200.4: Serial Transverse Enteroplasty (STEP) for the Short Gut Syndrome (SGS) Patients with Gut Failure (GF)

Abstract

Introduction: With recent evolution of gut rehabilitation, bowel lengthening is increasingly utilized to restore nutritional autonomy in patients with GF. This is the first largest single center experience with STEP particularly among adults with different causes of SGS including Crohn’s and allograft rejection. Methods: Over 7 years, 65 SGS-GF-patients received a total of 79 STEP procedures. Sixty one(94%) patients were adults and 4(6%) were children with an age ranging from 2 to 79 years. All patients suffered loss of nutritional autonomy with the requirement for total parenteral nutrition (TPN), or IVF-micronutrient replacement. The leading causes were vascular occlusion (n=22), surgical adhesions (n=13), and Crohn’s disease (n=12). Interestingly, the procedure was performed in an isolated intestinal allograft after partial recovery from acute rejection. The mean pre-STEP length of the residual bowel was 71 ± 13 cm with partially or fully preserved colon in 54(83%) and intact ileo-cecal valve in 14(22%) Reestablishment of gut continuity was accomplished preoperatively in 24(37%) and simultaneously performed in 41(63%). The procedure was reproducible in a total of 13(20%) patients. GLP2 was used as an adjunct therapy before and/or after the STEP procedure in 11(17%) patients. Results: With a total of 79 STEP-procedures and overall total number of 2 to 36 cuts, there was an increment in the bowel length ranging from 2 cm to 50 cm. The increase in the bowel length was influenced by length of the residual bowel, intestine diameter and the cumulative number of the transverse cuts. With a mean follow up of 19 ± 7 months, a total of 28(43%) patients achieved full nutritional autonomy with discontinuation of TPN therapy. The remaining 37(57%) experienced partial reduction in the TPN and IVF support. Length of residual bowel, volume/caloric contents of initial TPN therapy, and presence of the ileo-cecal valve were significant predictors of successful outcome. Conclusions: STEP along with autologous gut reconstruction is an effective bowel lengthening procedure for the management of SGS –GF patients. The operation is also technically feasible in Crohn’s disease patients and recipients of intestinal allografts.