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fbtwitterlinkedinvimeoflicker grey 14rssslideshare1
Languages: English
Types: Doctoral thesis
Subjects:
Introduction:\ud Short bowel syndrome (SBS) results from surgical resection, congenital defect\ud or disease-associated loss of absorption and is characterized by the inability\ud to maintain protein-energy, fluid, electrolyte or micronutrient balances when\ud on a conventionally accepted, normal diet 1 . In order to survive, the SBS\ud patient necessitates parenteral nutrition or an alternative medical or surgical\ud treatment to improve intestinal absorptive capacity. The surgical treatment\ud options are autologous gastrointestinal reconstruction, intestinal lengthening\ud or intestinal transplantation. Longitudinal intestinal lengthening and tailoring\ud (LILT) and serial transverse enteroplasty (STEP) are the main modalities of\ud intestinal lengthening with successful outcome.\ud Aim:\ud To systematically evaluate the result of this autologous "lengthening"\ud procedures in adults and children and determine their morbidity, mortality and\ud the frequency with which patients can expect restoration of nutritional and\ud metabolic autonomy. To evaluate their clinical effectiveness and an\ud assessment of their utility for adults and paediatric patients with intestinal\ud failure in the UK.\ud Results:\ud 330 patients underwent 343 intestinal lengthening procedures between 1980\ud and 2011. Age ranged from 1 day old to 66 years old. The most common\ud causes of SBS requiring intestinal lengthening in children were small bowel\ud atresia (27%), gastroschisis (27%), necrotising enterocolitis (16.5%) and\ud midgut volvulus (16.5%). In adults, the causes were mainly acute mesenteric\ud infarct, surgical resection and mid gut volvulus.\ud Two hundred and thirty one patients (67.3%) underwent LILT and 96 patients\ud (28%) had STEP as primary procedure. Further 13 patients (3.8%) had re-\ud STEP operation and 2 had Kimura procedure.\ud There was an increase in total mean bowel length of 61.9% (29.4 cm); 55.1%\ud in STEP and 67.2% in LILT. Total parenteral nutrition (TPN) was successfully\ud discontinued in 53% of patients after between 10 weeks and 5 years of follow\ud up.\ud The most common operative complications were bowel obstruction (19.8%),\ud re-dilatation (15.1%) and leaks (8.1%). Catheter related complications\ud (12.8%) were the most common non surgical complication, followed by liver\ud failure (10.5%). Sixty three deaths (19.1%) were registered mainly due to liver\ud failure and sepsis (66.6%), of which 9 patients died post-transplant.\ud Fifteen adults underwent lengthening, with a median age of 38 (18-66) yrs.\ud There were 8 LILT and 7 STEP procedures. One death was reported due to\ud liver failure as the patient refused to undergo transplant surgery.\ud Conclusion:\ud Intestinal lengthening appears to be a valuable treatment option for the\ud paediatric short bowel patient, allowing approximately 50% to regain\ud nutritional independence. The experience in the adult population is much\ud more limited. Intestinal lengthening procedures are associated with morbidity\ud in up to 20%. Although 20% of patients died, the majority of deaths were not\ud related lengthening surgery but to complications of end stage liver disease\ud resulting from short bowel syndrome.

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