respectively. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for three FC cut offs are shown in table 1. Conclusion We report that stoma FC has a sensitivity and specificity which is similar to stool FC at all three cut offs. These results suggest that FC is a useful adjunct to clinical assessment and investigations, and a prospective trial in which there is a shorter interval between FC and the diagnostic test is required.

Patients who have a bowel resection for mesenteric infarction may require parenteral nutrition (PN). This study primarily aimed to determine the aetiological factors for a mesenteric infarction and the effects of restoring bowel continuity on the long-term PN requirements.A retrospective review of data on patients treated for mesenteric infarction from 2000 to 2010.A total of 113 patients (61 women, median age 54 years) were identified. Seventy-four (65%) had a superior mesenteric artery thromboembolism, 25 (22%) had a superior mesenteric vein thrombosis, and 4 (3%) had superior mesenteric artery stricture or spasm. Patients younger than 60 years most commonly had a clotting abnormality (n = 23/46, 50%), whereas older patients had a cardiological risk factor (n = 11/17, 65%). All patients with a jejunostomy required long-term PN. Fifty-seven (49%) patients had restoration of bowel continuity (colon brought into circuit). After this, PN was stopped within 1 year in 20 (35%), within 2 years in 29 (50%) patients and within 5 years in 44 (77%) patients (P = 0.001).A thrombotic tendency is the main etiological factor in most patients younger than 60 years. An anastomosis of the remaining jejunum to the colon can allow PN to be stopped.

Aim The primary aim of this study was to determine whether the in-hospital mortality for acute mesenteric infarction has reduced in the last decade. The secondary aim was to determine if there was a statistical difference in mortality between patients having acute primary mesenteric infarction due to different causes. Method A literature search was performed of PubMed, Ovid (Embase) and Google Scholar databases. Studies on acute mesenteric infarction of primary vascular pathology were included for pooled analyses while studies that had reported comparative mortality between arterial, venous and non-occlusive mesenteric infarction (NOMI) were included in meta-analyses. Their quality was assessed using the National Institute for Health and Care Excellence assessment scale. Odds ratios (ORs) of mortality were calculated using a Mantel−Haenszel random effect model. Results The total number of patients was 4527 and the male/female ratio was 1912/2247. The pooled in-hospital mortality was 63%. There was no significant reduction of in-hospital mortality rate in the last decade (P = 0.78). There was a significant difference in in-hospital mortality between acute arterial mesenteric infarction (73.9%) compared with acute venous mesenteric infarction (41.7%) [OR 3.47, confidence interval (CI) 2.43−4.96, P

We investigated the relationship between preoperative comorbidity and postoperative survival after intestinal transplantation. Each patient received a score for preoperative comorbidity. Each comorbidity was given a score based on the degree it impaired function (score range 0-3). A total score was derived from the summation of individual comorbidity scores. Patients (72 adults (M : F, 33 : 39)) received an isolated intestinal graft (27) or a cluster graft (45). Mean (standard deviation) survival was 1501 (1444) days. The Kaplan-Meier analysis revealed a significant inverse association between survival and comorbidity score (logrank test for trend, P < 0.0001). Patients grouped into comorbidity scores of 0 and 1, 2 and 3, 4 and 5, 6, and above had hazard ratios (95% confidence intervals) for death (compared to group 0 + 1), which increased with comorbidity scores: 1.945 (0.7622-5.816), 5.075 (3.314-36.17), and 13.77 (463.3-120100), respectively, (P < 0.0001). Receiver-operator curves at 1, 3, 5, and 10 years postoperative had "C" statistics of 0.88, 0.85, 0.88, and 0.92, respectively. When evaluating patients for transplantation, the degree of comorbidity should be considered as a major factor influencing postoperative survival.

Background & Aims: Clinical studies showed teduglutide to increase urine production and reduce need for parenteral support volume in patients with short bowel syndrome (SBS) with intestinal failure, increasing intestinal wet weight absorption and reducing diarrhea. However, the effects of teduglutide on parenteral support vary among patients. We performed a post hoc analysis of a phase III placebo-controlled study to identify characteristics of patients in whom teduglutide has the largest effects on parenteral support volume response. Methods: We collected data from 85 patients with SBS with intestinal failure, according to the European Society for Clinical Nutrition and Metabolism classification system, who received teduglutide or placebo between November 25, 2008, and January 4, 2011, at 27 sites in 10 countries. Changes in parenteral support volume were evaluated according to baseline parenteral support volume, bowel anatomy (group 1, jejunostomy/ileostomy; group 2, ≥50% colon-in-continuity without stoma; and group 3, other colon anatomies), and disease features (with inflammatory bowel disease, mesenteric vascular diseases, or other conditions). Correlation analyses were conducted using simple linear regression models, with unadjusted r2 values reported. Two-sided t tests were used for comparisons between treatment groups. Results: We correlated parenteral support volume reduction with teduglutide treatment and baseline parenteral support volume (y = –0.3870x + 90.0279, r2 = 0.61; P

Introduction Standard management of type 3 intestinal failure (IF) is long-term parenteral support (PS). While it is clear that PS is lifesaving treatment for IF, it carries significant morbidity and mortality, both dependent and independent of the underlying aetiology of the IF. We report the largest single-centre series assessing the long-term survival of adult patients on all forms of home PS (parenteral nutrition and parenteral fluids) for type 3 IF. Method Clinical records of 978 adult patients receiving home parenteral support for IF at our tertiary referral centre were analysed from January 1979 until October 2016. Demographic data, underlying aetiology, intestinal length, colonic continuity, complication rates and survival was recorded. Differences between groups were analysed by chi-squared tests. Kaplan-Meier and Cox’s regression models were used to assess factors affecting survival. Results Overall probability of survival for all patients on PS was 86%, 63%, 52%, 43%, 31%, 24% at 1, 5,10, 15, 20 and 30 years respectively. When active malignancy is excluded as a cause of IF, survival rates were 90%, 66%, 55%, 45%, 33% and 25% (graph 1). There is a significant difference in survival dependent on underlying IF aetiology. The worst 1 year survival of 62% was seen for malignancy and the best with pseudo-obstruction (excluding scleroderma) at 93%. Multivariate analysis demonstrated a significant relationship between survival and the following factors; age at start of PS; HR 1.03 (p Conclusion Our data have shown that several factors are associated with long-term survival. A better prognosis was associated with an earlier age of onset of type 3 IF and the presence of colonic continuity, while a worse prognosis was associated with underlying aetiologies such as malignancy and radiation enteritis. To our knowledge, this is the largest single-centre case series looking at survival in type-3 IF to date and adds to our current understanding of the long-term outcomes in type 3 IF. Disclosure of Interest None Declared

Introduction Intestinal failure (IF) occurs when there is reduced intestinal absorption causing malnutrition and/or dehydration. The management of this condition has changed since the very first patients were started on long-term parenteral support in the form of parenteral nutrition in the 1960s. At our unit our first patient was started on long-term parenteral support in the 1970’s. We now care for the largest number of HPN patients in the UK. We describe changes in aetiology as seen in our unit over the last 36 years. Method Clinical records of 974 adult patients receiving home parenteral support for IF at our tertiary referral centre were analysed from a period from January 1979 until October 2016. Demographic data including age, sex, underlying aetiology, complication rates and survival was recorded. Difference between groups were analysed by with chi-squared tests, and the Cox’s regression model was used to assess survival. Results The mean age of patients treated at our unit has increased from 31±16.5 to 52±17.6 years from pre 1989 to 2010–2016. During the same period there has been a change in the underlying aetiology, with a greater percentage of patients with IF due to surgical complications (3.4% to 28.8%% (p Conclusion At our institution there has been a significant change in the underlying aetiology and demographics of patients with IF. The age of initiation of home parenteral support is increasing, and there has been a reduction in the proportion of patients with IBD as the underlying cause of IF with an increase in surgical complications and malignancy. Our data also shows that there has been a reduction in the rates of complications related to IF including catheter related blood stream infection rates and rates of central venous thrombosis. Notably survival outcomes were significantly better in the period pre 1995, which is likely explained by the fact that we now are treating older patients with complex underlying conditions associated with poorer outcomes. Disclosure of Interest None Declared

Background: Tumour necrosis factor alpha (TNF-α) is a cytokine elevated in inflammatory bowel disease enterocutaneous fistula (IBD ECF). Dendritic cells are antigen presenting cells that orchestrate the immune responses and regulate the production of cytokines by immune cells including T cells. No study to date has assessed the level of TNF-α or the presence of dendritic cells in non-IBD ECF. The aim of this study was to assess the inflammatory activity, with a particular emphasis on TNF-α in non-IBD ECF when compared with control small bowel tissue. Methods: Tissue biopsies were obtained from ECF at operation from non-IBD patients and from terminal ileum in normal colonoscopy control patients. After overnight culture, accumulation of intracellular TNF-α was measured by flow cytometry in cells treated with monensin to assess the on-going cytokine production. Data were acquired using FACS Canto II. Unpaired Student's t-test was used to compare variables between groups and p < 0.05 was regarded as significant. Results: The on-going production of TNF-α from dendritic cells (p = 0.0007), putative monocyte and B cell populations (p = 0.04) and CD3+ T cells (p = 0.04) was significantly higher in non-IBD ECF tissue than that from control tissue. Conclusions: This study reveals results which provide evidence for the potential use of anti-TNF-α agents in the treatment of non-IBD ECF. A pilot study to evaluate this treatment as an alternative option in an already surgically challenging group of patients is planned. Positive findings would be a major medical advance with a new use for anti-TNF-α agents.

Purpose of review To examine the most recent literature on the clinical trials associated with the relevant growth factors that have been of interest in the treatment of short bowel. Recent findings Short bowel is a rare but devastating condition that condemns patients to lifelong parenteral support. Historically, treatment options negating the need for parenteral support were limited. Therapeutic growth factor use is of interest, but the clinical trial data are inconclusive. The STEPS-2 trial was the first trial that showed a sustained positive effect of the growth factor glucagon-like peptide-2 (GLP-2). This led to a phase shift in the management of short bowel, with the US Food and Drug Administration approval of the GLP-2 analogue teduglutide in 2012. This review summarizes all the relevant clinical trials of growth factors in the treatment of short bowel. Summary GLP-2 has shown that growth factors can revolutionize the treatment of short bowel. Data however are lacking with regards to the solitary use of other factors. This review highlights the need for further work using the factors in combination as well as considering their use in novel methods for example in the field of regenerative medicine.

Intestinal transplantation (IT) is considered for patients with irreversible intestinal failure who develop life-threatening complications of parenteral nutrition or have extensive intra-abdominal disease requiring evisceration. Developing indications may include quality of life (QOL) considerations and therefore assessment of QOL and performance status (PS) after IT is important. We report QOL and PS before and after IT in our cohort.Consecutive patients undergoing IT were included. QOL was assessed using the generic 36-item short form survey (SF 36) tool at assessment and 6-month intervals post-transplantation. Performance was assessed using a visual analogue scale (VAS), Karnofsky scale (KS), and the Eastern Cooperative Oncology Group scale at three time points: premorbidly, at listing, and after transplantation.Data were available for 21 patients. There were 11 complete SF 36 datasets and 15 performance scores. Data were not available from 3 patients, and the overall response rate was 62%. Overall, there was a trend for improved SF 36 scores post-transplantation in approximately half of the patients with scores remaining stable in approximately one third. The results of the SF 36 significantly improved in 1 patient (P .01). After IT, 66% of patients had better VAS scores than at listing and75% of patients scored better or the same in KS compared to status at listing. However, PS after IT did not improve to premorbid levels.We found a trend for QOL scores to improve in approximately half of the patients compared to their status at listing, remain static in approximately one third, and a minority experience a decline. For the majority, differences were not statistically significant. PS of patients after transplantation is equal or better than that at listing in 75%, but rarely reaches that of the premorbid status. Longer-term studies are needed and may reveal progressive improvement.

The first intestinal transplantation in the United Kingdom was performed in Cambridge in 1991. Thirty-eight intestinal transplantations have since been performed in 35 patients. All deaths in the first postoperative month related to hemorrhage, in 2 cases to severe portal hypertension (SPH) and poor venous access in 2. We have modified our practice to reduce the bleeding risk with SPH. Loss of venous access can be avoided by timely referral. Rejection was implicated in 3/14 deaths all dying of sepsis. Cytomegalovirus disease resulted in 2 deaths; we try to avoid CMV-positive donors giving to CMV-negative recipients. Three deaths were related to psychiatric illness, which led to loss of graft in 2 others. Three patients were retransplanted (2 rejections and 1 infarction) and all remain alive. Most patients (10/13) experienced a fall in body weight in the first postoperative year after SB/MV transplantation. Body weight fell by as much as 25%. As transplantation resulted in a net gain in small bowel in most cases, the postoperative loss of native body weight may be underestimated. Interestingly this was not associated with a significant fall in midarm circumference or handgrip strength. Long-term nutrition can be maintained with oral intake in the majority of patients post-SBT. There is improvement in handgrip strength post-transplant. Transplantation does not significantly alter weight, albumin, or other common anthropometric markers. Despite these problems, our 5-year survival results remain relatively good at 73% in the cohort from 1991, 79% from 2003, and 80% from 2008. We consider that deployment of strategies learned from our experiences has improved outcomes.

The aim of this study was to decellularize a 30 cm long segment of porcine small intestine, determine its in vivo behaviour and assess the type of immunological reaction it induces in a quantitative manner. A segment of porcine ileum up to 30 cm long, together with its attached vasculature, was decellularized via its mesenteric arcade as a single entity. The quality of the acellular scaffold was assessed histologically and using molecular tools. The host response to the scaffold was evaluated in a rodent model. Stereological techniques were incorporated into quantitative analysis of the phenotype of the macrophages infiltrating the scaffold in vivo. Lengths of ileal scaffold, together with its attached vasculature, were successfully decellularized, with no evidence of intact cells and DNA or collagen and GAGs overdegradation. Analysis of explants harvested over 2 months postimplantation revealed full-thickness recellularization and no signs of foreign body or immune reactions. Macrophage profiling proved that between weeks 4 and 8 in vivo there was a switch from an M1 (pro-inflammatory) to an M2 (pro-remodelling) type of response. We show here that the decellularization process results in a biocompatible and non-toxic matrix that upon implantation triggers cellular infiltration and angiogenesis, primarily characterized by a pro-remodelling type of mononuclear response, without inducing foreign body reaction or fibrosis. Copyright © 2013 John Wiley & Sons, Ltd.

Background and Aim Intestinal failure (IF) is a rare but devastating complication of Crohn's disease (CD). The clinical and surgical factors that predispose to IF are poorly understood. The aim of this study was to define clinical factors that predispose to IF. Methods A retrospective case–control study was performed using consecutive CD patients with IF who were identified from a prospective database. Local population-based controls were selected with which to compare demographic, phenotypic, and clinical outcomes. Results Eighty-two CD patients requiring long-term intravenous fluids or nutrition were studied. Diagnosis at age 16 years or less (P = 0.01) and a family history of inflammatory bowel disease (P = 0.02) were associated with a significantly higher risk for developing IF. Among the IF group, 53% had perioperative complications from intestinal resections contributing to long-term IF. Furthermore, these patients had more abdominal surgeries (P = 0.05) and stricturing disease was less common than in patients with primary active CD (P = 0.01). IF due to primary active CD was associated with penetrating behavior (P = 0.02) and early age at first surgery (P = 0.004). The need for intravenous nutrition as opposed to intravenous fluids correlated inversely with small intestine length (P

Biologically derived scaffolds are becoming viable treatment options for tissue/organ repair and regeneration. A continuing hurdle is the need for a functional blood supply to and from the implanted scaffold. We have addressed this problem by constructing an acellular ileal scaffold with an attached vascular network suitable for implantation and immediate reperfusion with the host's blood. Using a vascular perfusion approach, a segment of porcine ileum up to 30 cm long, together with its attached vasculature, was decellularized as a single entity. The quality of the decellularized scaffold was assessed histologically and using molecular tools. To establish vascular perfusion potentials of the scaffold, a right-sided nephrectomy and end-to-end anastomosis of the decellularized scaffold's vasculature to a renal artery and vein were performed in a pig of similar size to the donor animal. Lengths of ileal scaffold, together with its attached vasculature, were successfully decellularized, with no evidence of intact cells/nuclear material or collagen degradation. The scaffold's decellularized vascular network demonstrated optimum perfusion at 1, 2 and 24 h post-implantation and the mesenteric arcade remained patent throughout the assessment. The 1, 2 and 24 h explanted scaffolds demonstrated signs of cellular attachment, with cells positive for CD68 and CD133 on the vascular luminal aspect. It is possible to decellularize clinically relevant lengths of small intestine, together with the associated vasculature, as a single segment. The functional vascular network may represent a route for recellularization for future regeneration of bowel tissue for patients with short bowel syndrome. Copyright © 2013 John Wiley & Sons, Ltd.

SummaryBackground Anti-tumour necrosis factor (TNF)s form a major part of therapy in Crohn's disease and have a primary nonresponse rate of 10%-30% and a secondary loss of response rate of 5% per year. Myopenia is prevalent in Crohn's disease and is measured using body composition analysis tools. Aim To test the hypothesis that body composition can predict outcomes of anti-TNF primary nonresponse and secondary loss of response. Methods Between January 2007 and June 2012, 106 anti-TNF naive patients underwent anti-TNF therapy for Crohn's disease with body composition parameters analysed using CT scans to estimate body fat-free mass. The outcome measures were primary nonresponse and secondary loss of response. COX-regression analysis was used with 3 year follow-up data. Results A total of 106 patients were included for analysis with 26 (24.5%) primary nonresponders and 29 (27.4%) with secondary loss of response to anti-TNF therapy. Sex-specific cut-offs for muscle and fat were ascertained by stratification analysis. On univariate analysis, primary nonresponse was associated with low albumin (OR 0.94; 0.88-0.99, P = .04) and presence of myopenia (OR 4.69; 1.83-12.01, P = .001) when taking into account patient's medical therapy, severity of disease and body composition. On multivariate analysis, presence of myopenia was associated with primary nonresponse (OR 2.93; 1.28-6.71, P = .01). Immunomodulator therapy was associated with decreased secondary loss of response (OR 0.48; 0.23-0.98, P = .04). BMI was poorly correlated with lean body mass (r2 = 0.15, P = .54). Conclusions In this cohort study, body composition profiles did not correlate well with BMI. Myopenia was associated with primary nonresponse with potential implications for dosing and serves as an explanation for pharmacokinetic failure.

BACKGROUND: In phase III clinical studies, treatment with teduglutide was associated with clinically meaningful reductions (≥20% from baseline) in parenteral support (PS; parenteral nutrition and/or intravenous fluids) requirements in adult patients with intestinal failure associated with short bowel syndrome (SBS-IF). This analysis reports clinical characteristics of patients who achieved complete independence from PS during teduglutide treatment.MATERIALS AND METHODS: Post hoc analysis of adult patients who achieved complete PS independence during treatment with teduglutide 0.05 mg/kg/d. Data were pooled from 5 teduglutide clinical trials (2 phase III placebo-controlled trials [NCT00081458 and NCT00798967] and their respective extension studies [NCT00172185, NCT00930644, NCT01560403]). Descriptive statistics were used; no between-group comparisons were performed because of the small sample size and lack of comparator.RESULTS: Of 134 patients, 16 gained oral or enteral autonomy after a median of 5 years of PS dependence and 89 weeks of teduglutide treatment. Demographic and baseline disease characteristics varied among patients (median age, 55 years; 50% men; median baseline PS volume, 5.1 L/wk; median residual small intestine length, 52.5 cm). Most patients who achieved PS independence had colon-in-continuity; however, there was no significant difference in the frequency of PS independence among patients who maintained colon-in-continuity vs those who did not.CONCLUSION: Findings from this post hoc analysis suggest that oral or enteral autonomy is possible for some patients with SBS-IF who are treated with teduglutide, regardless of baseline characteristics and despite long-term PS dependence.