Management of Five Hundred Patients With Gut Failure at a Single Center

Abstract

Objective(s): To define the evolving role of integrative surgical management including transplantation for patients gut failure (GF). Methods: A total of 500 patients with total parenteral nutrition-dependent catastrophic and chronic GF were referred for surgical intervention particularly transplantation and comprised the study population. With a mean age of 45 ± 17 years, 477 (95%) were adults and 23 (5%) were children. Management strategy was guided by clinical status, splanchnic organ functions, anatomy of residual gut, and cause of GF. Surgery was performed in 462 (92%) patients and 38 (8%) continued medical treatment. Definitive autologous gut reconstruction (AGR) was achievable in 378 (82%), primary transplant in 42 (9%), and AGR followed by transplant in 42 (9%). The 84 transplant recipients received 94 allografts; 67 (71%) liver-free and 27 (29%) liver-contained. The 420 AGR patients received a total of 790 reconstructive and remodeling procedures including primary reconstruction, interposition alimentary-conduits, intestinal/colonic lengthening, and reductive/decompressive surgery. Glucagon-like peptide-2 was used in 17 patients. Results: Overall patient survival was 86% at 1-year and 68% at 5-years with restored nutritional autonomy (RNA) in 63% and 78%, respectively. Surgery achieved a 5-year survival of 70% with 82% RNA. AGR achieved better long-term survival and transplantation better (P = 0.03) re-established nutritional autonomy. Both AGR and transplant were cost effective and quality of life better improved after AGR. A model to predict RNA after AGR was developed computing anatomy of reconstructed gut, total parenteral nutrition requirements, cause of GF, and serum bilirubin. Conclusions: Surgical integration is an effective management strategy for GF. Further progress is foreseen with the herein-described novel techniques and established RNA predictive model.

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

“…However, the newly introduced “Trifecta” procedure is described to manage patients with global dysmotility with preserved liver functions, with the intent to treat or as a bridge for intestinal transplant. It consists of subtotal colectomy, chimney ileostomy and pyloroplasty [6 ▪ ]. The Trifecta procedure is not effective for patients with global GD with massive gut dilatation [40 ▪ ].…”

“…The procedure helps to alleviate abdominal pain, restore oral tolerance and ameliorate the bacterial overgrowth symptoms. A recent study showed that the Trifecta is superior to the single or combined reductive/decompressive procedures in restoring full nutritional autonomy with a 3-year success rates of 71% and 55%, respectively [6 ▪ ]. The Trifecta procedure achieved a better quality of life compared to transplantation with higher performance and fewer hospital re-admissions.…”

“…In a recent report on comprehensive management of 500 GF patients, we proposed a treatment algorithm for GF (Fig. 1) with a central role for rehabilitative surgical procedures, and gut transplantation as the rescue ultimate therapy [6 ▪ ]…”

“…Autologous gut reconstruction (AGR) is the first surgical gut rehabilitative approach to be offered to surgical GF with SGS patients. AGR comprises different reconstructive procedures to reestablish gut continuity, restore normal alimentary flow and modulate transit time, with the utilization of the remaining native gastro-intestinal tract [6 ▪ ,9 ▪ ]. In addition to re-establishment of gut continuity, bowel lengthening procedures can enhance intestinal adaptation with better achievement of nutritional autonomy [10,11].…”

Interdisziplinäre Betreuung von Patienten mit Kurzdarmsyndrom in Deutschland: Eine Cost-of-Illness-Analyse der stationären und ambulanten Behandlung im Vergleich zum erzielten DRG-Erlös

“…Maßnahmen, die eine zunehmende orale Autonomie der Patienten ermöglichen, werden hauptsächlich nach Erreichen der Stabilisierungsphase der Patienten begonnen. Chirurgisch sind vor allem rekonstruktive Eingriffe (autologe Darmrekonstruktion AGR) der Darmkontinuität und der Bauchdecke zu nennen [20]. Des Weiteren sind medikamentöse sowie ernährungsmedizinische Maßnah-men und in Einzelfällen spezifische KDS-Behandlung bspw.…”