Surgical management and autologous intestinal reconstruction in short bowel syndrome

Short bowel syndrome (SBS) is a serious condition with considerable morbidity and mortality. When treatment with parenteral nutrition fails and life-threatening complications occur, autologous intestinal reconstruction (AIR) should be considered before intestinal transplantation (ITx). Single or combined ITx should be reserved for patients with severe liver disease and as last resort in the treatment of SBS. Longitudinal intestinal lengthening and tailoring (LILT) has proven its value in AIR, but its availability depends on the expertise of the surgeons. Serial transverse enteroplasty (STEP) has similar success rates as LILT and fewer patients progress to ITx. STEP is also applicable at small bowel dilatation in ultra-short bowel syndrome. The scope may be widened when duodenal dilatation can be treated as well. Spiral intestinal lengthening and tailoring (SILT) is a promising alternative. More research is needed to confirm these findings. Therefore we suggest an international data registry for all intestinal lengthening procedures.     

Duodenal motility after tapering duodenoplasty for high jejunal and multiple intestinal atresia

Duodenal motility after tapering duodenoplasty was investogated by radiography and video-fluoroscopy. Two patients underwent tapering duodenoplasty, one at the time of duodenojejunostomy for double high jejunal atresias and another 6.5 months after the restoration of intestinal continuity for multiple intestinal atresias. Both patients showed a satisfactory postoperative course and were doing well. Radiographic and video-fluoroscopic studies demonstrated that the tapered portion of the duodenum had restored active peristalsis and excellent passage of contrast material, while the proximal, non-tapered portion remained dilated and dismotile soon after the operation. Tapering duodenoplasty proved to be a valuable procedure for restoring duodenal motility. Correspondence to: M. Honzumi     

Discontinuation symptoms in users of selective serotonin reuptake inhibitors in clinical practice: tapering versus abrupt discontinuation

Objective Tapering of selective serotonin reuptake inhibitor (SSRI) therapy, as opposed to abrupt discontinuation, has been recommended by several guidelines and in the literature in order to diminish the occurrence of discontinuation symptoms. However, the evidence of a favourable effect of tapering is limited, and it is unclear how patients ought to discontinue SSRIs in daily life. The aim of this study was to examine the way in which patients discontinue SSRI therapy in clinical practice and to compare the effect of tapering with that of abrupt discontinuation on the occurrence of discontinuation symptoms.Methods Patients (n=74) who recently discontinued SSRI therapy completed a questionnaire containing questions about discontinuation symptoms (DESS events), the prescribed SSRI, reasons for discontinuation, way of discontinuation, knowledge of discontinuation symptoms, impact on daily life and patient counseling and education. The number of DESS events was compared among groups (abrupt discontinuation versus tapering; age; male versus female; paroxetine versus other SSRIs; knowledge of discontinuation symptoms at start of therapy versus lack of knowledge).Results A total of 66 patients were eligible for analysis. Of all patients ending SSRI therapy, 21% abruptly discontinued therapy. There was a significant difference in the number of DESS events between abrupt discontinuation and tapering of SSRI therapy (12.0 versus 5.9). There was also a tendency for an adverse effect of lack of knowledge of discontinuation symptoms at the start of therapy on the number of DESS events (8.9 versus 5.5).Conclusion One in five patients abruptly discontinued their SSRI therapy in clinical practice. Abrupt discontinuation caused a larger increase in the number of discontinuation symptoms than tapering. We therefore advise tapering SSRI therapy in clinical practice to prevent unnecessary adverse effects of discontinuation.     

Serial transverse enteroplasty as primary therapy for neonates with proximal jejunal atresia

Small bowel atresia is associated with a large size discrepancy between the proximal and distal segments of bowel that has traditionally been managed by resection of the dilated segment, tapering enteroplasty, or plication. Longitudinal intestinal lengthening is rarely performed at the time of the initial operation. Many patients with small bowel atresia also have a short length of residual small intestine secondary to in utero resorption. The authors present the clinical application of the novel intestinal lengthening procedure, the serial transverse enteroplasty, in a neonate with proximal jejunal atresia and suggest that it become part of the armamentarium for surgeons treating patients with this anomaly.     

The second STEP: the feasibility of repeat serial transverse enteroplasty

Background

Serial transverse enteroplasty (STEP) lengthens and tapers dilated bowel. Redilation of the STEP segment occurs in some patients with intestinal failure. The feasibility of a repeat STEP procedure in a pig model is evaluated.

Methods

Six pigs underwent reversal of an intestinal segment distal to the ligament of Treitz. At 6-week intervals after reversal, each animal had 2 STEP procedures on the bowel proximal to the reversed segment. Necropsy was performed up to 6 weeks after repeat STEP.

Results

Bowel length increased by 11.3 ± 3.9 cm and bowel diameter decreased from a mean of 5.3 ± 0.8 to 1.8 ± 0.4 cm (P < .0001) after the first STEP. After repeat STEP, bowel length increased by 16.7 ± 13.3 cm (P < .01), and the bowel was tapered from a mean of 5.4 ± 0.9 to 2.2 ± 0.4 cm (P < .01). Five pigs did well after repeat STEP, and 1 pig had early necropsy for bowel obstruction. None had histologic evidence of bowel ischemia in the repeat STEP segment.

Conclusions

A second STEP operation is feasible in a pig model and may be considered to optimize bowel length and function in select patients with intestinal failure.     

Methotrexate dosage reduction in patients with rheumatoid arthritis beginning therapy with infliximab: the Infliximab Rheumatoid Arthritis Methotrexate Tapering (iRAMT) trial

ABSTRACT

Objective: Infliximab plus methotrexate (MTX) is approved for the treatment of rheumatoid arthritis (RA). Based on the benefit/risk profile of this combination therapy, lower doses of MTX would be preferable when infliximab efficacy can be maintained. We evaluated the ability of patients receiving infliximab plus MTX to achieve and maintain a clinical response while the dose of MTX was tapered.

Methods: Infliximab infusions were administered at a minimum dosage of 3?mg/kg at 8‐week intervals (following three loading doses at weeks 0, 2, and 6) to patients who had an inadequate response to MTX. MTX tapering was initiated at week 22 or later when at least a 40% improvement in the combined tender and swollen joint count was achieved; dosages were reduced by 5?mg every 8 weeks to a protocol-specified minimum dosage of 5?mg per week. If the required dosage of MTX after a flare was greater than the baseline dosage, the patient was considered a treatment failure.

Results: Of the 210 patients enrolled, 159 (76%) achieved a 40% or better improvement in the combined tender and swollen joint count and had their MTX doses tapered. In these 159 responders, the median (mean) dose of MTX was reduced from 15 (16.5)?mg per week at baseline to 5 (7.1)?mg per week at week 54. From the time of initial response, 79% of these patients had a zero- or a one-vial increase in infliximab, corresponding to an approximate dose increase of 1?mg/kg, through week 54.

Conclusion: Approximately 75% of the patients participating in this trial achieved at least a 40% reduction in the combined swollen and tender joint count (correlating with an American College of Rheumatology 20% [ACR20] response in 83% of patients) while reducing the mean MTX dose by 57%.     

Short bowel mucosal morphology,proliferation and inflammation at first and repeat STEP procedures

Background

Although serial transverse enteroplasty (STEP) improves function of dilated short bowel, a significant proportion of patients require repeat surgery. To address underlying reasons for unsuccessful STEP, we compared small intestinal mucosal characteristics between initial and repeat STEP procedures in children with short bowel syndrome (SBS).