SURGICAL MANAGEMENT OF DUODENAL STUMP AFTER TOTAL SMALL BOWEL RESECTION. IMPACT OF THE GASTROINTESTINAL RECONSTRUCTION ON THE NUTRITIONAL REQUIREMENTS AND OVERALL SURVIVAL.
Ruy Cruz*1,2, McGurgan Jenee2, Butera Laurie2, Jennifer Joyce2, Vikraman Gunabushanam1,2, Ajai Khanna1,2, David G. Binion2
1Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; 2Gastrointestinal Rehabilitation and Transplant Center, Pittsburgh, PA
Background: Total enterectomy (TE) is a rarely performed procedure. Re-establishment of bowel continuity, quality of life, and overall outcomes are important aspects to be considered in patients who might need a TE. We describe our experience with the operative and medical management of patients with "no gut syndrome", with special interest on the effects of gastrointestinal (GI) reconstruction on the degree of parenteral nutritional (PN) dependency. Methods: We retrospectively reviewed 1005 adult patients who were referred to our center between January 2013 and October 2022. Results: Twenty-seven patients (2.7%) with a mean age of 41.7 years (range 17 to 66 years) underwent total enterectomy. In two patients the duodenum was also resected as part of original operation. Main indications for small bowel resection were vascular event (n = 11), and trauma (n = 8). Ten patients (38%) had reestablishment of GI gastrointestinal tract continuity after total enterectomy with duodenocolostomy (n = 9) or gastrocolostomy (n=1). Tube decompression (n=11) or ostomy creation (n=6) was used for foregut decompression in the remaining patients. Duodeno- or gastrocolonic anastomosis were at mid transverse colon (n=7), cecum (n=2) and hepatic flexure (n=1). There were no intraoperative or perioperative (< 30 days) deaths. All patients were on home parenteral nutrition (PN) infused over a 10- to 16- hour period. Average PN volume and calories were 2,600 mL/day (range 1,600 to 4,000) and 1,624 Kcal/day (range 1,125 to 2,320), respectively. Patients who underwent duodeno- or gastrocolonic anastomosis received smaller PN volume (33.2 vs 44.4 mL/kg/day). PN dependency index (PN intake/ basal energy expenditure %, mean±STD) was 116±18% in patients with tube decompression and ostomy and 94±20% in patients with colon in continuity (P < 0.05). Patients who underwent autologous reconstruction of their GI tract presented better short- and long- term survival (p <0.05). Seven patients underwent uneventful isolated small bowel and multivisceral transplantation with one- and three- year patient and graft survival of 100% and 85%. Another six patients are being evaluated or are already listed for visceral transplantation. Conclusion: Long-term survival can be achieved after total enterectomy in intestinal failure specialized centers. In addition, reestablishment of GI tract continuity after TE decreases the daily fluid and electrolyte requirements by approximately 25%. The addition of the colon in patients with no gut also results in a reduction in the parenteral energy requirements. This data reinforces the idea of the colon as an energy-salvaging organ even in patients with no gut.
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