Approach Considerations, Medical Therapy, Surgical Therapy. Choice of operative approach. Operative therapies for short- bowel syndrome can be divided into two broad categories: (1) intestinal or combined liver- intestinal transplantation, and (2) nontransplant operations. Nontransplant components of the surgical armamentarium for the treatment of short- bowel syndrome include intestinal lengthening (Bianchi) procedures, intestinal tapering for dilated dysfunctional bowel segments, strictureplasty, and creation of intestinal valves or reversed bowel segments for patients with rapid intestinal transit times. In 1. 99. 5, Thompson et al reported results from various nontransplant and transplant surgical procedures in 1. Intestinal tapering creates a decrease in the circumference of dilated bowel by imbrications or resections of a portion of the antimesenteric side of the intestine. Approximately 8. 7% of these 1. Gmail is email that's intuitive, efficient, and useful. 15 GB of storage, less spam, and mobile access. Please note that once you make your selection, it will apply to all future visits to NASDAQ.com. If, at any time, you are interested in reverting to our default. Today we are the market leader and one of the largest independent transporters and. Not all patients with. DesignWorkshop ® is a family of software power tools for creating 3D models, renderings, and walkthroughs, from initial sketches to polished presentations. Small- bowel remnants 9. Both of these patients improved clinically. A reversed segment was placed in one patient but subsequently was taken down because of poor bowel function. Frequently, these biochemical abnormalities are self. Bruno's Marketplace offers gourmet food products from Northern California, including Bruno's Wax Peppers, Sierra Nevada Chileno Peppers, Waterloo BBQ Sauce, Bruno's. Intestinal lengthening was performed in 1. This converts one dilated loop of intestine into two parallel segments that then are anastomosed in series. Clinical improvement was observed in 8. In 1. 99. 7, Thompson and Langnas reported additional results from nontransplant operations for treatment of short- bowel syndrome. ![]() Clinical improvement rates of only 5. In contrast, Panis reported good results with segmental small- bowel reversal. The patients had very short small bowel remnants (median, 4. The median length of the reversed segment was 1. One patient died of pulmonary embolism in postoperative month 7. ![]() Of the remaining seven patients, three were completely liberated from parenteral nutrition, one required only IV fluid and electrolyte therapy, and three received only three to five nocturnal cycles of parenteral nutrition per week. Javid et al published their results with serial transverse enteroplasty (STEP) for the treatment of short- bowel syndrome in infants. No significant perioperative complications were reported. The percentage of protein- energy nutrition that the patients were able to take enterally increased significantly in this group following STEP (P < 0. One child was completely liberated from parenteral nutrition, and another child's severe cholestasis was reversed. Oliveira et al examined 5- year outcomes after STEP in 1. Among these eight patients, seven were weaned off parenteral nutrition by age four. Repeat STEP or bowel tapering was not necessary in any of the patients. Organ transplantation was a later addition to surgical treatment of this syndrome. From the outset, intestinal transplantation faced many hurdles, first and foremost because of the massive amount of lymphoid and immunologic tissue associated with the GI tract. Effective immunosuppressant drugs had to be developed. ![]() Techniques and postoperative care had to be refined, and the indications for transplantation had to be clarified. Worldwide, an estimated 2. In 1. 99. 5, Todo et al reported their experience with 7. University of Pittsburgh Medical Center. Thirty- five grafts had been lost. Sepsis (n = 1. 9) was the most common cause of graft loss, followed by management errors (n = 1. The authors performed linear regression analysis to identify factors correlated with graft loss. During the course of this study, four patients received combined intestinal. They were all doing well at 2- 3 months of follow- up. Langnas et al described their experience at the University of Nebraska with 1. ![]() ![]() Six patients had been liberated from parenteral nutrition. All three who received isolated intestinal grafts were alive and free from parenteral nutrition. Most significant complications were related to sepsis and graft rejection. In 1. 99. 8, Abu- Elmagd et al updated the University of Pittsburgh experience with liver- intestinal and isolated intestinal transplantation. These patients received either liver- intestinal (n = 5. Twenty were augmented with donor bone marrow. Tacrolimus was the primary immunosuppressant used in all cases. With a mean follow- up duration of 3. The actuarial patient survival rates at 1 and 5 years were 7. Bone marrow transplantation did not appear to increase graft survival. In 2. 00. 7, Sudan et al published their clinical results of intestinal lengthening procedures. Fifty pediatric patients and 1. All patients had dilated small bowel loops greater than 3. The patients underwent 4. Bianchi procedures and 3. STEP procedures. The average intestinal length increased from 4. Bianchi procedure and from 4. STEP procedure. The authors of this study concluded that surgical lengthening procedures result in an improvement in enteral nutrition. Procedural details. Patient selection is paramount to operative success. Tailor nontransplant operative approaches to the patient's remaining length of intestine, the presence or absence of strictures or areas of stasis, bowel dilatation, and the intestinal transit time as described above. Various radiographic techniques, including contrast small- bowel follow- through and computed tomography (CT), are helpful in the decision. Transplant surgery is usually reserved for patients who are dependent on parenteral nutrition, who have run out of venous access, who have had several episodes of central line. Identify these patients early and perform transplant before hepatic cirrhosis develops. This may obviate the need to perform a combined liver- intestinal transplantation, and results are better in patients who have not yet developed cirrhosis, according to Vanderhoff and Langnas. Some details that bear discussion here were published by Abu- Elmagd et al. These investigators have preserved the donor enteric and celiac ganglia as a measure to decrease postoperative graft dysmotility. Nontransplant operations require meticulous technique as well. The bowel must be handled gently and the blood supply guarded jealously. Abdominal visceral organ procurement may begin with an attempt at GI tract sterilization by intragastric administration of a nonabsorbable antibiotic suspended in a cathartic solution. Proximal and distal abdominal aortic control is achieved at the aortic hiatus and caudal to the inferior mesenteric artery. The proximal aorta is clamped, and the distal aorta is cannulated. Cold preservation solution is used to perfuse the abdominal viscera to be excised and transplanted. Drainage is provided by the creation of a venotomy in the suprahepatic inferior vena cava. The bowel is stapled proximally and distally. Other visceral vascular connections are divided and the graft specimen removed. If the patient is to receive a transplant consisting of the liver and intestine, GI tract continuity is restored by proximal and distal anastomosis. Some authors have advised creation of proximal and distal stomas via limbs of intestine because prolonged intestinal decompression may be necessary in the early postoperative period. Arterial blood supply is reestablished by anastomosis of a Carrel patch of the celiac axis and superior mesenteric artery to the aorta, or, if donor aorta is included, an aorto- aortic anastomosis is possible. Venous drainage of the intestine is intact to the liver in a combined hepatic- intestinal transplant. Hepatic venous drainage can be accomplished by harvesting donor retrohepatic inferior vena cava with preservation of the donor hepatic veins distally. This is anastomosed to the recipient inferior vena cava circumferentially. Alternately, the donor inferior vena cava can be anastomosed to the recipient vena cava via an anterior venotomy. This requires ligation of the caudal aspect of the donor inferior vena cava. Venous outflow for the recipient's retained organs, such as the stomach, pancreas, and duodenum, can be established by anastomosis of the recipient portal vein to the donor vena cava or the donor portal vein. When isolated intestinal grafts are used, a Carrel patch of the donor superior mesenteric artery is anastomosed to the recipient aorta. A long segment of donor superior mesenteric and portal vein is preserved for anastomosis to the recipient portal vein. GI tract continuity is reestablished as described above.
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