John K. DiBaise1, Samuel Kesseli2, and Debra Sudan2 1 Mayo Clinic in Arizona, Scottsdale, AZ, USA 2 Duke University Medical Center, Durham, NC, USA Short bowel syndrome (SBS) is a disabling malabsorptive condition typically occurring after intestinal resection associated with a number of complications and high utilization of healthcare resources, that substantially impairs quality and duration of life. The causes of SBS vary by age group (Box 24.1). Three remnant bowel anatomies may occur in SBS and may be classified into groups based upon the location of the anastomosis after resection (e.g., jejunocolic or jejunoileocolonic) or when no anastomosis is present (e.g., end‐jejunostomy) (Figure 24.1). The clinical manifestations and outcome of SBS vary depending upon the bowel anatomy and its residual function. Intestinal adaptation refers to a process following intestinal resection in which the remaining bowel undergoes macroscopic and microscopic changes in response to a variety of internal and external stimuli, including nutrients, gastrointestinal secretions, hormones, growth factors, other genetic/biochemical factors, and the remaining bowel, in order to increase its absorptive ability (Box 24.2). A variety of complications can affect the patient with SBS. These complications may result from the underlying disease, the altered bowel anatomy and physiology, or its treatment, including the need for parenteral nutrition (PN) and its associated central venous catheter (Box 24.3). In some instances, the pathogenetic roles of the altered bowel and PN cannot be clearly separated. The care of SBS patients requires a comprehensive, multidisciplinary approach and attention to detail. Specific dietary intervention combined with medical management and, occasionally, surgical strategies offer the potential of PN reduction, enteral independence, and overall improved clinical outcome (Figure 24.2). There is a lack of information regarding the long‐term benefits and patient adherence to dietary modifications among SBS patients. Despite the limitations, current clinical experience supports the benefits of an optimized diet with respect to improving feeding tolerance, reducing stool output, and facilitating weaning of PN (Table 24.1). Nearly 50% of patients with short bowel syndrome will require additional surgery at some point after their initial hospital discharge. It is crucial that as much bowel as possible be preserved in subsequent operations and the focus be on maximizing the function of the remaining bowel (Box 24.4). Intestinal lengthening procedures include longitudinal intestinal lengthening and tailoring (LILT; sometimes referred to as the Bianchi procedure) and serial transverse enteroplasty (STEP). LILT is performed by transecting the bowel distal to the dilated segment to be tapered. The two leaves of the mesentery carrying blood supply to each half of the circumference of the small bowel are separated longitudinally to create a tunnel, through which a stapler is passed along the length of the dilated bowel, dividing the bowel into two equal lengths. The segments are then anastomosed in isoperistaltic fashion, doubling the length of the original segment (Figure 24.3a). STEP involves serial transverse applications of a linear stapler from alternating directions in an overlapping and partially transecting fashion (Figure 24.3b).
CHAPTER 24
Short bowel syndrome and small bowel transplantation
Etiology
Bowel anatomies
Intestinal adaptation
Complications
Management
Oral diet
Nontransplant surgery
Intestinal lengthening procedures
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