Small Bowel Length Research Articles

P007 Double Balloon Enteroscopy in Pediatric Crohn’s Disease for Decision Therapy and 10 Years Follow up

BACKGROUND: Crohn’s disease (CD) is a chronic recurrent inflammatory disease that may affect any segment of gastrointestinal tract. In 60-70% of CD may involve the small bowel (SB) and present a diagnostic challenge to decision regarding therapy. Double Balloon Enteroscopy (DBE) is one of endoscopic modality for children that allow the diagnostic and therapeutic procedures of SB disease. Objectives: Evaluate the feasibility, validity and safety of DBE in patients of a tertiary pediatric center with CD. In addition, we analysed its impact on treatment strategies, and established other diagnoses (malignancy, stenosis) in 10 years follow up. METHODS: Between 2007-10, 20 patients (age 2-20 years) with CD diagnosis, refractory to treatment were selected to undergo SB evaluation by DBE, oral route. We used general anesthesia (children < 12 y) or deep sedation with propofol (patients >13 y). Previously all had performed radiological imaging to exclude structuring. A 10-year follow up of patients was performed. RESULTS: Among 20 patients, 90% had SB CD in jejunum or ileum, and 10% had solely lesion in SB, which was not detected by colonoscopy. The DBE findings were: Active duodenojejunal ulcers, ulcer healing and/or pseudo polyps, sub-stenosis and mucosal granularity. Mean length of SB examined was 220 cm beyond the ligament of Treitz (range 120 to 360 cm). No significant complications were related to the procedure. Currently 14 patients are in follow up, 5 children in paediatric GI clinic and the other 9 at adult GI clinic. In 10 years follow up one patient had an extra intestinal malignancy diagnosis; one had IL-10 and/or IL-10R gene mutation and one change the diagnosis to ulcerative colitis. Curiously, the proportional number of patients in therapy, particularly biologic, had decreased. CONCLUSION(S): DBE is a useful tool to make differential diagnosis in SB paediatric pathologies, especially in CD who require escalating and de-escalating treatment. DBE has a good safety profile with a low index of complications when performed in reference centers.

Effects of Probiotics on Intestinal Failure-Associated Liver Disease in Adult Patients Receiving Prolonged Parenteral Support: A Tertiary Care Center Experience.

It has been hypothesized that dysbiosis plays a significant role in the pathogenesis of intestinal failure-associated liver disease (IFALD). Therefore, we aimed to investigate the effect of probiotics on IFALD in patients receiving parenteral support, namely home parenteral nutrition (HPN) and home intravenous fluids (HIVFs). We retrospectively reviewed charts of patients with intestinal failure who received HPN or HIVF for >2 weeks at our tertiary center between January 2005 and August 2016. We excluded patients <18 years of age, patients with other causes of liver disease, patients who used probiotics for <30 days, patients with <6 months' follow-up, and those who had long-term antibiotic use (>30 days). Bivariable and multivariable logistic regression analyses were used in this study. A total of 282 patients who received parenteral support were included. Eighty-five percent of our sample received PN. A total of 78 (27.7%) patients used probiotics. The prevalence of IFALD in patients who used probiotics was 35.9% vs 54.4% in patients who did not use probiotics, P = .005. In multivariable analysis, only small-bowel length of 10-90 cm and HPN use showed a significant impact on IFALD, odds ratio (OR) = 4.394 (95% confidence interval [CI], 1.635-11.814; P = .003) and OR = 4.502 (95% CI 1.412-14.351; P = .011), respectively. Our study revealed that the prevalence of IFALD was comparable among the probiotic users and nonusers. Only small bowel length of 1090 cm and HPN use showed a significant impact on IFALD.

Correlation Between the Total Small Bowel Length and Anthropometric Measures in Living Humans: Cross-Sectional Study

BackgroundVariation in the outcome of bariatric surgery is still an unraveled phenomenon. This variation could be multifactorial. Several reports implicate the total small bowel length (TSBL) in this process. However, the basic information regarding the normal bowel length and its relation to the anthropometric parameters of the living subject is scarce. This study aims at reporting the normal total bowel length in living adult humans and its correlation with the anthropometric parameters.MethodsThis study included 606 participants (380 females and 226 males). Their mean age was 39.8 ± 11 years, weight = 135.7 ± 29.7 kg, height = 165 ± 9 cm, and BMI = 49.5 ± 7.5 kg/m2.The mean TSBL was 630 ± 175 cm. There was a statistically significant but very weak positive correlation but between the TSBL and both weight and height.Males had significantly higher weight and were significantly taller compared with females. TSBL was significantly longer in males at 661.5 ± 186 cm versus 612 ± 164 cm in females.ConclusionThe study reports an average TSBL greater than what is reported in the literature from living humans with a greater range of variation. There is no clinically important correlation between the TSBL and the weight and height of the individual participants in this series.

Longer small bowel segments are resected in emergency surgery for ileocaecal Crohn\u2019s disease with a higher ileostomy and complication rate

BackgroundRepeated intestinal resections may have disabling consequences in patients with Crohn’s disease even in the absence of short bowel syndrome. Our aim was to evaluate the length of resected small bowel in patients undergoing elective and emergency surgery for ileocolic Crohn’s disease.MethodsA prospective observational study was conducted on patients undergoing surgery for ileocolonic Crohn’s disease in a single colorectal centre from May 2010 to April 2018. The following patients were included: (1) patients with first presentation of ileocaecal Crohn’s disease undergoing elective surgery; (2) patients with ileocaecal Crohn’s disease undergoing emergency surgery; (3) patients with recurrent Crohn’s disease of the distal ileum undergoing elective surgery. The primary outcomes were length of resected small bowel and the ileostomy rate. Operating time, complications and readmissions within 30 days were the secondary outcomes.ResultsOne hundred and sixty-eight patients were included: 87 patients in the elective primary surgery group, 50 patients in the emergency surgery group and 31 in the elective redo surgery group. Eleven patients (22%) in the emergency surgery group had an ileostomy compared to 10 (11.5%) in the elective surgery group (p < 0.0001). In the emergency surgery group the median length of the resected small bowel was 10 cm longer than into the group having elective surgery for primary Crohn’s disease.ConclusionsPatients undergoing emergency surgery for Crohn’s disease have a higher rate of stoma formation and 30-day complications. Laparoscopic surgery in the emergency setting has a higher conversion rate and involves resection of longer segments of small bowel.

950 Effects of Probiotics on Intestinal Failure-Associated Liver Disease in Adult Patients Receiving Prolonged Parenteral Support: A Tertiary Care Center Experience

INTRODUCTION: It has been hypothesized that dysbiosis plays a significant role in the pathogenesis of intestinal failure-associated liver disease (IFALD). Therefore, we aimed to investigate the effect of probiotics on IFALD in patients receiving prolonged parenteral support, namely home parenteral nutrition (HPN) and intravenous fluids (HIVF). METHODS: We identified a cohort of patients with intestinal failure (IF) who received HPN or HIVF for &gt;2 weeks at our tertiary center between January 2005 and August 2016. (Table 1) We excluded patients &lt; 18 years of age, patients with other causes of liver disease, patients who used probiotics for &lt; 30 days, patients with &lt; 6 months follow up and those who had long-term antibiotic use ( &gt;30 days). Bivariable and multivariable logistic regression analyses were used in this study. RESULTS: A total of 282 patients who received prolonged parenteral support were included. Eighty-five percent of our sample received PN, while the remaining got HIVF. A total of 78 (27.7%) patients used probiotics. The prevalence of IFALD in patients who used probiotic was 35.9% vs. 54.4% in patients who did not use probiotics, P = 0.005. In multivariable analysis, only small bowel length of 10-90 cm and HPN use showed a significant impact on IFALD, OR = 4.114 (95% CI = 1.557-10.874, P = 0.004), OR = 4.164 (95% CI = 1.325-13.087, P = 0.015) respectively (Table 2). CONCLUSION: Our data does not support the use of probiotics to prevent IFALD in patients receiving prolonged parenteral support. Only small bowel length of 10-90 cm and prolonged HPN use showed a significant impact on IFALD.

A234 Laparoscopic Reversal of a Gastric Bypass for Shortgut from a missed Internal hernia

The patient had a Roux en Y gastric bypass two years ago and had presented to an outside hospital for increasing abdominal pain. The patient was evaluated in the ER and was evaluated with a CT scan which was read as normal with no obstruction. General Surgery was consulted and felt patient would be appropriate for a medical floor bed. Patient was admitted to the medicine service with presumed diagnosis of marginal ulcer, placed on PPI and pain medications and GI medicine consult was obtained. Gastroenterology agreed with PPI's and schdeuled pt for outpatient endoscopy after discharge. Over the weekend patient's pain medications were escalated and on Monday morning patient begged his attending physician and stated " this amount of pain cannot be normal". The attending physician arranged for an inpatient endoscopy, Endoscopy revealed a necrotic roux limb. The patient was then transferred emergently to a nearby hospital that had a Bariatric Surgeon who emergently explored the patient and found necrotic bowel from an internal hernia with volvulus and resected bowel and refashioned the gj and recreated a jejunojejunostomy. Patient was left with 200 cm of total small bowel length with a 50 cm roux limb. Over the next several months patient had tremendous diarrhea and was treated with antidiarrheal agents, gatex and enteral supplementation. When pt was referred to us his albumin was 1.2 with anasarca. for 3 months he was given TPN and when his albumin was 2.8 we took him for a reversal.

Outcomes of Children With Chronic Intestinal Failure: Experience Over 2 Decades at a Tertiary Paediatric Hospital.

The aim of the study was to aid decisions on prognosis and transplantation; this study describes the outcome of children with intestinal failure managed by the multidisciplinary intestinal rehabilitation program at the Royal Children's Hospital, Melbourne. Retrospective review of children requiring parenteral nutrition (PN) for >3 months who were assessed for home PN between 1991 and 2011. A total of 51 children were included. Forty-two (82%) had short bowel syndrome (SBS), 5 (10%) had chronic intestinal pseudo-obstruction syndrome, and 4 (8%) had congenital enteropathies. Median small bowel length for patients with SBS was 45 cm (interquartile range 30-80) or 23.9% of the expected length for age (interquartile range 17.0%-40.6%). Overall survival rate was 84% (43/51). Mortality in children (n = 7) occurred after a median of 13.2 months (range 6.2-29.2) with intestinal failure-associated liver disease (IFALD) being the only predictor (P = 0.001). Out of 50 children 21 (42%) had IFALD. Children who were premature (P = 0.013), had SBS (P = 0.038), and/or frequent sepsis (P = 0.014) were more likely to develop IFALD. PN weaning occurred in 27 of 35 (77%) SBS survivors, after a median of 10.8 months (up to 8.2 years), with longer residual small bowel (P = 0.025), preservation of the ileocecal valve (P = 0.013) and colon (P = 0.011) being predictors. None of 5 (0%) patients with chronic intestinal pseudo-obstruction syndrome and 2 of 4 (50%) patients with congenital enteropathies weaned off PN. Overall sepsis rate was 7.3 episodes/1000 line days. Frequency of sepsis and longevity of central lines improved with time as patients grew older (both P < 0.001). Long-term PN with intestinal rehabilitation was effective in treating most children with intestinal failure. Children with severe refractory IFALD may have benefited from intestinal transplantation.

Early Predictors of Enteral Autonomy in Pediatric Intestinal Failure Resulting From Short Bowel Syndrome: Development of a Disease Severity Scoring Tool.

Patients with short bowel syndrome (SBS) are dependent on parenteral nutrition (PN) while their bowel attempts to compensate. Our objective was to create an SBS disease severity score to predict the probability of achieving enteral autonomy (EA). A retrospective cohort study of children with SBS managed by our Intestinal Rehabilitation Program was completed. Data abstracted included demographic, bowel anatomy, and outcome variables including conjugated bilirubin (CB) and enteral nutrition (EN) tolerated 6 months postoperatively. Univariate analysis and Cox proportional hazards (CPH) model were performed. A score was created based on weighting of coefficients. An α-value of < 0.05 was considered significant. One hundred thirty-nine patients were analyzed (61% males). Ninety-five (68%) achieved EA. Patients possessing >50% residual small bowel (hazard ratio [HR] 2.68 [95% confidence interval {CI} 1.60-4.49], P<0.001), ileocecal valve intact (HR 0.61 [95% CI 0.37-1.01], P<0.055), and >50% enteral tolerance at 6 months (HR 5.70 [95% CI 2.77-11.74] P<0.001) were positively associated with EA. CB >34 µmol/L (2 mg/dL) was negatively associated with EA (HR 0.42 [95% CI0.27-0.66], P<0.001). A severity score was created by weighting CPH parameter estimates (small bowel length >50%, ileocecal valve intact, CB <34 µmol/L, and EN >50% for a maximum score of 8), and disease severity strata were developed (severe [25.7% EA], moderate [52.9% EA], and mild [97.1% EA]). We propose a pediatric SBS disease severity score that predicts probability of EA. The score allows prognostication of individual patients and could assist research by adjusting outcome reporting or stratifying recruitment.

Measuring the small bowel length may decrease the incidence of malnutrition after laparoscopic one-anastomosis gastric bypass with tailored bypass limb

BackgroundLaparoscopic one (single)-anastomosis gastric bypass (OAGB) is an effective and durable treatment for morbidly obese patients. However, the ideal length of the small bowel bypass remains controversial. ObjectivesThe study aimed to report the clinical results of using a tailored bypass based on the total length of the small bowel. SettingAcademic medical center. MethodsSince 2005, we have performed OAGB with tailored limb according to preoperative body mass index. From July 2014, we modified our technique, measuring the whole small bowel length to keep the common channel at least 400-cm long. Data from 470 patients treated with the new technique (Group II) were compared with those of a matched group treated with tailored bypass only (Group I). The preoperative clinical data and outcomes were analyzed. All clinical data were prospectively collected and stored. ResultsBoth groups had similar clinical profiles at baseline. All procedures were completed laparoscopically. Group II had a significant longer operation time (161.9 versus 122.6 min; P < .001), but shorter hospital stay (2.9 versus 5.3 d; P < .001) and lower complication rate (.2% versus 1.5%; P = .002) than Group I. One year after surgery, the mean body mass index (27.4 versus 26.8 kg/m2; P = .244), percent total weight loss (32.0% versus 34.0%; P = .877), and diabetes remission rate (84.7% versus 84.1%; P = .876) were comparable between the 2 groups. However, Group II patients had a significantly lower incidence of anemia (5.9% versus 11.1%; P < .001), secondary hyperparathyroidism (21.7% versus 33.8%; P < .001) and hypoalbuminemia (1.5% versus 2.8%; P < .001) than did Group I. ConclusionRoutine measurement of the whole bowel length to keep the common channel at least 400-cm long may reduce the incidence of malnutrition after OAGB with tailored limb bypass, without compromising efficacy in weight loss and diabetes resolution.

Clinical outcomes in pediatric intestinal failure: a meta-analysis and meta-regression

ABSTRACTBackgroundIntestinal failure (IF) is associated with significant morbidity and mortality, yet specific parameters that determine medium- and long-term outcomes remain ill defined.ObjectiveThe aim of this study was to determine the long-term outcomes in childhood IF and identify patient characteristics associated with clinical endpoints.DesignMEDLINE and EMBASE were searched for cohorts of >10 pediatric-onset IF patients with >12 mo follow-up. Random-effects meta-analysis and meta-regression weighted by follow-up duration were used to calculate clinical outcome rates and patient factors associated with outcomes. Primary outcome was mortality rate; secondary outcomes included neurodevelopmental status, transplantation, IF-associated liver disease (IFALD), enteral autonomy, and sepsis.ResultsIn total, 175 cohorts (9318 patients and 34,549 y follow-up) were included in the meta-analysis. Overall mortality was 5.2% per y (95% CI: 4.3, 6.0) and was associated with sepsis and IFALD on meta-regression. Mortality rate improved with time from 5.9% per y pre-2000 to 4.5% per y post-2005. Sepsis rate was also predictive of IFALD and liver failure. Enteral autonomy was associated with small bowel length but not presence of ileo-cecal valve. There was a relative lack of data on neurodevelopmental outcomes.ConclusionsSepsis is the primary modifiable factor associated with mortality and liver failure, whereas enteral autonomy correlates with small-bowel length. No clear parameters have been identified that accurately predict neurodevelopmental outcomes, and hence further research is needed. Together, our findings are helpful for parental counseling and resource planning, and support targeting reduction in sepsis.

Proximal Roux-en-Y gastric bypass: Addressing the myth of limb length

BackgroundSome studies suggest that changes in weight or metabolic outcomes are affected by the lengths of the gastrointestinal limbs in the Roux-en-Y gastric bypass. MethodsParticipants (N = 1,770) underwent primary Roux-en-Y gastric bypass and were followed ≤7 years in the Longitudinal Assessment of Bariatric Surgery-2, a multicenter US cohort study. Alimentary limb and biliopancreatic limb lengths were measured according to research protocol; common channel was measured in a subsample (N = 547). Aimentary limb, biliopancreatic limb, and common channel ratio to total small bowel length were calculated. ResultsMedian presurgery body mass index was 46 (25th–75th percentile: 43–51) kg/m2. Medians (25th–75th percentiles) for alimentary limb length were 125 cm (100–150), for biliopancreatic limb length were 50 cm (50–60), and common channel length were 410 cm (322–520). Statistics for ratios to the small bowel length were 0.23 (0.18–0.27) for alimentary limb, 0.09 (0.07–0.10) for biliopancreatic limb, and 0.69 (0.63–0.73) for common length. There were no significant associations between alimentary limb, biliopancreatic limb, common channel, alimentary limb ratio, biliopancreatic limb ratio or common channel ratio, and either weight loss or improvement in cardiometabolic outcomes. ConclusionThe common channel length in Roux-en-Y gastric bypass is highly variable between individuals. None of the limb lengths in this study, nor alimentary limb, biliopancreatic limb, or common channel ratios, seem to be related to weight loss or metabolic improvements >7 years.

250.5: Early Predictors of Enteral Autonomy in Pediatric Intestinal Failure:Development of a Disease Severity Score

Introduction: Patients with short bowel syndrome (SBS) are dependent on parenteral nutrition (PN) while their bowel attempts to compensate for loss of function. Our objective was to create a SBS disease severity score that would predict the probability of achieving enteral autonomy (EA) using clinical variables available in the early postoperative period. Methods: A retrospective cohort study of SBS children managed by our Intestinal Rehabilitation Program (IRP) was completed. Data abstracted included demographic, anatomic and outcome variables including serum conjugated bilirubin, proportion of enteral nutrition (EN) and episodes of sepsis specifically at 6 months post gut loss. A univariate analysis and Cox proportional hazards (CPH) model was performed. A score predicting EA was created based on weighting of Cox model coefficients. For all analyses, an alpha-value of <0.05 was considered significant. Results: 139 patients were analyzed (61% males). Ninety-five (68%) achieved EA. Those who achieved EA had a longer residual small bowel (75% vs 24%; p<0.0001) and colon (100% vs 75%; p<0.0001) and were less likely to have the ileocecal valve removed (26% vs 57%; p=0.0005). At 6 months, children who achieved EA had higher enteral tolerance (100% vs 30%; p<0.0001), a lower conjugated bilirubin (0 vs 71.5umol/L; p<0.0001) and less septic episodes (1.0 vs 2.0; p=0.0112). Cox proportional hazards modeling found >50% residual small bowel (HR 2.68 [95%CI 1.60–4.49], p<0.001), ICV intact (HR 0.61 [95%CI 0.37–1.02], p<0.06) and >50% enteral tolerance at 6 months (HR 5.70 [95% CI 2.77–11.74] p<0.001) were positively associated with EA. Conjugated bilirubin >34umol/L at 6 months was negatively associated with EA (HR 0.42 [95%CI 0.27–0.66], p<0.001). A severity score was created by weighting CPH parameter estimates [small bowel length >50%, ICV intact, CB<34umol/L and EN>50% for a maximum score of 8. Disease severity strata were developed (severe [0–2; 25.7% EA], moderate [3–5; 52.9% EA] and mild [6–8; 97.1% EA]. Disease severity strata were developed (severe [0–2; 9/35 (25.7%) EA], moderate [3–5; 18/34 (52.9%) EA and mild [6–8; 68/70 (97.1%) EA]. Conclusion: We propose a paediatric intestinal failure disease severity score that predicts probability of EA, stratified into mild, moderate and severe. The score allows prognostication of individual patients, and could assist research by adjusting outcome reporting or stratifying recruitment.

320.9: The Double-Barrel Enteroplasty: A Novel Intestinal Lengthening Procedure for Short Bowel Syndrome

Advances in the management of Short bowel syndrome (SBS) has resulted in children with shorter lengths of small bowel coming off TPN and achieving enteral autonomy. Although existing bowel lengthening procedures such as the Bianchi Longitudinal Intestinal Lengthening and Tailoring (LILT) procedure and Serial Transverse Enteroplasty (STEP) have enjoyed moderated degrees of success, they have not been without complications and better alternatives are still being sought after. We present our experience with a novel bowel-lengthening procedure for SBS termed the double-barrel enteroplasty (DBE) that is simpler to perform, is less disruptive to anatomy and has the potential to achieve similar to superior results to existing bowel lengthening procedures. Methods: Ten patients have undergone the DBE at the Children’s Hospital at Westmead between January 2011 and November 2018. Baseline characteristics, complications, time to TPN weaning and growth parameters were recorded prospectively. Results: The mean age at operation was 21 months (range 4–41 months). Mean pre-operative small bowel length was 74.6cm (36-167cm) with a mean length of 35.6cm (17-60cm) undergoing enteroplasty. Mortality and progression to transplantation remains zero. Six patients have achieved complete enteral autonomy within 2.8 months (0.5–5 months). The most recent patients are still weaning TPN. All patients have normalising growth parameters. One patient required an extension of the DBE for on-going proximal dilatation. Discussion: The DBE is a safe, effective and potentially superior alternative to existing bowel lengthening procedures for SBS. Advantages include its simplicity to perform, less disruption of bowel and mesentery, less anastomoses, decreased possibility of stenosed segments and maintenance of neuromuscular integrity.

P2.26: Optimizing the Management of intestinal pseudo-obstruction with effective bowel decompression using a pan intestinal decompressive tube

Children with intestinal psuedoobstruction are notoriously hard to manage. Refractory abdominal distension, small bowel bacterial overgrowth, inability to feed, frequent line infections, septic episodes and intestinal failure related liver damage are unfortunate realities in the management of these children. It’s also hard to determine how contributory adhesive bowel obstruction is to the ongoing abdominal distension. One of the central factors contributing to all this is the inability to effectively decompress the inherently poorly peristaltic long tubular length of the intestine. We devised a simple solution to effectively decompress the entire length of small bowel by passing a perforated decompresive tube all along its length that went from the DJ flexure to the caecum. Low profile devices at both ends ensured decompression into bags at both ends. The resulting decompressed bowel with reduced luminal calibre prevented stasis and promoted some peristalsis. In, addition it stented the bowel in a non-obstructive pattern in the abdomen. 8 children with intestinal pseudo obstruction had pan intestinal decompressive tubes placed. Ages ranged from 5 weeks to 16 years. All children had improvement in their abdominal distension, were able to take oral feeds and started stooling more frequently. 2 children with gastroschisis came off TPN after 4 and 6 months. Serum bilirubin improved initally in all children. In 2 children, after temporary relief, there was progression to liver failure and eventual death. In 3 children, additional procedures to reduce leakage around the tubes and skin excoriation were done. In 7 children, this reduced hospitalization significantly and allowed management to continue from home. In children with intestinal psuedoobstruction, the placement of a pan intestinal decompressive tube can mitigate several of the problems associated with this condition. In gastroschisis with hypomotilitiy, it has the potential to restore motility and avoid the need for a transplant.

P3.59: Surgical rehabilitation of pediatric chronic intestinal failure, long term results and change of paradigms at a single center

Introduction: Autologous gastrointestinal tract reconstruction surgery (AGIRS) and serial transverse enteroplasty (STEPS) are worldwide accepted strategies for children and adults aiming to achieve intestinal rehabilitation. The aim of this study is to show a series of children with intestinal failure (IF) that underwent surgical rehabilitation at a single center and their outcomes. Material and methods: This is a retrospective review of a prospectively filled database, from March 2006 to December 2018, including every patient <18 years of age with chronic IF that was referred to this program and underwent abdominal surgery with the aim of intestinal rehabilitation. Demographic data, diagnosis, type of surgery, intestinal anatomy (type 1 -terminal jejunostomy-; type 2 -jejuno colonic anastomosis-; type 3 -jejuno ileo colonic anastomosis-; subtypes A < 40 cm and B > 40 cm) and PN independence are analyzed. Results: From a total number of 102 Pediatric patients (pts) referred with IF, 18 underwent rehabilitation surgery; 17 of them are followed at our center and were included in the analysis. Type of surgery performed was: STEP (6); AGIRS (11). The mean time of follow up after surgery is 65 months (sd ± 49.6). A total of 8 pts gained enteral autonomy after surgery, in a mean time of 12.3 months (sd ± 7), additionally 2 pts reached enteral autonomy on hormonal therapy (teduglutide), initiated 63 and 129 months respectively after surgery (table 1). Seven pts continued on PN; from those, 2 pts underwent intestinal transplant due to loss of venous accesses, 1 pt died on the intestinal transplant waiting list due to liver failure and 4 pts remain PN dependent with no indication of transplantation (2 are in the process of starting teduglutide treatment). At the end of the studied period, the Kaplan Meier freedom from PN survival is 83.2% (graphic 1). Conclusions: Surgical rehabilitation should be considered as the first strategy to achieve intestinal autonomy; the indication for STEP or AGIRS should be done in the context of a multidisciplinary team. The only variable analyzed that showed statistical significance for surgical rehabilitation was residual small bowel length. The introduction of hormonal therapy provides an additional benefit, limiting the need for transplantation.

P3B.12: Spiral intestinal lengthening and tailoring (SILT) as a rescue procedure for SBS patients with difficult clinical situations.

Introduction: Autologous gastrointestinal reconstructive (AGIR) procedures are essential component of intestinal rehabilitation program for patient with short bowel syndrome (SBS). Unfortunately, several patients develop postoperative bowel re-dilatation with loss of bowel adaptation. Spiral intestinal lengthening and tailoring (SILT) technique promises to regain intestinal physiology by tailoring the bowel even if there is no massive bowel dilatation. The aim of this study was to report our experience using SILT in SBS with difficult clinical situation. Methods: Retrospective review of the single AGIR surgeon was performed from 2012 to date. Patients’ demographics, pre- and post-procedure bowel length, surgical complications, and postoperative parenteral nutrition (PN) requirements were analyzed. Data were compared using independent samples, Mann-Whitney’s U-test. Data were expressed in mean (IQR) Results: 9 children with SBS underwent SILT between 2012 and 2017. Rescue SILT was performed in 4 patients with age at procedure of 58.5 months (45–143.3). 3 patients had previous STEP in history of SBS post gastroschisis while one had mild dilatation after AGIR due to long segment Hirschsprung. Preoperative small bowel length measured 66 cm (49.5–75.7) with a diameter of 7 cm (6–8). SILT allowed a median increase in length of 68.5% (p = 0.34) and a significant tailoring of the dilated segment providing a reduction in diameter of 63% (p = 0.02). No major complications related to SILT were encountered and none of the children required further surgical intervention following a follow-up of 6.5 months (4.5–39.6). Interestingly, a significant reduction of PN requirement at 4 months (p = 0.02) associated with improve of liver function was reported. Conclusion: In this study SILT was reported to have no peri-operative complication and to have good results in complex SBS patients. This procedure offers a safe alternative for SBS children after the failure of conventional AGIR procedures.

P2.38: Contemporary outcomes of pediatric intestinal failure: a multicenter study

Introduction:Important changes in the management of pediatric intestinal failure (IF) have been implemented over the last 15 years. Objective:To assess the impact of those changes on the outcome of a contemporary cohort of pediatric IF patients from 6 IF programs, 5 of which offer intestinal transplantation. Methods:Retrospective analysis of a multicenter IF cohort. Entry criteria included patients < 18 years of age receiving PN for more than 42 consecutive days, primary gastroenterological disorder and diagnosis of IF between 2010 and 2015. Primary outcome was death, transplant or enteral autonomy. Kaplan-Meier analysis was used for time-to-event and competing risk analysis for cumulative incidence rates. Comparisons were conducted with a log rank test and Cox regression analysis. Results:443 patients (male 61%) with a median gestational age of 34 weeks (29–37) and birth weight of 2.1 kg (1.2–2.8) constituted the study group. Patients were followed for 3.8 years (2.3–5.3). Median time on PN was 384 days (110–947). Patients had 40% (16–100) of expected small bowel length for age remaining and 250 (56.4%) patients had intact full colon in continuity. Main etiologies included necrotizing enterocolitis (29.3%), abdominal wall defects (30.5%), dysmotility disorders (7.2%), and mucosal enteropathies (6.8%). Eighty-one patients (18.3%) developed progressive intestinal failure associated liver disease (IFALD) with a bilirubin >75mmol/l. All patients were managed with hepatoprotective nutritional strategies (fish oil based lipids or lipid lowering strategies). The presence of IFALD impacted negatively on transplant free survival (P<0.001) and achievement of enteral autonomy (P<0.01). Overall, 213 (48.1%) patients achieved enteral autonomy, 137 (30.9%) remained on PN, 53 (12%) were transplanted and 40 (9%) patients died. Achievement of enteral autonomy was associated with short bowel syndrome (P<0.01), NEC (P=0.026), intact colon (P<0.01), and ileocecal valve (P<0.01). Conclusions:This contemporary cohort achieved a significantly lower incidence of death and transplantation compared with previous multicenter reports. However, the number of children achieving enteral autonomy has not changed while a larger number of patients remain PN dependent. Although this cohort may represent a more complex group of patients due to potential referral bias, these findings suggests a shift in outcomes and a need for new strategies for the achievement of enteral autonomy.

P3B.14: Glucocorticoid treatment improves enteral feeding tolerance in pediatric short bowel syndrome patients with chronic intestinal inflammatory changes

Introduction: Studies suggest that chronic local and systemic inflammation are related to short bowel syndrome (SBS). We believe that glucocorticoids may reduce inflammation and improve enteral tolerance in pediatric SBS patients. A group of patients from our intestinal rehabilitation program developed chronic intestinal inflammation under biopsy while struggling weaning off parenteral nutrition (PN). We treated them with oral prednisolone taper, maintenance budesonide and sulfasalazine. We will describe the treatment outcome. Method: Our study included 15 patients whose lab values, pathology results and clinic notes were reviewed, and excluded patients who took steroids for post-transplant immunosuppression or severe food allergy to maintain the homogenous of our patient cohort. Results: The most common reason for SBS was gastroschisis. The small bowel length range was 20–108 cm. Thirteen patients had more than ½ colon remaining. The median age of starting steroid therapy was 3.3 years. Twelve patients had decreased PN calorie count or normalized follow-up histology. Six patients were able to wean off PN completely with median treatment duration of 5 months, five of which remained on maintenance budesonide for significant period of time (median: 7.5 months), the other one had steroids stopped 5 months before being off PN due to clinical improvement and concern for medication noncompliance. Six out of fifteen children had significant eosinophils in their initial biopsy, five were able to wean off PN while one had significant symptom improvement (GI bleeding stopped). Two patients were not on steroids continuously, as they resumed steroids months later due to histological recurrence of the chronic inflammatory process. Three patients were still not able to be cut down PN calorie. Two patients’ intestinal biopsies findings were still consistent with chronic inflammatory process. Conclusion: For SBS children with histologically confirmed chronic intestinal inflammatory changes, steroid therapy may help to promote enteral feeding tolerance and wean off PN. Patients may respond better if their initial histology has chronic intestinal inflammation with significant eosinophilic infiltrate. Patients may need to remain on maintenance steroids for a period of time even if they were able to wean off PN or significantly reduce PN calories as they may experience regression on enteral tolerance or evidence of GI bleeding as weaning off steroids is attempted.

P3.49: GLP-2 therapy for patients with short gut syndrome and intestinal insufficiency: A single center experience with future considerations

Introduction: The field of gut rehabilitation has recently evolved to restore nutritional autonomy without the need for home parenteral nutrition (PN) and subsequent transplantation. Methods: A total of 35 short gut syndrome (SGS) patients received glucagon-like peptide-2 (GLP-2) and were followed from April 2013 through February 2019 in the Cleveland Clinic-Center for Gut Rehabilitation and Transplantation. Of these, 34 were adults with a mean age of 53.4 ± 12.6 years (range: 14–72) and a female to male ratio of 2.5:1. Thirty-two (91%) of the 35 patients, were PN-dependent and 3 required IV fluid with micronutrient replacement. Leading causes of SGS were vascular occlusion (n=11), inflammatory bowel disease (n=10) and secondary motility disorders (n=5). Autologous gut reconstruction was performed in 32 of the patients (20 at our center and 12 at other institutions) with a mean small bowel length of 88.8 ± 56cm (range 10-220cm). Intestinal lengthening utilizing serial transverse enteroplasty (STEP) was performed in 11 patients. The retained colon was partial in 31 (88.6%) patients and full with intact ileocecal valve in the remaining 4 (11.4%). The duration of GLP-2 therapy ranged from 2 to 63 months with an average dose of 0.32mL/d. Results: With a mean follow up of 34 ± 19 months, 33 patients (94.3%) are currently alive and 2 died of PN-related liver failure and advanced systemic arteriosclerosis. Full nutritional autonomy was achievable in 18 (54.5%) of the 33 current survivors with an overall success rate of 54.5%. Of these 18 patients, 14 (78%) continued to sustain the restored nutritional autonomy for 1 to 48 months after discontinuation of GLP-2 therapy. Meanwhile, a reduction in PN and IV fluid requirements was observed in 19 patients who failed to restore (n=15) or sustain (n=4) nutritional autonomy. None of the patients developed significant complications that warranted permanent discontinuation of GLP-2 therapy. There were no documentation of recurrent or de novo malignancy except in one adult patient who developed prostate cancer. Conclusion: GLP-2 is an effective therapy for patients with SGS-associated intestinal insufficiency. This novel treatment should be more frequently utilized as a primary therapy or as an adjunct to autologous reconstruction and bowel lengthening. In addition, such a biologic agent should considered as an innovative approach to enhance the recovery and function of rejected intestinal allografts.

One Anastomosis Gastric Bypass-Mini Gastric Bypass with Tailored Biliopancreatic Limb Length Formula Relative to Small Bowel Length: Preliminary Results.

One Anastomosis Gastric Bypass-Mini Gastric Bypass (OAGB-MGB) is rapidly gaining popularity and is currently being performed by an increasing number of bariatric surgeons worldwide. However, excessive postoperative weight loss and malnutrition still remain a major concern regarding this procedure. The aim of this observational retrospective study was to investigate whether a tailored biliopancreatic limb (BPL) length relative to small bowel length (SBL) is superior to a fixed BPL length of 200cm in terms of weight loss results and nutritional deficiencies in morbidly obese patients 1year following OAGB-MGB. Sixty-four patients who underwent OAGB-MGB were divided into two consecutive groups depending on the BPL length used: fixed 200-cm BPL and tailored BPL groups. Anthropometric measurements (%EWL, TWL, %TWL) and nutritional parameters (vitamin A, vitamin D3, vitamin B12, serum iron, serum albumin, total protein) were compared between the two groups at 1-year follow-up. No statistically significant differences were observed between the patients in two groups in terms of %EWL, TWL, %TWL. The number of patients with deficiencies of vitamin A (p = 0.030), vitamin D3 (p = 0.020), and albumin (p = 0.030) was significantly higher in fixed 200-cm BPL group as compared with tailored BPL group, 1year following OAGB-MGB. No statistically significant differences were seen between the patients in two groups in terms of vitamin B12, iron, and total protein deficiencies. Tailoring BPL length by bypassing about 40% of the SBL seems to be safe and effective. According to preliminary results of this study, a tailored BPL length relative to SBL is even likely to be superior to the fixed 200-cm BPL as it is associated with less nutritional deficiencies while providing similar weight loss results. Further randomized studies with larger sample sizes and longer follow-up periods are necessary to confirm the primary results of this study.