Autologous Intestinal Reconstructive Surgery to Reduce Bowel Dilatation Improves Intestinal Adaptation in SBS

Abstract

To the Editor: Almond et al (1) reported 8 of 26 patients referred with intestinal failure (IF) from short bowel syndrome with >40 cm of dilated residual bowel. The study aimed to establish whether surgery to reduce dilatation could improve outcome; timing of surgery varied from approximately 3 months to 3 years (median approximately 10 months). Strikingly, 7 of 8 patients developed severe IF-associated liver disease (IFALD) (2) (mean peak bilirubin 250 μmol/L) preoperatively, yet liver function tests normalised after surgery, and 7 of 8 patients were weaned from parenteral nutrition. These interesting observations should be interpreted with caution. This seems to be an extremely unusual group of patients because, as the authors stressed, all were totally dependent on parenteral nutrition for nutrient requirements. It appears that despite “hepatosparing” strategies, severe IFALD (bilirubin >100 μmol/L) (2) developed in all but 1. Underlying condition and interventions were heterogeneous, including serial transverse enteroplasty procedure, longitudinal intestinal lengthening, and tapering enteroplasty. Although the authors considered small intestinal bacterial overgrowth to be a key factor in failure of adaptation, no diagnostic tests were performed (3), and no information was given about empirical preoperative treatment with antibiotics or prokinetics. This article brings into focus a difficult group of patients with bowel dilatation, but raises questions about the optimal nature and timing for surgery, difficulty in reliably diagnosing small intestinal bacterial overgrowth, and whether aggressive medical management of early IFALD, including prokinetics and antibiotics, may have facilitated enteral feeding and gut adaptation, while preventing the progression of liver disease. Robust research will be needed to provide definitive answers to these questions.