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Bioenterics intragastric balloon for treatment of morbid obesity in Prader–Willi syndrome: Specific risks and benefits
Abstracts / Digestive and Liver Disease 40 (2008) A41–A118
PA68 IN SITU SPLIT LIVER TRANSPLANTATION FROM PEDIATRIC DONORS: EARLY RESULTS OF A PEDIATRIC LIVER TRANSPLANT PROGRAM N. Lopez, E. Cama, P. Catalano, D. Cintorino, M. Spada, F. Di Francesco, S. Riva, M. Sciveres, G. Maggiore, D. Biondo, B. Gridelli Istituto Mediterraneo Trapianti e Terapie ad Alta Specializzazione-University of Pittsburgh Medical Center in Italy, Palermo, Italy The technique of split liver transplantation (SLT) divides the liver of a heart-beating donor into an extended right graft (ERG) and a left lateral segment (LLS), including segments I, IV-VIII, and segments II-III, respectively. Split liver transplantation with paediatric donors is still not worldwide accepted. Our experience with the use of paediatric donors for split liver transplantation in the paediatric population is reported. Patients and methods. From July 2003 to April 2008 83 paediatric liver transplants were performed in 71 patients: 16 from whole livers (WL), 13 from ERG, 54 from LLS. Twentythree were obtained using grafts from 22 donors younger than 15 years, generating 12 WL, and 13 partial grafts: 7 ERG and 6 LLS. Paediatric split liver donors weighing <40 kg were used in 14 cases. Results. After a median follow up of 20 months graft and patient survival from donors younger than 15 years and not are 73% and 77% for graft, 90% and 84% for patients respectively. Seven children underwent retransplantation and three of them after SLT from a 5, 7, 8, year’s old deceased donor, respectively. One patient transplanted with SLT from paediatric donors developed hepatic artery thrombosis. Portal vein thrombosis developed in 3 patients (5%); in one of them, transplanted with LLS from a 14 years old donor, was secondary to hepatic outflow obstruction. Biliary complication rate was 18%, only one case involved SLT graft from paediatric donor. Conclusion. With an appropriate selection of donors and correct dimensional matching of recipient split liver transplantation is in our opinion a safe procedure in children. doi:10.1016/j.dld.2008.07.301
A113
PA69 BIOENTERICS INTRAGASTRIC BALLOON FOR TREATMENT OF MORBID OBESITY IN PRADER–WILLI SYNDROME: SPECIFIC RISKS AND BENEFITS O. Adorisio a , F. De Peppo a , G. Di Giorgio c , M. Germani a , E. Ceriati a , P. Marchetti a , C. Galli b , M.G. Umbertini d , S. Spera c , G. Ferrante e , M. Cuttini e , M. Cappa d , G. Castelli Gattinara c , M. Rivosecchi a , A. Crinò c a Paediatric Surgery Unit, Bambino Gesù Children’s Hospital, Research Institute, Palidoro (Rome), Italy b Anestesiology Unit, Bambino Gesù Children’s Hospital, Research Institute, Palidoro (Rome), Italy c Pediatric and Autoimmune Endocrine Diseases Unit, Bambino Gesù Children’s Hospital, Research Institute, Palidoro (Rome), Italy d Endocrinology Unit, Bambino Gesù Children’s Hospital, Research Institute, Palidoro (Rome), Italy e Epidemiology Unit, Bambino Gesù Children’s Hospital, Research Institute, Rome, Italy
Background. Prader–Willi syndrome (PWS) is the most common genetic cause of obesity and is due to a paternally derived deletion of the q11–13 region or to a maternal uniparental disomy of chromosome 15. It occurs approximately in 1 of 15,000–25,000 live births Obesity in Prader-Willi Syndrome (PWS) is progressive, severe, and resistant to dietary, pharmacological, and behavioural treatment. A body weight reduction is mandatory to reduce the risk of cardio-respiratory and metabolic complications. The aim of the study was to assess risks and benefits of BioEnterics Intragastric Balloon (BIB) for treatment of morbid obesity in PWS patients. Methods. The study group included 12 Prader–Willi patients (four male, eight female), aged from 8.1 to 30.1 years (18.7 ± 7.07 years; median 19 years), who were followed at the Paediatric and Autoimmune Endocrine Diseases Unit of the Bambino Gesù Children’s Hospital in Palidoro (Rome), and were admitted to the Paediatric Surgery Unit of the same hospital from March 2002 to July 2007. Twenty-one BIB were positioned in 12 PWS patients, and removed after 8 ± 1.4 months (range: 5–10 months). Under general anaesthesia with oro-tracheal intubation or heavy sedation with Propofol, BIB was introduced into the gastric cavity following routine esophagogastroscopy to exclude the presence of any contraindications. After positioning at the level of the gastric fundus, BIB was inflated under endoscopic vision with a mean of 576 ± 61.54 ml of saline (range 500 to 700); 10 ml of methylene blue solution were added to allow an early detection of a balloon rupture by colouring patient’s urine and faeces. The patients were discharged with a restricted caloric food intake (700–1000 Kcal). Auxological, clinical, and nutritional evaluations were performed every 2 months. Variations in body
A114
Abstracts / Digestive and Liver Disease 40 (2008) A41–A118
composition were analysed by dual energy X-ray absorbiometry (DXA). Results. One patient (28.5 years, BMI: 59.3 kg/m2 ) died 22 days after BIB positioning because of gastric perforation. In another case (26.2 years, BMI: 57.6 kg/m2 ), BIB was surgically removed after 25 days because of symptoms suggesting gastric perforation (not confirmed at the surgical exploration). The remaining ten patients showed a significant decrease of BMI (p = 0.005) and of fat tissue as measured by DXA (p = 0.012). No significant modifications in bone mineral density (BMD) occurred, but a slight loss in lean body mass (p = 0.036) was documented. In five patients, BIB treatment was repeated more than once. Conclusion. To our knowledge, this is the first reported experience of BIB use in PWS patients. In these subjects, bioenteric intragastric balloon may represent an alternative treatment for body weight control when other pharmacological or dietary approaches have failed. Being totally reversible and repeatable, BIB can be used more than once to lead pediatric patients to adult age maintaining their BMI as close as possible to normal values, therefore reducing the risk of comorbidities. This study shows that when non-invasive pharmacological therapies fail, BIB may be effective to control body weight in PWS patients with morbid obesity, particularly when treatment is started in early childhood. However, careful clinical follow-up and close collaboration with parents are crucial to avoid severe complications, which can be caused by persisting unrestrained food intake. doi:10.1016/j.dld.2008.07.302 PA70 COMPOSITION AND FORTIFICATION OF HUMAN MILK INFLUENCE GASTROESOPHAGEAL REFLUX IN PRETERM INFANTS L. Corvaglia, A. Aceti, E. Mariani, B. Battistini, V. Paoletti, G. Faldella Istituto Clinico di Pediatria Preventiva e Neonatologia, Policlinico Sant’Orsola-Malpighi, Università di Bologna, Italy Aims. Human milk (HM) is considered a better choice than formula also for preterm infants’ nutrition, because it provides unique nutritional components, contributes to host defences, exerts trophic effects on gastrointestinal tract and promotes maternal-infant bonding; furthermore, feeding human milk to preterm infants may lead to short and long term beneficial effects. However, both preterm milk and banked term human milk provide insufficient amount of energy and essential nutrients needed for rapid growth and normal development as if infant had remained in uterus. For this reason, preterm HM is usually supplemented with commercially-produced multicomponent fortifiers (HMF): nonetheless, HM fortification such that intake really meets requirements is difficult, because HM protein and fat content is highly variable among mothers, gestational age at delivery, number of weeks after delivery, and time of day. To our
knowledge, no previous studies have evaluated the influence of human milk nutritional and chemical features, and neither the effect of fortification, on gastroesophageal reflux (GER), which is common in preterm infants. The aim of our study was to evaluate whether the features of HM before and after fortification affect the pattern of gastroesophageal reflux in symptomatic preterm infants. In particular, fat and nitrogen content and osmolarity of HM were correlated with GER features. Methods. We studied seventeen preterm infants with symptoms suggestive of GER (frequent regurgitations and/or post-prandial desaturations). Each patient underwent a twenty-four-hour, continuous and simultaneous measurement of intra-esophageal impedance and pH by Multichannel intraluminal impedance and pH monitoring (Sandhill Scientific). During the study period, seven meals were given: the first one was always of unfortified HM, to avoid a potential carry over effect due to the features of previous feeding. The other six were divided into three couples (two meals of unfortified HM, two meals of HM + FM85 Nestlé 3% [Vevey, Switzerland], and two meals of HM + FM85 Nestlé 5%). The order of the three couples of meals was randomly assigned. Mother milk’s fat and nitrogen content was analysed by a Near Infrared Reflectance Analysis (NIRA). Furthermore, the osmolarity of each mother’s milk was tested. Results. An inverse correlation was found between human milk protein content and the main reflux indexes, especially the acid ones, measured after the two HM meals. No correlation was found between fat content and any reflux index, neither between human milk’s fat and protein content. No correlation was found between osmolarity values and GER indexes. We further analysed whether HM composition continued to be related to the pattern of GER also after fortification: we found that the correlation between HM protein content and the main GER indexes detected after fortification tended to reverse. We calculated the difference between RIpH detected after HM+HMF3% and the one detected before fortification ( RIpH 3%), and also the difference between RIpH detected after HM+HMF5% and the one detected before fortification ( RIpH 5%): these indexes showed a significant direct correlation with HM protein content. In other words, patients who had a low protein content of naïve HM showed a reduction of GER indexes after fortification. On the contrary, patients who had a high protein content of naïve HM showed an increase of GER indexes after fortification. Conclusions. The evaluation of nutritional content of preterm HM may allow a more precise and individualised fortification regimen, and thus improve nutritional management of preterm infants with gastroesophageal reflux. doi:10.1016/j.dld.2008.07.303
PA68 IN SITU SPLIT LIVER TRANSPLANTATION FROM PEDIATRIC DONORS: EARLY RESULTS OF A PEDIATRIC LIVER TRANSPLANT PROGRAM N. Lopez, E. Cama, P. Catalano, D. Cintorino, M. Spada, F. Di Francesco, S. Riva, M. Sciveres, G. Maggiore, D. Biondo, B. Gridelli Istituto Mediterraneo Trapianti e Terapie ad Alta Specializzazione-University of Pittsburgh Medical Center in Italy, Palermo, Italy The technique of split liver transplantation (SLT) divides the liver of a heart-beating donor into an extended right graft (ERG) and a left lateral segment (LLS), including segments I, IV-VIII, and segments II-III, respectively. Split liver transplantation with paediatric donors is still not worldwide accepted. Our experience with the use of paediatric donors for split liver transplantation in the paediatric population is reported. Patients and methods. From July 2003 to April 2008 83 paediatric liver transplants were performed in 71 patients: 16 from whole livers (WL), 13 from ERG, 54 from LLS. Twentythree were obtained using grafts from 22 donors younger than 15 years, generating 12 WL, and 13 partial grafts: 7 ERG and 6 LLS. Paediatric split liver donors weighing <40 kg were used in 14 cases. Results. After a median follow up of 20 months graft and patient survival from donors younger than 15 years and not are 73% and 77% for graft, 90% and 84% for patients respectively. Seven children underwent retransplantation and three of them after SLT from a 5, 7, 8, year’s old deceased donor, respectively. One patient transplanted with SLT from paediatric donors developed hepatic artery thrombosis. Portal vein thrombosis developed in 3 patients (5%); in one of them, transplanted with LLS from a 14 years old donor, was secondary to hepatic outflow obstruction. Biliary complication rate was 18%, only one case involved SLT graft from paediatric donor. Conclusion. With an appropriate selection of donors and correct dimensional matching of recipient split liver transplantation is in our opinion a safe procedure in children. doi:10.1016/j.dld.2008.07.301
A113
PA69 BIOENTERICS INTRAGASTRIC BALLOON FOR TREATMENT OF MORBID OBESITY IN PRADER–WILLI SYNDROME: SPECIFIC RISKS AND BENEFITS O. Adorisio a , F. De Peppo a , G. Di Giorgio c , M. Germani a , E. Ceriati a , P. Marchetti a , C. Galli b , M.G. Umbertini d , S. Spera c , G. Ferrante e , M. Cuttini e , M. Cappa d , G. Castelli Gattinara c , M. Rivosecchi a , A. Crinò c a Paediatric Surgery Unit, Bambino Gesù Children’s Hospital, Research Institute, Palidoro (Rome), Italy b Anestesiology Unit, Bambino Gesù Children’s Hospital, Research Institute, Palidoro (Rome), Italy c Pediatric and Autoimmune Endocrine Diseases Unit, Bambino Gesù Children’s Hospital, Research Institute, Palidoro (Rome), Italy d Endocrinology Unit, Bambino Gesù Children’s Hospital, Research Institute, Palidoro (Rome), Italy e Epidemiology Unit, Bambino Gesù Children’s Hospital, Research Institute, Rome, Italy
Background. Prader–Willi syndrome (PWS) is the most common genetic cause of obesity and is due to a paternally derived deletion of the q11–13 region or to a maternal uniparental disomy of chromosome 15. It occurs approximately in 1 of 15,000–25,000 live births Obesity in Prader-Willi Syndrome (PWS) is progressive, severe, and resistant to dietary, pharmacological, and behavioural treatment. A body weight reduction is mandatory to reduce the risk of cardio-respiratory and metabolic complications. The aim of the study was to assess risks and benefits of BioEnterics Intragastric Balloon (BIB) for treatment of morbid obesity in PWS patients. Methods. The study group included 12 Prader–Willi patients (four male, eight female), aged from 8.1 to 30.1 years (18.7 ± 7.07 years; median 19 years), who were followed at the Paediatric and Autoimmune Endocrine Diseases Unit of the Bambino Gesù Children’s Hospital in Palidoro (Rome), and were admitted to the Paediatric Surgery Unit of the same hospital from March 2002 to July 2007. Twenty-one BIB were positioned in 12 PWS patients, and removed after 8 ± 1.4 months (range: 5–10 months). Under general anaesthesia with oro-tracheal intubation or heavy sedation with Propofol, BIB was introduced into the gastric cavity following routine esophagogastroscopy to exclude the presence of any contraindications. After positioning at the level of the gastric fundus, BIB was inflated under endoscopic vision with a mean of 576 ± 61.54 ml of saline (range 500 to 700); 10 ml of methylene blue solution were added to allow an early detection of a balloon rupture by colouring patient’s urine and faeces. The patients were discharged with a restricted caloric food intake (700–1000 Kcal). Auxological, clinical, and nutritional evaluations were performed every 2 months. Variations in body
A114
Abstracts / Digestive and Liver Disease 40 (2008) A41–A118
composition were analysed by dual energy X-ray absorbiometry (DXA). Results. One patient (28.5 years, BMI: 59.3 kg/m2 ) died 22 days after BIB positioning because of gastric perforation. In another case (26.2 years, BMI: 57.6 kg/m2 ), BIB was surgically removed after 25 days because of symptoms suggesting gastric perforation (not confirmed at the surgical exploration). The remaining ten patients showed a significant decrease of BMI (p = 0.005) and of fat tissue as measured by DXA (p = 0.012). No significant modifications in bone mineral density (BMD) occurred, but a slight loss in lean body mass (p = 0.036) was documented. In five patients, BIB treatment was repeated more than once. Conclusion. To our knowledge, this is the first reported experience of BIB use in PWS patients. In these subjects, bioenteric intragastric balloon may represent an alternative treatment for body weight control when other pharmacological or dietary approaches have failed. Being totally reversible and repeatable, BIB can be used more than once to lead pediatric patients to adult age maintaining their BMI as close as possible to normal values, therefore reducing the risk of comorbidities. This study shows that when non-invasive pharmacological therapies fail, BIB may be effective to control body weight in PWS patients with morbid obesity, particularly when treatment is started in early childhood. However, careful clinical follow-up and close collaboration with parents are crucial to avoid severe complications, which can be caused by persisting unrestrained food intake. doi:10.1016/j.dld.2008.07.302 PA70 COMPOSITION AND FORTIFICATION OF HUMAN MILK INFLUENCE GASTROESOPHAGEAL REFLUX IN PRETERM INFANTS L. Corvaglia, A. Aceti, E. Mariani, B. Battistini, V. Paoletti, G. Faldella Istituto Clinico di Pediatria Preventiva e Neonatologia, Policlinico Sant’Orsola-Malpighi, Università di Bologna, Italy Aims. Human milk (HM) is considered a better choice than formula also for preterm infants’ nutrition, because it provides unique nutritional components, contributes to host defences, exerts trophic effects on gastrointestinal tract and promotes maternal-infant bonding; furthermore, feeding human milk to preterm infants may lead to short and long term beneficial effects. However, both preterm milk and banked term human milk provide insufficient amount of energy and essential nutrients needed for rapid growth and normal development as if infant had remained in uterus. For this reason, preterm HM is usually supplemented with commercially-produced multicomponent fortifiers (HMF): nonetheless, HM fortification such that intake really meets requirements is difficult, because HM protein and fat content is highly variable among mothers, gestational age at delivery, number of weeks after delivery, and time of day. To our
knowledge, no previous studies have evaluated the influence of human milk nutritional and chemical features, and neither the effect of fortification, on gastroesophageal reflux (GER), which is common in preterm infants. The aim of our study was to evaluate whether the features of HM before and after fortification affect the pattern of gastroesophageal reflux in symptomatic preterm infants. In particular, fat and nitrogen content and osmolarity of HM were correlated with GER features. Methods. We studied seventeen preterm infants with symptoms suggestive of GER (frequent regurgitations and/or post-prandial desaturations). Each patient underwent a twenty-four-hour, continuous and simultaneous measurement of intra-esophageal impedance and pH by Multichannel intraluminal impedance and pH monitoring (Sandhill Scientific). During the study period, seven meals were given: the first one was always of unfortified HM, to avoid a potential carry over effect due to the features of previous feeding. The other six were divided into three couples (two meals of unfortified HM, two meals of HM + FM85 Nestlé 3% [Vevey, Switzerland], and two meals of HM + FM85 Nestlé 5%). The order of the three couples of meals was randomly assigned. Mother milk’s fat and nitrogen content was analysed by a Near Infrared Reflectance Analysis (NIRA). Furthermore, the osmolarity of each mother’s milk was tested. Results. An inverse correlation was found between human milk protein content and the main reflux indexes, especially the acid ones, measured after the two HM meals. No correlation was found between fat content and any reflux index, neither between human milk’s fat and protein content. No correlation was found between osmolarity values and GER indexes. We further analysed whether HM composition continued to be related to the pattern of GER also after fortification: we found that the correlation between HM protein content and the main GER indexes detected after fortification tended to reverse. We calculated the difference between RIpH detected after HM+HMF3% and the one detected before fortification ( RIpH 3%), and also the difference between RIpH detected after HM+HMF5% and the one detected before fortification ( RIpH 5%): these indexes showed a significant direct correlation with HM protein content. In other words, patients who had a low protein content of naïve HM showed a reduction of GER indexes after fortification. On the contrary, patients who had a high protein content of naïve HM showed an increase of GER indexes after fortification. Conclusions. The evaluation of nutritional content of preterm HM may allow a more precise and individualised fortification regimen, and thus improve nutritional management of preterm infants with gastroesophageal reflux. doi:10.1016/j.dld.2008.07.303