Nutritional support of the pediatric surgical patient.

This review discusses the important developments in pediatric surgical nutrition over the past year. Sepsis and total parenteral nutrition-associated cholestasis remain complex problems for patients on total parenteral nutrition. Investigations suggest that total parenteral nutrition may compromise bactericidal activity, increasing the risk of sepsis. Sepsis possibly sensitizes the liver to cholestatic injury. Small volume enteral feeds may restore immune system function. Current research does not support an association between phytosterols in parenteral lipid solutions and total parenteral nutrition-associated cholestasis. Methionine has been identified as a potential hepatotoxin. Ursodeoxycholic acid and S-adenosyl-L-methionine are the most promising treatments of total parenteral nutrition-associated cholestasis. Small bowel transplant is now a reasonable option for patients with irreversible intestinal failure. Patient and graft survival rates have improved with FK-506 (Tacrolimus) immunosuppression. Isolated intestinal grafts have the best survival rate (92% at 1 year). Most surviving graft recipients are weaned off of total parenteral nutrition. The Cox Proportional Hazard model may help to identify candidates for small bowel transplant. This equation predicts the duration of dependence on total parenteral nutrition. Patients with irreversible intestinal failure can then be referred for early small bowel transplantation.