Nutrition in necrotizing enterocolitis and following intestinal resection

This review aims to discuss the role of nutrition and feeding practices in necrotizing enterocolitis (NEC), NEC prevention, and its complications, including surgical treatment. A thorough PubMed search was performed with a focus on meta-analyses and randomized controlled trials when available. There are several variables in nutrition and the feeding of preterm infants with the intention of preventing necrotizing enterocolitis (NEC). Starting feeds later rather than earlier, advancing feeds slowly and continuous feeds have not been shown to prevent NEC and breast milk remains the only effective prevention strategy. The lack of medical treatment options for NEC often leads to disease progression requiring surgical resection. Following resection, intestinal adaptation occurs, during which villi lengthen and crypts deepen to increase the functional capacity of remaining bowel. The effect of macronutrients on intestinal adaptation has been extensively studied in animal models. Clinically, the length and portion of intestine that is resected may lead to patients requiring parenteral nutrition, which is also reviewed here. There remain significant gaps in knowledge surrounding many of the nutritional aspects of NEC and more research is needed to determine optimal feeding approaches to prevent NEC, particularly in infants younger than 28 weeks and \u3c1000 grams. Additional research is also needed to identify biomarkers reflecting intestinal recovery following NEC diagnosis individualize when feedings should be safely resumed for each patient

Epithelial cell specific Raptor is required for initiation of type 2 mucosal immunity in small intestine

AbstractIntestinal tuft cells are one of 4 secretory cell linages in the small intestine and the source of IL-25, a critical initiator of the type 2 immune response to parasite infection. When Raptor, a critical scaffold protein for mammalian target of rapamycin complex 1 (mTORC1), was acutely deleted in intestinal epithelium via Tamoxifen injection in Tritrichomonas muris (Tm) infected mice, tuft cells, IL-25 in epithelium and IL-13 in the mesenchyme were significantly reduced, but Tm burden was not affected. When Tm infected mice were treated with rapamycin, DCLK1 and IL-25 expression in enterocytes and IL-13 expression in mesenchyme were diminished. After massive small bowel resection, tuft cells and Tm were diminished due to the diet used postoperatively. The elimination of Tm and subsequent re-infection of mice with Tm led to type 2 immune response only in WT, but Tm colonization in both WT and Raptor deficient mice. When intestinal organoids were stimulated with IL-4, tuft cells and IL-25 were induced in both WT and Raptor deficient organoids. In summary, our study reveals that enterocyte specific Raptor is required for initiating a type 2 immune response which appears to function through the regulation of mTORC1 activity.</jats:p

Double-illumination photoacoustic microscopy of intestinal hemodynamics following massive small bowel resection

Massive small bowel resection (SBR) results in villus angiogenesis and intestinal adaptation. The exact mechanism that causes intestinal villus angiogenesis remains unknown. We hypothesize that hemodynamic changes within the remnant bowel after SBR will trigger intestinal angiogenesis. To validate this, we used photoacoustic microscopy (PAM) to image the microvascular system of the intestine in C57B6 mice and to measure blood flow and oxygen saturation (sO_2) of a supplying artery and vein. Baseline measurements were made 6 cm proximal to the ileal-cecal junction (ICJ) prior to resection. A 50% proximal bowel resection was then performed, and measurements were again recorded at the same location immediately, 1, 3 and 7 days following resection. The results show that arterial and venous sO_2 were similar prior to SBR. Immediately following SBR, the arterial and venous sO_2 decreased by 14.3 ± 2.7% and 32.7 ± 6.6%, respectively, while the arterial and venous flow speed decreased by 62.9 ± 17.3% and 60.0 ± 20.1%, respectively. Such significant decreases in sO_2 and blood flow indicate a hypoxic state after SBR. Within one week after SBR, both sO2 and blood flow speed had gradually recovered. By 7 days after SBR, arterial and venous sO_2 had increased to 101.0 ± 2.9% and 82.7 ± 7.3% of the baseline values, respectively, while arterial and venous flow speed had increased to 106.0 ± 21.4% and 150.0 ± 29.6% of the baseline values, respectively. Such increases in sO_2 and blood flow may result from angiogenesis following SBR

Double-illumination photoacoustic microscopy

Recent developments of optical-resolution photoacoustic microscopy (OR-PAM) have improved its spatial resolution and imaging speed. However, the penetration depth of OR-PAM is still limited to ∼1  mm in tissue, owing to the strong tissue scattering. Here, we have developed double-illumination PAM (DI-PAM), which illuminates the sample from both top and bottom sides simultaneously. Through phantom and in vivo experiments, we have demonstrated for thin targets that DI-PAM has a penetration depth of ∼2  mm in tissue at 532 nm and a focal zone of 260 μm, both significant improvements over traditional reflection or transmission-mode OR-PAM

Immediate alterations in intestinal oxygen saturation and blood flow after massive small bowel resection as measured by photoacoustic microscopy

Purpose: Massive small bowel resection (SBR) results in villus angiogenesis and a critical adaptation response within the remnant bowel. Previous ex vivo studies of intestinal blood flow after SBR are conflicting. We sought to determine the effect of SBR on intestinal hemodynamics using photoacoustic microscopy, a noninvasive, label-free, high-resolution in vivo hybrid imaging modality. Methods: Photoacoustic microscopy was used to image the intestine microvascular system and measure blood flow and oxygen saturation (SO_2) of the terminal mesenteric arteriole and accompanying vein in C57BL6 mice (n = 7) before and immediately after a 50% proximal SBR. A P value of less than .05 was considered significant. Results: Before SBR, arterial and venous SO_2 were similar. Immediately after SBR, the venous SO_2 decreased with an increase in the oxygen extraction fraction. In addition, the arterial and venous blood flow significantly decreased. Conclusion: Massive SBR results in an immediate reduction in intestinal blood flow and increase in tissue oxygen utilization. These physiologic changes are observed throughout the remnant small intestine. The contribution of these early hemodynamic alterations may contribute to the induction of villus angiogenesis and the pathogenesis of normal intestinal adaptation responses

Up-regulation of hypoxia-inducible factor 1 alpha and hemodynamic responses following massive small bowel resection

Purpose: Massive small bowel resection (SBR) results in an adaptive response within the remnant bowel. We have previously shown an immediate reduction in intestinal blood flow and oxygen saturation (sO_2) after SBR. We therefore sought to determine the duration of resection-induced intestinal hypoxia and expression of hypoxia-inducible factors (HIFs) following SBR. Methods: C57B6 mice were subjected to 50% proximal SBR or a sham procedure. Photoacoustic microscopy (PAM) was used to measure blood flow and sO_2 on postoperative days (PODs) 1, 3, and 7. Ileal tissue was harvested 6 h postoperatively and on PODs 1 and 2, and HIF1α, HIF2α, and VEGF mRNA expression were assessed via RT-PCR. A p value of less than 0.05 was considered significant. Results: Following SBR, reduction in intestinal blood flow persists for 24 h and is followed with hyperemia by POD 3. The immediate reduction in venous sO_2 and increased tissue oxygen utilization continued through POD 7. Enhanced expression of HIF1α was demonstrated 6 h following SBR. Conclusion: Massive SBR results in an immediate relative hypoxic state within the remnant bowel with early enhanced expression of HIF1α. On POD 7, increased tissue oxygen extraction and elevated blood flow persist in the adapting intestine

Transgenic soybean production of bioactive human epidermal growth factor (EGF)

Necrotizing enterocolitis (NEC) is a devastating condition of premature infants that results from the gut microbiome invading immature intestinal tissues. This results in a life-threatening disease that is frequently treated with the surgical removal of diseased and dead tissues. Epidermal growth factor (EGF), typically found in bodily fluids, such as amniotic fluid, salvia and mother's breast milk, is an intestinotrophic growth factor and may reduce the onset of NEC in premature infants. We have produced human EGF in soybean seeds to levels biologically relevant and demonstrated its comparable activity to commercially available EGF. Transgenic soybean seeds expressing a seed-specific codon optimized gene encoding of the human EGF protein with an added ER signal tag at the N' terminal were produced. Seven independent lines were grown to homozygous and found to accumulate a range of 6.7 +/- 3.1 to 129.0 +/- 36.7 μg EGF/g of dry soybean seed. Proteomic and immunoblot analysis indicates that the inserted EGF is the same as the human EGF protein. Phosphorylation and immunohistochemical assays on the EGF receptor in HeLa cells indicate the EGF protein produced in soybean seed is bioactive and comparable to commercially available human EGF. This work demonstrates the feasibility of using soybean seeds as a biofactory to produce therapeutic agents in a soymilk delivery platform

Lipid absorption and overall intestinal lymphatic transport are impaired following partial small bowel resection in mice

Short bowel syndrome (SBS) is associated with diminished levels of serum fats caused by unknown mechanisms. We have shown that mesenteric lymphatics remodel to a more primitive state one week after small bowel resection (SBR); therefore, this study focuses on the effect of chronic lymphatic remodeling and magnitude of resection on intestinal lipid uptake and transport. C57BL6 and Prox1 creER-Rosa2

Double-illumination photoacoustic microscopy of intestinal hemodynamics following massive small bowel resection

Massive small bowel resection (SBR) results in villus angiogenesis and intestinal adaptation. The exact mechanism that causes intestinal villus angiogenesis remains unknown. We hypothesize that hemodynamic changes within the remnant bowel after SBR will trigger intestinal angiogenesis. To validate this, we used photoacoustic microscopy (PAM) to image the microvascular system of the intestine in C57B6 mice and to measure blood flow and oxygen saturation (sO_2) of a supplying artery and vein. Baseline measurements were made 6 cm proximal to the ileal-cecal junction (ICJ) prior to resection. A 50% proximal bowel resection was then performed, and measurements were again recorded at the same location immediately, 1, 3 and 7 days following resection. The results show that arterial and venous sO_2 were similar prior to SBR. Immediately following SBR, the arterial and venous sO_2 decreased by 14.3 ± 2.7% and 32.7 ± 6.6%, respectively, while the arterial and venous flow speed decreased by 62.9 ± 17.3% and 60.0 ± 20.1%, respectively. Such significant decreases in sO_2 and blood flow indicate a hypoxic state after SBR. Within one week after SBR, both sO2 and blood flow speed had gradually recovered. By 7 days after SBR, arterial and venous sO_2 had increased to 101.0 ± 2.9% and 82.7 ± 7.3% of the baseline values, respectively, while arterial and venous flow speed had increased to 106.0 ± 21.4% and 150.0 ± 29.6% of the baseline values, respectively. Such increases in sO_2 and blood flow may result from angiogenesis following SBR