MASSIVE RESECTION OF SMALL BOWEL AND TOTAL COLECTOMY: USE OF REVERSED SEGMENT

Segmental reversal of the small bowel can end permanent parenteral nutrition dependency: an experience of 38 adults with short bowel syndrome

OBJECTIVE

This study aimed to assess the results of segmental reversal of the small bowel (SRSB) in patients with short bowel syndrome (SBS) who were "permanently" dependent on parenteral nutrition (PN) and to identify possible prognostic factors for weaning.

SUMMARY BACKGROUND DATA

SRSB is a nontransplant surgical option for patients with SBS who require long-term PN. Few studies have reported outcomes in humans.

METHODS

: All patients who were permanently dependent on PN and underwent a SRSB between 1985 and 2010 for SBS were included. The data were retrospectively retrieved.

RESULTS

Thirty-eight patients underwent SRSB. The median age was 55.5 years (range, 18-76). The median length of the small bowel remnant was 49 cm (20-140), including a reversed segment of 10 cm (6-15). The median follow-up was 57.7 months (1-304). At the 5-year follow-up, 17 patients had been weaned from PN (45%). In the remaining patients, PN dependency had decreased from 7 ± 1 to 4 ± 1 days per week. The survival rate was 84%. The prognostic factors for weaning were a short time between subtotal enterectomy and SRSB (P = 0.036), a longer than typical stay in the nutrition unit (P = 0.035), and an SRSB longer than 10 cm (P = 0.024).

CONCLUSIONS

SRSB has a role as a conservative alternative to small bowel transplantation in patients with SBS permanently dependent on PN. With a segmental reversal of 10 to 12 cm, almost half of the patients can be expected to be weaned from PN.

Short bowel syndrome: parenteral nutrition versus intestinal transplantation. Where are we today?

Current management of short bowel syndrome (SBS) revolves around the use of home TPN (HPN). Complications include liver disease, catheter-related infections or occlusions, venous thrombosis, and bone disease. Patient survival with SBS on TPN is 86% and 75% at 2 and 5 years, respectively. Surgical management of SBS includes nontransplant surgeries such as serial transverse enteroplasty and reanastomosis. Small bowel transplant has become increasingly popular for management of SBS and is usually indicated when TPN cannot be continued. Posttransplant complications include graft-versus-host reaction, infections in an immunocompromised patient, vascular and biliary diseases, and recurrence of the original disease. Following intestinal-only transplants, patient and graft survival rate is 77% and 66% after 1 year. After 5 years the survival figures are 49% and 34%, respectively. Future improvements in survival and quality of life will enhance small bowel transplant as a viable treatment option for patients with SBS.

Segmental reversal of the small bowel as an alternative to intestinal transplantation in patients with short bowel syndrome

OBJECTIVE

This article reports the results of segmental reversal of the small bowel on parenteral nutrition dependency in patients with very short bowel syndrome.

SUMMARY BACKGROUND DATA

Segmental reversal of the small bowel could be seen as an acceptable alternative to intestinal transplantation in patients with very short bowel syndrome deemed to be dependent on home parenteral nutrition.

METHODS

Eight patients with short bowel syndrome underwent, at the time of intestinal continuity restoration, a segmental reversal of the distal (n = 7) or proximal (n = 1) small bowel. The median length of the remnant small bowel was 40 cm (range, 25 to 70 cm), including a median length of reversed segment of 12 cm (range, 8 to 15 cm). Five patients presented with jejunotransverse anastomosis, and one each with jejunorectal, jejuno left colonic, or jejunocaecal anastomosis with left colostomy.

RESULTS

There were no postoperative deaths. Three patients were reoperated early for wound dehiscence, acute cholecystitis, and sepsis of unknown origin. Three patients experienced transient intestinal obstruction, which was treated conservatively. Median follow-up was 35 months (range, 2 to 108 months). One patient died of pulmonary embolism 7 months postoperatively. By the end of follow-up, three patients were on 100% oral nutrition, one had fluid and electrolyte infusions only, and, in the four other patients, parenteral nutrition regimen was reduced to four (range of 3 to 5) cyclic nocturnal infusions per week. Parenteral nutrition cessation was obtained in 3 of 5 patients at 1 years and in 3 of 3 patients at 4 years.

CONCLUSION

Segmental reversal of the small bowel could be proposed as an alternative to intestinal transplantation in patients with short bowel syndrome before the possible occurrence of parenteral nutrition-related complications, because weaning for parenteral nutrition (four patients) or reduction of the frequency of infusions (four patients) was observed in the current study.

Human amniotic membrane as an intestinal patch for neomucosal growth in the rabbit model

This experiment was carried out as a preliminary study, an attempt to grow new intestinal mucosa on human amniotic membrane in the terminal ileum in 37 rabbits. After ketamin sulfate anesthesia at laparatomy, 5-cm ileal defects were patched with human amniotic membrane (5 x 2 cm). These patched intestines were investigated on the first postoperative day and the 2nd, 5th, 10th, and 20th weeks corresponding to 4, 5, 5, 10, and 10 rabbits, respectively. Only three rabbits died in the early postoperative period. There was no evidence of intestinal obstruction or dilatation with barium meal. Microscopically, the neomucosa consisted of a thin layer of columnar epithelial cells at 2 weeks with more maturity of the villi and less irregularity and branching by 20 weeks. All patches were covered with neomucosa commencing at 2 weeks and covering the whole patch area by 20 weeks. This technique's advantages are the large size and the ease of the availability of the human amniotic membrane for neonates at risk without jeopardizing the neonates tissues. It is hoped that this method might be considered when neonatal material is scarce.

Functional adaptation of rat remnant colon after proximal hemicolectomy

Functional adaptation of the remnant intestine after extensive resection of small bowel is well documented. The effects of partial resection of large bowel on the remaining colon have not been characterized. Transepithelial potential (VT), tissue resistance (RT), and short-circuit current (Isc) were measured in vitro across distal colonic tissue of rats three weeks after proximal hemicolectomy with ileotransversotomy and compared to the same parameters measured in the distal colon of control animals. In a second series of experiments, an in vivo perfusion technique was used to measure changes in sodium, potassium, and water transport in distal colon following proximal hemicolectomy. A 2.5-fold increase in VT (P less than 0.01), a 62% increase in RT (P less than 0.001), and a 35% increase in Isc (P less than 0.05) were observed three weeks following hemicolectomy when compared to control animals. A 64% increase in net sodium absorption (P less than 0.025), no significant change in net potassium transport, and a 115% increase in net water absorption (P less than 0.01) were demonstrated in hemicolectomized animals when compared to control. It is concluded that in the rat the distal colon is capable of functional adaptation to increase net sodium and water absorption within three weeks after proximal hemicolectomy. The mechanism responsible for this adaptive process has yet to be defined. Our findings may explain the lack of chronic diarrhea in patients undergoing right hemicolectomy.

Severe short bowel syndrome with a surgically reversed small bowel segment

We report a case of short bowel syndrome (60 cm of jejunum anastomosed to the left colon) with reversal of the distal 15 cm of jejunum in a 21-year-old man. The nutritional absorptive capacity and digestive motility was studied for 18 months postoperatively. His absorptive capacity reached subnormal values allowing him oral nutritive autonomy and normal social life. The results of the manometric study suggested that the reversed segment delayed intestinal transit time. The prolonged contact of the chyme with the intestinal absorptive mucosa possibly increased its absorptive capacity. Our data and the literature reports suggest that reversal of a bowel loop could help wean patients from their dependence on parenteral nutrition.

Short bowel syndrome in infants and children

This article defines short bowel syndrome and reviews the pathophysiology, medical management, and surgical manipulations proposed to improve intestinal absorption. Emphasis is also placed on possible future methods of management.

[Reversal of small bowel segments to delay intestinal passage after total colectomy (author's transl)]

Five female mini-pigs underwent total colectomy including resection of the ileocecal valve. Sparing the terminal rectum, we reformed an end-to-end anastomosis between terminal ileum and remaining rectal cuff. In a second series 8 female mini-pigs have been colectomized using the same model. To delay intestinal passage, in addition a 10-12 cm long reversed segment of terminal ileum has been inserted between small bowel and rectal stump. Both groups were compared with a group of normal unoperated mini-pigs in a study up to 1 year, observing intestinal transit time, blood chemistry and general development of the animals. It could be proved that the reversal of a small bowel segment in colectomized animals leads to a prolongation of the intestinal transit time, to normalization of electrolytes and general appearance. Colectomy was only survived by animals with a reversed segment. The clinical application of a reversed small bowel segment following total colectomy in 1 patient was successful.

Antiperistaltic bowel segment for prevention of ileoproctostomy diarrhea

Persistent diarrhea accompanied by water, electrolyte, and nutritional depletion and skin excoriation can occur following subtotal colectomy with ileoproctostomy. Attempting to improve the course of these patients, an experimental study using dogs was undertaken to evaluate the use of antiperistaltic ileal segment in the management of ileoproctostomy diarrhea. Subtotal colectomy with ileoproctostomy was performed in dogs. One animal died from weight loss and massive diarrhea with water and electrolyte depletion. The surviving dogs had water and electrolyte imbalance and lost an average of 30.6% of their body weight. A second group of animals was treated identically except that an antiperistaltic ileal segment was placed one foot proximal to ileorectal anastomosis. These dogs maintained their weight and electrolyte and water balance. The stools of these animals became solid, as opposed to the watery diarrhea of the animals with ileoproctostomy only. Ileoproctostomy diarrhea can be successfully controlled by the use of antiperistaltic ileal segment.

Treatment of severe postvagotomy diarrhea by reversed jejunal segment

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Antiperistaltic bowel segment in the treatment of the short bowel syndrome

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