Tapering enteroplasty in infants with bowel atresia and short gut

ESPEN guideline on chronic intestinal failure in adults - Update 2023

BACKGROUND & AIMS

In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines.

METHODS

The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly.

RESULTS

The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%).

CONCLUSIONS

It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.

Growing experience of surgical gut rehabilitation: essential role in the management of gut failure in adult patients

PURPOSE OF REVIEW

With the inherent therapeutic limitations of gut transplantation, the concept of surgical gut rehabilitation was introduced to restore nutritional autonomy in pediatric patients. With favorable outcomes in these young patients, there has been increasing interest in the applicability of gut rehabilitative surgery to a growing population of adults with gut failure due to various etiologies. We aim to review the current status of surgical gut rehabilitation for adult gut failure patients in the era of multidisciplinary gut rehabilitation and transplantation.

RECENT FINDINGS

Indications for surgical gut rehabilitation have been gradually expanding, with gut failure after bariatric surgery recently added. Serial transverse enteroplasty (STEP) has been used with favorable outcomes in adult patients, including those with intrinsic intestinal disease. Autologous gut reconstruction (AGR) is the most frequently used surgical rehabilitative method; its outcome is further improved with conjunctive use of bowel lengthening and enterocyte growth factor as a part of comprehensive gut rehabilitation.

SUMMARY

Accumulated experiences have validated the efficacy of gut rehabilitation for survival, nutritional autonomy, and quality of life in adults with gut failure of various etiology. Further progress is expected with growing experience around the world.

Outcome of Tapering Enteroplasty in Managing Jejunoileal Atresia

Background

Jejunoileal atresia (JIA) represents a common cause of neonatal bowel obstruction. There is a discrepancy between the diameters of the proximal and the distal bowel loops and this is managed with excision or tapering of the dilated proximal bowel loop. We aim primarily to evaluate the outcome of tapering enteroplasty (TE) in managing JIA and secondarily to compare the outcome of TE to non-TE.

Materials and Methods

A retrospective analysis of records of all neonatal admissions with JIA from January 2017 to December 2018 at a tertiary university children's hospital. Type and location of atresia, time to full enteral feeds, length of stay (LOS), complications, and outcome were assessed in TE and non-TE groups.

Results

Forty-one patients were included in the study; 29 (70.7%) cases had jejunal atresia and 12 (29.3%) had ileal atresia. Seventeen (41.4%) patients had TE. The median days to full feeds was 19; 28 in the TE group versus 16 in the non-TE group (P = 0.022). Four (9.7%) cases needed a re-exploration because of failure to start feeds; all in the non-TE group. The median LOS was 33 days for TE versus 22 days for non-TE (P = 0.101). Twenty-one cases (51.2%) developed a wound infection and showed a significantly longer median LOS of 29.5 versus 19 days (P = 0.019). Mortality was 7 (17.1%).

Conclusions

TE did not show a superior outcome when compared to resection of the dilated bowel. It was associated with longer time to reach full enteral nutrition and longer LOS.

Autologous Intestinal Reconstruction Surgery in Short Bowel Syndrome: Which, When, and Why

Short bowel syndrome (SBS), secondary to any natural loss or after any extensive bowel resection for congenital malformations or acquired disease, is the most common cause of intestinal failure in children. Extensive introduction of parenteral nutrition (PN) has dramatically changed the outcome of these patients, allowing for long-term survival. The main goal in children with SBS remains to be increasing enteral tolerance and weaning from PN support. Post resection intestinal adaptation allows for achievement of enteral autonomy in a subset of these patients, but the inability to progress in enteral tolerance exposes others to long-term complications of PN. Autologous intestinal reconstruction surgery (AIRS) can facilitate the fulfilment of enteral autonomy, maximizing the absorptive potential of the remaining gut. All the different intestinal reconstruction techniques, from simple procedures like tapering, reversed segments, and colon interposition, to more complex lengthening procedures (LILT: longitudinal intestinal lengthening and tailoring, STEP: serial transverse enteroplasty, and SILT: spiral intestinal lengthening and tailoring) and techniques designed for peculiar problems like controlled intestinal tissue expansion or duodenal lengthening are presented. AIRS indications, clinical applications, and results reported in the literature are reviewed.

Modified Antimesenteric Tapering Enteroplasty: An Alternative Technique for the Treatment of Dysfunctional Anastomosis in Patients With Short Bowel

INTRODUCTION

Several techniques have been described to taper the dilated small bowel to improve intestinal motility and decrease complications related to overdilated small bowel, including longitudinal intestinal lengthening and tapering, serial transverse enteroplasty, and spiral intestinal lengthening and tailoring. We propose an alternative technique designed to optimize bowel function and minimize the effects of recurrent small-bowel bacterial overgrowth in patients with short or ultra-short gut syndrome and dysfunctional anastomosis with maintenance of the actual absorptive surface.

TECHNIQUE

The dilated side-to-side anastomosis is identified, and the mesentery leaves from both the proximal and distal small-bowel loops are separated by using blunt dissection. The previous anastomosis is divided longitudinally with a GI stapler. Once the small-bowel transection is completed, 2 separate blind loops of intestine are created, each one with half the circumference of the dilated side-to-side anastomosis. The antimesenteric stapled line is then reinforced with an outer layer of running suture. The blind loops of the tapered small bowel are then trimmed and anastomosed in an end-to-end isoperistaltic fashion in 2 layers.

RESULTS

There were no postoperative complications. The length of the tapering ranged from 10 to 23 cm, corresponding to approximately 16% (range, 13%-20%) of the remaining small-bowel length. Three of 4 patients presented significant improvement of their symptoms and were able to have their parenteral support discontinued.

CONCLUSIONS

Modified antimesenteric tapering enteroplasty is an alternative technique to improve intestinal motility and treat patients with short-bowel syndrome and dysfunctional side-to-side anastomosis without the need for further small-bowel resection. This bowel-sparing technique represents a valuable option in the armamentarium of the surgeon who manages patients with intestinal failure.

Enhancement of Colonic Absorptive Function after the Massive Resection of the Small Intestine Based on the Creation of an Artificial Colonic Valve

The colon can have an absorptive function similar to that of the small intestine after the massive resection of the small bowel. To improve colonic absorptive function, we created a valve in the colon (artificial colonic valve, ACV). ACVs were created in 20 rats that had 80 percent of their small intestine resected, with an observation time of 30 weeks. The ACV rats were compared with those in the non-operated control group, the short bowel syndrome (SBS) group and the colon interposition (CI) group. The ACV rats were much heavier than those in the control group, SBS group and CI group. In terms of histology and the levels of α-amylase and the Na⁺-dependent bile salt transporter, the absorptive function of the colons before the valves resembled that of the small intestine. The colonic absorptive function was more obvious in ACV rats than in CI rats. An ACV can enhance colonic absorptive function after the massive resection of the small intestine. The colonic absorptive function of ACV rats was better than that of the rats in the CI group.

Intestinal Atresia: Experience at a Busy Center of North-West India

Objective: To evaluate the presentation, management, complications and outcome of intestinal atresia (IA) managed at our center over a period of 1 year.

Materials and methods: Records of patients of IA admitted in our center from January 2015 to December 2015 were retrospectively analyzed. Demographic data, antenatal history, presenting complaints, location (duodenal, jejunoileal, colonic) of atresia, surgery performed and peri-operative complications were noted.

Results: Total 78 cases of IA were included in the analyses. Mean age and weight at the time of presentation was 5.8 days (range 0-50), and 1.9 kg (range 1.1-3.2), respectively. IA included duodenal atresia [DA (32)], jejuno-ileal atresia [JIA (40)], colonic atresia [CA (3)] and atresia at multiple-location (sites) in 3 cases. Ninety percent of patients underwent surgery within 5 to 20 hours of admission. All cases of DA except one underwent Kimura's diamond shaped duodeno-duodenostomy. One case with perforated duodenal web underwent duodenotomy with excision of web. Seven patients with JIA and CA required primary stoma, while rest were managed by excision of dilated proximal segment and primary anastomosis. Complications included anastomotic leak in 5, proximal perforation in 2, functional obstruction in 7, aspiration pneumonitis in 3, and wound infection in 6 patients. Mean hospital stay for survivors was 11 days. Overall survival was 63%.

Conclusion: Late presentation, overcrowding in intensive care unit, septicemia, functional obstruction and anastomotic leak are the causes of poor outcome in our series. Early diagnosis, some modification in surgical technique, use of total parenteral nutrition and adequate investigations for other congenital anomalies may improve the outcome.

ESPEN guidelines on chronic intestinal failure in adults

BACKGROUND & AIMS

Chronic Intestinal Failure (CIF) is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF.

METHODS

The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members.

RESULTS

The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%.

CONCLUSIONS

CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.

Surgical options to enhance intestinal function in patients with short bowel syndrome

PURPOSE OF REVIEW

This review will provide the practitioner with an understanding of the spectrum of nontransplant surgical options for managing patients with short bowel syndrome (SBS).

RECENT FINDINGS

Intestinal lengthening procedures are a promising therapy to allow autonomy from parenteral nutrition. The recently described serial transverse enteroplasty is an effective procedure that is easier to perform and has similar outcomes to the more standard longitudinal lengthening procedure described by Bianchi.

SUMMARY

There are several surgical options for management of the SBS, including construction of intestinal valves or reversed intestinal segments, interposition of segments of colon, or intestinal lengthening procedures. The choice of technique is dictated by the patient's underlying pathophysiology and includes such factors as intestinal transit time, length of remnant bowel, presence of intact colon, and degree of small bowel dilation. Nontransplant surgical interventions are important adjuncts to the elimination of parenteral nutrition dependence and need for intestinal transplantation.

Prognostic factors in jejuno-ileal atresia

OBJECTIVE

Primarily to study morbidity and mortality in jejuno-ileal atresias (JIA) and prognostic factors for outcome. Secondarily to look at the incidence of reintervention.

METHODS

Retrospective review of 63 patients diagnosed with JIA over a 30-year period (1975-2005).

RESULTS

Sixty-three patients (34 male) of mean gestational age 36 weeks and mean birth weight 2,858 g with JIA were studied. There were 14 type I, 14 type II, 16 type IIIA, 9 type IIIB, and 10 type IV atresias. Thirty-three patients (52%) had associated anomalies. Fifty-one patients underwent resection and anastamosis, five patients Bishop-Koop procedure, five ileostomies, and one strictureplasty. Intestinal dilatation severe enough to warrant surgical intervention was seen in seven patients with the more severe variants of atresia. Five tapering procedures, one Bianchi operation and one STEP procedure were performed. Average hospital stay was 41 days (8-332 days). Fifty-six were alive at follow ups averaging 1.7 years (6 months to 11 years). Nine patients needed reoperations for adhesions before the first year of life. There were seven deaths. Most patients who died had associated anomalies (P = 0.017) or types IV/V atresias (P = 0.007).

CONCLUSION

Mild atresias have an excellent prognosis and long-term survival. Severe atresias are associated with longer PN support and secondary procedures for intestinal failure. Associated anomalies adversely affect outcomes in JIA.

Intestinal lengthening for short bowel syndrome

Our recommendation at this time is that surgical bowel lengthening be considered in any chronically PN-dependent patient when there is substantial bowel dilation, regardless of remnant bowel length. Timing is determined when maximal adaptation has been achieved or when the rate of progression in enteral calories is slow and hampered by bacterial overgrowth. Currently, it seems premature to recommend primary STEP in all patients in whom surgical lengthening is considered, but it is certainly technically easier than the Bianchi procedure. These procedures are clearly indicated in patients experiencing life-threatening complications of PN, but careful selection of patients without evidence of hepatic decompensation is important. Patients with advanced liver disease are poor candidates for lengthening and should be referred for intestinal transplantation instead.

Intrauterine omphalic ileal entrapment as an unusual cause of ileal atresia: report of a case

We report a case of ileal atresia (IA) caused by an omphalic ring closure anomaly. A 2-day-old male neonate started vomiting bile, accompanied by abdominal distention. Laparotomy revealed that the distal part of the ileum was entrapped within the omphalic ring and that this entrapped segment of ileum was atretic. To our knowledge, this potential mechanism of IA has not been described before.

Reduced distribution of pacemaking cells in dilated colon

Interstitial cells of Cajal (ICC) act as pacemaker in gastrointestinal smooth muscle. In animals, small bowel dilatation produces a reduction in ICC numbers and in pacemaker function. With resolution of dilatation, ICC numbers and pacemaking function are partially restored. In human colonic disease states, dilatation is associated with dysmotility. The effect of dilatation on ICC distribution has not previously been examined in the human colon. Tissues from a neonate with colonic atresia and a 17-year-old adolescent with acquired megasigmoid were fixed, sectioned and incubated with anti cKit antibodies followed by fluorescent secondary antibodies. Distended and non-distended segments of colon were examined for ICC distribution using immunohistochemistry to c-Kit. Images were obtained with confocal microscopy. In both patients, there was a marked reduction in cKit-immunoreactive cells in the circular muscle and the myenteric plexus of the distended colon compared to the distal non-distended colon. Dilatation of the human colon is associated with a marked reduction in ICC. A resulting loss of pacemaker function could contribute to dysmotility associated with distension. Further studies assessing pacemaking function in human subjects and investigating reversibility of ICC disruption may allow new therapeutic strategies.

Operative strategies for necrotizing enterocolitis: The prevention and treatment of short-bowel syndrome

Necrotizing enterocolitis (NEC) is the leading cause of short-bowel syndrome (SBS) in infancy. Studies on the acute medical and surgical management of NEC have traditionally focused on short-term morbidity and mortality, with less emphasis on long-term outcomes. Acute surgical management of NEC involves the often competing priorities of controlling sepsis and preserving bowel length. Bowel-preserving strategies for NEC, designed to limit SBS, are based on peritoneal drainage, limited resection, or a combination of both. Drainage-based strategies are generally favored in smaller neonates, while laparotomy-based strategies are favored in larger patients, especially those with a more limited extent of intestinal injury. Comparisons of drainage-based approaches and resection-based approaches are limited by confounding variables, and neither approach is clearly superior with regard to subsequent SBS. These traditional as well as more creative approaches to bowel preservation have application in NEC, yet they depend on a series of patient and treatment characteristics that include the ability of diseased but viable bowel to recover both absorptive and motility function after acute NEC, the ability of the infant to tolerate appropriately drained intraperitoneal contamination, and the ability of the injured intestine to subsequently undergo intestinal adaptive change. In addition, there are a series of operative options that have been designed to mitigate the impact of SBS once it is established. These procedures are not uniquely applied exclusively for NEC-induced SBS. However, strategies that slow intestinal transit, improve peristaltic function, or enhance mucosal absorptive function each have application in the management of SBS.

Tissue engineering of the gastrointestinal tract for surgical replacement: a nutrition tool of the future?

Optimal nutrition depends on the multiple complex functions performed by the gastrointestinal tract, which range from basic functions such as storage, conduit and mechanical processing to more finely regulated capabilities such as vectorial transport, immune defence and cell signalling. Surgical strategies to supply lacking gastrointestinal tract tissues have relied on either replacement by proxy (surgical substitution) or the introduction of prostheses. Tissue engineering seeks to replace missing tissues with engineered tissues that more accurately reproduce the native physiological and anatomical milieu. It is now possible to engineer several areas of the gastrointestinal tract with high fidelity, and to employ tissue-engineered bowel in replacement in animal models. These replacement models have reflected excellent anatomical and physiological recapitulation of native bowel by the tissue-engineered constructs in vivo.

Proximal Malecot vent in neonatal small-bowel anastomosis

We describe a simple technique of venting the dilated intestine proximal to a small-bowel anastomosis in nine neonates that promoted uneventful healing and early enteral feeding.

Small bowel tissue engineering using small intestinal submucosa as a scaffold

BACKGROUND

Small intestinal submucosa (SIS) is an extracellular matrix used in tissue engineering studies to create de novo abdominal wall, urinary bladder, tendons, blood vessels, and dura mater. The purpose of this study is to evaluate the feasibility of using SIS as a scaffold for small bowel regeneration in an in situ xenograft model.

MATERIALS AND METHODS

Twenty-three dogs had a partial defect created on the small bowel wall which was repaired with a SIS patch. Four dogs underwent small bowel resection with placement of an interposed tube of SIS. The animals were followed 2 weeks to 1 year.

RESULTS

Three of the 23 dogs with SIS placed as a patch died shortly after surgery due to leakage from the site. The other 20 dogs survived up to time of elective necropsy with no evidence of intestinal dysfunction. At necropsy, the bowel circumference in the patched area had no stenosis. Histological evaluation showed the presence of a mucosal epithelial layer, varying amount of smooth muscle, sheets of collagen, and a serosal covering. Architecturally, the layers were not well organized in the submucosal region. An abundance of inflammatory cells was present in the early postoperative period but receded with time. All 4 dogs with a tubular segment of SIS interposed had significant problems. One had partial obstruction at 1 month, and 3 died in the early postoperative period due to leakage.

CONCLUSIONS

This preliminary study suggests that SIS patches can be used for small bowel regeneration. Tubular segmental replacement is not feasible at this time.

Abnormalities of enteric neurons, intestinal pacemaker cells, and smooth muscle in human intestinal atresia

BACKGROUND/PURPOSE

Intestinal dysmotility, which usually has been encountered in the severely dilated proximal segment, is an important problem in postoperative management of patients with intestinal atresia (IA). Changes of enteric nerves had been histochemically examined in both the proximal and distal segments of IA, but a systemic immunohistochemical analysis is still lacking. The aim of this study was to examine precisely alterations of neuronal and muscular elements and pacemaker cells in intestines from patients with IA.

METHODS

Resected intestines were obtained from 5 patients with ileal atresia, 3 patients with jejunal atresia, and 3 controls without gastrointestinal diseases (congenital diaphragmatic hernia). All specimens were immunochemically stained with a monoclonal antibody to alpha-smooth muscle actin (SMA) as a smooth muscle marker, polyclonal antibodies to protein gene product (PGP) 9.5 as a general neuronal marker, and to c-kit protein as a maker of intestinal pacemaker cells. In addition, all specimens also were stained by NADPH-diaphorase (NADPH-d) to know the distribution of inhibitory nitrergic nerves.

RESULTS

A hypoplasia of the myenteric ganglia and a marked reduction of intramuscular nerve fibers, including nitrergic neurons, were observed in the dilated proximal segment of IA. C-kit-positive cells were localized around the myenteric plexus, but rarely found within the muscularis propria in the proximal segment. The distribution of nerves and c-kit-positive cells in the distal segment was comparable with that seen in controls. A reduced staining intensity for alpha-SMA was mainly observed in the hypertrophic circular muscle layer of the proximal segment.

CONCLUSIONS

A hypoplasia of intramural nerves and pacemaker cells was seen predominantly in the proximal segments of IA. Hypertrophy and reduced immunoreactivity for alpha-SMA also were observed in the circular muscle layer of the proximal segment. These alterations of the proximal segment may thus contribute to the postoperative intestinal dysmotility in IA cases.

Alterations of the intramural nervous distributions in a chick intestinal atresia model

The postoperative intestinal dysmotility seen in intestinal atresia (IA) is usually found in association with a dilatation of the proximal intestinal segment, but the etiology of this disorder is not yet fully understood. A chick IA model was made by cutting the postumbilical midgut on d 11 in ovo. The operated chicks were euthanized 2 d after hatching. The samples were divided into two groups according to the extent of the dilatation of proximal ileal segments. Cryostat sections were processed for immunohistochemistry by the use of antisera to protein gene product 9.5, vasoactive intestinal polypeptide, substance-P, and alpha-smooth muscle actin and were also stained by NADPH-diaphorase. Tn highly dilated proximal segments, a decreased number of protein gene product 9.5-positive fibers was found in both the circular muscle and submucous layers. The number of nerve fibers positive for vasoactive intestinal polypeptide, substance-P, and NADPH-diaphorase also decreased in the circular muscle layer, particularly in the deep muscular plexus. Hypertrophy and an alteration of the staining intensities in the circular muscle layer were also revealed by a-smooth muscle actin staining. The nerve distribution of the distal segments was indistinguishable from that of the age-matched controls and the sham-operated group. Abnormalities in the intramural nerves are only found in the proximal ileal segment of the IA models. The abnormal nerve distribution of the proximal segment might thus be implicated in the postoperative dysmotility of the intestine in IA.

Short bowel syndrome

Short bowel syndrome has significant morbidity and is potentially lethal especially when intestinal loss is extensive. The pathophysiology of short bowel syndrome, its aetiology, prognosis and our understanding of the mechanisms of adaptation are reviewed. Management by a multi-disciplinary nutritional care team is advocated and should be directed to the maintenance of growth and development, the promotion of intestinal adaptation, the prevention of complications and the establishment of enteral nutrition. The choice of enteral feed, the role of drugs and the use of pro-adaptive nutrients and agents are discussed. Complications including cholestasis and catheter related sepsis are outlined with strategies to reduce them. Finally the roles of secondary surgical interventions including transplantation are discussed.

Autologous gastro-intestinal reconstruction: the composite ileo-colic loop

A reproducible technique was developed experimentally in pigs for construction of a 'composite bowel tube' (CBT) made up of ileal mucosa that was grafted to a mucosally denuded colonic muscle surface vascularised by the colonic mesentery. Macroscopic and microscopic studies at terminal laparotomy revealed a viable, mucosally lined, patent peristaltic loop of bowel in six of the eight animals. Two animals died after sloughing the grafted mucosa. In vivo absorption studies, using l-alanine as an index of amino acid absorption, showed a transport pattern through the grafted mucosa of the composite ileo-colic loop appropriate to ileum when compared with controls. The CBT constitutes another autologous gastro-intestinal reconstructive technique for redistribution of available absorptive mucosa over a longer intestinal length, and may therefore be of benefit in the management of the short-bowel syndrome.

Edgar J. Poth Memorial Lecture. Surgical aspects of the short-bowel syndrome

BACKGROUND

Surgeons are frequently confronted with patients with the short-bowel syndrome. Important surgical issues are maintaining intestinal continuity, treating complications, and performing procedures to improve intestinal function.

METHODS

A comprehensive review of the English language literature and the author's own experience were employed to make recommendations about surgical management of the short-bowel syndrome.

CONCLUSION

At the time of initial resection, ostomy formation is often prudent. The decision to restore continuity at a later time should balance anticipated functional outcome against potential complications. Several surgical strategies can be employed at reoperation in these patients to minimize further loss of intestine. Prophylactic cholecystectomy should be considered because of the increased risk of cholelithiasis. Gastric hypersecretion rarely requires operative therapy. Surgical therapy for the short-bowel syndrome includes procedures to slow intestinal transit, optimize intestinal function, and increase intestinal surface area. The choice of operation is influenced by intestinal remnant length and caliber and its function. Only a small proportion of patients are candidates for nontransplant procedures, of which intestinal lengthening is most efficacious. Intestinal transplantation, either alone or combined with the liver, is emerging as the most promising therapy in short-bowel syndrome.

Jejunal mucosal function of the isolated bowel segment created by omentoenteropexy in dogs: a study by in situ luminal perfusion

An isolated bowel segment (IBS) was created in dogs by omentoenteropexy, using staged procedures. (1) Omentoenteropexy was performed at the antimesenteric border of a 15-cm jejunal segment, which was exteriorized at both ends (IBSB). (2) After 6 weeks, once dual vascularization to the IBS had been established, its mesentery was divided (IBSA) or longitudinally split, thus achieving its elongation (IBSE). A control dog underwent a Thiry-Vella (T-V) loop procedure of an identical jejunal segment. Viability of the IBSB and IBSA was previously proven by the authors, through angiographic studies. In the present study, the absorption capability of IBS variants was assessed using in situ luminal perfusion, with a bicarbonate buffer containing glucose and labeled glycine. Jejunal transport rates of these solutes were calculated from the differences in their concentrations in the perfusion solution and in the effluent. Comparisons were made among the IBS variants and between them and the T-V loop. No significant difference in the absorption capability of glucose and glycine was noted between the various IBS variants. There was a marked reduction of glucose absorption and a moderate reduction of glycine absorption in all IBS variants. when compared with the fresh T-V loop, most probably because of disuse atrophy of the mucosa. In conclusion, absorption of glucose and glycine is preserved in the IBS, created by omentoenteropexy, both after its mesenteric division and following the IBS elongating procedure.

Creation of the isolated bowel segment in animals by omentoenteropexy

An isolated bowel segment (IBS) was created in rats and dogs by a two-stage procedure. Initial coaptation of the bowel segment to the omentum ("omentoenteropexy") is followed by division of its mesentery several weeks later. The viability of the segment is maintained by angiogenesis at the coaptation site. Neoformed blood vessels were shown by angiographic studies, and in a dog the IBS was used for esophageal interposition.

Short bowel syndrome: metabolic and surgical management

The management of short bowel syndrome requires long-term nutritional support and monitoring, medication, and occasionally additional surgical procedures. Constant attention is required to ensure adequate adaptation of the gut. This article reviews the normal function of the small bowel, adaptation following resection, total parenteral and enteral nutrition, and the role of adjunctive surgical procedures in the management of short bowel syndrome.

Management of the short bowel syndrome in the pediatric population

The short bowel syndrome in the pediatric population most commonly results from neonatal necrotizing enterocolitis. Multiple remedial surgical procedures have been developed to manage the rapid intestinal transit, decreased mucosal surface area, ineffective peristalsis, and short intestinal length in these patients. Despite significant morbidity, the overall outcome is favorable and warrants aggressive nutritional support, medical management, and surgical intervention in selected patients.

Duodenal manometry in postobstructive enteropathy in infants with a transient enterostomy

Intestinal motility was studied in 11 children with a transient enterostomy secondary to a neonatal organic small intestine obstruction (5 total colon Hirschsprung's disease, 2 necrotizing enterocolitis, 1 intussusception, 3 ileal atresia). Eight children presented with a postobstructive enteropathy (severe grade I [5], moderate grade II [3]) and three were considered as controls (grade III). They were assigned to one of the three groups on the basis of the duration of parenteral nutrition and constant rate enteral nutrition needed and the oral feeding tolerance. Barium small intestine transit showed no persistent partial obstruction or peritoneal adhesions. The abnormal inert marker transit times were statistically correlated with the clinical groups as well as duodenal manometric abnormalities. Manometric recordings were characterised by the absence (grade I) or abnormal phase III (grade II) of the migrating motor complex and decreased motility index (grades I and II). This study confirms that this enteropathy is due to a chronic alteration in motility induced by prenatal or postnatal obstructions.

Postobstructive enteropathy in infants with transient enterostomy: its consequences on the upper small intestinal functions

Repeated or prolonged organic obstruction of the small intestine in the neonatal period can lead to severe refeeding problems, despite a transient ostomy. These problems are thought to result from a postobstructive enteropathy (POE) of the apparently normal small intestine segment above the obstruction. Ten infants with a POE, characterized by limited oral caloric and carbohydrate intakes and increased ostomy effluent, were compared with 8 controls with an enterostomy and a normal postoperative refeeding pattern. There was no statistical difference in the histomorphometric appearance of the mucosa or its digestive or absorptive capacity (brush-border hydrolases, glucose transport) between the two groups. The effluent and duodenal floras of the two groups were similar. However, all POE patients showed significant abnormal peristalsis characterized by barium and carmin transit times. This suggests that repeated or prolonged obstruction in the neonatal period could lead to a POE, caused by chronic motricity abnormalities of the small intestine above the obstruction. Although this POE is more frequent after small bowel atresia, it may also occur with other conditions causing prenatal and postnatal intestinal obstruction.

Experience with intestinal lengthening for the short-bowel syndrome

Patients with the short-bowel syndrome frequently develop dilated intestinal segments that may lead to impaired motility and malabsorption. Although intestinal tapering alone improves motility, the intestine can be lengthened as well. We reviewed our experience with six children undergoing intestinal lengthening to improve intestinal absorption secondary to the short-bowel syndrome. The procedure was performed by dissecting the vessels along the mesenteric border and dividing the intestine longitudinally with a stapler. Five patients were receiving total parenteral nutrition (TPN) and one was becoming malnourished with enteral feedings alone. Bacterial overgrowth was documented in four patients and abnormal liver function in three patients. The intestinal segments were dilated up to 10 cm in diameter and remnant length ranged from 15 to 79 cm. Segments 5 to 25 cm in length were divided, resulting in an average increase in length of 52%. Necrosis of one of the divided limbs necessitated resection in one patient. Follow-up ranged from 2 to 84 months. TPN has been discontinued in four patients and avoided in another. Symptomatic improvement occurred in all patients. We feel the tapering and lengthening procedure should be considered in patients with symptomatic, dilated intestinal segments in whom the need for TPN may potentially be obviated.

Management of the short-bowel syndrome

The patient with short-bowel syndrome after massive small-intestinal resection represents one of the greatest clinical challenges a general surgeon must face. Maintaining optimal nutritional and metabolic support until maximum bowel adaptation can occur is the top priority of therapy. Currently, no operative procedure for adjunctive management of the short-bowel syndrome is sufficiently safe and effective to recommend its routine use. Long-term parenteral nutrition remains the cornerstone of successful management.

Lethal short-bowel syndrome

Infants with short-bowel syndrome are difficult to manage. Despite supportive measures with parenteral nutrition and surgery to lengthen remaining bowel or increase functional absorptive surface area, the outcome for many of these infants is poor. We have reviewed a series of seven infants diagnosed with severe short bowel. Causes included volvulus (3), multiple atresias (2), and total intestinal aganglionosis (2). Survival time ranged from 15 days to 8 months. During the hospital course, each infant underwent one to three operative procedures to diagnose and manage the short bowel and all received total parenteral nutrition (TPN) ranging from 10 days to 6 months. One infant died of liver failure and two others developed significant liver dysfunction secondary to TPN. Most infants remained hospitalized until their death. Death occurred at an average of 9 weeks following the diagnosis of short-bowel syndrome. This review suggests that infants with less than 6 cm of small bowel beyond the Ligament of Treitz will inevitably die of their disease or treatment complications. Until bowel transplant becomes a viable alternative, operative intervention and nutritional support may prolong survival but will not change the outcome of these infants and will only contribute to additional morbidity. A decision to withhold further therapy would be reasonable at the time the diagnosis is established.

Adaptation of jejunal to colonic mucosal autografts in experimentally induced short bowel syndrome

The behavior of jejunal to colonic mucosal autografts was studied in an experimental animal model of short bowel syndrome (SBS). Histological appearances, enterocyte enzyme activities, and in vitro glucose transport were studied at the donor and recipient graft sites in control, short-bowel syndrome, and gastrocolic fistula 5-week-old Sprague-Dawley rats. Small intestinal function was maintained in the jejunocolonic graft after 80% small bowel resection; animals in which small bowel was not resected showed loss of graft function and enzyme activity. This effect is dependent on the presence of jejunal chyme: after gastrocolic fistulae, the jejunum to colon grafts lost jejunal functional activities. Total parenteral nutrition did not alter graft behavior but improved the postoperative mortality of the procedures. The results provide additional information on intestinal adaptation in SBS.

Surgical techniques in short bowel syndrome

An operation according to Bianchi in a 2-year-old girl is described and indications as well as technical procedure are discussed. The girl was born with a gastroschisis. There was a jejunal perforation 10 cm below the ligament of Treitz caused by a volvulus. Only 20 cm of the jejunum remained. Moreover, only the left part of the colon was present. Total parenteral nutrition for 2 years was necessary. The principle of the operation is based on a longitudinal division of the remaining bowel and a creation of two separate bowel tubes out of the divided bowel halves, thus effecting an isoperistaltic serial connection by means of two anastomoses. This is technically possible since each half of the bowel wall has its own blood supply. The vessels originating from the mesenterium branch off before they reach the bowel wall so that the mesenteric dissection line can be anastomosed longitudinally with the antimesenteric border. This results in doubling of the bowel length, narrowing of the preoperatively dilated bowel diameter, closer contact of bowel contents with the mucosa, prolonged transit time and a Bacteroides colonization which is reduced by more effective peristalsis. Indications, time of operation and our own experiences are discussed and three cases are described. All children are alive and show marked improvement in nutrition.

Polysplenia and jejunal atresia with agenesis of the dorsal mesentery

Polysplenia syndrome has been well described. It is associated with gastrointestinal atresia in patients with situs inversus abdominus; however, it appears that this case represents the first occurrence of polysplenia with jejunal atresia having agenesis of the dorsal mesentery and partial situs inversus abdominus.

Intestinal atresia: factors affecting survival

Eighty-four patients with congenital jejuno-ileal or colonic atresia treated at this hospital during the years 1961-86 were studied. There were 42 cases of jejunal atresia, seven cases of jejuno-ileal atresia, 33 cases of ileal atresia and two cases of colonic atresia. Multiple atresias occurred in 19 patients. During the first 15 years of the study the mortality rate was 56%. In the last 10 years it was 22%. Multivariate linear modelling techniques were used to determine the factors associated with a fatal outcome. In order of magnitude associations were found between death and year of treatment (P less than 0.01), the type of anastomosis performed to correct the atresis (P less than 0.05), the presence of other congenital abnormalities (P less than 0.01) and presence of a malrotation (P less than 0.02). The anastomoses associated with the highest mortality were those with a stoma. The mean length of bowel resected proximal to the anastomosis was 15 cm and the mean length resected distally 5 cm. Eleven patients had 60 cm or less of small bowel remaining after surgery and only three of these survived. The highest mortality rate can be expected in patients with other congenital abnormalities and those with a malrotation. A primary anastomosis without a stoma is recommended.

Myoelectric activity differences in acute and chronic models of lamb intestinal atresia

Clinical and experimental investigations of intestinal atresia have reduced mortality and clarified etiology. However, the morbidity of this lesion remains excessive and its pathophysiology uncertain. The purpose of this project was to produce the first long-term model of intestinal atresia and thereby to study the motility of the adapting bowel. Intestinal atresia was induced in nine fetal lambs at midgestation by mesenteric avulsion. At term, this experimental group and eight control lambs underwent resection with anastomosis, decompression gastrostomy, and implantation of electrodes proximal and distal to the anastomosis. Vigorous resuscitation and constant intensive care were critical for survival. Slow wave activity (SWA) and spike potential activity (SPA) were recorded in the first 24 hours and every 48 hours thereafter for a 6-hour interval. Three of nine lambs with atresia and five of the eight control animals survived over 48 hours (chronic). Analysis of 220 hours of recording showed, in the first 24 hours of life, a statistically significantly different SWA of 16.4 cycles/min (+/- 1.15 SD) in the chronic atretic survivors compared with 13.1 cycles/min (+/- 2.6 SD) in the acute (died less than 48 hours) atretic group (P less than .05). The SWA of the chronic atretic survivors was similar to the SWA of the chronic nonatretic control animals, 15.1 cycles/min (+/- 1.4 SD). SPA was present on the first day of life in the microintestine of the chronic atresia group in contrast to the acute animals of this study and of Doolin and Hill's previous study. Delayed function has been attributed to the absence of SPA in the microintestine of acute models.(ABSTRACT TRUNCATED AT 250 WORDS)

Motility abnormality in intestinal atresia

This study was designed to investigate the motility of the small bowel of the lamb under the conditions of experimental intestinal atresia. Of 26 fetal lambs operated upon (50 to 90 days gestation), 13 came to term. All term lambs exhibited a type 3a atresia. Six were successfully repaired and had intestinal myoelectric activity monitored for periods from 2 to 27 hours. A slow wave pattern (12 to 13/min) was present in the bowel of control lambs and in the proximal dilated bowel and the microbowel of atretic lambs, confirming the presence of functional smooth muscle. Spike potentials, which indicated circular muscular contractions, occurred 10% of the time in the control intestine, 5% in the proximal dilated gut (P less than .2), and 0% in the microbowel (P less than .001). A previously undescribed myoelectric transient of variable amplitude and frequency (6 to 24/min) was identified in all lambs studied. Histologic evaluation demonstrated villous hyperplasia in the microbowel and mucosal flattening in the distended bowel. The data suggest that the quiescent microbowel distal to the atresia contributes significantly to the functional obstruction.

Strategies for preserving intestinal length in the short-bowel syndrome

Total parenteral nutrition now permits long-term survival in patients after massive intestinal resection. Surgical therapy for the short-bowel syndrome is still largely experimental and cannot be recommended routinely. Thus, prevention of intestinal resection and conservation of intestinal length, when resection is necessary, should be emphasized. Strategies are presented that can be employed to preserve intestinal length when surgery is required in patients with a shortened bowel. These include strictureplasty, minimal resection, serosal patching, and intestinal tapering. In suitable candidates strictureplasty can relieve obstruction from strictures while avoiding resection. Minimal resection of involved intestine can be performed safely in selected patients with radiation injury or Crohn's disease. Serosal patching is an alternative to resection for the treatment of perforation or strictures of the intestine. Intestinal tapering can improve the function of dilated intestinal segments and eliminate the need for resection in intestinal atresia. The judicious use of these procedures can preserve intestinal length and obviate the need for long-term parenteral nutrition in patients after massive intestinal resection.

Surgical management of multiple intestinal atresias

The unusual problem of multiple intestinal atresias associated with jejunal atresia has been reviewed and seven cases have been summarized. Maintaining maximal bowel length without jeopardizing the patient is of utmost importance. The shish kebob technique has been illustrated in a patient with 15 obstructions. The other cases include one patient with the apple peel deformity and two with atresias associated with gastroschisis. Although these children are small in general, they are bright and otherwise healthy. The 90 percent mortality reported previously has been reversed by a combination of techniques and lessons learned from the leaders in pediatric surgery.

Short bowel syndrome in infancy and childhood. Analysis of survival in 60 patients

This report concerns 60 infants and children with short bowel syndrome, most commonly caused by necrotizing enterocolitis in this study. Resection of atretic or gangrenous bowel was performed in 53 patients, tapering enteroplasty and primary anastomosis was performed in 13 patients, and temporary enterostomies were performed in 40 patients. Second-look laparotomy was useful in two of four cases of questionable bowel viability. The ileocecal valve was resected in 33 patients and remained intact in 27. The mean length of remaining bowel was 58.4 cm (range 13 to 150 cm). Seven patients with total aganglionosis and mid to proximal small bowel extension were managed with an initial enterostomy, whereas three had a pull-through procedure with an aganglionic patch enteroplasty. All patients received total parenteral nutrition and early enteral feedings. Home hyperalimentation was attempted when 50 percent of the calorie intake was enteral. Intestinal adaptation required from 3 to 14 months. Frequent setbacks were related to catheter sepsis, rotavirus infection, carbohydrate intolerance, and liver dysfunction. The overall survival rate was 85 percent, with mortality due to liver failure and sepsis associated with total parenteral nutrition.

Surgical therapy for the short bowel syndrome

The introduction of total parenteral nutrition has resulted in more patients surviving massive intestinal resection. Long-term parenteral nutrition is expensive, has potential complications, and causes inconvenience for the patient. Therefore, interest persists in surgical therapy for the short bowel syndrome. The goals of surgical therapy in the short bowel syndrome are to slow intestinal transit, increase the area of absorption, and reduce gastric hyperacidity. Patients with sufficient absorptive area, but rapid intestinal transit, benefit from antiperistaltic segments or colon interposition. Intestinal valves yield inconsistent results. Recirculating loops are associated with prohibitive morbidity and mortality. Experience with intestinal pacing is limited. Patients with dilated bowel segments may benefit from intestinal tapering or lengthening. Growing neomucosa holds promise but has not been evaluated clinically. Recent improvement in the results of intestinal transplantation in animals may warrant clinical trials. The efficacy of H2 receptor antagonists makes procedures for reducing gastric hyperacidity less necessary. None of the operations to treat the short bowel syndrome are sufficiently safe and effective to recommend their routine use. Operations should be performed only on selected patients to achieve specific goals. Although investigation continues, our emphasis should continue to be conservation of as much of the intestine as possible when massive resection is necessary.