To Wean or Not to Wean: The Role of Autologous Reconstructive Surgery in the Natural History of Pediatric Short Bowel Syndrome on Behalf of Italian Society for Gastroenterology, Hepatology and Nutrition (SIGENP)

Abstract

Pediatric Short Bowel Syndrome (SBS) can require prolonged parenteral nutrition (PN). Over the years, SBS management has been implemented by autologous gastrointestinal reconstructive surgery (AGIR). The primary objective of the present review was to assess the effect of AGIR on weaning off PN. We also evaluated how AGIR impacts survival, the need for transplantation (Tx) and the development of liver disease (LD). We conducted a systematic literature search to identify studies published from January 1999 to the present and 947 patients were identified. PN alone was weakly associated with higher probability of weaning from PN (OR = 1.1, p = 0.03) and of surviving (OR = 1.05, p = 0.01). Adjusting for age, the probability of weaning off PN but of not surviving remained significantly associated with PN alone (OR = 1.08, p = 0.03). Finally, adjusting for age and primary diagnosis (gastroschisis), any association was lost. The prevalence of TX and LD did not differ by groups. In conclusion, in view of the low benefit in terms of intestinal adaptation and of the not negligible rate of complications (20%), a careful selection of candidates for AGIR should be required. Bowel dilation associated with failure of advancing EN and poor growth, should be criteria to refer for AGIR.

Etiology and Management of Pediatric Intestinal Failure: Focus on the Non-Digestive Causes

“…The impact of surgery on weaning off PN was assessed by a recent systematic literature review [122]. It found that surgery has low benefit in terms of intestinal adaptation and therefore it should not be proposed to all patients with SBS, but only to selected candidates.…”

“…Main requirements to refer for surgery should be radiologically evident bowel dilation associated with signs or symptoms of small bowel bacterial overgrowth, such as failure of advancing enteral nutrition and poor growth. Early signs of intestinal failure-associated liver disease (IFALD) should also be considered, if associated with intestinal dilation, as a factor in favor of eligibility for surgery [122].…”

“…(3) Treatments for chronic DIF and NDIF able to reduce PN dependency over time (e.g., analog of glucagon like peptide 2 and surgical procedures to increase mucosal surface area in SBS or prokinetic drugs in PIPO [15,21,22,26,27,29,49,62,[81][82][83][84][85][86]90,[122][123][124] The advances in EN tolerance over time and the progressive decreasing in calories and fluids provided by PN will be the clinical markers of successful application of specific and non-specific therapies.…”

Comparing bowel lengthening procedures: which, when, and why?

“…There's not much recent literature that describes the outcomes or complications of LILT. The latest review on LILT sums up research showing that a patient has a chance of 55,5–100% to become PN independent within 2 years after undergoing a LILT procedure [ 3 ▪ ]. A recent single-center retrospective study by Shah et al shows similar results (5 out of 9 patients weaned off).…”

“…An elongation of on average 75% is achieved according to a recent analysis of 19 studies [ 3 ▪ ]. A comparative retrospective study showed an increase in length of 25 cm and initial feeding time of 8 days, however without differences in outcome compared to LILT [ 4 ].…”