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Surgical Management of Short Bowel Syndrome After Bariatric Surgery
Gaurav Jain*1, Abhishek Challa1, Gates Cook1, Jon Thompson1, 2, Fedja a. Rochling1, David F. Mercer1
1Intestinal Rehabilitation andTransplant Surgery, University of Nebraska Medical Center, Omaha, NE; 2Department of Surgery, university of Nebraska medical center, Omaha, NE
Background: Short bowel syndrome is a devastating complication of bariatric surgery, with incidence of about 4% after undergoing gastric bypass surgery. The management of these patients is challenging and may require multiple operations, multiple specialties, and a prolonged hospital stay.
Aim: To assess various surgical management strategies of short bowel syndrome after bariatric surgery and its outcome.
Method: A retrospective analysis of all patients referred for intestinal rehabilitation after bariatric surgery from 1997 to 2014 was performed. Data included patient demographics, type of bariatric surgery, cause of short bowel syndrome, non-operative treatment, indication and type of reconstruction procedures, indication and type of transplant and outcomes.
Result: Twenty five patients were referred to the intestinal rehabilitation and transplant unit for management of short bowel syndrome after bariatric surgery. The mean patient age at the time of bariatric operation was 35.7 years (range 17 to 64). Male to Female ratio was 1 to 5. Majority (88%) of patients underwent gastric bypass (n=22), one patient (4%) had jejunal-ileal bypass (JIB), and 2 (8%) patients had gastroplasty. The most common cause of short bowel syndrome was bowel resection due to volvulus (48%), 24% (n=6) patients had internal hernia, 12 % (n=3) had bowel obstruction from adhesions and 16% (n=4) patients had mesenteric ischemia. Mean residual short bowel length was 48 cm (range 9 cm to 128 cm). All patients were on parenteral nutrition on presentation. Five patients were treated non- surgically with intestinal rehabilitation TPN weaning program. Twenty patients underwent surgical procedures. Eight reconstructive bowel anastomoses surgeries, 1 tapering enteroplasy, 1 STEP procedure, 3 G/J tube insertions, 3 adhesiolysis, 6 bypass revision, 3 enterocutaneous fistula closure and 2 stoma takedowns were performed. Five patients needed reconstruction of abdominal wall, with or without biological mesh. Four patients (16%) underwent isolated small bowel transplant. The most common indications for transplant were multiple severe line infections, and non-reconstructable GI tract, respectively. Two patients (8%) received multi-visceral abdominal allograft (liver/pancreas and small bowel) due to TPN induced liver failure. The 1 year graft survival rate for isolated small bowel and multi-visceral transplant was 75% and 50%, respectively. Currently 9 patients remain TPN-dependent, 3 have died, and 13 are off TPN.
Conclusions: Patients with short bowel syndrome after bariatric surgery should be treated by dedicated multispecialty teams at intestinal rehabilitation and transplant centers. Corrective reconstructive surgery remains a safe and feasible option in majority of patients, while some patients require isolated small bowel or multi-visceral transplant.
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