Sarah Almond

Specialist Registrar in Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, United Kingdom

Intestinal failure is a common consequence of neonatal small bowel pathology. Following initial management, persistent dysmotility and dilatation of the residual gut result in failure of enteral feeding in affected infants. Gut stasis leads to overgrowth of enteric pathogens, predisposing patients to sepsis. Prolonged periods of parenteral nutrition (PN) are associated with liver disease, central line sepsis and loss of venous access sites. Many of these patients fail medical management and are placed on the waiting list for intestinal transplantation. However, despite advancements in small bowel transplantation, outcomes remain poor. In our experience, bowel dilatation is often responsible for the intestinal failure state in these patients and can be successfully managed by reconstructive surgery to reduce the gut diameter.

We report eight patients (2 congenital atresia, 2 gastroschisis with atresia, 1 simple gastroschisis, 3 necrotising enterocolitis) with intestinal failure associated with gut dilatation. Data are expressed as mean (range).

Patients were managed by longitudinal intestinal lengthening and tailoring (LILT, n=3), serial transverse enteroplasty (STEP, n=2) or tapering enteroplasty (n=3). Pre-operatively, all patients were totally PN-dependent. Mean age at time of surgery was 353 (49-1059) days. Gut length increased from 49cm (30-75cm) to 73cm (45-120cm) following surgery, p=0.016, 2-tailed paired t-test. Post-operatively PN was discontinued after 196 (35-537) days for seven patients; one patient remains on TPN 111 days after surgery. Although three patients were assessed for small bowel transplant prior to surgery, none subsequently required it.

These data indicate that reconstructive surgery to reduce bowel diameter is an effective technique for treating intestinal failure associated with gut dilatation, without sacrificing intestinal length. We suggest that this technique may ameliorate the need for bowel transplantation in this group of patients.