Correspondence

Abstract

The reports Kim et al entitled “Serial transverse enteroplasty (STEP): A novel bowel lengthening procedure,” and “Serial transverse enteroplasty for short bowel syndrome: A case report” (J Pediatr Surg 38:425–429; 38:881–885, 2003) deserve some comments about the method utilized by the authors. The first report is based on only 1 group of 6 young pigs that underwent interposition of a reversed intestinal segment to create a functional obstacle and to produce proximal small bowel dilatation. After a period of 5 weeks, the animals underwent a second surgery to resect the reversed jejunal segment and to perform the lengthening procedure in the proximal dilated bowel. In fact, the technique described by the authors is very elegant, and the bowel lengths are increased by the surgical procedure. However, the observed positive effects, mainly the weight gain, were not necessarily caused by the STEP procedure but more to the resection of the reversed jejunal segment, that represented a functional obstacle to the intestinal transit. So, the authors should have included another similar group of animals (control group), submitted to the same surgical manipulations excepting the STEP procedure, to better compare the results and take the conclusions more appropriately. As to the second report the authors performed this procedure in a 2-year-old boy born with short bowel syndrome and dependent on total parenteral nutrition (TPN). Initially, this patient was found to have 55 cm of jejunum and a viable colon from the splenic flexure distally. In our opinion, the lengthening procedures (Bianchi and STEP) were not useful, because the patient had to be maintained on TPN all the time, and there were few evidences of the benefits of the STEP procedure. In a similar case of a newborn with an apple peel small bowel, volvulus, and multiple ileal atresias, we had to perform 7 anastomoses in a 28-cm remaining segment of intestine. This child was maintained on TPN for 1 year, and after this period he was able to take all his calories enterally without any additional surgical approach to the intestines. We have treated more than 30 children with short bowel syndrome, and we have concluded that the small bowel lengthening procedures must be faced with criticism, because they do not increase the mucosal absorptive surface area, and, so, prolonged parenteral nutrition is the treatment of choice while the intestinal adaptation occurs.