Postoperative short bowel syndrome

BACKGROUND: Unanticipated massive resection after intraabdominal procedures is an increasing cause of short bowel syndrome (SBS). Our aim was to determine the frequency and potential mechanisms of postoperative SBS. STUDY DESIGN: We reviewed retrospectively the clinical course of 210 adult patients with SBS evaluated over a 20-year period. RESULTS: Fifty-two (25%) patients had postoperative SBS. The initial operations included colectomy (n=20), hysterectomy (n=8), appendectomy (n=5), gastric bypass (n=5), and other (n=14). Intestinal obstruction (n=38) was the most common reason for resection leading to SBS, either from adhesions (n=26) or volvulus (n=12). Postoperative intestinal ischemia led to resection in 14 patients. SBS occurred from 1 day postoperatively to years later, with 16 (30%) intestinal resections occurring within 1 month. Patients undergoing resection for intestinal ischemia were more likely to undergo resection during the first month than were patients with adhesions and volvulus (86% versus 4% and 25%,respectively, p < 0.05): Patients undergoing resection for ischemia and volvulus were more likely to have remnant length<60 cm compared with those with adhesions (57% and 58% versus 23%, respectively, p < 0.05). Patients undergoing resection for adhesive obstruction were more likely to undergo multiple resections. Thirty-five (67%) patients required longterm parenteral nutrition. Seven (13%) patients died, three in the early postoperative period and four from complications of SBS. CONCLUSIONS: SBS is a potential postoperative complication of intraabdominal procedures and accounts for a considerable proportion of tertiary referrals for SBS. Surgical treatment of postoperative obstruction after common surgical procedures is the most frequent cause. Preventing adhesions, avoiding technical errors, diagnosing a potentially ischemic intestine in a timely manner, and approaching the frozen abdomen cautiously are important strategies for preventing this condition.     

�̳��ۺ��������ƽ�չ

短肠综合征 (以下简称短肠 )是指因各种原因引起广泛小肠切除 ,造成剩余的功能性小肠过短而导致水、电解质代谢紊乱以及各种营养物质吸收不良的综合征。肠道的代偿能力甚强 ,切除 50 %的小肠并不引起症状 ;切除 75%以上可因吸收面积减少而出现严重腹泻、吸收不良 ,水、电解质紊乱 ,代谢障碍和进行性营养不良。肠外营养问世以前 ,造成短肠病人死亡的主要原因是原发病本身 (如广泛的血管病变或肿瘤 )、肠道吸收功能障碍导致的营养不良和肠外营养及其并发症所造成的感染和肝肾功能损害。随着肠外营养技术的进步以及对短肠综合征病理生理过程和…     

Neonatal short bowel syndrome: a cohort study

Background

To date, our knowledge of morbidity and mortality in neonatal short bowel syndrome (SBS) is based on individual case series. Shortcomings of the published literature include long patient recruitment time, selection bias, variable SBS definitions, failure to account for gestational age, and incomplete follow-up. By applying more rigorous methodology, our aim was to determine outcomes of SBS neonates compared with a control group of neonates without SBS.

Methods

A cohort study of all neonates with abdominal pathology requiring laparotomy between January 1, 1997, and December 31, 1998, with observation through July 1, 2001. Short bowel syndrome was defined as patients requiring parenteral nutrition for more than 42 days or residual small bowel length of less than 25% predicted by gestational age. Student's t test, Mann-Whitney U test, and χ² were used where appropriate. Kaplan-Meier curves were used to determine cumulative survival. Covariates important in the development of SBS were examined using forward step-wise logistic regression.

Results

There were 175 patients (with SBS = 40, without SBS = 135) with a mean gestational age of 30.7 ± 4.6 weeks vs 35.9 ± 4.8 weeks, respectively (P < .0005). The patients with SBS suffered significantly more morbidity than the group without SBS in all categories of investigation (surgical complications, septic events, central venous line complications, duration to adaptation and parenteral nutrition independence, cholestasis and liver failure, and duration of hospitalization). The case fatality rate was 37.5% in patients with SBS vs 13.3% in patients without SBS (P = .001). Most of the deaths were caused by liver failure or sepsis and occurred within 1 year from the date of surgery. Presence of an ileostomy (exp(B) = 12.29; P < .0005) and a residual small bowel length less than 50% of the original length (exp(B) = 26.84; P < .0005) were the only 2 variables in a logistic regression analysis found to be independently associated with the development of SBS.

Conclusion

This cohort study clearly illustrates the tremendous morbidity experienced by infants with SBS relative to other surgical neonates. Accurate estimates of the morbidity associated with SBS enables clinicians to appropriately counsel parents, allocate resources and initiate therapeutic trials.     

短肠综合征时结肠的代偿研究

目的　观察及评价短肠大鼠结肠代偿性增生及结肠对营养物质吸收的促进作用。　方法　制作切除（80～85）%的超短肠大鼠模型,用百普素(Pepti-2000)做肠内营养（EN）治疗,观察全身营养状况和结肠形态学的改变,并在术后第21天用木糖和15N-甘氨酸混合液对带血管蒂的结肠进行封闭式灌注,观察结肠对水、碳水化合物和氨基酸的吸收情况。　结果　EN组于术后第21天净氮平衡与对照组（CONT）无差异,体重仅比术前减轻(10±18)g。结肠壁明显增厚,皱襞增大增粗,结肠壁的厚度、粘膜厚度、皱襞高度和皱襞表面积与CONT组相比差异具有非常显著性意义（P＜0.01）。EN组与CONT组相比DNA指数1.21±0.11vs.1.01±0.15(P＜0.05),S期细胞百分比（52.6±5.5）%vs.（42.9±4.1）%（P＜0.05）。连续循环灌注3h之后EN组对水、木糖和氨基酸的吸收明显高于CONT组（P＜0.05）。　结论　大鼠结肠在短肠综合征时发生了明显的形态和功能上的代偿。早期适当的肠内营养不但可使超短肠大鼠获得足够营养支持,并且能够促进短肠大鼠结肠代偿。     

短肠综合征治疗方法的选择

短肠综合征（SBS）是肠衰竭的主要病因,有着较高的并发症发生率和病死率.近年来,随着重症医学和全肠外营养（TPN）技术的进步,大大提高了丧失大部肠道病人的长期存活率.SBS治疗措施的制定应该基于病人的年龄、残存胃肠道的长度和功能、基础营养状况、总的健康状况和可能发生的并发症,要求内科学、营养学、外科学和心理学的综合治疗.肠道吸收面积减少引起吸收障碍,导致多种营养相关问题是其临床治疗的主要难点.     

Intestinal adaptation in short bowel syndrome

Regaining enteral autonomy after extensive small bowel resection is dependent on intestinal adaptation. This adaptational process is characterized by hyperplastic growth of the remaining gut, which is accompanied by both an increase of cell division at the level of the crypt cells and by an increased rate of programmed cell death (apoptosis). Apart from the absorptive function, the small bowel also has a barrier function and plays an important role in interorgan metabolism. Also, these functions are greatly affected by a massive intestinal resection and subsequent recovery by intestinal adaptation. This review aims to give an overview of the debilitating effects of massive intestinal resection on gut function and subsequently discusses intestinal adaptation and possible factors stimulating adaptation.     

����Ԥ���̳��ۺ���

生物赖营养得以生存,人的营养主要来自于对食物的消化吸收.消化系统的肝、胆、胃肠等均直接参与人体的代谢与组织合成,肠道更是消化吸收的首要器官,一旦功能障碍,营养难以获得补充.若大部分小肠丧失（剩余肠段不足70cm）,在20世纪70年代前,静脉营养尚不能满足人体的营养需要,难以吸收营养;70年代以后,全肠外营养应用于临床使部分病人获得了存活的时间,肠功能得以代偿,恢复从肠道吸收部分或大部营养的功能,或是全赖肠外营养维持营养的需要量.     

Bombesin in short bowel syndrome.

Short bowel syndrome comprises the sequel of nutrient, fluid, and weight loss that occurs subsequent to greatly reduced functional surface area of the small intestine. The aim of this study is to investigate the trophic and functional effects of bombesin on remaining gut in rats with experimentally induced short bowel syndrome. Thirty-two rats were allocated randomly and experimental short bowel syndrome was induced by 80% bowel resection in all rats. A regular enteral diet and isocaloric elemental enteral nutrition for 12 days were given in the control group and the elemental nutrition group, respectively. In the bombesin group 10 microg/kg subcutaneous bombesin (t.i.d.) for 10 days with regular enteral diet for 12 days was given. In the elemental nutrition and bombesin group the diet consisted of 10 microg/kg subcutaneous bombesin (t.i.d.) for 10 days with isocaloric elemental enteral nutrition for 12 days was given. All rats underwent physical, histological, and biochemical evaluation. Reduction in weight loss, bowel diameter, fecal fat content, and glycemia, increase in cellularity, and d-xylose absorption were observed in all treatment groups. These changes were more evident in the bombesin treatment groups. Increases in serum protein and albumin levels were seen with bombesin treatment with or without elemental diet, whereas reductions in villous height and crypt depth were observed only with bombesin treatment without elemental diet. Serum calcium, iron, and vitamin B(12) levels were not affected with any treatment. It is concluded that bombesin may be a useful trophic agent contributing to increased absorptive capacity and improved biochemical values even in the absence of elemental nutrition.     

Isoperistaltic bowel lengthening for short bowel syndrome in children

BACKGROUND: Short bowel syndrome, secondary to a variety of causes, can be lethal in infancy and childhood. Isoperistaltic bowel lengthening, performed by longitudinal division of dilated small bowel with end-to-end anastomosis, has shown early promise but long-term outcome is unknown. METHODS: Sixteen infants and children (aged 3 months to 14 years) had short bowel syndrome from necrotizing enterocolitis (8), gastroschisis (4), atresia (2), and volvulus (2). All of these patients were partially or totally dependent on parenteral nutrition and have undergone isoperistaltic bowel lengthening for short bowel syndrome (length <100 cm). Bowel length was increased by 22% to 85% (mean 42%) with the procedure. Studies of intestinal function were performed preoperatively and postoperatively. RESULTS: Isoperistaltic bowel lengthening resulted in significant improvement in stool counts, intestinal transmit time, intestinal clearance of barium, D-xylose absorption, and fat absorption at 6 months and 12 months postoperatively. Fourteen of 16 patients (88%) have been weaned from parenteral nutrition. CONCLUSIONS: These data show that isoperistaltic bowel lengthening can be an effective operation for short bowel syndrome in children, improving absorption and motility, and allowing weaning from parenteral nutrition.     

Current management of the short bowel syndrome

Short bowel syndrome is a challenging clinical problem that benefits from a multidisciplinary approach. Much progress has recently been made in all aspects of management. Medical intestinal rehabilitation should be the initial treatment focus, and several new potential pharmacologic agents are being investigated. Surgical rehabilitation using nontransplant procedures in selected patients may further improve intestinal function. Intestinal lengthening procedures are particularly promising. Intestinal transplantation has increasingly been used with improving success in patients with life-threatening complications of intestinal failure.     

Chemically induced bowel denervation improves survival in short bowel syndrome

This study evaluates the effect of chemically induced bowel denervation on survival, weight gain or loss, transit time, and d-xylose absorption in rats following 80% small bowel resection. Forty-three male Sprague-Dawley rats (150 g) underwent 80% midsmall bowel resection and anastomosis. Twenty rats were short bowel controls (group I). In 23 rats (group II), a 2.0 cm segment of jejunum proximal to the anastomosis was denervated by application of 0.1% benzalkonium chloride (BK) for 30 minutes. Ten additional rats underwent sham laparotomy without bowel resection. Five remained untreated (group III) and in 5 (BK) denervation was added (group IV). Bowel denervation was confirmed by histologic study in all (BK) rats. Weight and daily food and water intake were measured for 30 days and the groups compared. Weight in group I was 43.8 +/- 52.9 g, group II 95.0 +/- 50.1, (P less than .005), group III 177 g, and group IV 175 g. Food intake was greater in group I than II (P less than .05) and was similar to groups III and IV. Water intake calculated as animal weight (g)/mL H2O ingested was lowest in group I (P less than .05). Mortality was 30% in group I (6/20) and only 8.6% in group II (2/23). No deaths were observed in unresected controls (III and IV). Twenty-four additional rats were evaluated for d-xylose absorption and transit time by bringing out a loop enterostomy 10.0 cm from the Ligament of Treitz. Twelve rats were ostomy controls (group V).(ABSTRACT TRUNCATED AT 250 WORDS)     

Small bowel volvulus leading to gangrene and short bowel syndrome

A young man was operated for acute abdomen. Laparotomy revealed small bowel diverticulosis with very short mesentery leading to volvulus of near total small bowel. Resection and end to end anastomosis was performed. Patient ended up with short bowel syndrome.     

Massive small bowel resection during pregnancy causing short bowel syndrome

Massive small bowel infarction in pregnancy is rare but has devastating complications. Diagnosis is difficult because pregnancy masks the symptoms. Our aim was to assess risk factors and outcomes of massive resection associated with pregnancy. We conducted a review of nine patients with short bowel syndrome (SBS) secondary to massive bowel resection during pregnancy. The most common cause of bowel resection was midgut volvulus in seven patients. Four of these also had malrotation. Three others had previous abdominal operations, including gastric bypass. The two remaining patients had vascular insufficiency. Five of the nine patients presented after a cesarean delivery. There were three fetal deaths. Resulting small bowel length was less than 60 cm in all but one patient. All patients required parenteral nutrition (PN). Seven patients developed significant complications related to SBS and long-term PN. Four patients underwent transplantation. Massive small bowel resection during pregnancy is a devastating complication, which requires a high degree of suspicion to diagnose. Most patients have risk factors, which include previous surgery, congenital malrotation, and a hypercoagulable state. Surviving patients usually need long-term PN or transplantation.     

Mesenteric thrombosis causing short bowel syndrome in nephrotic syndrome

Nephrotic patients are at risk of developing venous and arterial thrombotic complications. Pulmonary embolism due to affected deep leg veins is by far the most common event. Renal or cerebral vein thromboses have been described. Thrombosis of arterial vessels is less frequent. Mesenteric infarction is a rare but severe complication in patients with nephrotic syndrome (NS). We report a 7-year-old boy with a steroid-dependent (SD) NS and a homozygous mutation of methylenetetrahydrofolate reductase, increasing the risk of thromboembolic events. He developed a thrombosis of his superior mesenteric artery during his ninth relapse, which was responsible for a necrosis of 240 cm of his small bowel, necessitating resection of necrotic parts and double external ostomy diversion. Remission was achieved with pulse prednisolone therapy. Corticoids were reduced over 4 months progressively. Oral cyclosporin A (CyA) was initiated for long-term treatment. Due to a short bowel syndrome with severe malabsorption, even oral administration of 22.5 mg/kg per day CyA did not lead to sufficient plasma levels. Intravenous cyclophosphamide pulse therapy over 6 months led to a complete remission. No relapse occurred over a period of more than 5 months after the last cyclophosphamide pulse. Anticoagulation and screening for increased susceptibility for thrombotic events are necessary in every nephrotic patient. Intravenous cyclophosphamide pulse therapy is a useful alternative in SDNS with impaired intestinal absorption of applied immunosuppressive drugs.