REVIEW

Short bowel syndrome: Surgical therapy

W DONALD BUIE, MD, OUN G Tl IL RSTl)N, M [), RICI lt\RD N FEDORAK, MD

ABSTRACT: Many surgical solutions to short bowel syndrome have been proposed; however, none has proven robe uniformly successful. Some of these solutions, combined with optimal medical management, may represent the patient's only hope for survival without parenteral nutrition. Most forms of surgical therapy are supportive and aim at controll ing three basic pathophysiological defects: decreased intestinal transit time, gastric hypersecre­tion, and reduced functional mucosa! surface area. Conservative resection and, thus, prevention of short bowel syndrome remains the best form of treatment at present. In the fu ture, small bowel transplantation may prove to be an important advance in therapy; however, this remains largely experimental due to continued problems with rejection. Can J Gastroenterol 1990;4(4): 167-173

Key Words: Shore bowel syndrome, Surgical therapy

Syndrome de l'intestin court: Traitement chirurgical

RESUME: De nombreuses solutions chirurgicales one ete proposees pour traiter le syndrome de l'intestin court mais aucune n 'a remporte un succes uniforme. Certaines, combinees a un traitement medical optimal, represencent peut-etre le seul espoir de survie du patient sans le recours a l'alimentacion parentcrale. La plupart des interventions chirurgicales apportenc un traitement de soutien et visent a controler trois defauts physiopacho logiques de base: d iminution du transit intestinal, hypersecretion gastrique et reduction de la surface fonction­nelle de la muqueuse. La resection conservatrice, c'est-a-dire la prevention du syndrome de l' incestin court, reste <lone la meilleure forme de tra itemenr pour le moment. Dans l'avenir, la transplantation du grele sera peut-erre un progres therapeutique important; clans une large mesure, cette in te rvention reste toutefois experimentale, les problemes de rejet continuant a se manifester.

AS A COMMON CAUSE OF SI IORT

bowel syndrome is surgical resec­tion, it is not surprising that many sur­gical solu tions co short bowel syndrome have been proposed. Although none has been uniformly successful, some have proved co have merit when used in

conjunction with medical therapy, and often represent the patient's only chance to become independent from parenteral nutrition.

The l:iest form of surgical 'treatment' remains that of prevention with conser­vative resect ions (I). Even the reten-

Departments of Surgery cmd Medicine. Unrversiry of Alberca, Edmonwn. Alberca Corres/Jondence and reprmt.s: Dr Richard N Fedorak, Univermy of Alberta. Deparonent of

Medicine. Division of Gastroenterology. 5 19 Roben Newton Research Building, Edmon con, Alberta T6G 2C2. Telephone ( 403) 49 2-6941

Received for publication March 28. 1989. Accepted December 12. 1989

CAN J 0ASTR0ENTEROL VOL 4 No 4 MAY/JUNE 1990

tilm nf a few extra centimetre~ nf bowel can have a profound influence on the intestine's a bi li t y to adapt, and thus on the eventual prognosis. Many aurhors have advocated construct ion of multi­ple ostomies with a second look proce­dure for all marginal bowel which may l:ie vial:ile (l-3).

Surgical treatment can l,e c lassified into three ca tegories based on pathophysiologic processes: slowing transit time; decreasing gasrric secre­tions; nnd increasing the effective mucosa! surface area (4).

SLOWING INTESTINAL TRANSIT

Surgical therapy to decrease intes­tinal transit time is based on the con­struc tion of a partial small bowel obst ruction . Many different methods have been devised; however, a ll are un­predictable in their eventual effect. Most of the complications which arise from each merhod are due co bowel obstruction. Antiperistaltic segments: Reversal of intest inal segments to create anciperis­taltic regions was originally described by Mall in 1896 (5). He reversed vari­able segments of small bowel in th ree dogs, two of which d ied of bowel obstruction, while the third lived for th ree months. At laparotomy two months later, the segment showed rete nti o n o f reversed peris talsis. T h rough the use of glass beajs as markers, Mall a lso demonstrated a delay 111 intestinal transit time. The proce­dure was viewed as impossible until the

167

RUll:eta/

1950s when Hammer (6) demon traced that the d uodenum could he reversed successfully resulting in an increase in intestinal transit t ime (6). Later in 1955, Hammer demonstrated that an 80% small howel resection in the dog could be tolerated with the addition of a reversed ilea! segment as short as 2 inches (7). In a controlled fo llow-up exreriment, he demonstrated th.at dogs could survive a 90% resection for up to

two years with rhe reversal of a small segment of intestine.

The first human report of egmental reversal was by Gibson (8) in a female with short bowel syndrome from a mes­enteric infarction. She recovered fo l­lowing the reversal of a 7.5 cm segment of jejunum. Subsequently, Srahlgren (9) demonstrated that the fecal output of fat and, to a lesser degree, nitrogen, decreased with the insertion of an an­tiperistaltic segment in the jejunum of dogs. Using 3 co 4 cm paired proximal and distal reversed segments, Keller ( 10) proposed that the mechanism by which intestinal reversal worked was a prolongation of intestina l transit with an increase 111 the contact time of mucosaand luminalcontents. Venables m 1966 ( 11) in the first human study of absorpt ion showed a 50% decrease in fecal fat absorption with the insertion of a reversed segment.

T here are two c rit ica 1 factors in c reating antiperistaltic segments: the length of the segment and its location. If the segment is too short there will be no benefit, whereas a long segment will cause a bowel obstruction. Fink and O lson ( 12) favoured a 10 cm segment located proximally to retard gastric emptying; however, the weight of evi­dence is now for distal placement. Wil­more ( 13) fai led in his attempt to treat ileostomy diarrhea over the long term with a distal 10 cm segment; however, there was a small short term decrease in ileosromy volume. Pertsemlidis ( I 4) a lso felt that the segment should be placed as distally as possible, and used a 14 cm segment 12 cm proximal to the ostomy to prevent stagnant loop syndrome and bacterial overgrowth. Warden in 1978 (15) reported five babies with a 3 cm reversal placed as distally as possible, with survival in four.

168

In summary, intestinal reversal to

create an antiperiscal tic region anJ delay transit bone of the more common surgical interventions used in the treat­ment of ,hort howcl syndrome. The ideal length in the adult seems to be 10 to l 5 cm with placement as distally as possihle. Nevertheless, inconsistent results and difficulty in predicting which patients are likely to respond have consistently dampened en­thusiasm for this arproach. Recirculating loops: The recirculating loop is an extension of intestinal rever­sal and was first suggesteJ by Stafford et a l in 1959 (16). Mackby in 1965 (I 7) showed an improved surv ival in dogs when a recirculating loop was com­bined with a separate antiperistaltic segment. Aleman ( 18) in a controlled experiment on 20 dogs found that animals with recirculating loops had better fat absorption hut lost more weight, and often died due to anorexia compared with controls. In a separate study comparing recirculating loops co segmental reversals, the latter were more often technically successful and had fewe r complications (19). Al­though a further report of successful cl inical applicat ion of the recirculating loop was submitted in 1975, the proce­dure has fa llen into general disfavour due to the strong evidence against its being superior to a simple reversal and to the fact that the procedure is compli­cated, uses long lengths of bowel and is fraught with complications causing a high mortality race (20). Colon interposition: Colon interposi­tion has also been used in the treatment of short bowel syndrome. Use of the colon has three main advantages: an intrinsically slow peristalsis; decreased likelihood of causing obstruction due to the fact that colon can be placed iso­peristaltically; and no requirement for the use of small bowel which is a lready compromised in residual length . Initia l­ly, antiperistaltic colonic segments were used and shown to be of benefit in a dog model (21). In 1967, Trinkle anJ Bryant (22) placed a 5 cm ant iperistal­tic segmen t of t ransverse colon in a three-week-old infant after massive re­section for a mid gut volvulus. Al­though the patient died, she initially

gained weight and haJ an 111crease m transit time with a Jecrease in stool frequency. Later, isoperistalric colon interposition was investigated hy H.utcher (23,24 ). In a series of experi· ments with beagle puppies, he showed increased survival with the interposi­tion of a 15 cm segment of isoperistaluc colon both pre-ilea! and pre-jejuna! after a 90% small bowel resection. The animals in both cases attained approxi­mately 70% of their expected growth with a decrease in morta lity and mor­bidity compared with controls. Garcia et al (25) interposed a 24 cm segment of isopcristaltic colon to a L 5 cm length of small bowel with an imacc ileocecal va lve in a human patient. After an aJaptive period, intesti nal transit time increased from 10 to 105 mins am! the patient was able Lo maintain adequate nutri t ion by oral feedi ng. In this patient, the development of a D-lactic acidcmia was postulated to be Jue to bacterial overgrowth. Comparison of iso- and antiperistal tic colonic inter­posit ion was examined by LloyJ (26,27) using a 90% small howel resection in the rat. In a series of experiments, he found that antiperisraltic colonic inter­posi tion effectively prolonged transit time but had other unpredictable ef­fects. Some animals acquired a small bowel obstruction and had, on average, lower body weights with on ly a slight increase in rhe absorption of albumin and no change in the absorption of fat compared to controls. He concluded that there was no advantage to ant1-peristaltic interposition over isoperis­ta lcic a nd , indeed, there may be disadvantages. Further studies in dogs by Carner (28) showed that the inser­tion of a 20 cm length of anti peristaltic colon made no d ifference in xylose ab­sorption, 24 h fat excret ion , bowel tran­sit time or ave rage weight loss. Although his numbers were small, he concluded that antiperistalt ic colonic interposition was of no benefit.

G lick et al in 1984 (29) published a series on six infants in which a proximal isoperistaltic segmen t of colon was used to t reat short bowel syndro me. The seg­ments were 11 to 15 cm in length and three of the infants survived whi le the ochers d ied of sepsis and total parenteral

CAN J GA~TROENTEROL VOL 4 No 4 MAY/JUNE 1990

nutrition-inducet.l liver failure.His con­clusions were that surviva l was associ­ated with greater residual small bowel length, colon interposition at a younger age and a shorter duration of medical management. Unfortunately, the aver­age residual bowel length in the wr­vivors was 86 cm and these patients may well have adapted on their own with nme. Brolin (30) puhlished a case re ­port of a 34-year-old female with 12 cm of residual le ngth of sma ll bowel in whom an isoperistaltic colonic in­terposition was done. Postoperatively, she did well in the shon te rm; how­ever, no nutritional studies were done.

lsoperisca I tic colonic interposition is a viable a lternat ive in the treatment of short bowel syndrome. Proximal place­ment seems co be best; however, the optimal length of the segment has yet to be detennined. The range in the literature is from 8 co 24 cm. A 11 of these lengths are reported to prolong intes­tinal transit t ime. Whether or not the segment has the abi li ty to absorb nutri­ents has nor heen established. The ac­tual mechanism of improved absorption is presumed to be through prolonged intestinal transit time and greater mu­cosa! contact time with luminal con­tents. There appear to be no short term difficulties with the procedure. In the long term, bacterial overgrowth due to stasis with resultant n-lactic acidcmia and possible encephalopathy may prove to be a problem, especially in the infant population. Experimental valves: The recognition that the presence of an ileocecal valve has a positive effect on the residual in­testine's ability to adapt to resection has led co attempts to create an 'artificial' ileocecal va lve. Experimental va lves have been looked at as another means of slowing intestinal transit t ime. Intes­tinal valves of many different types have been used, including ablation of the outer longitudinal muscle layer (3 l ,32), the reverse incussusception valve (33 ), and several ocher va lves of similar construction ( 34-38).

The valves have all increased transit time, but the effects have not always been predictable. Schille r (31) at­tempted to show that the o uter muscle

ablating sphincter was better than in­testinal reversal in promoting survival after a 90% resection; however, his numbers were very small. Waddell (33) presented three pat ien ts with an incus­susception valve: one patient having marked success, one satisfactory, and the third eventually acquiring a bowel ohstruction such that the valve had co be raken down. Vinograd (36) publish­ed a study of the submucosally tun­nelled valve constructed much like the re-implantation of a ureter into the hlaJder. He found the optimal length to be 4 to 6 cm in a dog model in prolong­ing intestinal transit time wirh no demonstrable reflux. Chardavoyne et a l (39) examined the efficacy of a surgical­ly created nipple valve in a dog hy in­troducing labelled hacteria below the valve. The occurrence ofhacteriaahove the valve was no different than with an intact ileocecal valve.

le is nm surprising that clinical series examining imescinal valves are very few in number. The unpredictability, the occurrence of bowel obstruction and th e loss of further in testinal length to construct the valves arc all major deterrents co their routine use. Retrograde luminal pacing: It has heen known for. ome time that the propaga­tion of peristalsis distally in the inies­tine is ch rough electrical impulses from a pacemaker in the duodenum. Phillips et a l (40), in a series of experiments in dogs, demonstrated that retrograde electrical pacing of intact jejunum en­hances absorpt ion of glucose, water and sodium. When the bowel was trans­sected co e liminate t he proximal pace­maker, retrograde pacing had a profound effect on absorption such that it was greater than the absorption from in tact jejunum with or without retro­grade pacing. It appears that retrograde pacing slowed transit time and in some cases reversed the flow of luminal con­tents (41,42). Layzell (43) later dem­onstrated that dogs with retrograde luminal pacing showed an increase in body weight and a decrease in fecal fat and nitrogen excretion.

Investigation in to the mechanism of action has shown chat the effect of pacing can be inhibited by an a lpha­adrenergic blockade, and thus the effect

CAN J GASTROENTEROL VOL 4 No 4 MA Y/)UNE 1990

Short bowel syndrome: Surgical therapy

must be mediated, at least in part, hy ;m adrenergic mechanism ( 44 ).

This therapy has remained cxpen­menta 1, since entrainment requires transsection of the duodenum to elim­inate the intrinsic pacemaker, pro­longed function of the electrodes has been difficult, and the electrodes must be implanted surgically and removed su rgically when they foil.

DECREASING GASTRIC HYPERSECRETION

As mentioned previously, gastric hy­persecretion has been recognized as a component of the short bowel syndrome for some time. This was felt to be detrimemal for a number of reasons: there would be an increase in the volume of intestinal secretions presented to an already compromised absorptive system; t he acidification of the lumen of the intestine would hinder the action of the digestive enzymes; and the resultant osmotic and volume load would further compound the fluid, electrolyte and nutrient losses al ready occurring in the compromised bowel.

The realization chat patients with prev inus vagotom ies and gastreccom ies were more tolerant of massive resection led to the use of these procedures for the control of gastric hypersecret ion in short bowel syndrome. Today, with the emergence of the H2 receptor anta­gonists and the realization that gastric hypersecretion is probably temporary, there is no place for the surgical treat­ment of gastric hypersecretion.

INCREASING THE EFFECTIVE MUCOSAL SURFACE AREA Attempts at increasing the effective

mucosa! surface area has led to three completely different approaches: t he growth of neomucosa; bowel lengthen­ing and capering procedures; and small bowel transplantation. Neomucosa: Neomucosa was originally investigated by Cywes in 1968 ( 45) and Binningcon in 1974 (46). T hey ob­served chat the ~erosa of neighbouring bowel could be used as a bed co stimu­late the growth of a mucosa! covering. In a series of experiments on dogs and pigs, they found chat if the small bowel was opened along its an timesenteric

169

Rt II· ~1 al

border anJ sutured lu the ,em~,t ol n neighhnurmg r1ece nf hnwd ma longt· 1ud111al intestinal paiLh, the 111terven mg sero"t would be co,TreJ with a mucosa wh1<.:h was rrnven to c<1nra 1n emyme le,·eb ~,mdar to nl)tmal mucosa ( 46). The functional nutrient ahsorp· t1vcahtl1tyol th1smuc<1s,l, howc,Tr, was not known.

An l'xhaw,u, e series nf expcrunents h) Thnmpson (47 50) LulmmateJ 111 a paper 111 1988 which seemed lll sum mari:e nenmucosa ( 51 ) . I k ohen·ed that 1ntesunal patching haJ an 111·

h1h1tory effect on 111te,t111al adaptat11>n in Jogs suhJected tn 75°0 imestmal resecllon and intestinal palching. I !is Jara showed ,1 decrease 111 overall gmwth of 1he 111te~t1ne and in villus height. Trnns1t ume wa~ pmlongeJ l:iut the animals lost weight and had lower alhum111 leveb. Funhermnrc, the in· crease 111 mtesunal mucosa[ surface area was ms1gnificant. It would seem that nenmucosa has lmle 1f anythmg to off er in the treatment of short bowel syndrome at the present time. Tapering and lengthening procedures: Intestinal tapering and lengthening rrocedwcs have met with much more success. Tapering was originally propo~cd when 1t was noted thai bowel rmximal to an atretk segment ,1lways became so mmkcJly dilated that re, anastomosis was difficu It. Peristalsis was felt to be functionally meff ective. ln1· ually, the anrimesenterit. border was opened and a longitudinal strir ofl:iowel was re1mwed before re-approx1mat1ng the l:iowel. The cal 1l:irc of the rema111111g howcl was reduced so Lhat anastomosis was easier anJ pcnstab1s was a1deJ due to apposition of the bowel wall during peristalsis. Panencs treated 111 this way did 111deed gain weight, anJ many were able to come off total parenteral nulri· non (52). The major drawhack w elm procedure was that 1t necessitated the loss of valuable mucosa! surface area. A modification of this technique called 'rlicat1on ' (111ternal infolding) per· formed alung the antimcsenteric border was compared 10 antimescntenc ex· c1sion hy Ramanujan (53). He tound that rlicated 1:iowel was eventually in· corporated 111to the bowel wall anJ was better struCLurall y and funcmmally

170

after anillLrnll) mduced hl1wel ddata· 110n 111 a dog mlldel

In 1980 B1a1Kh1 (54) described 111 a pig nmdel ,m elegant protedure callcJ 111tesunal lengthening. The rrocedure 1s l:iased llll the prembe that the hlmxl surpl) w the small howcl runs 111 an ,ilcernaung fashion around e,1Lh side of the bowel. This allows an ,l\,hLular plane w he developed hl't ween the two leaves ot the mesentery sud1 that a GIA stapler can l:,c rassed down the centre, dn·1d111g the howel men two rarallel tul:ies. These rnn l:ie arrmxtmateJ end­w-end in an 1sopen,talt ic fashion to

give a segment which is twice as long hut only half I he d iamcter of the ong111al bmvel. The prtlledure was first used clinically by Boeckman and Tray I or (55) on achdJ with short l:,owel syndrome from a gastrm,ch is1s with bowel necrosis. The chi ld was left with 39 cm of small bowel anastomosed to

the transverse colon. This grew to a length of 50 cm over the ensuing years; however, the child weighed only 9.2 kg at four years of age. Following a Bianchi procedure, the patient required total parenLeral nutrition for a further I 0 weeb but was rmgres cd to a full diet and <ltd not require .irtificial nutr1t1on after th.ts tune.

Aigram 111 1985 (56) puhl1shed a

report of another infant with short bowel syndrome who had an mtestmal lengthen111g procedure done. Post· operatively, ~he remained nn total parenteral nutrition for four weeks hut was then ,tble t0 progress to a regular J1et. He moJ1fied the procedure to

some extent l:,y re-anascomosing the lengthened bowel 111 a helical forma· t1on to rrevent traction on the mesentcnc vessels. The problems en· countereJ postoperatively 111cluded bacterial overgrowth rmximal ro the lengthened loop, nutrit10nal 111·

tolerance and gastmesophagcal reflux. Bacterial overgrowth was felt ro be due to roor pcriscalsb 111 the proximal di­lated duodenum which was nm tapered. Ora l tolerance of feed mg was complete by eight months, although continuous tube feed suprlemencat1on still main· tained a large rroportlon of the caloric intake. U rcc holme was used to combat the reflux with complete success.

Thompson ct al 111 1985 ( 5 7) were unsucLessful 111 their attemr1 to appl\ the 81anch1 prtJLedurl' 10 a child with the short bowel syndrome. After tb 1J ing the bowel they rL··anastomn,eJ 1t, on ly to have one segment of the lengthened bowel become nnnv1ahle lntercmngly, the pallent ,1pparcntly 1mrmveJ clinically and the ,1uthor~ at· trihuteJ this to the result.int tapering of the rcmammg segment nf l:iowel.

A direct comparison pf 1he efficacy of mtestinal lcngthenmg relative to

other surgical treatments of ,hon howd syndrome has been rerformed in a pig model by Stgalct et .11 (unruhli,hed data). They compan:d isorerntaltic colon 1nterrosn 1on and 1nteslln~l lengthening. While hoch group, showed superior weight ga111 to control arnmals rece1v111g no treatment, mtes­tinal lengthening was found co he superior to 1sopern,taluc colon inter· prn,1tioning.

Intestinal lengthen mg arpears 10 he a viable alternative m the surgical ireat· mcnt of short bowel syndrome. Ap pl1camm of this procedure seems to h~ tailored to the subset of the population in which the residual bowel has dilated so markedly that peristalsis 1s relative!} ineffective (58). The advantages m elude the face that nn mucosa! surface area need be sacrificed; a slowing of transit ume is obtained wilhout cau,mg a funct 1onal ol:istruction; and normal peristalsis is restored to ;1 previou:,ly Ji. lated segment. Small bowel transplantation: Succe~­ful small bowel transplantarnm may he the ultimate treatment for short bowel syndrome. The tech111cal fcas1bil1ty was first escal:ilished expernnentally in the late 1960s by Ull1he1 111 a Jog m()(.lel ( 59). Hts procedure cons isted of transplaming the entire small intestine with vascular anastom<):,is between the respective mesenteric vessels of the graft and hnst. I !is autografts survived indefinitel y, but the a llografo all rejected in a maner of days. At present, the maior obstacle is ~ti II rejection, as the large amount of lymrho1J us,ut' present 111 the transplanted organ make, it extremely tmmunoge111c (60,61) Control of rejection can be approache<l by either general 1mmuno:,uppress1on of

CAN j GASTROENTERUL VOL 4 No 4 MA Y/)UNI: 1990

the host or by alreramm of the 1m munogen1c1ty of the donor organ. Nu­merous methods of temporary control llf reiection have hccn accomplished 111

the dog moJcl using co1wcnc1nn,1l hmt 1mmunosuppress1vc I hcrapy. Unfortu­nately, b()th a:athiupnnc and predn1 wne interfere w11 h muc.:w,al cell replication and thus the function ofthl· graft (60). Anulymphocytl' scrum alone has hcen shown to be 1m11fficien1 111 averting rCJCCtl(m tn Jng~ (62).

The development of the 1mmunll­,uppress1ve agent, cyckisponne, at· rracted new interest. Monn drug therapy wnh cyc.:losporine 111 a rat model (15 mg/kg/day) given for four wceb postoperntt vcly can prcvc:nt reiection (63). Recently, low Jose cyclosporme ( 5 mg/kg/Jay) given o\'l'r two weeks has also prcvenu:d rcjecttnn in rats (64). Unfortunately, the results in large an11nal moJels have not hcen as successful. Remick ct al 111 1982 (65) JemonstrntcJ tha1 intramuscular cyclospcmne (25 mg/kg/d,1y) would pnilong survival Ill a trnn~planteJ dog from a mean nf 12. 5 LO I 03.8 days. The importance of parenteral admmtstrn· tion of t1ie drug was underlined in an extension of this work hy Craddock ct al (66) who Jemomcrated that dogs with incont1nuny grafts given oral cyclosponne survived fnr less than one month (66). This emphasized the fact 1hac absorpuve func.:tinn of an nllografr i\ mitially suhoptimal, and 1mmunosup­pressi ve therapy should he av compl1sheJ parcnterally. Furtht.'r ,tudies by Ricour (67) and Crane (68) m pigs confirm these findings . The aJ­Jmon of predmsone Lo cyclnspnnne therapy has been shown in dogs to im­prove survival over c.:yclospnnne alone (69); however, these results have nnt heen comistendy reproduced. High Jose cyclrn,porme therapy may not he w1thouc its own problem ; a rcvers1hlc impairment of 1ncescinal absorption with a protein-losing cmeropathy has been described 1n dogs (70). Ex­perimental altcmpts at passive immune enhancement (antiJonor antibody) have been entirely un~uccessful 111

prolonging survival (61). Attempts at reducing the immuno­

genicity of the graft tissue have met

wnh failure. Schrauc (60) 1rrad1atl'J the graft llssue prior to trnnsplant,lll\ll1 in rats with no increase in graft survival. Whl'n lymph mides from the graft were cxammeJ 1111croscopically there was considerable lymphocyte depletion hut man} lymphnqtes were still present. This f,11lure Lll eradicate all lymph m sues may explain the lnck of success. Muc.:11 of the 1mmunngen1city of the graft 1~ felt w he due w the c.:lass II an11gcn-hcaring cells. A new approach ustng prerransplant ,1Jmm1strat1on of mnnnclonal antihcxltcs to class 11 anti­gens i., hcmg 11westigated. This method has .ii read) hc:cn shm, n Lil prohmg graft sun 11,11 of p,mLrcalll islet transplants (7 l) . Other approaches tnLlude prct ransplant hlnod transfus1nns and segml'nral grafts (72, 7, ). The l.1t ter ts ,1 direct attemp1 w deul'ilsc the im­munngentL load wbidl, in cum, has resu lrcd 111 I, i11 er c ycl(isp,inne dosl'S nccc~sary tn prL·1·ent re ice t ion. Another complicating foctnr in intestinal transplants 1s that onl' of the ftrs1 funv ttons to fail with reiect1nn 1s the mucosa I barrier. Thb cnahles thl' tram­locu11m ofhac.:tena tnlll the suhmuc<1-a and, eventually, mto thl' hlond stream with resulrant sepsis. I( the reJL'Ction pmcess proceeds to this pomt, 11 1s 1rre­vcrs1hlc.

Small bowel gralts conta111 large amounts of lymphoid t1s,ut' wh1d1 cre,ircs the pntcn1 ial fnr graf1 ven,us host disease. Some au1hors feel that this 1s a lahmawry phenomenon Jue to che hcavy immunosuppress1on of the host immune system. Most, howcvl'r, fed chat reiecc1nn and graft vc:rsus ho,c dis­ease arc not mutually exclusive ,md can coexist (74). (irafL versus host dbeasc can m,mifest itself even if reJCLttnn ts prevemed hy cyclosponnc (75). This ts contrary to lither organ system models 111 wh 1ch graft versw, host d1sea,e can be prevented by large doses of 1mmun,isup­press1vc agents. The use of amilym­phoc.:yte serum co pretrcat the donor along with c yc.:lospnnne treacmem to

the recipient has hccn shown LO

uniformly prevent graft versus h(ist dis­ease 111 rats (76).

In aJdit11ln, there remain technical prohlems assouared wnh small bowel transplant,Hum at present. Mos1 early

CAN J GASTROENTl:Rtll VDL 4 Nt l 4 MAY/Jl NI l 990

Short bowel syndrome: Surgical therapy

graft failures arc due w ,1rterul and venow, thromh11Ms nf 1he graft and 111-testtnal vnlvulus (65.77). The 111-udentc nf the l.lltl'r c,1n hl' decreased hy cnsur111g propl·r onc:nt,n 10n of the LransplameJ bo\wl. Mon1wnng the 111

\ 11·0 funlt1on nf t hq.:raft to ensure early de1ectwn pf rl'Jl'C11on P, d1ff1cult. rum. 11onal rests of water, st>lltum and sug;1r absorpt tlll1 ll'tt h rl'peatcd small howcl h1opsy h,11·c hc:cn pmposl•d as the mosl reliable methods (78). A recent study by Banner ct al (79) suggl'sh th,ll sub­clinical rejectHm Lan pl'rsl'>t 111 tht· 111-testinal wall 111 the suhmucosa and muscle undetcctahle by mucosa I h1np­sy a lnne. Add I t1on,1 I tee 11111.: ,1 I prohlems Lent re around short 1crm graft preservauon. Presently, mcravascular tlush111g with a balanced s,1lt soluuon contain111g frucwse 111 combinntion wnh hypothermia will provide up tn

I H h of prcservauon ( 61 ) . Th 1s has a bo hecn shown to decrease grnft immuno­grniuL y (80).

At present, sm.111 bowel transplama­tion remains an cxperimemal altcrna­llVL: m the treatment of short bowel ,ynJrome (61,62). Control of reieccion ts still the maior obstacle to successful 1 ransplanr,. Clinical experience with ,mall howel transplantatwn and cyc.:losponnc therapy rcma1m limited. N inc pauents ( 111c.:luding four children w11 h mulr1v1sCl'ral grafts) have under­gone small bowel transplantation under cyclospmme coverage. four have sur-11ved. alrhough three have had their grafts removed. The remaining five have all dieJ due to ~epsb, hemorrhage or unknown causes (81).

CONCLUSIONS Management of the short bowel

syndrome contmues co be a difficult clmical problem. Over the long term, the clm1uan depends on mtrin~ic adap­tation of the residual in1estinc and this, 1n turn, is dependent on length, type ,ind functional state of the residual hnwel alnng wtth the presence or ah­,encc of an ileocecal valve and colon. The mecha111sms of adapt,lt1on arc n11t ent1rcly under~too<l, thus prevcnung active 1ntcrvenllonal therapy to ac­celerate adapcamm. As the moM cnm­mon cause of .,hon hnll'el syndrome ts

171

BUIE et al

surgical resection, the best therapy is prevention using conservative resec­tions anJ 'seconJ look' proceJures in the case of howcl of quc~ti(mable viability. Pre~ent therapy, whether medical or surgical, is purely supportive

ACKNOWLEDGEMENTS: Dr Fcdorak 1s the rccipientd a Clinical lnvestigarorsh1p from the Alberrn Heritage Foundation for Medical Research. Th is work 1, supported by a grant from the Alberta Heritage Founda-rion for Medical Research and the Depart-mcnt of Surgery, University of Alhena. The ,1urhon, express appreciatinn ro Mrs Michel PollMJ for her expert sccreranal a,sim111ce.

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