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ObjectiveThis article reports the results of segmental reversal of the small bowel on parenteral nutrition dependency in patients with very short bowel syndrome. Summary Background DataSegmental reversal of the small bowel could be seen as an acceptable alternative to intestinal transplantation in patients with very short bowel syndrome deemed to be dependent on home parenteral nutrition. MethodsEight patients with short bowel syndrome underwent, at the time of intestinal continuity restoration, a segmental reversal of the distal (n = 7) or proximal (n = 1) small bowel. The median length of the remnant small bowel was 40 cm (range, 25 to 70 cm), including a median length of reversed segment of 12 cm (range, 8 to 15 cm). Five patients presented with jejunotransverse anastomosis, and one each with jejunorectal, jejuno left colonic, or jejunocaecal anastomosis with left colostomy. ResultsThere were no postoperative deaths. Three patients were reoperated early for wound dehiscence, acute cholecystitis, and sepsis of unknown origin. Three patients experienced transient intestinal obstruction, which was treated conservatively. Median follow-up was 35 months (range, 2 to 108 months). One patient died of pulmonary embolism 7 months postoperatively. By the end of follow-up, three patients were on 100% oral nutrition, one had fluid and electrolyte infusions only, and, in the four other patients, parenteral nutrition regimen was reduced to four (range of 3 to 5) cyclic nocturnal infusions per week. Parenteral nutrition cessation was obtained in 3 of 5 patients at 1 year and in 3 of 3 patients at 4 years. ConclusionSegmental reversal of the small bowel could be proposed as an alternative to intestinal transplantation in patients with short bowel syndrome before the possible occurrence of 401

A possible technical problem encountered when performing ileoanal anastomosis with reservoir is the occurrence of tension when the reservoir is drawn to the anal canal. An anatomic study was performed to assess the gain of caudad reach that can be obtained by dissection of the mesentery root and vascular divisions applied to S- and J-shaped reservoirs, in association with angiographic control of terminal ileum vascularization. The study confirms the clinical experience that caudad reach of ileal reservoirs can be critical in some cases. Complete dissection of the root of the mesentery is a poor lengthening technique, the limiting factor being tension of the superior mesenteric artery. It is simple, however, and should be performed systematically because it can provide 1 or 2 useful centimeters of caudad reach. Division of the ileocecal pedicle is a safe, reproducible, efficient lengthening procedure that can serve all types of reservoirs. In this study, it gave a 5 cm or more gain in caudad reach in 80 percent of the cases, with a slight advantage to the S-shaped reservoir. Distal division of the superior mesenteric pedicle seems more hazardous and can serve only the J-shaped reservoir. For J-shaped reservoirs, maximum caudad reach was achieved when the pouch was built over the most inferior ileal point, which should be checked prior to the procedure, not judged according to predefined measures. The angiographic study showed that, in 38 percent of the cases, cecal vessels participated in vascularization of the last centimeters of the terminal ileum by means of recurrent ileal arteries, which, in 28 percent of the cases, provided exclusive blood supply to this area. Vascularization of the terminal ileum can and should be carefully preserved.

Complications that might lead to surgery in severe attacks of ulcerative colitis have been found to be correlated with the depth of colonic ulcerations as measured by pathological examination of colectomy specimens. In order to evaluate the value of colonoscopy for the assessment of colonic ulcerations, we have reviewed the clinical, biological, colonoscopic, and anatomical findings in 85 consecutive patients with attacks of ulcerative colitis involving at least the rectosigmoid and part of the descending colon, seen in our center between 1981 and 1989. All had colonoscopy performed by a senior endoscopist at entry. Extensive deep colonic ulcerations were diagnosed in 46 of them, and moderate endoscopic colitis in 39. No complication related to colonoscopy occurred except for one colonic dilatation. Forty-three of the 46 patients with severe endoscopic colitis were operated upon; 38 of them failed to improve with high-dose corticosteroids and five had a toxic megacolon. Extensive ulcerations reaching at least the circular muscle layer were found at pathological examination of colectomy specimen in 42 of the 43 patients. Conversely, 30 of 39 patients with moderate endoscopic colitis went into clinical remission with medical treatment, and only nine patients needed further surgery because of medical treatment failure. Six of these nine patients underwent another colonoscopy prior to colectomy, and all six showed features of severe endoscopic colitis. Deep ulcerations reaching the circular muscle layer were found at pathological examination in five of these six patients and in one additional patient whose colonoscopy had been performed 21 days before colectomy.(ABSTRACT TRUNCATED AT 250 WORDS)