Intestinal Failure Following Bariatric Surgery

Abstract

Introduction: Though short gut syndrome/intestinal failure (SGS/IF) following Bariatric Surgery (BS) is uncommon, its prevalence is increasing as more BS procedures are performed. This study aimed to analyze the outcomes of SGS/IF in BS patients. Methods: A retrospective review of a prospective, single center, intestinal rehabilitation database revealed 25 referred patients (7% of all adult referrals) with a history of BS. Demographic, surgical and outcome variables were analyzed by standard statistics. Multidisciplinary evaluation resulted in 3 treatment groups – A) intestinal rehabilitation (IR); B) transplantation; or C) TPN (neither IR nor transplantation). Results: 88% were female; median age was 45 yrs. Median BMI was 53 kg/m2 at BS but 28 kg/m2 at the onset of SGS/IF. Most BS were Roux-en-Y gastric bypass (RYGB 92%). Major cause of SGS/IF was intestinal volvulus through internal hernia 72%. Median time from BS to SGS/IF was 48 months (0.3-156). Initial treatment arms were A (n = 15), B (n = 5) and C (n = 5). Group A, median bowel length was 50 cm (10–70). 46% discontinued TPN (median time 15 months from referral). 27% were partially weaned TPN and 27% failed IR. Surgical rehabilitation included RYGB reversal, restoration of GI continuity, ostomy/fistula takedown and STEP. Actuarial 1-yr and 5-yr overall survival (OS) were 94% and 67%. 7 patients were listed for transplantation including 5 from group B and 2 from group A. The transplant types at listing were: 3 isolated intestinal (iITx), 2 isolated liver (iOLT), 1 multi-visceral and 1 liver-intestine. Outcomes from listing were: iITx (n = 2; 11.4 yrs alive; 1.1 yrs dead), iOLT (n = 1; 1.9 yrs alive), remains listed for iITx (n = 1), delisted improved (n = 1), delisted dead (n = 2). 6 patients required long-term TPN including 5 from group C and 1 from group A. 4 patients are alive on TPN and 2 were dead. Estimated median OS was 48 months. Conclusion: SGS/IF following BS is an increasing problem facing intestinal rehabilitation and transplant centers. Internal hernia is the most common etiology. Surgical rehabilitation should be the first line therapy and affords the best outcome. Transplantation is reserved for rescuing patients who failed rehabilitation or develop TPN complications. Long-term TPN should be reserved for patients who cannot undergo rehabilitation or transplantation.