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Nutrition and Cancer
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Maintaining Gut Integrity During Parenteral Nutrition of
Tumor-Bearing Rats: Effects of Glucagon-Like Peptide 2
William T. Chance , Sulaiman Sheriff , Teri Foley-Nelson , Ingrid Thomas & A.
Balasubramaniam
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To cite this article: William T. Chance , Sulaiman Sheriff , Teri Foley-Nelson , Ingrid Thomas & A. Balasubramaniam (2000):
Maintaining Gut Integrity During Parenteral Nutrition of Tumor-Bearing Rats: Effects of Glucagon-Like Peptide 2, Nutrition and
Cancer, 37:2, 215-222
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NUTRITION AND CANCER, 37(2), 215–222
Maintaining Gut Integrity During Parenteral Nutrition of
Tumor-Bearing Rats: Effects of Glucagon-Like Peptide 2
William T. Chance, Sulaiman Sheriff, Teri Foley-Nelson,
Ingrid Thomas, and A. Balasubramaniam
Abstract: Maintaining tumor-bearing rats on total pa-
renteral nutrition (TPN) for eight days significantly reduced
mass, protein, and DNA in small intestine and colon.
Coinfusion of glucagon-like peptide 2 (GLP-2) significantly
increased each of these variables in the duodenum, jejunum,
and ileum, but not in the colon. Histological analysis of tis-
sue revealed normal mucosa thickness and villus height in
the small intestine of GLP-2-treated rats, whereas non-
treated rats maintained on TPN exhibited villus shortening
and thinning of the mucosa. Compared with TPN alone, no
significant effects of GLP-2 were noted on tumor growth,
liver weight, or heart weight. Coinfusion of GLP-2 with TPN
had no significant effect on TPN-associated immuno-
suppression, as measured by mitogen-induced proliferation
of cultured splenocytes. Although translocation of bacteria
to the mesenteric lymph nodes appeared to be reduced in
GLP-2-treated rats, the difference between groups was not
statistically significant. These results suggest that hormonal
alterations may be more important than an absence of lu-
minal nutrition in TPN-associated mucosa changes in tu-
mor-bearing rats. Additionally, maintenance of gut integrity
during TPN does not appear to be a sufficient condition for
the avoidance of the negative sequelae associated with this
route of supplemental nutrition.
two decades, however, nutritional support has generally not
produced positive results. Although the goal of nutritional
support is to reduce cachexia and improve survival, clinical
studies (5,6) have not generally demonstrated improved sur-
vival or increased protein accrual subsequent to total
parenteral nutrition (TPN).
In addition to the lack of significant protein accrual (5),
specific problems associated with TPN include intestinal at-
rophy, at least in experimental studies (7,8), and increased
infection rate (9,10). This increased rate of infection appears
to be due in part to decreased immunologic status (11,12) as
well as to increased translocation of bacteria across the in-
testinal barrier (13). Alteration in immune status may occur
through changes in cell- (11) and gut-mediated immunity in-
volving secretory immunoglobulin A (12). The secretory
immunoglobulin A immune system is particularly important
for bacterial translocation, since this immunoglobulin re-
duces bacterial adherence to gut mucosa.
Although the use of liquid enteral nutrition may spare the
small intestine the depleting effects of TPN, studies utilizing
enteral nutrition to replete tumor-bearing (TB) organisms
have also not consistently demonstrated improvement in
host response (14). In addition, in certain circumstances,
such as cancer involving the gastrointestinal system, TPN
must be employed for a period of time. Because immuno-
suppression is characteristic of cancer patients, particularly
if they are receiving chemotherapy or radiation, additional
suppression of the immune response by TPN may lead to
further deterioration of the patient. Therefore, the determi-
nation of nutritional and pharmacological methods to limit
intestinal atrophy and stimulate the immune response during
TPN remains a goal of high priority.
Recent results indicate that a peptide fragment of the
proglucagon hormone glucagon-like peptide 2 (GLP-2) has
intestinal growth-promoting effects in mice (15). Thus,
treating mice for 10 days with GLP-2 at 12.5 µg/day sc ele-
vated mass, protein, and DNA in the small intestine by 50%.
We have also observed that coinfusing GLP-2 with TPN in
Introduction
As early as 1930, Warren (1) identified nutritional deple-
tion as a major cause of death of cancer patients. In addition
to increased mortality, anorexia/cachexia contributes signif-
icantly to cancer morbidity, with malnourished patients
responding less well to therapy (2,3). Therefore, the aggres-
sive use of available cancer therapy may also be severely
limited in anorectic/cachectic patients (4).
A solution to the problem of cancer anorexia and cachex-
ia would appear to be the utilization of nutritional support. In
experimental and clinical studies conducted over the past
W. T. Chance is affiliated with the Medical Research Service, Department of Veterans Affairs, Cincinnati, OH 45220. W. T. Chance, S. Sheriff, T. Foley-
Nelson, I. Thomas, and A. Balasubramaniam are affiliated with the Department of Surgery, University of Cincinnati Medical Center, Cincinnati, OH 45256-
0558.

normal rats at a daily dose of 150 µg/kg totally prevented the
gut atrophy normally associated with this form of nutritional
support (16). In the present study we sought to extend these
observations to nutritional support of TB organisms and re-
port that coinfusing GLP-2 with TPN also prevented gut
hypoplasia in TB rats.
segment were also taken, fixed in 10% buffered formalin,
and stained with hematoxylin-eosin for visualization of mor-
phological changes by observers who were blinded to treat-
ment conditions. Protein (18) and DNA (19) content of the
gut sections were also determined. Tumors were removed
and weighed, and the gastrocnemius muscle was taken for
protein determination as an index of cachexia. To permit de-
termination of organ specificity of GLP-2 effects, the liver,
stomach, and heart were also removed and weighed.
As an estimate of cell-mediated immunity, the mitogen re-
sponse of isolated splenocytes was determined according to
the methods published by Ogle and co-workers (20). The
spleens were rapidly removed aseptically and placed in RPMI
1640. Splenocytes were isolated and adjusted to a concentra-
tion of 2 × 106 cells/ml in 5% heat-inactivated bovine serum
albumin and 1% penicillin-streptomycin. Aliquots (100 µl) of
each cellular suspension were incubated at 37°C in 5% CO2,
and 10 µl (5 µg/ml) of pokeweed mitogen, phytohemag-
glutinin, concanavalin A, or control mitogen were added to
each well. The culture plates were incubated for 24 hours at
37°C (5% CO2) and pulsed with 0.5 µCi of tritiated thymidine
in 10 µl of medium per well 18 hours before cells were har-
vested and counted. Reduced response to the mitogens was
considered evidence of immunosuppression.
Methods
After one week of habituation to the laboratory environ-
ment, methylcholanthrene sarcoma tissue (50 mg) was inoc-
ulated subcutaneously into the midscapular region of 18
male (250–300 g) Fischer 344 rats (Charles River Labora-
tories, Wilmington, MA). The fresh tumor tissue, which was
maintained by serial transplantation every 30 days for sev-
eral years, was provided by a donor rat taken from our tumor
colony. These tumor inoculations were accomplished using
a 4-mm-diameter trocar after anesthetization with halothane
(Halocarbon Laboratories, River Edge, NJ). An additional
six rats received sham inoculations, which involved insert-
ing the empty trocar. Eighteen days later, after anesthetiza-
tion with ketamine and xylazine (80 and 10 mg/kg im,
respectively), Silastic catheters (Dow Corning 602-155)
were surgically implanted into the external jugular veins of
12 of these TB rats. An additional six TB and six non-TB
(NTB, control) rats received sham operations involving
unilateral occlusion of the external jugular vein. These oper-
ations were conducted aseptically, according to our previ-
ously published report (17).
The catheters were connected to syringe pumps (Harvard
Apparatus) by 22-gauge feed-through swivels (Harvard Ap-
paratus) that allowed free movement of the rats inside the
stainless steel metabolic cages. Normal saline was infused
through the catheters for the first three days after surgery at a
rate of 2 ml/h. After this period of adaptation, the rats received
our standard TPN solution, which is isocaloric and
isonitrogenous to the macronutrient content of rat chow. This
TPN formulation was constituted as 6% amino acids
(Freamine III), 21.5% dextrose, and 1.5% lipid and supplies
1.1 kcal/ml (17). In six of the catheterized rats, GLP-2 (hu-
man proglucagon 126–159, American Peptide, Sunnyvale,
CA) was added to the TPN solution at a concentration of 0.5
µg/ml, which was infused at a rate to equal the caloric intake
of the chow-fed rats (2.8 ml/h). The remaining catheterized
rats were maintained on TPN only, at an identical flow rate,
whereas all sham-operated rats continued to be maintained on
rat chow. Rats were maintained on TPN for a total of eight
days, then they were euthanized by decapitation.
The mesenteric lymph nodes were also removed asepti-
cally and cultured for 24 hours on agar plates to provide evi-
dence of the translocation of bacteria from gut sources.
Statistical evaluations were determined using a one-way
analysis of variance, with individual means being compared
post hoc by Tukey’s corrected t-test. All procedures were re-
viewed and approved by the animal care committees at the
respective institutions.
Results
As illustrated in Figure 1, the rats maintained on TPN and
the TB group maintained on chow (TB-chow) grew at a sim-
ilar rate. All TB groups gained body weight at a faster rate
than did the NTB chow-fed (NTB-chow) rats, a common ob-
servation with this animal model of cachexia. This differ-
ence in body weight was primarily due to the presence of the
tumor, with nontumor body weight being decreased signifi-
cantly in TB-chow rats (Figure 2). Although tumor weights
at sacrifice tended to be reduced in the rats maintained on
TPN (47 7 g) or TPN + GLP-2 (47 7 g) compared with
TB-chow rats (66 5 g), the difference was not statistically
significant. Nontumor body weight, however, was reduced
significantly (p < 0.05) in the TB-chow group and restored
to a near-normal level in TB groups maintained on TPN
(TB-TPN; Figure 2). The TB-chow group also exhibited sig-
After the animals were euthanized, the entire small intes-
tine and colon were removed and flushed with ice-cold nor-
mal saline. The small intestine was stretched at a constant
force over a chilled dissection plate and sectioned into duo-
denum (pylorus to ligament of Treitz), jejunum (proximal 20
cm), and ileum (terminal 20 cm), which were frozen in liq-
uid nitrogen. The colon was also removed and flushed, and
10 cm were frozen in liquid nitrogen. Small sections of each
nificant (p < 0.05) anorexia (22.0
1.2 vs. 14.3
2.4
kcal/100 g body wt) by the third infusion day, which was
also 25 days after tumor inoculation. Determination of pro-
tein content of the gastrocnemius muscle revealed signifi-
cant (p < 0.01) depletion in TB-chow rats (251 23 vs. 320
10 mg/muscle), with the content of the gastrocnemius
216
Nutrition and Cancer 2000

NTB-chow rats (p < 0.01). Although colon mass was also
decreased significantly in the TPN group compared with the
NTB-chow rats, GLP-2 treatment had no significant effect
in this area of the gut. Stomach mass was reduced (p < 0.01)
in all TB groups, whereas heart mass was not affected signif-
icantly by any of the treatments. Liver weight was increased
in the TB-TPN + GLP-2 group, but only in comparison with
the NTB-chow (p < 0.01) and TB-chow (p < 0.05) groups.
Determination of protein concentration in the four seg-
ments of the gut (Figure 4) revealed significant (p < 0.01)
loss of protein in the duodenum and jejunum of TB-TPN
rats. As observed with intestinal mass, coinfusing GLP-2
with the TPN completely prevented the loss of protein in
each of these segments. Protein concentration in the ileum
was also increased significantly (p < 0.01) in the TB-TPN +
GLP-2 group. No significant alterations in protein concen-
tration were observed in the colon in any treatment groups.
The concentrations of DNA in the duodenum and jeju-
num were also reduced significantly in TB-TPN rats (Figure
5). Consistent with the observations for protein measure-
ments, adding GLP-2 to the treatment increased DNA con-
centrations in each segment of the small intestine to levels
Figure 1. Body weights of tumor-bearing (TB) and control [non-TB
(NTB)] rats maintained on chow or total parenteral nutrition (TPN) and
treated with glucagon-like peptide 2 (GLP-2). Values are means SE.
Figure 2. Tumor weight and nontumor body weight (BW) of TB and NTB
rats maintained on chow or TPN with and without GLP-2 for 8 days. Values
are means SE.
muscle of TB-TPN rats (273 23 mg/muscle) or TB-TPN +
GLP-2 (283 11 mg/muscle) not statistically significant
from that of NTB-chow or TB-chow.
As summarized in Figure 3, there was significant loss of
small intestine mass in the rats maintained on TPN. Addition
of GLP-2 to the TPN formulation, however, increased the
weight of the small intestine beyond that observed in the
Figure 4. Protein concentrations in segments of small intestine and colon
from TB and NTB rats maintained on chow, TPN, or TPN + GLP-2. Values
are means SE.
Figure 3. Mass of small intestine, colon, and other organs from TB and
NTB rats maintained on chow or TPN and treated with GLP-2. Values are
means SE. gps, Groups.
Figure 5. DNA concentrations in small intestine segments from TB and
NTB rats maintained on chow or TPN and treated with GLP-2. Values are
means SE.
Vol. 37, No. 2
217

greater than those observed in chow-fed rats. DNA concen-
tration was not altered in the colon by any experimental
treatments.
over the past two decades, nutritional support of cachectic
cancer patients employing TPN has generally not produced
positive results in terms of repleting protein or increasing
survival (5,6). Because in certain situations, such as cancer
of the gastrointestinal system, parenteral nutrition must be
employed, delineation of methods to increase its efficacy
would be helpful.
Although much of the research describing problems asso-
ciated with TPN has been done in experimental animals
(7,8,11–13), evidence of morphological and biochemical
changes has also been reported in humans after a period of
TPN (22,23). In addition, reports of complications, infec-
tions (9,10,24), and, apart from pediatric cases, general ab-
sence of clinical improvement (5,6) suggest that TPN may
be inappropriate for repleting cancer patients. Because a
portion of the problem with TPN has been thought to be sec-
ondary to mucosal depletion and translocation of bacteria to
sites outside the gut (13), it was hypothesized that treatments
that spared the mucosa would reduce bacterial translocation
and improve immunosuppression.
The present results demonstrate complete normalization
of gut mass, protein, DNA, and morphology in TB rats
maintained on TPN and treated with GLP-2. Histological
examination of the tissues indicated that the mucosal area of
the gut is the site of savings, with the muscular tissue being
largely unaffected by GLP-2. The increase in tissue DNA
content indicates that the effect is true hyperplasia and not
merely cellular enlargement or nonspecific protein synthe-
sis. An absence of statistically significant increases in the
mass of heart, liver, or stomach compared with the TPN-
alone group suggests that the hyperplastic effect of GLP-2 is
highly tissue specific. This observation is in agreement with
previous reports of the specificity of GLP-2-induced hyper-
plasia to the small intestine (15,16).
In past studies conducted in our laboratory, no significant
alterationin colon mass, protein, or DNAwas observed in rats
maintained on TPN and treated with GLP-2. In the present
study, although colon mass was not increased significantly
after GLP-2 infusion, the significant decrease in rats treated
with TPN alone was obviated. A similar trend was observed
for colon DNA (data not shown). A significant effect of GLP-
2 or of the protease-resistant analog [Gly2]GLP-2, has been
reported for mouse colon tissue (25,26). In these mouse stud-
ies the dose of GLP-2 (5 µg/mouse) was typically twice as
large on a body weight basis (~200 vs. 100 µg/kg/day) as that
used in the present study. In addition, the protease-resistant
analog increased colon mass and protein in situations where
native GLP-2 was without effect (26). Therefore, the effect of
GLP-2 on the colon appears to occur at dosages that are
higher than that required for significant hyperplastic effect of
the native compound on the small intestine.
Histological analysis of sections of duodenum, jejunum,
and ileum supported the positive effect of GLP-2 on gut mu-
cosa in rats maintained on TPN. Representative sections of
jejunum and ileum are presented in Figure 6. In both areas of
the gut, the primary effect in GLP-2-treated rats was to
increase mucosal thickness, with villus height being more
pronounced in these animals. Ileal villi in the TB rats main-
tained on chow or TPN appeared to be flattened, whereas the
villi in the TB-TPN + GLP-2 group appeared better devel-
oped and exhibited more typical apical morphology. Villus
height and total thickness were increased significantly (p <
0.01) in each section of the small intestine, compared with
any other group, in the GLP-2-treated rats (Figure 7). Signif-
icant (p < 0.05) decreases were observed in villus height and
total thickness of TB-TPN rats only in the jejunum. Al-
though crypt depth was not affected significantly in any
group, the villus height-to-crypt depth ratio was also in-
creased in TB-TPN + GLP-2 rats compared with all other
groups for the duodenum (p < 0.01) and ileum (p < 0.05).
There was no difference in this ratio between any other
groups for any sections of the gut.
Figure 8 illustrates the mitogenic response of cultured
splenocytes to phytohemagglutinin, pokeweed mitogen, and
concanavalin A. Each of the TB groups of rats exhibited a
significantly reduced growth response to each of the
mitogens, suggesting suppression of cell-mediated immu-
nity. Administration of TPN or TPN + GLP-2 did not
improve the growth response to any of the mitogens. Assess-
ment of translocation of bacteria to the mesenteric lymph
nodes gave ambiguous results, with all groups exhibiting
some colony-forming units in the node cultures (NTB-chow
= 2/6, TB-chow = 3/5, TB-TPN = 5/5, TB-TPN + GLP-2 =
2/6). Although the mean number of colony-forming units
appeared to be greater in the TB-TPN group (131 69) than
in the TB-chow (2.6 1.5) or TB-TPN + GLP-2 (0.7 0.5)
group, the degree of variability precluded any statistical sig-
nificance.
Discussion
The development of malnutrition is a significant risk fac-
tor for patients with malignancies. Complicating the treat-
ment of cancer patients is the reality that chemotherapy and
radiation often induce an additional anorectic stimulus and
always present a greater metabolic stress burden. Because
unexplained weight loss may be a presenting sign of a malig-
nancy and better nutritional status generally correlates well
with positive postsurgical outcome (2,3,21), the availability
of an adequate method to replete cancer patients before and
after treatment is important.
Despite the normalization of gut mucosa, however,
immunosuppression did not appear to be reduced in TB rats
maintained on TPN and treated with GLP-2. Thus cell-
mediated immunity, as estimated by the mitogenic response
of cultured splenocytes, was decreased in each group of TB
rats. Maintaining the rats on TPN with or without GLP-2 had
A solution to the problem of cancer cachexia would ap-
pear to be found in the utilization of nutritional support.
However, in experimental and clinical studies conducted
218
Nutrition and Cancer 2000

Figure 6. Representative histology sections of jejunum (Rows A and B) and ileum (Rows C and D) from chow-fed control (Rows A and C, Column 1) and TB
rats maintained on chow (Rows A and C, Column 2) or TPN (Rows B and D, Column 1) and treated with GLP-2 (Rows B and D, Column 2). Magnification
×34.
Vol. 37, No. 2
219

Figure 8. Mitogenic response of cultured splenocytes to phytohemag-
glutinin (PHA), pokeweed mitogen (PWM), or concanavalin A (ConA).
Spleens were taken from TB and NTB rats maintained on chow, TPN, or
TPN + GLP-2 for 8 days. CPM, counts per minute.
Figure 7. Villus height (VH) and total thickness (TT) of small intestine
histology sections from TB and NTB rats maintained on chow or TPN and
treated with GLP-2. Values are means SE.
no effect on the immunosuppression. Similarly, transloca-
tion of bacteria to the mesenteric lymph nodes was not re-
duced significantly by the GLP-2 treatment. Although a
suggestion of decreased translocation was present in GLP-2-
treated rats, the degree of variability precluded any chance
of statistical significance. These results are similar to the ob-
servation of Helton and Garcia (27), who reported preserva-
tion of gut mass, protein, and DNA in rats maintained on
TPN and treated with oral prostaglandin E2. As in the present
study, mass of the small intestine was normalized, but trans-
location of bacteria was not affected.
hormone. Furthermore, the greatest response was observed
when all the compounds were administered together, sug-
gesting separate mechanisms of action of the various factors
that may potentiate each other.
In addition to increased mucosa growth, elevated func-
tional activity appears to accompany GLP-2 treatment. Thus
absorption of sugars (40) and amino acids (40) in the small
intestine of rats was increased after 14 days of GLP-2 intra-
venous infusion. The activities of brush-border enzymes
were also reported to be increased in mouse duodenum after
ten days of GLP-2 treatment (41). Suggestions of small in-
testine hyperplasia due to elevated levels of endogenous
GLP-2 come from reports of gut hypertrophy in patients (42)
and mice (15) with tumors that overproduce proglucagon,
from which GLP-2 is derived after translation primarily in
the gut (43). In addition, proglucagon gene expression is in-
creased (44) and circulating levels of enteroglucagon are el-
evated (45) after the development of small bowel resection-
induced gut hypertrophy in the rat. This resection-induced
gut hypertrophy was increased further by treating the ani-
mals with [Gly2]GLP-2 (46). Furthermore, diabetes-induced
gut hypertrophy has been associated with elevated levels of
GLP-2 (47). These studies, along with the many demonstra-
tions of the effectiveness of GLP-2 in stimulating growth of
the small bowel, suggest strongly that it may function nor-
mally to maintain continued growth of this organ.
The GLP-2 receptor has been recently cloned (48), and
the distribution of the receptors appears to correspond to lo-
cations where GLP-2 exhibits its greatest effects. Thus GLP-
2 receptor RNA concentrations were highest in the jejunum,
with sequentially lower levels being found in the duodenum,
ileum, colon, and stomach. In agreement with morphologi-
cal results, no GLP-2 receptor RNA was detected in the
brain, heart, kidney, liver, lung, muscle, or spleen. On the
basis of the differential hyperplastic effects, the receptors in
the proximal small intestine would appear to be most sensi-
tive to GLP-2. However, it is not known whether the prote-
ase-resistant analog [Gly2]GLP-2 bound to the high-affinity
binding site (48) because no value was supplied for this test.
A few other treatments have been shown to produce sig-
nificant savings in gut mucosa of mammals maintained on
TPN. The addition of glutamine to the TPN formula has
been shown to elicit a small savings in intestine protein in
rats, with the effect being potentiated by concomitant epi-
dermal growth factor treatment (28). In humans, adding
glutamine to TPN increased villus height and decreased per-
meability (22). Treatment with urogastrone-epidermal
growth factor has been reported to increase gut mass in rats
maintained on TPN (29). Coinfusing peptide YY with TPN
has also been shown to induce modest savings in rats main-
tained on TPN (30). In addition, gastrin (31), cho-
lecystokinin (31), secretin (31), neurotensin (32), and a
nucleotide-nucleoside mix (33) have been shown to reduce
TPN-induced gut atrophy to some degree. Recent studies
have shown that treatment of rats maintained on TPN with
insulin-like growth factor-I (IGF-I) preserves gut mucosa,
while also increasing mass of other organs (34–36). Thus the
specificity of GLP-2 for small intestine was not observed
with other hyperplastic agents, such as IGF-I (37) or neuro-
tensin (38,39), which may cause growth in other organs or
produce tumors when administered along with TPN. A re-
cent study (26) compared GLP-2, the protease-resistant ana-
log [Gly2]GLP-2, epidermal growth factor, IGF-I, IGF-II,
and human growth hormone for efficacy in increasing bowel
mass in mice. The GLP-2 analog was the most potent of the
compounds tested, and a degree of synergy appeared to exist
when [Gly2]GLP-2 was administered with IGF-I or growth
220
Nutrition and Cancer 2000

7. Dworkin, LD, Levine, GM, Farber, NJ, and Spector, MH: Small intes-
tinal mass of the rat is partially determined by indirect effects of
intraluminal nutrition. Gastroenterology 71, 626–630, 1976.
8. Hughes, CA, and Dowling, RH: Speed of onset of adaptive mucosal
hypoplasia and hypofunction in the intestine of parenterally fed rats.
Clin Sci 59, 317–327, 1980.
However, similar to native GLP-2, this analog did stimulate
cAMP systems and promoted intestinal mucosa growth.
Clearly, further investigation of high-affinity binding of na-
tive GLP-2 and the protease-resistant analog is required to
answer questions concerning whether this receptor is pri-
mary for the hyperplastic effects of GLP-2.
9. Klein, S, Simes, J, and Blackburn, GL: Total parenteral nutrition and
cancer clinical trials. Cancer 58, 1378–1386, 1986.
These results suggest that indirect hormonal effects,
rather than direct stimulation of the gut by food, are respon-
sible for maintaining gut integrity. Thus, even though the gut
lumen was not exposed to food for at least eight days, the
mucosa appeared normal from biochemical and morphologi-
cal assessments. However, improvement in immunosuppres-
sion or bacterial translocation was not found after GLP-2
treatment, suggesting that mechanisms other than depletion
of gut mucosa may be involved in these negative sequelae of
TPN. This conclusion is supported by other reports (49,50)
suggesting that immunosuppression and infections are asso-
ciated with additional factors, including bacterial over-
growth and viability.
Regardless of whether GLP-2 alone will restore the im-
mune system and reduce infection, utilization of this peptide
for a variety of diseases or trauma that involve intestinal de-
pletion or require TPN appears promising at this time. In ad-
dition, induction of tumors and nonspecific stimulation of
organ growth may not present a problem for utilization of
this peptide to preserve gut mucosa. Therefore, it appears
that GLP-2 treatment may be one additional putative thera-
peutic intervention in the nutritional management of absorp-
tion, permeability, and nutrition problems in a variety of
patients.
10. Christensen, ML, Hancock, ML, Gattuso, J, Hurwitz, CA, Smith, C, et
al.: Parenteral nutrition associated with increased infection rate in chil-
dren with cancer. Cancer 72, 2732–2738, 1993.
11. Alverdy, JC, and Burke, DB: Total parenteral nutrition: iatrogenic
immunosuppression. Nutrition 8, 359–365, 1992.
12. Alverdy, J, Chi, HS, and Sheldon, GF: The effect of parenteral nutri-
tion on gastrointestinal immunity. Ann Surg 202, 681–684, 1985.
13. Alverdy, JC, Aoys, E, and Moss, GS: Total parenteral nutrition pro-
motes bacterial translocation from the gut. Surgery 104, 185–189,
1988.
14. Yeung, CK, Smith, RC, and Hill, GL: Effect of an elemental diet on
body composition: a comparison with intravenous nutrition. Gastro-
enterology 77, 652–657, 1979.
15. Drucker, DJ, Ehrlich, P, Asa, SL, and Brubaker, PL: Induction of intes-
tinal epithelial proliferation by glucagon-like peptide 2. Proc Natl
Acad Sci USA 93, 7911–7916, 1996.
16. Chance, WT, Foley-Nelson, T, Thomas, I, and Balasubramaniam, A:
Prevention of parenteral nutrition-induced gut hypoplasia by coin-
fusion of glucagon-like peptide-2. Am J Physiol 273, G559–G563, 1997.
17. Chance, WT, Cao, L, Nelson, JL, Foley-Nelson, T, and Fischer, JE:
Acivicin reduces tumor growth during total parenteral nutrition (TPN).
Surgery 102, 386–394, 1987.
18. Hartree, EF: Determination of protein: a modification of the Lowry
method that gives a linear photometric response. Anal Biochem 48,
422–427, 1972.
19. Lovtrup, S, and Roos, K: Observation on the chemical determination
of deoxyribonucleic acid in animal tissues. Biochim Biophys Acta 53,
1–10, 1961.
20. Ogle, CK, Arita, H, Nagy, H, Wood, S, Palkert, D, et al.: The immuno-
suppressive effects of the in vivo administration of endotoxin as influ-
enced by macrophages. J Trauma 29, 1015–1029, 1989.
21. Smalee, BF, Mullen, JL, Buzby, GP, and Rosato, EF: The efficacy of
nutritional assessment and support in cancer surgery. Cancer 47,
2375–2381, 1981.
22. van der Hulst, RR, van Kreel, BK, von Meyenfeldt, MF, Brummer, RJ,
Arends, JW, et al.: Glutamine and the preservation of gut integrity.
Lancet 341, 1363–1365, 1993.
Acknowledgments and Notes
This study was supported by a Department of Veterans Affairs Merit
Review Grant to W. T. Chance. Address reprint requests to Dr. William T.
Chance, Dept. of Surgery, ML 558, University of Cincinnati Medical Cen-
ter, 231 Bethesda Ave., Cincinnati, OH 45267-0558.
23. Buchman, AL, Moukarzel, AA, Bhuta, S, Belle, M, Ament, ME, et al.:
Parenteral nutrition is associated with intestinal morphologic and func-
tional changes in humans. J Parenter Enteral Nutr 19, 453–460, 1995.
24. Veterans Affairs Total Parenteral Nutrition Cooperative Study Group:
Perioperative total parenteral nutrition in surgical patients. N Engl J
Med 325, 525–532, 1991.
Submitted 16 February 2000; accepted in final form 4 April 2000.
References
25. Tsai, CH, Hill, M, Asa, SL, Brubaker, PL, and Drucker, DJ: Intestinal
growth-promoting properties of glucagon-like peptide-2 in mice. Am J
Physiol 273, E77–E84, 1997.
26. Drucker, DJ, DeForest, L, and Brubaker, PL: Intestinal response to
growth factors administered alone or in combination with human
[Gly2]glucagon-like peptide-2. Am J Physiol 273, G1252–G1262,
1997.
27. Helton, WS, and Garcia, R: Oral prostaglandin E2 prevents gut atrophy
during intravenous feeding but not bacterial translocation. Arch Surg
128, 178–184, 1993.
1. Warren, S: The immediate causes of death in cancer. Am J Med Sci
184, 610–615, 1932.
2. DeWys, WD, Begg, C, and Lavin, PT: Prognostic effect of weight loss
prior to chemotherapy in cancer patients. Am J Med 69, 491–497,
1980.
3. Lanzotti, VJ, Thomas, DR, Boyle, LE, Smith, TL, Gehman, EA, et al.:
Survival with inoperable lung cancer: an integration of prognostic vari-
ables based on simple clinical criteria. Cancer 39, 303–313, 1977.
4. Costa, G: Cachexia, the metabolic component of neoplastic diseases.
Cancer Res 37, 2327–2335, 1977.
5. Shamberger, RC, Brennan, MF, Goodgame, JT, Lowry, SF, Maher,
MM, et al.: A prospective, randomized study of adjuvant parenteral nu-
trition in the treatment of sarcomas: results of metabolic and survival
studies. Surgery 96, 1–12, 1984.
6. Koretz, RL: Parenteral nutrition: is it oncologically logical? J Clin
Oncol 2, 534–538, 1984.
28. Jacobs, DO, Evans, DA, Mealy, K, O’Dwyer, ST, Smith, RJ, et al.:
Combined effects of glutamine and epidermal growth factor on the rat
intestine. Surgery 104, 358–364, 1988.
29. Goodlad, RA, Wilson, TG, Lenton, W, Wright, NA, Gregory, H, et al.:
The proliferative effects of urogastrone-epidermal growth factor
(EGF) on the intestinal epithelium. Gut 28, S37–S44, 1987.
Vol. 37, No. 2
221

30. Chance, WT, Zhang, X, Balasubramaniam, A, and Fischer, JE: Preser-
vation of intestine protein by peptide YY during total parenteral nutri-
tion. Life Sci 58, 1785–1794, 1996.
40. Kato, Y, Yu, D, and Schwartz, MZ: Glucagonlike peptide-2 enhances
small intestine absorptive function and mucosal mass in vivo. J Pediat
Surg 34, 18–21, 1999.
31. Hughes, CA, Bates, T, and Dowling, RH: Cholecystokinin and secretin
prevent the intestinal mucosal hypoplasia of total parenteral nutrition
in the dog. Gastroenterology 75, 34–41, 1978.
41. Brubaker, PL, Izzo, A, Hill, M, and Drucker, DJ: Intestinal function in
mice with small bowel growth induced by glucagon-like peptide-2. Am
J Physiol 272, E1050–E1058, 1997.
32. Wood, JG, Hoang, HD, Bussjaeger, U, and Solomon, TE: Neurotensin
stimulates growth of small intestine in rats. Am J Physiol 255,
G813–G817, 1988.
33. Kishibuchi, M, Tsujinaka, T, Yano, M, Morimoto, T, Iijima, S, et al.:
Effects of nucleosides and a nucleotide mixture on gut mucosal barrier
function on parenteral nutrition in rats. J Parenter Enteral Nutr 21,
104–111, 1997.
34. Inaba, T, Saito, H, Fukushima, R, Hashiguchi, Y, Lin, MT, et al.: Ef-
fects of growth hormone and insulin-like growth factor-I (IGF-I) treat-
ments on the nitrogen metabolism and hepatic IGF-I-messenger RNA
expression in postoperative parenterally fed rats. J Parenter Enteral
Nutr 20, 325–331, 1996.
42. Bloom, SR: An enteroglucagon tumour in man. Gut 13, 520–523,
1972.
43. Mojsov, S, Heinrich, G, Wilson, IB, Ravazzola, M, Orci, L, et al.:
Preproglucagon gene expression in pancreas and intestine diversifies at
the level of post-translational processing. J Biol Chem 261, 11880–
11889, 1986.
44. Jacobs, LR, Bloom, SR, and Dowling, RH: Response of plasma and
tissue levels of enteroglucagon immunoreactivity to intestinal resec-
tion, lactation and hyperphagia. Life Sci 29, 2003–2007, 1981.
45. Taylor, RG, Verity, K, and Fuller, FJ: Ileal glucagon gene expression:
ontogeny and response to massive small bowel resection. Gastro-
enterology 99, 724–729, 1990.
35. Lo, HC, and Ney, DM: GH and IGF-I differentially increase protein
synthesis in skeletal muscle and jejunum of parenterally fed rats. Am J
Physiol 271, E872–E878, 1996.
46. Scott, RB, Kirk, D, MacNaughton, WK, and Meddings, JB: GLP-2
augments the adaptive response to massive intestinal resection in rat.
Am J Physiol 275, G911–G921, 1998.
36. Peterson, CA, Ney, DM, Hinton, PS, and Carey, HV: Beneficial effects
of insulin-like growth factor-I on epithelial structure and function in
parenterally fed rat jejunum. Gastroenterology 111, 1501–1508, 1996.
37. Coppola, D, Saunders, B, Fu, L, Mao, W, and Nicosia, SV: The insu-
lin-like growth factor Lance 1 receptor induces transformation and
tumorigenicity of ovarian mesothelial cells and down-regulates their
Fas-receptor expression. Cancer Res 59, 3264–3270, 1999.
38. Reubi, JC, Waser, B, Schmassmann, A, and Laissue, JA: Receptor
autoradiographic evaluation of cholecystokinin, neurotensin, somato-
statin, and vasoactive intestinal peptide receptors in gastrointestinal
adenocarcinoma samples: where are they really located? Int J Cancer
81, 376–386, 1999.
47. Fischer, KD, Dhanvantari, S, Drucker, DJ, and Brubaker, PL: Intestine
growth is associated with elevated levels of glucagon-like peptide 2 in
diabetic rats. Am J Physiol 273, E815–E820, 1997.
48. Munroe, DG, Gupta, AK, Kooshesh, F, Vyas, TB, Rizkalla, G, et al.:
Prototypic G protein-coupled receptor for the intestinotrophic factor
glucagon-like peptide 2. Proc Natl Acad Sci USA 96, 1569–1573,
1999.
49. Reynolds, JV, Kanwar, S, Welsh, FKS, Windsor, ACJ, Murchan, P, et
al.: Does the route of feeding modify gut barrier function and clinical
outcome in patients after major upper gastrointestinal surgery? J
Parent Enteral Nutr 21, 196–201, 1997.
50. Illig, KA, Ryan, CK, Hardy, D, Rhodes, J, Locke, W, et al.: Total
parenteral nutrition-induced changes in gut mucosal function: atrophy
alone is not the issue. Surgery 112, 631–637, 1992.
39. Maoret, JJ, Anini, Y, Rouyer-Fessard, C, Gully, D, and Laburthe, M:
Neurotensin and a non-peptide neurotensin receptor antagonist control
human colon cancer growth in cell culture and in cells xenografted into
nude mice. Int J Cancer 80, 448–454, 1999.
222
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