Elucidating Short-Bowel Syndrome
Washington University pediatric surgeons, physicians and researchers at St. Louis Children’s Hospital are conducting collaborative basic science research to solve a long-standing clinical problem: the complications and poor prognosis often associated with short-bowel syndrome.
In older children and adults, short-bowel syndrome most often results from surgery undergone to treat intestinal diseases, injuries or congenital defects; these procedures can require removal of half or more of the small intestine. In infants, the most common cause is necrotizing enterocolitis, which occurs with premature birth and leads to death of bowel tissue.
In the 1930s, one-year survival was low: about 20 percent. Subsequent improvements in nutrition and surgical approaches have led to improved survival, but patients still battle dehydration, malnutrition, infections and weight loss as their bodies work to digest food.
“Unfortunately, the long-term complication of this is liver failure with the possibility of a liver and/or small intestine transplant,” says Brad Warner, MD, the Jessie L. Ternberg, MD, PhD Distinguished Professor of Pediatric Surgery and chief of pediatric surgery.
Warner and colleagues hope to find a solution through T1-stage research in the laboratory. They are investigating what happens to the gut microbiome — the collection of gut microorganisms and their genes — in response to removing the intestine; their long-term goal is to manipulate the microbiome to allow greater nutrient absorption and prevent bacterial infections. Collaborators Barbara Warner, MD, a pediatrician in newborn medicine, and Phillip Tarr, MD, director of the Pediatric Division of Gastroenterology, are analyzing stool samples from babies with necrotizing colitis, and Warner’s lab is examining the microbiome in a mouse model. Jeffrey Gordon, MD, director of the Center for Genome Sciences & Systems Biology, is collaborating in the studies. In another project studying a mouse model, urologic researcher Jeffrey Arbeit, MD, and David Curiel, MD, PhD, director of the Department of Radiation Oncology’s Division of Cancer Biology, aim to develop a method to deliver growth factor to endothelial cells lining the gut to enhance the cells’ function.
“We hope to improve patients’ ability to tolerate oral feeding and, ultimately, their outcomes,” says Warner.
Workgroup addresses clinical effectiveness
Pediatric surgeons formed the Program for Optimal Outcomes in Pediatric Surgery (POOPS) to improve clinical effectiveness. Jacqueline Saito, MD, MSCI, leads the group, which works with other centers in clinical trials and the study of severe birth defects.
The group participates in the Midwest Pediatric Surgery Research Consortium (MPSR), a research partnership of pediatric surgeons at 10 children’s hospitals. With surgeons at the other MPSR centers, they are conducting trials on the use of needle aspiration alone instead of a chest tube to treat pneumothorax and treatment of uncomplicated appendicitis with antibiotics instead of appendectomy.
Surgeons have also joined the NIH-funded DHREAMS (Diaphragmatic Hernia Research & Exploration; Advancing Molecular Science) study to better understand the molecular genetic basis of congenital diaphragmatic hernia, an often fatal defect in which a hole in the diaphragm allows organs from the abdomen to move into the chest. Future projects include looking at outcomes for another abnormality, esophageal atresia.
Highlights
- Martin Keller, MD, medical director of trauma, found there were fewer hospital-acquired conditions in trauma patients at St. Louis Children’s Hospital after the hospital became an American College of Surgeons-verified Level 1 Pediatric Trauma Center in 2012. He reported the findings at the Department of Surgery’s First Annual Patient Safety and Clinical Effectiveness Meeting in 2014. The improvements resulted from more standardized care.
- Keller now provides pediatric surgical services on chest wall abnormalities at Shriners Hospitals for Children – St. Louis.
- Washington University pediatric surgeons now provide an outpatient clinic and outpatient surgical services at CoxHealth in Springfield, Missouri, twice a month. Patients and their families travel to St. Louis Children’s Hospital for inpatient operations. Pediatric surgeons continue to provide coverage for surgical services at University Hospital in Columbia.
- Kathryn Bernabe, MD, was named medical student pediatric surgery rotation director for third- and fourth-year students, working with Clerkship Director John Kirby, MD, and Clerkship Coordinator Douglas Brown, PhD, in this new position.
- Pediatric surgeons and other Washington University pediatric specialists now treat children at the new Children’s Specialty Care Center in West St. Louis County, which features a full-service outpatient center and the Pediatric Acute Wound Service (PAWS).
- Working with the World Pediatric Project, Brad Warner, MD, provides advanced esophageal surgery for children in other countries who suffer caustic injury from ingesting lye. Patients from as far away as Liberia and the Dominican Republic have traveled to St. Louis for surgery.