Neha Parekh

Criteria for the use of recombinant human growth hormone in short bowel syndrome.

Extensive resection of the intestinal tract with resulting malabsorption is known as short bowel syndrome (SBS). Adaptation and rehabilitation of the remaining small bowel occurs spontaneously after resection and can be enhanced by diet, medications, and use of intestinal trophic factors such as recombinant human growth hormone (r-hGH). Many trials have been published on the influence of r-hGH therapy in SBS patients, with varying results. Analysis of the trials has produced a set of criteria that can be used to define the patient most likely to benefit from r-hGH therapy.

Intestinal Failure Management at the Cleveland Clinic

The Cleveland Clinic institutional guidelines for the management of intestinal failure, including long-term or home parenteral nutrition and related complications, intestinal rehabilitation, and small bowel transplantation, were reviewed. PubMed was searched for relevant articles. The search was performed in November 2008; keywords used were home parenteral nutrition, short bowel syndrome, intestinal rehabilitation, and small-bowel transplantation. Randomized, prospective, observational, retrospective reviews and case report articles that contained relevant data for long-term parenteral nutrition, intestinal rehabilitation, and intestinal transplantation were selected. Researchers reviewed 67 selected articles that met our inclusion criteria. Our institution data registries for intestinal rehabilitation and home parenteral nutrition were also reviewed for relevant data. The survival of tens of thousands of children and adults with complicated gastrointestinal problems has been possible because of parenteral nutrition. In selected patients, a program of intestinal rehabilitation may avoid the need for long-term parenteral nutrition.

Percentage of Weight Loss as a Predictor of Surgical Risk: From the Time of Hiram Studley to Today

Hiram Studleys 1936 article of research was the first publication to present a connection between preoperative weight loss and adverse postoperative outcome. Almost 70 years later, weight loss remains one of the most prominently used tools to assess nutritional status and predict surgical risk. This paper provides an overview of surgical practices at the time of Dr Studley and demonstrates Studleys unique contributions to the field of nutrition support. The search for more accurate methods of preoperative nutrition assessment is traced to show how subsequent research continues to validate the use of weight loss in the assessment of surgical risk. New developments center on techniques of body composition assessment to quantify weight lost as functional weight and clarify the impact of malnutrition on operative outcome.

Autologous Reconstruction and Visceral Transplantation for Management of Patients With Gut Failure After Bariatric Surgery: 20 Years of Experience.

OBJECTIVE Bariatric surgery (BS) is currently the most effective treatment for severe obesity. However, these weight loss procedures may result in the development of gut failure (GF) with the need for total parenteral nutrition (TPN). This retrospective study is the first to address the anatomic and functional spectrum of BS-associated GF with innovative surgical modalities to restore gut function. METHODS Over 2 decades, 1500 adults with GF were referred with history of BS in 142 (9%). Of these, 131 (92%) were evaluated and received multidisciplinary care. GF was due to catastrophic gut loss (Type-I, 42%), technical complications (Type-II, 33%), and dysfunctional syndromes (Type-III, 25%). Primary bariatric procedures were malabsorptive (5%), restrictive (19%), and combined (76%). TPN duration ranged from 2 to 252 months. RESULTS Restorative surgery was performed in 116 (89%) patients with utilization of visceral transplantation as a rescue therapy in 23 (20%). With a total of 317 surgical procedures, 198 (62%) were autologous reconstructions; 88 (44%) foregut, 100 (51%) midgut, and 10 (5%) hindgut. An interposition alimentary conduit was used in 7 (6%) patients. Reversal of BS was indicated in 84 (72%) and intestinal lengthening was required in 10 (9%). Cumulative patient survival was 96% at 1 year, 84% at 5 years, and 72% at 15 years. Nutritional autonomy was restored in 83% of current survivors with persistence or relapse of obesity in 23%. CONCLUSIONS GF is a rare but serious life-threatening complication after BS. Successful outcome is achievable with comprehensive management, including reconstructive surgery and visceral transplantation.

The Multidisciplinary Approach to the Care of Patients with Intestinal Failure at a Tertiary Care Facility

Intestinal failure is a complex disease state for which extensive therapy is often required. Parenteral nutrition is one of these therapies, but with its long-term use, life-threatening complications may develop. Intestinal rehabilitation to enhance intestinal absorption and function through diet and medication is another therapy that can be used in hopes of weaning parenteral nutrition and preventing malnutrition. For patients who develop complications from parenteral nutrition and fail intestinal rehabilitation interventions, intestinal transplantation may be the best option. In this review, therapies available for intestinal failure and the use of a multidisciplinary approach to the patient with intestinal failure will be reviewed.

Bariatric surgery complications leading to small bowel transplant: a report of 4 cases.

Obesity is a major chronic disease affecting the U.S. population. Bariatric surgery has consistently shown greater weight loss and improved outcomes compared with conservative therapy. However, complications after bariatric surgery can be catastrophic, resulting in short bowel syndrome with a potential risk of intestinal failure, ultimately resulting in the need for a small bowel transplant. A total of 6 patients became dependent on home parenteral nutrition (HPN) after undergoing bariatric surgery at an outside facility. Four of the 6 patients required evaluation for small bowel transplant; 2 of the 6 patients were successfully managed with parenteral nutrition and did not require further small bowel transplant evaluation. Catheter-related bloodstream infection, a serious complication of HPN, occurred in 3 patients despite extensive patient education on catheter care and use of ethanol lock. Two patients underwent successful small bowel transplantation, 1 died before transplant could be performed, and 1 was listed for a multivisceral transplantation. Surgical procedures to treat morbid obesity are common and growing in popularity but are not without risk of serious complications, including intestinal failure and HPN dependency. Despite methods to prevent complications, failure of HPN may lead to the need for transplant evaluation. In selected cases, the best therapeutic treatment may be a small bowel transplant to resolve irreversible, post-bariatric surgery intestinal failure.

Metabolic Consequences of Restorative Surgery After Gastric Bypass

Roux-en-Y gastric bypass (RYGB) improves the metabolic profile of patients with type 2 diabetes mellitus (T2DM). Surgical weight loss can improve insulin sensitivity and β-cell function. Furthermore, there is a growing body of evidence explaining improvement of T2DM after bariatric surgery by weight-independent neurohormonal mechanisms, including changes in gut hormones, bile acids, and gut microbiota. Changes to gastrointestinal anatomy (for example, exclusion of the duodenum in RYGB) can directly influence glucose homeostasis, independent of weight loss (1–3). Bariatric and metabolic surgery is not without some risk, though, and reoperation is sometimes necessary to manage long-term complications. Metabolic consequences of reoperative bariatric procedures have not been well characterized (4,5). The aim of this report is to present examples of how reoperative surgery can impact the metabolic effects of these operations. The first patient was a 47-year-old woman with a BMI of 38 kg/m2. She had a history of T2DM …

Composite and Multivisceral Transplantation: Nomenclature, Surgical Techniques, Current Practice, and Long-term Outcome

The successful development of multivisceral and composite visceral transplantation is among the milestones in the recent history of human organ transplantation. All types of gastrointestinal transplantation have evolved to be the standard of care for patients with gut failure and complex abdominal pathologic conditions. The outcome has markedly improved over the last 3 decades owing to technical innovation, novel immunosuppression, and better postoperative care. Recent data documented significant improvement in the long-term therapeutic indices of all types of visceral transplantation close to that achieved with thoracic and solid abdominal organs.

Medical Management of the High-Output Enterostomy and Enterocutaneous Fistula

Medical management of the high-output enterostomy or enterocutaneous fistula (ECF) requires an understanding of mechanisms behind the malabsorption associated with short bowel syndrome (SBS) and intestinal failure (IF). A traditional definition of SBS is <200 cm of remaining viable jejunum and ileum following surgical resection for disease, trauma, infarction, or congenital defect. A more functional definition involves consideration of the quality of the bowel in continuity and the clinical status of the patient, both of which may further interfere with absorptive capacity of the bowel. A thorough examination of remaining functional and structural anatomy can reveal potential causes of persistent malabsorption.