Intestinale Rehabilitation bei Kurzdarmsyndrom und chronischem Darmversagen

Was ist neu?

Anatomische und funktionelle Klassifikation Das chronische Darmversagen (CVD) bei Kurzdarmsyndrom (KDS) wird sowohl durch die postoperative Anatomie als auch funktionell anhand des parenteralen Kalorien- und Volumenbedarfs klassifiziert.

Spontane intestinale Adaptation Die postoperative Anpassungsreaktion nach Darmresektion verläuft in 3 Phasen, die jeweils eines interdisziplinären Managements bedürfen.

Therapie des chronischen Darmversagens bei Kurzdarmsyndrom Ziel der Therapie ist eine ausreichende Kalorien- und Nährstoffversorgung unter Vermeidung einer Hyperalimentation bzw. die Linderung/Beherrschung der Diarrhöen.

Chirurgische Maßnahmen einschließlich Transplantation Die chirurgische Wiederherstellung der Kontinuität ausgeschalteter Darmabschnitte ist unverzichtbar. Es bestehen prinzipiell verschiedene Optionen der Transplantation, der Nachweis für eine Verbesserung der Gesamtprognose steht allerdings noch aus.

Funktionelle intestinale Rehabilitation durch GLP-2-Analoga Durch die Einführung von Glucagon-like-peptide-2-Analoga (GLP-2-Analoga) in die funktionelle intestinale Rehabilitation von KDS-Patienten ist nunmehr eine kausale Behandlung dieses Malabsorptionssyndroms möglich. Durch die GLP-2-Analoga-vermittelte Steigerung der Flüssigkeits-, Nährstoff- und Kalorienabsorption ist eine Reduzierung der parenteralen Substitution (PS), im Idealfall mit kompletter Entwöhnung, möglich.

Abstract

Patients with severely orally decompensated malsaborption due to surgical rescetion suffer from short bowel syndrome (SBS). The resultant decrease in intestinal surface area after rescetion of parts of the intestines leads to chronic functional intestinal insufficiency or even complete failure (cIF) which requires parenteral fluid and nutrient restoration for establishment of metabolc stability. Since the introduction of glucagon-like peptide (GLP)-2 analogues such as teduglutide functional rehabilitation of the remaining gastrointestinal tract has become a causal treatment option. Teduglutide functionally and effectively enhances intestinal absorption of fluid as well micro- and macronutrients allowing a reduction of parenteral nutrition and/or volume with even complete weaning off in some patients. This results increased metabolic stability, oral autonomy, quality of life and putatively less complications.

Schlüsselwörter

Kurzdarmsyndrom - chronisches Darmversagen - parenterale Ernährung - intestinale Rehabilitation - Glucagon-like-peptide 2

Key words

short bowel syndrome - chronic intestinal failure - parenteral support - intestinal rehabilitation - glucagon-like peptide-2

• Literatur

• 1 Pironi L, Arends J, Baxter J. et al. ESPEN endorsed recommendations. Definition and classification of intestinal failure in adults. Clin Nutr 2015; 34: 171-180
• 2 Lamprecht G, Pape UF, Witte M. et al. S3-Leitlinie der Deutschen Gesellschaft für Ernährungsmedizin e. V. in Zusammenarbeit mit der AKE, der GESKES und der DGVS Klinische Ernährung in der Gastroenterologie (Teil 3) – Chronisches Darmversagen. Aktuel Ernährungsmed 2014; 39: e57-e71
• 3 Joly F, Baxter J, Staun M. et al. Five-year survival and causes of death in patients on home parenteral nutrition for severe chronic and benign intestinal failure. Clin Nutr 2018; 37: 1415-1422
• 4 Pape UF, Maasberg S, Pascher A. Pharmacological strategies to enhance adaptation in intestinal failure. Curr Opin Organ Transplant 2016; 21: 147-152
• 5 Messing B, Crenn P, Beau P. et al. Long-term survival and parenteral nutrition dependence in adult patients with the short bowel syndrome. Gastroenterology 1999; 117: 1043-1050
• 6 Pironi L, Konrad D, Brandt C. et al. Clinical classification of adult patients with chronic intestinal failure due to benign disease: An international multicenter cross-sectional survey. Clin Nutr 2018; 37: 728-738
• 7 Martin GR, Beck PL, Sigalet DL. Gut hormones, and short bowel syndrome: The enigmatic role of glucagon-like peptide-2 in the regulation of intestinal adaptation. World J Gastroenterol 2006; 12: 4117-4129
• 8 Zanfi C, Lauro A, Cescon M. et al. Comprehensive surgical intestinal rescue and transplantation program in adult patients: Bologna experience. Transplant Proc 2010; 42: 39-41
• 9 Gerlach UA, Vrakas G, Reddy S. et al. Chronic intestinal failure after Crohn disease: when to perform transplantation. JAMA Surg 2014; 149: 1060-1066
• 10 Drucker DJ, Erlich P, Asa SL. et al. Induction of intestinal epithelial proliferation by glucagon-like peptide 2. Proc Natl Acad Sci 1996; 93: 7911-7916
• 11 Pevny S, Maasberg S, Rieger A. et al. Experience with teduglutide treatment for short bowel syndrome in clinical practice. Clin Nutr 2018; DOI: 10.1016/j.clnu.2018.07.030.
• 12 Jeppesen PB, Sanguinetti EL, Buchman A. et al. Teduglutide (ALX-0600), a dipeptidyl peptidase IV resistant glucagon-like peptide 2 analogue, improves intestinal function in short bowel syndrome patients. Gut 2005; 54: 1224-1231
• 13 Jeppesen PB, Gilroy R, Pertkiewicz M. et al. Randomised placebo-controlled trial of teduglutide in reducing parenteral nutrition and/or intravenous fluid requirements in patients with short bowel syndrome. Gut 2011; 60: 902-914
• 14 Jeppesen PB, Pertkiewicz M, Messing B. et al. Teduglutide reduces need for parenteral support among patients with short bowel syndrome with intestinal failure. Gastroenterology 2012; 143: 1473-1481
• 15 Schwartz LK, O’Keefe SJ, Fujioka K. et al. Long-Term Teduglutide for the Treatment of Patients With Intestinal Failure Associated With Short Bowel Syndrome. Clin Transl Gastroenterol 2016; 7: e142 . doi:10.1038/ctg.2015.69
• 16 O'Keefe SJ, Jeppesen PB, Gilroy R. et al. Safety and efficacy of teduglutide after 52 weeks of treatment in patients with short bowel intestinal failure. Clin Gastroenterol Hepatol 2013; 11: 815-823
• 17 Jeppesen PB, Gabe SM, Seidner DL. et al. Factors Associated With Response to Teduglutide in Patients With Short-Bowel Syndrome and Intestinal Failure. Gastroenterology 2018; 154: 874-885
• 18 Schoeler M, Klag T, Wendler J. et al. GLP-2 analog teduglutide significantly reduces need for parenteral nutrition and stool frequency in a real-life setting. Therap Adv Gastroenterol 2018; DOI: 10.1177/1756284818793343.
• 19 Blüthner E, Bednarsch J, Stockmann M. et al. Determinants of Quality of Life in Patients With Intestinal Failure Receiving Long-Term Parenteral Nutrition Using the SF-36 Questionnaire: A German Single-Center Prospective Observational Study. JPEN J Parenter Enteral Nutr 2019; DOI: 10.1002/jpen.1531.
• 20 Chen K, Mu F, Xie J. et al. Impact of Teduglutide on Quality of Life Among Patients With Short Bowel Syndrome and Intestinal Failure. JPEN J Parenter Enteral Nutr 2019; DOI: 10.1002/jpen.1588.
• 21 Ukleja A, To C, Alvarez A. et al. Long-Term Therapy With Teduglutide in Parenteral Support-Dependent Patients With Short Bowel Syndrome: A Case Series. JPEN J Parenter Enteral Nutr 2018; 42: 821-825
• 22 Ukleja A, Alkhairi B, Bejarano P. et al. De Novo Development of Hamartomatous Duodenal Polyps in a Patient With Short Bowel Syndrome During Teduglutide Therapy: A Case Report. JPEN J Parenter Enteral Nutr 2017; DOI: 10.1177/0148607117718480.