Survival rate and prognostic factors in patients with intestinal failure

doi:10.1016/j.dld.2003.09.015

Digestive and Liver Disease

Volume 36, Issue 1, January 2004, Pages 46-55

https://doi.org/10.1016/j.dld.2003.09.015 Get rights and content

Abstract

Background. Intestinal failure impairs nutritional status and survival expectance. Though intestinal adaptation and enteral independence may be achieved, artificial nutrition is needed in about half of the patients.

Aims. This study is aimed at assessing the causes of death, survival rate, enteral independence in time, and factors affecting the clinical outcome in a group of patients with intestinal insufficiency.

Patients. Sixty-eight patients with intestinal insufficiency, due to major intestinal resection in 60 cases (short bowel syndrome) (remnant intestine length 101–150 cm in 31 cases, 50–100 cm in 23 cases, <50 cm in 6 cases), and due to chronic idiopathic pseudo-obstruction in 8 cases, were enrolled and followed-up for (median) 36 months (25th and 75th percentile in 12 and 60 months, respectively). In 60 short bowel syndrome patients, the main conditions that led to intestinal failure were ischemic bowel (28), major surgery complications or severe adhesions (17), radiation enteritis (10), Chron’s disease, intestinal tuberculosis, small bowel lymphoma and trauma (others).

Methods. Seventeen variables age, underlying disorders, length of remnant bowel, type of surgery, hospital stay, type of nutrition (hospital and home) and its variations in time, causes of death, survival rate and time were considered. Statistical analysis was carried out by Mann–Whitney U-test, Pearson χ², Spearman correlation test, Kaplan–Meyer method and Cox’s proportion hazards regression model.

Results. At the time of admission to the hospital, none of the patients had nutritional independence, 54 (79.4%) were on parenteral nutrition and 14 (20.6%) were on enteral nutrition. At the time of discharge, 23 (33.8%) patients showed enteral independence, 39 were on home parenteral nutrition, 3 on enteral nutrition + i.v. feeding, 1 on enteral nutrition, and 2 needed oral supplementation with hydroelectrolyte solutions only. After a median value of 36 months, 30 and 2 patients were on home parenteral nutrition and enteral nutrition + i.v. feeding, respectively, 2 on enteral nutrition, 2 on oral supplementation with hydroelectrolyte solutions, and 26 cases reached enteral independence. A significant relationship was detected between the length of remnant bowel and types of nutrition at both admission (r=0.38; P=0.001) and discharge (r=0.48; P=0.001), parenteral nutrition being more frequent in patients with very short bowel. Twenty-two patients (32.4%) died (4 from newly occurring malignancies), 40 (58.8%) survived, and 6 (8.8%) were lost to the follow-up. Eleven of 22 patients died from conditions related to intestinal failure (8 cases) and/or home parenteral nutrition complications (3 cases). At 12, 24, 36, 48, 60 and 72 months, survival rates were 95.4, 93.3, 88.1, 78.6, 78.6 and 65.5%, respectively, but it was significantly lower for patients with <50 cm of remnant bowel than those with longer residual intestine (P<0.05), and in patients who started home parenteral nutrition above the age of 45 years (P<0.02). Survival rate was higher in patients with enteral independence than those with enteral dependence (P<0.05). Better survival rates were registered in patients with chronic obstructive intestinal pseudo-obstruction and major surgery complications, whereas ischemic bowel and even more radiation enteritis were associated with a lower survival expectance.

Conclusions. Actuarial survival rate of patients with intestinal failure quotes 88 and 78% at 3 and 5 years, respectively. It is influenced by the length of remnant intestine, age at the start of home parenteral nutrition, enteral independence and, to some extent at least, by the primary disorder. Enteral independence can be achieved in time by about 40% of the patients with intestinal insufficiency, but for home parenteral nutrition-dependent cases, intravenous feeding can be stopped in less than one out of five patients during a median 3-year period.

Introduction

Intestinal failure is a rare condition, usually secondary to major intestinal surgery, leading to short bowel syndrome (SBS). This disorder is characterised by inadequate intestinal function for absorption of nutrients and electrolytes, which would affect nutritional status and survival expectance without intravenous administration of nutrients and electrolytes. Though enteral independence can be achieved in time [1], [2], [3], in about half of the cases, parenteral nutrition (PN) is indicated for irreversible and chronic intestinal failure (CIF) [4], [5], [6]. Artificial nutrition contributes to socially rehabilitate these patients with an acceptable quality of life, at least in the younger ones [7]. Home parenteral nutrition (HPN) compares favourably with intestine transplantation [1], the latter however being available only in a few qualified centres.

Intestinal dysfunction has a wide range of clinical and nutritional pictures: some cases can be managed with PN only (complete intestinal failure), whereas other patients are affected by transient or less severe intestinal insufficiency. Intestinal adaptation can occur in time and early oral or enteral nutrition (EN) can foster it [8], [9], [10]. In any case, the most adequate, simple and less expensive nutritional treatment should be prescribed. Dietary advice is usually given [11] and regular food intake promoted too [1], [4], [8].

A certain number of reports have described the outcome of patients with intestinal failure, giving information on intestinal adaptation [8], [10], survival, nutritional treatment, complications, dependence on artificial nutrition, hospital readmissions, factors affecting the outcome and cost/benefits [1], [6], [12], [13], [14], [15].

During the last 13 years, we have had the opportunity to follow a group of patients with intestinal insufficiency sent to our specialised gastrointestinal rehabilitation unit by other Italian centres. This study is aimed at evaluating survival rate, causes of death, enteral independence, in-hospital and in-home artificial nutrition, factors affecting the outcome in a group of patients with intestinal insufficiency.

Section snippets

Patients

A group of 68 consecutive patients (30 males, 38 females), aged 55.4 years (S.E.M. 2.09; median 57.5; range 12–86) with intestinal insufficiency, admitted to and discharged from our unit between 1990 and 2001, were recruited in this study. None of the patients were affected by cancer at the time of enrolment, except for one patient with intestinal lymphoma with no sign of active GI disease and/or extraintestinal involvement. The series includes 10 patients with radiation enteritis (undergone

Nutritional treatments

This series includes 68 patients who, on admission, were allocated to different nutritional supports. On the basis of a comprehensive clinical and nutritional evaluation, nutrition was usually modified according to a step-down strategy. Further attempts to make nutritional therapy easier and less expensive were also made during the follow-up. Median hospital stay lasted 29.5 days (range 7–240; 75th percentile 48), length being longer in patients discharged on PN (mean 50.27; S.E.M. 14.7; median

Discussion

We have described the clinical outcome of a group of patients affected by intestinal insufficiency associated with different primary disorders, nutritional treatments, death rate and causes, survival time and rates, and factors influencing their life expectance. Twenty-two patients (32.35%) died during the follow-up, 6 of them because of malignancies occurring for the first time (4 cases) or from cancer relapse (2 cases), the cancer having occurred more than 5 years before enrolment in the

Acknowledgements

We are very grateful to all the nurses of our unit for the highly professional assistance given to patients with intestinal failure, and to Mrs. Carol Thomas for reviewing English language.

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Cited by (96)

ESPEN guideline on chronic intestinal failure in adults – Update 2023
2023, Clinical Nutrition
In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines.
The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly.
The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is “strong consensus” for 148 (99.3%) and “consensus” for one (0.7%) recommendation. The grade of consensus for the statements is “strong consensus” for 14 (87.5%) and “consensus” for two (12.5%).
It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.
Mortality and parenteral nutrition weaning in patients with chronic intestinal failure on home parenteral nutrition: A 30-year retrospective cohort study
2023, Nutrition
Home parenteral nutrition (HPN) is the standard treatment for patients with chronic intestinal failure (CIF). Mortality and weaning rates of these patients differ widely among cohorts; however, these outcomes were often considered independent—rather than competing—events, leading to an upward bias of the retrieved estimates.
The aim of this retrospective cohort study was to evaluate, evaluating through a competing risk analysis, the rates and predictors of mortality and weaning in CIF patients from an Italian referral center.
All adult patients with CIF receiving > 3 mo HPN from 1985 until 2016 were enrolled. Clinical information was collected from the database of the Intestinal Failure Unit of Torino, Italy. Patients were stratified according to the presence or not of short bowel syndrome (SBS).
The cumulative incidences of death and weaning were 27.3% and 32.3% and 39.0% and 33.7% at 5 and 10 y from HPN initiation, respectively. At multivariable competing risk analyses, mortality was predicted by age (sub-distribution hazard ratio [SHR] = 1.65 per 10-y increase; 95% CI, 1.35–2.01), type 3 SBS (SHR = 0.38; 0.15–0.94), small bowel length ≥ 100 cm (SHR = 0.42; 0.22–0.83), and reconstructive surgery (SHR = 0.11; 0.02–0.64) in SBS patients, and by age (SHR = 1.38 per 10-y increase; 1.16–1.64) and presence of stoma (SHR = 0.30; 0.12–0.78) in non-SBS patients. In the same model, weaning was predicted by type 3 SBS (SHR = 6.86; 3.10–15.16), small bowel length ≥ 100 cm (SHR = 3.54; 1.99–6.30), and reconstructive surgery (SHR = 2.86; 1.44–5.71) in SBS patients, and by age (SHR = 0.79 per 10-y increase; 0.66–0.94) and presence of stoma (SHR = 2.64; 1.38–5.07) in non-SBS patients.
Surgical procedures strongly affected mortality and weaning risk in CIF patients.
Survival in patients initiating home parenteral support due to nonmalignant short bowel syndrome compared with background population
2022, Clinical Nutrition ESPEN
Citation Excerpt :
Hence, SBS-IF patients are expected to have a reduced survival compared with healthy individuals. Survival of patients receiving HPS has been estimated to be between 60 and 92% after 5 years [5–13]. When interpreting survival rates, physicians and patients tend to consider an ideal long-term survival of 100%, which in nature is not feasible.
Survival has frequently been studied and reported in patients with long term intestinal failure (IF). However, studies comparing the survival and mortality rates with the background population are rare. This study compares the survival in an adult IF, non-malignant, short bowel syndrome (SBS) cohort with a control group and with age- and sex-specific background mortality rates.
Patients with SBS, defined by a small bowel length of 200 cm or less, due to non-malignant disease, were included and followed until death or censoring on 31 December 2017. Causes of deaths occurring during home parenteral support (HPS) were assessed by review of the charts. Each case was matched with ten controls from the background population according to year of HPS initiation, age, and sex, and their survival was compared. Furthermore, age- and sex-specific mortality rates of the background population were used to calculate the standardized mortality ratio (SMR) and excess mortality.
After five years, patients who initiated HPS had a relative survival of 76%. The SMR was 5.0 and the excess mortality was 50 per 1000 years. HPS-related deaths were assessed to account for 11% of deaths during HPS and occurred with an incidence of 10 per 1000 years. The excess mortality was as low as 15 per 1000 years in cases aged less than 40 years. Patients weaning off HPS had a mortality rate closer to that expected in the background population.
In adult patients with a non-malignant cause of SBS-IF, the excess mortality was 50 per 1000 years. However, HPS related deaths were rarely registered with an incidence of 10 HPS related deaths per 1000 HPS treatment years.
Outcome of adult patients receiving parenteral support at home: 36 years’ experience at a tertiary referral centre
2021, Clinical Nutrition
Citation Excerpt :
These include avoidance of soybean-oil based lipid content in PS and early recognition and improved management of sepsis in particular CRBSI [3]. Overall long-term survival rates for patients receiving home PS have shown a 1 year survival between 86% and 97% [4,7,25–33], a 5 year survival of between 60 and 87% [4,7,25–28,30,32–37], a 10 year survival of 44%–71% [4,7,26,27,33]. Only one paper to date has documented 20 year survival at 28% [7].
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.
ESPEN practical guideline: Clinical nutrition in chronic intestinal failure
2021, Clinical Nutrition
This practical guideline is based on the ESPEN Guidelines on Chronic Intestinal Failure in Adults.
ESPEN guidelines have been shortened and transformed into flow charts for easier use in clinical practice. The practical guideline is dedicated to all professionals including physicians, dieticians, nutritionists, and nurses working with patients with chronic intestinal failure.
This practical guideline consists of 112 recommendations with short commentaries for the management and treatment of benign chronic intestinal failure, including home parenteral nutrition and its complications, intestinal rehabilitation, and intestinal transplantation.
This practical guideline gives guidance to health care providers involved in the management of patients with chronic intestinal failure.
Understanding short bowel syndrome: Current status and future perspectives
2020, Digestive and Liver Disease
Short bowel syndrome (SBS) is a rare malabsorptive disorder as a result of the loss of bowel mass mostly secondary to surgical resection of the small intestine. Other causes are vascular diseases, neoplasms or inflammatory bowel disease. The spectrum of the disease is widely variable from single micronutrient malabsorption to complete intestinal failure, depending on the remaining length of the small intestine, the anatomical portion of intestine and the function of the remnant bowel. Over the last years, the management of affected patients has remarkably improved with the increase in patients’ quality of life and survival, mainly thanks to advances in home-based parenteral nutrition (PN). In the last ten years new treatment strategies have become available together with increasing experience and the encouraging results with new drugs, such as teduglutide, have added a new dimension to the management of SBS.
This review aims to summarize the knowledge available in the current literature on SBS epidemiology, pathophysiology, and its surgical (including intestinal lengthening procedures and intestinal transplantation) and medical management with emphasis on the recent advances.
Moreover, this review attempts to provide the new understanding and recent approaches to SBS complications such as sepsis, catheter thrombosis, and intestinal failure-associated liver disease.

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Alimentary TractSurvival rate and prognostic factors in patients with intestinal failure

Abstract

Introduction

Section snippets

Patients

Nutritional treatments

Discussion

Acknowledgements

Gastroenterology

Lancet

Gastroenterology

Gastroenterol. Clin. North Am.

Gastroenterology

Nutrition

Gastroenterology

Gastroenterology

Lancet

Dig. Liver Dis.

Clin. Nutr.

Dig. Liver Dis.

Surgery

Gastroenterology

Lancet

Dig. Liver Dis.

Clin. Nutr.

Dig. Liver Dis.

Assessing the quality of life of patients with intestinal failure on home parenteral nutrition

Gut.

Continuous enteral nutrition during the early adaptive stage of the short bowel syndrome

Br. J. Surg.

Alimentary Tract
Survival rate and prognostic factors in patients with intestinal failure