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SHORT BOWEL SYNDROME

SHORT BOWEL SYNDROME. Wong Wui Bun Tuen Mun Hospital. Short bowel syndrome. Overview Pathophysiology Intestinal rehabilitation program Medical treatment Operative treatment Transplantation. 1. OVERVIEW. Heterogeneous disease. 1. Overview. Definition:

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SHORT BOWEL SYNDROME

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  1. SHORT BOWEL SYNDROME Wong Wui Bun Tuen Mun Hospital

  2. Short bowel syndrome • Overview • Pathophysiology • Intestinal rehabilitation program • Medical treatment • Operative treatment • Transplantation

  3. 1. OVERVIEW Heterogeneous disease

  4. 1. Overview • Definition: • Malabsorptive state that is associated with extensive resection of small bowel as well as a range of congenital conditions (American College of Surgeons) • Heterogeneous group of patients • Spectrum of disease severity • Reduced survival • (2 year 86%, 5 year 75%) • Significant morbidity http://www.nejm.org/na101/home/literatum/publisher/mms/journals/content/nejm/2011/nejm_2011.364.issue-14/nejmicm1001885/production/images/large/nejmicm1001885_f1.jpeg

  5. 1. Overview - causes Mesenteric ischaemia is the most common cause in adult

  6. 2. PATHOPHSIOLOGY Anatomy is the key

  7. 2. Pathophysiology • Fluid, electrolyte and nutritional deficiencies • Dysregulation of enteric hormone • Disturbance in bowel motility • Change in bowel flora • Catheter related complications • Intestinal failure related liver failure • Bone resorption, gallstone and renal stones

  8. Effect of anatomy on pathophysiology

  9. Surgical considerations • Limit resection • Use of second look operation • Prevention of stoma/ early closure • Preservation of ileocaecal valve • Post-operative care • Early establishment of central venous assess • Early involvement of multi-disciplinary team

  10. 3. INTESTINAL REHAB Planned multidisciplinary care

  11. 3. Intestinal rehabilitation program • Multidisciplinary, protocolized care • Combination of enteric nutrition +/- hormonal stimulation • Workload hypothesis • Oral nutrition stimulate intestinal adaptation Morphological: Epithelial hyperplasia Increased villi height Increased crypt depth Remodeling of bowel Functional: Up-regulation of transport molecule and brush border activity http://surgery.med.umich.edu/pediatric/chirp/clinical/mm/pathophysiology.shtml

  12. 3. Intestinal rehabilitation prgram • Systemic review 2013 by Stanger et.al. • Historical control (n=103) vs IRP (n=130) • Reduction in septic episodes (0.3 vs. 0.5 event/month; p=0.01) • Increase in overall patient survival (22% to 42%) • Weaning from PN (RR=1.05, 0.88-1.25, p=0.62) • Incidence of IFALD (RR=0.2, 0-17.25, p=0.48 • Relative risk of liver transplantation (3.99, 0.75-21.3, p=0.11).

  13. Enterotrophic hormone

  14. Intestinal failure • Predictors: • Bowel length <100 cm • End jejunostomy/ jejunocolic anastomosis • Reduced Citrulline level (<20umol/L correlated with PN dependence) Definition: Failure of intestine to adequately meet the body’s requirement for fluid, macronutrients and micronutrients Long term parenteral nutrition required

  15. 4. MEDICAL TREATMENT Nutrition is backbone, what is more…

  16. Medical treatment • Bacterial overgrowth • Increase parenteral nutrition requirement • D- lactic acidosis, mucositis, worsen diarrhoea • More common if ileocaecal valve absent • Empirical treatment with antibiotics

  17. Medical treatment • Symptomatic care • Control of bowel motility and secretions • Lomotil, Imodium • Atropine • Proton pump inhibitor

  18. 5. OPERATIONS In selected patients

  19. Autologus intestinal reconstruction • Indicated in intestinal failure with complications • Intestinal tapering • Longitudinal intestinal lengthening and tailoring (LILT) • Serial transverse enteroplasty (STEP) • Antiperistaltic segment • Colonic interposition

  20. Choice of procedure • Preservation of absorptive surface • Dilated segment has impaired peristalsis • Technical difficulty • Feasibility of procedure: • Any bowel dilatation? • Any previous procedure? • Problem with transit time? • Antiperistaltic segment • Patient with a dilated bowel? • STEP/ LILT

  21. Operative treatment - LILT

  22. Operative treatment - STEP

  23. Operative treatment

  24. Role of operation • Improve bowel autonomy • Decrease PN requirement • Decrease need for transplantation • Reverse liver disease up to 80% • Complications: • Intestinal obstruction • Anastomotic leakage • Bowel ischaemia • Mortality ~ 10%

  25. 6. TRANSPLANTATION Graft and patient survival problem

  26. Transplantation • Intestinal transplant • Combined liver-intestinal transplant • Indications: • 1. Presence of PN-associated liver disease • 2. Loss of central venous access • 3. Recurrent catheter-related sepsis or a single episode of fungal sepsis • 4. Recurrent bouts of severe dehydration or metabolic abnormalities • (US Centers for Medicare and Medicaid Services) • ?Better catheter care • ?Improved parenteral nutrition • ?Quality of life • Early referral to specialist centre

  27. Bring home message • Limit bowel resection • Early stoma closure • Intestinal rehabilitation program • STEP vs LILT • Considerations for transplant

  28. Reference • Modern treatment of short bowel syndrome. Jeppesen PB. Curr Opin Clin Nutr Metab Care. 2013 Sep;16(5):582-7. doi: 10.1097/MCO.0b013e328363bce4. Review. • Short bowel syndrome – surgical perspectives and outcomes. Nicola Smith, Rachel Harwood, Sarah Almond. Paediatrics and Child Health Volume 24, Issue 11, November 2014, Pages 513–518 • Serial transverse enteroplasty (STEP) for patients with short bowel syndrome (SBS). American College of Surgeons. • Management of short bowel syndrome. Jason P. SulkowskixJason P. Sulkowski. Pathophysiology. February 2014. Volume 21, Issue 1, Pages 111–118 • Surgical management of short bowel syndrome. Iyer KR1. JPEN J Parenter Enteral Nutr. 2014 May;38(1 Suppl):53S-59S. doi: 10.1177/0148607114529446. Epub 2014 Mar 25. • Long-term outcome of short bowel syndrome in adult and pediatric patients. Wasa M1, Takagi Y, Sando K, Harada T, Okada A. JPEN J Parenter Enteral Nutr. 1999 Sep-Oct;23(5 Suppl):S110-2. • Effect of growth hormone, glutamine, and enteral nutrition on intestinal adaptation in patients with short bowel syndrome. Guo M, Li Y, Li J. Turk J Gastroenterol. 2013;24(6):463-8. • Short bowel syndrome: highlights of patient management, quality of life, and survival. Kelly DG1, Tappenden KA, Winkler MF. JPEN J Parenter Enteral Nutr. 2014 May;38(4):427-37. doi: 10.1177/0148607113512678. Epub 2013 Nov 18. • Overview of short bowel syndrome: clinical features, pathophysiology, impact, and management. Storch KJ1. JPEN J Parenter Enteral Nutr. 2014 May;38(1 Suppl):5S-7S. doi: 10.1177/0148607114525805. Epub 2014 Mar 6. • Pathophysiology of short bowel syndrome: considerations of resected and residual anatomy. Tappenden KA1. JPEN J Parenter Enteral Nutr. 2014 May;38(1 Suppl):14S-22S. doi: 10.1177/0148607113520005. Epub 2014 Feb 5. • Teduglutide: A Review of its Use in the Treatment of Patients with Short Bowel Syndrome. Celeste B. Burness, Paul L. McCormack. Drugs. June 2013, Volume 73, Issue 9, pp 935-947 • Are plasma citrulline and glutamine biomarkers of intestinal absorptive function in patients with short bowel syndrome? Luo M1, Fernández-Estívariz C, Manatunga AK, Bazargan N, Gu LH, Jones DP, Klapproth JM, Sitaraman SV, Leader LM, Galloway JR, Ziegler TR. JPEN J Parenter Enteral Nutr. 2007 Jan-Feb;31(1):1-7. • Intestinal dysbiosis in children with short bowel syndrome is associated with impaired outcome. Engstrand Lilja H, Wefer H, Nyström N, Finkel Y, Engstrand L. Microbiome. 2015 May 4;3:18. doi: 10.1186/s40168-015-0084-7.

  29. THANK YOU! Questions welcomed

  30. Elemental diet • Peptamen • Vivomax • Monosaccharides • Disaccharides • Medium chain fatty acid • Amino acids • Vitamins • Minerals

  31. Parenteral nutrition • >50% carbohydrates • 30-40 % fat emulsion • Amino acids • Electrolytes • Additives: • Vitalipid: Vitamin A, D2, E, K1 • Soluvit: Vitamin C, Vitamin H, Vitamin Bs, folic acid • Addamel: trace elements

  32. Options of venous access • Considerations: • Venous thrombosis rate per 1000 catheter day • Sepsis rate per 1000 catheter day • Reusability • Tunneled central venous access • Peripheral inserted central catheter (PICC) • Aseptic technique • 70% ethanol block • Heparin solution flush

  33. Benefit of stoma closure • Recruit of distal bowel for adaptation • Resumption of enterohepatic circulation of bile salt • Production of short chain fatty acid (SCFA) in colon • Activation of L cell for enteric hormone production

  34. Enteric hormone

  35. Enteric hormones

  36. STEP

  37. STEP

  38. SILT

  39. Teduglutide

  40. Transplantation

  41. Transplantation • 5 hours cold ischaemic time • Higher level of immunosuppression • Higher risk of graft rejection • Higher risk of drug toxicity • Higher risk of lymphoproliferative disease

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