Experience By J.S. Thompson,
With Intestinal Lengthening Short-Bowel Syndrome L.W. Pinch, N. Murray,
J.A. Vanderhoof,
for the
and L.R. Schultz
Omaha, Nebraska 0 Patients with the short-bowel syndrome frequently develop dilated intestinal segments that may lead to impaired motility and malabsorption. Although intestinal tapering alone improves motility, the intestine can be lengthened as well. We reviewed our experience with six children undergoing intestinal lengthening to improve intestinal absorption secondary to the short-bowel syndrome. The procedure was performed by dissecting the vessels along the mesenteric border and dividing the intestine longitudinally with a stapler. Five patients were receiving total parenteral nutrition (TPN) and one was becoming malnourished with enteral feedings alone. Bacterial overgrowth was documented in four patients and abnormal liver function in three patients. The intestinal segments were dilated up to 10 cm in diameter and remnant length ranged from 15 to 79 cm. Segments 5 to 25 cm in length were divided, resulting in an average increase in length of 52%. Necrosis of one of the divided limbs necessitated resection in one patient. Follow-up ranged from 2 to 94 months. TPN has been discontinued in four patients and avoided in another. Symptomatic improvement occurred in all patients. We feel the tapering and lengthening procedure should be considered in patients with symptomatic, dilated intestinal segments in whom the need for TPN may potentially be obviated. Copyright o 1991 by W.B. Saunders Company INDEX WORDS: Short-bowel intestinal lengthening.
syndrome;
intestinal tapering;
A
N INCREASING number of individuals now survive extensive intestinal resection because of improved surgical care and nutritional support.’ Although intestinal absorption of nutrients improves after resection as a result of intestinal adaptation, many patients with the short-bowel syndrome survive only because they receive long-term nutritional support via total parenteral nutrition (TPN). However, this therapy is expensive, inconvenient, and associated with potentially life-threatening complications,
including sepsis and hepatic failure.‘” Surgical therapies for the short-bowel syndrome continue to be investigated but are largely unsuccessfuL4 Thus, preserving intestinal length and maximizing its functional capability remain important objectives in managing these individuals.5 Patients with the short-bowel syndrome frequently develop dilated intestinal segments as a result of partial intestinal obstruction or intestinal adaptation. This may lead to impaired motility and malabsorption.6 Whereas intestinal tapering alone improves motility, intestinal tapering and lengthening can result in additional length as well.’ Since initially described by Bianchi,8 this procedure has been described in children in several case reports.‘-13 We report here our experience with six children undergoing intestinal lengthening to improve intestinal absorption secondary to the short-bowel syndrome. MATERIALS
Age/Sex
NO.
Etiology
METHODS
Intestinal lengthening has been performed in six children at Children’s Memorial Hospital and University of Nebraska Hospital between 1983 and 1988. These three boys and three girls ranged in age from 3 months to 10 years (Table 1). The short-bowel syndrome resulted from resection for volvulus in three patients, intestinal atresia in one patient, necrotizing enterocolitis in one
From the Departments of Surgery and Pediatrics. University of Nebraska Medical Center and Children’s Memorial Hospital, Omaha, NE. Date accepted: October 29, 1990. Address reprint requests to Jon S. Thompson, MD, Department of Surgery, Universityof Nebraska Medical Center, 42nd and Dewey Ave, Omaha, NE 68105. Copyright 0 1991 by W.B. Saunders Company 0022-3468191 I2606 0019$03.OOiO
Table 1. Preoperative Patient
AND
Findings
Remnant
Preoperative
Other
Length
TPN
Findings
1
3
Atresia
10cm&15cmcolon
Y
Elevated liver function tests
2
8 yr/female
volvulus
79 cm & leh colon
N
Malabsorption, weight loss, hypocalcemia
3
3 yr/male
Volvulus, gastroschisis
8 cm & left colon
Y
Bacterial overgrowth, vomiting, diarrhea
4
2 yr/female
volvulus
55 cm 81 left colon
Y
Bacterial overgrowth, nausea, vomiting,
volvulus
44 cm & left colon
Y
Vomiting, elevated liver function tests,
NEC
42 cm & left colon
Y
Vomiting, elevated liver function tests,
ma/female
with tetany, stricture
nephrocalcinosis 5
10 y/male
6
3 y/male
bacterial overgrowth bacterial overgrowth Abbreviations: NEC, necrotizing enterocolitis; TEN. total parenteral nutrition; Y, yes; N, no.
JournalofPediatric Surgery, Vol 26, No 6 (June), 1991: pp 721-724
721
722
THOMPSON
Fig 1. Intestinal tapering and lengthening. (A) Dissection longitudinally between the blood vessels on the mesenteric border permits the stapler to be used to (B and C) divide the bowel longitudinally. (D) The two parallel segments are then anastomosed end to end. (Reprinted with permission.“)
patient, and in association with gastroschisis in the final patient. Five patients were receiving chronic TPN and one patient was becoming malnourished with enteral feedings alone. Bacterial overgrowth was documented in four patients. Liver function tests were abnormal in three patients. Three patients had persistent vomiting which prevented oral intake. One patient had undergone a previous tapering procedure (patient 5). All patients had significant dilation of the duodenum as well. Intestinal tapering and lengthening was performed as described previously (Fig l).” The dilated segment to be lengthened was transected distally. Dissection was carried out in the space between the vessels in the mesenteric border. With each 5 cm dissected, a Penrose drain (Smith and Nephew, Massilon, OH) was passed through the space and used to pass the gastrointestinal anastomosis (GIA 55; Autosuture, Atlanta, GA) stapler. The GIA stapler was then fired to divide the bowel longitudinally preserving blood vessels to both sides. This procedure was repeated until the desired length was achieved. The longitudinally developed segments were then anastomosed end to end.
RESULTS
Initial remnant length ranged from 8 to 79 cm (Table 1). Segments 5 to 25 cm in length were divided, resulting in an average increase in length of
ET AL
52% (Table 2). Tapering of the duodenum was also performed in one patient (patient 4). Necrosis of one of the divided limbs necessitated resection in one patient (patient 2). The 3-month-old infant died 8 weeks postoperatively secondary to sepsis. Length of postoperative hospitalization averaged 27 days (range, 9 to 60 days), but three patients were discharged within 14 days of operation. Intestinal motility was slow to return (more than 10 days until oral intake) in three patients. Gastrostomy tubes were placed in five patients. Recurrent dilation of the lengthened segments was evaluated by barium contrast studies four patients. One patient underwent reoperation for recurrent dilation but the dilated segment was the duodenum, which had previously been tapered by imbrication (patient 4). This procedure was repeated. Four patients had home TPN discontinued and another was able to avoid home TPN with an increase in body weight percentile
With Intestinal Lengthening Short-Bowel Syndrome L.W. Pinch, N. Murray,
J.A. Vanderhoof,
for the
and L.R. Schultz
Omaha, Nebraska 0 Patients with the short-bowel syndrome frequently develop dilated intestinal segments that may lead to impaired motility and malabsorption. Although intestinal tapering alone improves motility, the intestine can be lengthened as well. We reviewed our experience with six children undergoing intestinal lengthening to improve intestinal absorption secondary to the short-bowel syndrome. The procedure was performed by dissecting the vessels along the mesenteric border and dividing the intestine longitudinally with a stapler. Five patients were receiving total parenteral nutrition (TPN) and one was becoming malnourished with enteral feedings alone. Bacterial overgrowth was documented in four patients and abnormal liver function in three patients. The intestinal segments were dilated up to 10 cm in diameter and remnant length ranged from 15 to 79 cm. Segments 5 to 25 cm in length were divided, resulting in an average increase in length of 52%. Necrosis of one of the divided limbs necessitated resection in one patient. Follow-up ranged from 2 to 94 months. TPN has been discontinued in four patients and avoided in another. Symptomatic improvement occurred in all patients. We feel the tapering and lengthening procedure should be considered in patients with symptomatic, dilated intestinal segments in whom the need for TPN may potentially be obviated. Copyright o 1991 by W.B. Saunders Company INDEX WORDS: Short-bowel intestinal lengthening.
syndrome;
intestinal tapering;
A
N INCREASING number of individuals now survive extensive intestinal resection because of improved surgical care and nutritional support.’ Although intestinal absorption of nutrients improves after resection as a result of intestinal adaptation, many patients with the short-bowel syndrome survive only because they receive long-term nutritional support via total parenteral nutrition (TPN). However, this therapy is expensive, inconvenient, and associated with potentially life-threatening complications,
including sepsis and hepatic failure.‘” Surgical therapies for the short-bowel syndrome continue to be investigated but are largely unsuccessfuL4 Thus, preserving intestinal length and maximizing its functional capability remain important objectives in managing these individuals.5 Patients with the short-bowel syndrome frequently develop dilated intestinal segments as a result of partial intestinal obstruction or intestinal adaptation. This may lead to impaired motility and malabsorption.6 Whereas intestinal tapering alone improves motility, intestinal tapering and lengthening can result in additional length as well.’ Since initially described by Bianchi,8 this procedure has been described in children in several case reports.‘-13 We report here our experience with six children undergoing intestinal lengthening to improve intestinal absorption secondary to the short-bowel syndrome. MATERIALS
Age/Sex
NO.
Etiology
METHODS
Intestinal lengthening has been performed in six children at Children’s Memorial Hospital and University of Nebraska Hospital between 1983 and 1988. These three boys and three girls ranged in age from 3 months to 10 years (Table 1). The short-bowel syndrome resulted from resection for volvulus in three patients, intestinal atresia in one patient, necrotizing enterocolitis in one
From the Departments of Surgery and Pediatrics. University of Nebraska Medical Center and Children’s Memorial Hospital, Omaha, NE. Date accepted: October 29, 1990. Address reprint requests to Jon S. Thompson, MD, Department of Surgery, Universityof Nebraska Medical Center, 42nd and Dewey Ave, Omaha, NE 68105. Copyright 0 1991 by W.B. Saunders Company 0022-3468191 I2606 0019$03.OOiO
Table 1. Preoperative Patient
AND
Findings
Remnant
Preoperative
Other
Length
TPN
Findings
1
3
Atresia
10cm&15cmcolon
Y
Elevated liver function tests
2
8 yr/female
volvulus
79 cm & leh colon
N
Malabsorption, weight loss, hypocalcemia
3
3 yr/male
Volvulus, gastroschisis
8 cm & left colon
Y
Bacterial overgrowth, vomiting, diarrhea
4
2 yr/female
volvulus
55 cm 81 left colon
Y
Bacterial overgrowth, nausea, vomiting,
volvulus
44 cm & left colon
Y
Vomiting, elevated liver function tests,
NEC
42 cm & left colon
Y
Vomiting, elevated liver function tests,
ma/female
with tetany, stricture
nephrocalcinosis 5
10 y/male
6
3 y/male
bacterial overgrowth bacterial overgrowth Abbreviations: NEC, necrotizing enterocolitis; TEN. total parenteral nutrition; Y, yes; N, no.
JournalofPediatric Surgery, Vol 26, No 6 (June), 1991: pp 721-724
721
722
THOMPSON
Fig 1. Intestinal tapering and lengthening. (A) Dissection longitudinally between the blood vessels on the mesenteric border permits the stapler to be used to (B and C) divide the bowel longitudinally. (D) The two parallel segments are then anastomosed end to end. (Reprinted with permission.“)
patient, and in association with gastroschisis in the final patient. Five patients were receiving chronic TPN and one patient was becoming malnourished with enteral feedings alone. Bacterial overgrowth was documented in four patients. Liver function tests were abnormal in three patients. Three patients had persistent vomiting which prevented oral intake. One patient had undergone a previous tapering procedure (patient 5). All patients had significant dilation of the duodenum as well. Intestinal tapering and lengthening was performed as described previously (Fig l).” The dilated segment to be lengthened was transected distally. Dissection was carried out in the space between the vessels in the mesenteric border. With each 5 cm dissected, a Penrose drain (Smith and Nephew, Massilon, OH) was passed through the space and used to pass the gastrointestinal anastomosis (GIA 55; Autosuture, Atlanta, GA) stapler. The GIA stapler was then fired to divide the bowel longitudinally preserving blood vessels to both sides. This procedure was repeated until the desired length was achieved. The longitudinally developed segments were then anastomosed end to end.
RESULTS
Initial remnant length ranged from 8 to 79 cm (Table 1). Segments 5 to 25 cm in length were divided, resulting in an average increase in length of
ET AL
52% (Table 2). Tapering of the duodenum was also performed in one patient (patient 4). Necrosis of one of the divided limbs necessitated resection in one patient (patient 2). The 3-month-old infant died 8 weeks postoperatively secondary to sepsis. Length of postoperative hospitalization averaged 27 days (range, 9 to 60 days), but three patients were discharged within 14 days of operation. Intestinal motility was slow to return (more than 10 days until oral intake) in three patients. Gastrostomy tubes were placed in five patients. Recurrent dilation of the lengthened segments was evaluated by barium contrast studies four patients. One patient underwent reoperation for recurrent dilation but the dilated segment was the duodenum, which had previously been tapered by imbrication (patient 4). This procedure was repeated. Four patients had home TPN discontinued and another was able to avoid home TPN with an increase in body weight percentile
