Experiences with intestinal failure from an intestinal rehabilitation unit in a country without home parenteral nutrition

Abstract

Objective: For the first time, we reported experiences with an intestinal rehabilitation unit (IRU) from a country without home parenteral nutrition (HPN). Methods:We included patients with a diagnosis of intestinal failure (IF) since the establishment of our IRU from February 2018 to February 2020. We further report on our protocols for management of enterocutaneous fistulas (ECFs), short-bowel syndrome (SBS), chronic intestinal pseudo-obstruction and motility disorders.Results: Among a total of 349 patients who have been admitted, 100 patients had IF and were included . Mean (SD) age of patients was 46.3 ± 16.1 years. Most common cause of IF was ECFs (32%), SBS (24%), and SBS + fistula (22%). Most common causes of SBS were mesenteric ischemia (63.3%) and repeated surgery (22.4%). Median (interquartile range [IQR]) duration of parenteral nutrition (PN) for patients was 32 (18-60) days. The most common reconstructive surgery performed was resection and anastomosis (75.4%), followed by serial transverse enteroplasty procedure (10.5%) and closure of ostoma (7%). Patients were hospitalized for a median (IQR) of 33 (17.5-61) days. Most common complications were sepsis (45%), catheter infections (43%), and catheter thrombosis (20%), respectively. At the final follow-up, 61% stopped receiving PN, 23% became candidates for transplantation, and 16% died. Conclusion:Considering that most countries lack facilities for HPN, by establishing IRUs using specific treatment protocols and autologous gastrointestinal reconstruction techniques will provide a means to manage patients with IF, thus decreasing death rates and number of patients who require intestinal transplantations due to IF.

Growing experience of surgical gut rehabilitation: essential role in the management of gut failure in adult patients

“…In 2022, an intestinal rehabilitation unit in Shiraz, Iran, reported their initial experience treating adult GF patients [45,46 ▪ ]. This report was equally important to the Argentina report because no center has established an organized intestinal rehabilitation program in the Middle East, where home PN services are severely limited [44].…”

Update on surgical management of enteroatmospheric fistulae in intestinal failure patients

“…In these instances, surgery will be planned at an earlier timepoint. In countries where facilities for HPN do exist, time of surgery should be delayed to a minimum of six months up to one year, as mentioned above [30 ▪ ,31 ▪ ]. Multiple episodes of fistula-related complications may also warrant earlier surgery (for example recurrent CLABSI or destructive inflammation of the skin).…”

“…To achieve the best outcome, the operation should be performed in a tertiary health center where adequate experience with this type of surgery exists [36 ▪ ]. A study by one of the authors, Nikoupour et al [30 ▪ ] showed that establishing an intestinal rehabilitation unit (in a country without HPN availability) drastically reduced mortality (42% vs. 6.2%).…”

“…The incision should be premarked and started from a naïve area or from under the xyphoid process [30 ▪ ,34 ▪ ]. Careful evaluation of CT scans helps to identify areas most likely free of underlying intestine.…”

Serial transverse enteroplasty and nipple valve construction, two life saving techniques for patients with short bowel syndrome, a report of 5 cases

“…Acutely ill and metabolically unstable IF patients who have survived a complicated abdominal surgery are cared for in intestinal rehabilitation units (IRU) by a multidisciplinary team (MDT) including surgeons, pharmacists, nutritionists and various other specialists [ 9 ]. The MDT designs essential PN and hydration, manages fistulae, open abdomen, PN complications and infections until the patient becomes independent of inpatient PN or is prepared for further abdominal operations including autologous intestinal reconstruction (AGIR) or intestinal transplantation [ 10 – 12 ]. AGIR refers to various surgical techniques to enhance intestinal absorptive mucosa in order to minimize dysmotility and the need for intestinal transplantation [ 13 ].…”