Rebecca A. Weseman

Current management of short bowel syndrome.

ntestinal failure refers to a condition that results from obstruction, ysmotility, surgical resection, congenital defect, or disease-associated oss of absorption and is characterized by the inability to maintain rotein-energy, fluid, electrolyte, or micronutrient balance. The short owel syndrome (SBS) is a type of intestinal failure caused by intestinal esection leading to a shortened intestinal remnant and is characterized by he inability to maintain protein-energy, fluid, electrolyte, or micronutrint balances when on a conventionally accepted, normal diet. SBS ccounts for approximately three-fourths of intestinal failure patients in dults and more than one half in children. The pathophysiologic changes hat occur in SBS relate primarily to the loss of intestinal absorptive urface and more rapid intestinal transit. The consequences of malabsorpion of nutrients include malnutrition, diarrhea, steatorrhea, specific utrient deficiencies, and fluid and electrolyte imbalance. These patients re at risk for other specific complications, which include an increased ncidence of cholelithiasis, gastric hypersecretion, nephrolithiasis, and iver disease. The history of SBS is one of long-standing interest but more recent dvancements. Koeberle reported the first patient surviving massive esection of the small intestine in 1880. The clinical consequences of iarrhea and malabsorption were described by Senn in 1888. Mall eported using reversed intestine segments to improve these symptoms in 896. Functional adaptation after massive resection was well documented y Flint in 1912. In 1935, Haymond reviewed 257 cases of extensive 8 feet resected) intestinal resection. He found that only 50 (20%) urvived for more than 1 year and further suggested that loss of 50% of he intestine was the upper limit of safety. Simons and Jordan reported 0 SBS patients ( 4 feet remaining small intestine) in 1969. Mesenteric ascular disease was the most common diagnosis and mortality remained igh. An important milestone was the demonstration by Wilmore and udrick in 1968 that parenteral nutrition (PN) would support nutritional

Current Management of the Short Bowel Syndrome

Short bowel syndrome is a challenging clinical problem that benefits from a multidisciplinary approach. Much progress has recently been made in all aspects of management. Medical intestinal rehabilitation should be the initial treatment focus, and several new potential pharmacologic agents are being investigated. Surgical rehabilitation using nontransplant procedures in selected patients may further improve intestinal function. Intestinal lengthening procedures are particularly promising. Intestinal transplantation has increasingly been used with improving success in patients with life-threatening complications of intestinal failure.

Nutrition management of small bowel transplant patients

Nutrition therapy after small bowel or combined liver/small bowel transplantation is challenging. The objective is to restore enteral autonomy to a patient with a complex past surgical history and equally complex posttransplant immunosuppressive regimen in the context of a newly created surgical anatomy. Improved surgical techniques and immunosuppressive regimens have led to superior outcomes. Accompanying these advances is a range of nutrition issues that require specific management strategies. This review outlines the current clinical practice and decision making used to create individualized nutrition regimens for small bowel or combined liver/small bowel transplant recipients. Successful small bowel transplant outcomes require a coordinated effort from a transplant team to restore nutritional autonomy to transplant recipients and free them from parenteral nutrition.

Evaluation of Bacterial Contamination of a Sterile, Non-Air-Dependent Enteral Feeding System in Immunocompromised Patients

Background: Bacterial contamination of enteral feeding solutions has been associated with a variety of infectious complications. In order to minimize contamination of enteral feeding solutions, it is recommended that their infusion times be limited. This leads to wasted product and inefficient use of personnel time. The contamination rate for sterile, non-air-dependent, closed system enteral feeding solutions and the length of time over which they can be safely infused in immunocompromised patients is not known. Methods: Enteral feeding was administered to 15 liver transplant recipients via a sterile, closed, non-airdependent system. At the conclusion of infusion of each bag of enteral feeding solution, the residual solution was quantitatively cultured. Subjects were also monitored for infectious complications. Results: The mean infusion time per 1.5-L bag of enteral feeding solution was 22.7 hours (range 10 hours to 35 hours). None of the 52 samples harbored bacteria. No subject developed a nosocomial in...

Radiation therapy increases the risk of hepatobiliary complications in short bowel syndrome

UNLABELLED Patients developing short bowel syndrome (SBS) are at risk for hepatobiliary complications. Radiation enteritis and radiation-induced liver disease are potential complications of radiation therapy (XRT). The authors hypothesized that SBS patients with a history of abdominal XRT would be at increased risk for hepatobiliary complications. METHODS The authors reviewed 92 adult patients developing SBS as a complication of operation for malignancy (n = 37) and/or XRT (n = 55). Hepatobiliary disease was evaluated by liver function tests, radiologic imaging, endoscopy, and histologic studies. RESULTS Rectal cancer was the most frequent tumor in both groups (36% vs 35%). There were significantly more ovarian cancers (18% vs 3%, P < .05) in the radiation group and fewer desmoid tumors (0% vs 24%, P < .05). Intestinal remnant length was similar, but radiation patients more frequently had colon present (87% vs 62%, P < .05) and were less likely to have type I anatomy (33% vs 65%, P < .05). Radiation patients were less likely to be weaned off parenteral nutrition (PN; 16% vs 41%, P < .05). Cirrhosis/portal hypertension was more frequent in the radiation group (35% vs 11%, P < .05). Radiographic evidence of fatty liver, end-stage liver disease and the risk of cholelithiasis post-SBS were similar in both groups. CONCLUSIONS SBS patients with a history of XRT were more likely to develop cirrhosis and portal hypertension than SBS patients with malignancy alone. Radiation SBS patients were less likely to wean from PN despite more favorable intestinal anatomy.

Review of Incidence and Management of Chylous Ascites After Small Bowel Transplantation

Nutrition management of intestinal transplant recipients continues to be a challenging and essential component of the early postoperative care of this patient population. The absorptive capacity of the graft can be affected by immunologic and nonimmunologic factors, including enteric lymphatic disruption, preservation injury, central denervation, viral enteritis, systemic infections, and rejection. Chylous ascites, the extravasation of milky chyle into the peritoneal fluid, defined by elevated triglycerides levels of > or = 200 mg/dL, can occur as a result of trauma, obstruction, or interruption of the lymphatic system. It seems the incidence of chylous ascites after small bowel transplantation is low; however, this may be due in part to the limitation of enteral long-chain triglycerides in the early posttransplant period of 2-6 weeks. After this time frame, clinical evidence suggests that fat assimilation normalizes. In the event that chylous ascites develop as a posttransplant complication, limitation of oral or enteral nutrition support to a very-low-fat regimen may be required, or parenteral nutrition (PN) will need to be provided until clinical status improves. Long-term posttransplant, lymphatic regeneration generally occurs and the majority of intestinal transplant recipients achieve the ultimate goal of nutrition autonomy.

Preresection Obesity Increases the Risk of Hepatobiliary Complications in Short Bowel Syndrome

Patients developing the short bowel syndrome (SBS) are at risk for hepatobiliary disease, as are morbidly obese individuals. We hypothesized that morbidly obese SBS individuals would be at increased risk for developing hepatobiliary complications. We reviewed 79 patients with SBS, 53 patients with initial body mass index (BMI) < 35 were controls. Twenty-six patients with initial BMI > 35 were the obese group. Obese patients were more likely to be weaned off parenteral nutrition (PN) (58% vs. 21%). Pre-resection BMI was significantly lower in controls (26 vs. 41). BMI at 1, 2, and 5 years was decreased in controls but persistently increased in obese patients. Obese patients were more likely to undergo cholecystectomy prior to SBS (42% vs. 32%) and after SBS (80% vs. 39%, p < 0.05). Fatty liver was more frequent in the obese group prior to SBS (23% vs. 0%, p < 0.05) but was similar to controls after SBS (23% vs. 15%). Fibrosis (8% vs. 13%) and cirrhosis/portal hypertension (19% vs. 21%) were similar in obese and control groups. Overall, end stage liver disease (ESLD) was similar in obese and control groups (19% vs. 11%) but was significantly higher in obese patients receiving PN (45% vs. 14%, p < 0.05). Obese patients developing SBS are at increased risk of developing hepatobiliary complications. ESLD was similar in the two groups overall but occurs more frequently in obese patients maintained on chronic PN.

Risk of Intestinal Malignancy in Patients With Short Bowel Syndrome

Background: Postresection intestinal adaptation is an augmented self-renewal process that might increase the risk of malignant transformation in the intestine. Furthermore, patients with short bowel syndrome (SBS) have other characteristics that might increase this risk. Our aim was to determine the incidence of new intestinal malignancy in SBS patients. Methods: We reviewed the records of 500 adult SBS patients identified from 1982–2013. There were 199 men and 301 women ranging in age from 19–91 years. Follow-up from the time of diagnosis of SBS ranged from 12–484 months. A total of 186 (37%) patients were followed >5 years. Results: The cause of SBS was postoperative in 35% of patients, malignancy/radiation in 19%, mesenteric vascular disease in 17%, Crohn’s disease in 16%, and other in 13%. Twenty-eight (6%) patients received growth stimulatory medications. Fifteen percent of patients had a prior total colectomy. Twenty-eight (6%) patients underwent intestinal transplantation, and 115 (23%) patients had a previous abdominal malignancy, including colorectal cancer in 43 patients. Thirty-six (7%) received radiation therapy. Recurrent colon cancer was found in 2 patients, one at a stoma and the other with lung metastases. New colon cancer was found in 1 patient (0.2%), a 62-year-old woman with long-standing Crohn’s disease. Conclusion: The incidence of colon cancer in this heterogenous group of patients with SBS was similar to that of the normal population. This suggests that the risk of developing a new colon cancer in patients with SBS is not increased.

Su1783 Risk of Intestinal Malignancy in Patients With Short Bowel Syndrome

S A T A b st ra ct s had gastroplasty. The most common cause of short bowel syndrome was bowel resection due to volvulus (48%), 24% (n=6) patients had internal hernia, 12 % (n=3) had bowel obstruction from adhesions and 16% (n=4) patients had mesenteric ischemia. Mean residual short bowel lengthwas 48 cm (range 9 cm to 128 cm). All patients were on parenteral nutrition on presentation. Five patients were treated nonsurgically with intestinal rehabilitation TPN weaning program. Twenty patients underwent surgical procedures. Eight reconstructive bowel anastomoses surgeries, 1 tapering enteroplasy, 1 STEP procedure, 3 G/J tube insertions, 3 adhesiolysis, 6 bypass revision, 3 enterocutaneous fistula closure and 2 stoma takedowns were performed. Five patients needed reconstruction of abdominal wall, with or without biological mesh. Four patients (16%) underwent isolated small bowel transplant. The most common indications for transplant were multiple severe line infections, and non-reconstructable GI tract, respectively. Two patients (8%) receivedmulti-visceral abdominal allograft (liver/pancreas and small bowel) due to TPN induced liver failure. The 1 year graft survival rate for isolated small bowel and multi-visceral transplant was 75% and 50%, respectively. Currently 9 patients remain TPN-dependent, 3 have died, and 13 are off TPN. Conclusions: Patients with short bowel syndrome after bariatric surgery should be treated by dedicated multispecialty teams at intestinal rehabilitation and transplant centers. Corrective reconstructive surgery remains a safe and feasible option in majority of patients, while some patients require isolated small bowel or multi-visceral transplant.