Original ArticleFrom the Cradle to Enteral Autonomy: The Role of Autologous Gastrointestinal Reconstruction
Section snippets
The Short Gut Problem
Antenatal midgut loss presents with bowel atresia and intestinal obstruction. The massively dilated residual proximal small bowel represents some 10%–20% of normal small bowel length, with the distal colon often being the next available bowel. In this context, the natural doubling in bowel length during the last trimester of pregnancy is an advantage to the premature child.1 Attempted relief of mechanical bowel obstruction by anastomosis of the massively dilated proximal jejunum to the small
PN
It must be acknowledged that PN has been the key factor in survival for the short gut patient. Its administration is complex, and infection hazards are constant. Detailed analysis of PN is beyond the scope of this paper. It is, however, relevant to note that the feeding solutions are not perfect and are thought to be partly responsible for severe cholestasis with hepatic fibrosis rapidly leading to end-stage liver failure and a reduced bowel adaptive response, impacting on the timely
AGIR Techniques
Surgical attempts at improving mucosal absorption have been varied and imaginative (Table 2). Some, such as “recycling loops” and “pouches,” have not proven beneficial. Others, including bowel pacing, neomucosal growth, mucosal stem cell regeneration, and tissue-engineered intestine,7 may yet develop to clinical application. Progressive understanding of bowel physiology has stimulated varied and interesting concepts, which have been excellently reviewed by Thompson and Rikkers (1987),8 Warner
Common Trends in AGIR Techniques
Analysis of the various techniques in AGIR reveals some common trends. Most procedures are relatively simple and free from major morbidity or mortality, and some, such as colon interposition, reversed segments, and intestinal valves are reversible. All have been shown to slow transit, to increase mucosal contact, and to enhance absorption. The LILT procedure has been associated with significant increases in absorption, allowing many patients to be weaned from PN. It is abundantly clear from the
Criteria for AGIR and Transplantation
Barksdale and Stanford10 suggested that the indications for AGIR possibly within the first year of life are a failure to progress with weaning from PN and the presence of life-threatening complications such as PN-related liver disease, recurrent central line sepsis, and limited vascular access. The authors indicate that patients with ultrashort segment disease, ie, <10% with ICv, or <20% without ICv, often benefit from “adjunctive proadaptive surgery,” ie, AGIR with the choice of procedure
Discussion
The management of the child with a short bowel is a complex multidisciplinary process over a prolonged period of several years. The long-term outlook for these children continues to improve with developments in PN support, bowel reconstructive procedures, and transplantation. The number of children with short bowel and intestinal failure is not great, and early management has often been uncoordinated, haphazard, and less than ideal. Current evidence can only be indicative of potential benefits
References (33)
- et al.
Normal intestinal length in preterm infants
J Pediatr Surg
(1983) - et al.
The role of phytosterols in the pathogenesis of liver complications of pediatric parenteral nutrition
Nutrition
(1998) - et al.
BAPS prize lecture: new insight into mechanisms of parenteral nutrition-associated cholestasis: role of plant sterols
J Pediatr Surg
(1998) - et al.
Functional liver recovery parallels autologous gut salvage in short bowel syndrome
J Pediatr Surg
(2004) - et al.
Sequential intestinal lengthening procedures for refractory short bowel syndrome
J Pediatr Surg
(1994) - et al.
Surgical options for short bowel syndrome
Semin Pediatr Surg
(2001) - et al.
Prejejunal transposition of colon to prevent the development of short bowel syndrome in puppies with 90% small intestine resection
J Pediatr Surg
(1973) - et al.
Colon interpositionan adjuvant operation for short gut syndrome
J Pediatr Surg
(1984) Intestinal loop lengtheninga technique for increasing small intestinal length
J Pediatr Surg
(1980)- et al.
Bowel lengthening for shortgut syndrome
J Pediatr Surg
(1981)
Long-term outcome of intestinal lengthening
Transplant Proc
Early improvement in intestinal function after isoperistaltic bowel lengthening
J Pediatr Surg
Problems with intestinal lengthening
J Pediatr Surg
Letter to editor
J Pediatr Surg
Partial intestinal obstruction induces substantial mucosal proliferation in the pig
J Pediatr Surg
Serial transverse enteroplasty for short bowel syndromea case report
J Pediatr Surg
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