Autologous intestinal lengthening procedures for short bowel syndrome. A systematic review of clinical effectiveness and an assessment of their utility for adult and paediatric patients with intestinal failure in the UK

Heydari Khajehpour, S

Abstract

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

• Thesis Type: Dissertation
• Deposit Date: Mar 8, 2016