Surgical approaches to improving intestinal function in the short-bowel syndrome

Hypothesis: Nontransplantation surgical approaches to improve intestinal function in patients with the short-bowel syndrome have a satisfactory outcome in selected patients. Patients: Ninety adult (aged >18 years) patients with intestinal remnants shorter than 180 cm were evaluated between 1980 and 1998. Main Outcome Measures: Clinical improvement (reduction in parenteral nutrition, resolution of anatomical problems, decreased symptoms, or improved oral intake) and postoperative morbidity and mortality rates. Results: There were 17 deaths within 30 days after resection. Thirty-seven (51%) of the surviving 73 patients underwent 43 procedures to improve intestinal function. Fourteen procedures (33%) were intended to expand intestinal surface area by restoring intestinal continuity (n = 10), recruiting additional length (n = 3), or longitudinal lengthening (n = 1). Twenty-six procedures (60%) aimed to alter intestinal function, either by relieving obstruction (n = 10), repairing fistulas (n = 8), slowing transit (n = 4), eliminating diseased bowel (n = 3), or improving motility (n = 1). Three patients had stomas created to improve oral intake and relieve perianal symptoms. Postoperatively, 2 anastomoses leaked, 2 fistulas recurred, and there was 1 death (mortality, 2%). Thirty-seven procedures (86%) resulted in clinical improvement. Eleven (46%) of the 24 patients receiving parenteral nutrition were able to discontinue it and 5 patients were able to reduce the amount of parenteral nutrition received. Twelve procedures that increased surface area (86%) and 22 procedures that addressed functional problems (85%) resulted in clinical improvement. Success was lowest (50%) in patients having procedures to prolong transit time. Conclusions: Various nontransplantation surgical procedures have a role in improving intestinal function in short- bowel syndrome. These procedures usually result in clinical improvement in properly selected patients. Success is lowest for procedures designed to prolong intestinal transit time; thus, these procedures should be used only in carefully selected patients.