Assessment and management of patients with intestinal failure: a multidisciplinary approach

Abstract

Intestinal failure (IF) is a condition characterized by the inability to maintain a state of adequate nutrition, or fluid and electrolyte balance due to an anatomical or a physiological disorder of the gastrointestinal system. IF can be an extremely debilitating condition, significantly affecting the quality of life of those affected. The surgical management of patients with acute and chronic IF requires a specialist team who has the expertise in terms of technical challenges and decision-making. A dedicated IF unit will have the expertise in patient selection for surgery, investigative workup and planning, operative risk assessment with relevant anesthetic expertise, and a multidisciplinary team with support such as nutritional expertise and interventional radiology. This article covers the details of IF management, including the classification of IF, etiology, prevention of IF, and initial management of IF, focusing on sepsis treatment and nutritional support. It also covers the surgical aspects of IF such as intestinal reconstruction, abdominal wall reconstruction, and intestinal transplantation.

Considerations for the management of enterocutaneous fistula

“…Minimising the risk factors prior to the initial surgery helps to reduce the incidence of anastomotic leak and sepsis occurring (Grainger et al, 2018).…”

“…This is when the gut function is reduced so far it falls below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth (Pironi et al, 2015). IF can be classified into three types according to its onset, metabolic and expected outcome criteria (Grainger et al, 2018) (Table 1). Acute IF, which typically lasts from a few days to months, may arise from ECF, high-output stoma, small bowel dysfunction, postoperative ileus or bowel obstruction, whereas chronic IF can be attributed to short gut, gut bypass, small bowel motility disorders or chronic persistence of any acute intestinal aetiology (Adaba et al, 2017).…”

“…Early involvement of the nutritional team is beneficial to prevent malnutrition, thus clinical © 2019 MA Healthcare Ltd reducing the risk of further deterioration of an already debilitated patient. Parenteral nutrition is generally indicated if the patient has failed to tolerate an adequate enteral diet for 5-7 days (Grainger et al, 2018).…”

“…In these circumstances the minimum amount of surgery should be undertaken to enable adequate drainage of infection, resection of any perforation and then formation of stomas. Once acute sepsis and urgent conditions requiring interventions have been excluded and immediate nutrition addressed to stabilise the patient, further work up for reconstructive surgery becomes key (Box 1) (Grainger et al, 2018).…”

“…This is because a chronic infection may manifest itself with difficulty in gaining weight, hypalbuminemia, hyponatremia and even jaundice. Spontaneous healing of a fistula is less likely in the presence of active infection and resolution of sepsis is fundamental for maintaining adequate nutrition (Grainger et al, 2018).…”