Gut failure in pediatric and adult patients. Candidates for small-bowel transplantation in southern Finland

Reconnection surgery in adult post-operative short bowel syndrome < 100 cm: is colonic continuity sufficient to achieve enteral autonomy without autologous gastrointestinal reconstruction? Report from a single center and systematic review of literature

A systematic bibliographic research concerning patients operated on for SBS was performed: inclusion criteria were adult age, reconnection surgery and SBS < 100 cm. Autologous gastrointestinal reconstruction represented an exclusion criteria. The outcomes of interest were the rate of total parenteral nutrition (TPN) independence and the length of follow-up (minimum 1 year) after surgery. We reviewed our experience from 2003 to 2013 with minimum 1-year follow-up, dealing with reconnection surgery in 13 adults affected by < 100 cm SBS after massive small bowel resection: autologous gastrointestinal reconstruction was not feasible. Three (out of 5168 screened papers) non randomized controlled trials with 116 adult patients were analysed showing weaning from TPN (40%, 50% and 90% respectively) after reconnection surgery without autologous gastrointestinal reconstruction. Among our 13 adults, mean age was 54.1 years (53.8 % ASA III): 69.2 % had a high stomal output (> 500 cc/day) and TPN dependence was 100%. We performed a jejuno-colonic anastomosis (SBS type II) in 53.8%, in 46.1% of cases without ileo-cecal valve, leaving a mean residual small bowel length of 75.7 cm. In-hospital mortality was 0%. After a minimum period of 1 year of intestinal rehabilitation, all our patients (100%) went back to oral intake and 69.2% were off TPN (9 patients). No one was listed for transplantation. A residual small bowel length of minimum 75 cm, even if reconnected to part of the colon, seems able to produce a TPN independence without autologous gastrointestinal reconstruction after a minimum period of 1 year of intestinal rehabilitation.

Outcomes of intestinal failure--a comparison between children with short bowel and dysmotile intestine

BACKGROUND

We investigated whether mortality, intestinal adaptation, and liver function differ between intestinal failure (IF) patients with either short bowel (SB) or bowel dysmotility (DM).

PATIENTS AND METHODS

Twenty-six consecutive patients with SB (n = 20) or DM (n = 6) treated between 2000 and 2007 were retrospectively assessed. Intestinal failure was defined as less than 25% of age-adjusted small intestinal length or dependence on parenteral nutrition (PN) more than 6 months.

RESULTS

Median age-adjusted small intestinal length (17% vs 45%) and gestational age (35 vs 40 weeks) were (P < .05) shorter, whereas proportion of the remaining colon (86% vs 0%) was (P < .05) higher in the SB group relative to the DM group. Overall survival was 92%. Median peak serum bilirubin (80 vs 25 micromol/L) and rate of cholestasis (11/20 vs 0/6) were higher (P < .05) in the SB group. Short bowel rather than DM as an etiology of IF predicted weaning off PN (RR, 39.3; 95% confidence interval [CI], 1.43-526; P < .01) and development of cholestasis (risk ration [RR], 18.3; 95% CI, 0.658-127; P < .05). Three SB children developed liver failure and two died, whereas neither of these occurred in the DM group.

CONCLUSIONS

Children with SB are more likely to wean off PN but more prone to cholestatic liver disease than those with DM as an etiology of IF.

Treatment of intestinal failure: intestinal transplantation

Over the past 15 years, intestinal transplantation for the treatment of intestinal failure has changed from a desperate last-ditch effort into a standard therapy for which a good outcome is expected. Patient survival after intestinal transplantation has improved in the past 3-5 years and now approaches that of other solid organ allograft recipients, including liver and kidney, and is similar to survival on permanent therapy with parenteral nutrition. Complications are more common and often more severe during the initial hospitalization period after intestinal transplantation than they are after transplantation of other solid organs. After intestinal transplantation the initial hospitalization period is, therefore, usually 3-8 weeks long. Nearly all patients discharged after intestinal transplantation have good allograft function and have been weaned from total parenteral nutrition. The cost of the initial hospitalization period is one to two times the cost of permanent total parenteral nutrition for 1 year, which means that, in most cases, intestinal transplantation is cost-saving within 2 years of transplantation. In addition, quality of life after intestinal transplantation, as determined by standardized quality of life measures, is good or normal.

Ileal nutritional function after one-stage orthotopic ileum transplantation in the growing pig: reversal of lethal short bowel syndrome

Intestinal isolation is associated with hypoplasia of defunctioned mucosa and reduction in the segmental absorption, whereas the presence of luminal nutrition is essential for the expression of the ileal adaptive response after proximal small bowel resection. On the other hand, intensive postoperative graft monitoring is obligatory because of the disastrous consequences of small bowel graft rejection. Thus, the authors sought to develop an experimental ileum transplantation model that provided immediate graft placement in bowel continuity, together with readily available graft monitoring connection through a proximal Roux-en-Y enterostomy. Four groups of pigs were prepared: RESTX (n = 9), proximal 50% small bowel resection with simultaneous orthotopic ileum autotransplantation; RES (n = 7), proximal 50% small bowel resection; NONRES (n = 6), transection; and SB (n = 5), short bowel. Early (1 to 4 weeks) and long-term (5 to 12 weeks) studies of animal growth, nutritional status, disaccharide absorption, water and electrolyte balances, and liver function were performed after ileum autotransplantation (IAT) in relation to small intestine of variable length with undivided mesentery (intact neural and lymphatic connections). The perioperative transplantation mortality rate remained at about 10%. Reasons not related to the transplantation procedure accounted for the late complication rate of 38%. In the ileum autotransplantation (RESTX) group, weight gain was recovered 2 to 3 weeks after transplantation, and the mean weight reached the preoperative level at 5 weeks. The SB pigs underwent progressive weight loss. The transection (NONRES) and proximal resection (RES) animals gained weight at similar rates. IAT had no effect on the plasma protein concentrations. Proximal resection, with or without IAT, was associated with depressed plasma cholesterol contents in the early period. Plasma cholesterol levels amended long-term, after both IAT and proximal resection. IAT resulted in deficient intraluminal processing of maltose, whereas isolated proximal resection tended to enhance disaccharide absorption early after the surgery. The short bowel pigs were not able to preserve sufficient nutritional status, and demonstrated a marked decline in the hemoglobin, protein, and cholesterol levels. No biochemical signs suggestive of potential liver damage caused by portocaval graft vascularization were recognized. These findings suggest that one-stage ileum autotransplantation provides sufficent absoprtive capacity to reverse otherwise lethal short bowel syndrome in the growing pig. However, transplantation disturbs the in vivo absorptive function of the nonrejecting ileum. Long-term impairment in disaccharide absorption may be partially related to an altered intestinal adaptive response secondary to proximal resection when combined with simultaneous transplantation. The authors developed this ileal small bowel transplantation model using rapidly growing pigs, wherein body weight gain represents an objective parameter of intestinal absorptive function. Only this type of animal model can yield clinically relevant data in the evaluation of a transplant's ability to provide sufficient nutritional function in a growing recipient.