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Presenter: Masato, Fujiki, Cleveland, United States
Authors: Masato Fujiki, Cassandra Pogatschnik, Lisa Moccia, Neha Parekh, Mohammed Osman, Koji Hashimoto, Ajai Khanna, Guilherme Costa, Kareem Abu-Elmagd
Masato Fujiki1, Cassandra Pogatschnik1, Lisa Moccia1, Neha Parekh1, Mohammed Osman1, Koji Hashimoto1, Ajai Khanna1, Guilherme Costa1, Kareem Abu-Elmagd1.
1Center of Gut Rehabilitation and Transplantation, Cleveland Clinic, Cleveland, OH, United States
Introduction: With the recent evolution of gut rehabilitation, bowel lengthening has been increasingly utilized to restore nutritional autonomy in patients with chronic gut failure. This is the first largest single center experience with Serial Transverse Enteroplasty Procedure (STEP) for patients with different causes of gut failure including Crohn’s disease and intestinal recipients with short bowel syndrome (SBS).
Methods: Over the last 5 years, 40 patients received a total of 49 procedures at the Cleveland Clinic, Center of Gut Rehabilitation and Transplantation. Thirty-six patients were adults and 4 were children with a median age of 48 years (range; 2-79 years). Thirty-five (88%) patients required full total parenteral nutrition (TPN) with a mean duration of 21±28 months. The underlying pathology for SBS was vascular occlusion (n=22), surgical complication (n=9), Crohn’s disease (n=4), intestine transplant with SBS (n=1), and others (n=4). A mean length of residual small bowel was 70±42 cm. The colon was preserved in 37 (93%) with intact ileocecal valve in 9 (23%) and gut continuity in 13 (33%). The procedure was simultaneously performed with autologous gut reconstruction in 20 (50%) and as a second stage operation in the remaining 20 (50%) patients. The number of cuts ranged from 3 to 21. The STEP procedure was reproducible in 8 patients.
Results: Bowel lengthening was accomplished with a median increase of 20 cm (range:1-92 cm). There was a linear correlation between the length of the residual bowel and the increase in the bowel length after the STEP procedure. With a mean follow up of 14±11 months, 26 (74%) patients achieved full nutritional autonomy with discontinuation of TPN therapy. The remaining 10 patients continued to require partial TPN and adjunct GLP-2 therapy was initiated in 4. Predictors of successful outcomes include length of residual bowel, volume/caloric contents of TPN therapy, and presence of ileocecal valve. There was no significant impact of the underlying disease on achievement of nutritional autonomy.
Conclusions: STEP is an effective bowel lengthening procedure that should be offered to most of the SBS patients with gut failure. It is a valuable therapeutic option with patients with quiescent Crohn’s disease and intestinal recipients with short allograft syndrome and residual absorptive functions.
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