Role of surgical management

The majority of patients with short bowel syndrome will require additional surgery at some point [96]. It is crucial that in subsequent operations as much bowel as possible be preserved, and the focus should be on maximizing the function of the remaining bowel. Examples of such operations include surgeries that restore continuity, relieve obstruction, repair a fistula and eliminate diseased bowel. In addition, non-transplant surgical therapeutic procedures have been devised with the goal of maximizing the function of the SBS patient's existing intestine [97]. These procedures are sometimes referred to as surgical intestinal rehabilitation or autologous gastrointestinal reconstruction. The choice of surgery is influenced by the existing bowel length, function and caliber and can be divided into procedures that optimize function (e.g., lengthen, taper) or slow transit (e.g., reversed segment). These procedures should only be considered after the initial adaptive period and with specific goals in mind. Additionally, operations such as these should only be considered when the patient is stable and medical and dietary management has been maximized. While there are encouraging results from case series, evidence of long-term success has not yet been documented, and only a small proportion of SBS patients are candidates for these procedures [98].

Intestinal transplantation may be considered in SBS patients with a life-long need for PN when complications of PN such as liver disease, loss of venous access sites or recurrent episodes of life-threatening catheter sepsis occur [1, 99]. Small bowel transplantation (SBT) can be performed in isolation, in combination with liver transplantation or in combination with transplantation of multiple organs. The outcome following intestinal transplantation has improved considerably with the development of more potent immunosuppressants and improvements in surgical techniques and other aspects of care following transplantation [99]. The SBT patient survival rates are beginning to approach those of liver transplant patients, particularly in those patients who are well enough to wait at home for their transplant [100]. Nevertheless, graft survival rates remain significantly lower than patient survival rates and a considerable percentage of patients with a functioning graft may still require PN [100, 101]. Therefore, while transplantation remains a very promising and exciting therapeutic option, before it can be recommended to more SBS patients, improved patient and graft survival and an increased likelihood of graft function in order to ensure the discontinuation of PN are necessary.

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