Current update of short-bowel syndrome

Omega Loop Gastroileal Bypass (OLGIBP/SAGI) Versus One Anastomosis Gastric Bypass (OAGB): Medium-Term Results

INTRODUCTION

In bariatric surgery, new surgical techniques are continually being developed. The one anastomosis gastric bypass (OAGB) has become increasingly common since 2001. However, some patients experience bile reflux or excessive weight loss. This study aimed to assess a new bariatric procedure designed to avoid some of the drawbacks of conventional OAGB.

MATERIAL AND METHODS

To lower the complication rate and pathophysiological impact after OAGB, we performed an omega loop gastroileal bypass (OLGIBP/SAGI) with a 300-cm common limb. We compared this technique with OAGB.

RESULTS

Seventeen patients underwent OLGIBP and 23 underwent OAGB. Mean operative time was 108 min for OLGIBP vs 103 min for OAGB. The mean hospital length of stay was 3 days (1 to 7). No complications related to the gastroenterostomy occurred. At 3 years, among OAGB patients, there were 5 (21.7%) cases of bile reflux including 2 (8.7%) requiring a revision to Roux-en-Y gastric bypass. Among OLGIBP patients, there were 3 (17.6%) cases of bile reflux 1 (5.9%) requiring a revision to Roux-en-Y gastric bypass. There was no albumin deficiency. At 3 years, % of total weight loss (TWL) was 43.6 + - 6.2 in the OAGB group vs 48.2 + - 7.4 in the OLGIBP group.

CONCLUSIONS

The bariatric and metabolic outcomes of OLGIBP are expected to be similar to those of OAGB. The OLGIBP technique should reduce the risks of malnutrition and bile reflux. The two techniques can be safely performed and offer alternatives in bariatric surgery.

The effect of colonic tissue electrical stimulation and celiac branch of the abdominal vagus nerve neuromodulation on colonic motility in anesthetized pigs

BACKGROUND

Knowledge on optimal electrical stimulation (ES) modalities and region-specific functional effects of colonic neuromodulation is lacking. We aimed to map the regional colonic motility in response to ES of (a) the colonic tissue and (b) celiac branch of the abdominal vagus nerve (CBVN) in an anesthetized porcine model.

METHODS

In male Yucatan pigs, direct ES (10 Hz, 2 ms, 15 mA) of proximal (pC), transverse (tC), or distal (dC) colon was done using planar flexible multi-electrode array panels and CBVN ES (2 Hz, 0.3-4 ms, 5 mA) using pulse train (PT), continuous (10 min), or square-wave (SW) modalities, with or without afferent nerve block (200 Hz, 0.1 ms, 2 mA). The regional luminal manometric changes were quantified as area under the curve of contractions (AUC) and luminal pressure maps generated. Contractions frequency power spectral analysis was performed. Contraction propagation was assessed using video animation of motility changes.

KEY RESULTS

Direct colon ES caused visible local circular (pC, tC) or longitudinal (dC) muscle contractions and increased luminal pressure AUC in pC, tC, and dC (143.0 ± 40.7%, 135.8 ± 59.7%, and 142.0 ± 62%, respectively). The colon displayed prominent phasic pressure frequencies ranging from 1 to 12 cpm. Direct pC and tC ES increased the dominant contraction frequency band (1-6 cpm) power locally. Pulse train CBVN ES (2 Hz, 4 ms, 5 mA) triggered pancolonic contractions, reduced by concurrent afferent block. Colon contractions propagated both orally and aborally in short distances.

CONCLUSION AND INFERENCES

In anesthetized pigs, the dominant contraction frequency band is 1-6 cpm. Direct colonic ES causes primarily local contractions. The CBVN ES-induced pancolonic contractions involve central neural network.

Influence of repeated measurements on small bowel length

Purpose

Measurement of small bowel length (SBL) is a common procedure in gastrointestinal surgery. When required, repeated SBL measurements can be done during surgery. Our aim was to evaluate whether these repeated measurements differ in SBL results.

Methods

Small bowel length was measured during laparotomy in 28 patients between ligament of Treitz and caecum, using a standard measure, two times in each patient consecutively by two different surgeons from the anti-mesenteric border of the bowel.

Results

The median age was 33 (19–67) including 18 male. There were 16 healthy donors for living related liver transplantations. Second measurements, performed immediately after the first measurements, significantly shortened the measured SBLs in the same patients (580 ± 103 vs. 485 ± 78 cm, p < 0.001).

Conclusions

During surgery, repeated length measurements caused contractions in the small bowel and this resulted to a significant decrease in the SBL. This should be keep in mind to prevent mismeasurements.

Improved tolerance for enteral nutrition after serial transverse enteroplasty (STEP) in infants and children with short bowel syndrome--a seven-year single-center experience

BACKGROUND

Serial transverse enteroplasty (STEP) was designed to lengthen and taper the small intestine in patients with short bowel syndrome (SBS) and dilated small bowel. We hypothesized that tolerance for enteral nutrition (EN) improves after STEP.

METHODS

Patients who underwent STEP between March 2004 and January 2011 were identified. Candidates for STEP had radiographic evidence of dilated small bowel and either failed to advance EN or demonstrated deterioration in tolerance for EN. Clinical and nutritional data were analyzed pre- and post-STEP. EN was defined as the percentage of calories administered enterally. Statistical analysis employed the signed rank test with significance assumed when p<0.05.

RESULTS

Twenty STEPs were performed at a median age of 13.7 months. Median pre-STEP bowel length was 30 cm with a median increase in bowel length of 42%. Five patients achieved enteral autonomy at a median of 6.5 months post-STEP. EN increased in 75%, while 25% exhibited unchanged or decreased EN post-STEP. In aggregate, median EN tolerance increased from 22% at one month pre-STEP to 61% at six months post-STEP (p=0.003).

CONCLUSIONS

The STEP is an effective adjunct in the treatment of patients with intestinal failure. While enteral autonomy is eventually possible in some patients, improved enteral tolerance can be achieved in a majority of cases.

Bowel length: measurement, predictors, and impact on bariatric and metabolic surgery

BACKGROUND

Small bowel length (SBL) determines the caloric absorptive capacity. The aim of this study was to evaluate SBL to identify patient-specific predictors and the interrelationships of SBL with anthropometric variables.

METHODS

Sex, age, and weight were recorded at the time of surgery when SBL and the estimated jejunal length (JLe) were measured by 3 different methods.

RESULTS

The mean SBL of 443 patients undergoing laparotomy (78% female) was 690±93.7 cm (range 350-1049 cm). Sex was correlated with SBL, as men had a longer small bowel than women (729±85 versus 678±92, P<.0001) and were significantly taller (173±8.2 versus 161±6.9, P<.001). Age did not correlate with SBL. The differences in length between fully stretched small bowel and nonstretched small bowel and between fully stretched small bowel and laparoscopic bowel were 137±19 cm and 32.4±11.4 cm, respectively. In a multivariate linear regression analysis model that included sex, age, height, and weight, only height was significantly correlated with SBL (P<.00001) and explained 12% of the variance in SBL. Sex, age, height, and JLe, but not SBL, were statistically highly significant in predicting 75% of the variance of body weight.

CONCLUSIONS

A positive association between height and SBL was found. Sex, age, height, and JLe may be strong predictors of weight. Individual JLe may be of importance in determining the weight loss and resolution of metabolic co-morbidities. Measuring the SBL can prevent the risk of nutritional consequences in malabsorptive, revisional, and metabolic procedures.

Intraoperative small bowel length measurements and analysis of demographic predictors of increased length

Few studies have measured small bowel length (SBL) in live humans and many textbooks base their "normal" SBL values on cadaver data. Here, we present a series of intraoperative SBL measurements and analyze predictors of increased length. SBL from ligament of Treitz to ileocecal valve was measured in patients undergoing laparotomy for colorectal resection. Patients with Crohn's disease and those who had undergone prior bowel resections were excluded. In the 240 patients studied, mean SBL was 506 ± 105 (285-845) cm. Height was positively associated with increased SBL (P < 0.001) and men had longer SBL than women (533 vs. 482 cm, P < 0.001). A multivariate linear regression model using patient sex, age, height and weight was significant (P = 0.001) and the predictors explained 8% of the variance in SBL. In this model, only height was independently predictive of increased SBL (P = 0.03). Correlation results differed between sexes. In men, height correlated with increased SBL (r = 0.20; P = 0.03), whereas in women it did not. In men, age had a positive correlation with SBL at a trend level (r = 0.17; P = 0.08), whereas in women age had a negative correlation with SBL (r = -0.18; P = 0.04). The mean SBL was 506 cm in live patients, as compared with the 600-700 cm range derived from prior cadaver studies. Male sex and height had positive correlations with SBL. SBL may decrease with age in women but not in men.

Insulin-like growth factors in the gastrointestinal tract and liver

The liver is a major source of insulin-like growth factors (IGFs) and IGF binding proteins (IGFBPs) that are present in the circulation and have important endocrine activities relating to energy metabolism, body size, carcinogenesis, and various organ-specific functions. Although IGFs have only minor effects on the normal liver itself, production of IGFs and IGFBPs in a tissue-specific manner in the gastrointestinal tract exert important regulatory effects on cellular proliferation, survival, and apoptosis. IGFs and IGFBPs play important regulatory roles in the response of both the liver and the gastrointestinal tract to inflammation and in the development of neoplasia.

Short bowel syndrome: current medical and surgical trends

Short bowel syndrome is a chronic malabsorptive state usually resulting from extensive small bowel resections. A combination of diarrhea, nutrient malabsorption, dysmotility, and bowel dilatation may constitute the clinical symptomatology of this syndrome. The remaining bowel undergoes a process called adaptation, which may replace lost intestinal function. Chronic complications include nutrient, electrolyte, and vitamin deficiencies. Therapy depends largely on the administration of various factors stimulating intestinal adaptation of the remaining bowel. If the patient despite medical therapy fails to return to oral diet alone, then long-term parenteral nutrition is required. However, long-term parenteral nutrition may gradually induce cholestatic liver disease. Surgical methods may be required for treatment including intestinal transplantation, as a last resort for the treatment of end-stage intestinal failure. The goal of this review is to analyze the clinical spectrum and pathophysiologic aspects of the syndrome, the process of intestinal adaptation, and to outline the medical and surgical methods currently used to treat this complicated group of patients.

The second STEP: the feasibility of repeat serial transverse enteroplasty

BACKGROUND

Serial transverse enteroplasty (STEP) lengthens and tapers dilated bowel. Redilation of the STEP segment occurs in some patients with intestinal failure. The feasibility of a repeat STEP procedure in a pig model is evaluated.

METHODS

Six pigs underwent reversal of an intestinal segment distal to the ligament of Treitz. At 6-week intervals after reversal, each animal had 2 STEP procedures on the bowel proximal to the reversed segment. Necropsy was performed up to 6 weeks after repeat STEP.

RESULTS

Bowel length increased by 11.3 +/- 3.9 cm and bowel diameter decreased from a mean of 5.3 +/- 0.8 to 1.8 +/- 0.4 cm (P < .0001) after the first STEP. After repeat STEP, bowel length increased by 16.7 +/- 13.3 cm (P < .01), and the bowel was tapered from a mean of 5.4 +/- 0.9 to 2.2 +/- 0.4 cm (P < .01). Five pigs did well after repeat STEP, and 1 pig had early necropsy for bowel obstruction. None had histologic evidence of bowel ischemia in the repeat STEP segment.

CONCLUSIONS

A second STEP operation is feasible in a pig model and may be considered to optimize bowel length and function in select patients with intestinal failure.

Haplotype insufficiency for suppressor of cytokine signaling-2 enhances intestinal growth and promotes polyp formation in growth hormone-transgenic mice

GH may improve intestinal growth or function in patients with short bowel syndrome. Excessive trophic effects of GH or IGF-I may contribute to neoplastic growth or increased colorectal cancer risk in acromegaly. Identification of mechanisms that limit the tumorigenic potential of GH and IGF-I is desirable. Suppressor of cytokine signaling-2 (SOCS2) limits GH action on body and organ growth, but its role in GH action on intestine is unknown. We tested the hypothesis that SOCS2 limits GH-induced intestinal growth or neoplasia in vivo. GH-transgenic (GH-TG) mice were crossed with SOCS2 null mice to generate wild-type (WT) or transgenic (TG) mice with zero (HO-WT; HO-TG), one (HT-WT; HT-TG), or two (WT-WT; WT-TG) functional SOCS2 genes. No HO-TG mice were derived from crossbreeding. WT-WT, HT-WT, WT-TG, and HT-TG were compared. Body weight, small intestine and colon growth, and levels of jejunal IGF-I and sucrase-isomaltase mRNAs were assessed. Colon was analyzed for abnormal lesions. HT-WT did not differ from WT-WT. Compared with WT-TG, HT-TG had significantly increased body weight, small intestine growth, and local IGF-I expression and decreased sucrase-isomaltase expression. HT-TG colon spontaneously developed multiple hyperplastic and lymphoid polyps. GH-induced activation of STAT5 DNA binding activity was enhanced in intestine of SOCS2 null mice compared with WT control. Haplotype insufficiency for SOCS2 promotes trophic actions of GH in small intestine and promotes preneoplastic growth in colon during excess GH. Small variations in SOCS2 expression levels may significantly influence the outcome of therapeutic GH or acromegaly in intestine.