From the cradle to enteral autonomy: the role of autologous gastrointestinal reconstruction

Controlled tissue expansion in the initial management of the short bowel state

The treatment of short gut syndrome has evolved dramatically during the past decade. The combination of surgical techniques and medical management in the context of a multidisciplinary approach has improved the outcomes of these children. The authors describe in detail their technique of controlled tissue expansion of the bowel before lengthening procedures. Monitoring of the child and troubleshooting actions during the controlled tissue expansion program also are discussed.

Neonatal short bowel syndrome

Neonatal short bowel syndrome is a disease with a high morbidity and mortality. The management of these patients is complex and requires a multidisciplinary approach. Recent advances in medical and surgical treatment options have improved outcomes. The following review highlights salient points in the management of this challenging patient population.

Antenatal diagnosis of bowel dilatation in gastroschisis is predictive of poor postnatal outcome

PURPOSE

Although gastroschisis infants usually have a good outcome, there remains a cohort of babies who fare poorly. We inquired whether the presence of bowel dilatation in utero is predictive of postnatal course in infants with gastroschisis.

METHODS

We compared the clinical course of infants who had bowel dilatation with those who did not. Bowel dilatation was defined as more than 20 mm in cross-sectional diameter on ultrasound at any gestational age. Outcome measures used were length of time of parenteral nutrition, death, and surgery for intestinal failure.

RESULTS

A review of 170 infants with gastroschisis identified 74 who had dilatation of more than 20 mm (43.5%). There was no significant difference in the incidence of intestinal atresia in those with bowel dilatation and those without (P = .07). Those with bowel dilatation spent a longer period on parenteral nutrition. There were significantly more deaths in the group with bowel dilatation (P = .01). There was no significant difference in the number of infants requiring surgery for intestinal failure between the 2 groups (P = .47).

CONCLUSIONS

We found that sonographically detected bowel dilatation more than 20 mm in utero in fetuses with gastroschisis may have value in predicting clinically significant adverse postnatal outcomes.

Utility of liver function tests including aminotransferase-to-platelet ratio index in monitoring liver dysfunction in short-gut infants of varying ages and intestinal lengths

BACKGROUND/PURPOSE

Aspartate aminotransferase-to-platelet ratio index (APRI) has good correlation with liver fibrosis progression in the infant and toddler short-gut population. This study applies laboratory liver function testing, including APRI, to monitor liver dysfunction over time for short-gut infants, with further analysis of at-risk subpopulations.

METHODS

Study inclusion criteria included infants younger than 1 year at initial intestinal resection with subsequent continuous parenteral nutrition dependence of 3 months minimum. Bilirubin, aspartate aminotransferase, alanine aminotransferase, APRI, and biopsies were collected for 26 weeks postresection. Subgroup analysis was stratified by (1) estimated gestational age, (2) age at intestinal resection (AGE), and (3) remaining intestinal length.

RESULTS

Thirty-one children were included, all with AGE younger than 2 months at initial intestinal resection (mean, 13 days). Aminotransferase-to-platelet ratio index was the only marker associated with fibrosis progression (median, APRI by METAVIR grade: F0/F1/F2, 1.9; F3, 5.7; F4, 14.7 [P = .02]). At 8 and 18 weeks postresection, there are separations seen within study subgroups, indicating the onset and progression of liver dysfunction.

CONCLUSION

Aminotransferase-to-platelet ratio index is associated with liver fibrosis progression in this population. There are marked changes in liver dysfunction at 8 and 18 weeks postresection, with subgroup differences within estimated gestational age, AGE, and remaining intestinal length.

Short bowel syndrome

The short bowel syndrome (SBS) is a state of malabsorption following intestinal resection where there is less than 200 cm of intestinal length. The management of short bowel syndrome can be challenging and is best managed by a specialised multidisciplinary team. A good understanding of the pathophysiological consequences of resection of different portions of the small intestine is necessary to anticipate and prevent, where possible, consequences of SBS. Nutrient absorption and fluid and electrolyte management in the initial stages are critical to stabilisation of the patient and to facilitate the process of adaptation. Pharmacological adjuncts to promote adaptation are in the early stages of development. Primary restoration of bowel continuity, if possible, is the principle mode of surgical treatment. Surgical procedures to increase the surface area of the small intestine or improve its function may be of benefit in experienced hands, particularly in the paediatric population. Intestinal transplant is indicated at present for patients who have failed to tolerate long-term parenteral nutrition but with increasing experience, there may be a potentially expanded role for its use in the future.

Successful management of short gut due to vanishing gastroschisis - case report and review of the literature

Vanishing gastroschisis is a rare in utero complication of gastroschisis. It is associated with a high mortality. We present a case report of an infant with vanishing gastroschisis that was managed with a combination of reconstructive bowel surgery and hepatosparing parenteral nutrition. The technique is described and a review of the literature is provided.

Use of the aspartate aminotransferase to platelet ratio index to follow liver fibrosis progression in infants with short gut

BACKGROUND

Infants with parenteral nutrition dependence may develop liver dysfunction and progress to liver failure requiring transplantation. The aspartate aminotransferase-to-platelet ratio index (APRI) has good correlation with liver fibrosis progression in adults. This study applies APRI scoring to parenteral nutrition-dependant, short-gut infants to determine hepatic fibrosis progression.

METHODS

Laboratory values and biopsies were collected from initial intestinal resection (time 0) up to transplantation (end). Fibrosis scoring ranged from F0 (normal) to F4 (cirrhosis). Children were divided into 3 groups: (1) isolated intestine; and combined liver/intestine with gestational age (2) 34 weeks or greater and (3) 30 weeks or less. Liver function values over time, including calculated APRI, were analyzed as predictors of fibrosis.

RESULTS

Fifteen children who had 33 biopsies were included. Median APRI by fibrosis grade was F < or = 2: 1.88, F3: 3.23, and F4: 14.16 (P < .01). Median APRI at transplant by study group was (1) isolated intestine: 2.47, (2) liver/intestine 35 weeks or longer EGA: 14.16, and (3) liver/intestine 30 weeks or less EGA: 14.74 (P = .04).

CONCLUSION

Progression of APRI up to 60 days initially demonstrates similar values among study groups, but over time the score distinguishes those children with impending liver cirrhosis and differentiates fibrosis grade and study group.

Autologous intestinal reconstruction surgery

Multidisciplinary management of intestinal failure has progressed over the last 30 years, facilitating the transition to enteral autonomy in many pediatric patients. However, there remains a select group of patients who reach a plateau in advancement of their enteral nutrition. Numerous surgical options have been pursued to attempt to slow intestinal transit, taper dilated bowel, and promote intestinal adaptation. The purpose of this chapter is to review the current literature on autologous intestinal reconstruction surgery, including a brief historical perspective, descriptions of procedures, and reported surgical outcomes.

Repeat STEP procedure to establish enteral nutrition in an infant with short bowel syndrome

The serial transverse enteroplasty (STEP) procedure is a safe and successful way to lengthen the small bowel in patients with short bowel syndrome. However, postoperative dilatation of the intestine may occur, which induces bacterial overgrowth and malabsorption leading to liver failure. We describe the case of an infant boy with short bowel syndrome caused by jejunal atresia requiring the STEP procedure twice. The first STEP improved the liver function, and the second STEP allowed 80% of the total calorie intake to be tolerated enterally. One should not hesitate to perform a second STEP if after the initial bowel lengthening procedure the patient develops small bowel dilatation that interferes with enteral nutrition.

The dilated bowel: a liability and an asset

The gastrointestinal tract responds to significant mechanical or functional obstruction by dilatation and hypertrophy of the segment proximal to the obstruction. Excessive dilatation compromises motility, and absorption and is associated with considerable morbidity (intraluminal stasis, sepsis) such that bowel dilatation represents a major liability that predisposes the patient to intestinal failure. The dilated bowel proximal to an obstruction provides valuable autologous material for reconstruction with "tissue appropriate to the part." Bowel elongation and dilatation are integral to the natural intestinal adaptation response to loss of small bowel and can also be induced through a structured "Bowel Expansion" program. The additional absorptive tissue that is progressively generated is essential for reconstruction of the bowel (tailoring and lengthening), to restore gastrointestinal dynamics (effective propulsion and absorption), and to reduce morbidity (intraluminal stasis, sepsis). In enhancing the prospects for enteral autonomy, dilatation and elongation of the residual autologous bowel are crucial to long-term survival and good quality life, and represent a most welcome asset. This paper reviews the impact and management of bowel dilatation along the gastrointestinal tract.

Long-term outcome in patients with short bowel syndrome after longitudinal intestinal lengthening and tailoring

OBJECTIVES

Longitudinal intestinal lengthening and tailoring (LILT) is a well-established surgical treatment for short bowel syndrome. It has been shown to enhance peristalsis, decrease bacterial overgrowth, and extend mucosal contact time for nutrients. We present the results of a long-term follow-up of patients who underwent LILT and define prognostic parameters for the survival of these patients.

PATIENTS AND METHODS

Between 1987 and 2006, 53 patients underwent LILT in our institution. The main diagnoses were gastroschisis, intestinal volvulus, intestinal atresias, and necrotizing enterocolitis. LILT was performed at a mean age of 24 months (range 4144 months). The follow-up time was 79.76 months (range 6234 months).

RESULTS

After LILT, 41 of 53 patients survived, and 36 of 41 surviving patients were successfully weaned from parenteral nutrition (PN). In long-term follow-up 79% stayed free of PN. The overall survival rate was 77.36%. Weight gain occurred in 58% of the patients after LILT. The quality of life after LILT is on a high level, with most patients having normal physical strength and participating in normal social life and education. Prognostic factors for survival after LILT in short bowel syndrome are length of small intestine (0.06582 + 0.0131 x bowel cm), length of large bowel (P = 0.039), preoperative liver function, and successful weaning from PN within 18 months postoperatively (P = 0.0032).

CONCLUSIONS

Patients undergoing LILT in short bowel syndrome have a high survival rate, weight gain, and a high quality of life. Autologous gastrointestinal reconstruction remains therefore the first choice in the treatment of patients with short bowel syndrome.

Influência de válvulas artificiais sobre a morfometria intestinal de ratos

OBJETIVO: Avaliar o papel de válvulas artificiais constituídas por seromiotomias circunferenciais duplas no comprimento dos vilos, no diâmetro do intestino delgado e no peso de ratos. MÉTODO: Foram utilizados 40 ratos, distribuídos em quatro grupos. Os animais do Grupo R foram submetidos à ressecção de 50% do intestino delgado, sem criação de válvulas. No Grupo RV associaram duas válvulas à ressecção intestinal. No Grupo V foram criadas duas válvulas, sem ressecção intestinal. O Grupo C forneceu a altura normal dos vilos. A eutanásia deu-se entre o décimo e o 14º dia pós-operatórios. RESULTADOS: Houve aumento no comprimento dos vilos nos grupos R, RV e V. Comparado ao Grupo R, o comprimento dos vilos nos grupos RV e V foi semelhante nos segmentos proximal e distal. No Grupo RV, os vilos do segmento proximal tiveram comprimento superior ao do distal. No Grupo V, o comprimento dos vilos do segmento proximal foi menor que do distal. A alça intestinal teve diâmetro maior que no pré-operatório no Grupo R e nos segmentos proximal à primeira válvula e distal à segunda, dos grupos RV e V. A ressecção intestinal levou à perda ponderal nos grupos R e RV, sem diferença entre os grupos. No Grupo V houve ganho de peso, significativo quando comparado aos grupos R e RV. Apesar de não impedirem a perda ponderal em animais submetidos à ressecção, as válvulas não determinaram perda superior à da ressecção isolada. CONCLUSÃO: Essas válvulas parecem influenciar positivamente a adaptação intestinal e podem ser incluídas entre as técnicas de reabilitação intestinal cirúrgica, isoladamente ou precedendo intervenções de alongamento do intestino.

Estudo morfológico do intestino de ratos após a criação cirúrgica de esfíncteres artificiais

OBJETIVO: Avaliar as alterações morfológicas ocorridas após à confecção de esfíncteres no intestino delgado de ratos. MÉTODO: Foram estudados 30 ratos, Wistar, distribuídos em três grupos de 10 animais. Grupo A, controle, foi retirado um segmento de intestino delgado de 20mm de extensão. Grupo B, foram realizados dois esfíncteres, um a 100mm e outro a 150mm da junção íleo-cecal. Grupo C, um esfíncter à 100mm da junção íleo-ceco-cólica. Entre 10º e 14º dia os animais do Grupo B e C foram re-operados para a ressecção do segmento intestinal envolvendo os esfíncteres com margem de 10mm proximal e distal. As aferições de peso foram feitas no pré-operatório das duas intervenções. O diâmetro das alças foi computado antes e depois da confecção dos esfíncteres. Nas peças ressecadas dos três grupos foram medidas as alturas das vilosidades dos segmentos pré e pós-esfíncter dos Grupos B e C, segmento intermediário do Grupo B e segmento intestinal do Grupo A. Os dados obtidos foram submetidos à análise estatística do programa SPSS. RESULTADO: O peso dos animais aumentou nos dois grupos com significância no grupo B. Aumento do diâmetro das alças e a média das alturas das vilosidades foram significante. CONCLUSÃO: A confecção dos esfíncteres leva a alterações da camada de vilos e dos diâmetros das alças, semelhantes àquelas que ocorrem na fase de adaptação intestinal após ressecções.

Short bowel syndrome

Treatment of short bowel syndrome (SBS) is often a difficult endeavor due to the high variability among patients with SBS in regard to remaining anatomical structure and functional capacity. Research efforts to substantiate the use of existing therapies in the treatment of SBS are ongoing, with newer developments yet to be fully explored. Current therapy for SBS begins with the implementation of a modified diet based on the presence or absence of the colon. Patients with difficulty ingesting enough nutrients and fluids for weight maintenance and fluid balance may benefit from nocturnal enteral nutrition and hydration. Those with inadequate absorptive capacity despite maximization of oral and enteral intake will need parenteral nutrition (PN) or hydration. Medications, including antisecretory agents, antidiarrheals, pancreatic enzymes, bile acid sequestrants, and antibiotics, often are useful in abating symptoms commonly associated with SBS. Growth factors, including recombinant human growth hormone and glucagon-like peptide 2, may be trialed to stimulate intestinal adaptation and enhance absorption in PN-dependent SBS patients. The gradual refinement of surgical procedures for SBS, including small bowel transplantation, has led to improved outcomes, and early referral of SBS patients to centers of excellence will optimize care.

Ultrashort bowel syndrome: surgical management and long-term results of an exceptional case

Management of the short bowel syndrome is a multidisciplinary and very complex problem. The authors report the successful long-term results of an original combination of autologous gastrointestinal reconstruction in a boy who at the age of 16 years lost all but 5 cm of the small bowel. This case demonstrates that lengthening and antipropulsive interposition of a long segment of the colon can be another alternative to early transplantation in exceptional cases.

Sustainability of mechanically lengthened bowel in rats

INTRODUCTION

It has been shown that the length of an intestinal segment may be doubled by applying gradual mechanical stretching. This study evaluated whether the lengthened intestinal segment retained the structure and function after the stretching device was removed.

METHODS

A 1.5-cm jejunal segment was separated from intestinal continuity in 20 rats. After advancing a screw into the isolated jejunal segment by 5 mm 3 times a week until it was stretched by 3 cm, the screw was removed. Three weeks later, the jejunal segments were retrieved for analyses. Comparisons were made between the lengthened jejunal segments.

RESULTS

The jejunal segment doubled its length after gradual stretching and retained this length 3 weeks after the screw removal (3.1 +/- 0.8 vs 3.2 +/- 0.4 cm, P > .05). The villous height, the muscular thickness, and the total alkaline phosphatase and lactase activities of the stretched jejunal segments were also unchanged 3 weeks after the screw removal.

CONCLUSIONS

Mechanical force induced the sustained lengthening of isolated jejunal segments in rats. The histologic and enzymatic alterations also persisted 3 weeks after the mechanical force was removed. This phenomenon may provide a novel method for the treatment of short bowel syndrome.