Malnutrition, nutritional interventions and clinical outcomes of patients with acute small bowel obstruction : results from a national, multicentre, prospective audit

Objective: The aim of this study was to assess the nutritional status of patients presenting with small bowel obstruction (SBO), along with associated nutritional interventions and clinical outcomes. Design: Prospective cohort study. Setting: 131 UK hospitals with acute surgical services. Participants: 2069 adult patients with a diagnosis of SBO were included in this study. The mean age was 67.0 years and 54.7% were female. Primary and secondary outcome measures: Primary outcome was in-hospital mortality. Secondary outcomes recorded included: major complications (composite of in-hospital mortality, reoperation, unplanned intensive care admission and 30-day readmission), complications arising from surgery (anastomotic leak, wound dehiscence), infection (pneumonia, surgical site infection, intra-abdominal infection, urinary tract infection, venous catheter infection), cardiac complications, venous thromboembolism and delirium. Results: Postoperative adhesions were the most common cause of SBO (49.1%). Early surgery (<24 hours postadmission) took place in 30.0% of patients, 22.0% underwent delayed operation and 47.9% were managed non-operatively. Malnutrition as stratified by Nutritional Risk Index was common, with 35.7% at moderate risk and 5.7% at severe risk of malnutrition. Dietitian review occurred in just 36.4% and 55.9% of the moderate and severe risk groups. In the low risk group, 30.3% received nutritional intervention compared with 40.7% in moderate risk group and 62.7% in severe risk group. In comparison to the low risk group, patients who were at severe or moderate risk of malnutrition had 4.2 and 2.4 times higher unadjusted risk of in-hospital mortality, respectively. Propensity-matched analysis found no difference in outcomes based on use or timing of parenteral nutrition. Conclusions: Malnutrition on admission is associated with worse outcomes in patients with SBO, and marked variation in management of malnutrition was observed. Future trials should focus on identifying effective and cost-effective nutritional interventions in SBO

Chemokine (C-C Motif) Receptor 2 Mediates Dendritic Cell Recruitment to the Human Colon but Is Not Responsible for Differences Observed in Dendritic Cell Subsets, Phenotype, and Function Between the Proximal and Distal Colon.

BACKGROUND & AIMS: Most knowledge about gastrointestinal (GI)-tract dendritic cells (DC) relies on murine studies where CD103+ DC specialize in generating immune tolerance with the functionality of CD11b+/- subsets being unclear. Information about human GI-DC is scarce, especially regarding regional specifications. Here, we characterized human DC properties throughout the human colon. METHODS: Paired proximal (right/ascending) and distal (left/descending) human colonic biopsies from 95 healthy subjects were taken; DC were assessed by flow cytometry and microbiota composition assessed by 16S rRNA gene sequencing. RESULTS: Colonic DC identified were myeloid (mDC, CD11c+CD123-) and further divided based on CD103 and SIRPα (human analog of murine CD11b) expression. CD103-SIRPα+ DC were the major population and with CD103+SIRPα+ DC were CD1c+ILT3+CCR2+ (although CCR2 was not expressed on all CD103+SIRPα+ DC). CD103+SIRPα- DC constituted a minor subset that were CD141+ILT3-CCR2-. Proximal colon samples had higher total DC counts and fewer CD103+SIRPα+ cells. Proximal colon DC were more mature than distal DC with higher stimulatory capacity for CD4+CD45RA+ T-cells. However, DC and DC-invoked T-cell expression of mucosal homing markers (β7, CCR9) was lower for proximal DC. CCR2 was expressed on circulating CD1c+, but not CD141+ mDC, and mediated DC recruitment by colonic culture supernatants in transwell assays. Proximal colon DC produced higher levels of cytokines. Mucosal microbiota profiling showed a lower microbiota load in the proximal colon, but with no differences in microbiota composition between compartments. CONCLUSIONS: Proximal colonic DC subsets differ from those in distal colon and are more mature. Targeted immunotherapy using DC in T-cell mediated GI tract inflammation may therefore need to reflect this immune compartmentalization

National prospective cohort study of the burden of acute small bowel obstruction

Background Small bowel obstruction is a common surgical emergency, and is associated with high levels of morbidity and mortality across the world. The literature provides little information on the conservatively managed group. The aim of this study was to describe the burden of small bowel obstruction in the UK. Methods This prospective cohort study was conducted in 131 acute hospitals in the UK between January and April 2017, delivered by trainee research collaboratives. Adult patients with a diagnosis of mechanical small bowel obstruction were included. The primary outcome was in‐hospital mortality. Secondary outcomes included complications, unplanned intensive care admission and readmission within 30 days of discharge. Practice measures, including use of radiological investigations, water soluble contrast, operative and nutritional interventions, were collected. Results Of 2341 patients identified, 693 (29·6 per cent) underwent immediate surgery (within 24 h of admission), 500 (21·4 per cent) had delayed surgery after initial conservative management, and 1148 (49·0 per cent) were managed non‐operatively. The mortality rate was 6·6 per cent (6·4 per cent for non‐operative management, 6·8 per cent for immediate surgery, 6·8 per cent for delayed surgery; P = 0·911). The major complication rate was 14·4 per cent overall, affecting 19·0 per cent in the immediate surgery, 23·6 per cent in the delayed surgery and 7·7 per cent in the non‐operative management groups (P < 0·001). Cox regression found hernia or malignant aetiology and malnutrition to be associated with higher rates of death. Malignant aetiology, operative intervention, acute kidney injury and malnutrition were associated with increased risk of major complication. Conclusion Small bowel obstruction represents a significant healthcare burden. Patient‐level factors such as timing of surgery, acute kidney injury and nutritional status are factors that might be modified to improve outcomes

Postoperative Crohn's Disease: an examination of local immunologic and microbiological factors influencing disease recurrence

After ileo-caecal resection for Crohn’s disease, postoperative Crohn’s disease (POCD) recurrence rates are high and focused on the ileum. High recurrence rates, responsiveness to antibiotics and the predilection for recurrence to favour the ileum are incompletely understood. Dendritic cells (DC) are well characterised in inflammatory bowel disease and health for their roles in tolerance and inflammatory responses, but studies have focused heavily on colonic DC. Hence DC data comparing ileum and colon in controls, as well as POCD is sparse. We hypothesised that the DC profiles in small and large intestine differ and in POCD this may predispose recurrence to favour the ileum. Myeloid and plasmacytoid DC lineages in small and large intestine of healthy control subjects as POCD were examined. Plasmacytoid DC in POCD expressed less TLR-2 and 4 and more CCR7 and 9 than controls. The degree of POCD recurrence correlated with Th1/Th17 cytokine profiles within the neoterminal ileum. Additionally the small intestine in controls and POCD had a more inflammatory DC cytokine profile than the large intestine. LPS altered the DC cytokine toward a more inflammatory response in controls but minimally in POCD small intestine. Modulation with probiotics in controls had more effect within the small intestine than in colonic DC in controls, with no benefit seen in POCD small intestine derived DC. The microbiota plays an important role in POCD. As with previous studies we noted a dysbiosis within inflamed mucosa at surgery. POCD recurrence also correlated with clinical risk factors recurrence and microbiota at the time of surgery as well as there being a dysbiosis in patients who develop endoscopic recurrence. In conclusion we have shown altered DC profiles in POCD, predisposing this area to recurrence. Microbiota at surgery correlates with predetermined risk factors for disease recurrence and dysbiosis is noted with increasing endoscopic recurrence.Open Acces

Impact of a simulation-based induction programme in gastroscopy on trainee outcomes and learning curves.

BACKGROUND Pre-clinical simulation-based training (SBT) in endoscopy has been shown to augment trainee performance in the short-term, but longer-term data are lacking. AIM To assess the impact of a two-day gastroscopy induction course combining theory and SBT (Structured PRogramme of INduction and Training - SPRINT) on trainee outcomes over a 16-mo period. METHODS This prospective case-control study compared outcomes between novice SPRINT attendees and controls matched from a United Kingdom training database. Study outcomes comprised: (1) Unassisted D2 intubation rates; (2) Procedural discomfort scores; (3) Sedation practice; (4) Time to 200 procedures; and (5) Time to certification. RESULTS Total 15 cases and 24 controls were included, with mean procedure counts of 10 and 3 ( = 0.739) pre-SPRINT. Post-SPRINT, no significant differences between the groups were detected in long-term D2 intubation rates ( = 0.332) or discomfort scores ( = 0.090). However, the cases had a significantly higher rate of unsedated procedures than controls post-SPRINT (58% 44%, = 0.018), which was maintained over the subsequent 200 procedures. Cases tended to perform procedures at a greater frequency than controls in the post-SPRINT period (median: 16.2 13.8 per mo, = 0.051), resulting in a significantly greater proportion of cases achieving gastroscopy certification by the end of follow up (75% 36%, = 0.017). CONCLUSION In this pilot study, attendees of the SPRINT cohort tended to perform more procedures and achieved gastroscopy certification earlier than controls. These data support the role for wider evaluation of pre-clinical induction involving SBT