Debra Sudan, Kishore Iyer, Jon Thompson, Steve Raynor, Clarivet Torres, Simon Horslen, Wendy Grant, Jean Botha, Alan Langnas, University of Nebraska Medical Center, Omaha, NE

Background: Treatment of intestinal failure is most commonly by the administration of parenteral nutrition. In some patients however, surgical therapy may increase the ability to use the intestine for nutrition and thereby decrease the complications of TPN therapy. Methods: A multidisciplinary comprehensive intestinal failure program was initiated at the University Nebraska Medical Center in October 2000. Here we describe the surgical approaches to patients with short bowel syndrome and the subsequent impact on the need for parenteral nutrition and survival. Results: Fifty-two patients (children = 31, adults = 21) underwent surgical procedures to restore intestinal continuity (n = 5), repair enterocutaneous fistulas (n = 5), resect dysmotile or strictured/obstructed bowel segments or mesenteric desmoid tumors (n = 6), stricturoplasty (n = 4), Bianchi tapering and lengthening (n = 21), STEP enteroplasty (n = 6), and other (n = 7). Of these 52 patients 3 patients did not require TPN after surgical intervention and 7 had remnant small bowel anatomy that precluded TPN weaning (ex. end duodenostomy) and were listed for transplantation. Of the 42 remaining patients most received the majority of calories from TPN at the time of referral, i.e. mean calories from TPN = 90%. Subsequent to the surgical and medical therapy, 21 (50%) have been completely weaned off of parenteral nutrition. In addition, 11 had substantial decreases in their TPN requirements (i.e. from 95% of calories at onset decreased to a median 44% (range 10-80%) of required calories to date). Six patients remained on the same amount of TPN support and 4 patients are early after surgical intervention and too early to further evaluate. Four of the 7 patients listed for transplantation underwent successful transplantation and 3 died waiting for transplantation. Despite the complications of short bowel syndrome 92% (n = 48) of the patients are alive and well with mean follow-up of 1.8 years. Patient deaths occurred primarily in those listed for transplantation (3 of the 4) and were related to advanced liver disease (n = 2) or line sepsis (n = 2). Conclusions: In this series of patients with short bowel syndrome, surgical intervention led to weaning or discontinuation of TPN support in 76% of patients. An organized multidisciplinary approach to the patient with short bowel syndrome is recommended.