Surgical and Medical Approach of Patients Requiring Total Small Bowel Resection. Managing the “no gut syndrome”

Abstract

Background: Total resection of jejunum and ileum is a rarely performed procedure, and indicated after mesenteric vascular events, trauma or resection of abdominal neoplasms. We describe herein our recent experience on the surgical and medical management of patients with “no gut syndrome”. Methods: We retrospectively reviewed 341 adult patients who were referred to our Center between January 2013 and December 2016. Results: Thirteen patients with a mean age of 42.5 years (range 17 to 66 years) underwent a near total enterectomy. Indications for the small bowel resection were vascular event (n=5), intraabdominal fibroid (n=4), and trauma (n=4). Foregut secretions were managed with duodenocolostomy (n=5), tube decompression (n=5), and end duodenostomy (n=2). Duodenal stump was stapled off in 4 cases. One patient underwent a spleen-preserving duodenopancreatectomy combined with a total enterectomy; the biliary secretion was managed with a choledochocolostomy. All patients were discharge on full total parenteral nutrition infused over a 10–16 hour period. Average total parenteral nutrition volume and calorie requirement were 2800 ml/day (range 2000 to 4000) and 1774 Kcal/day (range 1443 to 2290), respectively. Patients underwent to duodenocolonic anastomosis received smaller TPN volume (33.8 vs 49.8 ml/kg). Supplemental intravenous fluid was required in ten (77%) patients. There were no intraoperative or perioperative deaths. One patient lost follow-up two months after surgery. After 20 months, median follow-up (range 4 to 48 months), nine patients are still alive (75%). All patients with duodenocolostomy remain alive (median follow-up 36.4 months). Two patients underwent an uneventful isolated small bowel transplant and another five are being evaluated or are already listed for visceral transplantation. Conclusion: In summary, resection of the entire small bowel is feasible and can be a lifesaving procedure for a selective group of patients. Long term survival can be achieved in specialized centers. In addition, reestablishment of the continuity of the gastrointestinal tract after a total enterectomy appears to be the best option for fluid and electrolyte management postoperatively.