Objectives: The development of Gut failure (GF) is detrimental to human well-being and value of health care. The surgical management of such an emerging field has yet to be fully defined and comprehensively addressed. This prospective study is the first to describe multifaceted innovative surgical approaches to restore gut autonomy in patients with complex abdominal pathology. 

Methods: Over the last 5 years, 1000 patients were referred to our recently launched gut rehabilitation program with 450 (45%) evaluated for catastrophic/refractory gut disorders. Of these, 317 (70%) had surgical/functional GF, necessitating at least one major open abdominal surgery. Age ranged from 8 months to 88 years with 302 (95%) adults and 205 (65%) females. With up to 25 prior abdominal operations, primary causes of GF were developmental (10.5%), inflammatory (13%), dysmotility (14%), neoplastic (9%), vascular (21%), and technically flawed/related laparoscopic/open surgery (32.5%). Surgical intervention was intended as definitive rehabilitative therapy or to rescue transplant candidacy.  

Results: A total of 507 collective restorative procedures were performed: 28 (6%) corrective, 354 (70%) autologous-reconstruction, 58 (11%) adaptive (intestinal lengthening) and 67(13%) allotransplantation. Auto-reconstructions were 115 (32%) foregut, 201 (57%) midgut, and 38 (11%) hindgut with 16 vascularized alimentary conduits, intestinal allografts were 83% liver-free and 17% liver-contained. The overall cumulative survival was 96% a 1-year and 92% at 3-years with reversal of GF in 90%. Outcome predictors included surgical/functional residual gut anatomy, prior surgeries, renal function, coexistence of multi-resistant-microorganisms and associated-comorbidities.  

Conclusions: GF is an evolving medical specialty with the demand for comprehensive multidisciplinary care including surgical ingenuity. There is also a continual need for residency training and competence in open surgical techniques.