Total pancreatectomy with islet autotransplantation reduces opioid use and improves nutritional support in children with debilitating pancreatitis.

BACKGROUND: Chronic pancreatitis (CP) can result in opioid dependence and nutritional challenges in children. Total pancreatectomy with islet autotransplantation (TPIAT) is a viable surgical option in appropriately selected patients. We examined differences between children who met criteria for TPIAT versus those who did not and continued with non-operative management. METHODS: Retrospective observational cohort study of patients evaluated for TPIAT between August 2014 and July 2020 was performed. Cohort-based analyses between TPIAT and non-TPIAT groups were performed. RESULTS: Analyses included 121 patients, 69 of whom underwent TPIAT. Demographics, genetic risk factors, and anatomic variants did not differ between groups. TPIAT patients were more likely to have CP (88% vs 71%; p = 0.02), had higher median number of endoscopic retrograde cholangiopancreatography procedures (2.0 vs 1.0; p = 0.0001), and had higher likelihood of opioid use (61% vs 42%; p = 0.04) and nutritional supplementation (23% vs 4%; p = 0.004), compared to non-TPIAT. At 6 months post-TPIAT, patients had lower use of any analgesic pain medications (39% vs 73%; p = 0.0002) and lower use of opioids (9% vs 39%; p = 0.0006), compared to non-TPIAT patients at 6 months after evaluation. At 6 months post-TPIAT, rate of exclusively oral nutrition increased from 77% to 86%, and total parenteral nutrition use decreased from 13% to 0% (p = 0.02). CONCLUSIONS: In children referred for TPIAT evaluation, there is greater burden of disease in those selected for operation, compared to patients who do not undergo operation. TPIAT achieves lower analgesic pain medication use compared to continuation with non-TPIAT management and achieves freedom from nutritional supplementation. Level of evidence: Retrospective comparative study, Level III.

Antibiotic Stewardship Through Standardized Diagnosis and Treatment of Small Bowel Bacterial Overgrowth in Pediatric Patients With Short Bowel Syndrome Reduces Antibiotic Exposure and Improves Cost of Health Care.

BACKGROUND: Small bowel bacterial overgrowth (SBBO) is difficult to diagnose in pediatric patients with short bowel syndrome due to the invasive nature of the gold standard testing. Alternative testing methods also have barriers leaving providers to diagnose clinically. This has led to antibiotic overprescribing in this population. An algorithm for SBBO identification and standardized treatment is proposed. OBJECTIVE: Standardize SBBO identification and treatment in pediatric short bowel syndrome. METHODS: 1-year retrospective chart review and literature review. RESULTS: Final analysis of 146 admissions revealed diagnostic and antibiotic prescribing inconsistencies. In total, 28% (n = 41) received antibiotics for SBBO including those who continued home antibiotic (n = 27), those prescribed an antibiotic based on clinical suspicion (n = 12), and those prescribed an antibiotic based on duodenal aspirate (n = 2). In 10.2% (n = 15) patients, antibiotics were prescribed without clear clinical indication resulting in 342 antibiotic exposed days and $24,000 in prescription costs. CONCLUSION: Clinical research is greatly needed as it relates to SBBO. In the meantime, the proposed algorithm guides providers through diagnosis and treatment decision-making. Thoughtful antibiotic prescribing is key to optimizing outcomes while minimizing adverse effects of antibiotics. IMPLICATIONS FOR NURSING: The algorithm empowers nursing to minimize antibiotic overuse through collaborative teamwork.

Early Enteral Nutrition in Children With Acute Pancreatitis.

Nutrition is an integral part of acute pancreatitis (AP) management and is not adequately studied in pediatrics. The goal from the present study was to evaluate the effect of nutrition and fat content on the length of stay and pain severity in patients with AP. This is a retrospective review of our nutrition database between May 1, 2014 and December 1, 2014. Pain levels were similar between patients who were allowed to feed and patients kept nill per os. Higher fat intake grams per kilogram per day was associated with significantly lower pain scores. Early feeds are feasible in pediatric patients with AP. Pain was not increased in the group that had more fat in their diet.