Retracing our STEPs: Four decades of progress in intestinal lengthening procedures for short bowel syndrome

The surgical management of intestinal failure secondary to short bowel syndrome has undergone tremendous evolution in the last several decades. From the landmark description of an intestinal lengthening procedure by Bianchi in 1980 to the multidisciplinary modern care paradigm known as intestinal rehabilitation, innovative new treatments in this field have vastly improved patient outcomes. Initial attempts to treat short bowel syndrome surgically saw the birth of reversed intestinal segments, artificial valves and colonic transposition, all aimed at decreasing transit time and thus increasing absorption. In the long term, a common pitfall of these approaches, and intestinal adaptation itself, is bowel dilation and the associated poor motility, dysfunction and propensity for bacterial overgrowth. The development of techniques to mitigate these unfavorable conditions was a prelude to the birth of modern day operations aimed at increasing bowel length and improving function. This review examines the relevant historical approaches to short bowel syndrome and how they provided the foundation for the development of current intestinal lengthening surgery, followed by an in-depth discussion of surgical techniques and their outcomes.