Results of Surgical and Medical Rehabilitation for Adult Patients With Type III Intestinal Failure in a Comprehensive Unit Today: Building a New Model to Predict Parenteral Nutrition Independency

Abstract

Background: Short-bowel syndrome remains the primary cause of intestinal failure (IF) in adult patients. We aim to report the long-term results of medical and surgical rehabilitation in a cohort of patients with type III IF (III-IF) and develop a formula to predict parenteral nutrition (PN) independency. Methods: We used a retrospective analysis of a prospective database for III-IF patients undergoing autologous gastrointestinal reconstruction surgery (AGIRS) from March 2006 to August 2018. Analyzed variables included demographic data, postsurgical intestinal length (PSIL), postsurgical anatomy, teduglutide (TED) treatment, and PN volume reduction. Univariate analysis, Cox regression, logistic regression forward stepwise models, and receiver operating characteristic (ROC) curve were done using SPSS v20. Results: AGIRS was performed in 88 patients. The most frequent anatomy at first visit was type 1. Prevailing anatomy after surgery was type 3. Eight patients started TED; 6 achieved freedom from PN. At a mean follow-up time of 1606.1 ± 1190.25 days, freedom from PN survival was achieved in 83%. Variables identified at the logistic regression analysis led to a novel formula to predict intestinal rehabilitation, including PSIL, presence of ileocecal valve, and use of TED as part of postsurgical treatment. Conclusions: AGIRS in this group of patients enabled intestinal length increase and also intestinal anatomy conversion into a more favorable type for intestinal rehabilitation. TED treatment was useful to discontinue PN in patients with classical negative anatomical predictors. The novel predicting formula has an ROC area under the curve = 0.82. Further studies are necessary to validate this formula.

Postsurgical Intestinal Rehabilitation Using Semisynthetic Glucagon‐Like Peptide‐2 Analogue (sGLP‐2) at a Referral Center: Can Patients Achieve Parenteral Nutrition and sGLP‐2 Independency?

“…The same paper clearly states (and this argument should be closely followed by our countries) that particular attention should be given to patient selection to identify the ones most likely to wean from PN completely. That was our primary statement in 2014, but now there are predictive formulas available for this group of patients, helping physicians objectively assess them 14,15 . Raghu et al 42 recognized that in their analyses, the burden of SBS on an individual, or on the family, extends far beyond direct medical costs, including lost wages from work and the time required to provide such high‐level home care; however, these considerations remain to be analyzed 37 …”

“…Over the past few decades, the progressive recognition and growth in the applicability of surgical procedures to convert an unfavorable anatomy into a more favorable one, such as autologous gastrointestinal reconstructive surgery (AGIRS) and intestinal lengthening procedures known as longitudinal intestinal lengthening and tailoring, spiral intestinal lengthening and tailoring, and serial transverse enteroplasty, have modified the natural history of the disease, increasing the number of patients able to achieve PN independency. In adults, the most frequently used procedure is AGIRS, which involves all procedures that aim to reconstruct the gastrointestinal tract, recruit abandoned intestinal segments into the abdomen, and close ostomies, reestablishing the continuity of intestinal transit 12–15 . After AGIRS, earlier standard medical therapy (antimotility, antisecretory drugs, pancreatic enzymes, octreotide, antibiotics, and nutrition) had focused on optimizing the function of the remnant intestine, counteracting the effects of bowel resection, and enhancing the adaptive response 16,40 .…”

“…In adults, the most frequently used procedure is AGIRS, which involves all procedures that aim to reconstruct the gastrointestinal tract, recruit abandoned intestinal segments into the abdomen, and close ostomies, reestablishing the continuity of intestinal transit. [12][13][14][15] After AGIRS, earlier standard medical therapy (antimotility, antisecretory drugs, pancreatic enzymes, octreotide, antibiotics, and nutrition) had focused on optimizing the function of the remnant intestine, counteracting the effects of bowel resection, and enhancing the adaptive response. 16,40 Patients unable to rehabilitate continued to receive HPN as the only alternative until complications related to this support developed, and they had to be considered transplant candidates.…”

Rehabilitación del intestino utilizando un Análogo Semisintético del Péptido 2 similar al Glucagón (sGLP-2). Primera experiencia con Teduglutide en Uruguay.

“…En 2012 el sGLP-2 fue aprobado por la FDA. La probabilidad de alcanzar la suficiencia intestinal, incluso en pacientes con anatomía desfavorable, ha aumentado con su introducción en los protocolos de tratamiento para pacientes seleccionados (8)(9)(10)13,26) . Actualmente en centros de referencia, únicamente aquellos pacientes que no pudieron continuar reduciendo el volumen de NPD en un período de aproximadamente 6 meses, son evaluados para iniciar sGLP-2.…”

“…Resulta así completamente inaccesible para poblaciones de bajos recursos, existiendo únicamente casos puntuales en nuestro país, como el del paciente que presentamos (7) . Por otro lado, el procedimiento quirúrgico más utilizado para convertir una anatomía altamente desfavorable en una más favorable para la rehabilitación del intestino es la cirugía de rehabilitación autóloga del tracto gastrointestinal (CRATGI), proceso que involucra a todos los procedimientos que tienen como objetivo reconstruir el tracto gastrointestinal, reclutar segmentos intestinales abandonados en el abdomen y cerrar ostomías, restableciendo la continuidad del tránsito intestinal (8)(9)(10)(11) . Este procedimiento, cuando es desarrollado por un equipo experimentado, junto a otras estrategias de alargamiento intestinal, ha modificado la historia natural de la enfermedad.…”