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29 Short Bowel Syndrome
451
Parenteral Nutrition
Key Concept: Despite the multitude of potential complications associated with its use, parenteral nutrition is a lifesaving intervention for many patients with SBS, and a
signifi cant percentage of patients can eventually be weaned
off parenteral nutrition completely.
Total parenteral nutrition (TPN) is often the fi rst form of
alimentary support initiated following massive bowel resection, and in most instances it is continued for at least 7–10
days. Parenteral nutrition can be used to provide macronutrients and energy required for intestinal adaptation and to prevent defi ciencies in vitamins and minerals [ 3 , 5 ]. To replace
water and electrolyte losses during the immediate postoperative period, usually both parenteral nutrition and supplemental intravenous fl uid are needed. Sodium, potassium, and
magnesium are commonly defi cient in this context, and their
serum levels should be closely monitored to help guide the
composition of parenteral solutions.
In general, patients require approximately 25–35 kcal/kg/
day; parenterally, this is delivered with a combination of
dextrose, lipids, and amino acids. Fat should account for
20–30 % of the total energy requirement, and protein should
be provided at 1.0–1.5 g/kg/day [ 1 ]. Intravenous lipid emul-
sion, traditionally derived from soybean oils, is thought to
contribute to parenteral nutrition-associated liver disease
(PNALD) [ 58 ]. Several groups have recently suggested the
use of fi sh oil-based lipid emulsions to mitigate and reverse
cholestasis [ 59 – 61 ]. While these early reports have demon-
strated encouraging results with fi sh oil, further studies are
required to better defi ne its safety and effi cacy.
Some patients may require parenteral supplementation of
certain vitamins, depending on their remnant bowel anatomy
and amount of enteral intake. Water-soluble vitamin defi ciencies are rare in SBS except in patients with a proximal
jejunostomy. To maintain normal thiamine levels, 3 mg of
thiamine hydrochloride may be included in TPN solutions
62 ]. Vitamin B 12 defi ciency should be anticipated following
[
resection of more than 60 cm of ileum, and subcutaneous
injections of 200 μg monthly may be required [
supplementation of fat-soluble vitamins is often needed after
loss of ileum due to impaired absorption of fat and bile acids
[ 9 ]. Trace metals can also be replaced parenterally when
enteral intake is unable to match gastrointestinal losses. In
particular, zinc and selenium defi ciencies may arise in the
setting of severe diarrhea [ 63 , 64 ].
Home parenteral nutrition is the mainstay of therapy for
the majority of patients with chronic intestinal failure [ 57 ].
Its successful implementation requires a multidisciplinary
effort that extends beyond hospital discharge with home care
support until patient self-management is achieved. While in
hospital, patients and their caregivers should receive education regarding preparation and administration of parenteral
7 , 8 ]. As well,
solutions, catheter care, and signs and symptoms of potential
complications [ 1 ].
Parenteral nutrition is usually tapered as enteral feeding is
successfully advanced. Depending on the amount and function of a patient’s residual bowel, complete or partial transition to enteral intake may be possible. Tolerance of enteral
and oral nutrition can continue to improve over the fi rst few
years after resection, as the remnant intestine’s absorptive
function is enhanced through adaptation [ 55 ]. Overall, up to
half of patients who initially require home parenteral nutrition are able to achieve independence from it [ 65 , 66 ].
Complications Associated with Long-Term Parenteral Nutrition
Key Concept: The long-term use of parenteral nutrition is
associated with several potentially life-threatening complications. Their repeated occurrences often curtail continued
delivery of parenteral nutrition and account for signifi cant
mortality among patients with chronic intestinal failure.
Parenteral nutrition is not without a wide array of morbidity and mortality [ 65 , 67 ]. A range of liver pathologies have
been associated with chronic parenteral nutrition, including
cholestasis, steatosis, steatohepatitis, fi brosis, and cirrhosis
[ 68 ]. Cholestatic liver disease is particularly common among
SBS patients due to other contributory factors such as lack of
enteral intake and recurrent sepsis related to bacterial overgrowth or indwelling catheter [ 31 ]. In one study of 90
patients with intestinal failure receiving home parenteral
nutrition, chronic cholestasis occurred in 65 % of patients
after a median of 6 months, and complicated liver disease
(extensive portal fi brosis or cirrhosis) was demonstrated in
50 % of patients at 6 years [ 69 ]. To reduce to the risk of these
complications, the study’s authors suggested limiting the
intake of ω-6 rich lipid emulsions to less than 1 g/kg/day
[ 69 ]. Excessive dextrose feeding should also be avoided
[ 70 ]. Other strategies to prevent liver disease include opti-
mizing the patient’s enteral intake and preventing sepsis of
any etiology [
58 ]. As mentioned previously, the use of fi sh-
oil- based lipid emulsions have also shown some promise in
this regard [
59 – 61 ]. The use of ursodeoxycholic acid can
also be considered, as there is limited evidence for its benefi t
in treating cholestasis [ 71 , 72 ].
Sepsis related to the indwelling venous feeding catheter is
a signifi cant cause of mortality among patients on chronic
parenteral nutrition. A French study involving 124 adults
with nonmalignant SBS found that 5 of the 32 deaths (16 %)
among patients with permanent intestinal failure were
directly attributable to catheter-related sepsis [ 39 ]. However,
with proper line care technique, the incidence of line sepsis
can be as low as 0.26 episodes per patient year [
73 ]. A local
infection at the catheter’s exit site will often respond to intravenous antibiotic therapy with empiric coverage for S.
aureus , though the choice of antimicrobial agents may
452
I. Yang and R.P. Boushey
require subsequent adjustment based on culture and sensitivity results [
1 ]. Lack of response to antibiotic therapy, evi-
dence of infection along the subcutaneous tunnel tract, or
septicemia in an unstable patient will mandate removal of
the catheter [ 1 , 57 ].
Thrombosis of the catheter is a relatively rare event,
occurring at an incidence of 0.07 episodes per catheter year
in patients receiving home parenteral nutrition [ 74 ]. Venous
access occlusion accounts for approximately one quarter of
all catheter removals [ 75 ]. Furthermore, catheter-related
venous thrombosis may be complicated by SVC syndrome
and pulmonary embolus [ 74 , 76 ]. It is not uncommon for
catheter-related sepsis to precede thrombosis, and the former’s presence should raise the index of clinical suspicion
for the latter and prompt consideration of prophylactic anticoagulation with either warfarin or heparin [ 57 , 77 ].
Treatment for confi rmed venous thrombosis usually consists
of at least 6 months of anticoagulation with low-molecularweight heparin [ 57 ].
Other complications that have been described in patients
requiring chronic parenteral nutrition include renal dysfunction, metabolic bone disease, and cognitive defi cits [ 67 , 78 ].
Enteral Nutrition and Oral Diet
Key Concept: Whenever possible, enteral intake should be
provided preferentially over parenteral nutrition as the former has several clear advantages. The composition should
be individualized based on the residual anatomy.
There is no question that the enteral route is preferred in
this setting, as the advantages are clear. Chief among these is
the dependence of intestinal adaption upon exposure of the
bowel to luminal nutrients [ 79 ]. As these nutrients come in
contact with bowel epithelium, adaptive hyperplasia of the
intestinal mucosa is induced [ 80 ]. In addition, enteral nutri-
tion increases the secretion of trophic gastrointestinal hormones that stimulate adaptation [
plethora of potential complications associated with longterm parenteral nutrition, enteral feeding is relatively safe.
As well, the administration of enteral nutrition is signifi cantly less labor intensive.
Following massive bowel resection, the introduction of
enteral nutrition is usually delayed until the patient is hemodynamically stable. Initially, enteral feeding may be continuously infused via nasogastric tube, gastrostomy, or
jejunostomy; this mode of delivery tends to be better tolerated than bolus feeds. As the patient’s overall condition
improves, gradual transition to oral diet can take place. There
is evidence to suggest that continuous tube feeding (exclusively or in conjunction with oral feeding) increases absorption of lipids, proteins, and energy compared with oral
feeding alone [ 81 ]. Therefore, even patients who are
79 ]. In contrast to the
tolerating an oral diet may benefi t from tube feeding supplementation as it can reduce or obviate dependence on parenteral nutrition.
The composition of enteral and oral feedings should be
individualized based on the patient’s remnant intestinal anatomy, comorbid conditions, and susceptibility to certain complications. In general, patients with an intact colon should be
given a high-carbohydrate diet to take advantage of SCFA
production via fermentation, an additional source of energy
[
24 ]. If concerns arise regarding d -lactic acidosis (see
above), mono- and oligosaccharides should be restricted in
favor of polysaccharides; in addition, thiamine
supplementation and broad-spectrum antibiotics are indicated [ 5 ]. While there were early advocates for restricting
dietary fat to reduce diarrhea, triglycerides are valuable
nutrients as they are relatively energy-dense – 9.0 kcal/g
compared to 4.0 kcal/g for carbohydrates – and, in the case
of long-chain fatty acids, particularly effective stimulators of
intestinal adaptation [ 2 , 82 ]. Therefore, a normal fat content
is recommended for patients with retained colon. The diet for
these individuals should be low in oxalate content to prevent
nephrolithiasis [ 5 ].
Compared to jejunum-colon patients, individuals with a
jejunostomy face greater challenges with respect to salt and
water depletion. Large amounts of stomal losses are exacerbated by enteral feeding, and careful attention must be given
to the composition of fl uid intake. Patients should drink
glucose- saline replacement solutions while limiting their
oral intake of hypotonic fl uids – such as water, tea, coffee, or
juices – to less than 500 ml daily [ 5 ]. Non-elemental diets
tend to be favored over peptide-based diets for macronutrient
delivery as the former have lower osmolarity while providing comparable absorption [ 83 ]. The diet of jejunostomy
patients should also contain a normal amount of fat. Increased
dietary fat leads to proportionately increased fat absorption
along the remaining jejunum without signifi cantly higher
stomal effl uent volumes [ 84 ].
Transition to oral diet should take place gradually for
patients with short bowel syndrome. Small and frequent
meals are better tolerated and absorbed. However, in order to
compensate for the malabsorbed portion of their dietary
intake, patients should be encouraged to eventually consume
more food overall than the amount to which they had previously become accustomed [ 85 ].
Pharmacologic Agents
Key Concept: Commonly used drug therapies in short bowel
syndrome constitute several different classes but act by either
mitigating secretory losses or slowing gut transit.
H2 blockers and proton pump inhibitors reduce gastric
acid secretion, and both medication classes have been shown
29 Short Bowel Syndrome
453
to decrease stomal effl uent volumes in SBS patients [ 86 – 88 ].
They also prevent peptic ulceration and esophagitis that may
result from transient hypergastrinemia and gastric hypersecretion in SBS [ 31 , 89 ]. It should be noted, however, that
these drugs neither alter macronutrient absorption nor reduce
the need for parenteral support [ 5 ]. Octreotide has similarly
been shown to reduce intestinal fl uid losses secondary to
diarrhea or high stomal output [
90 , 91 ]. In addition to decreas-
ing gastric and pancreatic secretions, octreotide also delays
gastric emptying and intestinal transit [ 92 ]. However, experi-
mental models have demonstrated octreotide to exert inhibitory effects on intestinal adaptation, a potentially signifi cant
downside to its use in short bowel syndrome [ 93 , 94 ].
Loperamide is an antimotility agent with proven effi cacy
in reducing water and sodium losses from an ileostomy [ 95 ,
96 ]. Typical doses are 4–16 mg/day, but much higher doses
may be required as the drug’s pharmacokinetics depend upon
the enterohepatic circulation which is often disrupted following massive bowel resection [ 3 , 5 ]. Codeine has similar
effects in decreasing diarrhea, but there is evidence to suggest that it impairs fat absorption [ 95 , 97 ]. With any medica-
tion that is administered orally to patients with short bowel,
there needs to be vigilance to ensure that it is being adequately absorbed as opposed to emerging undigested in stomal output or stool [ 5 ].
Cholestyramine can improve secretory diarrhea following
ileal resection by binding unabsorbed bile salts [ 98 ]. It
should be given at a dose of 4 g prior to meals, up to three
times daily [ 4 ]. However, this drug should not be used in
patients who have had more than 100 cm of ileum resected;
such extensive resection depletes the bile salt pool and renders cholestyramine ineffective, and the drug may actually
worsen steatorrhea and cause fat-soluble vitamin defi ciency
[ 1 , 2 , 99 ].
Growth Factors
Key Concept: The use of growth factors is an emerging class
of therapy for SBS with still widely variable results. While
promising, they are most commonly used in specialized centers or still under investigation.
An increasingly active area of research involves the
potential of several growth factors to enhance intestinal
adaptation and improve absorption in patients with short
bowel syndrome. The current depth of evidence varies
among these novel therapies, and some of these medications
have been incorporated into intestinal rehabilitation programs at specialized centers.
The application of growth hormone in the treatment of
SBS was fi rst suggested by early animal model studies that
demonstrated the substance’s positive effect on mucosal
hyperplasia after extensive bowel resection [
100 , 101 ].
Similarly, the amino acid glutamine, the primary fuel of
enterocytes, was shown to exert trophic effects on bowel and
stimulate nutrient absorption [
102 , 103 ]. By instituting regi-
mens that included growth hormone, glutamine, and dietary
fi ber, some centers have produced case series data showing
enhanced absorptive capacity and weaning from parenteral
nutrition [ 104 , 105 ]. However, the combination of growth
hormone plus glutamine failed to improve nutrient absorption compared to placebo in two randomized controlled studies [ 106 , 107 ]. The benefi t of growth hormone alone in SBS
has also been investigated in two randomized
placebo- controlled trials; one of the studies demonstrated
modestly increased absorptive capacity with growth hormone while the other detected no difference [ 108 , 109 ].
Similarly, glutamine alone has not been found to be benefi cial compared to placebo [ 110 ]. Nevertheless, these trials are
uniformly small in sample size, and the role and effi cacy of
these substances in treating SBS remain controversial.
Glucagon-like peptide-2 (GLP-2) is a naturally occurring
polypeptide synthesized by enteroendocrine l -cells located
primarily in the terminal ileum and colon [ 67 ]. Secreted in
response to enteral nutrition, GLP-2 promotes bowel mucosal growth, enhances absorptive capacity, and stimulates
mesenteric blood fl ow [ 80 , 111 , 112 ]. Accordingly, jejunos-
tomy patients without an intact colon, who are known to have
relatively little capacity for intestinal adaptation, have been
shown to exhibit markedly impaired GLP-2 activity following meals [ 113 ]. It follows, therefore, that GLP-2 therapy
may have a clinically signifi cant impact on bowel adaptation
and absorptive function in patients with SBS. In a small, nonplacebo-controlled study of SBS patients, GLP-2 treatment
reduced fecal wet weight but did not signifi cantly change
energy absorption or mucosal morphology [ 114 ]. Teduglutide,
a long-acting analogue of GLP-2, was similarly shown in an
open-label phase 2 study to increase wet weight absorption
[ 115 ]. In this study, the drug’s benefi t was seen even in
patients with an intact colon and near-normal endogenous
GLP-2 levels, a fi nding which suggests that supraphysiological doses of teduglutide may be advantageous. In a recent
multicenter, randomized, placebo-controlled trial, 83 parenteral nutrition-dependent SBS patients were assigned to
receive one of placebo, 0.05 mg/kg/day teduglutide, or
0.10 mg/kg/day teduglutide [ 116 ]. The study’s primary effi -
cacy end point was a graded response score (GRS) that
accounted for reduction in parenteral requirements and duration of response. The GRS was signifi cantly better in the
0.05 mg/kg/day teduglutide compared to placebo, while no
statistically signifi cant benefi t was seen with the 0.10 mg/kg/
day dose. Ad hoc analysis attributed the latter result to a trend
toward higher baseline parenteral volume in the 0.10 mg/kg/
day group. Three teduglutide-treated patients were completely weaned off parenteral support. The study also confi rmed teduglutide’s intestinotrophic effect through serum
454
I. Yang and R.P. Boushey
citrulline measurements, which increased with both low- and
high-dose treatment, but not with placebo. Interestingly, there
is also some literature that suggests teduglutide, which has
anti-infl ammatory properties, may induce remission and
mucosal healing in patients with Crohn’s disease [
Whether this may translate to demonstrable effi cacy of teduglutide in Crohn’s-related SBS is just one of many questions
surrounding this therapy that require further study.
Several other growth factors have received attention for
their potential role in the treatment of short bowel syndrome.
Transforming growth factor-α, a polypeptide found in epithelium along the gastrointestinal tract, has been shown to
improve intestinal adaptation in animal models of SBS [ 118 ,
119 ]. Hepatocyte growth factor, when administered in rats
following massive small bowel resection, enhanced intestinal epithelial cell function and mucosal mass beyond the
normal adaptive response [
tors including interleukin-11, insulin-like growth factor, and
keratinocyte growth factor also demonstrated positive effects
[
121 – 123 ]. The intestinotrophic effects of these peptides
have yet to be demonstrated in humans.
120 ]. Studies of other growth fac-
117 ].
Surgical Management
Key Concept: Surgery for SBS aims to improve the patient’s
quality of life by increasing residual absorptive function and
reducing overall morbidity and complications.
Surgical options for SBS include small bowel transplantation and a variety of non-transplant procedures. The choice
and timing of these interventions depend on the patient’s
remnant intestinal anatomy, comorbid conditions, and
response to medical management.
Restoration of Intestinal Continuity
Key Concept: Never miss out on an opportunity to restore
intestinal continuity if enough residual bowel remains.
For patients with an end stoma and residual distal bowel,
intestinal continuity should be reestablished when possible.
This intervention restores the absorptive functions and hormonal “braking” mechanisms of the previously diverted
bowel and prolongs intestinal transit [
improvement in overall absorption may be suffi cient to allow
weaning off parenteral nutrition [ 67 ]. When large bowel is
brought back into continuity, one should be cognizant of the
corresponding increase in the patient’s susceptibility to
complications such as nephrolithiasis and d -lactic acidosis.
With respect to timing, reoperation should be deferred
until the patient is hemodynamically stable and medically
optimized. Further waiting may be prudent to avoid diffi cult
adhesions and minimize surgical morbidity. Any intraabdominal sepsis should be resolved preoperatively,
124 ]. The resulting
if possible. Many underlying etiologies in SBS predispose to
stricture formation, and distal obstruction must be ruled out
prior to restoring intestinal continuity.
Procedures to Slow Intestinal Transit
Key Concept: For patients who have failed medical therapy
and have maximized adaptation, surgical procedures aimed
at slowing intestinal transit can improve absorption as fl uids
and nutrients remain in contact with bowel mucosa for longer periods of time.
In general, these slowing procedures should be considered only for patients whose residual bowel is already in
continuity and maximally adapted [ 125 ]. Of these individu-
als, the subset with relatively ample intestinal length, but
with lack of response to medical therapy, is most likely to
benefi t from this surgical strategy [ 67 ].
Among this group of procedures, segmental reversal of
small bowel has been most extensively evaluated and appears
to be the most effective [ 125 ]. The technique involves sepa-
rating a segment of small bowel from the adjacent intestine
while leaving its blood supply intact and subsequently reanastomosing the segment in the opposite direction of normal
intestinal fl ow. To avoid complete volvulus of the mesentery,
each of the proximal and distal parts of the bowel can be
rotated 90° so that the mesentery of the reversed segment only
needs to be rotated 180° [ 126 ]. The ideal length of reversed
segment appears to be approximately 10–15 cm; if the antiperistaltic segment is too long, bowel obstruction can result
[ 127 ]. The location of the reversed segment should be chosen
as distally as possible to decrease the symptoms of obstruction [ 31 ]. While results vary throughout the literature, adult
series have generally shown a favorable response to segmental reversal in approximately 70 % of the patients [ 124 ].
Other techniques to slow intestinal transit include colonic
interposition, creation of intestinal valves to produce a partial obstruction, and implantation of reversed electrical pacing devices [ 128 – 130 ]. Published experience is very limited
for these procedures, and they should only be employed by
highly experienced surgeons in the absence of more proven
alternatives.
Procedures to Lengthen Residual Bowel
Key Concept: Intestinal lengthening surgery should be considered for patients with dilated and severely shortened
bowel that precludes independence from parenteral nutrition
despite optimal adaptation and medical treatment.
These techniques create additional length by exploiting
the compensatory dilatation of the residual bowel that normally occurs following extensive bowel resection [
operations also taper the bowel, which results in improved
124 ]. The
29 Short Bowel Syndrome
455
a
underwent the procedure were successfully weaned off parenteral nutrition [
131 , 134 ].
A more recent addition to the intestinal lengthening armamentarium is the serial transverse enteroplasty (STEP) [
135 ].
The technique involves the partial transection of dilated
bowel using a linear cutting stapler, which is applied sequentially from alternating and opposite directions, in transverse
fashion (Fig.
29.2 ). The goal is to produce a zigzag pattern of
lengthened bowel with a diameter of approximately 2 cm. In
contrast to the Bianchi procedure, STEP can be employed for
recurrent bowel dilatation after previous lengthening [ 133 ].
Published results with this technique have been promising. A
multicenter registry of 21 SBS patients undergoing STEP
reported that the percentage of total calories tolerated enterally increased from 31 to 67 % at a median follow-up of 12.6
months [ 136 ]. A single-institution experience that included
b
34 STEP and 43 Bianchi procedures demonstrated a trend
toward a higher rate of weaning from parenteral nutrition in
patients who underwent STEP (60 % vs. 55 %) [ 131 ]. Long-
term outcomes after STEP were reported in a single-center
series of 12 pediatric patients; while 2 patients subsequently
received liver-intestinal transplants and 2 others died of liver
failure, 7 of the remaining 8 patients were weaned off parenteral nutrition by 4 years post-STEP [ 137 ].
Fig. 29.1 The Bianchi longitudinal intestinal lengthening procedure
(Reprinted from Bianchi [
divided longitudinally to yield two vascularized halves of the bowel
wall. ( b ) End-to-end anastomosis of the newly formed bowel loops
results in a longer but narrower segment of bowel compared to the original loop. © Elsevier 2006)
160 ], ( a ) The bowel and its mesentery are
motility and reduced bacterial overgrowth. It should be noted
that patients with advanced liver disease are poor candidates
for lengthening and should be referred for intestinal transplantation instead [ 131 ].
The Bianchi longitudinal intestinal lengthening procedure involves separating the two layers of small bowel mesentery, each layer containing blood vessels that enter one
side of the bowel wall (Fig. 29.1 ) [ 132 ]. The dilated bowel
is then divided longitudinally between the mesenteric layers
to form two parallel lumens. End-to-end anastomosis of
these two newly formed bowel loops creates an intestinal
segment that is longer but narrower than the original segment [ 125 ]. Over time, the absorptive surface area may
increase as the lengthened segment dilates [
124 ]. The
reported experience with the Bianchi procedure predominantly consists of case series data in the pediatric literature
[ 133 ]. In two larger series, the majority of patients who
Other Non-transplant Procedures
Key Concept: Dilation and adaption of the bowel can be
helpful but also can lead to complications that may need to
be addressed with other surgical procedures.
As alluded to previously, dilatation of the intestinal remnant normally occurs as an adaptive response following
resection in order to slow intestinal transit and increase
mucosal absorptive area [ 124 ]. However, this compensatory
process can lead to pathologic consequences such as dysmotility, bacterial overgrowth, and impairment of absorptive
function. For such scenarios in patients with moderately
shortened bowel, plication of the bowel wall and tapering
enteroplasty may be benefi cial [ 67 , 127 ].
Small Bowel Transplantation
Key Concept: Small bowel transplantation is a viable therapeutic option for intestinal failure as improvements have
occurred in immunosuppressive agents. While select patients
are typically in the end stage who have failed parenteral
nutrition, there is controversy regarding the need to expand
this to more patients earlier in their SBS course.
Historically, transplantation of the small intestine was
believed to be associated with seemingly insurmountable
challenges related to the organ’s immunogenicity and colonization with microorganisms [ 138 ]. Earlier efforts were
456
Fig. 29.2 The serial transverse
enteroplasty (STEP) procedure
(Reprinted from Javid et al. [
© Elsevier 2005)
I. Yang and R.P. Boushey
Antimesenteric border
161 ]
GIA stapler
associated with very high rates of morbidity and mortality
related to rejection, graft loss, and bacterial translocation
leading to sepsis. More recently, refi nement of surgical
technique in addition to enhanced immunosuppressive and
other perioperative strategies has signifi cantly improved
outcomes [ 138 , 139 ]. Therefore, small bowel transplanta-
tion has become fi rmly established as a viable therapeutic
option for intestinal failure. Depending on the extent of
liver disease and other abdominal pathology, a combined
liver-intestine or multivisceral graft may be indicated [ 139 ].
Recent data from high-volume intestinal transplant centers
demonstrate 1-year patient and graft survival rates that
exceed 80 and 70 %, respectively [ 140 – 142 ]. While long-
term survival has also dramatically improved in recent
decades, they still fall short of outcomes seen with other
abdominal organ transplants [ 143 ]. The Pittsburgh group
reported their series of intestinal and multivisceral transplants divided into time periods; for the 322 transplants performed during the study’s latest era (between 2001 and
2008), 5-year patient and graft survival rates were 68 and
53 %, respectively [
142 ]. There are ongoing efforts to
develop novel strategies to overcome late graft loss and its
sequelae [
142 , 144 ].
Traditionally, intestinal transplantation has been reserved
for patients with permanent intestinal failure who can no
longer be maintained on total parenteral nutrition therapy
[ 145 ]. Specifi cally, patients should be considered for trans-
plantation if they have impending or overt liver failure,
repeated loss of central venous access due to thrombosis,
recurrent episodes of catheter-related sepsis, or frequent
dehydration despite intravenous supplementation [ 146 ]. For
these patients, prompt referral to a transplant center for
evaluation is imperative for optimizing outcome [ 147 , 148 ].
Early transplantation, as defi ned by less than 12 months of
prior parenteral nutrition therapy, has been shown to be
associated with better survival [ 142 ]. As clinical outcomes
of intestinal transplantation continue to improve, some
experts have advocated for the restrictive indications to be
broadened [ 149 ]. Indeed, there has been increasing debate
regarding the role of “preemptive” transplantation in
patients who are at high risk of developing parenteral nutrition failure; this may apply to patients with ultrashort small
intestine (<50 cm), primary motility disorders, chronic
obstruction, and radiation injury [ 144 , 149 ]. The poor prog-
nosis associated with parenteral nutrition failure supports
early consideration of transplantation [ 149 ]. Furthermore,
there are multiple studies that demonstrate improved quality of life indicators following transplantation [ 143 , 149 ].
As well, intestinal transplantation has been shown to be
cost-effective for managing intestinal failure as long as
graft function is maintained for at least 2–3 years after
surgery [ 150 ].
29 Short Bowel Syndrome
457
Future Directions
Key Concept: We remain hampered by a widespread lack of
effective options for severe SBS, although emerging technology is in the investigative phase to give patients additional
hope.
Despite its recent advances, small intestinal transplantation continues to be limited by issues such as donor availability, graft rejection, and adverse effects related to
immunosuppression. As a potential solution to overcome
these diffi culties, tissue-engineered small intestine has been
studied in animal models [ 151 , 152 ]. The technology makes
use of biomaterials such as small intestinal submucosa to
generate new tissue and takes advantage of the regenerative
ability of intestinal epithelium [ 153 ]. While normal struc-
tural components have been successfully generated, peristaltic motion of the intestine has yet to be recreated [
well, it may be diffi cult to procure the necessary neonatal
intestinal organelles in humans and to scale up the size of the
tissue-engineered intestine to clinically useful dimensions
[
153 ]. Nevertheless, if this technology were to become fea-
sible in the future, it has the potential to dramatically alter
the management of short bowel syndrome.
133 ]. As
Outcomes
Key Concept: The prognosis of patients with short bowel
syndrome is determined by their remnant intestinal anatomy
and underlying disease and modulated by their response to
medical and surgical treatments.
Overall, patients who are dependent on home parenteral
nutrition (HPN) have higher mortality than their age-matched
counterparts in the general population [ 154 ]. A French group
recently reported their results over a 25-year period including
268 consecutive adult SBS patients who required HPN [ 66 ].
Survival was 94, 70, and 52 % at 1, 5, and 10 years, respectively. Complications related to SBS and HPN combined
accounted for only 26 % of the mortality. The study also
found the probabilities of a patient remaining dependent on
HPN were 74, 64, and 48 % at 1, 2, and 5 years, respectively.
Factors signifi cantly associated with HPN dependence at 5
years included remnant small intestinal length of less than
75 cm, less than 4/7 of colon remaining, and postoperative
citrulline concentration of less than 20 μmol/L. Comparable
results have been reported by other centers regarding the
prognosis of HPN-dependent patients, including 5-year survival rates ranging between 60 and 78 % [ 65 , 155 , 156 ].
There have been few studies addressing quality of life
(QOL) of patients on HPN. Jeppesen et al. used two validated (QOL) questionnaires on 49 HPN-dependent patients
and 36 patients who did not receive HPN but had anatomical
or functional short bowel [
157 ]. Compared to the latter
group, the former was found to have a poorer quality of life
that was comparable to that reported for dialysis-dependent
patients with chronic renal failure. Another research demonstrated that lowest QOL scores are more common during the
fi rst year on HPN, particularly if the patient was previously
well [ 158 ]. Quality of life then gradually improves under its
plateaus after 4–5 years on HPN. A US study found low
quality of life in patients requiring long-term HPN to be
associated with length of time on total parenteral nutrition,
lack of family supports, and fi nancial diffi culties [
respect to intestinal transplantation, there is increasing evidence that it results in improved quality of life measures
[ 144 ]. In a comparison of QOL measures between 79 adult
transplant survivors and 79 HPN patients, Abu-Elmagd et al.
reported superior results with transplantation across several
psychological, emotional, and social domains [ 143 ].
159 ]. With
Summary Pearls
You will be confronted with patients with SBS, and they may
be some of the most challenging that you will encounter. It is
important to remember that the management of the patient
with short bowel syndrome is guided by a thorough understanding of the remnant intestinal anatomy and physiology
as well as the underlying disease (Fig. 29.3 ). These factors
will largely determine the patient’s clinical manifestation,
which may range from mild malabsorption correctable with
dietary modifi cations to intestinal failure requiring complex
bowel rehabilitation and surgical strategies. As outcomes in
published series consistently correlate with residual length
of small intestine, it is worthwhile during the initial resection
operation to preserve as much of it as possible. Similarly, an
intact colon is valuable as it can compensate for the lost
absorptive function, and its presence is associated with independence from home parenteral nutrition.
A multidisciplinary approach is essential for the optimal
care of these complex patients. In particular, individuals who
are dependent on home parenteral nutrition should be managed by a center with appropriate expertise and resources.
This is likely to optimize intestinal rehabilitation, reduce
complications associated with long-term parenteral nutrition, and facilitate access to specialized medical and surgical
therapies. For nutritional support, you should use the enteral
route whenever possible; the presence of luminal nutrients is
necessary for intestinal adaption, a process which may continue for several years following resection. Antisecretory and
antimotility medications may be useful adjuncts for reducing
water and salt losses. Among the growth factors, GLP-2 and
its analogue, teduglutide, are promising intestinotrophic
agents that can augment a bowel rehabilitation regimen.
In the absence of contraindications to surgery, you should
attempt to restore intestinal continuity. For patients whose
458
Fig. 29.3 Algorithm for surgical
management of short bowel
syndrome
I. Yang and R.P. Boushey
Stoma+ residual distal
bowel?
Yes
Re-establish intestinal
continuity
Yes
Consider
transplantation
Dilated bowel?
Yes
Bianchi or STEP Colonic interposition
No
Severely short bowel?
No
Intestinal valve to
dilatation, followed by
Blanchi or STEP
Tapering enteroplasty
induce bowel
Yes
or plication
No
Dilated bowel?
No
Transit-slowing
Procedures
bowel is already in continuity, but cannot wean off parenteral
nutrition despite seemingly adequate intestinal length, segmental reversal of small bowel should be considered to slow
transit. On the other hand, for patients who are clearly limited
by a very short bowel that is dilated, either the Bianchi procedure or STEP may be appropriate. Of these two
bowel- lengthening operations, STEP is likely easier to perform and can be used as a repeat procedure. Finally, intestinal
transplantation has evolved over recent years to offer improved
survival and quality of life outcomes. Most importantly, for
SBS patients with adverse risk factors for failing parenteral
nutrition or if you do not feel comfortable or have the resources
to care for these patients, referral for evaluation regarding
transplantation should be considered early in their course.
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