Permanent Intestinal Failure Research Articles

Factors Associated With 5- and 10-Year Survival After Intestinal Transplantation in Infants and Children.

Intestinal transplantation is an option for permanent intestinal failure with parenteral nutrition intolerance. We sought to determine long-term intestinal graft survival in pediatric patients at our center and to identify factors influencing survival. Retrospective chart review of 86 patients transplanted between 2003 and 2013, targeting potential explanatory variables related to demographics, perioperative factors, and postoperative complications. Intestinal graft survival was 71% and 65% after 5 and 10 years, respectively. Five-year graft survival was attained in 79% of patients with a history of anatomic intestinal failure compared with 45% with functional intestinal failure (P = 0.0055). Compared with nonsurvival, 5-year graft survival was also associated with reduced incidences of graft-versus-host disease (2% vs 16%, P = 0.0237), post-transplant lymphoproliferative disorder (3% vs 24%, P = 0.0067), and de novo donor-specific antibodies (19% vs 57%, P = 0.0451) plus a lower donor-recipient weight ratio (median 0.727 vs 0.923, P = 0.0316). Factors not associated with 5-year intestinal graft survival included graft rejection of any severity and inclusion of a liver graft. Factors associated with graft survival at 10 years were similar to those at 5 years. In our experience, outcomes in pediatric intestinal transplantation have improved substantially for anatomic but not functional intestinal failure. Graft survival depends on avoidance of severe infectious and immunological complications including GVHD, whereas inclusion of a liver graft provides no obvious survival benefit. Reduced success with functional intestinal failure may reflect inherently increased susceptibility to complications in this group.

New Insights Into the Indications for Intestinal Transplantation: Consensus in the Year 2019.

In 2001, a Statement was published that described indications for intestinal transplantation in patients with intestinal failure expected to require parenteral nutrition indefinitely. Since 2001, advances in the management of intestinal failure including transplantation and patient survival, both on extended parenteral nutrition and after transplantation, have improved, leading to a reduction in the number of intestinal transplants worldwide from a peak of 270 per year in 2008 to 149 per year in 2017. These changes suggest that the original 2001 Statement requires reassessment. All patients with permanent intestinal failure should be managed by dedicated multidisciplinary intestinal rehabilitation teams. Under care of these teams, patients should be considered for intestinal transplantation in the event of progressive intestinal failure-associated liver disease, progressive loss of central vein access, and repeated life-threatening central venous catheter-associated infections requiring critical care. Additional indications for transplantation include large desmoid tumors and other intra-abdominal tumors with reasonable expectation of posttransplant cure, extensive mesenteric vein thrombosis and intestinal infarction, total intestinal aganglionosis, and nonrecoverable congenital secretory diarrhea. Quality of life typically improves after successful intestinal transplantation and may support the decision to proceed with transplantation when other indications are present. However, the requirement for life-long immunosuppression and its associated side effects preclude intestinal transplantation if motivated only by an expectation of improved quality of life. Increasing experience with intestinal transplantation and critical appraisal of transplant outcomes including graft survival and patient quality of life together with potential advances in immunosuppression can be expected to influence transplant practices in the future.

Long-term outcomes of pediatric intestinal failure

Management of pediatric intestinal failure has evolved in recent decades, with improved survival since the advent of specialized multidisciplinary intestinal failure centers. Though sepsis and intestinal failure associated liver disease still contribute to mortality, we now have growing data on the long-term outcomes for this population. While intestinal adaptation and parenteral nutrition weaning is most rapid during the first year on parenteral support, achievement of enteral autonomy is possible even after many years as energy and protein requirements decline dramatically with age. Intestinal transplant is an option for patients experiencing complications of long-term parenteral nutrition who are expected to have permanent intestinal failure, but outcomes are hindered by immunosuppression-related complications. Much of the available data comes from single center retrospective reports, with variable inclusion criteria, intestinal failure definitions, and follow-up durations; this limits the ability to analyze outcomes and identify best practices. As most children now survive long-term, the focus of management has shifted to the avoidance and management of comorbidities, support of normal growth and development, and optimization of quality of life for these medically and surgically complex patients.

Pediatric Small Bowel Transplantation

Purpose of Review Small bowel transplantation is the only currently available option for children with permanent intestinal failure that can allow for full enteral nutrition. The aim of this article is to provide a comprehensive review of the indications, surgical technique, allograft types, perioperative management, and outcomes of children who undergo intestinal transplantation.

Microvillus inclusion disease: a subtotal enterectomy as a bridge to transplantation

Background: Microvillus inclusion disease (MVID) is a known congenital cause of intractable diarrhea resulting in permanent intestinal failure. There is need for a lifelong total parenteral nutrition (TPN) from diagnosis and the prognosis is poor. Most patients die by the second decade of life as a result of complications of parenteral alimentation including liver failure or sepsis. The only available treatment at this moment is a small bowel transplantation. But before that moment, the patients often suffer from a persistent failure to thrive and electrolyte disturbances despite continuous TPN.Methods and Results: We report what we believe is a first case of an extensive small bowel resection in a 5-month-old boy with proven MVID to act as a bridge to (liver-) intestinal transplantation to treat failure to thrive and intractable diarrhea.Conclusions: An extensive small bowel resection can be done to enhance the chance of survival leading up to the transplantation by managing fluid and electrolyte imbalance. It facilitates medical management of these patients and makes a bowel transplantation possible at a later stage.

Small Intestinal and Multivisceral Transplantation

The role of transplantation in the management of intestinal failure continues to evolve. Since the development of parenteral nutrition in the late 1960s, permanent intestinal failure has been medically managed with visceral transplantation, reserved for those who develop life-threatening complications. A multidisciplinary approach to intestinal care has led to the emergence of intestinal rehabilitation programs that have successfully achieved nutritional autonomy for many individuals through the promotion of adaptation. Whereas the short-term results of visceral transplantation have improved dramatically to the level of other solid organs, durable long-term graft survival has been elusive. This review covers intestinal failure, epidemiology, intestinal and multivisceral transplantation, and the future of intestinal and multivisceral transplantation. Figures show the embryonic origin of the multivisceral allograft, en bloc retrieval of the intestinal allograft, preparation for engraftment, vascularization of the isolated intestinal allograft, enteric reconstruction of the intestinal allograft, the liver-intestine allograft, preparation for liver-intestine engraftment, the modified multivisceral graft, arterial reconstruction in modified multivisceral transplantation, vascularization of the modified multivisceral allograft, recipient preparation in modified multivisceral transplantation, intestinal alloreactivity, graft survival among intestinal transplant recipients, patient survival among intestinal transplant recipients, candidates waiting for an intestine transplant, and distribution of candidates waiting for intestinal transplantation. Tables list causes of intestinal failure, predictors of outcome in intestinal failure, failure of total parenteral nutrition therapy as defined by the Centers for Medicare and Medicaid Services, histologic grading of acute cellular rejection, and criteria for chronic rejection in visceral allografts. This review contains 16 highly rendered figures, 5 tables, and 54 references.

Intestinal failure and transplantation in microvillous inclusion disease

Abstract Introduction Microvillous inclusion disease is a rare autosomal recessive condition, characterized by severe secretory diarrhoea that produces a permanent intestinal failure and dependency on parenteral nutrition. It usually begins in the neonatal period, and the only treatment at present is intestinal transplantation. Patients and methods A retrospective review was conducted on 6 patients (three males and three females) diagnosed with microvillous inclusion disease between 1998 and 2013. Results All debuted in the first month of life, with a median age of three days (range, 3–30 days), and had secretory diarrhoea dependent on parenteral nutrition, with fasting faecal volume of 150–200 ml/kg/day. Light microscopy of duodenal biopsy samples showed varying degrees of villous atrophy without cryptic hyperplasia, accumulation of PAS positive material in the cytoplasm of enterocytes brush border, and anti-CD10 immunostaining was suggestive of intracytoplasmic inclusions. Diagnostic confirmation was performed with electron microscopy. Two of them had a genetic study, and showed mutations in MYO5B gene. Three died and three are alive; two of them with an intestinal transplantation and the third waiting for a multivisceral transplantation.

PTH-196 Chronic cholestasis and parenteral nutrition: prevalence and effect of bowel restoration surgery

<h3>Introduction</h3> Patients with mesenteric infarction can have intestinal failure due to a short bowel thereby needing parenteral nutrition. A short bowel and parenteral nutrition can increase the risk of chronic cholestasis. Restoring bowel continuity after a mesenteric infarction results in reduction or stopping parenteral nutrition requirements. The aims of this study are to determine the prevalence and the effect of restoring bowel continuity on chronic cholestasis. <h3>Method</h3> A retrospective review of patients with a short bowel due to mesenteric infarction from 2000–2012. We defined chronic cholestasis as two of bilirubin, alkaline phosphatase and gamma-glutamyl transferase being 1.5 times the upper limit of normal for more than 6 months. <h3>Results</h3> One hundred and four (55 females, median age 54 years) patients were identified. Seventy three (70%) patients had bowel continuity restored while 31 (30%) patients did not have bowel continuity restored. The prevalence of chronic cholestasis was 29%. Fifteen (21%) of 73 patients had chronic cholestasis. Following restoration of bowel continuity, 8 (53%) of 15 patients had a return of liver biochemistry to normal range within a year. Univariate analysis showed restoring bowel continuity (p = 0.002) was associated with a reduced risk of chronic cholestasis. Multivariate analysis showed cessation of PN was a significant factor in reducing chronic cholestasis (p = 0.02). <h3>Conclusion</h3> The prevalence of chronic cholestasis is 29% for patients with a short bowel receiving parenteral nutrition. Chronic cholestasis resolves in over half patients after continuity is restored. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Cavicchi M, Beau P, Crenn P, <i>et al</i>. Prevalence of liver disease and contributing factors in patients receiving home parenteral nutrition for permanent intestinal failure. <i>Ann Intern Med</i>. 2000;132(7):525–32 Lloyd DAJ, Zabron AA, Gabe SM. Chronic biochemical cholestasis in patients receiving home parenteral nutrition: prevalence and predisposing factors. <i>Aliment Pharmacol Ther</i>. 2008;27(7):552–60 Nightingale JM. Management of patients with a short bowel. <i>World J Gastroenterol</i>. 2001;7(6):741–51 Salvino R, Ghanta R, Seidner DL, <i>et al</i>. Liver failure is uncommon in adults receiving long-term parenteral nutrition. <i>J Parenter Enter Nutr</i>. 2006;30(3):202–8

PTH-219 Prevalence of intestinal failure-associated liver disease within a home parenteral nutrition service

Introduction Intestinal failure-associated liver disease (IFALD) is a potentially life-threatening and historically common complication of long-term parenteral nutrition. In the past two decades advances in catheter sepsis prevention and the development of novel lipid formulations have reduced the prevalence of IFALD. We examined the point prevalence of surrogate markers of IFALD within the home parenteral nutrition (HPN) service at the Royal Berkshire Hospital. Method The records of the HPN service were examined to identify patients receiving HPN between January 2012 and December 2014. Clinic notes, electronic patient records and imaging results were used to extract clinical information. Results Twenty-four patients (13 male; mean age 60 years, range 21–83 years) received long-term home parenteral nutrition during the study period for a mean duration of 25 months (range 3–54 months). Underlying causes of intestinal failure included inflammatory bowel disease (7, 29%), vascular causes (5, 21%), surgical complications including fistulae, sepsis and adhesions (5, 21%), malignancy (4, 17%) and dysmotility (3, 12%). Most patients received a tailor-made PN bag 3–7 days a week (median 5 days a week) with a lipid emulsion (SMOF) bag twice a week. In this cohort 16 patients had persistently abnormal liver biochemistry (raised ALT and/or ALP greater than the reference range for longer than six months). Two patients had mildly elevated bilirubin (1–2 x upper limit of normal). There were no clinical presentations of decompensated liver disease. Nineteen patients had hepatic imaging (ultrasound or CT) during the study period. One patient had splenomegaly secondary to portal vein thrombosis and one patient had ascites related to Budd-Chiari syndrome. No other patients had radiological signs of portal hypertension or cirrhosis on imaging. Three patients underwent transient elastography measurement (Fibroscan ® ) one of which had an elevated reading (10.7kPa, IQR 1.5). Conclusion These results show that two thirds of patients on long-term parenteral nutrition had persistent abnormalities in liver biochemistry which may indicate steatohepatitis. No patients showed signs of cirrhosis on imaging or presented with decompensated liver disease during the three-year study period. Whilst this is a relatively short follow-up period to detect the development of chronic liver disease, previous studies have reported a prevalence of complicated liver disease of 26% after two years of PN. 1 We plan to prospectively monitor liver biochemistry, abdominal imaging and transient elastography in our HPN cohort to assess the natural history of IFALD. Disclosure of interest None Declared. Reference Cavicchi M et al . Prevalence of liver disease and contributing factors in patients receiving home parenteral nutrition for permanent intestinal failure. Ann Intern Med. 2000;132:525–532

Fracaso intestinal y trasplante en la enfermedad por inclusiones microvellositarias

IntroductionMicrovillous inclusion disease is a rare autosomal recessive condition, characterized by severe secretory diarrhea that produces a permanent intestinal failure and dependency on parenteral nutrition. It usually begins in the neonatal period, and the only treatment at present is intestinal transplantation. Patients and methodsA retrospective review was conducted on 6 patients (three males and three females) diagnosed with microvillous inclusion disease between 1998 and 2013. ResultsAll debuted in the first month of life, with a median age of three days (range, 3-30 days), and had secretory diarrhea dependent on parenteral nutrition, with fasting fecal volume of 150-200ml/kg/day. Light microscopy of duodenal biopsy samples showed varying degrees of villous atrophy without cryptic hyperplasia, accumulation of PAS positive material in the cytoplasm of enterocytes brush border, and anti-CD10 immunostaining was suggestive of intracytoplasmic inclusions. Diagnostic confirmation was performed with electron microscopy. Two of them had a genetic study, and showed mutations in MYO5B gene. Three died and three are alive; two of them with an intestinal transplantation and the third waiting for a multivisceral transplantation.

Intravenous lipid emulsions in term infants: impact on laboratory and clinical outcomes and long-term consequences.

Parenteral nutrition (PN) in term newborns and older infants is often required for nutritional support for temporary or permanent intestinal failure from any reason. Lipid emulsions (LEs) are an essential source of high-density energy, essential fatty acids, and fat-soluble vitamins. Depending on the fatty acid type, LEs may also have significant immunomodulatory effects. All LEs, starting with soybean oil-based LE and subsequently with medium-chain triglycerides-, olive oil- and fish oil-based LEs, have been investigated in newborns and infants. Laboratory data (mainly liver enzymes, plasma lipid profiles and some metabolic markers) have been investigated for some LEs. The outcome of intestinal failure-associated liver disease after switching to new fish oil-based LEs has been sporadically reported. Long-term outcome data have only looked at the relationship between PN and mortality/morbidity, especially liver disease, and a few studies have looked at growth. There are no controlled studies in this age group that investigated the relationship between different types of LEs and long-term outcomes. In spite of their contribution to understanding the use and indications of various LEs as well as their advantages and adverse effects, most studies in newborns and infants have been observational or retrospective, and the investigated population has been heterogeneous, either in terms of the degree of maturation, age or diagnoses. High-quality studies, preferably randomized and controlled, in this particular population are needed, especially with the widespread use of PN and the emergence of new LEs.

Ileal or ileocecal resection for chronic radiation enteritis with small bowel obstruction: outcome and risk factors

BackgroundThe choice of the optimum surgical procedure for chronic radiation enteritis (CRE) has not reached a consensus over the years. This study aimed to evaluate the outcomes in patients undergoing ileal or ileocecal resection for CRE and to identify predictive risk factors for postoperative complications. MethodsUnivariate and multivariate analyses of a retrospectively gathered database (2001 to 2011) were performed on a cohort of patients (N = 158) undergoing ileal or ileocecal resection for CRE obstruction at a single institution. ResultsOverall and major morbidity rates were 57.0% (90 patients) and 28.5% (45 patients), respectively. Surgical complications occurred in 20 patients (12.7%) and postoperative permanent parenteral nutrition dependence was 12.1% (12 of 99 patients). Multivariate analysis determined that an American Association of Anesthesiologists' score of III or higher, anemia, low platelet level, intraoperative transfusion, presence of radiation uropathy, and experience of surgeons were independent risk factors for Clavien-Dindo grades III to V morbidity. ConclusionsIleal or ileocecal resection for CRE has an acceptable risk of permanent intestinal failure and surgical complications. This study also provides the 1st evidence of predictive risk factors for postoperative morbidity of ileal or ileocecal resection for CRE.

Effects of a Multimodal Management Strategy for Acute Mesenteric Ischemia on Survival and Intestinal Failure

Acute mesenteric ischemia (AMI) is an emergency with a high mortality rate; survivors have high rates of intestinal failure. We performed a prospective study to assess a multidisciplinary and multimodal management approach, focused on intestinal viability. In an Intestinal Stroke Center, we developed a multimodal management strategy involving gastroenterologists, vascular and abdominal surgeons, radiologists, and intensive care specialists; it was tested in a pilot study on 18 consecutive patients with occlusive AMI, admitted to a tertiary center from July 2009 to November 2011. Patients with left ischemic colitis, nonocclusive AMI, chronic mesenteric ischemia, and other emergencies were excluded. Patients received specific medical management: revascularization of viable small bowel and/or resection of nonviable small bowel; 12 patients received arterial revascularization. We evaluated the percentages of patients who survived for 30 days or 2 years, the number with permanent intestinal failure, and morbidity. Lengths and rates of intestinal resection were compared with or without revascularization, and in patients with early or late-stage disease. Patients were followed up for a mean of 497 days (range, 7-2085 d); 95% survived for 30 days, 89% survived for 2 years, and 28% had morbidities within 30 days. Intestinal resection was necessary for 7 cases (39%), with mean lengths of intestinal resection of 30 cm and 207 cm, with or without revascularization, respectively (P = .03). Among patients with early or late-stage AMI, rates of resection were 18% and 71%, respectively (P = .049). Patients with early stage disease had shorter lengths of intestinal resection than those with late-stage disease (7 vs 94 cm; P = .02), and spent less time in intensive care (2.5 vs 49.8; P = .02). A multidisciplinary and multimodal management approach might increase survival of patients with AMI and prevent intestinal failure.

Anaesthesia for intestinal transplantation

The first small-bowel transplant occurred in the late 1980s, and since then intestinal transplantation has become an established treatment for patients with permanent intestinal failure. Between 1985 and 2007, 1720 intestinal transplants were performed worldwide. Intestinal transplantation has the potential to restore digestive and absorptive function and liberate patients from long-term parenteral nutrition (PN), thereby considerably improving subjective quality of life. Modern day approaches to immunosuppression, surgical, and anaesthetic management of these patients has led to improved shortand long-term survival rates, with patient and graft survival at 1 yr of 81 and 73.4%, respectively. If the patient and graft survive beyond 1–3 yr, intestinal transplantation becomes cost-efficient when compared with PN and its associated complications. More than 60 intestinal transplantation centres now exist worldwide. Adult UK centres include Oxford, Cambridge, and Leeds, with paediatric services in London and Birmingham (Fig. 1).

Role of enteral nutrition in adult short bowel syndrome undergoing intestinal rehabilitation: the long-term outcome.

The objective of this study is to evaluate the long-term clinical significance of enteral nutrition (EN) in weaning adult short bowel patients off parenteral nutrition (PN) undergoing intestinal rehabilitation therapy (IRT). Sixty-one adult patients with small bowel length 47.95+/-19.37 cm were retrospectively analyzed. After a 3-week IRT program, including recombinant human growth hormone (rhGH, 0.05 mg/kg/d), glutamine (30 g/d), and combined EN and PN support, patients were maintained on EN or plus a high-carbohydrate, low fat (HCLF) diet. Continuous tube feeding was used when EN was started. Patients were followed up for 50.34+/-24.38 months and had an overall survival rate 95.08% (58/61). On last evaluation, 85.24% (52/61) of the patients were free of PN. For 77.42% patients (24/31) with small bowel length<35 cm in jejunoileocolic anastomosis (type III) and <60 cm in jejunocolic anastomosis (type II), weaning off PN was achieved. EN comprised of 52.56+/-13.47% of patients' daily calorie requirements on follow-up. Five patients were maintained on home PN (HPN) plus EN. Nutritional and anthropometric parameters, urine 5-hr D-xylose excretion and serum citrulline levels all increased significantly after IRT and on follow-up compared with baseline. In conclusion, with proper EN management during and after IRT, a significant number of SBS patients could be weaned from PN, especially for those who were considered as permanent intestinal failure; continuous tube feeding is recommended for enteral access, and long-term EN support could meet the daily nutritional requirement in majority of SBS patients.

Response to Kelly and Howard

TO THE EDITOR: I read the comments from Drs. Kelly and Howard with interest. They raise two important points: (a) the comparison of survival rates between the two forms of treatment currently available for permanent intestinal failure, namely, home TPN (HPN) and small bowel transplantation (SBTx), and (b) the measurement of quality of life (QoL) after these two forms of treatment.

Chronic rejection with sclerosing peritonitis following pediatric intestinal transplantation

Intestinal transplantation is considered the usual treatment for patients with permanent intestinal failure when parenteral nutrition has failed. Chronic rejection is a complication difficult to diagnose because of the scarcity and lack of specificity in the symptoms and the characteristics of typical histological findings. We report the case of a four-yr-old patient who received an isolated intestinal transplant. After developing a chronic rejection he presented an intestinal obstruction secondary to a sclerosing peritonitis that required the surgical removal of the graft.

Nutrition and Quality of Life Following Small Intestinal Transplantation

The outcome from small bowel transplantation (SBTx) has improved progressively over the past decade raising questions as to whether indications should be broadened from those currently followed based on "TPN (total parenteral nutrition) failure." To assess current outcome, we studied the effect of transplantation on nutritional autonomy, organ function, and quality of life (QoL) measured by a validated self-administered questionnaire containing 26 domains and 130 questions, for a minimum of 12 months in a cohort of 46 consecutively transplanted patients between June 2003 and July 2004. The majority of transplanted patients (76%) had intestinal failure because of extreme short bowel, the remainder having either chronic pseudo-obstruction or porto-mesenteric vein thrombosis (PMVT). All but the PMVT patients were dependent on home TPN (HPN) (median 2, range 0-25 yr) and had developed serious recurrent infective complications with (25%) or without central vein thrombosis and liver failure. Sixty-one percent received a liver in addition to a small intestine. Follow-up was for a mean of 21 (range 12-36) months. Five patients died, two with chronic graft rejection. All the remaining patients have graft survival with an average of 1.2 (range 0-5) episodes of acute rejection. All patients were weaned from TPN by a median of 18 days (range 1-117 days) and from tube feeding by day 69 (range 22-272 days). There was a significant improvement in overall assessment of QoL and in 13 of 26 of the specific domains examined. Our results confirm the claim that a new era has dawned for SBTx, such that, with continued progress, it can potentially become an alternative to HPN for the management of permanent intestinal failure, rather than a last-chance treatment for "TPN failure."

Tissue Engineering of Small IntestineCurrent Status

Short bowel syndrome (SBS) has always posed a great threat to patients and has been one of the biggest challenges for doctors due to its high morbidity and mortality. So far, parenteral nutrition (PN) and small bowel transplantation remain the only viable therapeutic options. However, sepsis and liver failure associated with PN and limited availability of the donor organs and high graft rejection rates associated with transplantation have limited their use to a nonpermanent solution. Clearly, there is a need for an alternative therapy whereby increasing the absorptive surface area would help neonates and adults suffering from permanent intestinal failure. Techniques such as sequential intestinal lengthening are being explored in animal models with little success. Attempts to engineer small intestine since the late 1980s have achieved varying degrees of success in animal models with evolving refinements in biotechnology. The most encouraging results so far have been the generation of intestinal neomucosa in the form of cysts when intestinal epithelial organoid units isolated from neonatal rats were seeded onto biodegradable polymers before implantation in syngeneic adult rats' omentum. Although still experimental, continued attempts worldwide using cultured stem cells and improved polymer technology offer promise to provide an off-the-shelf artificial intestine as a novel therapy for patients with SBS. This article reviews the current status of progress in the field of small intestinal tissue engineering and addresses various types of cell sources and scaffold material having potential to be used in this field.

Small bowel transplantation

Until very recently, outcomes from small bowel transplantation (SBTx) lagged behind those in liver, heart, and kidney transplantation because of the magnitude of the immunologic burden; the strong expression of histocompatibility antigens; and the contamination in grafts by bacterial organisms. With novel techniques of immune-induction therapies, such as recipient "preconditioning" with lymphocyte reduction, followed by the more subtle use of immunosuppression-based single-agent tacrolimus, graft and host 1-year survival is now over 90% in the most active US centers, a finding that parallels the outcomes in liver and kidney transplantation. In contrast to the alternative therapy for permanent intestinal failure, home total parenteral nutrition (TPN), SBTx improves quality of life and restores digestive and absorptive function, making patients nutritionally autonomous. With survival beyond 1 to 3 years, the procedure is cost-effective. Current results support expansion of the indications for SBTx from use as salvage therapy for patients with TPN failure to preemptive therapy for patients at risk of developing TPN failure.