[Short bowel syndrome--surgical aspects]

Long-term survival after massive intestinal resection is now possible with parenteral nutritional support. The expense, morbidity, and inconvenience of this therapy, however, have led to continued interest in alternatives for the treatment of the short bowel syndrome. Patients with short bowel require a multi disciplinary approach over a prolonged period. HISTORICAL CONSIDERATIONS: The history of small bowel transplantation started in 1959 when Lillehei showed that autotransplantation of the small intestine in a dog was feasible. From 1964 to 1971, 7 attempts of small bowel allotransplantations in humans have been reported. All 7 patients died.

Short gut syndrome is a malabsorptive condition occurring after significant loss of intestinal absorptive capacity. The clinical syndrome is manifested by malnutrition, steatorrhea, weight loss, and diarrhea due to decreased absorptive capacity.

Etiologic factors leading to the short gut state include necrotizing enterocolitis, midgut volvulus, trauma, embolic phenomenon, and Crohn's disease.

Intestinal failure is the end result of several complex interacting mechanisms related to: reduced enterocyte mass, short small bowel length with consequent reduced mucosal contact time for absorption, massive proximal loop dilatation with poor propulsion, and intraluminal stasis and bacterial overgrowth lead to bacterial translocation to the liver systemically.

Patients with short bowel must be totally or partly supported with intravenous nutrition until enteral absorption can sustain survival and growth. Autologous bowel reconstruction attempts to reconfigure the residual bowel to eliminate negative factors of bowel dilatation and stasis, and redistribute the absorptive mucosa to enhance the adaptation response. Several procedures have been suggested to: prolong transmitting time and increase mucosal contact time, enhance absorption by bowel tailoring and bowel lengthening, and increasing the Enterocyte mass.

Autologous gastro-intestinal reconstruction is still in its infacny with prospect of new and different concepts for the future.