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Intestinal Rehabilitation & Surgical Management
Lauren K. Schwartz, MD
Concorde Medical Group
June 12, 2015
Financial Disclosures
NPS Pharmaceuticals
Member of scientific steering committee
Coram Home Care
Advisory board member
Overview Overview of SBS
Normal gut physiology
Short bowel pathophysiology
Intestinal rehabilitation
Evaluation for therapeutic planning
Traditional interventions
New trophic therapy
Intestinal transplant
Indications, Operations, Expectations
Short Bowel Syndrome Malabsorptive condition caused by loss of an extensive length of small intestine
<200 cm of post duodenal small bowel
Manifestations
Diarrhea
Dehydration, electrolyte derangements
Weight loss Malnutrition
Gastro 2006;130:S3-4
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SBS: EtiologiesAdults
Mesenteric ischemia
Crohn’s disease
Radiation enteritis
Trauma
Recurrent obstruction
Volvulus
Internal hernia
Children Necrotizing enterocolitis
Intestinal atresia
Volvulus
Extensive agangliosis
Gastroschisis
Congenital short bowel
Meconium peritonitis
The Healthy Intestine Small bowel: 6 meters (3‐8 m) or 20 feet
Colon: 1.5 meters or 5 feet
Duodenum 25 cm
Jejunum 2.5 m
Ileum 3.5 m
The Healthy IntestineAbsorption=8.8 L
Ingestion2000 mL/d water
Bile1000 mL/d
Intestinal secretions1000 mL/d
Small intestinal absorption 7500 mL/d
Ingestion + secretion=9 L
Colon absorption1000–3000 mL/d
Saliva 1000 mL/d
Gastric secretions2000 mL/d
Pancreatic secretions2000 mL/d
Fluid Secretion and Absorption
150-200 mL/d water excreted
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The Shortened Intestine
End-JejunostomyJejunocolic anastomosis
Jejunoileal anastomosis
Prognosis declines
Retained bowel
Jejunum
The Shortened Intestine Retained bowel anatomy determines functional capacity and PN dependence
Length of small bowel remaining
Presence of IC valve and colon
Type of small bowel (jejunum vs. ileum)
Health of residual bowel
Messing B et al. Gastroenterology 1999; 117
PN D
epen
den
cy Probab
ility (%
)
Years following final digestive circuit modification
Bowel Length and PN Dependence
0‐49 cm
50‐99 cm
100‐150 cm
The Shortened Intestine Minimal small bowel lengths separating need for transient vs. permanent TPN
Messing B et al. Gastroenterology 1999; 117
Intestinal Circuit Small bowel length
End enterostomy 100 cm
Jejunocolic 65 cm
Jejunoileocolic 30 cm
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Intestinal Adaptation Functional changes
Slowed transit
Increased transporters
Structural changes
Dilation, lengthening
Increased villous height, diameter
SBS: Treatment Options
Intestinal Rehab
Intestinal
Transplant
Long-term TPN
Surgical
Augmentation
Intestinal Rehabilitation The process of restoring nutritional status and intestinal function with ultimate goal of TPN withdrawal Optimize nutritional status
Control diarrheal losses
Enhance absorption
Wean TPN
Rehab modalities Diet, TPN, EN
Pharmacotherapy
Growth factors
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Malabsorption
Com
pens
ator
y
Flu
id o
r N
utrit
iona
l Sup
port
Intestinal insufficiency
Intestinal failure
Additional oral intake (hyperphagia)
Parenteral support
Spectrum of Short Bowel Syndrome
Heterogeneous population
• Anatomy and bowel function
• Ability to compensate orally for malabsorption
• Symptom severity
Initial Evaluation
Residual Anatomy
Intestinal lossesFluid balance
Nutritional Status
Surgical historyOperative recordsBowel disease
Ostomy, fistula, tubes
Small bowel series +/‐ barium enemaCT enterographyEGD/Colonoscopy
Transplant vs. TPN: SurvivalHome TPN Intestinal Transplant$
All patients*
1 year: 87‐96%
3 year: 70‐90%
Short bowel patients+
5 year:
93% length 100‐150 cm
79% length 50‐99 cm
57% length <50 cm
Patient survival
1 year: 79%
3 year: 66%
5 year: 63%
*Howard L. Gastro 1995;109:355+Messing B. Gastroenterology 1999; 117
$SRTR Data
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Conclusions: Short bowel syndrome is a complex condition requiring coordinated care between gastroenterologist, surgeon, and nutrition expert
Approach to intestinal rehab must be tailored to the individual patient, taking into account residual bowel anatomy
The goals of intestinal rehab are restoration of enteral autonomy and withdrawal of PN and IVF support
Should lead to reduced complications, elimination of need for transplant, improved quality of life
Conclusions: We are entering a new era of intestinal failure management with the availability of intestinal trophic hormones Promises to advance our ability to reduce PN dependence
When TPN withdrawal is not possible and patients experience major complications, referral for intestinal transplant is appropriate
Consider early referral to a transplant/intestinal rehab center for:
Baseline assessment
Extreme short bowel syndrome
Non‐transplant surgery (restore continuity, bowel lengthening, complex fistula repair)
Question A 32 year‐old woman with a history of Crohn’s disease and multiple related surgeries presents to you for management of a high output ileostomy. Her last surgery was 6 months ago, and resulted in a residual small bowel length of 180 cm. She is TPN dependent. All of the following are appropriate recommendations except:
Encourage hydration with oral rehydration solutions
Add IV famotidine to her TPN
Start cholestyramine twice daily
Start tincture of opium 30 minutes pre‐meals
Question A 44 year‐old woman with a history of roux‐en Y gastric bypass for obesity develops ischemic bowel due to an internal hernia. Her post op anatomy consists of 100 cm of small bowel ending in an ostomy and a colonic mucus fistula (retains ½ of her colon). She is TPN dependent but struggling with adequate hydration due to high ostomy losses. The next step in the management of this patient should be:
Encourage her to drink ample amounts of water
Encourage her to drink ample amounts of ORS
Refer her for surgery to restore intestinal continuity